look out

by Ursula Arens Freelance dietitian

Was Florence Nightingale the first dietitian?

Having a child in primary school is an excellent way to refresh one's grasp of the basics. That the Great Fire of London was started in Pud- ding Lane. That King Henry had six long-suffering wives. That a scalene triangle has no equal sides and no equal angles. And that Florence Nightingale was the most astonish- ing, heroic and stellar superstar and the first media celebrity, when this meant more than being able to shimmy in a pop video, or pout next to a pro footballer.

This year is the centenary of the death of Florence Nightingale and Westminster Abbey have just an- nounced the naming of a chapel in her honour. In 1859, the nearly-40-year-old Florence, having returned from the hell-on-earth hospital in Scutari, pub- lished her thoughts on nursing in the

book Notes on Nursing: what it is and

what it is not. The book was intended for the general public and sales of 15,000 copies in the first month made it a bestseller, and declared to be “as good as a novel,” by her friend, Sir Sidney Herbert. The tone of the book is of its time, but reveals a confident and perhaps bossy and controlling woman, but one with astonishing perceptive- ness, thoughtfulness and intelligence. All this is combined with a complete focus on the pragmatic actions needed to care for people who are ill or injured. Florence also dedicates two chapters in the book to food and diet.

Medical challenges past and present

Beyond some of the fussy tone of

dear Florence, her statements shoot across 150 years to hit bulls-eye targets into some of the feeding problems in hospitals today. The general observation of patients starved in the midst of plenty from want of attention, is an ongoing theme that is still a medical challenge. What does Florence advocate in

the chapter ‘taking food’? Very weak patients find it difficult to eat solid foods early in the day (before 11am), so she advises not to present them with eggs, or bacon, or mutton chops, but offer hourly spoonfuls of beef tea, or arrowroot-and-

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wine, or egg flip. In acute cases, doctors should take exceeding care to order and give nourish- ment with minute selection and punctuality. In chronic cases of ill health, Florence describes the need for close observation of the patient’s feeding preferences and accommodating these with ingenuity and perseverance. She chides the practice of leaving uneaten food by the side of a pa- tient (‘in hopes that he will eat it in the interval’) and calls for prompt removal at the right time. Meals should be extremely punctual and Florence commands that ‘nothing shall be done in the ward while the patients are having their meals’. Perhaps food quality was a

little inconsistent 150 years ago with the background of being at war in a distant country, but should milk-be-sour or eggs-be-bad, Florence calls for nurses not to disappoint patients and to ‘whip up something else in a few minutes.’ Could this be suggested to nurses or dietitians today? After all, as Florence observes in her book, ‘Nurses are not merely carriers of diets to and from the patient and should exercise her intel- ligence in these things.’

Recovery foods

The next chapter is entitled ‘what

food?’ There is some discussion of the appropriate uses of the already men- tioned beef tea and egg-flip, which appear to have been the first choices of nourishment for the very ill. Florence cautioned that some nurses depended too heavily on meat alone to sup- port patient recovery and particularly observes the risk of scorbutic sores. Cream, butter and cheese are praised as foods supporting recovery. Milk was a valuable food, but caution is needed, as, ‘of all articles, it is perhaps the most injurious’ because soured milk, which happened quickly in the pre-fridge era, was a common cause of diarrhoea. From further discussion about the

properties of individual food groups, Florence then steps back and calls on nurses where they can, to fulfil the patient’s ‘fancies’ for particular foods.

Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company. She was also a nutrition scientist at the British Nutrition Foundation for seven years. Ursula guides the NHD features agenda as well as contributing her regular column, Lookout.

She cautions against the chemistry-led formulation of ideal diets (‘you can- not diet a patient from a book’), and observes many cases where the patient’s stomach was right and the book was wrong. The final section in the ‘what food?’ chapter heaps praise on the tonic properties of a nice cup of tea. Not too much and not in the evening, (although early morning is fine), but few offer- ings can match the gentle restorative properties of moderate amounts of tea. Florence insists on the superior qualities of high-priced tea and notes that she is supported in such perhaps extrava- gant judgement by agreement on this from the good-old sort of women, such as laundresses and mistresses of dairy farms, who match hard manual labour with head-work (in contrast to the flimsy mistresses-of-houses, who cannot even go over their own house once a day). Discussion of many other aspects of nursing all conclude in a similar way to her insights on food provision, that close observation and thoughtful actions are the core of nursing care. Of course, this is also the essential basis for dietetic care and perhaps we as dietitians, should also be paying tribute to the genius of Florence Nightingale, in setting out such careful and insightful

notes for the feeding of patients.

*Notes on Nursing: what it is and what it is not. Florence Nightingale. ISBN 0-486-22340-X. from www.doverpublica- tions.com

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