The

origins and evolution of advice about

food and cookery for convalescents and
invalids

Peter Williams OAM

BSc(Hons) DipNutrDiet MHP PhD FDAA

Former Honorary Professorial Fellow

School of Medicine, University of Wollongong
Wollongong, NSW 2522, Australia

Tel: +61 410592707

Email: peterwilliams@ihug.com.au

Version 2
30 August 2020

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Funding: There was no funding for this study

Conflicts: The author declares no conflicts of interest

Keywords: Invalid cookery; convalescent food; cookbooks; food history

Word count: 9290

Biographical Information:

Peter Williams is a Fellow of Dietitians Australia and was an Honorary Professorial

Fellow in the School of Medicine at the University of Wollongong and a Professor of
Nutrition and Dietetics at the University of Canberra. He has been an active nutrition
researcher with over 110 peer- reviewed publications and an h-index of 38. He has
served on National Health and Medical Research Council working parties for reviews
of the Dietary Guidelines for Australia and on the Board of Food Standards Australia
New Zealand. He has conducted consultancy projects with the Agency for Clinical
Innovation to develop nutrition and therapeutic diet specifications for hospital
inpatients. In 2019 he was been awarded an Order of Australia Medal for services to
community health and to medical education.

Abstract

This article examines the origins of ideas about the appropriate feeding of invalids
and convalescents in the Western culinary tradition. It traces the evolution and
development of ideas from early Greek and Roman writers through the Middle Ages,
Early Modern and Modern eras. Cookbooks in the first half of the twentieth century
very often carried separate sections on invalid cookery but this feature has largely
disappeared from cookbooks today. The common ideas of convalescent food that
have survived over many centuries demonstrate the resilience of a culinary tradition
based mostly on personal experience rather than scientific research.

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Introduction

There has been relatively little research on advice about the preparation of food for
convalescents and invalids. One paper concluded that recommendations remained
remarkably consistent across the 16th to 18th centuries in Europe, despite radical
changes in knowledge and theories of physiology at that time (Albala 2012). Albala
suggests that ideas have persisted to the present day, passed down by non-
professional carers rather than being informed by medical research.

Until the 1950s, cookbooks were a common source of information about how to feed
sick patients. One bibliography which examined 889 Australian cookbooks published
between 1860 and 1950 found 25% included sections on food for invalids and
convalescents (Williams 2018). However that study found more than half of the
recipes were for beverages, desserts and soups of limited nutritional value: beef-tea,
barley water, gruel, broths, toast water, arrowroot and apple water were among the
most frequently cited (Williams 2019).

Common advice about feeding invalids in these cookbooks included serving small
frequent meals, never asking patients what they would like to eat, minimising the use
of fat or seasoning in foods, and avoiding foods regarded as too rich or indigestible for
invalids, such as pork, oily fish, pastry, full cream milk, and cooked oysters. Few of the
authors had any medical or nursing expertise and it appeared that much of the advice
was based on commonly held ideas rather than any scientific evidence.

This paper aims to summarise the history of dietary advice for invalids and
convalescents in Western culinary traditions, and examines the origin of some of the
more common recommendations made for those preparing this food.

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Definition of the terms invalid and convalescent
Convalescent care has rarely been addressed in the historiography of early medicine.
Newton suggests there has been an incorrect assumption that it was a later
nineteenth century invention (Newton 2015, 2018). However the concept, if not the
term, has its roots in Hippocratic-Galenic medical traditions and discussion of the
“neutral body” – a category of patients who were “neither sick nor sound” (van der
Lugt 2011). Early physicians envisaged three main bodily states: healthful, neutral, or
sick. The neutral category included those who were born with weak constitutions, the
feeble elderly, people recovering from illness, and mothers after childbirth (Weiss-
Amer 1993). Convalescents were no longer sick, but they functioned slowly and
weakly.

Both words date from the mid seventeenth century and are based on the Latin terms
invalidus, meaning “not strong” and convalescere, “to grow strong”. An invalid is
defined as a person made weak or disabled by illness or injury (Pearsall 2001). A
convalescent is a person recovering from acute illness or accident after the acute
phase has subsided, until a complete recovery or rehabilitation has been obtained
(Allice 1947). In the nineteenth century it became relatively common for some people
to self-identify as invalids: long-suffering individuals who regarded themselves as
beyond the ability of medicine to ensure recovery, and who required special care and
attention (Frawley 2004).


History of ideas
Antiquity
Diet was important in ancient medicine, with much treatment being preventative
(eating correctly balanced foods) and corrective (restoring harmony to the body),
rather than therapeutic (curing disease) (Edelstein 1967).

The most ancient dietetic texts of any scope from antiquity are those contained in the
books of the so-called Hippocratic Collection. They consider human food from three
points of view: digestibility, nutritive value and physiological effects (Trémolières
1975). Digestibility was assessed by subjective sensations and especially appreciated

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were light foods that did not cause digestive difficulties. Hard dry foods were suspect
especially salt meat, hard cheese, lentils, roots and unripe foods. Generally liquid
foods were regarded as the most digestible.

From a nutritive point of view meat, wheat, milk and fresh cheese, beans and sweet
fruits were best; fatty substances, non-bread cereals, and fermented cheeses were
considered less nourishing; greens and acid fruits were thought to give very little
nourishment.

Of all the physiological properties, the most important for the sick was the thermic
effect of food: the ability to heat or cool the body. At one end were the hot substances
– spices, pungent and aromatic plants, salt, honey, strong wine, wheat bread and the
flesh of adult mammals. At the other end were cold and cooling substances – slightly
acid or sweet plants and watery drinks. In between were more neutral substances:
meat of young animals, poultry, fish, milk and gruel made from non-bread cereals.

The theory of humours was influential, based on the writings of Hippocrates (450-
370BC). The human body, composed largely of liquids (“humours”), depended for its
good health on the right balance of four humours (blood, phlegm, yellow bile and
black bile) and on the right balance of the “qualities” of these humours (hot, cool,
moist and dry)(Wilkins 1996).

Since disease was thought to be caused by malignant alterations of the humours,

recovery was believed to involve the process of “concoction”, raising the natural heat
of the body to transform the humours. This could be by Nature itself (as in a fever) or
by the use of medicinal drinks that exhibited opposite qualities to the offending
humours (Newton 2015).

Galen (129-216AD) formulated what were to become the rules for healthy eating that
persisted into the Middle Ages and beyond. His dietetic writings cover some 400
pages of Greek and were available in Latin translations from 1490. His main sources
were the Hippocratic corpus, but also other Greek writers from around 300BC
(Nutton 1996).

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In Galenic theory, the most nutritious foods were those substances that resembled the
human body, consequently animals were deemed more nutritious than vegetables,
and meat was superior to fish since humans bore a closer resemblance to the former.
In general Galen believed that eating fruit was dangerous, although he did allow that
apples allowed to ripen and then stored, if baked or steamed, may benefit the sick.
Vegetables were thought to offer little nutrition, being cold and watery in consistency
and also because they tended to produce more undigested excrement, and therefore
less was retained by the body (Albala 2002). Natural philosophical ideas of the chain
of being also deemed birds nobler than land- and water-bound creatures because the
heavens were nearer to God; thus the most nutritious creatures were thought to be
those that could fly (Newton 2018).

As well as being nutritious, the convalescent’s food had to be easy to digest. A classic
example was the hen’s egg, a staple ingredient for the weak throughout this period.
The clue to digestibility was colour: white and pale tones signified food that was light
and could be digested easily (Albala 2012). For this reason white meat such as
chicken and partridges were thought best, whereas dark coloured meats like beef and
venison were not allowed because they were too heavy and dense (Hart 1663). To
make foods easier to digest, practitioners recommended mashing or liquefying
ingredients to spare the patient from any mastication or chewing. The cooking
process was also important and boiling was the best method because it was seen as
most similar to Nature’s own form of digestion in the stomach. Rufus of Ephesus (who
died around 100AD) also advised against excessive seasonings since this burdens the
stomach (Grant 1996).

In parallel with the Galenic ideas of this era, convalescent food recommendations can
also be found in the traditions of Indian Ayurveda developed from 300BC to 700AD
(Rastogi and Chaudhari 2014) and traditional Chinese medicine from 206BC to
220AD (Porkert 1974). However there is little evidence that they have had any direct
influence on Western culinary traditions, although Chinese traditional advice about
foods to eaten after childbirth is still followed today by in many westernized
communities (Pillsbury 1978).

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Middle Ages (5th-15th Centuries)
The ancient humoural theory became much elaborated in the Middle Ages,
particularly as physicians saw in it a rational means to define human health (Scully
1995). Physicians believed that modification of temperaments was fundamental to
treating disease and modifications of foods (which each had its own different
temperament), could produce harmful or beneficial changes in a person (Ottoson
1984).

The anonymous author of a Neapolitan recipe collection from the end of the 14th
century states that “some foods are appropriate for the sick and weak, such as gruels
of rice, oats or barley, and prepared with almond milk, chickpeas, pullet broths;
pomegranate wine, tisanes of pike, and figs and imported grapes” (Scully 1995).
Among other dishes described as suitable for delicate stomachs are a deep-fried
doughnut dipped in a syrup of honey and sugar; teased chicken cooked as a pancake
with ginger, rice flour, sugar and egg yolk; spiced chicken broth; pear or apple with
egg yolk; a porridge of wheat, oats, rice or millet in milk and egg yolks; and cheese
slices and egg yolks boiled in water, wine herbs and spices.

Whereas advice about the feeding convalescents in earlier times was found in medical
manuscripts, the first printed cookbooks date from the end of the fifteenth century
and often included recipes suitable for the sick (Willan and Cherniavsky 2012). Sick-
dishes can be easily distinguished in recipe collections, primarily by the presence of
sugar. Owing in part to the increased availability of this previously exotic ingredient
and in part to the nature that Arabic scholars attached to it, sugar became during the
fifteenth century one of the most valued and common ingredient in sick dishes.

Amiczo Chiquart, a master cook to Duke Amadeus of Savoy, compiled a famous
culinary manuscript (Du fait de cuisine) published in 1420, which has a distinct
section of sick-dishes, designed for convalescents. Barley broths and porridges
appeared routinely in standard cookbooks of the time, and among the seventeen sick-
dishes in Chiquart’s collection were wheat precipitate, a semolina dish, an oatmeal
porridge, a barley porridge and a dish of chickpeas (Scully 1995). Almond butter and
puree are common ingredients; fruits are used in quince turnovers and applesauce,

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and poultry appeared in strong broths of chicken or partridge, and capon or partridge
in white sauces.

In England, a collection of medical advice from the fifteenth century included the
following advice about the effect of food: “All bitter things comfort the stomach. All
sweet things enfeeble it. Roast things are dry. All raw things annoy the stomach.
Whoso will keep continual health [must] keep his stomach so that he put not too
much herein when he hath appetite, nor take anything into it when he hath no need”
(Dawson 1934).

Early Irish medicine also devoted much attention to the diet of the sick or injured. The
Bretha Crólige is a medico-legal text dating from 1468-74 and in one passage it states
that horse-flesh should not be given to any invalid as “it stirs up sickness in the body”.
Both meat cured with sea-salt and whale flesh are similarly banned on the ground
that “the produce of the sea impels one to drink”. An invalid may only take beer under
the direction of the physician (Kelly 2001).

In the same text, honey is forbidden when the invalid is suffering diarrhoea but in
general honey is regarded as especially healthy. Great emphasis is also placed on the
importance of herbs and vegetables in the invalid’s diet. The Bretha Crólige speaks of
“the great service given by garden plants in nursing” and claims that the primary
purpose of gardens is the care of the sick. There is frequent mention of two particular
vegetables cainnenn and imus, which are probably onion and celery respectively.
Sweet fruits are also recommended (Kelly 2001).

The most revolutionary innovation of this era was the rehabilitation of green plants
and especially fresh fruits. These foods had been considered particularly dangerous in
ancient dietetics. All this changed in the sixteenth century when northern doctors
such as Forestus in Leyden and Ronsoeus in Antwerp noted that fresh fruits and the
juice of acid fruits were the best remedies for scurvy (Trémolières 1975).

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Early Modern (16th-18th Centuries)
There is a rich historiography on early modern theories of disease and treatment
(Beier 1987, Stolberg 2011). An article specifically on convalescent cookery in early
modern Europe, drawing on writings in cookbooks and medical texts, notes that
recipes thought to be both comforting and easy to digest would be perpetuated from
generation to generation (Albala 2012). Albala interprets this continuity as a sign that
convalescent care was “not inherently derived from any theoretical structure” but
reflected the relative stagnation of therapeutics between the sixteenth and eighteenth
centuries.

In the first half of the early modern period, humourally-based nutritional theory
offered dietary guidance for established illness. By contrast, advice for convalescents
was usually vague. While based on humourally “neutral” foods such as bread cooked
into gruel and meat broths, it seems have been drawn from informal intuition about
the need for food that is easy to digest and light in colour and consistency so as not to
tax the body excessively.

One central idea at this time was that convalescents need food that is extremely
nourishing yet with a texture and consistency that can be easily broken down by a
weakened digestive system. Recommendations therefore focused on foods that
appear to be pre-digested – cooked to softness or pounded to a smooth paste, to
replicate the action of the stomach and other digestive organs. Convalescent dishes
were normally boiled or gently poached, rarely roasted and never fried, probably
because boiling seemed closest to the action of the stomach with its digestive heat.

The most common foods were long-cooked gruels, concentrated meat broths and
dairy products. Soups and purees were common along with white foods like bread,
chicken and almonds. Foods believed to be coarse such as meat or whole vegetables,
as well as anything prone to corruption, such as soft fruits, were normally forbidden,
as well as excessively dry foods like aged cheese, and salty, highly spiced or preserved
foods.

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The Sussex physician Thomas Twyne (1543-1613) recommended that in the first few
days of convalescence patients should retain the same diet they had taken during
illness, but consuming only liquid foods (Twyne 1576). Liquid foods were the most
advantageous because they could be quickly distributed around the body despite
being less nourishing than solid foods.

The first major cookbook to contain an entire chapter on convalescent cookery is
Bartolomeo Scappi’s Opera, published in 1570. Scappi was personal chef to Pope Pius
V and most of the dishes are regular recipes adapted for sick people (Albala 2012).
They include barley dishes, pastes and “acque cotte” (cooked water): boiled or
distilled drinks with cinnamon, anise, dried fruits, licorice, mastic or barley. Panada
was another dish in this section: it comprised breadcrumbs soaked in lean broth,
thickened with egg yolk or milk made from melon seeds or almond. Sugar was
optional. Milk, butter or almond oil could be added before service.

Convalescent diets at this time have been briefly explored in Anne Stobart’s book on
English household medicine (Stobart 2016). She argues that throughout the
seventeenth century easily digestible broths remained the staple food for recovering
patients, though new exotic ingredients, such as sassafras and china root, were
introduced in the 1600s. Nonetheless some physicians were still recommending
fasting as an appropriate treatment for illness, rather than attempting to nourish
those recovering from illness. Everard Manywaringe noted that “Physicians endeavor
to raise up their weak Patients by Restuaratives, Jellies, and nourishing Broths” but
that was a mistake as “Foul Bodies the more you feed them with high Nourishment,
the worse you make them” (Manywaringe 1696).

Convalescent care was part of a branch of medicine known as “analeptics”, which
meant “to cherish and renew the strength” (Newton 2018). A variety of forms were
recommended, including juleps and cordials (sweetened drinks and spirits), and
electuaries (powders mixed with honey or preserves). An example is the surgeon
Alexander Read’s restorative for weak convalescent persons, made of pistachios,
sugar and fragrant spices. Similar treatments were found in domestic recipe books.

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Another important consideration was the patient’s liking for a food and it was vital to
indulge the patients’ dietary predilections. The Manchester physician Thomas Cogan
justified this as follows: “Liking causeth good concoction [i.e. digestion]. For what the
stomacke liketh, it greedily desireth; and having received it, closely incloseth it about
until it bee duly concocted”(Cogan 1589).

Michael Stolberg has analysed over 2000 letters from patients in Germany from this
era to summarise their views about the experience of illness (Stolberg 2011). Most
comments about convalescent food reflect those found in cookbooks of the time. Too
heavy a meal was to be avoided because it could overburden the body. Easily digested
food was conducive to health and wine was often regarded as a welcome fortifier.
Very spicy food, and smoked or salted meats were avoided because it was suspected
they caused “acrimonies” (morbid impurities in the body), and patients had to avoid
any food or drink that caused increased inner heat.

The seventeenth century was the century of tea and coffee – drinks that were adopted
in Europe with uncanny rapidity, although doctors were not sure “whether this exotic
beverage (tea) is more palatable or more nutritious than home-raised barley
converted into broth” (Eden 1797).

The reputation of the English as meat-eaters had become established by the end of
the seventeenth century (Guerrini 2012). Tyron, in his much reprinted The Way to
Health, drew upon the concepts of Galen to advise simple meats and drinks with
minimal variety and ingredients (Tyron 1697). He ranked various forms of meat by
their healthful qualities: beef was high on his list; veal and pork were deemed less
wholesome; and wild fowl were healthier than domestic. At the same time, some
religious sectarians and radicals in the wake of the English Civil War proposed a
vegetarian diet among other attributes of an imitation of Christ and a new, more
egalitarian, England.

One example is George Cheyne, a popular physician among the elite of eighteenth-
century London. Cheyne promoted a mainly vegetable-based diet, with avoidance of
alcohol. He believed that digestion was crucial to the proper functioning of the body

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and gave special attention to the quantity and quality of food and liquid, along with
general comments on digestibility, including “the larger and bigger the vegetable or
animal …. the stronger and harder to digest is the food made thereof”; “dry, fleshy
fibrous substances” are more easily concocted than “fatty, glutinous substances” and
flesh which is white in colour is generally kinder to the digestion (Cheyne 1724).
Turner has summarised the foods Cheyne believed were easy to digest (including
poultry, whiting, asparagus and strawberries) or those less easy to digest (including
duck, salmon, apples and pears) (Turner 1982). Some of these ideas seem very
similar to those found in later books of advice about convalescent feeding.

Empirical forms of medicine were developed in Paris in the 1790s that proved more
intent on understanding medical conditions and developing cures through the
physical observation of organs and tissues rather than theoretical speculation, and
this brought forward new ideas on convalescent foods in the next century (Miller
2015).

Modern (19thCentury)
The nineteenth century can be considered the quantitative epoch of dietetics and by
the middle of the century great progress had been made in the chemistry and
physiology of food, chiefly as a result of the work of the German researchers. By the
1870s the different nutritional constituents of food and their energy value had been
established, reflected in Pavy’s Treatise on Food and Dietetics, one of the first books in
which full nutritional analyses of foods are given (Pavy 1874).

In 1804, the English physician James Adair wrote an essay on diet and regimen,
especially aimed at “the indolent, studious, delicate and invalid” (Adair 1804). His
dietary regimen is largely based on his personal observations of the digestibility of
different foods and some comparative studies of the anatomy of the stomach and
bowels in different animals. He concludes that animal foods are detained in the
stomach longer than vegetable foods, and recommends a diet largely based on
vegetables and grains. He prefers root vegetables over “cabbages, kails and salads
[which] do not seem to be very digestible”, and recommends oatmeal, and rye as
more digestible than wheat. In his regimen for invalids, meat is limited to no more

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than once a day but he admits lack of information about the relative digestibility of
different meats. His list of foods that are not easily digested include cooked egg white,
pork, nuts, onions and warm bread. Finally, he agrees with the standard
recommendation of liquid foods (including soup, broths, milk, cream, whey) as good
foods for delicate stomachs but cautions against coffee and tea as noxious foods that
weaken and undermine the constitution.

In 1835, another textbook on the care of invalids by an English physician included 64
pages of advice about food, with the emphasis being on digestibility (Robertson
1835). He provides comprehensive lists of the order of digestibility of different foods
(e.g., mutton > beef > lamb > veal > pork; whiting > haddock > cod >flounder >
salmon). This information appears to be based on a mixture of personal clinical
experience and some experiments observing the effects of gastric juices. The book
also includes several rules for eating: eat at regular intervals, never fast for longer
than five yours; make breakfast the principal meal, drink as little as possible while
eating; eat food slowly. Robertson agrees with the use of wine and spirits in
convalescence, especially ale, porter and port-wine, claiming their chief purpose is to
stimulate gastric secretion and cause blood flow to increase.

However, medical knowledge about convalescence was still quite rudimentary at this
time. In 1847, an American medical article on the management of convalescence
stated “after disease the sensibility of the stomach and intestines is exalted and their
tone diminished” and notes the difficulties of patient feeding when the stomach is
irritated or inflamed. The author offers no dietary recommendations aside from the
general advice to allow only as much food as the stomach can digest, advise the
patient to eat little and often, and submit the food to effectual mastication (Parise
1847).

Despite this, medical advice could be quite strict about the need for dietary
prescriptions during convalescence. An article in The Hospital journal included the
advice:
“Never satisfy the cravings of a convalescent patient, especially after fevers.
The clearly expressed and persistently repeated wishes of the patient himself

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 on the subject of the diet suitable for him cannot always be ignored; you
must however report the expression of such longings to the doctor. …. Unless
you observe this rule unflinchingly you will be guilty of some of the murders
or very questionable forms of homicide which are committed repeatedly
with chops, steaks, pickles, cheese, oranges, greens etc.” (Basil 1888).

In 1860 Florence published her Notes on Nursing, written to dispense “hints for
thought to women who have personal charge of the health of others” (Nightingale
1860). She once described herself as an “incurable invalid, entirely prisoner of my
bed” (Frawley 2004). Although she did not record any recipes, she held strong
opinions about food. Feeding the sick, she claimed, was about seduction. Patients
often reject food, but it nonetheless must be consumed for the body to regain its
strength. The ingredients were to be the best and freshest available, the dishes
prepared with utmost skill. She warned “Remember that sick cookery should do half
the work of your patient’s weak digestion”.

Throughout the nineteenth century there were increasing publications with advice
about feeding invalids – both from medical professionals and from cooks. Cookery for
the sick was an area that started to move out of the exclusively medical and nursing
realm and into ideas regarding the rational management of the domestic sphere
(Santich 2013).

Textbooks of domestic economy and household science for school pupils started to
include advice on food for invalids. One such book for use in schools, published in
London, contained the advice that “the first step in preparation of food in sickness is
to arrange that as much effort and work, that are thrown upon the stomach in health,
are performed by the preliminary operations of cooking. The employment of such
readily digested foods as beef-tea, simple broths, gruel, arrowroot, butter, cream and
various lighter combinations of milk and eggs with flour or bread, rests mainly upon
this ground” (Mann 1878). The author also notes that sweet things are neither
suitable for, nor palatable to invalids, and that water and tea are the best drinks,
although barley water and lemonade may be given at times.

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Another example of a mid-nineteenth century book is Notes From the Sick Room
(Stephen 1883). It includes some limited advice of food, including several methods for
making beef-tea, advice on how to prepare milk, and comments about the unpleasant
smell of green vegetables, and the preference for cold food for patients who are
nauseous.

More comprehensive manuals of invalid cookery, with extensive lists of recipes also
appeared from this time. Some were still authored by physicians (Fothergill 1880,
Neal 1861, Chase 1887), but increasingly these cookbooks were written by women
cooks (Pitkin 1880, Hooper 1876, Hamilton 1886, Earle 1897, Heritage 1897, Boland
1898, Davies 1898, Ryan 1881).

Scientific studies on the relative digestibility of foods and their suitability for an
invalid diet appeared in the second half of the nineteenth century (Fraser 1886,
Beddoe 1865), and research on the role of enzymes led to a reconceptualisation of
digestion as an energy intensive process. This notion was supported by empirical
observations that sick patients often had no appetite; that is, their powers of digestion
were reduced as the body’s energy resources were otherwise engaged (Haushofer
2018). As the physiologist William Darby explained, in a publication announcing one
of the first artificially digested foods, they “relieve the enfeebled stomach of its main
burden, and enable it to complete the process of digestion without overtaxing its
energies” (Darby 1870).

This concept soon found its way into popular advice for invalids: “In sickness the
whole of the body organs are weak, and cannot do the amount of work of which they
are capable during health. If much food is taken at once, the stomach will make a
violent effort to digest it, which effort will be a waste of energy, and will have on the
whole the same effect as if the patient had attempted manual toil which his limbs
were too weak to perform” (Stoker 1878).

In 1889 a professor of clinical therapeutics wrote, in a discussion on food for invalids,
“there is a general consent amongst all authorities that, owing to the interruption of
normal gastric digestion in fever, all food should be given in the fluid form, that is, in a
form that can be readily and immediately absorbed, that it should be given in small

15
quantities and at short intervals” (Yeo 1889). He particularly recommended whey,
milk, beef-tea, mutton, veal and chicken broths, strained gruels, and vegetable and
fruit juices.

Artificial digestion was originally developed as a research method to study the
mechanism of digestion. In the 1830s the German physiologist Theodor Schwann
characterized pepsin, a digestive enzyme secreted by the stomach, and soon after
German and French physicians trialled the use of pepsin as treatment for patients
with weak digestion. It entered the pharmacopoeias of Germany in 1861 and Britain
in 1873. In Britain, the medical physiologist William Roberts, championed the use of
pancreatic extracts as therapeutic digestive agents and the Benger company’s product
“Liquor Panreaticus” was one of the first to be commercially available in the 1880s.
Later they added a range of food products, including a peptonized beef jelly, and a
peptonized milk gruel (marketed as “pancreatised, farinaceous self-digestive food”)
called Benger’s food (Haushofer 2018).

Digestion was a topic of great political and scientific interest during the second half of
the nineteenth century, with particular interest in how to feed people most efficiently
for least cost, especially in institutions such as hospitals (Haushofer 2018). This led to
the creation of a number of nutritional products aiming to provide maximum
nutrition with minimal cost. Justus Leibig’s meat extract was the most well-known of
such products but many others were also marketed around the mid-century (Finlay
1992).

In 1880 a professor of medicine in the US noted that the tendency of cows’ milk to
form a large and compact coagulum is a great source of inconvenience to invalids and
that various methods have been used to reduce size of the coagulated casein in the
stomach, including addition of various gums, starches, gelatine, lime water, as well as
the use of pepsin or rennet (Nunn 1880). He advised that the use of peptonised milk
is particularly useful for dyspeptic invalids and consumptives with irritable stomach
and bowels, and noted that other preparations such as junket, whey and koumiss
have been found beneficial.

16
Nonetheless, as late as 1893 there was no precise scientific data available for
estimating the quantity of food appropriate and sufficient for the various classes of
invalids. The only reliable guide was the dietaries or rations provided in various
hospitals, which seem to have been suitable and sufficient. A summary of these
dietaries from ten English hospitals show a very limited range of foods provided,
generally limited to bread, butter, meat, potatoes, porter or beer, milk, beef-tea, tea or
coffee or cocoa, gruel, rice or bread pudding. Similarly a list of 82 hospital recipes
suggested for invalids shows a quite limited range of items, of which 42 are for
beverages (including broths, soups and beef-tea) and virtually none for vegetable or
fruit dishes (Yeo 1893).


Modern (20th Century)
In the 20th century, knowledge of the physiology of convalescence became more
sophisticated, and four phases of convalescence after physical injury were recognised
(Moore 1958):
1) Injury – with loss of lean tissue and fat and loss of nitrogen from the body. The
patient is weak and listless, with little appetite or desire for food.
2) The turning point – when patients take renewed interest in their surroundings
and there is an increase in gastrointestinal function.
3) Strength – a long period of anabolism, muscle regrowth and wound healing,
which cannot proceed normally without adequate food intake.
4) Fat redeposition – the patient continues to gain weight for several more
months.
There was a particular emphasis on feeding that provided adequate energy and
protein intake in stages 3 and 4, to overcome the negative nitrogen balance that
occurs in the first two stages (Howard 1945).

Increasingly the preparation of food for invalids became one of the roles of nurses in
hospitals, and training in invalid cookery was part of the nursing curriculum. Nursing
journals commonly contained articles on the service of food to invalids, with an
emphasis on small dainty serves, the value of liquid foods and strictly following
physician orders for food (Irwell 1912, Sargent 1915, Fewell 1920a,b).

17
Invalid cooking also became part of the teaching in schools of cookery and domestic
science from the beginning of the 20th century. Examples of such publications include
Invalid Recipes published in the UK (Mann 1901), Sick Room Cookery and Advice on
Sick Nursing, published in Ireland (Ferguson 1903), Food and Cookery for the Sick and
Convalescent, published in the USA (Farmer 1904), and the Australian text Cookery for
Invalids (Schauer and Schauer 1912). They contain general advice that is found in
many similar books from this time (Williams 2019), including:

• Never consult a patient as to the menu

• Fat must be rigorously excluded from an invalid’s diet
• Extreme care should be taken to season food lightly, using no herbs and spices
• Only the best and freshest ingredients should be used, and everything
prepared with scrupulous cleanliness.

These books reflect the maintenance of a traditional set of invalid recipes into the
twentieth century. Attempts to reform them in keeping with new discoveries in
chemical analysis and physiology seem to have had little impact (Adelman 2018). In a
speech to the British Medical Association in 1889, Charles Jessop endeavoured to
show that beef-tea, had no value to the invalid. He cited medical literature and
physiological experiments to support his ideas, but noted that “Nurses, cooks and
patients all clamour for clear beef-tea” (Jessop 1889).

By the 1930s and 1940s, with the development of nutrition science and the discovery
of new vitamins, medicine was coming to a more scientific understanding of the
physiology of convalescence and the specific nutritional requirements of recovery
(Bull 1935, Woodruff 1940, Ivy and Grossman 1944, Keyes and Mickelsen 1944, Anon
1945b, Cuthbertson 1945).- There was increasing awareness of the potential problem
of malnutrition during convalescence with traditional dietary restrictions, and a
greater emphasis on adequate energy and protein intakes to assist recovery from
illness. In the 1950s the importance of adequate vitamin C and calcium was also
recognised in addition to the emphasis on reversing negative nitrogen balance
(Meikelejohn 1954, Moore 1958).

18
However while this understanding became the basis of diet planning manuals in
hospital settings (Chima 2007, Rynbergen 1963), cookery books for the general
public from this time continued to offer the same sort of culinary advice that could
have been found fifty years earlier. Getting Better – a handbook for convalescents,
published in London in 1943 still included traditional recipes for calf’s feet jelly, beef-
tea, sweetbreads and wine whey (Pim 1943). The same convalescent dishes could
also be found in a textbook on cooking for the sick and convalescent co-authored in
1951 by a Professor of Physiology and a cookery writer (Heaton and Mottram 1951).


Some specific foods
The evolution of advice about the foods suitable for convalescence can be considered
with a few examples.

Barley
Even in the times of Greek physicians barley was regarded as an ideal food for anyone
who was out of sorts. Because barley was understood to possess a temperament that
was cool and dry, a moist broth was seen as ideal for the treatment of those
recuperating from fever (Scully 1995). In Hippocratic writings, barley water was the
first item of food to be introduced after a fast (King 1996). The Romans made flour
from barley into a gruel (much used as a restorative) and a highly nutritious barley-
water (White 1996).

In his Canon of Medicine, the influential Arab physician Avincenna (980-1037AD) had
recommended barley water for the feverish and its use was depicted in Tacuinum
sanitatis, an Italian manuscript from the end of the fourteenth century, and described
as “Nutritious and easy to digest, it is given with favourable results to feverish
patients to slake their thirst; it alleviates coughs and cleanses the lungs” (Adamson
2004). The privileged place of barley and barley water continued in nineteenth and
twentieth century texts (Adair 1804, Williams 2018), presumably based on this
antiquarian advice.

19
Chicken
Chicken turns up very frequently in sick-dish recipes in the Middle Ages.
Aldobrandino of Sienna (a 13th century professor of medicine at Bologna) stated:
“You should know that chicks have a flesh that is more temperate, that
digests more easily and that engenders better blood, that gives more
strength, and is more closely aligned to human nature than domestic fowl.
For these reasons they are well eaten by those who have wasted, or whose
stomach is weak, or who are just recuperating from illness”(Aldobrandino
of Sienna 1911).

Of all the domestic meats, chicken enjoyed a reputation for possessing, with veal, the
most moderately moist and moderately warm qualities – those most closely
approximating those of healthy humans and hence categorised as ideal by physicians.
Scully suggests that the overwhelming preference for chicken, compared to other
meats, as the basis of a sick dish may also have been due to its universal availability
and low cost (Scully 1995).

Interestingly, in the highly elaborated humoural theory of food in traditional Chinese
medicine chicken is also regarded as a warming food. A woman after childbirth is
understood to be very weak because her “beneficial hotness” has become depleted
and she is advised to eat chicken every day (Pillsbury 1978).

Oysters
In ancient Greece and Rome oysters were regarded as delicacies and their physicians
approved their dietetic properties. Both Celsus and Pliny agreed that oysters are an
excellent tonic for the stomach, and several Greek physicians recommend them as
strengthening and useful in cases of dysentery (Andrews 1948). However, some
nineteenth century medical writers disagreed, especially in relation to cooked oysters
(Robertson 1835). Early twentieth century medical advice was still that oysters are
more readily digested when raw than when cooked, but owing to the possible danger
of typhoid infection it is better not to give them to patients who are convalescing from
acute disease (Saundby 1908).

20
Liquid foods
Before the advent of intravenous therapy, hospitals and home caregivers were often
confronted with the challenge of providing adequate oral fluids and nutrition to
invalids and the infirm. From as early as the seventeenth century until the turn of the
twentieth century pap boats – open or half-covered pear shaped vessels with a spout
at one end – were used to serve pap or panada to patients (Herrman and Sanchez
1997). Pap was bread boiled with milk and sugar; panada was more substantial,
usually a sieved liquid based on ground cooked chicken combined with bread and
broth. Liquefied food was used because it was believed to be the “most easily
digested, and in cases of severe illness [could] be entirely relied upon” (Weeks-Shaw
1892).

In 1885, a comprehensive article on feeding the sick with liquid food summarised the
limited scientific understanding of this topic in relation to invalid feeding (Roberts
1885). The author supports the use of milk, egg drinks and fortified gruels, but notes
that beef-tea and other meat decoctions should rank only as stimulants rather than
nutrients, despite widespread misapprehension about this among the public.

Nonetheless most modern books on convalescent cookery contain recipes for beef-
tea, sometimes with up to four different methods of production. Once regarded as
highly nourishing for patients, several of the authors note that it is best regarded as a
stimulant rather than a food (Beeton 1923, Butler 1930-5). Nonetheless a commercial
peptonised version (Beefine) was still being sold in 1945 and promoted as “proved
for invalids … invaluable for convalescents, affords relief to sufferers from indigestion
and nerves … tones up the system, enriches the blood, is appetising, delicious,
refreshing and wholesome” (Anon 1945a).

Alcohol
Debates about the suitability of alcoholic beverages were still unsettled in the
nineteenth century. In 1865 Dr John Beddoe noted that at St Bartholomew’s Hospital
every patient received two pints of beer daily, while this was not the case in Scottish
and Irish hospitals. Partly on moral grounds supporting temperance among the

21
working classes, he prefers to limit beer only to extra portions on medical order
(Beddoe 1865).

In his book Food in Health and Disease, Professor Burney Yeo noted that brandy and
whisky diluted with water are commonly prescribed in England while lighter wines
are more commonly used in Continental countries. His own preference is to allow
port wine or champagne during convalescence, or “if the patient prefers a good claret
or Burgundy at this time, there is no objection to his having the equivalent quantity of
these wines” (Yeo 1893).

Brandy and whiskey were advertised in medical journals in the early twentieth
century. The British Pharmacopoeia of 1907 noted the value of alcohol as a cardiac
stimulant and in acute fever it was recommended “as an admirable food because it
requires no digestion and is easily absorbed” (White 1920). However it was also
recognised as a depressant and its use in convalescent feeding became much more
limited (Guly 2011). Nonetheless in the 1950s writers still advised that “if an invalid
is used to consuming alcohol he may often be allowed it in his diet, despite its
untoward effects, because he would be miserable without it and the misery would
produce a more deleterious effect than the alcohol” (Heaton and Mottram 1951).


Conclusion
Table 1 summarises the historical information presented here to show the evolution
of ideas about convalescent feeding over several millennia. Many of the ideas in
twentieth century books had their origins in early Greek and Roman writing, and
many do not seem to have been based on clear scientific evidence.

Beyond 1950 very few cookbooks included a separate section on convalescent food
and the provision of dietary advice for invalids seems to have become more
medicalised, with the development of the dietetic allied health profession (Williams
2019). However, advice about eating while recovering from illness is still prevalent
today on the Internet and in magazines. While some seems founded on reasonable
scientific evidence, encouraging adequate protein, fruits and vegetables, vitamin C,

22
probiotics and hydration (Haris 2018), others still republish traditional ideas that
could have been found a century earlier (Zandonella-Stannard 2013, van Straten
2018, Sacred Medical Order Church of Hope. 2019).

Although some advice about light diets for postoperative recovery can still be found
in evidence-based clinical guides (Agency for Clinical Innovation 2011), the common
ideas of convalescent food that have survived over many centuries mostly
demonstrate the resilience of a culinary tradition that was based on personal
experience rather than scientific research.

23
 Table 1. Key beliefs about cooking for convalescents and invalids Era

Era Theories Recommendations Sources

Antiquity Humoural theories of Animal foods Medical texts

(3000BC-4th century) health Barley
No excessive seasoning
Middle Ages Humoural theories Sugar Aristocratic
(5th to 15th centuries) Arabic medicine Chicken cookbooks
Eggs
Almonds
Early Modern Digestibility of food Liquid foods Popular cookbooks
(16th – 18th centuries) Patient acceptance Some spices Medical advice
Tea
Fruit
Vegetarianism
Modern Scientific Artificially digested foods Professional cooks
(19th – 20th centuries) understanding of Meat extracts & beef-tea Nursing and
digestion and Adequate protein and medical
nutrition energy sources publications

24
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