Hospital Libraries in the United States: Historical Antecedents BY PATRICIA A. WOLFGRAM, Librarian Saginaw Osteopathic Hospital 515 North Michigan Avenue Saginaw, Michigan 48602

ABSTRACT pital, founded in 1847, through a sum appropriated by trustees of the hospital [4]. Mt. Sinai Hospital The hospital health sciences library of today that Library was founded in 1883 through a personal reaches out to the world knowledge base through elec- tronic networks bears little resemblance to its forebears. contribution from Dr. Alfred Meyer [5]. Johns Yet to understand the challenges and future directions of Hopkins Hospital had one of the largest hospital the hospital library it is necessary to examine how it libraries, with more than 14,000 volumes. began and how it has evolved in more than 200 years. This During this era, the growth of medical publica- paper identifies five developmental periods in which As as John major strides were made: the colonial years through the tions was already apparent. early 1881, 19th century; World War I to the Great Depression; Shaw Billings warned of conditions to be expected World War II and the 1950s; the 1960s-the Great a century hence, should the steadily increasing Society and the Medical Library Assistance Act; and the production of medical books continue [6]. Billings 1 970s, an era of growth for hospital libraries. noted that there were approximately 850 medical periodicals published each year, with almost 20,000 substantive articles [7]. THE HOSPITAL LIBRARY of today has roots By the end of the 19th century, many of the extending from Colonial America. Its growth has earlier medical collections were evolving into out- paralleled the social transformation of medicine as standing libraries as the hospitals that they served identified by Harvard sociologist Paul Starr [1]. grew into teaching institutions affiliated with medi- Five major developmental periods are discussed: cal schools. Medical societies, among them the (1) the early years when hospital libraries were Medical Chirurgical Society of Maryland and the developed mainly through the efforts of local physi- Boston Medical Library, also supported large cians; (2) World War I through the Great Depres- libraries for their members. This period was one of sion; (3) World War II and the 1950s; (4) the informal beginnings, with small privately sup- 1960s-the Great Society and the Medical Library ported libraries that began to grow as both the Assistance Act; and (5) the 1 970s, an era of growth medical profession and its institutions responded to for hospital libraries. the growth of the country. According to Doe and Marshall, there were some twenty-four medical COLONIAL AMERICA THROUGH THE 19TH CENTURY libraries in hospitals and twenty-four libraries in medical colleges in the United States when the The earliest medical libraries in America were Medical Library Association (MLA) was founded outgrowths of private collections. Physicians often in 1898 [8]. pooled their resources to develop libraries for their Unfortunately, for these years there is a lack of hospitals. The first medical library, in the Pennsyl- survey data on hospital libraries in the United vania Hospital, Philadelphia, was founded in 1762 States, what they included in their collections, and through contacts made by Benjamin Franklin. By the number of trained librarians who administered 1790, it published the first catalog of medical them. It was during this period that the stage was library holdings, with 528 titles listed [2]. A collec- set for development of the modern hospital we tion founded by John Winthrop for New York know today. Hospital was later transferred and formed the library of the New York Academy of Medicine, WORLD WAR I THROUGH which by 1898 had over 23,000 volumes [3]. THE GREAT DEPRESSION Other outstanding older libraries include the In early America, hospitals were principally Treadwell Library of Massachusetts General Hos- institutions to which the sick and the destitute 32 Bull. Med. Libr. Assoc. 73(1) January 1985 HOSPITAL LIBRARIES IN THE UNITED STATES: HISTORICAL ANTECEDENTS came only with serious illnesses and often only to Frankenberger reported to the American College die. In this pre-Flexnerian era there was relatively of Surgeons that the purpose of the medical library little in the way of a hospital component to medical was to provide house staff and interns with a basic education, and except in a few great centers there working collection of the latest authoritative text- was little that hospitals could offer in the way of books and well-recognized reference works in the scientific medicine. One of these centers, the pre- various branches of medicine. He envisioned cursor to the Mayo Clinic, hired a librarian as early library service as well as collection development, as 1907 to meet the needs of specialty training and and he believed that the librarian could render to "organize a library to do editorial work in great assistance by compiling references, locating connection with the publication of papers" [9]. The specific articles, and scanning the contents of jour- Flexner Report of 1910, although directed toward nals for current information as they were received medical education, led to the development of full- [12]. time, hospital-based clinical departments affiliated In 1932 the American College of Surgeons pub- with medical schools. Hospital accreditation began lished its first list of books recommended for use in about this time, when the American College of the hospital library. Its Manual of Hospital Stan- Surgeons issued its Hospital Standardization Pro- dardization, published in 1940, includes a mini- gram in 1918 to improve hospital care. Thus, as mum standard for hospital libraries that covers hospitals assumed greater roles in patient care and resources, housing, personnel, extension facilities, in education, the inadequacy of private collections and a library committee. Although the standards became apparent. With the development of hospi- call for "the supervision of a qualified librarian," tal-based internships and residencies, libraries the sentence which follows-"She shall act as grew to meet their needs. custodian of its contents"-indicates a lack of understanding of the role of a librarian or the Services to Patients qualifications required [13]. An important development during this period The first formal gathering of members of the was the growth of library services to patients. As American Hospital Association (AHA) and affil- early as 1904 McLean Hospital (Waverly, Massa- iated groups interested in hospital libraries was chusetts), a private mental hospital, developed a held in Philadelphia in September 1934. At this patient library under a trained librarian. Massa- meeting the importance of the hospital library in chusetts General Hospital (MGH) was also one of patient care was stressed. In September 1936 when the earliest general hospitals to have a patient the AHA met in Cleveland, the Library Committee library with regular book service. The McLean and issued its Quarterly Book List. In the same year the MGH examples served as impetus for Iowa State to American College of Surgeons recognized the hos- authorize appointment of a supervisor of state pital library movement and at its Philadelphia institutional libraries [10]. The American Library meeting sponsored a formal roundtable discussion Association (ALA) issued two publications in of hospital libraries, led by Perrie Jones [14]. 1913: A Manual for Institution Libraries (C. E. One of the first formal medical librarianship Scott) and A Thousand Books for the Hospital programs, a course in hospital librarianship, was Library (E. K. Jones). developed in 1937. The University of Minnesota World War I brought development of patient Division of Library Instruction organized a lecture libraries in military hospitals. By June 1919 there course that included six weeks' internship in an were 145 librarians and six supervisors in the ALA approved hospital. Lecture topics included selec- War Hospital Service in America and 121 orga- tion of books for patients and medical reference as nized patient libraries in France. Having demon- well as hospital and medical library administration strated the value of books for recreation, education, [15]. and therapy in hospitals, librarians paved the way World War I was followed by a ten-year period for later development of hospital libraries, includ- of prosperity in America before the onset of the ing standardized library service in Veterans Great Depression that lasted until mobilization for Administration hospitals [11]. World War II. This was a period of retrenchment for the medical profession and hospitals as the nation attempted to cope with problems of unem- Early Development ofStandards ployment and feeding the population. Federal sup- It was during this period that standards for port of bibliographic services dwindled. The Index hospital libraries began to be formed. In 1931, Medicus, 1st series, which had been published Bull. Med. Libr. Assoc. 73(1) January 1985 33 PATRICIA A. WOLFGRAM continuously since 1879, was replaced in 1927 by Development ofStandards-Joint Commission the Quarterly Cumulative Index Medicus, pub- on Accreditation ofHospitals lished by the American Medical Association. It By 1952, with the cost and scope of the hospital was not until after World War II that hospital accreditation program outgrowing the administra- libraries experienced a great period of growth. tive capability of any one organization, the Joint Commission on Accreditation of Hospitals WORLD WAR II AND THE POSTWAR ERA (JCAH) was established. Initially it had represen- OF THE 1950s tation from the American College of Physicians, World War II proved unequivocally that the American College of Surgeons, American Hospital and practice of medicine was a team effort and that Association, American Medical Association, medicine had roots in sciences other than biology. the Canadian Medical Association (which later Johnson reflected: "We were confronted with a new withdrew). In December 1952, the Hospital Stan- orientation in medical practice, in medical research dardization Program of the American College of and in medical administration. The greatest impact Surgeons was officially conveyed to the JCAH. In of this change fell on the institution where the three 1953 the JCAH published its first set of standards, met: the hospital" [16]. Following World War II, which included the medical library as desirable, developments in research, education, and technol- but not an essential requirement for accreditation. ogy demonstrated that great advances could be Three facts became apparent: (1) ACS's "qualified achieved when massive research and development librarian" had become JCAH's "competent librar- funds were applied to predetermined objectives. As ian," although criteria for judging competency were lacking; (2) library use was the physician's a result, the production of information burgeoned, especially in medicine and the biological and physi- prerogative; and (3) no provision was made for cal sciences [17]. service to other hospital staff members. Three years later JCAH published a revision of its stan- dards in which the medical library became an Bibliographic Control essential service; however, reference to the librar- During this period, bibliographic control of pub- ian, formerly "qualified" or "competent," was now lications in the sciences became a problem. The deleted [20]. Quarterly Cumulative Index Medicus was now In 1953, the Hospital Libraries Division of ALA three years behind, and the National Library of issued Hospital Libraries: Objectives and Stan- Medicine began publication of the Current List of dards, a nineteen-page publication based on stan- Medical Literature. The computer was not yet dards developed in 1937 by Jones. The publication ready to be applied to production of the great represented the joint effort of committees of three abstracting and indexing services. Hospital librar- library associations: MLA, ALA and Special ians, aware of the need for ready access to current Libraries Association (SLA). Arranged in three literature of the health sciences, initiated national parts (patients' library, hospital medical library, and local efforts to produce their own indexes. and school of nursing library) the standards cov- In 1945, the American Hospital Association ered objectives, staffing, collection, budget, loca- published the first issue of its Index to Hospital tion, and equipment for each type. Each of the Literature. This manually produced index covered three parts carried not only the endorsement of the administrative aspects of hospitals and brought a library associations but also that of other appropri- large body of publications important to hospitals ate organizations: the American College of Sur- under control. geons and the AHA for the first two parts, and the Among local efforts in bibliographic control was National League for Nursing for the third [21]. a cooperative effort of seven hospital libraries in the Detroit area. Accessing the literature had become Professional Education so difficult that librarians were individually index- In 1959 the AHA pioneered hospital librarian ing limited numbers of journals for their own training by coordinating yearly institutes for new hospital staff. In 1953, the Detroit librarians personnel. From 1959 through 1968, the AHA pooled their efforts to index seventy-five much- conducted seven week-long institutes in different used titles [ 18]. At the same time, three California parts of the country. The Catholic Hospital Asso- hospital librarians began to compile an index to ciation, Veterans Administration, and MLA also nursing literature that is still being issued by Glen- provided continuing education for their members. dale Adventist Medical Center today [19]. The Hospital Library Section of MLA was founded 34 Bull. Med. Libr. Assoc. 73(1) January 1985 HOSPITAL LIBRARIES IN THE UNITED STATES: HISTORICAL ANTECEDENTS in 1948 to give hospital librarians a forum for Library Services in Health Care Institutions was addressing their educational interests and other endorsed by the AHA. Emphasis had changed concerns. from "libraries" to "library service"; a unified library serving the entire hospital population was 1960s: THE GREAT SOCIETY AND PASSAGE OF encouraged; quantitative criteria were eliminated; THE MEDICAL LIBRARY ASSISTANCE ACT elements common to both patients' libraries and Medical Library Assistance Act health sciences libraries were combined into a single section on "Management of Library Ser- Two studies during this period were of impor- vices"; and "hospitals" became "health care insti- tance to hospital library development. The first was tutions." The idea introduced in the 1953 state- the Surgeon General's Conference on Health Com- ment that a qualified, competent professional munications, held in 1962, whose recommendations librarian was the key to good library service was were incorporated into the Medical Library Assis- reinforced in the 1970 edition. Both "The Health tance Act. The second was the Report of the Science Library" and "The Patients' Library" sec- President's Commission on Heart Disease, Cancer, tions covered objectives, services, collections, space, and Stroke, issued in 1965, that documented the and equipment [24]. importance of medical libraries to the national In 1967 the Joint Commission established the health effort. The report urged authorization for an Medical Library Advisory Committee-three phy- extramural support program under the direction of sicians, one hospital administrator, and five librar- the National Library of Medicine (NLM). This ians-to rewrite the library standards. The stan- program would remedy past neglect and encourage dards, published in 1971, outlined three areas of expansion in new directions through training, service (reference, document delivery, and audio- research, and a national medical library network visuals), required an adequate and available basic formed from existing resources and patterns of collection, and recommended that hospitals provid- cooperation. The Medical Library Assistance Act ing extensive library service should employ at least of 1965, which emerged from the Commission's one full-time librarian. Librarians were disap- work, provided a variety of activities for improving pointed with the weaknesses and gaps which con- the transmission of information for patient care tinued from earlier versions [25]. In addition, few (221. The act's two major goals were: (1) to kid JCAH survey teams showed interest in reviewing health sciences libraries in developing services and the hospital library. resources that respond more effectively to uger The AHA continued its support of hospital needs, and (2) to promote a national system of libraries during the 1 960s. In 1962 the AHA regional health sciences libraries in order to equal- initiated the first national survey of hospital ize access for all health professionals. The act libraries that provided quantitative data on profes- authorized NLM to provide funds to accomplish sional libraries in approximately 59% of acute- these goals through grants to health sciences care, non-federal general hospitals [26]. As a mem- libraries [23]. ber of the Joint Commission, the AHA supported Eleven regions were established around strong its accreditation program rather than developing existing libraries that would serve as resource independent standards. In 1969, however, it pub- libraries. Although the regions were coordinated on lished the Statement on Role ofthe Health Science a national level, each had the freedom to imple- Library in the Hospital. "Service to all" was ment its own programs to serve local needs. One underscored and libraries were urged to participate element they had in common was their reliance on in library systems and communications networks hospital libraries and hospital librarians to act as [27]. The shift in emphasis from resource building informed intermediaries between health practition- to service became evident. ers and sources of information. Hospital Library Standards: Joint Commission Core Lists ofBooks and Journals and Other Organizations Although various organizations developed rec- In the mid-1960s, the Association of Hospital ommended lists of collections as early as 1913, the and Institution Libraries (AHIL) appointed a Brandon Selected List of Books for the Small Hospital Library Standards Committee, with rep- Medical Library, which first appeared in 1965, is resentation from ALA, MLA, SLA and related preeminent today. Another widely used list was library and health care agencies, to revise the 1953 Stearns' A Core Medical Libraryfor Practitioners standards. In 1970, the resulting Standards for in Community Hospitals. The Core was compre- Bull. Med. Libr. Assoc. 73(1) January 1985 35 PATRICIA A. WOLFGRAM hensive, with current texts and journals appropri- Expanded Rolesfor Hospital Libraries ate to patient care [28]. In 1970, Stearns and Specialized services and new technologies were Ratcliff published a list for all health sciences initiated in the 1 970s as hospital library roles began based on a survey of physicians and allied health to expand. In 1970, the Carnegie Commission professionals [29]. conducted a study of professional health manpower shortages within the context of geographic distribu- 1970s: ERA OF GROWTH FOR HOSPITAL LIBRARIES tion and education facilities. The study proposed that training and continuing education centers be Increased production of information that led to established in hospitals serving communities with- specialization in the medical sciences continued out a university health sciences center. These Area during the 1970s. Other issues in this period Health Education Centers led to an increased included rising costs, availability and quality of demand for library services. medical care, and the diversification of health care In response to needs of hospitals that are unable delivery (e.g., ambulatory care, hospital-based to maintain even a part-time professional librarian, physicians). Yast warned that the library's "very the Cleveland Health Sciences Library (CHSL) existence will depend on its being flexible enough developed the circuit rider librarian concept in and resilient enough to adapt positively and cre- 1973 [34]. This was one of many consortia atively to the inevitable changes in its parent approaches initiated in the 1 970s. institution" [30]. Recognition of the library's potential role in the hospital's information gathering and decision-mak- Standards: ALA, Joint Commission, and ing system resulted in the development of new Osteopathic Hospitals services tailored to specific user needs. The Univer- Until 1970 ALA had separate standards for the sity of Missouri-Kansas City (UMKC) School of patients' library, the hospital medical library, and Medicine requested funds from NLM "to plan and the school of nursing library. The development of evaluate a program to meet the biomedical commu- consortia for shared services, budget constraints, nication needs of ... health care team members in and the growing interdisciplinary nature of health a representative general hospital." Thus in 1971 care information contributed to ALA's recommen- the first clinical medical librarian joined the dation for a single set of standards for both health UMKC medical library staff [35]. A clinical sciences and patient libraries [31]. librarian project followed in 1974 at the University In 1973, MLA was asked by the Joint Commis- of Connecticut Health Center and Hartford Hospi- sion for recommendations on revision of the 1971 tal, directed by Gertrude Lamb. Within two years standards. MLA's revised standards were approved the concept was accepted as contributing to patient by the Joint Commission Board and published in care and educational activities [36]. the February 1978 edition of the Accreditation Another new service, reported in 1976 by Har- Manual for Hospitals. For the first time, library grave, involved attaching medical articles to a services were defined to meet the diverse needs of patient's chart, or Literature Attached To CHarts "the medical and hospital staffs." This view was (LATCH). At North Memorial Center, Minnea- also supported in the 1975 version of the AHA's polis, LATCH brought selected articles relating to statement Health Science Libraries in Hospitals a patient's medical condition to the nursing station, [32]. where all members of the patient care team had An innovative approach to standards for hospital direct access to it. The service was unique in libraries was proposed by the Academy of Osteo- making pertinent medical literature available at its pathic Directors of Medical Education. This group primary point of use-the patient's bedside [37]. wrote minimal requirements covering personnel, Expanded services to patients and the commu- space, classification and organization, utilization nity were also evident. In 1976 Fink, at Mount tools, textbooks, discard program, periodicals, and Auburn Hospital in Cambridge, met with public hours for libraries in osteopathic hospitals and hospital librarians and proposed development approved for intern or resident training. Most of a Community Health Information Network categories listed both a recommended and required (CHIN). This project was intended to increase minimum. The Academy recommendations were community health information by providing the adopted in 1971 by the American Osteopathic general public with access to health-related litera- Association [33]. ture. One of CHIN's first priorities was creation of

36 Bull. Med. Libr. Assoc. 73(1) January 1985 HOSPITAL LIBRARIES IN THE UNITED STATES: HISTORICAL ANTECEDENTS an interlibrary loan system for public library access professional education; bibliographic control; and to medical library resources [38]. involvement in planning at local, regional, and During the 1970s, hospital libraries kept pace national levels. Selected landmarks of the past have with their medical school counterparts through the been highlighted. These are the foundations upon use of new technologies. These included: three which we build. They provide us with the historical Washington, D.C., hospitals (VA, Washington context for understanding the future directions of Hospital Medical Center and Walter Reed General health care in this country. The remaining papers Hospital) among the first twenty-five MEDLINE in this symposium focus on the future of hospital users (1971); Riverside Methodist Hospital, libraries and librarians. Columbus, the first hospital library member of OCLC (1974); Michael Reese Hospital and Medi- cal Center, Chicago, one of the first to purchase a REFERENCES microcomputer (1976) and to develop computer- 1. Starr P. The social transformation of American assisted software (1977); and Glendale Adventist medicine. New York: Basic Books, 1982. Medical Center's installation of the Avitar Inte- 2. Thompson KS. America's oldest medical library: the grated Library System (1983). Pennsylvania Hospital. Bull Med Libr Assoc 1956 Oct;44(4):428-30. 3. Culp RW. The Mount Sinai Hospital Library, 1883 Professional Activities to 1970. Bull Med Libr Assoc 1972 July; 60(3):471-80. By the late 1 970s, hospital librarians were active 4. Myers GW. Medical libraries in hospitals. Med Libr at both the regional and national level. "The emer- and Hist J 1905 Oct;3(4):282-7. gence of hospital librarians as a creative and pro- 5. Culp RW. The Mount Sinai Library, pp. 471-80. ductive group of practitioners with professional 6. Rogers FB. Selected papers on John Shaw Billings. Chicago: Medical Library Association, 1965: strivings and close relationships with their clientele 128. represented a pool of talent which had already 7. Crawford S. Introduction. In: Cumulated index begun to make its mark" [39]. Johnson became the medicus, v.1, 1960. Chicago: American Medical first hospital librarian to serve as president of the Association, 1961. 8. Doe J, Marshall ML. Handbook of medical library Medical Library Association (1975/76). practice. 2d ed. Chicago: American Library Asso- Hospital libraries were represented on most of ciation, 1956. the governing boards of the Regional Medical 9. Wilson LB. A woman pioneer in a new profession, Libraries. In January 1978, eleven hospital librar- medical editing. Mayo Alum 1982 April;20-3. ians met at NLM to discuss the needs of hospital 10. Jones EK. Hospital libraries. Chicago: American Library Association, 1939. libraries and relations with NLM. Topics included 11. Ibid., p. 131. NLM online services, expanding databases, SER- 12. Frankenberger C. A suggested hospital medical LINE and other locator tools, funding, federal library. Bull Am Coll Surg 1932 June;16:30-44. support for interlibrary loans, copyright, training 13. Yast H. Standards for library service in institutions: B. In the health care setting. Libr Trends 1972 for health librarians, grants for library consortia, Oct;21 (2):267-85. and audiovisual needs. The meeting, which pro- 14. Kamman GR. Future aims of the hospital library. duced twenty recommendations, was an important Minn Med 1938 Aug;21(8):559-61. step in identifying the roles and needs of the 15. Jones EK. Hospital libraries, p. 154. and in the skills 16. Johnson BC. IFLA, libraries in hospitals sub-section: hospital library recognizing the integrated hospital library. Int Libr Rev required of the hospital librarian [40]. 1969;1:53-9. 17. Langner MC. User and user services in science libraries: 1945-65. Libr Trends 1974 July; DISCUSSION 21(l):7-30. From the earliest noncirculating collections of 18. Anderson FJ. The Detroit experiment in cooperative indexing. Bull Med Libr Assoc 1955 Apr; books for physicians to information centers serving 43(2):285-7. all health care professionals, hospital libraries have 19. Personal communication 9/5/84: Eugenie Prime. evolved to meet the changing needs of the health Glendale Adventist Medical Center; Glendale, care professions. This paper has traced the follow- Calif. historical antecedents: broadened scope of col- 20. Yast H. Standards for library service, p. 272. ing 21. Ibid., p. 268. lections; improved services through the use of new 22. Darling L. Changes in information delivery since technology; cooperative programs for delivery of 1960 in health sciences libraries. Libr Trends 1974 information; standards for service and collections; Jan;23(l ):3 1-62.

Bull. Med. Libr. Assoc. 73(1) January 1985 37 PATRICIA A. WOLFGRAM

23. Ibid., p. 45. 34. Feuer S. The circuit-rider librarian. Bull Med Libr 24. Yast H. Standards for library service, p. 268. Assoc 1977 July;65(3):349-53. 25. Ibid., p. 273. 35. Algermissen V. Biomedical librarians in a patient 26. Giesler RH, Yast HT. A survey of current hospital care setting at the University of Missouri-Kansas library resources. Hospitals, JAHA 1964 June School of Medicine. Bull Med Libr Assoc 1974 16;38:55-7. Oct;62(4):354-8. 27. Yast H. Standards for library service, p. 276. 36. Lamb G, et al. "And now, 'clinical librarians' on 28. Feeney MM. The regional medical libraries-region rounds." Hartford Hosp Bull 1975 June;30(2):77- I. NLM News 1976 May;31(5):3-5. 86. 29. Stearns NS, Ratcliff WW. An integrated health- 37. Hargrave S. LATCH-it works. Hosp Libr 1976 science core library for physicians, nurses and Sep;1:4-5. allied health practitioners in community hospitals. 38. Anonymous. The community health information net- New Eng J Med 1970 Dec 31;282(27):1489-98. work. Hosp Libr 1978 May;3(5):1-3. 30. Yast H. Standards for library service, p. 281. 39. Meyerhoff E. Foundations of medical librarianship. 31. Bowe MA. The medical librarian and the patients' Bull Med Libr Assoc 1977 Oct;65(4):409-18. library: what is her role? Hosp Libr 1978 40. Hospital librarians. NLM staff discuss mutual inter- May;3(5):4-5. ests. NLM News 1978 Feb;33(2):4-5. 32. Foster EC. Library development and the Joint Com- mission on Accreditation of Hospitals standards. Bull Med Libr Assoc 1979 Apr;67(2):226-31. Received September 1984; accepted October 33. Yast H. Standards for library service, p. 276. 1984.

38 Bull. Med. Libr. Assoc. 73(1) January 1985