4 9 THE THERAPEUTIC USE OF A HOSPITAL LIBRARY* ELIZABETH GREEN Librarian Barnes Hospital SIDNEY I. SCHWAB, M.D. Professor of Clinical Neurology and Neurologist to Barnes Hospital St. Louis, Missouri The broadening scope of the meaning of therapy may be seen from the many things that are used at the present time in further- ing the recovery of a patient in a hospital. The possibility of using a hospital library as a direct therapeutic agency is not particularly new. In practically every hospital of any size there has always been collections of books which were placed at the disposal of patients of all sorts. It is perhaps a somewhat new notion, however, to make a more definite and positively planned use of books, and it is with this idea in mind that we have planned this paper. It has been said by someone who, no doubt, had enjoyed a pleas- ant convalescence, that sickness should be regarded as an experience from which direct advantage might be obtained. Perhaps sickness might be thought of as an opportunity from which, under proper circumstances, the patient might obtain an increase in his personal- ity asset. A patient leaves a hospital with three possibilities before him as a result of his stay there. He may go out handicapped more seri- ously than when he entered; he may leave unchanged; or he may leave a more efficient individual than upon entrance. In all three in- stances therapy in its broader conception has something to offer quite apart from its application to the particular disease in question. It is to meet a phase of this broader therapeutic notion that hospi- tal libraries have found a place. That this place is not a very large or important one at the present time does not detract from its signifi- *Printed in August 1919 issue of The Hospital Social Service Quarterly. 2 The Therapeutic Use of a Hospital Library canoe nor does it exclude the use of books from the same kind of therapeutic analysis that would be directed to the more tangible cura- tive procedures. Whatever else may be said of sickness it is after all a very per- sonal thing and to each sick patient disease has a particular touch of ownership or possession. A sick person is quite a different thing from a disease entity, and it is to the sick man or woman that a therapeutic scheme must be mainly directed. The personality of a patient sticks out of the picture which the disease process overlays. Books play a varied part in the lives of people. To some, and per- haps the greater majority, there is little place to be given to litera- ture; little chance for its exercise and influence. To the few, how- ever, there is no more vitally directing influence. Of course the pur- pose of a hospital library is not to be confused with an analysis of literature as a proper expression of an experience with life or as an aspect of truth arising out of it, but rather as a means toward the restitution to the normal of a particular individual who may be handi- capped permanently or temporarily by sickness. Due to this he finds himself in a hospital separated from his usual surroundings and his usual activities. It is in this period of enforced leisure when mental activity of the usual kind is necessarily impossible that there is found the proper receptivity for the cultivation of an interest in reading, if none existed before, or of intensifying that which was already pres- ent. The long convalescent hours and uncomfortable periods when the disease is registering its presence by the emphasis on painful sensations, the periods when the future is obscured by contemplation of the present handicapping events furnish opportunity for the use of all kinds of extra medical efforts to mitigate the weight of the present distress. To pass the time pleasantly and quickly is surely a contribution to personal comfort and if reading does that then the place of a hospital library has made itself permanent. This is merely the general view and there has never been a lack of appreciation for the use of books or reading matter in this sense. It is, however, with the more precise application of books that we are here concerned ; rather with the attempt to find for books a more or less specific indi- cation in the treatment of disease and to write so to speak book pre- /&TO&H 01 . 7. 63 6L 8 T-i t: REMOTE SI' GfVt&S Elizabeth Green — Sidney I. Schwab, M.D. 3 scriptions in the same authentic way that is done in the general run of treatment given to patients in a hospital ward. It is obvious that the selection of books in a planned therapy cannot be directed with too much specific aim. The less rigid selec- tion happens to be, the more beneficial will the application be found. The classification of books must be based then not on literary value but on the purpose for which it is to be used. From the point of view of the patient, books as a whole may be divided into four groups. One group would be frankly selected with the idea of inter- esting the patient to such an extent that the long hours of conva- lescence or preparation might be gone through with as quickly as and as easily as possible. A second group might be based upon the capac- ity of a book to train the patient’s attention and concentration. The third group, and this is necessarily the. smallest, might be concerned with the attempt to cultivate in the patient some change or alteration of his point of view and to arouse in him a stimulus toward a fresh grip on the personal situation which confronts him, and which is represented by the symptoms which he presents. The fourth group would be frankly educational and instructive. The aim of this group would be to add something to the personal asset of the patient, some- thing that might aid him in his after-hospital life and to awaken in him, if possible, an appreciation and the liking for good literature. Of course, it is readily understood that nothing very ambitious can be hoped for in this sort of classification, especially in the last group ; but every now and then some bit of stimulus is given to a patient which later may be productive of unexpected and unhoped results. The selection of the book in any group depends upon a knowledge of the individual and the personal predilection of the selector — which in many instances would be the librarian of the hospital. Her own particular taste would largely govern the selection. Then, too, one might be influenced very largely by one’s own personal experi- ence. Looking back over one’s adventures in reading, there would readily come to mind books which have had a peculiar influence on the ways of thinking about things. Books to change people’s atti- 4 The Therapeutic Use of a Hospital Library tude to the problems of a day’s life and their influence is often not entirely as intangible as is commonly supposed. To illustrate — there is no doubt that the vogue of Kipling, some years ago, did have a marked influence on the development of many a youthful enthusiast. The crisp phrasing of expression, the easily appreciated appeal to an upstanding type of conduct, the simple notion of courage, candor, loyalty and humor are traceable in many a life to whom the early fascination of his stories has long since disappeared. The Rooseveltian literature carried many a boy, tem- porarily perhaps, over a difficult situation. The mysterious effect of an apt phrase influenced conduct in a way hardly to be measured at the present time. No lover of Conrad but would admit that his tales do not cease when the cover is closed, and to no honest reader will Lord Jim be remembered only as a story of adventure. The poems of Henley, especially in the hospital series, have a peculiarly definite influence on the sick patient awaiting the supreme test of courage for the thing that is before him. Even if perhaps there is a touch of the gruesome, particularly about the poems of the ward and operating room, there is here a touch of reality, the facing of the immediate thing and the adjustment to that thing which is by far the best mental preparation for going through any kind of hospital emer- gency. Stevenson might well be the pleasant companion of every invalid, of every dweller in a hospital, particularly so if his romantic struggle against tuberculosis be brought to his attention. These are mentioned merely as an illustration to point out that there is a chance for a very definite selection of books, aiming to implant in a patient’s mind some particular thing which he may at that moment lack or perhaps may arouse in him the incentive to develop the necessary attitude in regard to his own problem. There is no way by which the influence of books as indicated in this way can be measured. It is possible that the influence of reading even one’s favorite authors may be evanescent, particularly so in cases of the severely ill and in nervous patients, or to one to whom the stay in the hospital is a dreary and dull experience. It is more likely, however, that something remains behind — some small thera- peutic effect too subtle for analysis and often too intangible to record. Elizabeth Green — Sidney I. Schwab, M.D. 5 Such books as are planned to make the time pass more quickly are those that have the capacity of fixing the attention or claiming the interest of the patient by the passing story. Here again the selection is to be governed by a study of the individual, his capacity to appre- ciate a tale and its setting and his response to the narrative form of writing. Here we are on more secure ground, but fortunately there are very few to whom a story does not exercise its own influence. A taste for good literature is more wide spread than is commonly sup- posed, and it is not necessary to depart from what is acknowledged to be good literature even for one whose acquaintance with good books may have been slight. A certain standard of taste should be insisted upon in the hospital library, and no book should be prescribed that is not a good book. Books with a more strictly educational value in the narrow sense of the term as used in contrast to the others, are such as might awaken an interest in some subject dormant in a patient’s mind, or stimulate into a wide application some taste or experience already present. The application of this group is probably a narrow one, and is men- tioned merely as a possibility. In a hospital in which the over-turn of patients is so rapid as at the Barnes, it is impossible to dwell very much on the educational side of reading. Perhaps here even a taste might be awakened for the better things in books by even a short experience with good literature, or even the beginning of notions of future education may be brought about by a glimpse of training and application. This very briefly is an outline of the therapeutic possibilities of a hospital library to be used in the actual test of the ward. The Barnes Hospital library started a little more than four years ago, in response to a very urgent need, as our location, selected for quiet and fresh air, isolated us from library centers. Early in 1915, it became evident we were starving for reading matter, and unless we had a library of our own our resources for filling that need were too limited. To make a start we needed a collection of books, shelves on which to place them, and someone to supervise. These, demands were met by a loan of 75 books from the traveling library depart- ment of the St. Louis Public Library, extra bookshelves in the Rec- 6 The Therapeutic Use of a Hospital Library ord Room and the Record Department force to see that the books were properly issued. There is nothing so easy to acquire as books. Who has not gone through the experience some time in their lives, of finding all bookcases full, and books piling up on every available flat surface. When it became known that the Barnes Hospital was starting a library, there was an immediate response and the little collection grew until now it is limited by the shelving capacity to about 1,200 volumes, which are sufficient for our needs. Very often among the worn-out books are some that we value most and these we give to the Public Library and it in turn has them rebound in its bindery and sends them back to us as a loan. In this way we keep up the repair of our library and at the same time pro- long the lives of our most useful books, without cost to the hospital. It is important to place your library where it will be supervised intelligently, and where you can lock it up after hours. It is inter- esting to keep a record of the issue of books. Our monthly report shows how many volumes of fiction and non-fiction we have issued and to what type of reader; as an example, our last month’s report shows that we issued 247 volumes of fiction and 5 of non-fiction to ward patients, while we issued to janitors, non-fiction only. What at the first glance seems to be. merely statistical and of no impor- tance, sometimes puts you in touch with a very human need, which is of benefit to both the individual and the hospital. We try to keep in touch with all departments of work, and get books, where they are needed, on short loans from our local libraries. The Nursing Department for instance may need more copies of the History of Nursing, by Nutting and Dock. Word comes to us they will need Vol. 1 for two or three weeks for class work, can we borrow it on a short loan. The housekeeper finds a spot on a marble floor which does not respond to her efforts, and comes to our library for help. The laundry has a problem and the library is sought for advice. We issue books for two weeks, and in order to get them back promptly, a fine of two cents a day is charged for those overdue. This rule does not apply to patients, who for the most part are un- able to come to the library and are dependent on others to see that the books are returned. Elizabeth Green — Sidney I. Schwab, M.D. 7 In order to make the library available to bed patients, volunteer workers come at stated times, gather up a load of books in what was once a tea-cart (turned into a booktruck by the addition of a rail), by means of which some forty books may be wheeled to a patient’s bedside, offering a sufficient variety to suit most tastes. The social service this visit accomplishes is of real value, and the book is such a good excuse for approaching a patient. The assurance to the patient, that there is some interest beside a coldly scientific one, is given when a person other than a doctor or nurse, in stiffly starched uniform, comes to him with books, to see. if reading would not help to while away the tedium of a hospital experience. It stimulates the patient to know that his contentment and happiness are being con- sidered, and certainly the relation of trust and confidence established by caring for the homely things of every day life are of value to doctor, nurse and hospital, and therefore to the patient. It is easy and natural, once a trust in your interest is attained, to get at infor- mation that might seem intrusive, unless a mutual ground of under- standing had not been established. It is most interesting to see how a taste for reading may be developed. One of our workers tells of a man who met her approach with suspicion. She asked him if he liked to read and received a gruff reply. After assuring him there was no charge, and that he was under no obligation to read even if he took a book, she managed to leave one with him. When the next distribution day came, this same man brightened up when the worker came to him, took another book, and as the weeks went on read more and better things. Isn’t there possibly a social ser- vice through cultivating a taste for reading that will prove a pleasure and benefit to this man always, that may be laid to the door of our hospital library? New vistas are constantly opening in what your library can do for your hospital. It is a matter of more than passing interest to your doctor to have the right books given to his patients, and many and varied problems are presented to the librarian, for what is a wholesome literary diet for one patient, might be very unwhole- some for the next. If your doctors will work with you, much can be accomplished. 8 The Therapeutic Use of a Hospital Library Let us mention some diseases where book therapy is beneficial ; for instance, patients with Exophthalmic Goitre, who must not be excited owing to rapid hearts, and who are depressed and worried over their condition. These patients should have books that inter- est, keep their minds away from themselves, and yet are not suffi- ciently exciting to intensify their symptoms. Patients with frac- tures for the most part need all the absorbing books you can give them to while away the weary days while bones are knitting. Ortho- pedic cases can read anything that interests them, but care should be exercised that the patient on a Bradford frame has books chosen with regard to his position in bed. Such a patient should be given a light weight book with large print, for you can readily contribute to his fatigue if you give him a heavy one, and add the discomfort of a headache through eyestrain caused by the effect of small type on shiny paper. It is an excellent plan to have foreign languages represented in your library. Study the. nationality of the patients that come to your hospital and see that you have two or three books at least to offer the person who comes to you sick and without friends, and with practically no English. It means more than is generally appre- ciated to give a patient a book in his own tongue. How quickly it establishes confidence, for, through this homely act, the hospital expresses concern in his contentment and happiness. In such cases it seems to wipe away some of the loneliness of the situation and the friendly act often makes subsequent examinations and treatments, that through the lack of a mutual tongue are impossible to explain, accepted without question. A short time ago word came that one patient had exhausted our Yiddish collection, and a telephone message to the Public Library brought four books the next day. When the patient saw that her request had brought an immediate response, her face fairly radiated pleasure, for she had just been struggling with an English story. An annotated list called Five Hundred Books for Hospital Patients, by Margery Doud of the St. Louis Public Library, will soon be available. The value to the librarian of having a brief outline of subject matter assists enormously in selecting the book Elizabeth Green — Sidney I. Schwab, M.D. 9 most helpful to the patient who is receiving book therapy, and this list should prove of importance to all hospital libraries. There is another field for the hospital library, quite aside from the patients, that can not be overestimated in its social service, that is the working personnel of the hospital, the doctors, nurses, clerical force, cooks, janitors, etc., who directly or indirectly serve the patient. In this group you have every age, sort and condition, from the boy and girl who have just got their working papers, to the old man who runs an electric elevator. Everyone can come to the library in off time and select a book. Everyone has equal privileges. Everyone can have a book for two weeks and understand that it must be returned on the day it is due, or that the fine of two cents a day that helps us to get our books back, must be paid into the library. It is also known that if anyone wants to study, we will try to get books for that purpose. We advertised our library not long ago by a notice posted on the time-clock. At once there were two requests for books on special subjects. One man wanted elementary books on electricity, the other a history of the Congregational Church. The first man’s demands were easily met, but the second man’s thirst for knowledge had to be condensed to the size of a pamphlet published by one of our churches. The prompt response to his request estab- lished his relation and interest, and since then we have been able to provide him constantly with something to read when he has finished his day of mopping floors, and he has offered suggestions for certain additions to our collection which were very welcome. This same man also became the channel of providing a patient with a textbook. This patient, a young man, was with us a number of weeks and here was the leisure for studying geometry, and our janitor discovered his need and saw that it was supplied. To our amazement the first request from the laundry came from a young girl who wanted Fairy Tales. After all, it is natural to want to get away from the grind of a day’s work, and what could ca'rry you farther afield from laundry machinery, soapsuds and starch than Fairy Tales. We found that this Fairy Tale craving was not confine^fo our first young friend, and there has been a constant demand^ ever since. We now have some dozen volumes on our shelves, and there are always several in circulation. 10 The Therapeutic Use of a Hospital Library In the early days of our library when it was very small, there were two 14-year old boys employed as pages in the out-patient department, who proved very active readers. These boys were so anxious to read that they would come to the library and help paste in pockets, in order to put the new books into circulation. They felt the library was theirs, and as new pages came they were brought in, introduced and provided with stories. In time these boys took jobs elsewhere, but I was lucky enough to get a glimpse of how truly one boy had enjoyed the library, when he came to call one Saturday afternoon three years later. As we looked over the books together he pointed out those he had read and told me with great pride, that he now used the Public Library. After he had gone it occurred to me he might like some printed lists of good books, so I sent them with a note. In reply he expressed his delight in having them and said, “I have read very few of those listed, and I sure will read the balance.” Hasn’t our little library done something for that boy that will be a help always, in giving him the chance to browse among good books and create a taste for reading? We believe that it has and we also believe that having a library in a hospital, which of neces- sity is a place of military discipline, rank and grade, is distinctly worth while, for it gives one common meeting-ground in interest for all grades, provides one place where there are equal benefits, and through its democratic possibilities brings the esprit de corps that is so necessary.