IN REPLYING ADDRESS THE SURGEON GENERAL U.S. PUBLIC HEALTH SERVICE AND REFER TO ys Mt Abe Air £. preg at “TREASURY DEPARTMENT PUBLIC HEALTH SERVICE WASHINGTON November 5, 1935. PERSONAL AND CONFIDENTIAL Medical Officer in Charge, United States Narcotic Farn, Lexington, Kentucky. Sirs: I have been intending to write you a personal note concerning certain features of your institution observed during my recent visit. At the outset, I hope you will not take my comments in a sense of criticism of your administra- tion, since they are made with the object of being helpful in gathering together various loose ends of the threads of organization, and also to classify some of the objectives associated with the inception and development of the plant at Lexington. In the original scheme of developing Lexington, it was contemplated that the grouping of inmates would take on the flavor of segregating them in lots of 30 to 40 persons, based woon such factors in common as race, personality, cul- tural background, general manners, and behavior attitudes. Such a grouping is by no means new in institutional practice, but is a departure from general prison practice of treating, whether domiciliary or otherwise, a group of persons in mass. The general principle has been advocated and practiced in connection with the management of institutions for juvenile delinquents. However, in a public institution such as Lexing- ton, the nearest approach to individual care is by segregation in small groups. One gathers, after going about your institution, that there is a lack of group segregation and individual, ward. supervision. The units that are desigmed with sleeping, day ~and utility facilities, are not, in themselves, operated as individual units in the scheme as a whole, but with freer accessibility than would seem desirable. ‘In fact, one gathers the impression that there is a mass handling of your popula- tion, instead of small group administration. ~ 2 It is conceivable that some scheme or method of grading the various wards or units of your institution in terms of graduated amenities and the segregation of your population in groups in keeping therewith, would lend itself to more individual supervision and give those in immediate charge of such groups a more intimate lmowledge of each individual, and tend thereby to stem any mass group action on the part of inmates, isolating or segregating those who would give the most trouble or difficulty, in terms of maximum supervision. This method of meeting the problems of management in institutional population is not theoretical, but is kmown to be practical from actual experience. In planning Lexington, it was anticipated that the sleeping quarters in what is known locally as the Prolonged Treatment Units, would not be occupied during the day, since , me they were designed for ambulatory patients solely. If it is Gv necessary for persons to be in bed during the day, who are oo housed in those domiciliary units or Prolonged Treatment wards,) — he then such patients have no place in such wards or units, but . wa belong either in the hospital or the Reception Service, One gains the impression that there has been some reluctance or misunderstanding concerning the uses of the Reception Service and Hospital Units (W. H. and BE. H. respect- ively). The Reception Service Unit (W. H.) has three floors which can be used interchangeably for observation, classifica- tion and special stabilization of all new admissions. It was not contemplated that there should be any fixed time for resi- dence in the Reception Service, but that new patients or new inmates would remain in that Service sufficiently long to determine the type of individual and to carry on such studies as would involve the administration or discontinuance of ad- ministration, or detoxication of addicts. It would not be feasible or desirable for persons on drugs to mingle with those who are being taken off drugs, or for those entirely off drugs to mingle with those being taken off. For this reason, the Reception Service was divided into three units. It was somewhat disconcerting to find that one of b bo chayes the functions which the Reception Service was designed to per- form was being ignored by substituting a unit of the Hospital Section, or the E. H. wing. Woreover, it was contemplated that the Reception Service would be the place where investiga- tive work in connection with the withdrawal phase of drug addiction would be conducted and carried on, and that the man who had supervision over that particular phase of investigative work would administer and supervise the reception service under the direction of the Clinical Director. an | G -3- The Hospital Units are designed primarily for. medical and infirm cases, for the surgical cases and for the . 4 | f tuberculous. I do not believe from an administrative stand- % % ~“3* point. that the utilization of one floor of the hospital . building #11 prove satisfactory when you consider the scheme of classification as a whole. Reference may be made to the renaining parts of your institution, more especially the cell-block unit and hu aed the west and east wings B, G, and D. The cell-block unit | The. was not designed as punishment cells in the same sense as a $e A £ Os Re "brig, such as one finds in a prison institution. It was. designed for the intractable, difficult type of prisoner who could not or would not appreciate the amenities of other parts of the institution. This unit, you will ob- serve, provides for six sub-classifications, two on each floor. The windows of the top floor are very much higher than those on the lower floors, which does not allow the individual much freedom of outside view. These units can be used in terms of gradation, the upper floor representing the lowest in the group. The Prolonged Treatment units are wings having a total of 18 units, which, if used in terms of gradations, would offer advantages for classification and grouping of inmates in accordance with their ability to appreciate the advantages to which such units may lend themselves. The W. T. unit was added with four sections, with the idea that the better type of inmate, or those who are most amenable to treat- ment, would be housed. This gives you a total of 28 sub- classifications, and since there are many and diversified | types of persons addicted to drugs, you should have opportunity to meet the demands of a wide variety of classifications or groupings by separating your population into groups which have certain characteristics in common. Obviously, it would not be practicable to make such fine graduations in terms of 28 sepa- rate and distinct units, but it is possible to sub-divide that class which demands maximum supervision, that class which requires medium or moderate supervision, and that class which requires minimum supervision. It is possible that certain units might have a little better type of furniture, a radid, —-" - might be privileged to have greater access to literature and reading material, to stay up later in the evening, and other features which would make a distinction between units. I do not mean by this that there should be 28 different types of wards, but with the physical plan you could divide them into groups with the above objectives in mind. It is apparent that the custodial classes of classification, in terms of maximam custody, moderate custody, and minintmm custody mst \F VS & ~4- G and should be given consideration, but the plan which was had in mind camouflages this situation to a much better advantage and puts the whole administration on a much sounder medical approach. When we prepared the first anmual budget for the opening and operation of the institution, and prescribed the Moot Ard qualifications for guard attendants, it was anticinated that g those in charge of wards or units of the institution would have a background of medical nursing and a different approach an than that which you would obtain by employing lay guards only. It was anticipated, therefore, that the guard attendants would have charge of the various units concerned with the more pro- longed care and treatment, suoplemented, of course, by the assistance and assignment of attendants, who would possess less technical knowledge; furthermore, that guard attendants would not be assigned to duty where a female nurse was in charge of the supervision of a unit, but that she would have ae ley b the lower paid attendants, who possessed less technical know- ely edge and skill in the nursing field. I gathered the impression from my visit that the 30 guard attendants are being used to supplement the nursing Service, and not as was originally con- templated. I think the wards or units that are under the immediate supervision of attendants reflect the knowledge of such low-paid employees. I doubt very much if green and in- experienced attendants can satisfactorily supervise a unit concerned with the more prolonged care of inmates, and that their services would be better utilized to supplement those of nurses and of guard attendants, the two latter groups assuming the more responsible ward or unit supervisory posi- tions. Aside from your classification of minimum, moderate and maximum custody, you have automatically injected a fourth YAY classification on the basis of the legal qualifications for “er admission, namely voluntary patients. The voluntary classi- garb, fication is an exceedingly artificial one from the standpoint - birt of administration. The latter grouping is somewhat comparable creed Keuf. to a typhoid, a clean surgical, an osteomyelitis, a pneumonia, 8. tuberculous or a cardiac case occupying adjoining beds in a ward of a general hospital. Obviously, such practice would not be condoned, and there must be some comparable classifica- tion in terms of the clinical material coming under your super- vision and with which your institution deals. The day of my visit to W. T. Unit indicated a virgin chance for improvements along these lines, and certainly indi- cated the inadequacy in meeting anything like a satisfactory supervision. © C -5- In connection with the custody, restraint and safekeeping of voluntary patients, I have had several con- ferences with representatives of the Office of the General Counsel of the Treasury Department, and as a result of such conferences, we anticipate the receipt of formal opinion that the Medical Officer in Charge or his accredited repre- sentative has authority in law to restrain and hold persons admitted uncer the voluntary clause of the Act. As soon as this formal opinion is issued, you will be advised, but in anticipation, it might be well to make your plans so that the artificial distinction between inmates would exist only in the matter of official records of the institution, and that you would classify and group them from a standpoint of domiciliary care, which has for its objective the smooth and satisfactory acini etre tion of your institution in the treat- It is granted that you and your staff have had your hands full in getting the institution to its present state, and I am deeply appreciative, and take this opportunity to express my sincere regard and appreciation for the good work that you and your staff have accomplished thus far. I venture the opinion, however, that the general vrincivles respecting the classification of your inmates as suggested above would offer many advantages for more closely meeting your disciplin- ary problems, and add materially toward aiding the more hopeful case to regain his self-regard. I also recognize that there are certain custodial and industrial problems that must be met, and that may enter into the grouping of your material. I have personally put great store in you, Fuller and Ossenfort, to work out a satisfactory solution of the many diversified administrative details and problems confronting you, and in my experience I have yet to see a group of Service officers who did not have the ingenuity to works out a satis-— factory solution of any given problem when the more specific objectives were known and appreciated. There is one other phase of the administration of your institution which was brought to my attention by Dr. Ossenfort immediately before my departure. The manner in which the situation was handled was naturally an emergency one, but I feel impelled to designate the method as somewhat foreign to a medical approach. I refer especially to the situation associated with a "spurious riot" involving some six or ten inmates. These, as I understand it, were placed in isolation, in what is Imown as the cell-block, and deprived of food, which always brings to my mind the attitude of the L{Lan WA we rR 12 oe nlp e arlene re a OF treighenthe 24 Zac thy + U & l Gert q Misbies 4 & fa Le a a 4 hn Ae Grvd pong fee ty hu’ “4b 14. nhs i wg Abe (lee hgh ids Behe out Ahk, m > WK ~ 6 = Spanish Inquisition. Subsequently, food was offered these inmates, who refused it, and later, at least one of them was handcuffed to the door of the cell, or perhaps only threats were made to give him that form of punishment. I have been wondering if a modern medical approach hasn't passed that method of handling intractable and ob- streperous inmates. Should another situation of a similar character arise, involving an individual, I am wondering if you wouldn't like to try the continuous flow bath-tub, with suitable restraint hammocks, with which, I understand, the cell unit is equipped. On the other hand, should a similar situation involve a group of inmates, the use of a sedative hydro-therapeutic pack and blanket might offer a more humane Ake , method of restraint, and at the same time afford sedative = VAN ed hydro-therpeutic treatment, thus placing it on a more definite- [Mertld ly humane medical basis. The proper use of hydro-therapeutic packs will often put such cases in a non-combatie¢position or mood. The technique of applying the wet sheet pack is _ minutely described in Dr. Wright's book "Hydrotherapy in / Hospitals for Mental Diseases", Chapter 6, a copy of which volume you should have in your medical library. In the event that you do not have access to the volume in question, we shall be glad to loan the Service Library's copy to you pend- ing the purchase of the volume. In the event hydro-therapy and the use of packs shovld not be sufficient to meet the needs, it is likely that you might desire to resort to some form of chemical restraint, in terms. of _apomorpbine, which through my experience, will often dissolve the most belligerant attitude. I do not look with favor wpon the use of hyoscine for that purpose, because of an unfortunate experience, but it is sometimes used for that purpose. One of the several intravenous barbiturates also may and has been used for its sedative eitect on intract- able cases. I hope that you will not regard this letter with a feeling that I am disposed to offer criticisms of your adminis- tration, and I hope you will look upon them with the idea of their being helpful, and solely in a spirit of cooperation, in order that we may make the narcotic farm the scientific medical institution which it purports to be. Respectfully, Assistant Surgeon eneral, Division of Mental Hygiene.