U. &,. Narcotic Farn,
Lexington, Kentucky.

November 21, 1935.

PERSONAL

Asst. Surgeon General W. L. Treadway,
United States Public Health —
Washington, De Cs

Dear Dr. Treadway:

I have received your personal letter of November 5, 1935, in which you
make comments and suggestions based on observations made by you during your
recent visit at this station. I have diseussed with Dre. Fuller and: Ossen-
fort your various observations and what I say here may be considered the re-
sult of my conference with then.

It is noted that you do not think we have sufficient segregation of in-
mates according to types. Doubtless we could improve upon this somewhat and
are doing so all the time, but I believe that our policy as te grouping pa-
tients was not explained to you in eomplete detail. Our first grouping is
according to race but we recognize only two races « the colored and white <
and only the negroes are classed as colored. Our next and probably most in-
portant grouping, inaenuch as we do have prisoners, is according to grades of
custody; namely; maximum, close, medium and minimum. ‘Such e« classification
is necessary if we are to work our patients to their best adventage and to
reasonably guard against avoidable escapes. About 20 per cent of our popula-
tion are trusties. OGonsiderable study and observation is made before we make
a patient a trustie and, of course, this status may be taken away from him,
We find that petients work much better if they are made trusties and their
mental reaetion to the institution and to the whole scheme of treatment is
much better.

Within these two major classifications or groupings there are various

sub-groupings. For instance, we have the various types of sick patients
such as the chronically il11, surgical, tubercular, patients undergoing with-
drawal, ete. Another grouping is according to occupation; fer instance, the
fam group, the construction group, the kitchen group, night workers, ete.

We are aleo trying to group patients according to those who seriously want to
‘be cured and those who are indifferent about it, and there is, of course,a
grouping according to behavior.

Naturelly, with all these groupings, there is some inter-mixture of groups
here and there, but in general I believe it complies with your idea thet the
patiente should be grouped according to race, personality, cultural background
and behavior attitudes.
o Bm

We have a grouping of voluntary patients. You refer to this as rather
arbitrary and artificial, but I feel that we must keep some sort of voluntary
grouping even though the only difference between these and the other groups
is a legal ones Many voluntary patients are opposed to associating with pris-
oners and their friends are more concerned about this than they are. The
feeling they have about this is a natural one that we feel should be respect-
ed, but thet we should also try gradually to dissipate, and with this in view
we have begun to introduce into the Wl Unit the better type of prisoner and
have also taken a few of the worst type of voluntary patiete out of the YT
unit and put them with some harmless but more or less chronically disabled
prisoners. This inter-mingling of the two groups will proceed gradually and
we hope will eventually become quite extensive without arousing much if any
discontent. Wo éiétinction is made between the voluntary and prisoner patients
in the Hospitel, tubercular ward, withdrewal ward and in the quarantine section,

You should probably also know that there is a certain hostility emanating
from the prisoner patients towards the voluntary patients. Some of this is
doubtless uareasonable and much would probably disappear if there were no dis-
tinetion made from the beginning. As an illustration of what does happen, three
of our most untractable voluntary patients asked to be put among prisoners sev-
eral days ago and we did it, but the prisoners were so hostile thet these men-
immediately asked to be returned as they were so afraid of injury. The prison-
ers' veaction was that these fellows were intended ase “stool pigeons”, © The
Same Men are now among the old chronics above referred to and they will be kept
away from the WT Unit permanently,

About the sleeping quarters in the Prolonged Treatment Units,we have ntt
found it feasible to keep these units entirely clear of patiente during the day.
Our work outside depends largely on the weather and during bad weather these
patients have to stay ine Also, they come in for lunch et e certain time end
spend « short while in the Prolonged Treetment Unit before being sent out again.
Ae to sick patients, it would create a lot of paper work and unnecessary move
ing if we inmediately transferred from the prolonged Treatment Unite to the
Hospital every patient who because of some complaint it was decided not to
send out to work on that deys ‘hat we do is to study the patient there to find
out whether he really is ill or has only some minor discomfort that needs no
special treatment or that can be just as well treated for a day or two in the
Prolonged Trestment Unit. If e patient develops fever or has some condition
that needs continued treatment and prevents him from working, he is transferred
to the Hospitel section.

Prisoners often impale of very emall things or manety malinger. If we
ignordl these complaints entirely serious mistakes would be meade. Also, if we
paid so much attention to them as to transfer the authord of then immediately
to the Hospital before a definite decision as to their condition could be arrived
at, there would be mach confusion. As to the use of the Reception Service and
the substitution of one unit of the HH Wing for withdrawal studies, this: is
being corrected.

I have never felt kindly tonarés the establishment of a radewatery and 7
@ substitution ward in the Ei wing. A solution of the leboratory part of the
problem has been found tn that we have -gectaes with your epparat to convert
the fifth end sixth floors of the tower section of the Hospitel wing into a
laboratory for the special investigative work thet we hope to carry one You
have already been advised as to this in @ letter in which recommendation was
made that the Internes be moved from that seetion into ‘the fourth and fifth —
floors of the Administration Building, certain minor changes to be made in
this building to accommodate them, The substitution studies can be carried
on tin the Reception Unit leaving the edst Hospital wing to ve used for ite
original purpose, It will be continuglly necessary, however, for us to make
some adjustment not in the original plans if we are to utilize approximately
all the beds in the Reception Unit, but Male: cen be done without destroy ing
the origina? funetion of ‘the waht sen |

As to tne: Teolation Unit, T an wane e Pann wert neieheal how we
have used this unit for ‘some time past. You will note that there is a gredua-
tion according to the type of patients who oceupy it. The rules for WF~4,—
Isolation, may seem rather severe but we have nobody in it at present andvvery
seldom do, The rules for WPS are a little less severe and we have only five
patients in it now. ‘The rules for EF«3 are quite liberal and we have éleven
patients in it. The first floor of the Isolation Unit is at present being
used temporarily as sleeping quartere until we can make adjustments in the
wards for the last batch of Leavenworth patients, |

> Practically the only way we can find out who the tetrastavic ant obstrep-—
erous patients are is by observation of their behavier here. Of course, when
we get in what we know is a dangerous type of patient he ean te immediately
put into this so-called isclation section for sefe keeping, but observed be- .
havior is more important in relation to the use of this unit. After ell, the
woret type of criminel on the outside may be very good in an institution and
would profdtiby « more liberal environment then the isolation unit. We must
have discipline here and our poliey has been to make it mild, but nevertheless
have in the background the isolation unit as a place where disobedience of
orders, insolence, ri¢ting, ete. will lead a patient ‘to. Most of our discip-~
linary cases are merely reprimended., Some have a change of work prescribed
fer then; others, the more or less defiant and intractable type, are sent to
the Isolation unit and put under the charge of the Psychiatrist. Asa rule,
they stay in this section only a few days but there are some who will etay for
much longer periods and perheps indefinitely.

i gave specific orders in the beginning that we would not have any bread
' and weter type of isolation or punish the patients merely for vvwengeanee pure
poses and this order has been complied with. ‘The one incident that Dr. Ossen-
fort mentioned to you, in which several patients were deprived of food, was a
mild exeeption to the rule. - These patients demanded special food; they cursed
the guard eattendent and the physician on duty in the ward and threw the food
given to them out into the corridor. Three of these men were deprived of two
moals while they were in this defiant attitude. They also broke windows and
kept up a continued yelling end hollering and finally began to destroy the
fixtures in the cell, For instance, they tore down the bunk, stuffed towels
end papers into the toilet end wash stand, and the guard on duty, with the
consent of the Psychiatrist, I believe, decided to stop thie by handouff ing
theme This was done and in two hours the noisy part of the rioting was over.
I did not know at the time thet handcuffs were being used, but the results just-
ified this temporery expedient. Suche situgtion as this must be met wih:
firmness, but we never intend for it to be overly harsh or continuous. In
other words, as secon as the patients subside we withdraw all the restraints.
As an illustration of our policy an order was given by an officer who mis-
understood our intention that several of these patients should be deprived
of their evening meal for some ginor offense after the worst of the disturb-
ance was over. “hen this order was brought to my attention I immediately had
it countermanded,

I do not think thet continuous-flow baths are indicated in the type of
disturbance we had at that time. When a psychopathic patient decides he is
going to make all the disturbance he can, the bath, I believe, would not
work ag it would teke four or five attendants to hold him in it and there is
a queeticn whether apomorphine isn't a more cruel treatment than handeuffing
amen fora short time in order to show him that we will not tolerate the des-
truction of furniture and equipment. As to barbiturates you doubtless know .
thet a very large proportion of our patients would welcame having tantrums
treated by the use of them. The effect would doubtless be to produce more
tantrums, ‘

We agree with your suggestions concerning the proper use of Guard Attend-
ants and are now making changes in accordence therewith.

Iwas pleased to get your letter and wish to assure you that we welcome
at all times eriticiams and owmayeniens looking to the improvement of our Ser-
vice heres

Very truly yours,

lawrence Kolb,
Medicel Director,
Medical Officer in Charze.