SOME ADMINISTRATIVE PROBLEMS AND LIMITATIONS
OF THE SPRINGFIELD MEDICAL CENTER

By: Senior Surgeon Lawrence Kolb, Superintendent, ea

I shall discuss administrative problema here only as they differ from
those at an ordinary hospital.

. This institution is unique in many respects, It is both a prison and a
hospital and in it are treated not only the insane and mental defective which
are implied in the name, but also the tuberculous and certain types of chronic-
ally ill prisoners,

We have here, then, the problem of treating the sick as well as of -guard-
ing prisoners, To carry on both of these functions at the maximum degree of
efficiency so that treatment does not interfere with custody and custody does
not interfere with treatment has taxed our ingenuity to the utmost, It«goes
without seying that in a hospital for mental patients if custody alone is
thought of by the medical personnel, there could be Little interest in medi-
cine, In the languid and disinterested atmosphere that would ensue there would
be no spirit of inquiry, no sympathy with mental patients as aceh, no rapport
between patients and physicians, and no proper desire on the part of the
physicians to study and treat patients as patients, and the hospital would be
a@ hospital only in name. On the other hand, if in their interest and in sym-
pathy for weet eciti: the medical and nursing personnel fail to realize the im-
portance of custody, the inatitution must be a@ Setiune beswune the mandate of
the law that prisoners shall serve a certain period of time in prison must be
obeyed, The institution is, in other words, @ prison as well as a hospital
and the prison function must be maintained while the atmosphere is softened 80

thet the ill prisoner my, as far as possible, forget that he is a prison#

 

and receive the maximum benefit from hospital treatment.
« B «

The institution necessarily has a custodial and medical personnel. Most
of the custodial personnel had been dealing with the prisoners as prisoners
without mueh regara for pecularities of condutt due to disease, while most of
the medical personnel, who had had previous training, had beem dealing with sick
patients as aick patients without any necessity for regarding them other than
as persons who should he made as comfortable as possible and cured of their ill- ie
neat. We, therefore, found that a very good guard or nurse had to expand their vs
vision and unlearn sane things that they had learned in order to appreciate the.
Aenea of the ‘extra ‘duties imposed upon them in connection with the hant~
Ling of pationts at this institution.

‘it is, of course, obvious that two absolutely independent functions and
personnel units could not be maintained if we were to operate an efficient hos-
pital prison. The functions should be fused so that one supplements the other
without losing any of its own peauliar value. In order to wien about this tue
sheds the custodial force must be brought to understand the peculiarities and
weaknesses of sick people and the nursing force must be brought pe seine iate
the untrustworthiness of prisoners and their special duty to guard then,

It would seem that this problem could be settled merely by stating it, but
experience has shown that such is not the ease and it has required months of
training through the medium of talks, regulations and diseinkinaey actionito got
our personnel to appreciate the various ramifications of their functions and

duties and to perform them properly.

 

The disci pbine of patients has been treated by us as a medical matter and

especially the discipline of mental patients has been administered not as punish-
2 Be

ment but as a measure for the control of conduct, When used in this way it has
a therapeutic value. Many of our mental patients are the borderline tyre mre

have full possession of their wits and know the importance of obeying ait

 

lations for conduct and work that is laid down for them. When this type becones
| petenetiny as they often do they are restrained by a short period of isolation
or deprivation of certain privileges, This punishment is always softened by
sympathetic talks from the ward supervisor and physician so that the blow is
softened and their naturally rebellious mental attitude is mollified, The con-
sequence has been that patients reputed to be violent, dangerous and unmanageable
have gotten along very well here and our mental wards are about as quiet and
orderly as a mental ward could possibly be.

The same thing applies to our non-mental patients, These are, of course,
more responsible and are treated accordingly. It goes without saying, however,
that the average prisoner deviates somewhat from the normal in his mental re«

actions and outlooks on life and when this naturally dis i a outlook is further

 

aggravated by the discomfort and irritation of disease he is the source of some
petty irritations for which he is only partially responsible,

Sick people, and especially the tuberculous, are naturally more unreasone ble.
than average normal persons aside from any distortion of personality, and if |
treated with unreasoned severity thei condition is aggravated rather than helped,
Every ease is, then, treated individually with the result that enter and disci p-
line oni, in the main, very good,

Sex Peryergion.

In any prison the problem of sex perversion props up and gives more or

Less concern and trouble, and one would naturally expect that there would be nore i

of it here than elsewhere. This has not, however, proved to be the case, althouss
“4s
we have had sane evidence of pervert practices, It seems logicvto us that sex
perversion should be handled in a hospital from a onttint rather than from a legal
or disciplinary stendpoint., Our practice has then been to control this situation
by means of segregation and separation of parties suspected of it and to cure it

4n so far as possible by such psychotherapeutic means as seem applicable,

 

It is susconkis adeuptek that prisoners are better off if work is provided
for them. By occupying their time, work prevents disorder and arent while it
builds character, Work is especially important a6 a inte of therapy for insane
patients and the problem here has been how to provide work for these and other |
patients without endangering custody, |

4 large proportion of the patients want to work and,of course,many of then ,
have asked to work on the outaide with very Little restraint from a custodial |

| atandpoint. If the patient is trusted and some appreciation of his work is hots
it restores his self-respect and starts him on the road to recovery, but is an
easy matter to overstep the bounds of ordinary prudence if the possibilities for
abupéof privileges are not kept in mind, | | | |

We have dgvinet a method for classifying our patients as to their ability.
for work and the extent to which they ean be trusted, The ward physician,after
examining the patient and observing his reactions on the ward, decides what kind 3
of work he is payeiesiiy and wen able to do. He records én a preseribed' »
form whether the work should be light, active, heavy or none at allj whether it
preferably shoula be clerical, dining room, shop, indoor, outdoor, etec.; the
epecial ability, if any, the patient has, the supervision, if any, he needs, the

mental and emotional reactions, and cooperation to be expected of him, This
“Se.

material is then passed on to the Clinical Director, the Executive devices, and Ae
the Captain of the Guard who, after examining it and the prison and escape ane ve
classify the patient as to escape precautions that should be used into one of the |
four groups below:

a, Routine custodial precautions, Fi

by Routine custodial precautions for psychotics ©

Gy Custodial escape problem (special eseape precautions) a

a. Psychotic escape problem (Special escape precautions for psychotics)
After deciding the probabilities of eacspe the officers express an opinion as a ‘
whether the case should work inside or outside of the building and what pore of
eupenel nien it needs. The Superintendent then reviews the evidence together with
the opinione of the other officers and decides what class chs patient falls into
and what kind of work and under what supervision he may do it, after which the
Clinical Director makes the definite asal gnment. | | te a

The Captain of the Guard has been given a direct responsibility in connection ,

with working patients and if, in his opinion, the ‘sain is not safe fron a cus-
todial standpoint in the assignment given to it, another assignment is made.

About 68 per cent of the total number of patients capable of work had definite

 

assignments in June and July. Only a mall proportion of these were working in
the erafts shop. It is our opinion that constructive work outside of the regular _
occupational therapy shop is much better from a therapeutic standpoint than work
in the erafts shop. |

The pettense who w wk away on wate wards are given a pass depending upon
the amount of trust put in them, only same aon have passes to go outside and wrk.
without guard. ‘the others have some sort of supervision either in or outside of

the buildings, Doubtless more patients could be trusted outside, but there is al- |
c

oe Ba

ways the risk that some of then, especially psychopathic, will violate the trust,

 

The question has arisen whetiigr we should work psychotic patients under a
gun guard and our decision is wins payahianie patients known to be escape problems
should not be worked outside of the fence where they might make a break, as the
shooting of a patient of this kind, whether responsible or not, would be most un-
fortunate, The escape problems are, therefore, worked inside of the buildings
or courtyards or not worked at all.

A large proportion of the cases treated are the parsnoid scheming type of
individual who are very little deteriorated. We ao not have a large proportion
of docile, tractable, deteriorated, psychotic REE which are seen in great
numbers in state institutions, and who can be trusted to work in fields with very
little supervision, It is extremely unlikely that we ever will collect any great
number of these because, in the first place, the fact of the commia-
sion of crime usually denotes more aggressive initiative and mental agility than
is found in the average tractable mental patient; and in the second place, our
patients will be discharged at the end of their prison terms before they get into
a settled deteriorated condition. It, therefore, does not seem probable that we
will ever be able to depend on psychotic individuals to do a great deal of out-
side work unless the policy as to gun guards for them is changed,

This institution was designed with the idea that it should be a hospital and
that for the benefit of patients the exterior view and interior arrangements
ghould suggest prison as little as possible. The windows were given a mild appear-
ance and so setetweeted that they offered little resistance to ingenious vel saneres
the sunporches had no bars wintever} no guard towers were provided; an armory was

apparently not thought of; and the wall enclosing the courtyard was made so low that

it could be easily sealed, The idea behind all this was excellent from the stend-
ik.
point of the psychological effect it was hoped to obtain, but experience soon
taught that patients treated here had-as great an impulse to escape as the aver.
age pri soner in penitentiaries and jails,

The defects and omissions of construction have been or will be corrected
without detracting ona te ‘appearanee of the buildings, It was necessary to
erect guard towers manned by armed guards as well as to maintain an armory well
stocked with guns, but a solid wall, one of the most forbidding aspect of prison=

ers, Was avolded by the use of fences which seem adequate for our needs, The

 

shanges have not, in my opinion, detracted greati from the efficiency of the ine
stitution as a hospital, Nearly all of the va thenke accept them as a necessity
‘on we have nat been able to discover any bad psychological effect because of then.
The hospital still has a mild appearance in spite of them and also in spite of ;
the patrol police dogs. The inetitution because of these changes has developed.
an atmosphere of sterness in so far as wane ie concerned, which, in associa~
tion with the atmosphere of tolerance on the inside, has had a good psychological
effect on the patients.

In the original set-up for personnel a large number of tenale nurses was
wbetited for, Limited appropriations qonpelied an alteration of the plans so
that the number of female nurses was reduced and the number of guard attendants
and attendants correspondingly increased. Necessity here brought about a de-
sirable change, Some female nurses are nazeseazy to create the proper hospital
atmosphere and also because of the special nursing training they have had, but

it is our decision that in the main male ward attendants are needed in order to

sontrol the type of patients treated here, We would feel rather uneasy if it
-

« io

were necessary to # ive & ward with female nurses alone, Sick prisoners have re-— :

 

spect for women a a to a certain point are better controlled by them, but many
of our patients would go beyond the bounds of propriety if a male attendant is
not always on the ward,

One of the important custodial funetions of the nursing force ia the proper
accounting for patiente, Many of these work away from the wards; many others
necessarily pass to and a the wards jee treatment or examination; others go
to the courtyard for exercise. Because of this rather irregular movement of the
patient population, it has been found desirable to bring them all badk to the
wards for an official count at regular intervals during the day. These counts
are made at the change of the working shifts and none of the nursing or custodial
personnel is allowed to leave the reservation until it is verified, A count is
also made every half hour for a period of about 10 hours during the night and
telephoned to the armory every hour, |

Perhaps we are too nervous about our custodial situation, but our physical
layout and main objective differ from that of prisons. The windows give immediate
access to the outside and our rooms have no toilet facilities, It is more com
fortable for the patients and more convenient for the nursing force to have the
doors open at night, but more important still the patients are better behaved
when unnecessary restraint is removed and the psychologieal effect of this appear-
ance of freedom is benef ickal to them both physically and mentally. The doors |
are, therefore, not locked at hight except in the acute, psychotic wards and in
a few rooms in other parts of the institution where special escape problems are
quartered, As an added precaution the clothing d all patiente is taken from them

at night and locked in a ¢lothes room on the ward.
Dietetic Department:
It has been expedient here to have a dietician fill one of the stewards po-

sitions in omer that diets necessary in the treatment of certain conditions can
be properly prepared, This dietician, a women, necessarily has authority in the
Stewards Department. She must control male. prisoners who wrk there. At first
sight it might be eonsidered that this control would not be efficient, but ex-
perience has showm that male prisoners will work as well under the supervision
of a female stewardese as under 4 male steward, It depends altogether on the per-
sonality and ability of the individual. |

Our mess hall has given us considerable concern beeause we have not been able

to feed the hospital patients as cheay bey as inmates of prisons are fed and we have | |

  

about concluded that this is tapousthe if the me tisnte are to be fed properly. in

order to avoid naipinstaced feeding of patients who reqiire especial diets, the ateti~ )

¢ian has prepared a formula for numerous diets suitable for certain conditions so
that the sreinions sos order diets from these formulas and avoid the expense, con- |
fusion and discon nt that would arise if such articles were ordered for gertain .
patients, These diets are know as regulars, softs, liquids, ‘tubereulars, edentu-

lous, Sippys, high saledbes: salt and protein free, low earbohydrates, Bland

diets, and diebetics, present varieties suitable for any condition. :

A number of tubercular patients are treated here. These are provided wth
special between-meal nourishments, The feeding of tubercular patients in hospitals
is a more expensive proposition than feeding the average patient. The per diem
‘gost in sane of the Veterans hospitals is $1,00 or more per dey. We feed our
patients for less than 30 sents per day, and we feel that they are adequately
nourished,

The majority of our patients are feéd in the main dining room but many are
oo.
Z \

“10 =
necessarily fed onthe wards, This adds to the expense and also to the wrk of the

dietetic department.

Mail: |

The handling of inmtes' mail presents a problem somewhat different from that _
in the regular prison, Some onveto ls eileonsré especially are prohe to write pro-~ :
fusely, This writing is in many eases of benefit to them and their productions
afford valuable material for the study of their mental reactions, The jregven
for censoring mail has, therefore, been devised in which the physicians play an
important part. The ward physicians read all mail going to or from the psychotic | .
wadtes Much of this is filed with the clinical histories and does not reach the
mail elerk,. Letters after jansine them go to the mail clerk who attends to mat-
ters not in the provinee of the physicians. All eenetions of doubt in the ease
of mail from both psychotic and medigal patients are referred to a mail onxed
board, consisting of the Clinical Director, fhe Warden's Assistand did the
Superintendent. This sanewhat cumbersome routine has been devised so that both
patients and physicians may get the maximum benefit from correspondence without
running the risk of having objectionable matter introduced or sent sult ame
the medium of mail. | | | a

fhe haniling of writs and petitions to courts: give some concern at first.

We have no desire or right to prevent prisoners from appealing to the courts to
correct what they may think was a miscarriage of justice, but in the case of cere
tain psychotie patients the unrestrained sending out of writs and letters to
eourte becomes a nuisance, not only to the hospital but to the courts, Some af
our parsnoid patients never accept "no" from a court and would sine a new writ
every week if allowed to do sel The matter finally was settled by what amounted

to almost an order from the United States Court in this district hot to allow
c

| #~ ll +
mental patients directly to petition the court, Writs and letters from such
patients are now filed or returned to the patient with the information that he
ean take up such matters through the medium of a lawyer, a friend, or relative.
The prisoners* mail boxsis the psychotic wards also threataned to become
a nuisance and were removed with the consent of the Bureau, Paychotic patients
may still write to officials in Washington but their Leben are censored and

if of a nuisance nature are filed or destroyed.

Prison Camp: | |
A prison camp has been established here as an organization within the main

 

hospital organization, This camp provides trus é . rison labor for both indoor
and outdoor activities of the hospital, The atticer in charge of the camp makes
the work assignments after consultation with the Clinical Mredher or Executive
| Officer, depending upon the nature of the work to be done,
Prison camp inmates and hospital inmates are kept apert as much as is poss-
ible to do so, but a complete separation cannot be maintained because it has
been soetueary to work camp inmates in the wards, No serious neppenings have
developed from this contact probably because our camp inmates have been well 5e>
lected from the beginning and have been in the main trustworthy and reliable, :
We have feared especially the introduction of contraband by wae of these ine
mates because the camp men, if they had a mind to do so, would have an opportunity
to secure and introduce anything from narcotics to pistols,
The prison camp inmates are now housed in one of the hospital buildings
that will sooner or later be needed for patients. It does not seem likely that
all the work being done by the camp inmates can ever be taken over by patients
even though the patient popula tien is greatly increased, It will, therefore,
be necessary eventually to build quarters for about 100 camp inmates unless the

paid personnel is greatly increased, The retention of the camp seems more logical
and is preferred.
# 18

Industries and Business:
fhe farm and the routine hospital activities will probably always provide

all the work that is therapeutically newful and needed for our patients, It is
not our intention then to ask that any type of industry be established here as
such industry would only add to the administrative burden and detract from the
functions of the institution which are to care for, cure, and rehabilitate ill
prisoners and to study the effect of disease on crime.

The business activities of the hospital present some complexity in that the
personnel is about equally divided between two Jureaus and supplies and equipment
are bought through these two Bureaus, The majority of the business is, however,
Bureau of Prisons business, and since it would be illogical, uneconomical, con-
fusing and irritating to have two sets of store roome and two sets of clerks and
workman to handle and care for stores, order supplies and equipment, prepare pay-
rolls, vouchers, requisitions, purchase orders, etc., certain of the Bureau of
Prisons personnel have been trained in Public Health methods. The result is that
the business activities are unified and earried on with enketintien, efficiency

and very little additional effort.

The law establishing this hospital did not authorize us to keep patients
here indefinitely even though they have no place to go, and it is the definite
policy of the Bureau to get rid of ali patients at the expiration of their prison
terms, The states are equally determined that no public charge for whom they are
not definitely responsible shall be saddled on them and it has taxed our ingenu-
ity to dispose of some of our dangerously psychotic and helpless patients. Con-
tracts have been made with state organizations having to do with the disposal

of mental patients and with various state and welfare organizations who may take

care of the helpless, So far, we have been able to dispose of all whose terms
»~13~«<

have expired, but in one case our officers were threatened with arrest for bring-

ing @ public charge to the state; they, however, took him. In another instance
we received authority at the last minute from a judge to turn the patient over to
his court. In still another case a wire was received from a county clerk on the
last day of the patient's term ordering us not to bring the patient to his county
because the man had been divorced since he was sentenced to prison and was no
resident there, We, however, took him to an adjoining county and turned him over
to his pa renteg, es

There sink ali means by which Legally-free patients who still need care can

be disposed of, but no one would approve of dumping a helpless individual in

the street or turning a dangerous lunatic loose with nobody te assume responsi-~
bility for him. It is, therefore, inevitable that a few patients will be left

here indefinitely in spite of the law,
yo
C
LIMITATIONS OF THE MEDICAL CENTER

Theroretiecally there should be practically no limitation as to the type of
‘patient to be treated here, but we are faced by certain conditions, all of which
ean be corrected, but which at present limit either the scope or the efficiency

of the institution as an

 

fa. learound medical center, ’

We should be able to treat all types of desperate, insane criminals as well
as border-line psychopathic individuals who are not definitely insane, But the
weakness of the buildings from a custodial standpoint as well as our present shor te!
age of personnel make it undesirable to send to the Yotical qpnter all of the in- |
gene who are eligible for treatment in it. | |

The type of patient above referred to presents problems of especial interest

to psychiatrists and our medical force would like to have them to study and work with,

%

ie

Moreoter, such patients would be much better off in this hospital than in prison,
but accidents of eseape and even personal ‘ieisede might occur if they were treated
here now.

In order to remedy this situation and also better to treat some of the patients
we already have, a recommendation has been made for a strong hospital building with
@ separate yard where such patients can be safely and properly treated. A building
large enough to accommodate 25 difficult cases would be adequate for present needs,
but the building should be constructed so that it could be easily enlarged to accommo-
date 50 patients, The restrictions found necessary to properly safe-guard prisoners
at Alcatraz may bring about mental Aimhemant in a large number confined there. If
this happens the Springfield strong bhilding may soon have to be enlarged as this is
the proper place to treat such patients.

We are now able to take care of and treat any other type of psychotic prisoners
~ ph

Feeble-minded pri soners who become psychotic or who present behavior disorders
ghould be treated at Springfield an hey oni be better handled here than else-
where, but it is probable that the well-behaved feeblo-minded individual would
be better off at prisons because prisons afford a large ‘ontia Sy of work for such
patients and work is what they need above all other forms of treatment.

Theoretically, we should treat nek perverts here, as such patients present
many interesting paychological problems and some of them can be hel ped by psycho~
therapeutic measures, but it would probably raise some very different problems if |

all the perverts in the prison system were agssembled in one place, our efforts a

Biss
fore .

this behalf should, shoved | be limited to special cages, perhaps to some of those
who present some biological sex deviations,

| The tubercular building ori auais designed for this place was not constructed
and our present set-up for the treatment of tubercular se thente is not ideal in
that the beds oan not be wheeled directly from an inclosed room to an open corridor
or porch as would be desirable in favorable weather, ‘The rooms are also rather un-
comfortable in warm weather because the windows ean be opened only about 5 inches
at the bottom and top. We are, however, able to give our patients adequate light,
air and rest as well as aurgical attention when this is necessary and the worst

bed patients are treated on a sun porch where there are open windows and an annem
anee of light. The tubercular ward has accommodations for only 69 (six more gan :
be added in case of emergency) patients, and with the present personnel it would
not he possible to open another tubercular ward. These patients have proved to be
more difficult than any others from the standpoint of custody and discipline, and |
to open another tubercular ward without adequate personnel would be an extranely

hagerdous undertaking,
& "Ge C
oe

The provision of the law establishing this hospital, which provides for the
loss of good time on the part of mentel patients treated in it, has had an up~
‘getting influence especially on the border line psychotic patients, This feature
of the lew is doubtless a good one in that it keeps speeeeciiahtie patients away
from Society for a longer period of time, but practically all of our paychotic
pataantn think and worry and complain about it so that in some eases it probably

acts as a deterrent to recovery. It is probably that the law should be modified —

 

go that in the diseretion of the medical staff certain cases could go out on their
short time, This would give all who care about it something to look forward to

snd would secure from them more cooperation in treatment, The exception, of course,
should not be abused to the extent that markedly psychotic patients would be freed

by it.

 

The name of the hospital, containing as it does the words “defective | | jel ?
aceuha" is unfortunate and should be changed, These words carry @ # atigna that
only a few of the patients deserve and they have a disturbing influence that mili«
tates against successful treatment and adjustment of patients to the Suativation i

so that for this reason alone same ask to be returned to priso.lNo attention ehould).

 

be paid to a mere whim of a prisoner, but the classification “defective "delinquent" ©

 

is about the lowest classification that a human being can have and the objection to
it is not a mere whim, The classification is unreasonable as well as untrue, and ‘
if inmates of a penal institution are to be rehabilitated to the fullest extent
possible they should not go out feeling that they had been unjustly stiguatized
while in prison, It is felt, therefore, that the ame of the hospital should be
changed, eliminatihg the words ‘defective delinquent",

In conclusion, this institution affords a variety of interests to maintain the
medical and scientific spirit of the staff at a high level, There is practically
no limit to the constructive work that may be done if the proper spirit is maine

tained and the scientific personnel is inereased to the point where some time can
be devoted to study and research.