Clinical Practice in Correctional Medicine

566 Pages·2006·5.12 MB·English

by  Michael Puisis, D.O. (Eds.)

1600 John F. Kennedy Boulevard, Suite 1800
Philadelphia, PA 19103-2899
ISBN-13: 978-0-323-03265-0
Clinical Practice in Correctional Medicine ISBN-10: 0-323-03265-6
Second Edition
Copyright 2006, 1998 Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission of the publisher
(WB Saunders, 1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA 19103-2899).
Notice
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are
advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer
of each product to be administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of the practitioner, relying on his or her own
experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for
each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither
the Publisher nor the Editor assumes any liability for any injury and/or damage to persons or property arising
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Library of Congress Cataloging-in-Publication Data
Clinical practice in correctional medicine/[edited by] Michael Puisis.–2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-323-03265-6
1. Prisoners--Medical care. I. Puisis, Michael.
[DNLM: 1. Health Services–United States. 2. Prisons–United States. HV 8833 C641 2006]
HV8833.C53 2006
365’.66–dc22
2005052246
Editor:Rolla Couchman
Editorial Assistant:Dylan Parker
Marketing Manager:Laura Meiskey
Printed in United States of America.
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To Sam and Coral
To Armond Start and Bernard Harrison
and to all others have worked and continue to work
to improve the quality health care
to the inmate population
v
Associate Editors
B.Jaye Anno,Ph.D.,CCHP-A Lambert N.King,M.D.,Ph.D.
Partner, Consultants in Correctional Care Director of Medicine, Department of Medicine
Santa Fe, New Mexico Queens Hospital Center
Jamaica, New York
Robert L.Cohen,M.D. Principal Investigator, Searching for Common Ground Project
Assistant Professor, Social Medicine and Clinical National Commission on Correctional Health Care
Epidemiology Chicago, Illinois
Albert Einstein College of Medicine
Attending Physician, Department of Medicine Catherine M.Knox,R.N.,M.N.,CCHP
St. Vincent’s Hospital Director of Nursing, Health Services
New York, New York Washington Department of Corrections
Board Member, National Commission on Correctional Olympia, Washington
Health Care
Chicago, Illinois Madeleine LaMarre,M.N.,A.P.R.N.,B.C.
Representative, American Public Health Association Correctional Health Care Consultant
Washington, District of Columbia Atlanta, Georgia
Joe Goldenson,M.D. Jeffrey L.Metzner,M.D.
Assistant Clinical Professor, Family and Community Medicine Clinical Professor of Psychiatry, Department of Psychiatry
University of California, San Francisco University of Colorado School of Medicine
Director/Medical Director, Jail Health Services Denver, Colorado
San Francisco Department of Public Health
Medical Staff, Family and Community Medicine John M.Raba,M.D.
San Francisco General Hospital Chief Operating Officer, Cermak Health Services
San Francisco, California Cook County Department of Corrections
Attending Physician, Departments of Medicine and Family
Robert B.Greifinger,M.D. Practice
Consultant in Correctional Medicine John H. Stroger Hospital of Cook County
Dobbs Ferry, New York Chicago, Illinois
Newton E.Kendig,M.D. Ronald Shansky,M.D.
Medical Director, Federal Bureau of Prisons Consultant in Correctional Medicine
Department of Justice Chicago, Illinois
Washington, District of Columbia
vii
Contributors
Frederick L.Altice,M.D. H.Blair Carlson,M.D.,M.S.P.H.
Associate Professor of Medicine, Director of Clinical Research, Clinical Professor of Medicine
and Director of the HIV in Prisons Program University of Colorado School of Medicine
Yale University School of Medicine Fellow, American Society of Addiction Medicine and American
Section of Infectious Diseases, AIDS Program College of Physicians
Attending Physician, Department of Internal Medicine Past Member, Board of Directors
Yale-New Haven Hospital National Commission on Correctional Health Care
New Haven, Connecticut Denver, Colorado
Harold Appel,M.D.,CCHP Michael D.Cohen,M.D.,FAAP
Neurologist, Neurology Clinic Medical Director, Bureau of Health Services
Bellevue Hospital New York State Office of Children and Family Services
Neurologist Rensselear, New York
Specialty Clinics, Rikers Island
Prison Health Services, Inc. Joseph N.Costa,D.D.S.
Neurological Consultant, Correctional Health Services Dental Director
New York City Department of Health and Mental Hygiene Dwight Correctional Center
Neurological Consultant Dwight, Illinois
Medical Services, Manhattan Psychiatric Center
New York, New York Nancy Neveloff Dubler,L.L.B.
Director, Division of Bioethics
Getahun Aynalem,M.D.,M.P.H. Montefiore Medical Center and Professor of Bioethics
Epidemiologist, Sexually Transmitted Disease Program Albert Einstein College of Medicine
Los Angeles County Department of Health Services, Public Bronx, New York
Health
Los Angeles, California Joel A.Dvoskin,Ph.D.
Assistant Clinical Professor, Department of Psychiatry
Ronald Bajuscak,D.M.D.,M.S. University of Arizona College of Medicine
Associate Professor, Clinical Medicine Tucson, Arizona
A.T. Still Health Sciences School of Oral Health
Mesa, Arizona Richard L.Frierson,M.D.
Associate Professor and Director, Forensic Psychiatry
Marty Beyer,Ph.D. Fellowship
Independent Juvenile Justice and Child Welfare Consultant Department of Neuropsychiatry and Behavioral Science
Cottage Grove, Oregon University of South Carolina
Director, Forensic Psychiatry Education
Joseph A.Bick,M.D. Forensic Services
Chief Medical Officer, California Medical Facility Williams S. Hall Psychiatric Institute
California Department of Corrections Treating Psychiatrist, South Carolina Department of
Assistant Clinical Professor, Division of Infectious and Corrections
Immunologic Diseases Gilliam Psychiatric Hospital
University of California, Davis Columbia, South Carolina
Davis, California
Theodore M.Hammett,Ph.D.
Larry Burd,Ph.D. Vice President, ABT Associates
Professor, Department of Pediatrics Cambridge, Massachusetts
University of North Dakota
Grand Forks, North Dakota Lindsay M.Hayes,M.S.
Project Director
Gayle F.Burrow,R.N.,B.S.N.,M.P.H.,CCHP National Center on Institutions and Alternatives
Director, Corrections Health Mansfield, Massachusetts
Multonomah County Health Department
Multonomah County Detention Center
Portland, Oregon
ix
CONTRIBUTORS
Budd Heyman,M.D. Mary Ellen Lane,R.N.,M.B.A.,B.S.N.,CCHP
Chief of Prison Health Services, Bellevue Hospital Center Clinical Program Consultant, Health Services
Clinical Instructor, Department of Medicine Georgia Department of Corrections
New York University School of Medicine Atlanta, Georgia
New York, New York
Thomas Lincoln,M.D.
Daniel J.Hickey,D.M.D.,FAGD Assistant Professor of Medicine
CDR, U.S. Public Health Service Tufts University School of Medicine
Chief Dental Officer, Health Services Unit Boston, Massachusetts
Federal Correctional Institution Attending Physician, Division of Geriatric Medicine and
Morgantown, West Virginia Geriatrics and Brightwood Health Center
Baystate Medical Center
Riduan Joesoef,M.D.,Ph.D. Springfield, Massachusetts
Division of STD Prevention Primary Physician, Hampden County Correctional Center
National Center for HIV, STD, and TB Prevention Ludlow, Massachusetts
Centers for Disease Control and Prevention
Atlanta, Georgia Lannette Linthicum,M.D.,CCHP-A,FACP
Director, Health Services Division
Richard H.Kahn,M.S.
Texas Department of Criminal Justice
Division of STD Prevention Huntsville, Texas
National Center for HIV, STD, and TB Prevention
Centers for Disease Control and Prevention Mark N.Lobato,M.D.
Atlanta, Georgia Medical Epidemiologist, Division of Tuberculosis
Elimination, National Center for HIV, STD and TB
Michael F.Kelley,M.D.,M.P.H.
Prevention
Instructor, Community Health and Preventative
Centers for Disease Control and Prevention
Medicine
Atlanta, Georgia
University of Texas Medical Branch
Galveston, Texas
Nicholas S.Makrides,D.M.D.,M.A.,M.P.H.
Chief Dental Officer, Federal Bureau of Prisons
Jane A.Kennedy,D.O.
Department of Justice
Assistant Clinical Professor of Psychiatry, University of
Washington, District of Columbia
Colorado School of Medicine
Diplomate, American Board of Neurology and
Fleet W.Maull,M.D.,Ph.D.Candidate
Psychiatry with Added Qualifications in Addiction
Adjunct Faculty, Religious Studies & Core College
Psychiatry
Naropa University
Certified, American Society of Addiction Medicine
Founder and President, National Prison Hospice
Denver, Colorado
Association
Boulder, Colorado
Peter R.Kerndt,M.D.,M.P.H.
Associate Adjunct Professor, Department of Epidemiology
John P.May,M.D.
School of Public Health, University of California at Los
Medical Director, Armor Correctional Heath Services
Angeles
Coconut Creek, Florida
Associate Adjunct Clinical Professor in Medicine
NOVA, Southeastern University College of Medicine
Department of Internal Medicine, Division of Infectious
Fort Lauderdale, Florida
Disease
University of Southern California
Lawrence H.Mendel,D.O.,CCHP
Director, Sexually Transmitted Disease Program
Clinical Assistant Professor, Family Medicine
Los Angeles County Department of Health Services,
Ohio State University Medical Center
Public Health
Columbus, Ohio
Los Angeles, California
John R.Miles,M.P.A.
JoRene Kerns,R.N.,B.S.N.
Executive Director Programs, American Correctional Health
Executive Vice President, Correct Care Solutions
Services Association (ACHSA)
Topeka, Kansas
Senior Associate, McKing Consulting Corporation
Atlanta, Georgia
Seijeoung Kim,R.N.,Ph.D
Editor, Journal of Correctional Health Care
Postdoctoral Fellow, University of Illinois
National Commission on Correctional Health Care
School of Public Health, Division of Epidemiology and
Chicago, Illinois
Biostatistics
Chicago, Illinois
x
CONTRIBUTORS
Michael B.Nelson,D.O. Donna Marie Schwartz-Watts,M.D.
Chief, Health Services Branch Associate Professor and Director of the Division of Forensic
Health Services Division, Federal Bureau of Prisons Services of Neuropsychiatry and Behavioral Science
Department of Justice University of South Carolina, School of Medicine
Washington, District of Columbia Consulting Psychiatrist, Courtesy Psychiatry and Forensic
Services
Joseph E.Paris,Ph.D.,M.D.,CCHP,FSCP Palmetto Health Richland and Baptist
Medical Director, Georgia Department of Corrections Treating Psychiatrist, Columbia Behavioral Health
Atlanta, Georgia Treating Psychiatrist, South Carolina Department of Corrections
Gilliam Psychiatric Hospital
Becky Pinney,R.N.,M.S.N. Columbia, South Carolina
Division Vice President, Rikers Island Contract
Prison Health Services Steven Shelton,M.D.,CCHP-A
Whitestone, New York Medical Director, Health Services
Oregon Department of Corrections
Steven E.Pitt,D.O. Courtesy Staff
Clinical Associate Professor of Psychiatry, Department of Family Practice
Psychiatry Salem Memorial Hospital
University of Arizona Health Sciences Center Salem, Oregon
Tucson, Arizona
Hal Smith,M.P.S.,CCHP
Mary Raines,R.N.,B.S.N.,CCHP Clinical Associate Professor, Forensic Psychiatry, Department
Oregon Department of Corrections, Coffee Creek of Psychiatry
Correctional Facility State University of New York, Upstate Medical University
Wilsonville, Oregon Syracuse, New York
Executive Director/CEO
Stamatia Richardson,M.D. Correctional Mental Health Services
Senior Physician, Women’s Health Care Central New York Forensic Psychiatric Center
Cermak Health Services Marcy, New York
Cook County Bureau of Health Consultant, Forensic Mental Health, Inc.
Chicago, Illinois Schenectady, New York
William J.Rold,J.D.,CCHP-A Leta D.Smith,Ph.D.
Attorney at Law Director of Priority Initiatives and Mental Health
New York, New York New York State Office of Children and Family Services
(OCFS)
Lee H.Rome,M.D. Rensselear, New York
Director of Psychiatry and Mental Health Authority President, Forensic Mental Health, Inc.
Wayne County Jail Schenectady, New York
Detroit, Michigan
Steven S.Spencer,M.D.,FACP,CCHP-A
Elizabeth Sazie,M.D.,M.P.H.,CCHP Consultant, Correctional Health Care
Oregon Department of Corrections, Coffee Creek Santa Fe, New Mexico
Correctional Facility
Wilsonville, Oregon Erin M.Spiers,Psy.D.
Clinical Assistant Professor of Psychiatry, Department of
Gordon D.Schiff,M.D. Psychiatry
Associate Professor of Medicine, Department of Medicine Louisiana State University School of Medicine—New Orleans
Rush University New Orleans, Louisiana
Director of Clinical Quality Research and Improvement
Department of Medicine Sandra A.Springer,M.D.
John H. Stroger Hospital of Cook County Yale University School of Medicine
Chicago, Illinois Section of Infectious Diseases, AIDS Program
New Haven, Connecticut
xi
CONTRIBUTORS
Bruce G.Trigg,M.D. Phillip D.Woods,D.D.S.,M.P.H.
Medical Director, Public Health Program Lieutenant Commander, Dental Department
Metropolitan Detention Center United States Public Health Service
New Mexico Department of Health Federal Bureau of Prisons
Clinical Associate Professor, Department of Pediatrics Department of Justice
University of New Mexico Health Sciences Center National Periodontal Consultant, Bureau of Prisons
Albuquerque, New Mexico Phoenix, Arizona
Heather Villanueva,R.N. Ralph P.Woodward,M.D.
Assistant Administrator—Health Services Division Director of Clinical Services, Health Services Unit
Oregon Department of Corrections New Jersey State Department of Corrections
Salem, Oregon Trenton, New Jersey
xii
Preface
It is almost 7 years since the first edition of Clinical Practice in More than ever, public health plays an important role in
Correctional Medicine. The incarcerated population has correctional medicine. Incarcerated persons most often leave
increased unabated, albeit at a slower rate, since the first edition jails and prisons and return to society. Dr. Lincoln from the
of this book. For the first time in the history of this country, over Hampton County Jail, along with John Miles who worked at
2 million persons are incarcerated on any given day with over 10 the CDC, contributed to an important new chapter that
million persons discharged annually from local jails. The per- provides guidance on how to establish linkages between jails
sistence of this population has resulted in a continued need to and prisons and public health institutions in establishing con-
provide medical and mental health care and therefore a need for tinuity for inmates as they readjust to society. The dramatic
this type of textbook. This edition contains 15 new chapters and increase in incarceration has been fueled in large part by incar-
24 others that have been extensively revised. We want to warmly cerating persons who use drugs. Treatment of this population
welcome the 6 new associate editors and 46 new authors. has been neglected. Bruce Trigg from the New Mexico
Correctional medicine is now established as a necessary and Department of Health provides details on opioid replacement
important discipline of medicine. The various areas that differ- and other harm reduction strategies for incarcerated persons.
entiate this discipline from other disciplines are described in the Nurses are essential members of the correctional health care
first section that defines correctional medicine. Because this area team. New associate editors, Catherine Knox and Madie
of medicine concerns a vulnerable population without a public LaMarre, along with six other nurse authors, provide guidance
voice, we have added a chapter on health advocacy and the role to nurses on the practice of correctional nursing. Nurse sick call,
physicians may play in protecting and caring for this popula- infirmary care, primary care, and nurse infection control chap-
tion. ters provide nurse-specific information by nursing authors.
Evidence-based practices continue to provide new data that Several new special areas have been added to this edition. Dr.
make intake tests and annual health interventions more effective Ron Shansky and Dr. Gordy Schiff from Cook County Hospital
in screening and intervening for health conditions. The intake give information on performance measurement as a means to
chapter has been combined with a section on annual health improve outcomes in chronic illness and disease management.
interventions so that intake evaluations are seen as the first of a Dr. Robert Greifinger describes how quality of care can be
series of annual efforts to provide preventive health care for the improved through managed care systems. As the inmate popula-
inmate. The sick call chapter now has a nurse co-author tion ages, more elderly inmates are dying in prisons. Fleet Maull,
acknowledging and supporting the nurse in the sick call who previously helped establish a prison hospice program as an
assessment effort. Chronic disease care has been revised to inmate, gives a unique perspective on how hospice care is
support the concept of a team approach in providing chronic perceived by the patients it serves. Technology provides new tools
disease care to the patient who is a partner to health care to support clinical programs. Drs. Ralph Woodward and Larry
providers in managing his disease. Mendel describe how the electronic medical records and
Infectious and contagious diseases remain a very important telemedicine can improve services to inmates utilizing these new
part of correctional medicine. This section has a new associate technologies. Finally, Drs. Makrides and Costa, along with a
editor, Newton Kendig, an infectious disease trained physician group of contributors, provide the first-ever chapter on establish-
who is also the Medical Director for the Federal Bureau of ing a dental program in correctional centers.
Prisons. The chapter on tuberculosis screening and management This book would not have been possible without the consid-
has been updated and contains information that will be consis- erable assistance from all the authors and associate editors who
tent with the new Centers for Disease Control and Prevention donated their time and knowledge to advance the field of correc-
correctional guidelines for TB control in correctional facilities. tional medicine. Acknowledgment must be given to Elsevier for
Hepatitis C has become a significant challenge to correctional their commitment to this project and to this population. Rolla
physicians. A chapter has been added to provide up-to-date Couchman and his assistant Dylan Parker along with the entire
information on the management of viral hepatitis, including Elsevier team deserve special acknowledgment for their efforts to
hepatitis C. A new chapter on infection control has been added coordinate this project in its many facets. This project would not
to provide a clinical basis in establishment of an infection con- have been possible without their support and encouragement.
trol program in prisons and jails. All of those involved in this project hope that readers will
The mental health section has been significantly revised and find this edition useful for clinicians working in correctional
updated. Jeffrey Metzner, nationally renowned as a correctional facilities to improve care for their patients as well as for those
psychiatric expert, is the new associate editor for this section. In who have an interest in establishing a standard of care for the
addition to significant revisions to previous chapters, a new incarcerated population.
chapter was added to address the special population of behav-
ioral disorder patients and those who commit self-harm. Michael Puisis, D.O.
xiii
Doctors, Patients, and the
1
History of Correctional
Medicine
Lambert N. King, M.D., Ph.D.
The prison should, were the world not full of paradox, be a very A book, rather than a chapter, would be required to present
paradigm of the rule of law. a complete history of correctional medicine. In this chapter, I
have chosen to present six historical vignettes that illuminate the
Norval Morris, 1974, The Future of Imprisonment1 story of correctional medicine. These vignettes carry us from
1775 to 2005 and from England to France to the United States.
Each offers perspectives relevant to current conditions and issues
in correctional medicine. In particular, I have selected vignettes
■ INTRODUCTION that address the following questions:
The history of correctional medicine is the story of doctors car- • How have the history, culture, and purposes of correctional
ing for people in jails and prisons, for good or for ill. Before institutions isolated and shaped the practice of medicine
1775, imprisonment was rarely used as a punishment for crime. within them?
Since that year, however, rates of incarceration have grown dra- • Why is it important to collect and consider systematic data
matically, and physicians working in correctional institutions about the health status and problems of incarcerated persons?
have long struggled with conflicts between professional • Historically stigmatized and isolated, to what degree have
covenants and the purposes and conditions of their patients’ physicians in correctional medicine moved toward profes-
confinement. Like the history of public health, the story of cor- sional identity and autonomy, consistent with the mainstream
rectional medicine consists of successive redefinitions of the of medical practice in the United States?
unacceptable. As the number of people incarcerated in the • To confine and to punish are the most durable purposes of
United States steadily escalated, correctional medicine assumed prisons, whereas concern for rehabilitation has waxed and
greater importance for public health and the welfare of many waned. As members of a caring profession, what responsibili-
individuals. Moreover, initiatives to build stronger connections ties do physicians in correctional medicine have to help foster
between correctional health care and community-based health institutions or alternatives to incarceration that more effec-
services are necessary to reduce marked racial and economic dis- tively rebuild lives, not simply punish and incapacitate?
parities in health status and outcomes in the United States. • To what extent is it necessary and possible for correctional
Understanding the history of correctional medicine also encour- medicine to be synchronized with health care systems and
ages health care professionals to continue to push back walls of professional organizations in the larger community?
inevitability and transform stringent limitations into human
possibilities. ■ VIGNETTE 1:THE MEDICAL OFFICER
Through their work caring for patients within the military serv-
INVICTORIAN PRISONS
ices, Veterans Administration hospitals, and public health clinics,
doctors have long functioned within the constraints of government With growth in the use of incarceration after 1775, hygiene
and bureaucracy. However, the practice of medicine in prisons and problems became more visible in English prisons and other set-
jails is probably the most enduring example of physicians caring for tings in which the poor were congregated. Among those seeking
patients within institutional structures whose priorities subordi- reform was a wealthy philanthropist and devout ascetic, John
nate those of the medical profession. Thus, the context of correc- Howard, who, in 1773 at age 47, left his country estate and
tional medicine is of special interest today because growing began a career of prison and hospital reform throughout Europe.
numbers of physicians practice within large public and private His quest cost him his fortune and, finally, his life in a typhus
organizations that fundamentally shape relationships between ward in Russia in 1791. Among John Howard’s closest collabo-
physicians and their patients. Furthermore, correctional health rators was a well-to-do Quaker physician, John Fothergill,
programs in the United States have become ever more important whose involvement with prison reform was an outgrowth of his
as providers care for people who lack health insurance, have interest in improving urban and institutional sanitation. Like
received limited prior health care, and who often suffer from severe Howard, Fothergill was keenly interested in science, subsidizing
mental illnesses and chronic diseases, such as hypertension and Joseph Priestley’s experiments and writing treatises on hygienic
human immunodeficiency virus infection. burial practices. As Michael Ignatieff2 describes in his book,
3
SECTION I
T AJust Measure of Pain, hygienic reform was both a moral and a The English prison medical officer was also responsible for
H
E medical crusade. Disease was seen as an outcome of vice to admissions to the prison hospital, which were much sought after
C
O which the poor were susceptible. Jail fever was attributed to by inmates, because the food there was more abundant and
R
R improper discipline as well as poor hygiene. Moreover, typhus palatable. One inmate wrote, when he was at last admitted to
E
C and other forms of jail fever were spreading to outside commu- the hospital, “Now that I lay stretched helpless on my back
T
IO nities. Prison magistrates became convinced that some form of everyone was gruffly kind to me, so kind indeed, that in my
NA hygiene and medical supervision was needed to contain diseases. weakness I often cried softly into my pillow with gratitude.”6
L P The problem was to convince colleagues and government Inmates incarcerated in Victorian prisons wrote many
H authorities that the introduction of basic hygiene, uniforms, accounts of their experiences, some terrible and some laudatory,
Y
SIC clean clothing, regular medical attention, and regimented diets with prison medical officers. Priestley7 synthesizes these experi-
IA would not compromise the pain and humiliation for which pen- ences in an eloquent fashion:
N
itentiaries were intended.
Physicians involved in the hygienic reform movement viewed These touching and sentimental scenes from institutional life do
the sicknesses of the poor as manifestations of their lack of char- nothing to rescue the practice of Victorian prison medicine from the
acter and worthiness. In 1795, John Mason Good, a physician consequences of its appointment to fundamentally disciplinary tasks.
at Cold Bath Fields prison, wrote, “The poor are in general but The doctors patrolled the narrow straits that separate hunger from
little habituated to cleanliness” and “feel not, from want of edu- starvation and punishment from outright cruelty, hauling aboard
cation, the same happy exertion of delicacy, honour and moral the life raft of their dispensations this drowning soul or that, and
sentiment which everywhere else is to be met with.” Ignatieff3 repelling, with brute force if necessary, the efforts of others to climb
observes that Good and other 18th-century doctors were to safety. In doing so, they lent to the work of preserving their
inclined to view physical illnesses as having “moral causes.” One employer’s reputations whatever dignity and authority their emerg-
early hospital reformer, Jonas Hanway, described immorality as ing profession possessed—and lost it.
an “epidemical disorder which diffuses its morbid qualities.”
Although the views of the hygienic reformers toward the Some Victorian physicians did, however, become strong
poor were judgmental, John Howard’s4 famous account of the advocates for the powerless individuals in their charge. Charles
State of the Prisonsis a prototype for approaching social evils in Short was the visiting surgeon at Bedford Prison from 1810
terms of their consequences for the community’s health. For until 1844. In 1836, he drew public attention to the increasing
every prison in the country, Howard recorded details about cases of petechial disease, which he thought was caused by expo-
buildings, diet, inmate population, and even the weight of the sure to cold, poor living, silence, and solitary confinement. In
chains used. Through his revelations of the relation between jails 1838, he told court justices that an improved diet was needed to
and spreading of jail fever, Howard aroused and galvanized pub- correct the poor state of the prisoners’ health. In response to Dr.
lic opinion and made improved conditions possible. Short’s advocacy, the home secretary issued minimum standards
In early English prisons like Cold Bath Fields and for prison diets. The minimum diet was to include animal
Pentonville, the customary entrance medical examination con- food for prisoners employed at hard labor, a considerable por-
sisted of weighing and measuring, followed by a doctor’s exam- tion of the food was to be solid, and there was to be variety
ination, and a rapid determination of prisoners’ fitness to be in the kinds of food provided. In 1845, however, inspectors
assigned to labor, light labor, the hospital, or an observational found that Bedford prisoners were not getting the recom-
cell. The doctor’s examinations were cursory, sometimes per- mended minimums.8
formed with the prisoner fully clothed. However, on entry into
the Gloucester prison, convicts were stripped naked, probed and ■ IMPLICATIONS OF VICTORIAN
examined by a doctor, and then bathed, shaved, and uniformed.
PRISON MEDICINE
Ignatieff2 writes that this purification rite cleansed inmates of
vermin but also stripped them of defining marks of identity. In The paradoxical duties of physicians caring for individuals in
his book, Victorian Prison Lives—English Prison Biography, 19th-century English prisons were emulated in early prisons in
Philip Priestley5 writes about the role of the Victorian prison the United States, where they persisted, in whole or in part, well
medical officer in performing the medical examination and into the 20th century. To be sure, institutional conditions, the
making decisions concerning special diets and admission to the quality of nutrition, and the professionalism of the security staff
prison hospital. Deep ambiguity exists, both professionally and are far better today than in the 19th century, but the physician
ethically, in the work of the early English prison medical officer. working in correctional medicine must often try to balance the
Victorian prison officials sought to avoid providing food that primacy of the doctor–patient relationship with the imperatives
would be criticized as luxurious, while, at the same time, of security and institutional policies. In many jails and prisons
attempting to avoid severe malnutrition in those in their charge. today, physicians still face conditions and deficiencies that com-
An English public committee studying this issue in 1864 rec- promise the health of their patients, just as Dr. Short did in
ommended that the existing dietary scales be reduced but added Bedford Prison in 1838. These dynamics continue to raise ques-
the caveat that the prison medical officer see every prisoner on tions about whether physicians working in correctional medi-
admission to certify his fitness for placement on the various cine are best employed under the aegis of the correctional
diets. Priestley6 observes that the discretion placed in the doc- authority or should preferably be deployed at “arms length”
tor’s hands raised tantalizing visions of better food in the eyes of through a health care agency or independent contractor.
hungry prisoners and helped turn the practice of prison medi- Professional values, organizational structures, and administrative
cine into a battleground between desperate and cunning con- control remain pivotal issues that will shape the future of cor-
victs and suspicious and resentful physicians. rectional medicine.
4