CHAPTER XV.

THE MEDICAL SERVICE.

No account of the English Prison System would be complete without reference to the place and duty of the Medical Officer in the daily administration of a Prison. The English law requires that a Medical Officer shall be appointed to each prison. The appointment is made by the Secretary of State on the recommendation of the Prison Commissioners, and office is held subject to the approval of the Secretary of State. Great care is taken in selecting suitable men with high medical qualifications, and who are possessed of proved tact and discretion; a practical knowledge of insanity is also requisite. As the size of the prison varies very considerably, in the smaller prison the Medical Officer is generally a medical practitioner residing in the vicinity of the prison, who devotes a part only of his time to prison duties: at least one visit daily is required. In the larger prisons one or more medical men are appointed, whose whole time is at the service of the Commissioners, the senior appointments being filled by promotion from the junior rank. The prisons are frequently visited by a Medical Inspector who not only supervises and advises the Medical Officers, but forms a link with the whole of the Medical Staff, thus tending to standardize the medical work carried out in prisons. He is also available to visit and report on any individual prisoner when any difficulty arises necessitating special inquiry. He works under the Medical Commissioner, who represents the medical side of the service on the Prison Board, and deals with the administration of the Department.

The mere enumeration of his statutory duties reveals the great and varying responsibility imposed upon the Medical Officer:--examination on reception and discharge; visitation of the sick and those under punishment; the sanitary condition of the buildings; ventilation; food; water; clothing and bedding:--all these things are combined in the daily round. He classifies prisoners for labour according to their physical fitness. He carefully notes the effect of imprisonment on the mental or physical state of prisoners, and advises when, in his opinion, life or reason is likely to be endangered by the continuance of imprisonment, and it is satisfactory to record that no abuse of this great responsibility has occurred since the prisons were taken over by the State in 1878. He takes under special observation any case where he has reason to suspect that the mental state is becoming impaired or enfeebled by imprisonment, and carefully notes any sign of incipient insanity. The health of the prison officers and their families, and the sanitary condition of their quarters are also his special concern.

It is a striking testimony to the skill and care with which these duties are performed that, with receptions in a normal year, we will say, of 200,000 persons, and with some 15,000 serious cases treated annually in hospital, of both sexes, and some 25,000 under continuous medical treatment for seven days or over, the death-rate in prison should be generally less than ·50 per 1,000 receptions.

Our prisons have been described by a high medical authority as among the best sanatoria in England. This praise is well deserved, but it does not mean that illness is rare or only trivial, but that the skill, industry, and patience of the medical staff, operating in healthy sanitary conditions, equipped with modern knowledge and resource in dealing with the great variety of disease, which diagnosis on reception, or individual care during detention, reveals, is effective in maintaining a high standard of general health with a comparatively low death-rate, so far as prison conditions admit a comparison with the general death-rate of England and Wales.

For instance heart disease, pneumonia, and phthisis claim a regular roll of victims, though, in most cases, death would be due to chronic complaints in old, or prematurely old persons, with broken-down constitutions.

The incidence of infectious disease in prisons has, for some years past, been remarkably low. In a prison community, any illness of an infectious character is naturally viewed with great apprehension, and is always made the subject of strict inquiry--the danger of infection being, of course, very great when so many persons are daily received and brought into association at chapel, exercise, labour, &c. Against this danger, the chief prophylactic must be in the exact and unerring skill of the Medical Officer, who is able to detect symptoms on reception which, unless detected, might spread an epidemic throughout the prison. Thus, at the time of the small-pox epidemic of 1902, it was due to the precautions taken that, with few exceptions, this highly infectious disease was prevented from spreading. When the epidemic of enteric fever raged at Lincoln in 1905, not a single case occurred in the prison, though prisoners were being received daily from various parts of the city. Erysipelas is disease which is not uncommon in prisons in the early days of imprisonment. Prisoners are not infrequently received with cut hands and other wounds in a neglected or septic condition, and with a probable predisposition to the disease arising from a weak or unhealthy physical condition. Isolation, and the usual precautions, however, generally prevent the disease, which has a tendency to recur, from spreading.

Deaths from phthisis average from ten to twenty a year. It is very rare indeed for the disease to manifest itself for the first time during imprisonment, but is already existing on reception, and more often than not in a far advanced condition. It had been observed that for the ten years ending 1901, there had been an average death-rate of 16·7 from this cause, and in that year, special instructions were issued for the segregation and special treatment of tubercular disease. Cases were to be treated in the most airy cells, with southern aspect, and special precautions taken with regard to the provision of spittoons, disinfection of clothing, utensils, fumigation of cells, &c. To carry out the spirit of these instructions necessarily entails much circumspection and good-will on the part of all concerned, both officers and patients. The effect of these regulations is not easy to discern in Local, or short-sentence, prisons, owing to the fugitive character of the population, but in convict, or long-sentence, prisons, where the conditions incident to imprisonment are operative over a sufficiently long period, evidence may be found as to the measure of the effect of prison life on this particular disease. An inquiry made in 1906-7 shows that the death-rate from phthisis among males (cases very rarely occur among females) sentenced to penal servitude (_i.e._ not less than three years) was 1·38 per 1,000 of the daily average population. Previously to the regulations of 1901, the mortality was nearly double, amounting to 2·00 per 1,000. Since 1901, also, another cause has been operating towards a decline in the amount of tubercular disease, _i.e._, the more generous prison dietary of that year, with an increase in the proportion of fatty elements.

Inquiries made at the time of the appointment of the Royal Commission to inquire into the prevalence of Venereal disease in 1913 showed that of the receptions into prison during the six months between November and April 1914, 64,023 males and 17,161 females were received into prison. Of the males 1·58 per cent., and of the females, 1·98 were found to be suffering from some form of venereal disease. Full advantage is taken of the modern methods of treatment, and practically at all the larger prisons there is a clinic. Where facilities do not exist in the smaller prisons, prisoners are treated at an outside clinic, or transferred to a prison where there is one.

Medical Officers also have very important duties and responsibilities in connection with the feeding of prisoners. Prison dietaries in this country have always been prescribed by Statute, but these definite prescriptions--what a prisoner shall eat and drink--are always subject to the moderating discretion of a Medical Officer. Formerly, the prison dietary was regarded as an element of penal discipline. Sir J. Graham, when Home Secretary, had repudiated this principle as long ago as 1843, but the Secretary of State of those days had no power to enforce his views on the local Justices, who gave effect to the popular idea that the ordinary prison diet might properly be regarded as an instrument of punishment. It must not be supposed, however, that the elimination of the penal element necessarily connotes an attractiveness of prison fare. This is not the case; but the difficulties of framing a dietary which shall be sufficient and not more than sufficient, for the varying needs of many thousands of human beings of different ages and physique is admittedly very great.

The dietary of 1900 has, at least, removed one grave reproach against the system, _viz_:--that prisoners habitually, and almost invariably, lost weight. Under the old dietary, no less than 80 per cent. of prisoners engaged on hard labour for a month or less lost weight. The progressive improvement of dietary scale, proportioned to length of sentence, has been effective in mitigating the ill-effects arising from the application of the principle of punitive diet as a part of the sentence of imprisonment.

The skill and care of the medical staff would, however, be less positive in its results but for the sanitary condition of the interior of prisons, which has, for many years past, engaged the closest attention. Great improvements have taken place of late years in the construction of hospitals, and in the ventilation of halls and of cells, and in the reconstruction of drains on the most up-to-date lines. Formerly, the gas-lights, which are now in the corridors, were inside the cell--in many cases, naked lights,--an objectionable system from a sanitary point of view, and affording an easy means for mischief or self-destruction, while giving inadequate light for reading or working. It is not only with regard to artificial light that progress has been made. The opaque window glass excluding the light of day, and the hermetically closed window are now only memories of the past. All these things of late years have had the effect of improving the sanitary condition of prisons and the health of prisoners, and have, no doubt, contributed to the remarkable bill of health which our prisons present.

But it is not only with the physical state of prisoners and the sanitation of prisons that the medical staff is concerned. The prison Medical Officer has justly acquired a reputation as an expert in mental disease. Although a practical acquaintance with lunacy is expected of a candidate for the Medical Service, it is owing to the exceptional opportunities afforded for diagnosis of the varying and often peculiar mental states of prisoners that he is expected, and is able, to give an expert opinion, not only in the grave cases where sanity is in question, but also in those difficult and doubtful cases of mental defectiveness which are continually occurring in every mode and degree. Especially is great importance attached to the opinion of the Medical Officer of prisons as that of an unbiassed expert witness on the mental condition of cases charged with a capital offence. The growing practice of the Courts to remand for medical observation in prisons when any doubt exists as to the state of mind, has the desired result of preventing the commitment to prison of persons who would be certified to be insane almost as soon as received. Thus, twenty years ago the number certified insane after reception into prison was a little over one per cent. of the total receptions. To-day it is about half that number.

It is, however, with regard to a class of prisoner, who, for want of a more precise and descriptive term, is designated "mental defective", that the Medical Officer is called upon to exercise all his vigilance and powers of diagnosis. There are persons who cannot be deemed sufficiently irresponsible as to warrant certification, but who, from obvious mental deficiency, cannot be considered fit subjects for penal discipline. In 1901, a special treatment was established for this class in local and in convict prisons. The effect of the new regulations was largely to increase the rôle and responsibility of Medical Officers in controlling the daily routine in respect of food, labour, and punishment. It was about this time that the question of the best method of dealing with mentally defective persons, other than those certified under the Lunacy and Idiots Acts, came prominently before the public, and a Royal Commission was appointed to inquire into the matter. At the same time, an attempt was made to ascertain the number of persons in prison who, on account of mental defect, were deemed unfit for ordinary penal discipline. Medical Officers were requested to note down for six months the number of persons received into their respective prisons who, in their opinion, were of such a low order of intelligence as would be likely, by want of normal self-control, to get into mischief, or commit crime. The result was that 3 per cent. of both sexes of the total number of prisoners received were shown to fall within this category. Writing on this subject in 1912, Sir Herbert Smalley, until lately the Head of the Prison Medical Service, states:--

"The number of prisoners who are mentally defective is the subject of the very widest difference of opinion. There are some who would have us believe that all prisoners are mentally affected, in fact they urge that the mere fact of their committing crime is a proof of this. There are others, who, whilst not going this length, yet put the number at a very high figure. One well known writer recently alleged in the daily press that probably 40 per cent. of our criminals are mentally defective. A well known alienist writing to the "Times" some years ago stated that at least 20 per cent. of all police court cases belonged to the class of mental defectives. The Medical Investigators appointed by the Royal Commission for the care and control of the feeble-minded, after visiting several prisons and having seen some 2,553 prisoners, estimated the number as mentally defective at 10·28 per cent. This is again a higher rate than is generally returned by the prison authorities as the number of mentally defective persons amongst the prison population (irrespective of those certifiably insane who are obviously unfit to be at large), _viz._, 3 per cent.

"Here at once is a wide divergence of opinion and the reason for the great discrepancy is that so much depends on the view that is taken as to the degree of mental deficiency which justifies an individual being regarded as "Feeble-minded." There is no hard and fast line of demarcation, as has been asserted, between feeble-mindedness and sanity, any more than there is between a great many cases of insanity and sanity; from the normal down to the lowest idiot, or dement, it is only the question of degree of deficiency of mental power. This was pointed out by the Departmental Committee on Defective and Epileptic Children as far back as 1898."

"One of the Medical Investigators of the Royal Commission alleges that "the higher grade aments" are sometimes not recognised by the prison authorities, who are apt to think a man who works well and behaves well in prison must be normal. There is some truth, no doubt, in this, for in prison there is strict and close supervision, there is the daily routine and the absence of "stress," "alcohol" and "temptation," to which people are subject in the outer world; moreover, in many cases, their time in prison is very short and their true mental condition is masked by the condition in which they are received (as, for instance, under the influence of drink and deprivation) so that the medical officer very naturally hesitates before reporting them feeble-minded."

The Mental Deficiency Act, 1913, came into operation on the 1st April 1914. It provides for three forms of supervision for defectives, _viz_:--State Institutions for defectives of dangerous or violent propensities, Certified Institutions, and Guardianship. The last named can be ignored in considering criminal defectives.

When the Act came into force there were no State Institutions, and the accommodation in Certified Institutions was totally inadequate to meet the needs of the situation. A State Institution was secured towards the end of 1914, but was almost immediately handed over to the War Office. Little, or nothing, could be done in the way of provision of further accommodation, State or otherwise, during the continuance of the Great War, and, as a result, very few criminal defectives could be dealt with. Since the termination of hostilities, a State Institution for male and female defectives has been established, and further institutional accommodation provided, and it is hoped that in the near future full provision will be made for dealing with all defectives, guilty of criminal offences, who are certifiable under the Act.

From 1st April 1914 to 31st March 1919, 871 cases were certified under the Act, the total receptions into local prisons for this period being 376,000, _i.e._, 2·3 per 1,000 receptions. The prisoners certified in prison do not comprise the whole number of cases of criminal defectives dealt with, as Courts have power under the Act to send such defectives direct to Institutions, instead of to prison, and, as the working of the Act becomes more stabilised, advantage is taken of this power to an increasing extent.

But even so, there is a considerable discrepancy between the defectives dealt with under the Act and the official ante-Act estimate, which was considerably greater, and this is mainly due to the strict requirement of the Act that the defect must have existed from birth or from early age. Here at once a large number of prisoners regarded as mentally defective, forming 30 per cent. of the whole, were excluded from the operation of the Act owing to the fact that the mental defect from which they were suffering, _e.g._, senility, alcoholism, arose from causes operating later in life. Again, of the number of prisoners whose mental defect was regarded as of congenital origin, 77 per cent. were over 25 years of age, thus making it difficult to obtain proof of the existence of the defect from early age, without which a certificate cannot be given.

But the Mental Deficiency Act, limited as it is in its scope, and disappointing in its results, is a pioneer piece of legislation of considerable importance. Many Voluntary Associations and other bodies in this country interested in its administration are advocating an extension of its provisions, and I think we can anticipate with every confidence the time, to which the prison reformer has so long looked forward, when those unhappy persons, who through mental affliction drift inevitably into criminal courses, are removed from prison surroundings to the more appropriate atmosphere of institutions where they can remain under proper care and control.

The operation of the Mental Deficiency Act, 1913, and the discharge from Naval and Military Hospitals of numbers of men suffering from mental and physical disabilities arising out of the war, have accentuated the already growing interest shown by Justices, and others engaged in the administration of the Criminal Law, as to whether the means hitherto taken for dealing with persons committing offences are the best and most humane which could be adopted. The opinion has been growing in intensity for some years that mental and physical disabilities may largely contribute to the commission of crime, and that it is the duty of the community to investigate thoroughly such causes, when they exist, to determine whether they are beyond the ability of the individual to control, whether they do not limit wholly, or in part, the responsibility for the commission of the offence, and to what extent they should be taken into account in determining the question of punishment: and whether some form of _treatment_, rather than _punishment_, by imprisonment, cannot be devised, which shall be more scientific, efficacious and humane.

The Justices of the City of Birmingham, early in 1919, took action and approached the Prison Commissioners in the matter and asked that a whole-time Medical Officer might be appointed to the Prison, and that portions of the hospitals, on both the male and female side, might be entirely partitioned off from the rest of the Prison and adapted for the reception of persons on remand whose mental condition appeared such as to require investigation.

Effect has been given to the recommendations of the Justices and, at the time of writing, the scheme has been in operation for some 12 months with valuable results. The Medical Officer of the Prison works in the closest co-operation with the Justices and no person, in whose case there is any suspected mental element, is sentenced to imprisonment until after full investigation of his condition of mind and all other avenues of dealing with the case have been exploited. The "Birmingham" experiment, as it is termed, has aroused great interest throughout the country and an extention to other centres, in a modified form, has already resulted.

The institution of the Borstal System has given a new and additional importance to the rôle of the Medical Officer, who plays an important part in the daily administration of these Institutions. From the medical point of view, the system commends itself more particularly by its insistence on the influences which promote sound physical development. Special inquiries made by the Medical Staff in 1903 and 1907 furnish positive proof of the physical inferiority of the adolescent criminal, 16-21, relatively to the free population, notably in height and weight. These inquiries furnish a striking argument in favour of the soundness of the principles on which the Borstal System, as explained in a previous chapter, has been established.

The foregoing observations merely indicate generally the direction in which the manifold activities of the Medical Prison Service are exercised. I have laid stress on the part played in the discernment and investigation of mental disorder. That the question of guilt is identical with the question of mental soundness is a commonplace not only with those who seek to analyse by scientific inquiry the mysterious and subtle working of the human mind, but with those who, working in the name of humanity, are forced by personal observation, unaided by science, to the conclusion that many whom the law strikes are not fully responsible for their actions, and are not justly punished. In the United States of America, where science and humanity march hand-in-hand in exploring prisons and places of punishment, and in surveying the whole field of crime, we find that practical steps have been taken by the establishment of criminal laboratories, as at Chicago and Boston, to classify offenders, especially the young, according to the nature and degree of their mental capacity for distinguishing right from wrong. There is nothing so elaborate as this in England, but this is not because public opinion is not keenly alive to the importance of the medical aspect of cases, but because it would not be disposed to admit that the causes of a criminal act are discoverable by physical observation, or by the precise research of a criminal or clinical laboratory. It would be the duty, and the pride, of any civilized State to maintain a high standard of medical work in Prisons: it is a question whether the establishment of criminal laboratories does more than illustrate the practical benefits to be derived from good and thorough medical work in prisons, and whether experimental psychology, with its instruments of precision for testing the human mind, is a really effective auxiliary for the Court of Law in deciding guilt. It may be of value, as a supplementary aid to such diagnosis as a conscientious Medical Officer would apply, and it could be used as a means to support and justify opinion, but it cannot, by itself, be a substitute for other methods of observation. Though public opinion in England is increasingly sensitive to degrees of responsibility, as affecting punishment of crime, it would be more disposed to place its faith in a medical man having experience of mental disease than in the conclusions drawn from the employment of the precise methods of experimental psychology alone. It is disposed to take the view expressed by no less an authority than Dr. Binet, which is to the effect that the complex phenomena of human action cannot be expressed in a few terse formulas,--"_c'est de la littérature: ce n'est pas de la science_." He inclines to the view that the essential characteristic of normal man is in the _direction_ of choice. The want of direction is due to a disordered _moral_ nature. Of this moral degeneracy little is known. The subjective valuation of the alienist cannot in practical life be the test of responsibility--the Judge, as representing 'common sense,' must decide.

At the same time, it recognizes the enormous value of preventive medicine in relation to the detection of mental disorder in its earliest stages. Sir George Newman, in his recent work "An Outline of the Practice of Preventive Medicine" lays great stress upon this point. He states: "Here, as elsewhere, we must seek to begin at the beginning. An understanding of eugenic principles and practice, a new aptitude and alertness in the physician, a new type of clinic, special hospital and institution--"early treatment centres"--a system of "voluntary boarders" in approved homes and institutions, a wider education of the public in what causes and constitutes mental incapacity, a larger apprehension of the meaning of self-control--all this is necessary if we would prevent mental disease. It is obvious that such a policy raises many questions of science, law and administration. But the experience of the war and of our colleagues in America (at the Phipps clinic at Baltimore and the psychiatric hospital at Boston) all points in one direction, namely, the practicability of establishing suitable psychiatric clinics in this country for dealing with early cases of mental and nervous disorder."

In order that the whole-time staff of the prison medical service should be kept fully acquainted with modern developments in medicine and surgery, a system of "study-leave" was inaugurated in 1909, whereby a certain number each year take up a post-graduate course at the large hospitals. Special leave is allowed for the purpose, and the Commissioners pay the fees. Each officer chooses his own course of study, subject to the approval of the Medical Commissioner, due regard being paid to the special requirements of the prison service.

The nursing of sick prisoners is carried out by officers of the hospital staff, except in the smaller prisons where, for the present, outside nurses are engaged. The male officers are selected from candidates who have had nursing experience in the Royal Army Medical Corps or in Institutions, and they undergo a course of training in prison nursing and hospital duties at the invalid convict station at Parkhurst, Isle of Wight, before appointment to the hospital staff. As regards the female officers, these have, in the past, been officers trained in the larger female prison hospitals, but the question of securing more fully trained nurses for female prisons is now under consideration. With this object in view, a Voluntary Advisory Nursing Board has been established consisting, for the most part, of distinguished members of the medical and nursing professions to advise the Commissioners in formulating a scheme for a prison nursing scheme, and the Board will, it is hoped, be a useful auxiliary to the administration for this purpose in the future.