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bestowed upon the sick. The diet supplied to him was the common prison fare, and he lay on a piece of canvass spread on the floor.
12. If it be admitted that medical treatment is of any avail in promoting recovery from sickness, or postponing death, it follows that the complete absence of such treatment must retard recovery or hasten the coming end,
13. To the first question, therefore, we have to reply that the verdict of the coroner's jury at Hardle's inquest, was in accordance with the facts of the case, as we have aster- tained them, and we concur in it. And in regard to the further inquiry, who was to blame in reference to the neglect by which his death was accelerated, we are bound to say that through the want of proper care and diligence in the examination of the patient the Medical Officer failed to discover the man's disease, and, therefore, to order for him that treatment which he should have had, and the want of which, in all probability, hastened his death.
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14. At first sight it might appear that the keeper, as well as the doctor, was respon- sible for the negligence that occurred, since it might be presumed to have been his duty to send for the doctor when he found the prisoner getting worse. But there seems no reason to disbelieve the statement of Mr. Mapp, confirmed by others, that the prisoner did not appear to him at any time subsequent to the morning of the 22nd, when he was seen by the Medical Officer, so ill as to make it necessary to send specially for the doctor. if the indications of serious mischief were so slight as to deceive the doctor himself it is not to be wondered at that they conveyed no feeling of alarm to the mind of an unprofes- sional man, the keeper. And, however strange it may appear, it is yet a fact, which we believe rests on the best medical authority, that in persons of advanced life the onset and progress of fatal disease is sometimes so insidious that even professional observers, unless ever watchful, are in danger of being deceived. But for this consideration it would be impossible to hold the keeper free from blame: for, being aware, as of course he was, that according to custom there would be no medical visit again for several days, it would clearly, in our opinion, have been his duty to send for the doctor on the appearance of any new or untoward symptoms.
15. Indeed, we would venture to remark that the foregoing fact should be borne in
• mind in estimating the degree of blame that must fall on the doctor himself. It affords, however, no excuse for negligence or carelessness, though in some measure it may extenuate such an error as on the present occasion must be laid to his charge.
16. As to the second question proposed to us, we have no hesitation in saying that the building at present used as a hospital would be quite fit for such a purpose, were the patients requiring admission into it not so numerous as to overcrowd it, and were its rooms furnished with those appliances which are needful for the proper treatment of the sick. We regret, however, we cannot say that these rooms are free from objection in either of these respects. For we find, in the first place, that they are at present occupied by a larger number than they ought to contain. Secondly, that only two of the present occupants are supplied with beds, the other patients lying on pieces of canvass, called hammocks, spread on the floor; and thirdly, that there is not, and never has been, a nurse, or proper attendant of the sick, attached to the hospital. These are, no doubt, serious faults, and in noticing them we would specially draw attention to the last-named. It is one of such consequence, and at the same time so easily remedied, that we cannot but wonder that it has for so long been permitted to exist. The importance of such a functionary as a nurse is obviously great, not only for the purpose of supplying with regularity such food and medicines as may have been prescribed, but also of attend- ing to those offices, the neglect of which must be productive of discomfort, and tend to vitiate the atmosphere of the place.
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17. If overcrowding be detrimental to those in good health, it must clearly be far more so to such as are already struggling with disease. So long, therefore, as this hospital remains unduly filled, and continues to present the other defects we have endeavoured to point out, it cannot be pronounced fit for the reception of cases of serious disease.
18. Perhaps it might not be difficult to relieve it at once, by providing elsewhere for the more trifling cases.
⚫ 19. We think it would be an improvement if the ventilators, of which there is one in the roof of each room, were made much larger than at present, and differently constructed. As at present fixed, they are by no means so effective as they might be; the small pipes of about two inches bore now in the roof can be of little use.
20. With regard to the further inquiry suggested to us, namely, as to the number
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of cases sent annually from the Town Hall Gaol to the General Hospital, with the view of determining the question, whether diseases of a certain class are engendered or aggravated by residence in the Town Hall Gaol, we would respectfully beg to be excused from undertaking such an investigation at the present time. We are ready to admit the importance of such an inquiry, and to acquiesce in the opinion that much useful information would probably be gained by it, but we venture to think the subject altogether too large to be fitly or satisfactorily dealt with by the present Commission. The mere ascertaining of the number of cases of discase sent into the General Hospital from the Town Hall would of itself throw no light upon the question of the healthiness of that prison. For, supposing it to be shown, that a number of cases of constitu tional discase, say tubercular consumption, were thus annually transferred, or were received into the General Hospital after dismissal from the gaol, it would clearly be unjustifiable to draw the inference that the Town Hall Prison was alone to blame for the mischief,
21. A variety of other points would have to be considered, such as-
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(1.) The tendency to consumption which is alleged to exist in a marked and an increasing degree among the lower classes of the population, from whom the main body of prisoners is derived.
(2.) The effect of continued employment on such work as dredging (in which there is much exposure to wet and cold) on persons of peculiar constitutional dis- position.
(3). The nature of the diet whether, even if apparently sufficient in quantity, it be of the requisite quality, to maintain a healthy standard of vitality in men undergoing the severer forms of prison discipline, and
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(4.) The character of the medical care and supervision of the prisoners, whether it be sufficiently close, regular, and scrutinising, to reduce within the narrowest limits the chances of injury from excessive or inappropriate labour, and unsuitable food. Each of these causes in all probability has its share of influence in producing the result in question, and to each would have to be assigned its due proportion before a satisfactory conclusion could be arrived at.
22. If this were done it would probably be found that the share contributed by the presumed unhealthiness of the Town Hall Gaol has not been great, and is to be ascribed such as it might be, not to any essential fault in the site or construction of the rooms, but to the admission of undue numbers to those rooms.
23. For ourselves we strongly suspect that of the possible causes of ill health enumerated above, the 3rd and 4th would be found on careful inquiry to occupy a promi nent place; we find, for instance, that the diet in some respects at the Town Hall is less than that at Glendairy. And inasmuch as the Town Hall Gaol is not likely to continue much longer in use as a prison in such inanner as heretofore, it is less for the purpose of ascer- taining the sanitary shortcomings of this gaol, than of bringing to light and remedying such faults as may exist under these particular heads, that we should be glad to see a proper investigation of the matter set on foot.
We come now, in the last place, to the request that we should offer any suggestions that may occur to us as to the best mode of preventing in future such occurrences as that which has formed the subject of our present inquiry.
We have already pronounced it as our opinion, that the misdoing discovered in Hurdle's case was traceable to an act of carelessness or thoughtlessness on the part of the Medical Officer. Were this particular act the only thing to be blamed in all that in this inquiry has come to our notice, it might be regarded as one of those errors which, under the best systems sometimes occur, and which it is perhaps impossible altogether to prevent; but it is evident that the fault of want of thoroughness and spirit is one which extends itself generally to the manner in which the medical service of the Town Hall Gaol is performed.
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We observe that in the Rules drawn up for the management of Glendairy, the surgeon is required to visit the prison daily, while in those relating to the Town Hall, he is permitted to do so just so often as he may think fit, provided that an entry be made of the date and number of his visits in a book to be kept for the purpose. It is difficult, for us at least, to account for the distinction that is here made; but, manifestly it engenders the notion that a frequent and diligent medical attendance is of less consequence at the Town Hall than at Glendairy Prison. Thus, the notion of slackness in regard to the Town Hall is suggested to the Medical Officer by the Rules themselves. And accordingly, we find that two visits a-week to the gaol is all that has been deemed necessary, or required, as a rule, from the Medical Officer for the purpose of rendering to the prison discipline the aid which it expects and demands from medical skill.
PUBLIC RECORD OFFICE
Reference :-
CO. 885
PUBLIC RECORD OFFICE, LONDON
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