Introduction

Expanding the area of application of the penalty of deprivation of freedom, initially by court practice and then based on the law, resulted in its domination within the penal system of Serbia in the second half of the 19th century. Competent state authorities awared that prison population, as a particularly endangered population in terms of health, represent a great risk to the health of the remaining population at the same time, and made efforts to carry out the health care measures of convicts within the reform of penitentiary system. This is why the medical treatment of convicts became the subject-matter of legal regulations very early. The concept of health care was not defined by the regulations (Law on establishing the national medical fund in 1879 and the Law on regulation of medical profession and protection of the national health in 1881) [1], only the medical bodies and institutions as well as their respective duties were determined. The main tasks were to deter the population from quackery by providing medical treatment according to the rules of "scientific medicine" and to overcome the problems occurring due to medical assistants impersonating medical doctors or masters of surgery, who in the lack of real medical doctors might have been hired as physicians [2].

In the Principality/Kingdom of Serbia, the penalty of deprivation of freedom was served in three penal institutions: in the Belgrade penitentiary with Topčider prison (1851) [3], in the Požarevac penitentiary (1865) [4] and in the Niš penitentiary (1878) [5]. The rules on distribution of convicts depending on gender, type of penalty and territory in these three institutions were changed several times. During the longest period of time, it was in Belgrade and Niš that the adult male convicts served their penalties of imprisonment and hard labor, and it was in Požarevac where their respective sentences were served by adult males convicted to imprisonment, women convicted to imprisonment and hard labor as well as juveniles.

Trying to organize that serving the penalty of deprivation of liberty was based on modern penological principles, the Defenders of the Constitution legally established the health care system for the convicts. First the title of the medical doctor was established in 1853, in the Belgrade penitentiary which housed the highest number of convicts [6]. After the Law on building and organization of hospitals (state, county, district, municipal and private) had been adopted (in 1865) [7], a shift was made also in legal regulation of health care of the convicts. The Minister of Justice Đorđe Cenić prescribed the Rules on domestic order of the penal institution in Požarevac (1868) [8], the Rules according to which the hospital of Belgrade penitentiary should be run (1869) [9], and which were also applied in all penitentiaries, and the Law on release of convicts on parole [10]. The rights and duties of penitentiary doctors were defined by the Law on penitentiary doctors (of 1883) [11].

The health care of convicts, in addition to the usual medical treatments of the sick people, which the doctors in infirmaries and hospitals of penal institutions were in charge of, included the preventive measures: mandatory physical examination before coming into the penitentiary aimed at early detection of a disease, vaccination and revaccination. Particularly bad living conditions had additional aggravating influence on the convicts' health. Insufficient and inadequate housing capacities for serving the sentence of deprivation of liberty for a longer period of time made the "prison issue" the burning penological issue.

The penitentiary doctors made efforts through the Ministry of Justice to get the measures necessary to care for the convicts' health standardized, but their implementation was limited by the policy of government austerity measures. Creation of adequate living conditions and provision of medical supplies was connected with considerable financial costs, which resulted in forced decisions.

Penitentiary doctors

Health care of convicts was carried out in penitentiary infirmaries and hospitals, and also in county and town hospitals when required. The first significant step in the organization of health care of convicts was to establish the title of a special doctor who was in charge of monitoring the convicts and their hospital in the Topčider penitentiary (1853), at the time when only nine county towns in Serbia had their respective hospitals [6]. The largest number of convicts served their sentence in the Belgrade penitentiary which consisted of 16 dungeons in Belgrade and one building in Topčider [12]. The fact that the Belgrade penitentiary had its permanent doctor even before the Belgrade town hospital, where the town physicians treated patients until the appointment of Jovan Valenta for the head of the hospital in 1865, speaks about the awareness of the authorities that the prison population was a particularly risky population in terms of health. Continuous presence of a doctor, however, could not be provided in all penitentiaries due to the insufficient number of doctors in Serbia. Only the Belgrade penitentiary had its permanent doctor, while in other penitentiaries part-time doctors took care of the convicts' health.

According to the Rules (1869) [9], the duties of penitentiary doctors were: to have a detailed physical examination of the convicts when they are admitted to the penitentiary, to visit convicts regularly twice a day every day and additionally at any time of the day, particularly at times of epidemic, to treat sick convicts, to control the nutrition of the sick convicts (quality of food, dishes, water, milk and other drinks), to train nurses to take care of the sick, to control the work of hospital staff and hospital commissioner, to control implementation of protocols and statistical examinations of the sick, cured and dead convicts, the control of medicines used for medical treatment, food, bandages and medical supplies, to take care of the organization and maintenance of the hospital within the approved budget, to make and give regular medical reports to the Ministry of Justice (monthly and annual reports) on movement of the sick convicts and their health condition, to implement preventive measures in order to prevent spreading of infectious diseases, to take care of convict immunization and keeping records on vaccinated and revaccinated convicts, to prescribe doctor's orders on the diet and taking medicines by the sick convicts, to take care of serious injuries and training of nurses to take care of small injuries. The penitentiary doctor was also a member of the Consulting Committee of the penitentiary, who decided on the classification of the convicts into certain classes and made suggestions for their parole.

The penitentiary doctors, according to the 1883 Law on Penitentiary Doctors were appointed by the King's Executive Order at the proposal of the Minister of Justice [11]. The Law on Organization of Medical Profession and Preserving the National Health (1881) [2] prescribed that the penitentiary doctors had to be the doctors for the whole medicine or doctors of medicine and surgery, making them equal in terms of their rights, duties and salaries with county physicians.

It was the Belgrade Penitentiary that got its first doctor. In 1854 the master surgeon Jovan Siber was appointed a contractual doctor at the Topčider farm. Siber took care of the health of the convicts and the students of the Agricultural School at the same time, up until 1856. A county doctor and surgeon Josif Vardian was a county doctor twice (1856– 1857, 1859–1860), while in the meantime this duty was performed by Bernhardt Kalmanj (1857–1858) and then the physician Milosav Pavlović (1861). Temporary penitentiary doctors were Jovan Kovač (1862–1864), Bogoljub Đorđević (1865–1867), Mladen Obradović (1868) and Pavle Stejić (1874–1875). From 1865 to 1873 and from 1876 to 1880, the position of the penitentiary doctor was empty [13]. After the Law on Organization of Medical Profession and Protection of National Health (1881) [2] had been adopted, the following permanent penitentiary doctors were appointed again: Milutin M. Popović (1881–1895), Đura Gavrić (1896–1899), Selimir Đorđević (1899) and Milan Vasić (1899–1914) [13].

In the Požarevac Penitentiary, the following contractual doctors took care of the convicts’ health: Vladislav Jasnjevski (1884–1886), Viktor Skubica (1887–1888 and 1890–1892), Stanojlo Vukćević (in 1885 and 1892–1900), Milenko Đorić (1901–1904, in 1906 and in 1910), and Milovan Milovanović (1907–1909) [13]. In 1905, 1912 and 1914 respectively, the Požarevac penitentiary did not have a doctor at all. In the Niš penitentiary the contractual doctors were: Andrija Janković (1884–1885), medical captain Borisav Pavlović (1896), Jovan Bogdanović (1897–1903), Stojadin Stojanović (1906–1909) and Milutin Kopte (1910) [13]. This penitentiary was also without a doctor in 1904, 1905, 1911 and 1914.

Penitentiary nurses

Due to the lack of qualified hospital personnel, both male and female convicts worked as nurses in the penitentiary hospitals. Since working engagement in a penitentiary hospital could result in parole or amnesty of the convicts [14], given the prescribed conditions had been fulfilled, it was prescribed nurses could be taken among the convicts, especially those "who are healthy, strong, who are not disgusted by the diseases or the sick people and those who are hard-working, as well as those who are sentenced to minor penalties, who are obedient and are of generally good behavior" [9].

The penitentiary nurses were classified into two categories, the first one including just the literate convicts, while the literacy was not mandatory for the second category. A first-class nurse was in charge of five seriously ill people or ten ordinary sick bedridden convicts or twenty recovering patients, while six second-class nurses were in charge of fifty sick convicts with proportional increase (7 : 60, 8:70, etc.). The nurses had to treat the sick people humanely and fully observe the guidelines and recommendations of the doctors and the orders of the hospital commissioner. Their duties included taking care of regular diet and taking medicines by the patients, maintenance of hygiene of patients' clothing and bedding and bringing incense burner after washing up and tidying the room. They took special care of dying patients, and they had to inform both the doctor and the hospital commissioner immediately on the death of a convict. The first-class nurses had mandatory regular 24-h-on-call shifts with continuous presence of at least one nurse in every hospital room. The nurses on call controlled the presence of all patients at stationary treatment, registered every change in convict's health condition, took care of the order and hygiene and reported to the doctor in the morning. The second-class nurses took care of the hygiene of patient's rooms, washbasins and toilettes, of regular heating and lighting of all hospital premises and prepared the dead convicts for funeral [9].

Penitentiary hospitals

In Serbia in 1879, three out of 23 hospitals were intended for the treatment of convicts – in Topčider, Kragujevac and Požarevac, and from 1880 on in Niš. Penitentiary hospital did not necessarily mean a separate building. The Topčider hospital was connected with the Belgrade Penitentiary; the Niš Penitentiary had a separate building in the Fortress of Niš until 1903, while the Požarevac penitentiary consisted of individual convict's rooms. The sick convicts working in Kragujevac cannon foundry were treated in the county hospital.

Although Cenić considered that it would be best to build a separate building for the sick convicts within a penitentiary in order to prevent spreading a disease in case of some epidemic [15], due to the lack of money, he prescribed that two to three rooms should be assigned as penitentiary hospitals which are positioned at the healthiest and cleanest place in the building to be able to receive 20-30 sick convicts. Those who were sick with a dangerous infectious disease were to be immediately transferred from the penitentiary to the town hospital [15].

The convicts from 16 dungeons of the Belgrade Penitentiary were treated in the Topčider hospital. The hospital was under the same roof and directly connected with the penitentiary [16], which made it difficult to separate healthy and sick convicts and increased the risk of infectious diseases spreading. This is why those affected by infectious diseases were put into the rooms where prison guards lived. Since due to the increased inflow of convicts (at the end of 1897 it was 50 convicts a day), the number of prison guards increased as well, the accommodation of the convicts with infectious diseases became the most pressing issue. The penitentiary doctor Đura Gavrić asked the Ministry of Justice to have a separate building constructed for infectious diseases with six rooms or to make adaptation to the already existing building within the penitentiary complex. The new building could not be built due to the lack of money, and the attempt by the Minister of Justice to obtain the already existing building for that purpose 16 was without success since the management of the Topčider farm had already given its buildings to the army. After the morbilli epidemic, which in March 1898 affected Belgrade, and particularly Topčider where the proportions of the disease had been larger than in city dungeons (in Belgrade there were three infected persons per 110 convicts, while in Topčider this ratio was 700 : 20) [16], the convicts with infectious diseases were sent to the town hospital. In the Belgrade penitentiary hospital there was a hammam which was rarely used because it was difficult to purchase the wood for its heating and difficult to supply water which was brought in barrels from the Sava and the Danube [17].

The Niš hospital for the convicts was in a separate building of the Fortress of Niš until October 1903, when the penitentiary management ceded the building to the then town command [18]. The hospital building was demolished, and the material was used for erecting a new building for the army requirements. By reducing the accommodation capacity of the penitentiary the medical treatment of convicts became more difficult – 13 prison rooms could receive up to 500, and the mosque up to 200 convicts. In late 1904, through the Ministry of Justice, the penitentiary management asked the permission from the Minister of War to build a hospital for the convicts in the Fortress of Niš or at least the permission to use the buildings ceded to the army [19]. According to the approval of the Minister of War, Radomir Putnik, the penitentiary was given the stable and the mosque but not the sewing facility [18]. In addition to this, the penitentiary management also chose the three most comfortable dungeons for patient rooms [18]. The convicts with infectious diseases were sent to the town hospital.

The Požarevac hospital for the convicts consisted of three convict rooms – two for male and one for female patients. In the newly-built building of the women's prison (1874), one room was a hospital room. Due to limited hospital capacities and the lack of a permanent doctor, in addition to the convicts with infectious diseases, the penitentiary used to send other patients to the Požarevac general hospital. The condition partially improved by building two more additional premises to the hospital for men (1900) [20], and also in 1912 when the new juvenile penitentiary was built in Zabela with two hospital rooms [21].

By the 1869 Rules, hospital equipment was also prescribed. A hospital room had to have an iron bed for each patient with either a straw-mattress or a mattress, a sheet, a wool-filled pillow and a blanket, one long jacket and a linen cap and one pair of slippers. The hospital had to have a sufficient number of food and medicine dishes, bedpans and spittoons and one board for each bed to register the use of medicines. The reality was, however, different. The inventory in the prison hospitals was rather modest. In 1869, for equipping the Belgrade penitentiary hospital, the following was asked to be purchased as necessary: "30 spittoons; a necessary number of robes, caps and slippers, one tin funnel for the pharmacy; 60 wooden spoons for the patients, one water glass for each patient, one mortar to crash and compose medicines; one small scale with necessary units of mass to measure medicines for the patients and, in addition, one pharmaceutical pane to cook medicines, and one screen to strain the cooked medicines" [9]. In one inventory which was preserved for year 1889/1890 "listing the things in convicts' hospital", it can be seen that, in the category of medical supplies and equipment, the hospital also had various kinds of thermometers, douches, hygrometers, hernia trusses, as well as "jars with leeches" [22].

Health care measures for the convicts

The health care measures for the convicts included preventive doctor's examinations before sending them to the penitentiary, mandatory doctor's examinations when admitting the convicts into the penitentiary, immunization, hospital and infirmary treatment of the sick convicts, reducing the number of convicts by paroling them, as well as initiative by the penitentiary doctors to suspend wearing the shackles.

Mandatory doctor's examination of the convicts when sending them to penitentiaries was the most important preventive measure [9], and its frequent omission caused reaction by the penitentiary management [23]. In 1884, the Minister of Interior warned county police authorities to send only completely healthy convicts to penitentiaries. Some of them clearly continued to neglect this obligation, so in 1892 once again the Minister ordered the mandatory doctor's examination making it precise that "if it is established by the physical examination that the convict is seriously ill, and especially if he had an infectious disease, such as measles, typhoid, cholera, etc. he had to be sent to hospital and there he should be kept under care until healed, and only then sent to prison" [24].

The treatment of the sick convicts implied prescribing and application of the corresponding therapies by the penitentiary doctors in accordance with the professional rules and austerity measures, as well as a special diet and certain palliative measures. The same medicines were used to treat penitentiary convicts as for the treatment of the rest of the population. The diet of the convicts was, as for all other patients, dietary and individualized on a daily basis. The dietary regime of the sick convicts, proportionate to the illness and the health condition of a convict, implied restricted diet, half a diet and the whole diet.

Isolation of infectious patients was difficult because of insufficient accommodating capacities for all sick convicts. This is why they had to resort to forced solutions, such as to send those convicts to other penitentiaries until epidemic decreased or until the accommodation for all infected convicts was provided. Thus, for instance, when in 1906 in just one day seven typhoid-infected convicts were admitted to the Belgrade penitentiary hospital, the Minister of Justice ordered all first-instance courts not to send convicts into this penitentiary until March 1, 1907, [25] or until new shacks for accommodation of the sick people were built [26].

Infectious diseases were the greatest danger to convicts' health. The most serious disease and the most frequent cause of death of convicts was tuberculosis. Lymphatic gland tuberculosis was especially dangerous. It developed so fast in the population of young convicts after a long period of incarceration that they would die only two to three years later. In the period from 1900 to 1903, death rate from tuberculosis in convicts was 22% [27]. Prevention and suppression of tuberculosis in Serbian penitentiaries at the time was a part of general fight with this disease, for which according to the opinion of doctors it was necessary that "there was a harmony of: wise management, well prepared doctors and reasonable people" [28]. In addition to isolation, the measures of protection from tuberculosis spreading among the convicts were: to equip hospitals with the necessary number of white clay enameled spittoons which had to be filled with sublimate solution twice a day (up to 1/3 at 1: 1,000 ratio) and emptied twice a day into special pits disinfected with sublimate as well, to disinfect hospital beds, walls and floors surrounding them up to two meters in radius by sublimate solution [27][29]. In 1910, doctor Vasić of the Belgrade Penitentiary, recommended relatively inexpensive prophylactic measures to suppress tuberculosis in prisoners and convicts: regular fortnight medical examinations of convicts and enabling relatives to bring them food and clean clothing, to spend 6-8 hours a day in fresh air, washing and scrubbing of cells at least once a month, washing the woodwork with hot water and disinfecting with sulfur and painting the walls every three months, bathing, shaving and cutting hair of convicts at least once a month [30].

Cholera was particularly dangerous for convict population. Since in the first half of the 19th century Serbia faced cholera epidemic for five times, the instructions, rules and directions of doctors regarding this disease were made public rather early. The convicts in penitentiaries were particularly endangered since non-hygienic conditions in which they lived were rather favorable for the outbreak and spreading of cholera. When during the Balkan wars the cholera epidemic was transferred into neighboring countries and in August 1913 it affected Niš, the Committee for national defense asked in a telegram to the Ministry of Justice to provide 50 convicts to help in the fight with the epidemic. The request was denied since cholera had already affected the penitentiary as well [31], taking the first victim at the beginning of September [32]. The penitentiary management managed to stop the spreading of the disease by isolating the sick people in cholera shacks near the "Red Cross" – twelve out of 40 convicts died, and the rest were returned to prison when they recovered [32].

Scabies was almost regular company of the prison convicts. In addition to non-hygienic conditions in penitentiaries, the greatest problem in suppressing this disease was a huge daily inflow of those convicted to short-term imprisonment, who served their respective sentences in their own clothing – vagrants and beggars in dirt-filled "rags". In August 1908, in order to suppress scabies a separate building was built in the Belgrade penitentiary for disinfecting device which was moved from the town into the penitentiary complex as early as in 1900 [33].

Due to malnutrition, scurvy or "alkaline disease", as it was called, was also very spread among the convicts [34]. Although the positive effects of eating fresh vegetable and lemon juice in treating scurvy were known, their becoming a part of convicts' diet was connected with too many difficulties, therefore only pepper and spinach and more inexpensive alternatives such as sour cabbage and nettle were used. Pepper juice, which as early as in 1864 was recommended by the military doctor Maksim Nikolić-Miškovićev as an efficient and inexpensive therapy in treating scurvy, was forgotten since the committee underestimated his findings. The quantity of 20 g of flour per day per convict, which was used to make roux for meals, was reduced to 5 g in 1898 at the proposal of the doctor of the Belgrade penitentiary [34]. At the end of the following year, doctor Vasić of the Belgrade Penitentiary supported the proposition of the management to give fatty food to the convicts two times a week instead of five times a week and that daily portion of bread would be reduced from 1,000 to 750 g, which would ultimately reduce the number of convicts "suffering from scurvy, the disease very rare and almost unknown beyond this prison" [34]. A longtime doctor of the same penitentiary, Popović, disagreed with Vasić, finding that "further reduction of already small amount of meat would not be advisable" [34]. Governed by the reasons of government austerity measures, the Ministry of Justice prescribed for the convicts to continue to get "1,000 g of wheat bread, well baked", and starting from January 1, 1900 to get 200 g of beef or sheep meat only on Sundays and Thursdays when they are not fasting" [34].

Immunization in Serbia was already practiced in the first half of the 19th century. The greatest threat was from the smallpox. Vaccination against measles was prescribed as early as in 1839 by the so called Pacek's Law – The Ordinances for District and Municipal Physicians [35], it was performed "from hand to hand" until 1886, when vaccination with animal lymph was introduced.

Measures of mandatory vaccination and revaccination of the sick convicts were consistently carried out, so that there were no epidemics in prisons but only individual cases of falling ill. For instance, in 1896 the Medical Division of the Ministry of Interior sent 200 portions of animal lymph to the Belgrade Penitentiary for revaccination of the convicts who were working in Dobričevo, with the instructions for those who might be sick to be sent to the Ćuprija hospital [36] (Figure 1).

Figure 1 Medical division of the Ministry of Interior sends 200 portions of animal lymph for the revaccination of convicts (Historical Archives of Požarevac, raw archival material [36]).

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There was a smallpox outbreak in the Belgrade Penitentiary in 1886 after an infected prisoner came from the Niš Penitentiary [37], and the following year several convicts in the Niš Penitentiary also fell ill because Kruševac county superiors sent an infected convict without medical examination [38].

One of the forced health care measures was to reduce the number of convicts in penitentiaries. Most frequently those who had fallen ill without the possibility to recover or the convicts with severe bodily defects, as well as those sick convicts who fulfilled certain conditions for parole and whose health would be aggravated by further prison service, were acquitted from further serving of their respective sentences. These measures were often initiated by the penitentiary doctors, guided not only by the need to unburden the accommodation capacities of prison hospitals but also by medical and human ethics: "Considering that in such cases it is more humane to make necessary exceptions and allow the convict – a man – to keep at least his life, I find that such patients need better living conditions for the sake of their own preservation" [39].

Serving the sentence of deprivation of liberty in shackles aggravated convicts' health additionally. Day-and-night wearing of shackles, both in summer and in winter, even during work caused leg, back and even chest pains in some convicts.

Older and sick convicts were particularly endangered. Acknowledging that "long-term wearing of iron mutilated many people in such a way that they could not recover at all since tendons under knees remained contracted and from the knees downward completely numb", the penitentiary doctors often proposed for such convicts to be released from shacks [17].

Conclusion

The absence of thorough reform of penitentiaries due to the lack of financial resources reflected on the range of the convicts' health care measures. Insufficient number of permanent doctors and nurses, limited capacities of penitentiary hospital and infirmaries, the lack of medicines and equipment, in addition to non-hygienic and inadequate accommodating conditions and disrespect of regulations on mandatory medical examination of convicts before sending them to prisons, were the greatest problems. The conditions for serving the sentence of deprivation of liberty in the penitentiaries in Serbia were certainly considerably worse than those in the developed European countries, and preventive health care of the convicts practically boiled down to mandatory medical examinations and mandatory immunization. As a part of general progress of medical conditions in Serbia in the second half of the 19th century, which occurred mainly thanks to the efforts made by doctors, there were certain shifts made even in the health care of the convicts.