For the first five years in the United States, I worked as a surgical resident in a major teaching hospital that was owned and run by the county government (local government). As such it was also responsible for the healthcare of prisoners in the county jails. There were two jails near the hospital, one for men and another one for women.

During my five years, I took care of many prisoners that came for treatment of conditions that could not be taken care of in the medical clinics attached to the jails. We also got many ‘malingerers’ that had learned how to mimic serious conditions that required a trip to the hospital.

No, we did not have any rich inmates or politicians in these jails that used their wealth or political influence to get out of jail for a few weeks for treatment of essentially nonexistent medical problems. So medical transfers from the jails were treated as any other patient and provided appropriate treatment.

Most of the patients from the jails were genuinely sick and required proper hospital care. Appendicitis, hernias, stomach problems and in women tumours in the uterus (fibroids) breast problems and of course non-surgical conditions like infections and other diseases were most common.

As surgeons in training, I must admit that we had a reasonable experience taking care of these patients. Many minor and major surgical procedures were performed on these patients and most of these procedures were entirely appropriate and were supervised by faculty members of the hospital.

Most minor injuries were taken care of in the jail hospitals but more major ones needed a visit to the hospital. There were the occasional fractures from fights but one particular patient did manage to break a bunch of bones in both his feet after jumping out a window in an attempt to escape. This prisoner had been involved in a famous case a few years earlier.

One of my most vivid memories was of a jail patient that tried to snatch a gun from his police escort. During the scuffle the prisoner got shot in the chest. We ended up taking the patient to the operating theatre to unsuccessfully save his life. It was the first time after opening a chest and looking at the heart I saw air in the arteries of the heart.

Some patients as I mentioned above did turn up with problems that were not really of a medical nature but were self-inflicted injuries to produce seemingly surgical problems. There were two types of injuries that were difficult to diagnose as self-inflicted and had enough real consequences to require tests and observation in the hospital.

The commonest of these injuries was ‘instrumentation’ with some sort of a needle to produce injury inside the urethra causing blood in the urine. Tests that would then be done included an X-Ray test to outline the kidneys and the bladder to see if there was anything wrong with them. And if that was negative then a direct look-see into the urinary piping system was done under aenesthesia called cystoscopy.

Another self-inflicted injury was swallowing ground glass. This would produce real stomach pain and bleeding in intestines. Once such bleeding was determined to exist, then tests had to be done to establish an appropriate cause. These including X-Ray tests of the intestines and direct looks into the upper and lower parts of the intestinal system.

All this was before we had ‘flexible endoscopy’ systems available that make such examinations a lot easier. These attempts to come to the hospital went into the hospital and jail records making repeat hospital admissions for similar problems rather unusual.

Also, every jail patient in the hospital had two policemen present around the clock to guard them. This was a major expense for the county and an inconvenience for the police to hang around in the hospital. I must however admit that a few romances between members of the nursing staff and the police escorts of the patients did occur and blossomed on to more permanent relationships.

There was one type of patient complaint that did occasionally require hospitalisation. And that is what I was reminded of recently when the most honourable Chief Justice of Pakistan raided the room of a jailed politician that was being treated in a Karachi hospital for severe back pain.

Before I go into the specifics of this condition as far as my experience with such patients from the jail that I treated as a surgical resident are concerned, I want to mention a few things about this condition. The first thing is that chronic or recurrent back pain is a real problem and a major cause of medical disability in the US.

And yes, I have suffered over the years from this problem. For me it started when I was still a medical student. I was playing table tennis in one of the King Edward Medical College hostels when I hit a forehand top spin shot. My right hand after I hit the ball kept moving up and I fell to my left unable to move. I had to be picked up and taken home.

Since then once every so often I will develop bad backaches, usually after long plane or motor rides and after long surgical operations (not on me!). But rest and some non-steroidal anti-inflammatory drugs (NSAIDs) like Advil take care of it.

It is often said that there are certain medical conditions in humans that are a result of our ancestors’ decision to walk on two rather than four feet. These among others include haemorrhoids, varicose veins and chronic backache.

In many people that suffer from back pain, weight loss, exercise and observing some basic precautions when lifting heavy weights helps. In people that develop nerve damage along with back pain, spinal surgery might be needed urgently to prevent permanent nerve damage.

Many incidents of severe back pain are due to spasm of the back muscles and many such patients are prescribed muscle relaxants (medicines that decrease spasm) as treatment. Incidentally alcohol is an excellent muscle relaxant. So, the aforementioned jail patient might actually have been using alcohol as a medical treatment for his back pain.

So during my residency when we had patients complaining of severe back pain who had no abnormalities on X-Rays (this was before we had CAT scans or MRIs) and had no nerve problems, the only treatment was bed rest, ‘traction’ and non-opioid pain medicines.

The type of traction was pretty straight forward. The head of the patient’s bed was put down twenty degrees and a harness was attached to the patient’s pelvis that was then attached to a string passed over a pulley at the foot of the bed. To this string was then attached a forty pound weight. Of course the patient had to stay in bed and perform basic body functions suspended in mid-air.

Most of these jail patients rapidly improved after being treated by this system of what I referred to only half in jest as ‘punitive traction’. And were then only too happy to get back on their feet and back to jail.