paralysis, was operated on at a civilian hospital and was instructed to move his legs as little as possible. The prison guards who returned him to prison disregarded the warnings of hospital personnel, handcuffed him, and forced him to walk. On his return, On his return, he was placed in a cell without facilities to care for him and denied his prescribed medication. The court of appeals, in reversing the district court dismissal, stated that the defendants' conduct was more than mere negligence or poor medical judgment. If proven, the conduct would constitute deliberate indifference to explicit medical instructions, resulting in severe and obvious injuries.

A county jail inmate successfully alleged a constitutional violation in Westlake v. Lucas, 537 F.2d 857 (6th Cir. 1976). The plaintiff alleged that after he informed admitting personnel that he suffered from an ulcer, his request for a special diet and medication

was ignored. 149 His complaints of stomach pain were

unheeded, and when he began to vomit blood he was given only antacid. Although the district court dismissed since it could find no tangible residual injury, the court noted that a prisoner who is allowed to suffer when relief is readily available states a cause of action.

A complaint alleging denial of medicine to control epileptic seizures survived a motion to dismiss in Mitchell v. Chester County Farms Prison, 426 F.Supp. 271 (E.D. Pa. 1976). Upon his transfer to Chester County, plaintiff informed a sergeant and medical officer of his condition. Although they said the medication would be sent, it was not provided despite his constant requests until three days later; during an attack plaintiff hit his head and required hospital attention. Thereafter medication was provided. Since the complaint showed the behavior to be arbitrary and capricious, the court ruled that it conformed to the level required in Estelle.150

149. But see Carlisle v. Scott, 357 F.Supp. 1284 (N.D. Ill. 1973) (failure to provide bland diet as ordered is not constitutional violation in absence of allegation of specific intent to harm or presence of severe injuries); Snow v. Gladden, 338 F.2d 999 (9th Cir. 1964) (claim that special diet was discontinued is insufficient in absence of allegation of bodily injury). See note 147 supra.

150. See also Campbell v. Beto, 460 F.2d 765 (5th Cir. 1972) (improper to dismiss claim alleging warden knew of plaintiff's heart trouble and disability classification and ordered him assigned to field work which resulted in heart attack).

In Tolbert v. Eyman, 434 F.2d 625 (9th Cir. 1970), a diabetic whose disease affected his eye received treatment prior to incara ceration which substantially improved his vision. After being incarcerated in 1967, he received insulin and blood pressure medication only once a day. Doctors at the hospital were skeptical of his condition but told him he could have medication if he paid for it. However, the medication was returned for security reasons when sent by his wife and directly by the druggist. The court of appeals disagreed with the district court's reading of his complaint as a difference of opinion: "The gravamen of his claim is not that he was erroneously diagnosed by the prison doctor, but that the warden refused to allow him authorized medicine that he needed to prevent serious harm to his health. These allegations state a perfectly viable claim. "151 434 F.2d at 626.

In Sawyer v. Sigler, 320 F.Supp. 690 (D. Neb. 1970), prison officials required all medication to be taken in crushed or liquid form to prevent narcotics addicts from hoarding. Plaintiff, who suffered from emphysema, was required to take medication three times daily. However, this caused nausea when taken in crushed form, and although the doctors specifically ordered that it should not be taken in this form, prison administrative officials overruled him. The court noted: "In the absence of showing [that Sawyer has a tendency to abuse drugs] . . I conclude that requiring Sawyer to take his medication in a form which results in nausea is sufficiently unusual, exceptional and arbitrary to constitute both cruel and inhuman punishment and a denial of adequate medical treatment." 320 F.Supp. at 694.

Where plaintiff's sinus condition was diagnosed as requiring an operation as soon as possible in Derrickson v. Keve, 390 F. Supp. 905 (D. Del. 1975), the district court disagreed with defendant's contention that the surgery was of an elective nature and not urgent or a

151. But see Henderson v. Secretary of Corrections, 518 F.2d 694 (10th Cir. 1975) (no claim was stated for failure to fill prescription for corrective shoes).

While isolated instances of inadequate medical treatment merely state medical malpractice claims, a series of such incidents, taken cumulatively, may indicate the inadequacy of the entire prison medical system. The courts recognize such a claim where it is shown that prison officials had actual knowledge of the conditions or failed to make evaluations and act on them. Failure to maintain a minimally adequate medical system is actionable under the deliberate indifference standard of Estelle.

Since actions involving the adequacy of the medical system usually request equitable relief, the remedies available range from a judicial order requiring the institution to prepare long range plans to specific mandates dictating the number of personnel that must be hired and the physical improvements that must be made.

152. See also Hirons v. Director, Patuxent Institution, 351 F.2d 613 (4th Cir. 1965) (remand to develop additional facts where plaintiff alleged recommended jaw operation not performed); Wilbron v. Hutto, 509 F.2d 621 (8th Cir. 1975) (failure to perform needed surgery on injured hand and forcing plaintiff to work in fields without medical authority from prison physicians may constitute deliberate indifference).

Typically, complaints relating to the medical treatment system allege inadequate diagnostic procedures (lack of lab tests, medical procedures, or slow follow-up); lack of medical personnel (the number of doctors or medical staff members and the hours on duty); administrative procedures which result in denial of access to medical care (sick call procedures); and inadequate facilities for treatment (deficiencies in clinic facilities or lack of facilities). It is difficult to state general standards since the cases present a wide range of factual situations; sometimes the presence or absence of any one of the factors can be determinative of the adequacy of the entire system.

It is not unusual, upon a finding of an inadequate medical treatment system, for the court to order specific relief. Gates v. Collier, 390 F.Supp. 482 (N.D. Miss. 1975) found that the continued failure to provide for the physical health of the inmates violated the Eighth Amendment. In addition to requiring the formation of a timetable to correct other deficiencies, the court ordered that two additional doctors, including a psychiatrist, be employed and a new hospital built.

Similarly, in a class action alleging inadequate medical and dental care at a state institution for delinquent boys, the court in Morgan v. Sproat, 432 F. Supp. 1130 (S. D. Miss. 1977), addressed itself to specific areas which needed correction. The court required the formulation of a written timetable; the addition of an infirmary to provide overnight medical care; a registered nurse available twenty-four hours per day (instead of eight hours daily); complete intake physicals; routine innoculations; and facilities for routine care.

Minimum standards for medical, dental, and psychiatric care were specifically delineated by the court in Barnes v. Government of Virgin Islands, 415 F.Supp. 1218 (D. V. I. 1976): (1) The standard for medical, dental, and psychiatric care was required to be comparable with that offered the general public. (2) A medical doctor with regular hours known to the inmates and always available on call. (3) Provisions for twentyfour-hour emergency medical treatment. (4) Intake physicals. (5) Prescription of drugs under strict supervision by trained medical personnel. (6) Complete and accurate medical records. (7) Provision for special tests and the equipment needed to conduct them. This

was to be accomplished by medical furloughs, purchased services, or transfer to appropriate facilities. (8) Part-time dentist on call for curative and preventive treatment. (9) Psychiatrist to be provided one day per week within sixty days. (10) Psychiatric aide permanently on the staff. (11) Intake medical status exam and transfer to an appropriate facility if needed. (12) Establishment of an alcohol and drug rehabilitation program. 415 F.Supp. at 1234-35.

A claim for money damages against the warden and medical director was dismissed with prejudicé in Hines v. Anderson, 439 F. Supp. 12 (D. Minn. 1977). However, an order and consent decree was entered which stated that the provisions of the Minnesota Patient's Bill of Rights (Minn. Stat. § 144.651 (1974)) would apply to medical treatment given in state prisons. All entering inmates were entitled to receive a physical exam which included psychological testing, entitled to participate in mass innoculation, and entitled to the right to be treated by private physicians (inmate to bear the costs). The staff was required to have an administrative medical chief, fulltime physician, and an adequate number of nurses, daily sick call was to be provided, and personnel were prohibited from interfering with the delivery of medical care and the carrying out of treatment.

In Dillard v. Pitchess, 399 F. Supp. 1225, 1240 (C. D. Cal. 1975), the court asked a local medical association to designate a team of qualified doctors to survey the sufficiency of the medical facilities and report the findings to the court.

The proper standard for evaluation of the adequacy of a medical system was set forth in Laaman v. Helgemoe, 437 F.Supp. 269 (D. N.H. 1977). There the court stated:

In conclusion, the measure by which defendants' medical care services and the system of access to them are to be judged is whether or not defendants' facilities, acts or omissions, overall, endanger the health of the prison community in such a manner as to evince a deliberate and calloused disregard of the serious medical needs of plaintiffs. The medical unit must be -looked at as a whole because it is