1929 Report of Survey from Dr. Silk to Commissioner of Indian Service

1929 Report of Survey from Dr. Silk to Commissioner of Indian Service

Reports
Surveys

A report of survey of the Canton Asylum written by Dr. Samuel Silk, addressed to the Commissioner of Indian Service. Report covers conditions of the asylum and analyses of employees.

State Archives of the South Dakota State Historical Society

Copy from The National Archives

April 13, 1929; 4-13-1929

government records, public domain

April 13, 1929.
Commissioner of Indian Service,
Department of the Interior,
Washington, D. C.
Through Dr. William A. White,
Superintendent,
Saint Elizabeths Hospital,
Washington, D. C.
Sir:
In accordance with the letter from your office of March 13th addressed to me through Dr. William A. White, Superintendent of Saint Elizabeths Hospital, I was requested to proceed to Canton, S. D. for the purpose of surveying the institution known as an Asylum for insane Indians, Canton, S. D., and to make “a thorough investigation into the operation of Canton asylum in all its departments”, and upon the completion of this detail to submit a report to your office with recommendations regarding “the administration of the institution, such changes, additions in any branches of its departments including the personnel and physical set-up of the institution, and to indicate what changes may be necessary to bring this institution to a state of reasonable efficiency with reference to the care and treatment of patients hospitalized therein”.
I arrived at the Institution on the afternoon of March 20th, and until the afternoon of March 26th I devoted my entire time to the task assigned to me. During this period I made repeated inspections of the various wards of the Institution during the day, made two ward inspections after 9 P. M., and one at 6 A. M. During some of these inspections I was accompanied by Dr. H. R. Hummer, the Head Nurse or one of the nurses, while others were made by me unaccompanied.
In order to facilitate its presentation the report which follows is divided into two parts: First part is more or less a chronologic description of conditions observed from day to day during the period of my stay at the Institution, and includes facts brought out during various interviews with the Superintendent and other members of the personnel. The second part of the report is devoted to the general summary and recommendations for necessary improvements.
From the very beginning of the survey my object was not so much whether the institution has done well so far, but rather was my concern with its future conduct and to determine what can be done in order to bring up this institution to a reasonable standard of efficiency in accordance with present day methods of care of the mentally ill. While I aim to avoid criticism of past and present conditions a certain amount of it could not be prevented, especially when it was necessary to mention certain unsatisfactory conditions in the present in order to emphasize the necessity for changes in the future.
PART I.
First Visit
March 20, 1929,
1:30 P. M:
Accompanied by the Superintendent of the asylum, Dr. H. R. Hummer, I made a general inspection of the place. The patients are cared for in two buildings—Main and Hospital Buildings. The Main Building is a two-story brick and stone structure having a central projection and a wing on each side of it. The front of the projecting portion is occupied by the offices of the Superintendent, the Financial Clerk, sitting room and hallway, while the back of it is occupied by the patients’ dining room, serving room, pantry and kitchen. Each wing provides one ward on each floor. The right wing is occupied by males and the left by females. Each ward of this building accommodates twelve (12) patients and is arranged alike, having an 8-bed dormitory, two single rooms and one room for two beds, in addition a toilet room and bathroom.
The second building, so-called “Hospital” Building, is a two-story brick and cement structure consisting of a central portion of two side wings. Central portion provides space for the drug room, employees’ dining room and kitchen and two rooms and bath for employees on the first floor, while the second floor is occupied by more employees’ rooms and operating room. On each side of the central portion is a wing for patients of somewhat similar arrangement as in the Main Building, except that the two wards on the first floor are occupied by females while the two wards of the second floor are occupied by males. In addition, the south side of each floor has an enclosed glass porch, or so-called “solarium”.
The wards:
Each solarium provides room for four beds, while the ward adjoining each solarium has one room for four beds and another room for two beds, with bathroom and toilet room, while across the hall on each floor is a dormitory for eleven beds, so that the Hospital Building provides for 21 females on the first floor and 21 males on the second floor. This, with the 48 patients in the main building, makes up a capacity of 90 patients.
Inspection of the Main Building:
In going through this building on the female side there was only one attendant on duty and she had to look after a ward on each floor of the Main Building and two wards on the first floor of the Hospital Building, which is some distance from the Main Building. The same situation was found on the male side, one attendant being obliged to look after the first and second floors of the Main Building and after the two wards in the Hospital Building on the second floor. This, however, was a somewhat unusual situation inasmuch as one attendant left the institution without notice on March 11th, and two others, husband and wife, left the service the day of my arrival. The patients on the wards were rather poorly kept, some were on the floor and in a rather untidy condition. The female department was in charge of a rather nervous and tremulous aged woman. On the male side three patients were found padlocked in rooms. One was sick in bed supposed to be suffering from a brain tumor, being bedridden and helpless. He was locked up in order to prevent other patients from disturbing him. The second room was occupied by a patient who had been put to bed because he was somewhat weak, although recently he had shown some general improvement. This patient was kept locked up in a room because in the absence of an attendant he would be apt to fight with other patients. Incidentally, he is the patient who lost one eye during a fight with another patient about two years ago. The third room was occupied by a defective boy who, in addition to his being padlocked, was restrained in a strait-jacket. An enameled chamber pot without a cover was in his room although it was difficult to see how he could use it in his restrained state. On the Hospital side each of the four wards were padlocked and in addition to that, within the wards one patient was padlocked in the four-bed f[d]ormitory. The reason was that he is an epileptic and is apt to fight in the absence of an attendant.
During the evening meal which was visited by me, a number of patients were left on the wards unattended while the attendant took the others to the congregate dining room and had to serve meals to them. In the Main Building one of the patients who was kept padlocked was later on brought out from his room to the adjoining hall, where he was given his supper. While eating the meal he was barefoot, and his dress consisted of only a shirt which was open in the back.
In the Hospital ward during the evening meal two patients were found eating from individual trays in the bathroom of that ward. One patient (paraplegic) was sitting on the bare floor while the other was sitting on a chair in a dark corner (the bathrooms in all wards of both buildings are not kept locked).
The solarium on each floor was extremely hot and stuffy since the windows can be opened only with great difficulty, and as the wind slams them and breaks the panes they are almost always shut, wooden bars having been placed across each window through the center.
The Solaria:
Each contains four patients On the second floor one blind man was lying on the floor on a mattress. Another patient, a deteriorated epileptic, was in a low bed especially procured for him so that he would not injure himself in falling out. One bed was occupied by a young defective boy who was thought to be possibly tubercular, although his condition was not active.
The solarium on the first floor was occupied by four women, only one old woman was having some cough and thought to be possibly tubercular.
Under the present arrangements the patients in the solaria who might be tubercular get anything but fresh air, although they do get a lot of sunshine. In the summer time these places must be quite unbearable as there are no awnings or window shades.
A central door leading to the outside from each solarium was found to be padlocked.
Patients are allowed to smoke on the wards and as they are left unattended for an hour at a time during the day or night, also when attendants take the patients to the congregate dining room or for moving pictures or when employees eat their own meals, fire hazard is extremely great.
Operating Room:
Operating room was inspected. It had no equipment whatever, except for a surgical table, a slop sink and two wash bowls.
Physically Sick Patients:
Physically sick patients were scattered throughout both buildings, and each individual dose of medication had to be carried from the drug room which is on the first floor, Hospital Building.
Ward Employees:
Nigh force consisted of one male and one female attendant, each attendant spending one hour in the Main Building looking after two wards and one hour in the Hospital Building also looking after two wards. In the Main Building males and females are on two different floors, while in the Hospital Building one floor is occupied by males and one by females. The wards on each floor, however, are separated by employees’ quarters.
The regular force of ward employees consists of six attendants, three males and three females, on day duty, and two attendants, one male and one female, on night duty. However, as practically two employees are kept busy in providing relief on half days, Sundays, holidays and thirty days vacation, seldom are there more than four attendants on day duty. The four on day duty are distributed as follows: One female assigned to Main Building looks after two wards, one on first floor and one on second floor, while the second female looks after two wards on the first floor of Hospital Building. Similar duties apply to the two male attendants. Although the number of patients on both wards of Main Building are only 24 and one attendant could probably supervise them, the fact that these 24 patients are house in the two wards on different floors necessitates leaving each ward unattended half of the time. It would facilitate matters if all males could be placed on one floor and all females on the second floor. The doors leading to the intervening dining room could be kept open so that the attendant on duty could look out for both wards, and on the second floor the doors on each side of the present sewing room leading to the wards could be opened so that one attendant on duty could have a view of both wards. However, this can not be arranged as the building is so constructed that the males from the second floor would have to go through one of the wards of the female side in order to enter the dining room, or vice versa, if the females were placed upstairs they would have to go through one of the wards of the male side.
Perhaps here it should be stated that this building when originally constructed was ill adapted for the care of male and female patients of a great variety of types.
In the Hospital Building one female attendant looks after two wards on the first floor but one ward is padlocked while the attendant is on the other ward because the doors cannot be thrown open, as the central portion is occupied by employees, some of them having children, and the outside doors could not be kept locked. The same condition prevails on the second floor occupied by males.
Schedule for Meals:
Breakfast is served at 7:30 A. M., lunch at 1:30 P. M., evening meal 5:30 P. M. These are served in the congregate dining room, having eight tables seating eight patients each, so that the dining room has a seating capacity of 64 patients, leaving the other patients scattered throughout the wards of both buildings, and as the attendants have to be in the dining room to serve the food and look after their patients those remaining in the different wards are unattended and looked in, some of them in single rooms. Also, when all the patients return to the wards from each meal the employees have to go to their own meals and at such times all patients are left unattended. Letting half of the attendants go for their meals at a time would not help the situation very much as, for instance, in the Hospital Building there is only one female attendant and one male attendant and one could not relieve the other as it would necessitate the male attendant to look after female patients and the female attendant to look after male patients. This situation must have been still much more intolerable before the three nurses now on duty had arrived. It should be remembered that this inadequate number of attendants take afternoons off, Sundays and holidays, and get thirty days vacation, not counting Sundays and legal holidays, and a great deal of the time even this inadequate quote of employees is not filled.
Second Day,
March 21, 1929,
9 A. M:
A more careful inspection of the wards was made in an attempt to get acquainted with individual patients and their problems. Main Building, female side, first and second floors: General condition fairly clean. In the dormitories the beds were fairly well made and the general housekeeping was satisfactory, except that on the first floor one girl was padlocked in a room which ordinarily provides capacity for two patients, but one bed was removed. She was thought to be tubercular, although there was no clinical evidence of activity at the present time. She was in bed, her head covered up. The room was quite stuffy as the windows were shut. The reason she was not kept in the solarium was because it would be difficult to keep her in bed in the absence of an attendant on the war and she would, therefore, be a source of danger to patients.
On the second floor the eight-bed dormitory was in good condition: the beds were well made up. However, on one of the wards was a broken piece of mirror without a frame, with sharp edges, and as these eight patients are locked in during the night some catastrophe could take place. At least one of the patients who sleeps there was quite restless and impulsive.
One bathroom contained a shelving arrangement for patients’ clothing and ward linens. This room should be locked but as it also contains wash bowls it must remain open.
One of these bathrooms also had a fountain which at the time of inspection was not in commission and had been out of commission for a number of months. If the wash bowls and slop sink were moved to the adjoining room which is only occupied by two flush toilets and the fountain be placed in the hall where most of the patients sit during the day, it would provide better facilities for caring for the patients’ clothing and ward linen, and a small table and chair could be placed there for the nurse and for any records she may wish to keep on the ward. Under the present arrangements, each day and night attendant is supposed to make a report as to his or her activities for the period on duty in a special book provided for that purpose, but these books are kept in the Main Building in the room occupied by the Financial Clerk and the Head Nurse, so that while the attendant is writing out these reports the wards are again left unprotected. There is no room nor any facilities for making notations on the ward either by attendant, nurse or physician.
On the first floor, female war, Main Building, there is a room occupied by a female attendant so that in case of a fire or other serious accident she could unlock the individual rooms or the dormitories where patients are kept. On the second floor there was a deep, very dark closet without any light in it, and there the ward linen, floor blocks, fire extinguisher and all sorts of odd pieces were kept. It was quite smelly. The fire extinguisher should, of course, be in the hall in the open where it could be used in an emergency, and under present conditions it is locked in the closet. The hallway of the war which is to some extent used as a sitting room by patients had a number of lawn benches brought indoors for the winter. The hallway is somewhat dark. This could be improved by removing the present curtains and replacing the green window blinds with cream-colored ones. (I understand the change of window blinds has been approved and will be put in operation shortly).
On the male side conditions were less satisfactory. One attendant had been looking after two wards in the Main Building and two wards in the Hospital Building although he regularly belongs to the Hospital Building only. He could not tell the number of patients on each ward in the Main Building. Toilet room of first floor was in very dirty condition, in great disorder, and there were chamber pots all over the place. One sick boy was padlocked so that other patients could not bother him. Another patient was padlocked. He was kept in bed because of weakness. One idiot boy was padlocked in a strait-jacket. He had on a suit of overalls under the strait-jacket, no underwear, he was barefoot. The reason for the condition of his dress given by attendant was that he tears up clothing. This patient is rather a problem because of his untidiness and dribbling of saliva, but is otherwise harmless. The room where he was kept had only one bed although with quieter patients two could be accommodated there. The room was in a very unsatisfactory condition. It appears that no attempt has been made to develop any hygienic habits in this boy. When brought out of his room he walked about the hallway, but when an attempt was made to put him back in the room he objected strenuously; however, when left alone he walked about the hall towards the window and showed no unusual disturbance. If this ward had an enclosed porch, for instance, it would not be necessary to keep him confined to a room. No doubt when he is locked up in a room he does tear his clothing, but under some proper supervision he should not be a special problem of care. The male urinals on the male side did not flush, and this condition has been of long standing. Incidentally, it should be stated that there was also male urinals in the female side which also did not flush.
Window Guards:
This deserves special consideration. In the Main Building all windows, whether in the main hall, the ward dormitory, individual rooms, bathrooms, etc., have a guard consisting of galvanized iron network, the openings being rectangular. These guards, however, are inside the windows. They have hinges on one side while on the other side are locked with three individual padlocks. The windows from the top cannot be opened at all under this arrangement and from the bottom only with some difficulty by pushing a stick through one of the openings using it as a lever and thus raising it a very small distance, then by placing the stick in an opening at a higher level the window can be raised another inch. By means of several such manipulations the window can be raised a few inches. In order to clean the window frame or the space between the window frame and the outside screen this guard must be opened. It would be necessary to unlock three padlocks and this requires a stepladder. In addition to that the window blind, which is in front of the guard, does not clear it so that the window blind would have to be removed. From this arrangement it can easily be seen that this is being done very seldom, especially with the inadequate number of ward employees. In order to properly ventilate the entire ward and rooms after the patients get up it would be necessary to unlock some forty two (42) individual padlocks, remove window blinds, etc., and this, of course, is only rarely done. The result is that the window frames are very dirty and all wards are very stuffy. Even if an attendant has time enough to go to each window and direct special manipulations, raising the window some inches, it would have to remain at the same level for some time. In wards where mentally ill patients are kept and where they are apt to raise and lower the windows unnecessarily the attendant must have easy access to them so that they could be raised or lowered in accordance with the change of the outside temperature and conditions on the ward, but under present arrangement this is impossible. I asked one of the attendants on duty to show me how he would open this window guard. He thought it would be easy. He unlocked one padlock, then tried to reach for the second one but found that he had to go for a step-ladder. The third lock was fortunately off. When he was about to open the guard he discovered that the window blind prevented it. He apparently did not know of this condition although he had been employed in the hospital over a month. This perhaps gives an idea how frequently these guards are opened. This condition is especially intolerable at night when eight patients are locked in one room with eight individual uncovered chamber pots, and most of the time the windows are shut.
Bedding:
The bedding throughout all wards, and especially on the male side in the Main Building and on the Hospital side, is almost black, partly due to the soot from the soft coal used, partly due to the hard water which is being used in the laundry, making it almost impossible to do satisfactory washing also because the patients not having any sitting rooms, especially in the Hospital Building, are always on the beds and in the single rooms where the patients walk barefoot to and from the toilet on dirty floors the linen is in very bad condition. This linin is being changed once a week except in cases of untidy patients who soil themselves.
Plumbing:
Bathtubs, toilets, wash basins and general plumbing are of very inferior quality making it difficult to keep clean, and the hard water adds to the problem.
On the second floor, male ward, one patient who had been in the Hospital six years was padlocked in a room and according to the attendant had been secluded in this room for nearly three years. On opening the room the odor was very disagreeable. The patient complained of “too much bad breathing”. The attendant stated that this patient is supposed to be an epileptic although he never had any spells. Reason for his seclusion was that he gets into fights. Patient when spoken to was good natured, appeared to be neat and clean. He is allowed out of the ward to block the floor for an hour or so at a time and is occasionally taken outdoors for a walk. (This patient will be referred to later under general discussion of restraints and seclusions).
Hospital Building,
Afternoon of March
21, 1929:
Pharmacy:- Drugs are neatly kept, the supply being rather limited but perhaps fairly adequate for present needs. In the pharmacy was also a glass top dressing table, a dental chair and a few other odds and ends. This room should be combined with the office of the nurse assigned to this building. Everything else but drugs and sick room supplies should be removed from the pharmacy.
Female Wards
Hospital Building:
In the four-bed dormitory the beds were poorly made, the linen looked quite dirty for reason mentioned previously. The so-called tubercular cases, although none of them were considered active at the present time, are housed in the solarium, and several other helpless patients who cannot be taken to the congregate dining room, such as one paraplegic and one hemiplegic, are fed on the ward, the food being brought there from the Main Building kitchen. The dishes used by these patients are washed in the bathroom of the Hospital Building since Dr. Hummer does not want to mix them with the dishes of the Main Building. The dishes are all enameled, most of the enamel being badly chipped off, they are rusty in parts and cannot be kept clean. Same condition on second floor among male patients. (Subject of dishes will be discussed later on).
The second female ward, Hospital Building, consists of one large dormitory which at the time of inspection had twelve (12) beds. There was adequate room for that number although the usual capacity is only eleven (11) beds. Patients of this dormitory have no sitting room and they are, therefore, obliged to sit there during the day and this, of course, adds to the problem of keeping the beds in orderly condition and bedspreads clean. There is no adequate room for patients’ clothes or ward linen adjoining this dormitory and some of it is kept on the ward in various corners and odds and ends are kept between beds (everything superfluous should be removed from this dormitory). This is badly needed for a clothesroom as the closet nearby has no light, is very small and cannot be kept clean. With present facilities for patients’ clothing and ward linen it is unreasonable to demand of any employee, trained or untrained, maintenance of any orderly arrangement.
Male Ward
Hospital Building:
The second floor, Hospital Building, is devoted to male patients. In the eleven-bed dormitory a defective boy was smoking although there was no attendant on the ward and the ward had been padlocked. The flowing curtains could easily catch fire. The character of these patients is such that they could very easily be removed from this dormitory and be kept during the day on the first or second floor of the Main Building. Here may be mentioned that the hallways of each of the four wards in the Main Building could be turned into fairly attractive sitting room if the floors were covered with linoleum, a number of wooden benches of a type used in most of the mental hospitals be provided, also one or two small tables and a few individual plain chairs and rockers. At present these hallways on the first floor have only some lawn benches which, however, are soon to be placed outdoors so that in the summer time these hallways must be empty, and in rainy weather the patients would have to either be in their rooms, the dormitory or sit on the floor. In another ward in the three-bed room three patients were padlocked and they were all smoking. Another patient was padlocked in a four-bed dormitory. He is an epileptic and during his epileptic episodes he is apt to fight. When seen he was quiet and appeared quite good natured. In addition to the locks on these various rooms there were locks on each of the main ward doors. (Without desiring to be hypercritical one could refer to the institution as a place of padlocks and chamber pots. In all of my hospital experience, either general or mental, I have never seen so many chamber pots and I saw during my visit to this hospital).
Adjoining the male ward, Hospital Building, south side, there is a fairly large room used now by employees to store all sorts of odd pieces – furniture, lamps, etc. This would make a fairly nice, much-needed room for ward linen and patients’ clothing, perhaps for the entire floor (two wards). The employees could be provided with some storing space in the basement of the building. The second floor of the Hospital Building has a nice porch over the entrance porch which could be enclosed and used for patients as a sitting room and smoking room.
Operating Room:
The operating room, which is located on the second floor of the Hospital Building on top of the room occupied by the pharmacist on the first floor, should be equipped so that all minor surgery and various dressings could be done there. It should be equipped with a surgical cabinet (there are some surgical instruments on hand but some should be added), an electric sterilizer, irrigating stand, closet for dressings, some glass top and metal top dressing tables, metal chair, and the other usual pieces required in a minor surgery room.
Friday, March 22, 1929:
A general inspection of wards was made; conditions practically the same as the day before. Most of the patients were smoking in the wards and in various rooms.
Noon meal was inspected which consisted of fresh pork, boiled potatoes, gravy, spinach, bread, oleomargine, milk and tea. The food was well cooked and quite adequate.
Evening meal consisted of peas, potatoes, apple sauce, cinnamon buns, bread, milk and tea.
A number of the personnel were interviewed. Summary of facts brought out is given later in the report under general heading of Personnel.
Saturday, March 23, 1929:
In order to see conditions under which the patients arise in the morning, the attention they receive, and also to inspect the breakfast meal, I arrived at the institution at 6 A. M.
Inspection of the Main Building:
1st Floor, Male Ward: The odor in the eight-bed dormitory where patients were kept padlocked during the night with eight uncovered chamber pots was most sickening. All windows were tightly shut and most of the pots contained excreta. The three rooms which contained three patients previously referred to, were inspected. In the room where the sick boy (brain tumor) was kept, the window was open from below about two inches, chamber pot was filled with urine and there was an enameled pitcher badly chipped and quite rusty inside, containing some water which was not very clean. This was his drinking water. In a second room was the one-eyed boy. The window was tightly shut and the room was very smelly. The chamber pot was filled with excreta. The attendant opened the room and told the patient to empty the pot which he did. He walked from his room dressed in a shirt reaching his knees buttoned in the back with the only button which happened to be the top one. He walked barefoot on a dirty wooden floor to and from the toilet room and got into bed with his dirty feet. As the bedding is changed only once a week one can imagine how dirty it looked. As a matter of fact, the day before I showed Dr. Hummer how dirty and black the sheets were from patients’ dirty feet walking from the room to the toilet or to the table for their meals. The third room was padlocked; the idiot boy, about 10 years of age, was in a strait-jacket but lying quietly in bed. The main hallway was rather stuffy, all windows were down, and the bathroom and toilet were in a similar state.
2nd Floor, Male Ward:
On the second floor, male ward, no attendant was found. Several patients in the eight-bed dormitory were still in bed, while others were in the bathroom. Same general condition as below except that some of the windows had been raised and the chamber pots had been removed.
1st Floor, Female Ward,
Main Building:
Dormitory very smelly because of chamber pots and windows being down. One defective girl, half naked, was sleeping on a mattress on the floor in the bathroom and one nearly fell over her upon entering the bathroom. She had spent the night there having been placed there by the female attendant because she was “disturbed”. Ordinarily, it was stated, she sleeps in the eight-bed dormitory, but this is done whenever she is disturbed. The attendant on duty decides when to put her in the bathroom on the floor. This girl is a congenital defective and has no use of her lower limbs. Her “disturbance” consists in annoying the other patients in the eight-bed dormitory. The three rooms on the same ward were in use by quiet patients one of whom could have been moved to the dormitory, thus providing a room for this disturbed girl who spent the night on the bathroom floor. The decision as to patient’s disturbed state should not be left to the judgment of an untrained attendant.
2nd Floor, Female Ward,
Main Building:
Was in good condition; windows were all raised, beds were neatly made, and the chamber pots had already been removed by the patients themselves who were of a better class and in good touch with reality. But even this quiet and very neat and clean group had been locked in the dormitory during the night and deprived of toilet facilities except for the chamber pots without covers (this condition is inexcusable).
1st Floor, Hospital Building;
A female attendant was looking after two wards, one being locked and unattended while she was assisting the other patients. This female attendant is the most intelligent of the lot having had some hospital experience, in fact, she was a member of a training school of a general hospital and had spent her three months and was ready to put on her cap when she had to quit because she had two children to look after. She was strong, healthy, appeared to be good natured and kind to patients (reference will be made to her under Personnel). She was doing the best she could but conditions generally on the two wards were very unsatisfactory.
2nd Floor, Hospital Building:
One male attendant was trying to look after two wards. A lot of greasy pitchers which had contained food carried from the main kitchen for the bed-patients were on top of the stairway from the night before. It seems that food is carried from the kitchen in the Main Building to the Hospital Building in enameled pitchers without covers. These pitchers are in an extremely poor condition most of the enamel being chipped off outside and inside and they cannot be kept clean. They should be condemned and proper aluminum receptacles suitable for carrying food from one building to the other should be provided.
Miss Behrman, nurse assigned to Hospital Building, was interviewed. Summary of facts brought out is given later in the report under general heading of Personnel.
Visit to Yankton State Hospital,
Yankton, S. D.
Balance of the day was spent in making a visit, in company with Dr. Hummer, to Yankton State Hospital, Yankton, S. D. It was hoped that the care and treatment given to the patients in that institution could be used as a guide in making suggestions for the Canton Hospital.
Sunday, March 24,
1929, 8:30 A. M:
Continued interview with personnel until about 10:30 A. M. Summary of facts brought out is given later in the report under general heading of Personnel.
The rest of the day was spent with Dr. Hummer going over some of the patient’s records and obtaining information from him as to equipment on hand or its needs.
Interview with Dr. Hummer:
Dr. Hummer was questioned as to general routine followed at the Hospital and his opinion as to the various members of the personnel.
Hospital Routine:
Dr. Hummer stated that only recently has he been making regular morning rounds about 10 A. M., and since March 14th, upon the suggestion of Dr. Krulish, he has been making afternoon rounds about 4 P. M. Previously he made rounds once a day, but irregularly. Night rounds are never made but he gets occasional calls at night – practically emergencies. He could not say how often, but about once a month would cover it.
Meals:
He inspects noon meals frequently, very seldom evening meals, and never in the morning.
Fire Drills: No regular drills are carried out.
Fire Equipment:
Is tested twice a year by the engineer but Dr. Hummer is not present during these tests. Chemical extinguishers are recharged once a year.
Sick Patients:
In case of patients’ serious illness the Superintendent notifies relatives and respective agencies. There is no centralized place for sick patients. Until the recent arrival of nurses all medication was carried out by untrained ward help.
Engineer:
Dr. Hummer thought that present engineer was qualified and satisfactory. Knows some electricity but is a good plumber (?). (During interview with the engineer he did not claim any special knowledge of plumbing). The assistant engineer is an ordinary laborer without any qualifications but he occasionally does the carpentry about the place, which is naturally of a very poor character. They do not employ an electrician. Dr. Hummer thought the suggestion that a carpenter-electrician in place of the assistant to engineer, and one laborer under the two men would be a very desirable addition to the place. As it is, he needs a carpenter very badly, at least for six months if not for the entire year.
Farmer:
As to the farmer, Dr. Hummer stated that he has been employed there since the 1st of November, that his qualifications have not as yet been established but he has so far been satisfactory, except for the mater which he reported to the office upon which ground he requested the farmer’s dismissal.
The farm consists of 100 acres. At first 65 acres were farmed and he at that time employed one farmer. A new farm of 327 acres was purchased of which they have 227 acres under cultivation.
Dr. Hummer felt that additional help was needed to do the farm work, and from the interview with the farmer I felt quite sure that this is an absolute necessity. At least one man having some knowledge of farming should be added.
Patients’ Records:
No ward records of nay kind are kept but each ward attendant makes reports as to the happenings during his or her period on duty in a book provided for that purpose which is kept in the Main Building. It was suggested, and Dr. Hummer agreed, that a ward jacket should be installed for each patients and kept on the wards where the patients are located, and should contain temperature charts and nurses’ ward notes about patient’s condition; also that all orders for patients’ treatment should be given in writing by the physician on each ward, thus saving a great deal of time for the attendants who under present conditions must leave the wards in order to enter their reports in the special books, and it will also save a lot of Dr. Hummer’s time in reading these books which have a lot of stereotyped information repeated from day to day. The other patients’ records consists of an individual clinical jacket and correspondence jacket. The clinical history of each patient was very inadequate. The psychiatric history consists of a certain printed form sheet to which notations are added. Most of the notations are of such an indefinite character that they convey little information as to the patient. The physical examination consists also of a certain printed form sheet, and typewritten or longhand additions are made. Most of these additions consist of “normal” or “none”. No neurological examinations are performed. The psychiatric progress notes as to the patients’ condition and filed in the clinical record, are not based upon physician’s examinations but are typewritten by Dr. Hummer from the notations made once in two months by the ward attendants in accordance with a certain questionnaire which Dr. Hummer has given them. Most of the information in the records is of a stereotyped and valueless nature. No psychiatrist could get an adequate idea as to the mental condition of a patient from reading such a history. There is no information as to family history, personal history and no adequate account of present illness, and, of course, such information is absolutely essential in order to obtain any sort of conception as the patients’ mental difficulties. No record of any urinalyses is filed; no Wassermann examinations are performed. Serious accidents are not recorded or commented upon by the physician but a statement by the attendant of the ward where the accident had happened is filed. This practice was followed even in cases of such serious accidents as suicide or the loss of one eye to a patient. It is suggested that in case of an accident the physician should personally make a typewritten report in the record as to his version of the affair and not take the statement of the attendant on the war, especially when it is considered that the present ward attendants are entirely untrained and some of them have only been in the service from a few days to a few months. No summaries are made in the case of a patient’s death or discharge. No description of last illness, the only thing in the record indicating the patient died is the fact that a copy of the death certificate is filed. It must be stated frankly that the psychiatric records are absolutely inadequate and one can get little idea from such records as to what is being done for such patient. It should be stated, however, that under present personnel no adequate records could be installed, Dr. Hummer being the only physician in the place must perform a lot of administrative duties, he does a lot of paper work, in fact, personally typewrites into the records the information given to him by the various attendants. At least one other physician should be assigned to the Hospital. Such physicians should have had at least one year’s general hospital experience, one year psychiatric experience and, by preference, some laboratory experience, at least to the degree that he should be able to do routine urinalyses, blood counts, sputum and ordinary smear examinations. Also, a stenographer would be an absolute necessity if any sort of adequate psychiatric records are to be kept in the institution. The second physician could be entrusted with performing the routine mental and physical examinations, writing psychiatric progress notes on patients, while the Superintendent would attend to all administrative work and prescribe or direct treatment of the individual patients, and be the final authority as to the granting of patients’ discharge, parole or visit. No Salvarsan treatment is administered by the Institution, in fact, Dr. Hummer could not tell the number of patients who may be having syphilis, in spite of the fact that quite a percentage of his patients show evidence of having organic brain disease. The Institution has no laboratory and practically no laboratory equipment except for a microscope and a few re-agents for urinalysis. A blood counting apparatus, hemoglobinometer and ophthalmoscope would appear to be necessities for the place. Patients are not vaccinated upon admission but the entire hospital population is vaccinated about once in two years. There would appear to be little reason why patients should be vaccinated upon admission.
Dining Room:
Facilities are quite inadequate, especially if there is to be any increase of patients. The present dining room has as eating capacity of 64 patients; there are eight long tables seating eight patients at each table. The dining room is rather dark but this could be improved by replacing the present dark shades with lighter ones and by using a light, almost white, paint. Round tables seating four patients would be more preferable to the present ones. The dining room dishes are all of enamel ware and, as in the case of the other enamel ware previously mentioned, are badly chipped off and can not be kept clean. Heavy china dishes (delf) would be preferable. This is being sued in most mental hospitals and appears to be very satisfactory. Dr. Hummer, however, preferred aluminum dishes. Glass tumblers should also be provided for serving patients with water at the table. Patients are given knives, forks and spoons and as the knives are of blunt edge there could be no objection to their use, in fact, this practice should be continued. However, there should be a system of counting. The one in charge of the dining room should have a special box which could be locked, and before the knives, forks and spoons are placed on the table for each meal they should be carefully counted, and again counted when they are replaced in the boxes after each meal. This practice is being followed in most institutions handling mentally ill patients. This would prevent patients smuggling knives and forks with which they could inflict injuries upon themselves or others, or use them for making skeleton keys to get out of the ward as a few patients have done in this institution. The patients’ dishes in the main dining room are being washed in the kitchen, although there is a nice serving room between the kitchen and the dining room which would be a much better place for that purpose, especially if a small dishwashing machine was installed. One looking after the dining room should be responsible for all of the dishwashing and she could, of course, have assistance of some patients, but there is no reason why the dishwashing should be done in the kitchen by the cooks, as is done at present.
Water:
The Institution receives its water from two shallow wells 25 ft. deep; this water is very hard and very unsatisfactory for cleaning and washing purposes. There is also a well 322 ft. deep, but a pump recently installed was pumping more water than the well could supply and it has to be geared down so that no water is at present obtained from the deep well. This should be corrected with as little delay as possible.
Sewerage:
The sewage is disposed of through pipes connecting with the main city sewer. In the past it has been frozen regularly every year, and although the supposed cause of this difficulty was removed the year before, the sewer was again frozen this year although it was explained that the weather this past winter was unusually severe.
Light and Power:
Light and electric power for the operation of the pump, Frigidaire, bread mixer is bought from the Norther State Power Company. The heat of the institution is steam. There is a boiler in the basement of each building, and also a boiler in the laundry. Soft coal is being sued which is very unsatisfactory from the standpoint of cleanliness of the wards. A central heating plant, which would furnish all light and power, would seem to be a necessary improvement.
Ward Employees:
Personnel was discussed with Dr. Hummer: He stated that when he has a full quota of ward employees he has three (3) males and three (3) females on day duty, and one (1) male and one (1) female on night duty. As stated in a previous part of the report, this does not provide for regular off duty relief of two attendants such as half a day each week, alternate Sundays and holidays, and thirty days vacation, not counting Sundays and holidays, so that seldom are there more than four employees on day duty. This quota is absolutely inadequate and is the cause of unnecessary seclusions and restraints. As stated in a previous part of the report, two (2) males and two (2) female attendants on day duty must look after four wards located in two different buildings. They must also leave some patients on the various wards at each meal, when patients are taken to the congregate dining room, and they also leave the wards absolutely unattended during their own meals; also in summer time when a lot of farming is to be done, a ward attendant takes a group of patients from the wards to assist with the farming, leaving the other patients absolutely unattended, and during all such periods when the attendant is not on the ward the patients are padlocked in rooms or dormitories. This condition is inexcusable, and cannot be considered as proper care of mentally sick people.
Correspondence from various agencies show that they request admission of a patient to the institution because they are unable to care for him and that pending his admission such patient is kept locked in a jail. However, it must be admitted that a great number of patients at the Canton institution receive no different care than they would have received had they remained in jail.
The minimum number of ward employees should be four (4) females on day duty and four (4) males on day duty, two (2) males on night duty and two (2) females on night duty; one (1) male attendant for relief. It must be realized that each ward employee receives an afternoon a week, every other Sunday and every other legal holiday, besides thirty days vacation, not counting Sundays and legal holidays. Also that there are frequent resignations and dismissals, and there are periods from a few days to weeks before vacancies are filled. This relief attendant could relive the day and night force. Under present arrangement, when the night attendant has to be off duty for an equivalent of an afternoon the day attendant is on duty from 6 in the morning to 12 at night. One can appreciate how little attention such over-worked attendants can give to mentally sick patients. While the female ward attendants could possibly be relieved without additional help as it is, it is planned to have a graduate female nurse for each building and one at night. While visiting the Institution an aged nervous female attendant was actually on duty from 6 in the morning until midnight. During the day she had to take care of two wards in the Main Building, located on first and second floors, and at night she had, in addition to these two wards, two wards in the Hospital Building. This old lady was quite nervous, irritable and disgruntled. She was quite tremulous showing a coarse, steady head tremor, and there are other symptoms suggesting Parkinson’s disease. One (1) male attendant should also be provided to be in charge of a working group of ten or twelve males who in the summer time would be assisting with farm work, keeping the grounds in good condition, and in the winter time would assist with snow-shoveling and perform other services about the institution. The total ward personnel should be, therefore, as follows: One (1) head nurse, one (1) night nurse in charge of entire Hospital, one (1) nurse in charge of Main Building, one (1) nurse in charge of Hospital Building, four (4) male attendants and four (4) female attendants on day duty, two (2) male and two (2) female attendants on night duty, one (1) male relief, and one (1) male attendant for a working group. This would be an increase of seven (7) ward employees over the present quota, including the four (4) nurses recently provided for.
Employees’ Quarters:
The quarters for employees are very unsatisfactory. They are scattered through both buildings and occupy space badly needed for the patients. Two nurses occupy one room although deduction or quarters is made on the same basis as though each nurse had a separate room. Should the fourth nurse arrive there would hardly be any space for her. Also, for maintenance of proper morals of the institution the nurses, and if there is to be an assistant physician, should not have to eat in the same dining room with the other help. Under present conditions no satisfactory quarters whatever could be found for an additional physician, and it is doubtful whether any physician who has had modern psychiatric training would be willing to be attached to the institution unless a thorough reorganization with much improvement had been accomplished. Quarters for employees is an absolute and almost immediate necessity. This building should be carefully planned. It should be realized that graduate nurses cannot be treated on the same basis as kitchen help and it may be advisable to have two small buildings, one providing quarters for the assistant physician, who is most likely to be a married man, nurses, occupational aide, hydrotherapist, etc., while the other building be reserved for the general help of the institution. The quarters should be adequate and with private baths and toilets for the higher personnel. As the Hospital employs married couples with children adequate provision should be made for the care of such employees. It is very undesirable for small children to come in close contact with the patients, which condition prevails at the present time. Efficient employees can not be expected to live in the type of quarters now provided. If such were secured they would soon leave the place.
Plumbing:
The plumbing of the Institution is rather unsatisfactory. It is of an inferior grade, the hard water has ruined it to a great extent, and it is very hard to keep it clean.
Wash Bowls:
The wash bowls should be removed from the bathroom so that the latter could be locked.
Food:
The food furnished to the patients was found to be wholesome, of good quality and of sufficient quantity. Weekly menus have recently been adopted. These menus are made out by the head cook but they have not been followed and changes are made from day to day.
Root Cellar:
The root cellar maintained at the Institution has no ventilation; it needs a flue. The construction of this has been approved but the minimum bid was $105.00, and as the appropriation had only been $100.00 the work was not done.
Bakery:
The place when visited was rather unclean. Equipment consisted of a dough mixer and two ovens heated by wood. Electricity would be desirable. for it. The institution has no gas available for its use.
Hydrotherapy:
Although a hydrotherapeutic apparatus consisting of a treatment table, shower, needle spray and two hot cabinets were installed some years ago, this is not being used. A room which was to be provided with tables for packs is now being sued for storing coal. One wonders what Dr. Hummer meant when he stated in several of his annual reports to the Commissioner that the hydrotherapeutic department was functioning satisfactorily. Hydrotherapy is an accepted form of treatment in every hospital for the care of the mentally ill and this department should be put in immediate operation. Four or five tables for packs should be immediately made available, and this department should be in operation every day. As this department would have to e used for both males and females, each using it half a day, it would be impractical to employ two trained hydrotherapeutists. The most competent male and female ward attendants, however, should be assigned to this work after they have been given special instruction in this method of treatment.
The Institution has no continuous baths. At least two continuous bathtubs should be installed for the use of males and one for females. The present bathroom used by employees in the Hospital Building could be very well adapted for that purpose.
Dental Care:
The patients receive no dental attention whatever. Tooth brushes could be used by a great majority of the patients, and some provision should be made for the patients’ dental care. It may be practicable to make arrangements with a local dentist to visit the institution once or twice a week for a certain number of hours.
Occupational Therapy:
The Institution has no occupational department. Many female patients were found on the wards idling away their time, and the same prevailed on the male side. While during the summer months some males are no doubt employed on the farm, many must remain idle and this is especially so during the fall and winter months. Occupational therapy should be instituted in the Institution. The present head nurse fortunately happened to have had some experience in occupational therapy and she could perhaps organize that department, but with the present inadequate and incompetent ward help nothing could be accomplished. One trained occupational aide would be a very desirable addition to the Institution.
Carpenter-Electrician:
The Institution is badly in need of a carpenter and an electrician, especially if there is to be an increase in Hospital population. A mechanic who knows both carpentry and electrical work should be added to the place. At the present time this work is being done by the engineer and his assistant, who is a laborer without any training, and the work performed is of an extremely inferior grade and the necessary work is not performed within a reasonable period of time. The carpenter on this place would also be able to furnish some vocational training to a limited number of patients.
During the course of the interview Dr. Hummer freely admitted that the present conduct of the Institution, its equipment and personnel, cannot meet even the most modest requirements of a hospital for the care of the mentally ill. He attributed this to the fact that for some 16 or 17 years he was the only man on the place without any medical contacts whatever, that only during the past few years since the present Medical Director was appointed has the Indian Office shown any interest in his place, that most of his time was taken up with administrative duties and work of an ordinary clerical nature being compelled even to personally do the typing of the patients’ records; that he was compelled to conduct the Institution on a shoestring appropriation and that he has endeavored to cooperate with the Department by responding to the various circular letters requesting economy.
March 25, 1929:
An attempt was made to get some idea as to the types of mental cases treated there. The inadequacy and incompleteness of records, absence of laboratory reports made reliable diagnoses impossible. It would have consumed entirely too much time to examine carefully each patient individually, and this was not even attempted. However, as a result of a discussion with Dr. Hummer and wit the aid of the meagre records available the following classification was arrived at:
At the time of the interview there were 90 patients in the Institution, 45 males and 45 females, divided as follows:
CLASSIFICATION
Diagnosis Male Female
Dementia Precox 17 19
Mental Deficiency (Imbecility) With or Without Psychosis 10 9
Senile Dementia 2 4
Constitutional Psychopath without Psychosis 3 0
Intoxication Psychosis 1 0
Idiocy 3 1
Manic-Depressive Psychosis 0 3
Psychosis with Organic Brain Disease 0 2
Epilepsy 9 6
Baby 0 1
Total 45 45
The above diagnoses were based mainly upon symptoms presented by patients upon admission. Some of these have been there many years, and at the time of inspection of the Institution did not show any active evidence of mental disease.
Epileptics:
The group of epileptics deserves special consideration, particularly in view of the fact that for years the present Superintendent has been recommending a special building for epileptics. On going over the group of 15 patients, 9 males and 6 females, classified as epileptics by Dr. Hummer, it was found that Dr. Hummer applies the term “epilepsy” to any patient suffering from convulsions irrespective of the character and underlying cause of such convulsive seizures. A more careful consideration of the group reveals that a number of males and females are suffering from congenital cerebral palsies and other organic brain deficiencies responsible for the convulsions. The mental condition of the entire group also shows great variations, some showing marked mental defect varying from idiocy to low and high grade imbecility, while a smaller number only would fall into the so-called essential epilepsy group.
CLASSIFICATION OF THE SO-CALLED EPILEPTICS
Male Female
Essential Epilepsy 4 3
Cerebral Palsies, Congenital Idiocy and Imbecility with Convulsions 3 3
Organic Brain Disease with Convulsions 1 0
Alleged to be Epileptic; no Convulsions for two years 1 0
Total 9 6
It can be readily seen that such a diverse group of people presenting entirely different problems of care could not be kept in one building. Since if you consider the male and female groups under so-called Essential Epilepsy, we find that even these small groups would have to be sub-divided into two or three sub-groups. Some of those suffering from Essential Epilepsy show only slight deterioration and between convulsive attacks they make a very comfortable institutional adjustment, others are extremely deteriorated, have frequent convulsions but are not especially troublesome form the standpoint of care, while still others show periods of confusion and combativeness, preceding or following the attacks. The well behaved epileptics who are neat and clean, having a convulsion once in three or four weeks but not being able to work quite well between such attacks, could not be cared for on the same ward with an untidy and filthy idiot or low grade imbecile, merely because they both happen to have convulsions.
In the plain for a separate epileptic building Dr. Hummer suggested a congregate dining room. It is quite evident that such a heterogeneous group of so-called epileptics could not be brought into one dining room as the idiots and defectives would have to be spoon-fed and there would be others so deteriorated as to require individual care.
Under the present population of the Institution, and even if this was doubled, it would hardly be practical to have a separate building for epileptics as there would not be enough patients of one predominant type that could live on one ward, and certainly they could not be cared for in one dining room. It would require three or four small wards for males and a similar number for females, and as it would be very uneconomical to employ day and night attendants for such small groups such wards would have to remain part of the time unprotected, or the patients be isolated and locked up as under the present practice at the Institution.
Tubercular Patients:
An attempt was made to determine, if possible, the number of tubercular patients in the Institution, bearing in mind that the Indians are especially susceptible to T. B. and that the records of the Institution indicate that tuberculosis was responsible for nearly 50% of the deaths which have occurred in the Institution. Absence of reliable records, of careful physical examinations, temperature charts, sputum or X-ray examinations precluded any reliable conclusion on the subject. Dr. Hummer “thought” that he had eight tubercular patients, three males and five females, none of them, however, in his opinion, were showing any active clinical symptoms. These eight patients were distributed through various wards of both buildings.
The care of tubercular patients presents the usual problem of providing a special unit for a very small group of males and females. The present practice, however, is absolutely intolerable. A one or two-story small building for 16 or 20 beds, half for males and half for females, should be provided. This building should have a nurses’ ward office, dining room facilities and a sterilizer for dishes. It should be surrounded by porches where the patients could spend their time during the day. Such building should have at least 50% of single rooms to take care of disturbed and dying patients.
Night Rounds,
March 25, 1929,
8:30 P. M:
Inspection of Main Building: Both male wards when opened were in total darkness. There was no light in the hallway, bathroom, toilets or any of the corridors. The patient were padlocked in single rooms and also in the eight-bed dormitory. The male attendant on duty soon appeared with a lantern. It was then explained to me that there are no lights on the wards at night and that the attendant carries a lantern in making his rounds. This is done in order to economize on electricity, but it would appear to be an economy pushed to extreme. Of course, if the patients were not padlocked and they had access to the toilets some lights would have to be maintained in the hallways and the toilet rooms. Unlocking the various padlocks on the ward proved to be quite a job as it was difficult to find the keyholes under light available from the lantern. In the eight-bed dormitory, when the padlock was removed and the door opened, it was found to be quite hot an d stuffy, the weather that day and evening being quite mild and spring-like. The usual number of chamber pots was found in the room.
Female Wards,
Main Building:
The same conditions prevailed on the female wards, except that the doors of the single rooms were not padlocked but locked with the regular door locks, no doubt a concession to the weaker sex. However, the eight-bed dormitory was padlocked, and the same unsanitary conditions prevailed as ont h male side of the building. The attendant on duty was the same feeble, nervous, old lady previously mentioned. She was rather disgruntled which, no doubt, was partly due to the fact that she had been on duty since 6 A. M. and was to continue until midnight because the night female attendant was given four hours of. This situation apparently prevails throughout the year, and whenever the night attendant has to be off, either on the male or female side, the day attendant is obliged to work from 6 in the morning until midnight. This old lady was obliged to look after two wards in the Main Building, located on two different floors, and two wards in another building, walking through dark corridors with the help of a lantern. During the severe winter nights she was, no doubt, frequently tempted to forget to make an occasional round or two. It should also be borne in mind that the night attendants were doing their work without any supervision of any kind.
Hospital Building:
A visit to the Hospital Building disclosed the same unsatisfactory conditions previously mentioned in this report. The outside doors of each ward were padlocked and the rooms inside the wards were also padlocked.
Solarium:
The patients in each solarium, however, could roam about the wards in the darkness as they wished.
Electric Fixtures:
New electric fixtures have been recently installed so that the lights are near the ceiling. For reasons of economy, however, no central switch had been installed and the lights in the larger and smaller dormitories can only be turned on by pulling individual cords which are suspending from the socket of each light. Miss Behrmap, the nurse accompanying me on the rounds, could not reach the cords in order to turn on the light, and I succeeded in doing so only by standing on my tiptoes and makinga number of dives to catch the escaping cord. I talked to Dr. Hummer on the subject calling his attention to the great inconvenience and the danger of such an arrangement, but he stated that in order to have a central switch he would have been obliged to spend some three hundred dollars ($300.00) whereas without the central switch the work was done for less than one hundred dollars ($100.00). An economy of this nature can hardly be justified in an institution for the care of mentally ill people.
During this round I unlocked every single room and each dormitory but found not patient whose condition required forced seclusion. Even the idiot boy, who was both padlocked and restrained in a camisole, was lying on the bed, uncovered, barefoot, and sound asleep, but dressed and restrained in the same manner as throughout the day.
March 26, 1929:
This day was devoted to inspection of the dairy, horse barn, piggery and laundry accompanied by Dr. Hummer, interview with Dr. Hummer was continued, and a number of the personnel were questioned.
Inspection of Dairy:
The dairy was found in an unsatisfactory condition. The laborer who was on duty at the time explained that the farmer, with his assistance, had been busy clipping and dehorning animals. When asked if a water hose is used for cleaning the dairy he stated that the practice is to throw some buckets of water about the place and then sweet it up. This helper could not give any reasonable explanation for not suing the water hose in preference to buckets. The reason for this, however, became apparent to me at an interview with the farmer. He stated that the barn has no adequate drainage. That the urine from the cattle and liquid manure drains from a cement pit some six or so feet dep which has to be dipped out whenever it fills. This pit had been frozen since the early winter months and as a result there is no drainage in the barn, and the reason for throwing buckets of water about the dairy instead of using the water hose is that it would take entirely to much time if the latter was practiced as the water and liquid manure must be scooped up with shovels and removed in wheelbarrows. Dr. Hummer was apparently unaware of this condition because when I spoke to him about the frozen cement pit he removed the lid and pointed to me that it was not frozen. At a depth of about two feet appeared to be the floor of this pit which looked rather black as though covered with coal dust. However, when I sent for the farmer he remonstrated to me that this was not the floor of the pit, that, in fact, the actual floor was four feet below and that what appeared to us the level of the floor was the frozen solid and liquid manure four feet deep, this in turn blocking the drainage of the dairy.
Milking:
The milking in the dairy is done by means of mechanical milkers but as there is no hot water in the barn these are not sterilized but are washed in the general kitchen. The laborer assisting with the milking had a pair of extremely dirty overalls on, since he has to provide his own overalls for that purpose, and the patients assisting with the milking were not sufficiently clean to be fit to do the milking.
Piggery:
While near the dairy barn I saw the slaughter of a pig which was being done entirely in the open under a tree and under rather unsanitary conditions. As brought out during the interview with the farmer a pig is being slaughtered about once a week, and as boiling water has to be used it is very uncomfortable, to say the least, for an employee or patient to put their hands in this boiling water and then expose them to a temperature of 20 or more below zero. Some sort of closed place with a cement floor and running water should be provided for butchering pigs.
The place set aside for the pigs was in a quite unsatisfactory state. The Institution has no adequate piggery which appears to be a necessity.
Horse Barn:
The horse barn is very inadequate and quite dilapidated, but as provision has been made for a new structure no comments are made.
The general impression of visiting the dairy, horse barn, piggery, butchering place was an extremely unfavorable one. Certainly no responsible health authorities would permit a private individual or corporation to maintain such an unsanitary place.
Proper drainage for the dairy is, of course, an immediate necessity.
Heat for the barn would be very desirable as this would prevent freezing of water, and automatic drinking cups for cattle could then be installed. It could also provide hot water for cleaning diary utensils and mechanical milkers.
Some responsible person should see that those doing the actual milking, and that includes patients, should have their hands carefully scrubbed and have clean outside clothing or special gowns or unionalls for that purpose.
Financial:
Financial Clerk was interviewed as to the major items of expenditure for 1928, and the following information was obtained:
$19,103.00 was expended for salaries during 1928, practically 50% of the total appropriation. In this connection, it may be interesting to state that analysis of the operating expenses in 49 U. S. Veterans Bureau hospitals show that not less than three-quarters of the maintenance appropriations were spent for salaries. In smaller institutions this proportion is even larger, indicating insufficient expenditure for personnel at the institution at Canton. During 1928 out of the meager general appropriation the following unusual expenditures were made:
$2,061.00 was spent for the purchase of a truck, sedan and tractor; $1,100.00 was spent for replacing two boilers in the Main Building, and $375.00 for repainting the tank. Thus expenditures of about $3,500.00 were of a rather unusual nature. One, therefore, wonders why under such circumstances $2,000.00 was returned to the Treasury as unexpended.
While the amount and character of food furnished the patients appeared to be adequate judging from inspection of meals during my visit to the Institution, one or two items may be commented upon. Thus it would appear that during 1928, 550 dozen eggs were purchased. From the amount of eggs used during the year, considering the number of employees, patients must have received eggs very seldom, if at all. The same may be said as to the amount of chicken consumed during the year which amounted to only a thousand pounds.
For electricity, light and power there was expended during the year $1,100.00, but with the new pump recently installed put in operation the expenditures would be increased, and when proper lights are provided during the night for various wards and dormitories this expenditure would be increased still further.
In connection with expenditure for heat and light consideration should be given to the installation of a central heating plant, but experts in this field should decide whether a central heating place could be installed for such a small unit without any unreasonable expenditure for that purpose.
The hospital personnel was interviewed by me during various periods throughout my stay at the Hospital, but for convenience of presentation the facts brought out are given later consecutively.
March 27, 1929:
The morning of March 27th, which was my last visit to the Institution, was devoted to inspection of records of discharged and dead patients, and to investigations of miscellaneous character, such as seclusion and the use and abuse of mechanical restraint.
Records:
Records of the last five patients who died at the Institution were inspected. They were all found to be very inadequate; there was no description of symptoms of last illness, and the only information available was the death certificate giving cause of death.
One patient, according to the death certificate, died of pulmonary tuberculosis 15 days after admission to the Hospital. There was no record of a physical or mental examination or summary by the physician as to his condition before death. Attendant’s note was the only one in the record.
Second record inspected was that of a patient who committed suicide by strangulation. He was admitted to the Institution on December 7, 1920 but the first physical examination in the record was that performed on January 7, 1926. On January 18, 1929 he committed suicide by hanging. There was no record by the physician describing the circumstances under which this occurred, no notes in the record from which anyone could get an idea of this patient’s condition prior to his suicide. Such occurrence as a split nose sustained by this patient is mentioned on a loose piece of paper written in pencil and signed by the attendant of the ward. No other comments on the subject. A letter by the Superintendent reporting to the office in Washington that this patient hung himself while the other patients were attending a moving picture show is the only explanation of this accident. Last note which contained reference to the patient’s mental condition and made by the ward attendant is that on October 1928.
Another patient died at the Institution December 1, 1928. Cause of death given, pulmonary tuberculosis. She was under treatment since August 1909. Last attendant’s note on her mental condition written on July 15, 1928 mentions the fact that she “works hard in the kitchen”. The record of this patient contains a list of various physical conditions from which she suffered from time to time. The last few entries were as follows: On September 15, 1928, acute coryza; under October 4, 1928, cough; December 1, 1928, died. There was no evidence in the record to show upon what basis the diagnosis of pulmonary tuberculosis was made. No temperature recorded; no sputum examinations. As late as October 1, 1928 she worked in the kitchen, and in the Superintendent’s report to the reservation there was no indication of her serious condition.
Another patient was admitted to the Institution in September 1918 and died in 1928, death certificate giving cause of death cerebral hemorrhage. There was no note of last illness and no record of treatment given.
Another patient was admitted to the Hospital on October 9, 1928 and died on October 26, 1928. The death certificate gave the cause of death as angina pectoris, which diagnosis was apparently made on October 26, 1928. It appears, however, that she died at 3 A. M. on October 26, 1928, was not seen by the physician before her death, in fact, according to the attendant’s note, the patient was in her usual good condition at 2 A. M., but at 3 A. M. was found dead. There was no record of any urinalysis, blood pressure, no record of treatment given this patient, and from the record no evidence upon which diagnosis of angina pectoris was made.
To summarize: The inspection of records of dead and discharged cases indicate their absolute inadequacy, and this can be said of the records of the patients now at the Institution. Based on information contained in the records one would be forced to state that the patient received inadequate medical care and supervision.
Seclusions and Restraints:
As previously mentioned throughout the report, a good many patients are kept in solitary seclusion for long periods of time. Male patients are kept in rooms locked with special padlocks, while the females are shown a little more consideration, the rooms being locked with the ordinary ward lock. All patients are locked in during the night.
There is little justification for the amount of seclusion used in the Institution but the locking up of all patients during the night, depriving them of proper toilet facilities is inexcusable. Practically none of the patients required seclusion and the only apparent reason for such practice is the prevention of their escape when the wards are left unattended, although the physical construction of the buildings is not such as to make escape especially difficult. The practice of leaving wards unattended and locking patients in groups of from four to ten in one room certainly exposes them to great danger from sudden impulsive attacks on the part of anyone amongst them.
In addition to seclusion, several types of mechanical restraints are employed, such as camisoles, metal wristlets and metal shackles with or without an iron chain.
The camisole is laced in the back with blind sleeves which are tied together in such a way that the patient has practically no freedom of his hands and arms.
Ten pairs of metal wristlets, each wristlet having a locking device, is the “regulation” hospital equipment for restraining purposes at Canton. These have been used to restrain patients to their beds, one wristlet being applied to the frame of the bed. This form of restraint is applied to patients who have to spend the night in a dormitory with eight other patients but who would be apt to disturb the others. This form of restraint must be unreservedly condemned as it places the restrained patient in jeopardy, such patients could be attacked by others, and in case of fire would be helpless. Instances have occurred where the key to the locking device of such wristlets have been lost and it was necessary to saw through an iron link in order to free the patient from the bed. During my visit no patients were restrained in that manner. Two of them, however, had been restrained in such fashion for many months at a time, but the restraint had been discontinued a few weeks before my arrival. I saw the two patients in question; they were both rather deteriorated but quiet and under ordinary war supervision should not require restraint of any kind.
In addition to steel wristlets the Institution had in its possession a pair of shackles which had been borrowed from some sheriff and had been in the use of the Institution for more than six months. This appliance consisted of a pair of rather heavy steel nickel-plated rings having its own locking device and is applied to the ankles. The two rings are connected by a chain of heavy links, about a foot in length. These shackles have been used for restraining patients in the following manner: One metal ring is applied to the ankle, locked, and the other is applied to some water pipe wherever available. Under such circumstances the patient can only move a distance of about a foot from the pipe, but the patient usually sits on the floor near the pipe to which he or she may be shackled. At times in order to give the patient some freedom of movement the second shackle is attached to an iron chain of moderately heavy links about six feet long. The chain in turn is fastened to the pipe. During my visit this was applied on one occasion to a defective epileptic girl who ordinarily is quiet and child-like, but who immediately following convulsive seizures is apt to be disturbed, throwing things about. Such disturbance usually lasts about an hour or two. This girl for some reason was kept in the Hospital Building where there are no single rooms and during her disturbed states she would be shackled to a water pipe in the four-bed dormitory. However, very close to this pipe running parallel was a hot water pipe and as this patient was shackled while in her confused state following an epileptic convulsion her escaping serious burns is almost miraculous. Had this patient been kept in the Main Building she could have easily been placed in a room without any special restraint where she could spend the hour or two during her confusion following the epileptic episode without doing any special damage to herself or others. I had the various mechanical restrains, as used on the patients, applied to me personally by the same attendants who have in the past applied them to patients and I must, without any reservation whatever, absolutely condemn their use.
The mechanical apparatus used for restraint are being kept in the vault in the office of the Financial Clerk and when a ward attendant decides that a patient has to be restrained all he has to do is to go to the office of the Financial Clerk and the latter gives him the wristlets or the shackles. In no well regulated institution for mental cases would application of any form of restraint to patients he allowed unless specifically ordered so by a physician. The type of mechanical restraint, however, as used in Canton has no place in an institution which attempts to give humane and medical care to mentally ill people. The use of the camisoles should also be abolished, as with the adequate number of ward employees this form of restraint would be unnecessary. Other milder forms of restraint used should also be abolished.
As a result of my observations I am of the opinion that the patients at Canton when considered as a whole are much less difficult to manage when compared to a similar group of the white race. Most of them are quite well behaved and very few show any special combative tendencies. On the two occasions when I made night rounds all patients were quiet. Under the circumstances there appears to be still less justification for the amount of seclusion and type of restraints used at the Institution.
PERSONNEL
Financial Clerk:
Leon L. Giles, Financial Clerk: I have seen him casually in his office practically all the time I was at the Institution. He makes a very good impression and appears to be on the job. His books are neatly kept. He also attends to his own typewriting in connection with his work.
No attempt was made to audit his accounts but the major items of expenditure were secured from him. Some desirable information, however, could not be obtained by reason of the present bookkeeping system. Thus the Financial Clerk was unable to tell me the cost of coal for one year. He was able to tell me the approximate amount of tons of hard and soft coal which was used during 1928 and the price per ton F. O. B. at the mines, but could not give me the freight cost since settlement for freight, he stated, was made through the main office and charged to his account but as the settlement is made in bulk he could not tell how much of the freight bill is for coal and how much for other supplies.
Nursing Staff:
The relationship between the Superintendent and the nursing staff at the time of my visit to the Institution was extremely unsatisfactory, working a great detriment to the patients and preventing any possible improvement in their care. Under normal conditions the addition of trained nurses to the Institution would no doubt result in great improvement in the care and treatment accorded the patients. I had no desire to enter into the details as to the causes for friction and unsatisfactory relationship between the Superintendent and the nurses inasmuch as I felt that this is a matter of internal administration which should be handled by someone in authority directly in connection with the Institution, and also because a few days before my arrival Dr. Krulish had gone into the subject very exhaustively and was to make appropriate recommendations to the main office how to remedy this deplorable situation. During my interviews with Dr. Hummer and the nursing staff, however, I was to some extent drawn into their quarrel against my wishes. I refused, however, to sit in judgment and pass upon the merits of the case but only considered the points which had some relation to the qualifications and general efficiency of the personnel.
Head Nurse:
Grace O. Fillius, Head Nurse: Qualifications: Completely 2 ½ years course of training in State Hospital #3 (psychiatric), Missouri; this included six months affiliation in the General Hospital, Kansas City. Graduated in 1915, and in June of that year passed State Board examination for nurses, becoming a R. N. Since graduation did private duty, served in the Army, held position under the American Red Cross of Instructor, Home Hygiene, in care of the sick, receiving salary of $150.00 per month and all expenses. Took a course in Domestic Science (food selection and preparation) at the Missouri University one semester. Course of nine months’ duration in Occupational Therapy. Four months course, Public Health nursing in Missouri School of social economy, following which she held position of Public Health Nurse under the Red Cross for 1 ½ years. Night Superintendent, Columbia Hospital, Washington, D. C., for six months, and school nurse in Washington for eleven months, having passed a special examination in order to secure the position.
From the above one would have to consider her quite qualified for her position, and her experience in occupational therapy was especially fortunate.
Unfortunately, however, friction has developed between her and the Superintendent almost from the first day of arrival at the Institution and for some time Dr. Hummer has sought her dismissal. Under the circumstances her usefulness to the Institution is very much limited.
Her version of the story is that Dr. Hummer was and is opposed to having nurses in the Institution and that he has made her the beneficiary of his feeling of antagonism towards the nursing profession. She brought forth many arguments to prove that Dr. Hummer has used all sorts of unfair means to get rid of her, that he asked every employee, including kitchen, dining room help and ordinary laborers, to furnish affidavits against her and that a number of employees did so fearing to lose their jobs, so because they wished to get into Dr. Hummer’s good graces. She mentioned that some employees left the Institution after being asked to furnish affidavits.
As Dr. Krulish spent several days investigating these charges and countercharges I see no need for repeating them here. I felt also that this quarrel and friction between the Superintendent, the nurses and the farmer deplorable and demoralizing to the Institution, as they are problems of internal administration to be straightened out through the main office. In so far, however, as the various charges touched upon the personal fitness and qualifications of the personnel I could not disregard them and what is more I was almost forced to listen to them.
In justice to the Head Nurse I must say that as a result of the interview & the many opportunities to observe her during the various visits to the place I formed a rather favorable impression of her. She appeared interested in her work, had a sympathetic attitude towards the patients, was quick and alert, and assured me of her willingness to cooperate with Dr. Hummer in every respect if he would be willing to tell her what he expected of her.
On the other hand, most of Dr. Hummer’s charges against Mrs. Fillius were based upon rumors and gossip brought to him by various subordinate employees, and without going into the merits of the charges one must question the wisdom and propriety of encouraging or even permitting assistant cooks, dining room girls and unskilled laborers to judge and report upon the professional or personal conduct of a head nurse who in an institution like the Canton Asylum should be considered the second ranking officer in authority.
Nurse:
Elsie R. Behrman, Nurse assigned to Hospital Building: She graduated from St. Peter State Hospital, Minnesota, an institution caring for 1,800 patients and in charge of seven physicians and a Superintendent of Nurses, who was a registered nurse, and there was also an instructress, a registered nurse. The course was of three years duration but as the institution did not have an affiliation with a general hospital her diploma is not recognized for registration purposes. This fact, however, she made known to Dr. Krulush at the time of her application for the position and he was under the impression that this matter could be adjusted. She graduated from training school in 1923 and remained an employee of the St. Peter State Hospital until she reported for duty at the Canton Asylum, except for about eight months when she was doing private duty at Rochester at the Mayo Clinic. She stated that Dr. Krulish told her that it was the desire of the Indian Office to make the institution ideal. The first day she reported for duty she had only a brief interview with Dr. Hummer, but the following day, on Sunday, he called her into his office and told her that she came there in a queer time, that things were changing. That Miss Gregory (Head Nurse of the Indian Service) thought he was too old and wanted to get rid of him. He told Miss Behrman to keep her eyes and ears open and her mouth shut. He told her of the difficulties he had with Mrs. Fillius and stated that some of the employees were on his side, some on her side, and some on the fence and did not know where to flop. He told her that anything she could do for him would be appreciated, that she would then be made the head nurse, after the present one was dismissed. He told her: “A friend of mine in Sioux Falls said to me ‘your head nurse can hold a lot of booze’, but of course, he would not be able to testify”. He expected employees to be loyal to him. Miss Behrman states that she was highly surprised at the nature of the interview and did not know how to take it. She told him, however, that she came there to do her duty.
Miss Behrman is a mature young woman, not of the frivolous type. She gave the impression of being competent and conscientious in her work. Had she arrived at the Institution under normal conditions she would have, no doubt, been of great value to the Hospital. She was rather distressed at the prevailing conditions at the Institution and contemplated leaving the place. I urged her to stay and be a little more patient.
Katie Knox, Ward Employee:
Reference has previously been made to this attendant. She is in charge of two female wards on first and second floor of Main Building but has also done night duty at various times. While under supervision she could probably assist with some ward work, her present physical state and her nervous temperament would hardly justify allowing her to take full charge of two or more wards of sick people as she has been doing for a number of years in the past.
Emma M. Henke, Ward Employee:
This girl has been employed at the Hospital only since February 19th. Until March 4th she was assistant cook but since latter date has been on night duty, looking after two female wards in the Main Building and two female wards in the Hospital Building. She stated that she has never had any trouble with any patients and never personally applied any strait-jackets or shackles to anyone. She has had no experience in any hospital. During interview she did a lot of giggling and it was certain that he mental equipment was not above that of a moron. She was a strong, healthy young woman, good natured, and would, no doubt, be a good help on the ward under immediate supervision of a nurse, but she is entirely incapable of looking after half of the Hospital population without supervision as she had been doing while on night duty.
George H. Sinning, Ward Employee:
He gave his age as 21 although he looked like 18 or 19. Rather thin but neat and intelligent. He has been employed there about a month and has been on night duty until the other day when a new attendant took his place and he was placed on day duty. His hours on night duty were from 6 P. M. to 6 A. M., in the Hospital Building, his duties being to clean the dishes of the so-called tubercular patients and other bed-patients on the ward, spending an hour in the Hospital Building and another hour in the Main Building, having supervision of two wards in each building. Questioned as to the number of patients who were padlocked in rooms, especially with reference to Kee Catron and Henry Roberts, he stated that during his period of night duty he had no trouble with these patients and that they never attacked him or showed any disposition to fight.
Peter Anderson, Ward Employee:
This employee was observed by me on duty during my several inspections of the wards, and he was also interviewed. He has been employed at the Institution since 1923.
He was very slow in his manner and speech and quite deaf. He stated that he had been in the habit of writing “patient’s psychiatric notes” about once in two months, usually they were all alike but now and then he would make a little change. They were written in conformity with a certain form submitted to him by Dr. Hummer.
Since Mr. Anderson was one of the ward employees who had made some written affidavits about the nursing staff he was briefly questioned on the subject. He stated that everybody has treated him well and that he has no complaints against anyone. He added, smilingly, “at first I thought Mrs. Fillius was kind of riding me”, and when asked in what way he was rather vague, saying that he had worked at the Hospital for a number of years and did the best he could and Dr. Hummer was satisfied with his work, but when Mrs. Fillius arrived she kept him somewhat on the run. She would come on the ward and tell him to do this and do that. He stated, however, that he may have been mistaken about her trying to ride him and that he does not think so now.
Helen Bradsgard, Ward Employee:
This employee was interviewed by me because of the report that she intends to leave the Hospital. She has been employed there only since December 1928, previous to which she was a waitress in Canton Café in Sioux Falls. As stated in another part of the report, this ward employee was the most intelligent of the group of ward attendants, having been a member of the general training school in St. Joseph’s Hospital at Sioux City, Iowa. She voluntarily stated that Dr. Hummer wanted her to make a statement about the head nurse. That she, in fact, knew nothing derogatory about Mrs. Fillius and personally had no difficulties with her. On one occasion Dr. Hummer asked her if she though Mrs. Fillius was drinking or if she ever smelled liquor on her breath. Mrs. Brandsgard stated that she told Dr. Hummer that she never saw Mrs. Fillius drink nor did she smell liquor on her breath, but merely suggested that as Mrs. Fillius handles alcohol in the drug room she could have had the odor of it about her person. This she states Dr. Hummer interpreted as though Mrs. Brandsgard actually charged Mrs. Fillius with using liquor. Although it is probably that Mrs. Brandsgard intends to leave the Hospital for personal reasons, she tried to give the impression that her chief reason for giving up her present position was the unpleasant air about the Institution and her displeasure at being requested to make affidavits and quoting her erroneously concerning Mrs. Fillius.
John W. Faulkner, Nellis B. Faulkner, Sig. Monson, Ward Employees:
These three employees were not interviewed because they were given employment during my visit to Canton, and without any instructions they were given charge of a ward and one employee, Mr. Monson, was placed on night duty to look after all male patients of the Institution without acquainting him in the least as to the character of the patients he was to look after, or their special problems, and this has no doubt been the practice and vogue for many years.
Emma Giles, Head Cook:
This employee is the wife of the Financial Clerk. She has held this position for about six years. She stated that she has been making out menus for about two months but as she does not know the supplies on hand changes must be made practically daily. No weighing or measuring of food is being done. She also supervises the baking of bread. She stated that the nurses have made no unreasonable demands upon her, that she has had no trouble with anyone, has not observed anything unusual and has no complaints to make. She added that she had made a “statement” but when asked as to its nature she stated that she did not remember and was about to inquire of her husband (Financial Clerk) as to its contents, but she was told not to bother. She blamed the somewhat unsatisfactory condition of the bakery on the soot and coal dust.
Bertha L. McAllen, Temporary Cook:
She is cook in employees’ kitchen. Has been employed there since December 1928. Until about two weeks before becoming cook she was a ward attendant on night duty. During her three months night duty she stated that she had no trouble with any of the patients; was never attacked. As far as she knew all patients could be allowed to go to the toilet. With reference to the girl who occasionally got disturbed, she would put her in the bathroom in accordance with the previous custom. She put a strait-jacket on her only once when she attempted to destroy blankets or sheets. No other attempts to control her excitement were made. She stated that the attendant on duty decides when a strait-jacket is to be put on and makes an appropriate notation in the ward book kept in the office of the Main Building and is seen the following day by the Superintendent.
Anna Peterson, Assistant Cook:
This employee acts as second assistant to the cook in the Main Building kitchen. She has been employed there nine years. In addition to assisting with the cooking and relieving the first assistant cook she also washes dishes, scrubs floors, etc. (should be done by dining room girl). Two female patients and a male patient assist in the kitchen. The dining room girl does not take care of the dishes but does help “occasionally” in the kitchen when other employees are off. Recently some aluminum kettles were provided in place of previous enameled ones, which are a great improvement over previous dishes. She suggested a coffee percolator and a teapot. This employee also had no complaints against the Head Nurse and stated that the Head Nurse was always nice to her and gave no unreasonable orders and made no unusual demands upon her.
Cara Christopher, Dining Room Girl:
This employee has been in the Canton institution for 19 years. The first six years of her employment she was assistant cook and later on promoted to her present position in charge of patients’ dining room. Her hours of duty are from 6 A. M. to 1 P. M., and from 4 to 6 P. M. She also takes care of the cleaning of the front offices in the Main Building, and until recently was in charge of issuing of supplies at the Hospital, except drugs. Her duties consist in setting the patients’ tables and to help in serving the food. Female patients assist her in her work. The dishes, she stated, were washed by assistant cooks. She occasionally relieves in tekitchen when bread is being baked.
Questioned as to difficulties with the nurses she stated that she has had no difficulties with Miss Koepp and Miss Behrman, but indicated that it was different in the case of Mrs. Fillius. When asked to be specific she stated that Mrs. Fillius had been keeping her in a “rush”, and as an illustration, she stated that only this morning while she was cleaning up in front Mrs. Fillius told her to “hurry up because Dr. Silk is coming early”. Another occasion she mentioned was that Mrs. Fillius told her to assist Miss Koepp in the dining room, and when she was through with her work and was having a cup of coffee in the kitchen Mrs. Fillius told her that her place was in the dining room. When her attention was called to the fact that these were rather trivial matters she then stated that she did not think the nurse was dignified enough at the dinner table. That she often “carried on”. That if a patient did that she would have though she was either drunk or crazy. When asked to describe specifically the behavior of this nurse, she stated that Mrs. Fillius was telling the others at the table about a party she had attended where one of the lady guests was under the influence of liquor, and Mrs. Fillius was imitating that woman. Miss Christopher’s comment upon that was that “it was disgusting”. Upon further questioning it was brought out that the part of which Mrs. Fillius was telling at the dinner table was an occurrence in Washington, D. C., about three years before her arrival at Canton. She also mentioned the fact that Mrs. Fillius once invited her to go to Sioux Falls with her but she refused, adding “I would not say anything about her but would not want to keep company with her”.
As this girl had figure din some of the previous reports and had difficulties with the first nurse assigned to the Institution, Miss Edith Wilson, she was asked to give her opinion as to the letter. Her answer was that Miss Wilson was “the same as this woman”, meaning Mrs. Fillius. How? “She associated with women town who drank”, and Miss Christopher emphasized “I do not think that is lady-like”.
Asked as to the morals of Mrs. Ritter, who recently left the Institution after a period of employment of about four years, Miss Christopher stated that Mrs. Rittner was all right but she was not lady-like either. She smoked cigarettes. “I was not brought up that way”.
To further emphasize the unlady-like conduct of Mrs. Fillius, the Head Nurse, she asked to mention another incident which just came to her mind, which was that when a Mr. Donnelly, an attendant, was ill in his room the Head Nurse, Mrs. Fillius, requested Miss Christopher to take a pitcher of water into his room. Miss Christopher stated that she refused to do so as it was against Dr. Hummer’s rules, and added that she did not think that a woman should go alone to a man’s room, although she admitted that Mr. Donnelly was, in fact, quite ill.
This employee deserves some special comment. Most of the difficulties between Dr. Hummer and the Head Nurse are no doubt due to this employee, since she has made most of the reports to Dr. Hummer as to what Mrs. Fillius said or did. It need not necessarily be thought that Miss Christopher has been doing this out of malice or consciously tried to harm Mrs. Fillius. It should be remembered that we are dealing with an uneducated country girl, who for several years was an assistant cook, promoted to dining room girl, and later on was given charge of all supplies. That for a number of years she was practically the next ranking officer at the Institution. Ward employees and all the other help had to go to her for supplies. She no doubt became impressed with her own importance and it was only natural that she should have resent the appearance of any nurse who would attempt to boss her. In her opinion the Institution does not need any more competent help. She assumes a holier-than-thou attitude towards all the other employees and thinks that she has the night to be the moral censor of the nursing staff. Dr. Hummer has evidently considered her to be a reliable employee and has been in the habit of listening to her complaints of others. It will be recalled that she was the source of friction between Miss Edit Wilson, the first nurse assigned to the Institution. Miss Wilson was a graduate of the Training School of Saint Elizabeths Hospital, and in my personal opinion, as well as in that of others at the Institution who have known her, her character was irreproachable.
That a subordinate employee should be allowed to express an opinion as to the efficiency or character of trained nurses is a most impossible situation. The prospects that any trained nurse could make an adjustment to this girl are quite remote, and while there is no doubt that under different circumstances Miss Christopher could probably perform work of dining room girl or assistant cook in a fairly satisfactory manner, at this institution she would be a source of constant friction and her own efficiency would be much lowered. For the good of the Institution she should be transferred to another locality where she would have less opportunity for gossip and “moral” censorship.
Thea Underhill, Dining Room Employees:
(Husband employed as engineer at the place). She is the waitress in the employees’ dining room and relieves the employees’ cook when the latter is off duty. No menus are kept for employees’ dining room. She gets supplies for the whole week. She lacks storage room, the refrigeration is inadequate, no cupboards, general equipment is very bad. The range, she states, is in very poor condition and utensils unsatisfactory, not enough; the few on hand, however, are in good condition. Asked as to what additional equipment she should have, she mentioned potato parer, mixing bowls and various small articles useful in the kitchen. She indicated that there are too many things needed for her to mention during this interview. Pitchers used in this dining room are enamel and badly chipped off. Those used to store milk and cream in are kept uncovered. The kitchen has no slop sink; only one sink for water and dishwashing. Although there is a bakery, bread for the employees is baked in the employees’ kitchen. As this employee was quite intelligent and made a good impression, she was asked as to the Head Nurse, whether she had received any unreasonable orders. She stated that Mrs. Fillius has always treated her well and that she could make no complains about her. Prior to coming to the Hospital Mrs. Underhill worked in the Wisconsin State Hospital and also in the Connecticut State Hospital, and she stated that when she first came to Canton Asylum she was surprised at locking up patients, at the chamber pots, etc. Based on her own experience as night attendant for several months she saw no need for padlocking dormitories or the single rooms of the female patients. As far as she could judge the patients she would not have anticipated any trouble from them and none would need be locked. She mentioned the fact that shackles had been used on a patient by the name of Zana, reference to whom will be made later on.
Georgia Waldrop, Seamstress:
The seamstress was seen by me at work on various occasions. She does her sewing in a rather small room on the second floor in the Main Building which is located between two wards. Two female patients are assisting her. She should have more room for her work and more light for her own good and also for the good of the patients who assist her. Additonal female patinets could be assigned to assist her, but there is a deficiency of sewing machines.
Anna Fjelstad, Laundress:
This employee was very neat and appeared to give the impression of being very capable. She has no help except patients. She works daily from 8 A. M. to 4:30 P. M., and also relieves in the kitchen and dining room on Sundays. In mentioning the work she performed she incidentally stated that she is kept quite busy with curtains (“which we have a good many, and they are hard to iron”). Most of them should be condemned. The present wringer is fairly satisfactory but is out of commission quite frequently. The drying room is small and inadequate. The present mangler is fairly satisfactory but is old and rather worn out. She appreciates that the ward linens, such as bedspreads and sheets, do not come out of the laundry as white as she would like them to be but she attributes this, first, to the extremely dirty condition when they reach the laundry due to the fact that the patients lie on the bedspreads with their dirty shoes on, and also on account of the hard water which she is obliged to use at the present time. For about a week when a new pump which had been installed, was in working order and she had soft water, things were very much better. She also suggested a permanent ironing board on a stand and an electric iron. This employee had no complaints against the Head Nurse and stated that she had no difficulties of any kind with her.
(The reason why various employees were questioned as to their attitude towards Mrs. Fillius was the charge that she had antagonized all employees and disturbed the tranquility which had existed at the Institution prior to her arrival).
Dewey R. Gillard, Farmer:
This employee has been at the Hospital about five months previous to which he was employed seven months at the State Training School for Boys at Eldora, Iowa. Was assistant farmer, dairyman, and did some garden work. For about four years off and on he was employed as farm boss at State School for Boys at Kearney, Nebraska. His salary was $80.00 per month, room, board, and laundry. At the Canton Hospital he gets $1560.00 from which a deduction of $180.00 is made for quarters, heat and light, but he provides his own board. He stated that he arrived at the Institution under unfavorable conditions because last year’s crop had not been taken in. During the winter months he had to assist in hauling coal and wood, split wood. He also does the butchering, one hog being butchered a week. This work is done outdoors under a tree and in cold and bad weather they have to keep their hands in hot water and then expose them to a temperature of 28 or so below zero. He suggested a small enclosed place with a cement floor, water, etc. He stated that he still had 40 acres of corn on the field from last year and April is almost here when he has to sow oats. And in addition he has been plowing alfalfa. He though he needed more help. He has a laborer who assists him but eh latter has had no experience in farming and the dairy alone would take up one man’s time. When his attention was called to the fact that on a previous visit the dairy was not found in very good condition he stated that it was partly due to the fact that they were doing some extra work, that they were clipping hair and dehorning cattle, but principally due to the act that the dairy lacks proper drainage. The barn as a drain which empties into a cement pit. When this pit becomes filled it must be dipped out with buckets. At the present time this cement pit is more than half filled and all the liquid and solid manure is frozen, blocking the drainage from the dairy barn so that in order to clean the barn they throw a few buckets of water. This water has to be scooped up with shovels and this is the reason why they do not use the hose as if they did it would take them all day to get the water out of the dairy barn. The disposal of this waste is by means of wheelbarrows. They fill a wheelbarrow and empty it some distance away from the barn. Also, the water was frozen during the winter and only thawed out during the last few days. He stated that they had 17 milk cows, 9 calves, 2 bulls and about 100 hogs. The bulls he stated were related to the present herd and they are practically doing inbreeding which he did not consider a good thing, and he suggested that one bull be exchanged or sold. There is no heat in the barn, which prevents the installation of automatic drinking cups. The tractor is in good working order and recently a disk and a harrow were purchased. The Institution has four horses but another team of horses is needed which he thinks the Superintendent intends to provide. He felt that one man should be on duty in the dairy while two should be in the field, one using the tractor and the other looking after the horses. His present assistant was only today (March 26th) given an order to go after a patient. He may be away a week or so and another inexperienced man who knows nothing at all about the dairy will have to do his work. His own quarters are quite unsatisfactory as the house which he occupies now is in a dilapidated condition. It has no accessible water and he has to carry water in milk cans from the Main Building to his place, about a half a mile. He uses his own automobile for that purpose. There is a well near his house but it has not been in use for three years, is all stopped up and needs considerable work to put it in commission. As he boards himself and therefore does not use up a half an hour for breakfast as other employees, he reports for work at 6 A. M. instead of 6:30, when he spends about a half an hour doing the various chores, tending to the horses, tractor, fixing odds and ends, and is actually in the field at 7 A. M., and he works until 6 P. M. He indicated that the Superintendent thought that he should be in the field from sunrise to sunset. It would appear, however, that this man’s hours are long enough. He gave the impression of being honest and apparently capable. Upon further questioning as to the attitude of the Superintendent towards him he ventured the opinion that he was not wanted from the first day of his arrival. When he reported to the Superintendent and inquired as to his quarters, Dr. Hummer told him “I have one little room up there in that building”. When he told the Superintendent that he has a family and that the Indian Office promised him quarters, Dr. Hummer said: “Oh, yes, there is a house on the new farm. Go and see fi you can live there. The other farmer did not want to live there”. Pending the arrival of his own furniture he borrowed a few things and a few dishes but when he talked to Dr. Hummer on the subject of his needs he stated the Doctor “raved at him”, told him he did not care whether he had a family or not, etc., etc. Mr. Gillard then told Dr. Hummer that he talked to him as a gentleman and that he is not going to take this bawling out from him.
As to the report that he told Dr. Hummer that while previously employed he abused one of the inmates, he categorically denied it, and has his own explanation of the affair. He stated that one evening he mentioned to Dr. Hummer how Joseph Carpenter, a patient who had been assisting him, expressed his surprise and amazement at the new hay fork which they had bought. Dr. Hummer then told him what a bad patient this Carpenter had been in the past and how difficult he had been on previous occasions, upon which Mr. Gillard related to him how one of their troublesome inmates ran away and put up a stiff fight and how he, Gillard finally caught him and with the so-called “Strangle Hold” subdued him. This Strangle Hold, he explained, is a common expression, consisting of grabbing the man’s arm and the one who is subduing the patient puts his forearm under the other man’s chin.
Joseph W. Underhill, Engineer:
This man is not a licensed engineer and received most of his knowledge through a correspondence school. He stated that in addition to looking after the boilers, pumping station, etc., he does the plumbing and also carpenter work about the place. He stated frankly that he knows practically nothing about plumbing and just as little about carpentry. He knows something about electricity but does not consider himself as a qualified electrician. He stated that he is kept quite busy but has no complaints and though that everything was in good condition. He stated that he fixed the drinking fountain the other day but was surprised when told it had been out of order for more than six months. He could mention nothing he was in need of to make his work more efficient, and stated that Dr. Hummer is always good to him and buys him anything he needs.
From the interview with this engineer one would think that everything was 100% perfect at the place, and the general impression of him was that his efficiency does not reach a very high mark. Since, however, he is called upon to be a jack of all trades he can hardly be blamed for the various unsatisfactory conditions of the Institution either in the line of plumbing, carpentry or electricity.
Other Employees:
Other employees were seen about their duties but were not especially interviewed.
PART II.
GENERAL SUMMARY AND RECOMMENDATIONS
Inspection of the Institution over a period of six days disclosed most intolerable conditions in all of its departments. Without attempting in the slightest to place the blame in any one quarter for the very unsatisfactory conditions disclosed, it must be stated very frankly that the Canton Asylum does not meet in any of its major departments the very minimum standards required of an institution for the care and treatment of mentally ill people.
The physical set-up of the Institution is totally inadequate. The place as a whole is quite unsanitary, and little attention is being paid to the patients’’ general or personal hygiene. The fire hazard of the place is extremely great, especially under the present practice of locking in patients and leaving wards unattended during the day or night, while patients are allowed to have access to matches and smoke on the wards. The two buildings housing patients are of poor construction and neither are fireproof. The Main Building, which is the more substantial of the two, was built more than 25 years ago and was not planned by anyone who had any sort of appreciation of the problems involved in the care of a small number of mentally ill patients who present practically the same variety of types of mental disease as found in the larger institutions.
Under present conditions the patients receive no psychiatric or mental treatment of any kind worth while mentioning. They receive the poorest kind of medical attention and custodial care very much below the standard of a modern prison.
To build up the Institution on the basis of its present population to any reasonable standard of modern institutional care would require an expenditure which would raise the per capital cost to unjustifiable levels, but even if the population is to be doubled or even trebled it must be realized that no matter how economically the Institution may be conducted the per capita cost would still have to be much higher than that of an institution of a thousand of more patients. While the care and treatment of the mentally ill has been entirely revolutionized in the past twenty years, there is little evidence of any progress at the Canton Asylum. The methods of patients’ care in vogue during the inception of the Institution are still being used to date. The present appropriation for general maintenance is absolutely inadequate. It is relatively less than the amount appropriated for the same institution fifteen or more years ago, though it is well known that the purchasing value of the dollar is now almost half of what it was in 1915. Under the circumstances the patients cannot possibly receive the sort of acre which one has a right to expect of a Federal institution designed for the care of its unfortunate wards. It is only because of the isolated location and the fact that it is rarely being visited by patients’’ relatives that the Institution could escape serious criticism for its conduct.
RECOMMENDATIONS FOR IMPROVEMENTS
Under the present physical set-up of the Institution, its medical and ward personnel, recommended changes even if they could be carried out promptly, would not bring the Institution up to a point where it could meet the minimum standards of care as accorded patients in the average modern State hospital. The Institution needs modern buildings for the housing of patients and a thorough reorganization of its medical and nursing work. Before undertaking any extensive improvements the Government should definitely decide whether a separate institution for mentally ill Indians is, in fact, a necessity. If it is the intention of the Government to eliminate its guardianship over the Indian and transform them to independent and self-sufficient citizens the need for a separate institution for Indians would be less and less in the years to come, since the independent Indian would be eligible for admission to State institutions.
In this connection, it may be of historical interest to mention the fact that in 1898 when a Bill for the establishment of a separate institution for insane Indians was introduced in Congress the late Secretary of the Interior, C. N. Bliss, did not approve of the project, and in a letter addressed to the Chairman, Committee on Indian Affairs, U. S. Godding, at that time Superintendent of Saint Elizabeths Hospital, and stated: “In view of the statements made by Dr. Godding as to the annual cost for maintenance of the proposed institution, which greatly exceeds the annual cost of the insane Indians now cared for by the Government, and the fact that Congress has made provision for additional accommodations at the Government Hospital for the Insane, at Washington, D. C., I am of the opinion that the interests of the Indians would not be best subserved by the construction of an asylum proposed by the Bill, and I return the same without any approval”. Although nearly thirty years have elapsed one may still wonder whether there is a real need for a separate institution for Indians.
RECOMMENDATIONS
(These are made under the assumption that it is definitely decided to maintain the institution).
PHYSICAL IMPROVEMENTS
1. A new modern building to accommodate 120 patients – 60 males and 60 females – should be constructed at the earliest opportunity. It should be planned by a psychiatrist experienced in hospital management. It should provide accommodations for at least four distinct groups of patients: (1) Acute, (2) Physically ill and generally infirm, (3) Disturbed, noisy or combative, (4) Improved and convalescent.

This building should provide the necessary day-rooms for patients, nurses’ offices, clothesroom, linen room and proper toilet and bathing facilities. It should also have one general kitchen, two congregate dining rooms, one for males and one for females, and amusement hall and chapel. The central portion of the building, separating the male and female wings, should contain offices of the Superintendent, assistant physician, head nurse, financial clerk, stenographer, record room, visitors’ room, pharmacy, laboratory, hydrotherapy and physiotherapy room.

The present Main Building could be used for housing the mentally defectives, with or without convulsions, and for the more chronic deteriorated types.
2. A small building for tubercular patients, capacity 20 beds – 10 beds for males and 10 beds for females. It should contain 40% single rooms and have a small sitting room connected with semi-open porches. It should also have a small dining room, serving room, and sterilizer for dishes.
3. Quarters for employees: They should not be located in patients’ buildings. Adequate and special accommodations should be provided for an additional physician who may be married and have children; as also for nurses. Under existing conditions there can be little hope of retaining any efficient personnel which the Institution may be able to secure. If the policy of employing married personnel with children is to be continued special provision should be made for them.
IMPROVMENTS UNDER EXISTING CONDITIONS
Windows in the solaria should be remodeled to have upper and lower portions, and it should be possible to lower both through the window sill clear to the floor. Awnings or window blinds should be provided.
Window guards in the Main Building should be placed outside permitting free access to windows and doing away with the great number of padlocks.
The use of padlocks for ward doors, dormitories or single rooms should be abolished. They suggest methods of old time jails and would greatly retard removal of patients in case of fire. One type of lock for male wards and one for females should be used throughout the Institution.
Wash basins should be removed form bathrooms and placed in toilet rooms, and space made available in present bathrooms used for nurses’ office and for patients’ clothing and ward linen (only a makeshift).
Bathrooms should be kept locked when not in use.
Drinking fountain should be removed from bathroom and placed in the hall. Other fountains should be installed and kept in working order.
Lights should be installed in closets in Main and Hospital Buildings where patients’ clothes and ward linen are kept.
Fire extinguishers should be removed from locked closets and kept on the all where they could be seen and used in an emergency.
Hall of each of the four wards in Main Building should be fixed up for sitting rooms; floors should be covered with linoleum, and wooden ward settees, two small tables under a number of chairs and rockers should be provided.
Present curtains used in wards and halls should be condemned; they attract dust, darken the wards, add to fire hazard and provide a lot of unnecessary work for the laundress. (Material was furnished the Institution free of cost which is apparently the only reason for their use).
Present dark window blinds should be replaced by light ones. Wards should be painted pearl gray or similar light color making them less dark.
Enclosed porches should be added to first and second floors on south side of the Main Building. This would provide male patients with necessary smoking space and for other relaxation. Patients now smoke on wards which is very hazardous from fire standpoint, especially as they are left unattended.
Beds, bed springs and mattresses should be replaced; present equipment is of a very inferior grade.
More modern plumbing should be installed, especially whenever any replacement is required.
Second floor porch of Hospital Building should be enclosed to provide smoking facilities.
Enameled dishes and kitchen utensils used at present should be condemned. Kitchen utensils, as well as receptacles for carrying food to Hospital Building, should all be aluminum. Dishes should be heavy china (delf); glass tumblers should be provided, and patients served water with their meals.
Round tables with appropriate chairs should be provided for the dining room.
The wheel chairs should be provided for hemiplegic and paraplegic patients.
A small dishwashing machine should be provided.
Newly installed pump should be immediately placed in order to provide the soft water so much needed for the general cleanliness of the place.
The wisdom of maintaining two kitchens in such a small institution is questioned. The number of kitchen employees when considered in the light of the inadequate number of ward personnel, is excessive. Present number of kitchen help six, compared to eight ward employees.
All food should be cooked in the Main Building kitchen. One cook, two assistant cooks, and one waitress for employees’ dining room should be sufficient help under present conditions. Second assistant cook should do the work of the present dining room girl; she already does the dishwashing. More female patients could assist, if necessary; this would save two employees badly needed for the wards.
Ten-day menus should be provided and worked out on more modern dietetic principles than now in vogue. Weights and measures for patients’ food should be provided.
Wards should not be kept in darkness after patients retire. Small blue lights should be installed in each dormitory and main halls of each ward; stairways and bathrooms should remain lighted during entire night.
Central wall switches operated with a key, making them inaccessible to patients, should be provided throughout the Hospital Building, present individual cord-pullers should be abolished.
Dairy barn should be provided with proper drainage; present pit should be abolished. Heat for the dairy is desirable. it should be kept in a more sanitary condition. Milkers should be provided with clean clothing.
A butchering house should be built.
A proper piggery is a necessity.
MEDICAL IMPROVEMENTS
Medical care of patients requires complete reorganization; its execution is to a great extent dependent upon necessary physical improvements and urgently needed additional personnel.
An assistant physician should be added to the place. An attractive salary must be provided to secure a competent man.
Each patient should receive a complete psychiatric and physical examination, routine urinalysis and blood Wassermann test as soon after his admission as possible. The results of such examinations should be typewritten and with future periodic psychiatric examinations performed by a physician, and also typewritten, should constitute the Clinical Record. It should follow the form now in use by the more progressive State hospitals. Records as maintained at Saint Elizabeths Hospital should be the goal of the Institution.
Routine laboratory work should be performed at the Hospital; special provision should be made for Wassermann work.
All entries into clinical records should be made under proper date and the name of the examiner be given in each instance.
Accidents should be fully described.
Acute illnesses should be properly described, the symptoms observed, and treatment given noted.
In case of death or discharge a proper losing note by the physician should be dictated into the record before disposing of the case.
A laboratory with necessary equipment should be installed.
An X-ray machine should be provided.
Operating room should be equipped with instruments, instrument cabinet, glass top and metal top dressing tables, electric sterilizer, irrigating stand, closets for dressings, and other pieces required in a minor surgery room.
Under existing conditions seven additional ward employees must be provided. If, however, employees now living in the Hospital Building could be moved out the Institution could save the expense of two ward employees. Position of night nurse should be filled at once.
All acute physically ill patients should be brought together and not scattered throughout both buildings. The four-bed dormitories of the first and second floors, Hospital Building, for females and males respectively, may be utilized for that purpose.
No patients should be allowed to remain on any wards during the day unattended. While at night after patients retire one attendant may possibly look after two wards, provided patients are carefully classified, no patient should be locked in a room or in any dormitory while attendant is making rounds on the other ward. Outside ward doors should be the only ones locked. If the ward houses patients who could not be left with safety on the ward unattended even for a half an hour or an hour at a time, they should be placed on a ward where there is an attendant all the time and such a problem should not be met by seclusion or restraint.
Present methods of seclusion, isolation and restraint should be unreservedly abolished, and certainly no ward attendant should be permitted to apply any form of mechanical restraint without a physician’s specific order.
All chamber pots used in the Institution should be destroyed. A few regulation bedpans should be provided for bedridden patients. Toilet facilities should be made available for all other patients.
Hydrotherapeutic room located in the Hospital Building should be cleaned up and put in operation. Coal stored in the room originally provided for a pack room should be removed and four or five tables with other necessary pack-equipment provided.
Some provision for patients’ dental care should be made. Patients should be furnished tooth brushes.
Slippers and bath robes should be provided for bed-patients.
An occupational aide should be employed.
A good stenographer is an absolute necessity. Such an employee could also do all the filing of records and would relieve the Superintendent of a lot of clerical work, allowing him to give more personal attention to the patients.
Periodic inspections of the Institution, as recently initiated, should be continued but it would be advisable to have the Institution inspected at least once a year by a psychiatrist preferably in company with the regular medical inspection.
Difficulties between the Head Nurse and the Superintendent should be immediately adjusted.
The Head Nurse should be given full charge of all ward and domestic personnel, and all requests for leave, vacations, etc., should be made to her. She should have full authority to give orders to nurses, attendants and kitchen help in order to improve the general routine of the Institution, such orders being subject to revision by the Superintendent if found unworkable. Pending the arrival of an assistant physician the head nurse should be considered as ranking second officer in the Institutution.
Some of the clerical duties at present performed by the Superintendent should be turned over to the Financial Clerk pending the employment of a stenographer. The time now spent by the Superintendent for clerical work and keeping of records which are of vey little value should be devoted to patients’ individual problems.
All orders for medication should be given on the ward where the patient is located.
All written reports by ward attendants should be made on the ward.
Patients’ card index system should be installed. Such cards should contain the following information: Name, date of admission, age, education, social status, occupation, religion, ward where located and name of wards to which they may be transferred from time to time.
Comment: Under present system it is impossible to obtain any desirable information, and the little information available is scattered through various books and records.
All wards should be designated by numbers or letters, as Main Building Wards 1, 2, 3, and 4, and Hospital Building Wards 1, 2, 3, and 4. Each ward should have a record of patients housed there, and ward attendants should at all times be able to tell the number of patients on each ward.
The appointment of a consulting staff, consisting of specialists in the major branches of medicine, including neurology and ophthalmology, would be very desirable and would aid in placing the care and treatment given the patients on a scientific basis. It may be possible to select such specialists form the cities of Sioux Falls and Vermillion. Some of them could visit the Institution once or twice a month while others only upon special request, but they should constitute the official consulting staff and have the privilege of making suggestions in their respective departments.
Attached hereto are Exhibits A, B, C and D, being exact copies of records of patients now in the Institution. These records were not especially selected but were taken alphabetically from the clinical file. They are presented to illustrate their inadequacy from