The 1889 death of inmate Taylor Combs led to a scandal, and then major reforms, at the Rochester State Hospital for the Insane.

On April 1, 1889, attendants August Beckman and Edward Peterson reported a death to Dr. Jacob Bowers, superintendent of the Rochester State Hospital for the Insane. Inmate Taylor Combs, age thirty-seven, had fallen from a scaffold while cleaning the ceiling, requested a glass of water, and then left to lie down. He was found dead a short time later.

Bowers summoned the county medical examiner, who found that Combs had suffered a broken breastbone consistent with a fall and probably died of internal bleeding.

This version of events began to come apart the next day. John Date, a young painter working at the hospital, reported seeing Beckman and Peterson beating Combs with a cane, then a broom handle, and finally kneeling on his chest. Bowers immediately fired the two attendants but informed neither the county attorney nor the hospital board of the likely crime.

Date repeated his story, and word got out. Beckman and Peterson were charged with manslaughter, Bowers was suspended, and Governor William Merriam ordered an investigation.

Over the summer of 1889, 138 witnesses came forward. Their testimony ranged from praise for Bowers and his staff to disturbing tales of beatings and intimidation.

The investigative committee faced a difficult task. Many of the witnesses had been sent to the hospital for insanity, making their testimony at times doubtful. High turnover among attendants, which contributed to the abuse, meant that few of the accused could be confronted.

While the committee worked, the criminal justice system acted swiftly. In June Peterson and Beckman were convicted of manslaughter and sentenced to prison terms of three and four years, respectively.

In mid September the committee made its report. Though it absolved Bowers of wrongdoing, it found serious systemic problems. These included insufficient professional staffing; deficient supervision of attendants; twenty sustained cases of physical attendant-on-inmate abuse; and low pay rates that impeded the hiring of qualified staff.

The report also described how attendants concealed the abuse, teaching each other how to beat inmates without leaving marks. It revealed a culture of secrecy in which attendants concealed their coworkers’ crimes and intimidated inmates into silence.

One issue that the report did not address was race. Beckman and Peterson were young white men from the countryside of southern Minnesota (and, in Beckman’s case, from Germany). Combs was black, born a slave in Missouri. He had come to St. Paul as a youth, then twice been convicted of rape. He was serving a thirty-year sentence at Stillwater Prison when he was transferred, in 1887, to the state hospital for the insane for “chronic mania.”

Combs’s record at Rochester was mixed. He was polite and a diligent worker but made occasional, and loud, threats of violence. Just days before his killing he had had a high-volume dispute with Beckman. It is plausible that Combs’s status as triply abject — a convict, mentally ill, black — made him easier to kill. But the committee left Combs’s death mostly to the courts.

Bowers responded to the report with a letter of resignation. He argued that in a hospital whose inmate population exceeded eight hundred, and over ten years of service, twenty documented cases of abuse amounted to a commendable record.

At least some of the committee’s recommendations were put into effect. Medical staff was turned over, a female physician was hired, and a nurses’ training program was created. The new superintendent, Dr. Arthur Kilbourne, made positive changes in treatment. In February 1902 the St. Paul Globe printed a full-page story of praise entitled, “New Methods of Treating the Insane at Rochester.” It appeared that Taylor Combs’s killing had some good effects for those who came after him at Rochester.

Then on November 10, 1902, a different story broke. Attendants had killed an inmate at the Rochester State Hospital with blows to the ribs and sternum. Kilbourne’s reforms, it seemed, had improved the hospital but not assured that incidents like Taylor Combs’s murder could not happen again.

For more information on this topic, check out the original entry on MNopedia.