Table 3.-Total program expenditures from Federal and State funds for vocational rehabilitation of the blind by State commissions or agencies for the blind, fiscal year 1953

Saint Elizabeths Hospital

THE PATIENT is the most important person in the hospital; the entire organization of the institution revolves about him. The responsibility for the medical care of each of the patients in the Saint Elizabeths Hospital is assigned to the three Clinical Branches and the Medicine and Surgery Branch, the latter of which includes the tuberculosis service. All the other activities, such as the Laboratory, the Dietetic Service, the Construction Department, and so on, are auxiliary to these four branches.

A total of 8,795 patients were given hospital care and treatment during the year as compared with 8,516 the year before, or an increase of 279 patients. Of these, 397 were readmissions, that is, patients who had been cared for previously in this hospital or in similar institutions. Discharges increased also from 814 to 977 or 64.1 percent of admissions. The average stay of the 977 patients discharged showed an increase over the previous year from 520 to 699 days. On June 30, 1953, 7,382 patients remained on the hospital rolls, or an increase of 111 over a year ago. Patients actually in the hospital at the close of the year, 7,113, showed an increase of 74.

Division of Medical Services

The program of psychiatric and general medical care and treatment of patients carried out in the various branches of this division during the year is outlined below.

CLINICAL BRANCHES

Each clinical branch, comprising 2,000 or more patients, is in charge of a Clinical Director. The usual activities of the clinical branches, which deal with the treatment and care of patients, education, and re

search, have been maintained at a reasonably acceptable standard during the year, although the growing difficulties previously reported on account of overcrowding and shortages of personnel have continued in increased degree.

Attention has been given in previous reports to the problems of overcrowding of patients and shortages of professional and ward personnel. There are opinions in certain circles that the size of the hospital should not increase. The fact remains, however, whether or not this position be taken, that the number of patients is growing steadily, that their average age is increasing, and that the tendency of the older patients is to remain longer. Increasing attention to the possibilities of finding homes for patients outside of the hospital has resulted in an increase this year in the discharges, so that the net gain of patients in the hospital during the year was only 111 or 1.43 percent as against 3.57 percent last year.

The proper bed capacity of the hospital at the present time is 6,213. There were actually in the hospital on June 30, 1953, 7,113 patients, an excess of 900 or 14.2 percent over the actual bed space. It is expected that one of the two vacant wards in the Geriatrics Building may be occupied within the coming year, but the situation is still far from ideal. There should be at least 10 percent of vacant beds available at any time in order to have proper mobility of patient load. The proportion of ward personnel has not increased with the patient population; since August 1948 there has been a gain of 135 employees as against 886 patients. At present the ratio is approximately 25 percent below that considered proper by the American Psychiatric Association. In spite of all the difficulties, the staff of the hospital have been most energetic in bringing about releases, with a very satisfactory result overall for the current year.

It was reported last year that it was necessary to maintain a waiting list of prisoners in Howard Hall, the maximum security section of the hospital, and to accept prisoners as patients only as space permits. This was a most unfortunate situation, and all possible steps have been taken to remedy it. At present the number on the waiting list has been substantially reduced, and efforts are under way to reduce it still further. The replacement for the present Howard Hall is most urgently needed. The hospital's request for funds for planning a new maximum security division has been approved by the Bureau of the Budget and is now pending before the Congress. This section of the hospital contains the most destructive, violent, assaultive, and problem male patients of the entire hospital. Understaffing in a division of this type is particularly dangerous.

Reference has been made during the past several years to the difficulty of filling medical positions in the hospital; this condition persists. The number of internships and residencies available exceeds

by a considerable degree the number of candidates. For the coming year, for example, only 3 interns have been secured for the 12 available positions. The number of residents seeking training has tended to fall as well. The financial returns in the private practice of psychiatry are most tempting, with the result that very few of the residents care to stay in the hospital work once their training is completed. Another factor is the competition which exists from another agency of the Government which is permitted by statute to pay a salary premium of 25 percent to diplomates of specialty boards, a privilege which is not extended to Saint Elizabeths Hospital.

The problem of the elderly patient continues to become more serious. During the past year there was considerable increase in the proportion of women over 60 years of age who were admitted. A year ago about 33 percent were in this age category, whereas during the current year nearly 41 percent were 60 years of age or older. During the year a substantial number of elderly patients who were not in need of active psychiatric care and who were relatively quiet and orderly was sent to the District Home for the Aged and Infirm, although a number had to be returned to the hospital. Every effort is being made to send patients to the District institution as facilities permit. The Geriatrics Building has been functioning very satisfactorily despite difficult conditions of staffing. Several clinical studies have been made on patients there, and the building itself has attracted a large number of visitors from this and other countries. The number of voluntary patients admitted to the hospital appears to be steady; 90 were admitted during the current year.

The number of Miller Act patients, that is, the so-called "sexual psychopaths," has shown a distinct drop. This appears to be due to the change in policy on the part of the District Attorney's Office. Although since the passage of the act in 1948, 61 such inmates have been admitted, the number during the current year was only 5. Of the 61 who have been admitted, 33 have been discharged as having received the maximum benefit. If it appears likely that the Miller Act will be substantially used again, the hospital is prepared to recommend certain changes which will make it more flexible and probably on the whole considerably more useful.

As in the past, the hospital has attempted to follow an eclectic approach in the line of treatment, holding itself ready to utilize any inew methods of treatment which seem to offer help to the patient without incidental harm and without undue devotion to any preconceived notions as to psychopathology or treatment. The number of patients receiving individual psychotherapy has been increased during the year, and a very active program of group therapy is being continued. During the year the psychodramatist left for another position, but it is hoped to resume this therapeutic activity again in

the near future. It has been used on a modified scale during the current year in connection with the rehabilitation program.

This latter program has been carried out with the aid of the District of Columbia Rehabilitation Service, which has been very helpful in cooperating with the Social Service Branch. The Board of Education of the District of Columbia has provided a visiting teacher for the benefit of some of the young patients of the hospital, and the recreational and occupational therapy programs are still expanding. Electroshock, subshock insulin therapy, and hydrotherapy have been actively used, especially the latter. The hospital is not imbued with the idea that electroshock is a panacea, but in selected cases it seems very effective. Prefrontal leukotomy (lobotomy) is still looked upon as only an operation of last resort; very few cases are being approved for its use, then only after all other known applicable forms of therapy have been tried without benefit. Only 38 lobotomies were performed during the year. Transorbital lobotomy has not been utilized at all.

The number of petitions for habeas corpus has been considerably less this year than last, there being only 27 such writs issued, in addition to 15 orders to show cause. This is a very substantial drop from last year, the total number then being 54 writs and 12 orders. Even this number, however, represents a very considerable investment of the time of the physicians and the ward personnel, particularly when (as is sometimes the case) numerous continuances are ordered after the patient has been taken to court. During the year only 3 patients were released by the court as a result of such proceedings.

MEDICINE AND SURGERY BRANCH

This branch functions through the Medical, Surgical, Neurological, Syphilological and Clinic Services. This hospital is still the only public mental hospital in the United States which is approved by the American Medical Association for rotating internship. The hospital is also approved for a period of residency training in surgery and for internship in dentistry.

The services of this branch are available to the patients of the hospital and to those employees who become ill or injured while on duty. During the year, 2,468 patients were admitted to the wards of the branch and a total of 64,184 visits were made to the various clinics. A large staff of visiting physicians and consultants has augmented the services of the branch in various special fields, such as dermatology, ophthalmology, and so on. During the year it has been arranged to have in residence a fourth year resident in surgery from George Washington University Hospital who is supervised by daily visits of the various members of the surgical teaching staff of that hospital. This has resulted in a very substantial increase in the num