ity of the thyroid gland, and various types of anemias or tumors which sometimes involve the heart and the blood vessels, various types of endocrine disturbances which secondarily involve the heart and many other diseases, almost too numerous to mention.

We will speak of them in our discussion throughout the day using the term "heart disease" as inclusive.

Now, here are some of the facts which are staggering to the imagination, but nevertheless represent the picture as heart disease affects our country.

In the first place, heart disease is the leading cause of death in the United States. It causes the death of or kills more than 1 out of every 2 persons that die each year in our country.

It is anticipated that in the current year about 785,000 people will die of heart disease.

It is less understood that heart disease is the leading cause of death among children.

It is generally thought of as being a disease which primarily affects the aged and maybe perhaps in some persons' minds is considered inevitable. This is a misconception, although it does affect a very large number of people as they grow older.

It causes about one-sixth of all the deaths in the military ages, that is between 20 and 39.

It causes one-third of all the deaths in the productive years, shall we say, the most productive years between 35 and 54.

It causes half of all the deaths in the ages between 55 and 74, and it causes far more than half of all the deaths after the age of 74.

Now, in terms of manpower about 312 percent of all the World War II selective-service registrants examined were rejected because of heart disease. That represents figures somewhat as follows:

Three hundred and seventeen thousand five hundred men were rejected as of August 1, 1945, because of heart disease.

About 80,000 men were given disability discharges from military service or died in service because of heart disease in the war years between 1942 and 1945.

It is readily understood that this involved younger men in the socalled prime of their physical life.

Rheumatic fever alone immobilized more than 40,000 men in the Armed Forces during World War II.

Rejections from military service for heart disease were high during the Korean conflict also.

In 1 area in 1 State it was found that 1 out of every 8 men rejected, all under 26 years of age, were turned away because of organic heart disease.

In the Navy alone, in World War II, 4 million man-days were lost because of rheumatic fever and rheumatic heart disease.

The actual or potential manpower contribution-to defense or the Nation's general productiveness of 1 person out of 15 or 16 is limited to some degree because he or she has heart disease.

Approximately 176 million workdays are lost yearly because of heart disease.

At least 653,000 man-years are lost each year in industry alone because of heart-disease disabilities.

It is estimated that in 1951 about $2,124 million was the cost of heart disease in loss of productivity.

Compensation and pension payments to veterans in 1950 because of heart-disease disabilities were $168,250,000.

The proportion of insurance claim payments for deaths from heart disease has been steadily rising. In 1951 a major company paid the beneficiaries on account of heart disease a total of $173,680,000. This is just one company. This sum was about 311⁄2 times the amount paid for the same disease in 1931, showing a very marked increase in the disability cost of these diseases.

At a hospital rate of $12 a day, according to an estimate and example, 1 patient with chronic heart disease costs about $4,300 a year to maintain in a hospital. This would mean that if 50,000 patients-and that is not an excessive number-with heart disease received hospital care for a year, the cost would, in 1 year, equal $219 million for the hospital care of these patients.

Sixteen thousand dollars per case, or a total of $640 million, was the cost of the cases of the 40,000 men inactivated by rheumatic fever alone during the World War period.

Now, this is a small indication of the importance of heart-disease disability: The Bureau of Public Assistance of the Social Security Administration, Department of Health, Education, and Welfare, after a cross-section survey of 13,200 of 93,359 recipients of aid under its program for the permanently and totally disabled in the productive age bracket between 18 and 65 years reported very recently that diseases of the heart were found more frequently than any other group of diseases or impairments.

Cardiovascular disease accounted for the major or secondary impairment in over 42 percent of the recipients, and was the major impairment in 37 percent. Almost 71 percent of the recipients with a disease of the heart were aged 55 or over. Over one-fourth, however, were in the age bracket between 35 and 54.

For about 1 in every 4 of the recipients with heart disease the impairment was of 10 years or more duration. In other words, these diseases are long-term diseases, very frequently at an enormous economic and sociological cost to a community.

Now, I think it is worth while at this point to make a brief statement about what happens to a family; just a reminder as to what may happen to an individual and a family when that individual is stricken with heart disease. By this, I include many diseases of the blood vessels and also what are commonly known as strokes, or disease of the blood vessels of the brain.

For instance, if a man in the productive years of his life with perhaps three children in college, having had a reasonably good earning capacity, is suddenly incapacitated because of one or another of these diseases, it produces in most families a catastrophic situation. The children often have to be taken out of college. The economic stability and social relations of the family are disrupted. The man is lost from his productive years in business, frequently. Instead of being a producer, an earner, and taxpayer, he becomes not infrequently the recipient of aid and support from others, by compulsion. This is reflected in the entire economy of a community or a country when it is realized that approximately 1 million people in this country have suffered from hemiplegia, paralysis from a stroke; and that 10 million people have heart disease.

Fortunately that picture does not hold for a considerable proportion of individuals who have either a heart disease or a stroke. Many of them are able to return to livelihood, but frequently they are markedly handicapped in their productivity.

If it is a child the family activities must from that time on center around this child in an endeavor to restore the child to reasonable health or perhaps arrange for the care of this child throughout its remaining years.

I feel now that it is important to ask some of the gentlemen who have come with me to dilate on some of the problems which relate to more specifically the major diseases; rheumatic heart disease, high blood pressure, and hardening of the arteries or arteriosclerosis. I am, therefore, going to call upon Dr. Duckett Jones to speak on this subject of rheumatic heart disease; what it is; its importance; what we know about it; the way of prevention and treatment; where we are working in the direction of research; and what we need to know in the future.

Unfortunately, time does not permit a very complete dilation on these subjects, but we hope to outline them so that they are challenging and interesting.

Dr. Jones.

STATEMENT OF DR. T. DUCKETT JONES, MEDICAL DIRECTOR, HELEN HAY WHITNEY FOUNDATION, NEW YORK CITY

Dr. JONES. I will try to stick to the agenda items to give more or less a bird's-eye view from my own personal opinion.

Rheumatic heart disease is a common heart abnormality or difficulty which results from the disease rheumatic fever, which is very common, especially in childhood, but may occur at any age. The cause is unknown, although it is very clear to most observers that it closely follows, within 2 or 3 weeks, infection of the upper air tract (the chest, throat, or head), by the so-called hemolytic streptococcus, a common producer of respiratory infection.

In the last 15 or 18 years a tremendous volume of knowledge of considerable importance has been gained through measures which indicate that if you give daily prophylaxis, daily doses of either the so-called sulfa drugs or penicillin, that the number of clinically obvious illnesses of repetitive rheumatic fever-and repetition is one of its chief problems can be curtailed to a very large extent, probably 85 or 90 percent.

I am very pleased to note that one of the individuals who first gave prophylaxis in the early sulfanilamide days to the early patients is in the audience, Dr. Caroline Bedell Thomas.

A great deal of this information and strengthening of the concept concerning the importance of preventive measures came as the result of studies done during World War II in the Armed Forces. Prior to that we had looked largely at only rheumatic-fever populations, particularly in rheumatic-fever hospitals and institutions and rheumatic-fever clinics.

In addition to that we have learned in the last several years that if the new therapeutic agents-the antibiotics, of which penicillin is a common one-are used in treating a streptococcal sore throat, that

clinically evident rheumatic fever following this infection can be partially reduced. That is very valuable knowledge which came from 1 or 2 of the rheumatic-fever institutions, and was conducted on a very large scale and was strengthened greatly by work in the Warren Air Force Base in Wyoming under Dr. Charles Rammelkamp, working for the Armed Forces Epidemiological Board, Commission on Respiratory Diseases.

We then have some important preventive knowledge, and it seems very likely that there is presently a diminution in the amount of at least clinically evident severe rheumatic fever. I would believe that it looks as though the number of early deaths-which used to be 20 percent within 10 years after one contracted the disease—is being sharply curtailed.

The Heart Association is trying very hard to get these preventive knowledges utilized. There is no known measure as to how effective or on what scale this is being done, but the Heart Association is doing everything in its power to see that clinics and physicians utilize this important knowledge. However, we do not know yet whether these preventive measures will prevent the appearance of most or much of rheumatic heart disease in early adult life, because a great deal of the rheumatic heart disease develops as the result of the so-called silent or unrecognized rheumatic fever.

Important as these preventive measures are-and the fact that I believe we can now do a good deal—we do still have the problem and we do not know nearly all the answers.

I would say that the research which is presently going on, if it is continuously and adequately supported, strongly points to the probability of learning a tremendous lot more about the fundamental tissue changes and chemical interactions that occur in the important connective tissues of our body which are altered in this severe disease problem.

There are many avenues of research which are open to a large number of exceedingly good workers, and I would say that the amount of funds available at the present time are inadequate to assure the necessary continuity and stability which these and new and potentially able scientists need in order to pursue this problem to its most effective end, which would be to learn a great deal more than we presently know about the problem.

Dr. WRIGHT. Thank you, Dr. Jones. Are there any questions at this point?

The CHAIRMAN. Dr. Wright?

Dr. WRIGHT. Yes, Congressman.

The CHAIRMAN. I note the presence of Dr. Scheele, the Surgeon General of the United States Public Health Service. I have invited him to come and sit with the staff. And now, Mr. Dolliver would like to ask a question for the record.

Mr. DOLLIVER. Doctor Jones, I did not quite catch what you said about the progress which had been made in controlling heart disease as a result of rheumatic fever. Would you elaborate on that, or perhaps repeat what you said?

Dr. JONES. I think, sir, at the present time we have no very accurate data on how much rheumatic fever is being prevented with these new knowledges. I think it will take a few years for us to determine that.

But I am sure that the great majority of workers in the field believe that a considerable volume is being prevented at the present time. However, there is one very difficult feature. In order to treat a streptococcal infection early, and hence probably prevent the rheumatic fever that may succeed it, the streptococcal infection has to be clinically recognizable by the physician. One-third to one-half of such infections are the so-called silent infections and do not cause disease symptoms, and hence there is no possible opportunity for that method to prevent the initial attack in those instances in which it is preceded by a silent infection. On the other side, it should be said that there are many, many cases of streptococcal infection which can be recognized and treated early.

We, however, do not rely on early treatment of streptococcal infections in an individual who has been identified as having had rheumatic fever or rheumatic heart disease. We give them daily prophylaxis, either the sulfa drugs or penicillin, so that they will continually be protected from these types of infection.

I am quite sure that though these knowledges in prevention are of extreme importance and are very helpful, that they are not the full answer that we need. In other words, to take a drug, a preventive drug, continually is quite a difficult problem. It is expensive, also. We yet have not determined how much we are preventing.

I think the problem is still with us, and it has many complexities, but I think that tremendous progress is being made in this area.

That is true, also, in the rehabilitation of adults who have old rheumatic heart disease. Surgical correction of valve deformities at the present time is an important feature in helping some of the adult individuals with crippling heart disease to reassume reasonably active existence.

Dr. WRIGHT. Dr. Andrus wishes to address a question to Dr. Jones. Dr. ANDRUS. Is it not true, Dr. Jones, that the reported incidence of rheumatic fever is diminishing?

Dr. JONES. I think that is true, Dr. Andrus, but I am not at all certain that the records are very accurate on it, because diagnostically it is extremely difficult. I think all I could say is that it seems definitely to be decreasing. Certainly the number of early deaths, prior to adolescence, seems very much less.

Mr. DOLLIVER. Thank you very much.

Dr. WRIGHT. Any other questions?

Mr. DEROUNIAN. Dr. Jones, would an ordinary cardiograph reveal the existence of a rheumatic heart?

Dr. JONES. If you have a definite rheumatic heart disease cardiographs are usually abnormal, but the heart disease is of such a degree when that happens that you know perfectly well that the individual has a rheumatic heart disease.

As a help in rheumatic fever the temporary changes which occur and which are to some extent shown by electrocardiograms are one of the diagnostic features; and that is being used very extensively, sir. The CHAIRMAN. Mr. Heselton?

Mr. HESELTON. Doctor, you are with the Helen Hay Whitney Foundation?

Dr. JONES. Yes, sir.

Mr. HESELTON. Is there any connection between that foundation and the American Heart Association?