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hypertension were adequately controlled, half the strokes currently occurring in this country would still occur and the stroke mortality rate would decrease by 19 percent. Thus, the very large aspect of the nation's stroke problem which is not associated with high blood pressure demands our continuing research attention. An example is the joint NINCDS-industrial effort for the development of anti-platelet agglutination agents to diminish clots in cerebral blood vessels and prevent cerebral infarction, the most common type of stroke. Also, this year the NINCDS will complete Phase II of a three phase controlled clinical trial of the efficacy of a surgical procedure to by-pass an obstruction of a brain blood vessel to prevent stroke. This much publicized procedure (EC/IC anastomosis) is under study in 65 clinics around the world to evaluate whether the procedure in fact does all that individual reports claim.

Finally, I would like to comment on a new initiative the NINCDS has developed with the cooperation of the NCI, a targeted effort against brain tumors. The results of tumor growth in the brain are disastrous in two respects: one is the obvious effect of destruction of brain centers by the tumor; in addition, even a non-malignant tumor inside the skull is life threatening because of the increasing amount of space the growing tumor occupies within the limited confines of the bony skull. In the past, only surgery and radiation have been available to combat these tumors and diminish their invasive and space occupying characteristics. More recently chemical and immunological therapies, at first singly but now in combination, have become available. In our neurosurgical laboratory in Bethesda and in grant supported laboratories around the country, tissue culture methods are being developed by which a prescription for the individual patient's specific type of brain tumor can be ordered, thus tailoring therapy to the patient's tumor. We must temper our enthusiasm for the potential results of this approach, but can report with conservative enthusiasm that a specific and effective approach to brain tumor therapy may well be within our grasp.

I must balance these research successes with reports of areas in which we have not been as productive. Despite a continuing nationwide scientific effort, clinically applicable results for the treatment of head and spinal cord injury are still very meager. That unique loss of ability of tissue of the central nervous system to heal itself, still confounds us. We have made significant advances against several of the complications of such injuries and have improved the duration and quality of life resulting from them, but we have not yet been able to reverse the process and restore normal brain and spinal cord function. A small but dedicated group of skilled investigators is providing the stimulus necessary for attention to this most difficult of problems.

Another area for emphasis is amyotrophic lateral sclerosis (Lou Gehrig's disease). This fatal disorder results from the death of motor nerve cells in selected areas of the brain and the anterior portion of the spinal cord. The muscles dependent upon these cells wither, and the functions they control become increasingly impaired, leading eventually to death. But why are these specific nerve cells affected and not adjacent cells? Why their unique susceptibility to the process causing the disorder?

Despite our focused attention utilizing genetic, immunologic, viral and metabolic studies, we still do not have the answers to these questions. However, I can assure the Committee that we are hard at work addressing these problems and will continue our efforts until we resolve them.

Mr. Chairman, I could continue to describe the other significant research issues faced by the NINCDS. I have not discussed multiple sclerosis and the progress immunological studies are offering us, the exciting epidemiological and pharmacological studies initiated for the study of Huntington's disease and the leap forward being initiated against disorders of speech. A series of controlled clinical trials have been started in the areas of hearing impairment and we are exploring approaches to those troubling and common characteristics of modern life--headache and backache. Basic neuroscientists are doing an excellent job in providing the fundamental information upon which to build. A small but highly skilled cadre of clinical investigators are exploring methods for translating this core of information into clinically applicable methods of prevention and therapy. There are no easy roads to a better understanding of the brain and its disorders, but the programs of the NINCDS are moving ahead steadily and soundly towards the achievement of this goal through research.

I am pleased to share this information with you and will try to answer any questions you may have about these matters. Thank you.


Biographical Sketch

Murray Goldstein, D.O., M.P.H.



Acting Director, NINCDS

BIRTHPLACE & DATE: New York, New York; October 13, 1925


B.A., New York University, 1947

D.O., Des Moines Still College of Osteopathic
Medicine, 1950

M.P.H., University of California, School of Public
Health, 1959


Acting Director, NINCDS, 1981-present

Deputy Director, NINCDS, 1978-1981

Medical Officer, Commissioned Corps, PHS

(Assistant Surgeon General), 1953-present
Director, Stroke and Trauma Program, NINCDS,

Director, Extramural Programs, NINCDS, 1961-1976
Visiting Scientist, Mayo Clinic and Graduate
School, Rochester, Minnesota, 1967-1968
Chief, Special Projects Branch, NINCDS, 1960-1961
Asst Chief, Research Grants Review Branch, DRG,

Actg Chief, Section on Virus Diseases of the CNS,
Bureau of Acute Communicable Disease, Calif.
State Dept of Public Health, 1958



Director, Epidemiology and Biometry Training

Grant Program, DRG, 1956-1958

Asst Chief, Grants and Training Branch, NHI, 1953-

American Academy of Neurology

American Association for the Advancement of

American Heart Association, Council on Stroke
American Neurological Association

American Osteopathic Association

Association for Research in Nervous and Mental

Society for Neuroscience

The American Parkinson Disease Association,
Medical Advisory Board

Eisenhower Institute for Stroke Research
United Cerebral Palsy Research & Educational
Foundation Board of Directors

Consultant, World Health Organization Program on


Commission on Alternative Health Care, U.S.
Olympic Council on Sports Medicine

Beta Alpha Epsilon; Biology National Honor
Society, N.Y.U.

Psi Chi; Psychology National Honor Society, NYU
Sigmi Alpha; Osteopathic Scholarship National

Honor Society; College of Osteopathic Medicine
Delta Omega; P.H. National Honor Society;

Univ of California

Doctor of Science (Hon); Kirksville College of
Osteopathic Medicine

Certificate of Merit; ANA

Silver Star; Purple Heart, U.S. Army

Meritorious Service Medal; PHS

Associate Editor, Stroke, A Journal of Cerebral

Circulation, AHA

Editorial Board, Osteopathic Annals

Editorial Board, International Journal of


Author of over 20 scientific papers and monographs


Dr. GOLDSTEIN. Thank you Senator. May I introduce Dr. Katherine Bick. on my far left. Dr. Bick is the Acting Deputy Director of the Institute. And on my immediate left is Mr. William Matthews, Budget Officer of the Institute.

Thank you for the opportunity to present the programs of the National Institute of Neurological and Communicative Disorders and Stroke.

As you indicated, the scope of the Institute's program is very broadbased, affecting the entire nervous system and muscular system, hearing, and the very human attribute of speech and language. Because of the innumerable responsibilities of the Institute, we cover many areas. In the written presentation, sir, I have pointed out five examples of successful results of our research activities this past year.

Senator ANDREWS. Doctor, before you proceed, I notice that you are a graduate of the Still College of Osteopathic Medicine. One of my

family's great friends is an osteopath in Fargo, N. Dak., Hal Hanson, and Hal's daughter, Beverly, who was my age, became the women's national amateur golf champion-I am sure because she had the proper adjustment along the way.

Dr. GOLDSTEIN. I am glad it was helpful. I wish it would help my


Senator ANDREWS. You can still play a lot better golf than I can.
Go on. Continue.


Dr. GOLDSTEIN. Thank you, sir. The Institute supports a very extensive program of basic research. One of the primary reasons for this is the brain has been truly called "the last frontier." We understand so very little about how it works, and, even more important, so little about how it goes wrong. And for this reason, since for most of the disorders we deal with we still do not know the etiology or cause, we must invest in basic research. I am delighted to say that over the past 10 years, we have learned more about how the brain and nervous system works than in the preceding cumulative 50 years.


A second important area is the use of modern technology in research and an example of this is a program that we call our positron emission tomography program. This provides us for the first time with the opportunity to actually look inside the human brain and see how it works, and watch it working, with no ill effect at all on the patient. So, now, without opening the skull, we can actually look inside that brain and watch its activities, and identify where and how things go wrong.

This is primarily done through the use of very short-lived isotopes. With the support of the Congress, sir, we have been able to establish seven research centers in the United States, and one at the National Institutes of Health.


A third and very important area which has been spearheaded at our center in Bethesda in the intramural program is a group of disorders known as the enzyme deficiency disorders. These are errors of metabolism that children are born with, and because of these errors of metabolism usually due to a deficient enzyme, the children do not develop properly. Quite often, they die at a very early age-it is the problems of these kinds of children that have been associated with genetic counseling. We are now able in one disorder, Gaucher's disease, to give the child the needed enzyme replacement, and for the first time, we have a small group of children with this deficiency who appear to be developing normally.

This gives us a wonderful alternative and an opportunity to be looking at other alternatives for genetic counselors to offer.


The fourth area I would like to mention is stroke. Stroke remains the third leading cause of death in the United States. There have been remarkable advances against both the incidence of stroke and its mortality. In a joint effort with our colleagues in the National Heart, Lung, and Blood Institute, research programs have been launched the results of which have cut both mortality and incidence tremendously. This is true particularly in those types of stroke associated with high blood pres


Yet on the other hand, a substantial proportion of people who do have a stroke do not have high blood pressure. And so, high blood pressure research, as important as it is, and one in which we need to continue our activity, is not the ultimate answer to stroke or to the complete story of stroke. Therefore, we need to continue our research efforts with vigor.


Another very important area, sir, is the issue of head and spinal cord injury, and regeneration of the nervous system following these events. In some respects, head and spinal cord injury due to trauma such as automobile accidents, is a plague of modern American society. Most of the people who die in these horrible accidents die because their brain and spinal cord have been injured. This is a very, very difficult problem to solve, because we are dealing quite often with research problems the results of which affect life and death at the time of the accident or shortly thereafter.

To help those who do survive, we have started a very concerted research effort to see if it is possible to help the brain and the spinal cord to regenerate those damaged neurons, the nerve cells that have been injured.

We have had a tremendous breakthrough in this area, and the breakthrough is that for the first time we are not asking. "Can regeneration occur?" but we are now asking, "How can we make it occur?" It can occur. It does occur in lower organisms. For one reason or another, as we have evolved to the human state, we seem to have either lost or arrested that ability of nerve cell regeneration in the brain and spinal cord. We have hope. It is a very conservative hope. but we do have hope that we might be able to solve this problem.


Well. sir. we are truly called the "Institute of 600 diseases," because of all the things that can go wrong in the nervous system and in hearing and human communication. It is a very large task. but we are working hard at it, and hope that with your support we can continue to do so successfully.

Thank you. sir.

Senator ANDREW's. Well. I appreciate your most intriguing. very interesting opening remarks. Certainly, an investment in this area is really an investment in the future of this country, and could well result in savings down the line. in the cost of medical care for those people who have thus been brought back to full or nearly full health.

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