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from many disciplines in all the clinical and basic sciences. And it is this type of unique cross-fertilization that the Clinical Center facilities were designed to give.

This cross-fertilization of clinical and laboratory disciplines within the Institute and among all the National Institutes of Health will make possible the first complete frontal attack in history against neurological and sensory disorders. Such a comprehensive attack, we are convinced, will eventuate in yes-and-no answers to the problem of the crippling disorders which it is our responsibility to resolve. But the practical consequences in research to be achieved in the work in the Bethesda program are not its only contribution. In fact, it might well be that its greatest contribution will reside in the stimulus and special facilities it offers to visiting scientists from all parts of the country, who may come to Bethesda, participate in the program, and then return home with fresh concepts and technical formulations for their own special projects.

At this point I am going to interrupt myself to see if I can anticipate a question, and I think it is a good question, and that is, Why cannot the voluntary health agencies and the States take over the entire job of providing funds for research? Well, I have been the medical consultant to a voluntary health agency for 4 years, and at its incep

4 tion you had a choice between collecting money to educate the public about the disease or collecting money to turn over to research. We chose the latter. We spent in the last 4 years $500,000 on some thirtyodd research projects, but that does not begin to cover the need. We had requests for $3 million—six times the amount which we spentfor research, and we could not collect those funds. You go to a man and say, "I represent the Multiple Sclerosis Society. What about a donation?" He would say, "What is multiple sclerosis?” And the same might be said of muscular dystrophy or myasthenia gravis. Even the late Senator Tobey, whose daughter had multiple sclerosis, was not able to pronounce the name. He said, “Multiple cirrhosis."

That is the problem we are up against. We have even got funny names for these diseases; and when you mention to someone such terms as "myasthenia," some people will say that is a "dirty word.”

What about the situation in medical schools! A year ago I had a meeting in Albany with the commissioner of health and his staff, and we said, “Look, the voluntary health agencies cannot begin to cover the problem, the Federal Government cannot begin to cover the problem, and what can we get from the States?" He said the State hospitals were bulging out at the seams and there was not enough money to take care of patients who are already patients of the State; that they could not get increased appropriations for the patients and that they had patients sleeping in corridors and that they could not start a research program because it was hopeless.

The same thing happened when I had a conference with the deans of eight medical schools in New York to try to get them to introduce new research programs at their universities. They have the same problem. The medical schools are broke; they do not have the monetary source or the staff to make up the deficiency.

We are in a war atmosphere and in a war economy, and that takes the major part of our money, and the medical schools just cannot operate in new fields. They are doing well to survive with the job they have.

The same thing is true with training grants. Of the Nation's 79 medical schools, only 21 have complete neurology units for the training in research of neurological diseases, and there are only 151 available positions in the whole United States for the training of neurologists. There are today about 250 qualified neurologists in the entire country to support a burden of 20 million patients.

In some areas of this country there is 1 neurologist to 650,000 population. The neurology teachers in many of our medical schools are not qualified neurologists. Several States in the United States do not have a single qualified neurologist in the State, and there are ✓ such States. What this means in terms of the sufferers can be judged when we realize that of the 1.5 million epileptics in this country 1 million are not receiving the treatment for their disorder, where treatment can be successful in a majority of the cases. This is because of the lack of neurologists or of physicians interested in the diagnosis of neurological diseases.

It now takes an average of 6 years before a sufferer of multiple sclerosis is diagnosed as such and almost as long before cerebral palsy can be identified.

There is no field of medicine where any diagnosis is more important because once the central nervous system is really damaged that damage is irrevocable.

The funds needed for the training of teachers in neurological and sensory disorders in the medical schools throughout the country can be determined by the requests for aid from the schools themselves, and the average need based on a recent survey amounts to more than $2.5 million.

Well, there is the problem. I have tried to spell out the story of neurological and sensory diseases as they apply to the citizens of this country. I have spoken too much, but there is a lot I have left unsaid. Gentlemen, I am 58 years old and in 1927 I had tuberculosis. In 1950 I had my first attack of coronary disease and I also have osteoarthritis of my spine and my fingers, but I am working and I am in here punching, but, if I had epilepsy, I probably would not be here—I probably would not even have a job; if I had multiple sclerosis or chronic encephalitis or the shaking palsy, I would not be here; if I were totally deaf, I would not be here; if I had paralysis or hemiplegia or paraplegia, I might be here, but I would have to be here in a wheelchair with someone to push me; if I were blind, I might be here with someone to lead me. The epileptic, the multiple sclerotic, and the cerebralpalsy sufferer are loath to marry and raise families. They cannot travel; they cannot go to the movies or the theater; they are denied all the more pleasant aspects of living with others. The deaf cannot hear the voices of their loved ones and the blind cannot see the joys of the world or the faces of their friends and families. The economic loss to the country in these diseases is appalling.

When one considers the money that is spent in attempting to alleviate the symptoms of many of these diseases for which there is no one cause, the loss of wages of those so afflicted and those who have to care for them; when one considers the tremendous loss to the manpower pool and even for defense purposes, the result is incalculable. Many, many of these sufferers are public charges, represented only by deductions on the income tax. : Gentlemen, I am grateful for this opportunity. Thank




The CHAIRMAN. Are there any questions?

Mr. DOLLIVER. Doctor, I understand that these various diseases which

you have named, and many others like them, have in common the effect upon the central nervous system.

Dr. TRAEGER. Yes, sir; all of these diseases are characterized by their cause-and-effect relationship to a disease, either in the brain or the spinal cord or its appendages.

Mr. DOLLIVER. Are they generally thought of as degenerative diseases of those parts of the body?

Dr. TRAEGER. There are many of them which are considered degenerative diseases. We do not even know whether some are degenerative diseases or not. By that I mean it is quite possible to autopsy or examine the brain of people dying from many of these diseases, and these brains under the microscope look like a normal brain—the epileptic brain, that is, the epilepsy which is not caused by injury or by a blow on the head, but the so-called essential epilepsy and the kind that comes on for no apparent reason-such a brain looks the same as a normal brain.

In Parkinson's disease a brain does not show anything unless it is due to hardening of the arteries or to arteriosclerosis or to infection.

In multiple sclerosis we do have a very definite type of microscopic pathology. We can see small areas scattered indiscriminately throughout the brain and spinal cord of hard stony plaques which represent areas where nerves have been destroyed, and wherever those nerves go, that function is gone.

Might I interrupt, Mr. Chairman, to introduce two new witnesses who have just come in. One is Dr. Harry Sands. Would you rise and identify yourself?

Dr. SANDS. I am Dr. Harry Sands and I am executive director of the Epilepsy Association of New York, and also representing the National Epilepsy League. I have been director of the committee for public understanding of epilepsy and formerly on the faculty of New York University and Brooklyn College in New York. I am a psychologist, primarily interested in public education and in the improvement aspect of neurological disorders.

Dr. TRAEGER. Dr. Kety, would you rise and identify yourself!

Dr. Kety. I am Dr. Seymour Kety, associate director in charge of research for the National Institute for Mental Health and the National Institute for Neurological Diseases and Blindness. I am also professor of physiology at the University of Pennsylvania. My primary responsibility in the National Institute of Neurological Diseases and Blindness is director of the program for basic research in the nervous system. I am a physician and primarily a physiologist.

The CHAIRMAN. Could we have chairs for the gentlemen who have just risen and introduced themselves? The clerk will put chairs there for them so they can be seated with the other members of the panel.

Mr. Dolliver, you may proceed.

Mr. DOLLIVER. Now, from what you have said, I take it that diagnosis of these diseases is extremely difficult because they have similar manifestations to others!

Dr. TRAEGER. Dr. Bailey would like to answer that.

Dr. Bailey. I do not think these diseases are difficult to diagnose especially difficult-for trained individuals, but the big problem is we do not have the trained individuals to make the diagnoses, as Dr.


Traeger has brought out, and the training facilities in this field are very inadequate at the present time.

I might also emphasize that I do not think there is any category of disease where an early diagnosis is more important, as Dr. Traeger mentioned, once the nervous system is permanently damaged, it remains so. So, unless you make the diagnosis in a certain disease before this permanent damage arises in order to treat it, you may be dealing with a situation which is beyond your control and against the interest of the patient.

Mr. DOLLIVER. Are any of these diseases caused by organisms or germs?

Dr. BAILEY. Yes. The nervous system is very complex, but it is also very vulnerable to all types of diseases. You can have infection, you can have vascular disturbances, you can have accidents and injuries, you can have toxic diseases, poisons, industrial poisons, and so forth, all affecting the nervous system. In addition, you have those diseases which the societies here represent in which we do not know just what the causes are. We have ideas and we are developing new ways to attack them but we do not have the final answers. For the big population of permanently or semipermanently crippled individuals we have no specific treatment for at this time.

Inasmuch as they attack in an age group which is young, the crippled individual is cared for by the community or the family, and also by the tragic self-help that he can give himself in many instances.

Mr. DOLLIVER. The cases which are in this category which are caused by the invasion of germs, I assume, to a certain extent can be controlled if you find out what the germ is?

Dr. BAILEY. Yes, particularly if the germ is bacteria. It can be fought with penicillin. Neurosyphilis once was a very common

a scourge. Now it is rare.

Mr. DOLLIVER. Is there any evidence to indicate this category of diseases that you do not know the cause of are hereditary?

Dr. BAILEY. Not in very many cases. There are some considered congenital, which is not hereditary-some influence on the growing fetus. The hereditary element is not too strong even in epilepsy, which is very often considered as a hereditary disease.

Mr. DOLLIVER. Is it true that sometimes these diseases are caused by injuries of birth?

Dr. BAILEY. Yes; that is quite frequent.
Mr. DOLLIVER. Or prenatal abnormality ?

Dr. BAILEY. Yes. That is quite frequent. That is what I meant by the congenital as distinguished from hereditary when the actual gene is involved; the hereditary stream.

Mr. DOLLIVER. You make a distinction between the hereditary stream and the prenatal influence and the birth injury, I take it?

Dr. BAILEY. Yes, I do.

Mr. DOLLIVER. How far has the research gone? Perhaps it will come up later. How far has research gone with respect to what Dr. Traeger has referred to; namely, the reconstitution of damaged nerve and brain tissue?

Dr. Kety. If you were to have asked that question 5 or 6 years ago, I think the answer would have been a fairly hopeless one of complete ignorance. We all know that in the very common injuries of the


spinal cord the patient remains a hopeless cripple because of one very obvious defect. The spinal cord, and for that matter, the brain also, does not show any evidence of regeneration or of healing. If one fractures a leg, the bone of the leg heals and he eventually is restored to quite normal functioning. If one wounds the skin, the skin heals. If one wounds the spinal cord, however, the spinal cord does not heal in the sense that it can regenerate and restore its functions. It heals with a dense scar which prevents the growth of the nerve fibers which transmit the nerve impulses, and that has been classical pathology and classical clinical understanding of the nature of spinal injury.

Interestingly enough, about 5 years ago, Dr. Windle, who incidentally is coming to Bethesda as Chief of our Laboratory of Neuroanatomical Sciences, who was then professor of anatomy at the University of Pennsylvania, and Dr. Chambers, were working on a field which was not remotely connected with this problem of regeneration. They were studying the effects of a peculiar substance produced by bacteria which causes fever in animals and in man, and they were trying to localize the site of this fever production—where does it occur

and how does this material act. In order to do that they did as many scientists do, they performed a series of experiments in which they cut the spinal cord of cats under anesthesia. They cut the spinal cord in various places in an attempt to see if there was one place which if cut would prevent the rise in fever.

Well, their experiments on the site of localization of fever were not terribly important, and I do not recall whether they got anywhere with the experiments, but they made a very interesting incidental observation: That these cats who had their spinal cords cut, cats who should have remained completely paralyzed from then on, these cats who got this particular substance showed some regeneration of the spinal cord, and when they examined these cut spinal cords under the microscope they found, to their astonishment, that nerve fibers were growing across the cut. This was really an epoch-making discovery.

Incidentally, it comforts me because it was a discovery made in the line of basic research. These people were not looking for a cure for paraplegia; they were looking for something different. Incidentally, because they are trained observers and because they also had an element of good fortune, they found this very interesting phenomenon that regeneration was occurring in the spinal cords of these cats, a phenomenon which no one had ever observed before in any significant quantity.

They went on with this and implanted a nerve into the brain, and they gave their animals this particular substance and found that the nerve grew right in the brain in a most amazing manner, and their slides which I have seen and which were reported at one of the physiological society meetings, show these nerve fibers growing beautifully into the brain.

That, as I said, is an epoch-making discovery. It does not mean that we can go out right now and treat patients and they will immediately get well. There is a great deal more that has to be learned. It is not enough to have the nerve fibers grow across the spinal cord; we have to know where they go to. Their growth has to be controlled. It has to be possible to stop the growth after it has achieved an optimum distance and the fibers have grown to the regions where they are

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