and thrombosis that the former is very probably the result, in part at least, of the latter. Note recent finding of little or no atherosclerosis or thrombosis in certain parts of the world-Hong Kong and West Africa. I visualize the pathogenesis as follows, utilizing also the conclusions of both Meyer Texon and J. B. Duguid that the arterial intima begins even in childhood to be battered and slightly scarred and streaked at points of hydrodynamic stress from turbulent blood flow, followed by the accumulation of blood clotting and fibrosis at these areas. After that, especially in the presence of hypercholesterolemia, fat droplets and more blood clots are deposited in these scars of the intima, leading eventually to an encrustation which grows and grows, especially if there is no change in the victim's way of life, until it almost blocks the arterial lumen. Ischemia of the myocardium, normally supplied adequately with blood and oxygen through that artery, is the result, with the occurrence of angina pectoris, sudden death, or myocardial infarction, whether or not there is an addition of a thrombosis that finally blocks the artery completely.

While this evolution of atherosclerosis is going on in the major coronary arterial trunks, nature's gift of a collateral circulation via anastomotic channels, tiny at first but slowly developing through the years, may develop in the majority of individuals fast enough to by-pass the points of block satisfactorily, so that the new and very popular saphenous vein coronary by-pass operation becomes unnecessary. Herrick in 1912 (confirmed by Blumgart and Schlesinger decades later) pointed this out as one reason for the recovery and long survival of some cases of acute coronary thrombosis, but at that time we were unaware of how we might either slow the process of atherosclerosis or speed up the development of the collateral circulation.

I have gone into considerable detail about the pathogenesis of arterial disease and nature's remedy thereof in order to have a base on which to build my next comments, but before I do so, one other preliminary observation is of the greatest importance. Coronary atherosclerosis is not an isolated disease. Other arteries are also almost invariably involved by the same disease, especially the aorta which is often the first and most involved of all. Generally, however, serious results of aortic atherosclerosis are relatively rare, but such complications as abdominal aortic aneurysms, with fatal rupture unless cured by operation, have become quite popular, and embolism from debris on the aortic intima is doubtless more common than we realize. Somewhat less common than coronary atherosclerosis of clinical importance is the same disease importantly involving the arteries supplying the brain and the leg muscles, and in lesser degree the renal arteries.

Since coronary atherosclerosis is today responsible for more deaths in this country than any other disease and since what we can do prophylactically and clinically to prevent, delay, or relieve the process in the coronary circulation can act in the same way and simultaneously on the cerebral, leg, and renal circulations and on the aorta itself we should now present what experience has taught us to do. Much clinical, follow-up, and basic research is of course still needed, but we know enough already to get ahead. Therefore my duty today, as well as yours, is to apply what we do know. It is a mistake to wait another decade or two with folded hands for all the answer. Just the trial of these measures is a vital research in itself.

What are these measures which should sharply reduce serious atherosclerosis in our young and middle aged males, in our somewhat older middle aged females and in both sexes in their sixties, seventies, and early eighties? What is desirable longevity? My viewpoint at the moment, now that I approach 85, is ninety or a bit more but that may be unrealistic in either direction. The next generation should find out, either by the application of the measures about to be proposed through intensive and extensive education of our people of all ages, or by the discovery of some magical panacea, chemical or metabolic, which is yet to be discovered at the Fountain of Youth.

Although it is highly desirable to initiate these protective measures to halt or even perhaps to prevent for a few decades the inexorable evolution of arterial disease in young male candidates for early crippling, even before they are teenagers, I believe that it is almost never too late at any age, except in hopelessly involved invalids, to adopt these protective measures. A recent example of what can be done is the case of a man of 60 whom I first saw some twenty-five years ago in his 30's in quite good health but fearful of his fate because most of his male ancestors, father, and grandfathers and uncles too, had succumbed to coronary heart disease in early middle age. When I examined him a few weeks ago

he was still in good health, years older than the age at death of these male relatives. What did he begin to do at that earlier age which his ancestors and he himself had not done? It was this: I asked him when he was 34 to make every effort to carry out three recommendations which I now make to nearly every teenager, even though my patient whom I have just mentioned was already 15 or 20 years older:

(1) Do not gain a pound of weight after the age of 22 or if already overweight, get down to a hard weight. As for diet, limit calories to avoid obesity and reduce the intake of saturated (mostly animal) fat to a minimum.

(2) Exercise hard all through life until really old and then continue to exercise but not so strenuously. Walking is probably best because it is simple and possible in very old age and it involves the biggest muscles in the body which, utilizing nature's installation of valves in our veins, pump blood upwards, relieving the heart of some of its labor. My patient had walked religiously 5 or 6 miles a day in all those years.

(3) Don't smoke at all.

Sometimes of late years I have added a fourth directive in nervously hypersensitize persons to reduce emotional stress. Some individuals have a tendency, usually inherited, to be spasmophilic (subject to spasm of smooth muscle in artery walls, in the gastro-intestinal tract, and elsewhere, even I believe involving the coronary circulation). A rare patient of mine has had angina pectoris and even a minor heart attack despite the finding of a normal coronary angiogram. For such a person reduction of emotional stress but not of physical exercise, plus the use of tranquilizers when needed, seems to be the best program rather than, though sometimes added to, the nitrites. Much more study of this disorder which I call spasmophilia is in order. It is not the same as, although it may complicate, neurocirculatory asthenia, with its multiplicity of symptoms (sighing dyspnea, "heartache," palpitation, tendency to faint, and morning fatigue).

Because cardiovascular disease has been my specialty and because of lack of time to cover other important hazards to life and to health, such as cancer, accidents, arthritis, mental afflictions, blindness, and deafness I shall limit my concluding remarks to some thoughts and advice to the aged in general.

In the first place I heartily agree with the advice of many others not to initiate or to maintian efforts to keep the heart beating and artificial respiration going after the brain has died, as determined by electroencephalography and other tests adequately applied.

Secondly, "euthanasia" in the popular sense cannot yet be legally condoned by the medical profession depsite the obvious arguments in its favor, but the apparently hopeluessly ill and suffering patient can be kept comfortable by drugs that are available. Also an important consideration, although usually unlikely but remotely possible, is that a cure or source of great alleviation may be just around the corner, about to be discovered or at least available to be applied.

Next, a word to the families of the deceased aged man or woman. Post-mortem examination is still important even in advanced old age. We need more knowledge of the pathology of sensecence. Autopsy findings can be a great help for the family which needs to find out any clues for future protection of the descendants. Important surprises are common and should become a part of the family's archives, too little supplied with such information.

To return to rehabilitation. I myself recall some of the survivors of many years and of many ills, rehabilitated by my father before the term was invented and when it had much more to do with infectious disease and accidents than with damaged hearts. Some of us who happened to pioneer in Cardiology, a pure accident so far as I was concerned, rather suddenly discovered in the late 1920s that most patients with either angina pectoris or coronary thrombosis did not die within three years but were still in good health after five or more. This led to a much more optimistic attitude in the 1930s but was accompanied by the finding that it didn't pay to live a gay life simply because it was to be a short one. We found that total disregard of simple rules of health did favor a shorter life and so we began to advise our coronary and hypertensive patients and others too that it was unwise to smoke, to get fat from a surplus of rich food, and to cease using the leg muscles. This rehabilitation led us on to the more important idea of prevention and finally to recommend control of the now familiar risk factors, especially in the young candidates for early coronary heart disease. Individuals vary so much, however, that I believe that those with

an o

with little tendency to atherosclerosis need far less protection than not so lucky. But we have not gone so far yet as to put all the

prime candidates on anticoagulants or intestinal resection in their youth. And of course some fat men and physically inactive men and heavy smokers do reach my age but they are certainly very few in number.

May I end with a plea for our use of nature's methods to support and extend longevity and the use of as few drugs and other potential poisons as possible. I should add that the value of vitamins of all kinds as additives to the diet in old age is still a matter of careful investigation but it seems reasonable meanwhile to supply those that are safe and seem to help.

I am still interested in man's artificial control of such risk factors as diabetes, hypercholesterolemia, hypertension, and causes of pollution, and the amelioration by surgical therapy of defects in the heart and blood vessels, but basic research and a long follow-up of the application of therapeutic test measures are more important and demand the first priority for the present at least.

We are a long way from control of the diseases that beset the aged and especially from the control of the aging process itself, but I believe that we are now well on the way.

Thank you for your interest and patience.

Senator EAGLETON. The committee is adjourned.

(Whereupon, at 11:40 a.m., the hearing was recessed, to reconvene Wednesday, June 2, 1971, at 9:30 a.m.)

RESEARCH IN AGING AND NUTRITION PROGRAMS

FOR THE ELDERLY, 1971

WEDNESDAY, JUNE 2, 1971

U.S. SENATE,

SUBCOMMITTEE ON AGING OF THE

COMMITTEE ON LABOR AND PUBLIC WELFARE,

Washington, D.C.

The subcommittee met at 9:15 a.m., pursuant to call, in room 4232, New Senate Office Building, Senator Thomas F. Eagleton (chairman of the subcommittee) presiding.

Present: Senators Eagleton (presiding), Kennedy, Stevenson, and Taft.

Committee staff members present: James J. Murphy, counsel to the subcommittee; and Michael S. Gordon, minority counsel to the subcommittee.

Senator EAGLETON. The committee will come to order.

This morning, ladies and gentlemen, we have some scheduling and time problems so I am going to convene these hearings a bit early and maybe call a witness or two out of turn.

I have an opening statement which I will place in the record at this time.

OPENING STATEMENT OF HON. THOMAS F. EAGLETON, A U.S. SENATOR FROM THE STATE OF MISSOURI

This morning we will hear testimony on S. 1163, the bill introduced by Senator Kennedy to establish a nutrition program for the elderly under the Older Americans Act.

Hunger and malnutrition among our people result generally from an inadequate income and/or a lack of nutritional knowledge. Among the aged, 25 to 30 percent of whom live in poverty, these factors are important contributors to malnutrition.

But the aged also face other problems. Lack of physical mobility or of transportation may impair their ability to shop for food. Those who live in rented rooms may not have cooking and refrigeration facilities. And there are important social and psychological considerations. Those elderly people who live alone and are isolated from family and friends simply may lack the motivation to prepare adequate meals for themselves.

Congress recognized the special nutritional problems of the elderly in 1968 when it earmarked funds, under title IV of the Older Americans Act, for a special research and demonstration program to im prove nutritional services for the elderly.

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