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quently endures the normal span of years undoubtedly makes these disorders the most tragic personal problems and the source by far of the most tragic drain on the country's resources.
Some concept of our national economic losses may be given by just reviewing a single neurological problem. Statistics derived from the Journal of the American Medical Association indicate that 200,000 persons are absent from full employment every day of every year largely as a result of head injuries caused by industrial and automobile accidents. This represents a loss of 416 million man-hours of work and at an average of $1.50 per hour ($60 weekly), this amounts to wage losses of $624 million a year.
Exclusive of wages lost, however, reliable studies by industry cost accountants have shown that the average accident involves indirect costs which are at least four times as great. Another $600 million must be included for medical expenses and compensation payments, and twice this sum must be reckoned as the cost of time lost by superiors and executives, loss of materials, damage and repairs to tools and equipment, time lost by fellow employees, hearings before compensation boards, and the time of medical personnel. The economic losses due to head injuries in any given year must, therefore, be calculated at very close to $2.5 billion. And the total productive losses for all neurological disorders cannot be less than 10 times this sum.
The 260,000 totally blind, for example, are scarcely prcductive at all; in addition they cost the county $150 million in welfare expenditures, plus another $36 million in income tax deductions. A large majority of the 500,000 who incurred cerebral palsy in childhood will also not enjoy fruitful labor, will not pay income taxes, and cannot serve in the Armed Forces. The costs of maintaining just 50,000 epileptics in State institutions amounts to $35 million yearly. And one insurance company has estimated that the cost of indemnity and continuous hospitalization of a single paraplegic patient will amount to $400,000. While we do not know the exact number of paraplegics in the country, the estimates based on professional spot checks, range from 85,000 to 125,000.
In this bewildering array of costs due largely to the crippling effects of the neurological and sensory disorders, the national income as derived by tax revenue is also seriously affected. It has been estimated, for example, that at our present tax rate per capita, the 500,000 cerebral palsied, who incurred the disorder in infancy, should pay at least $600 each year in income taxes, or a total of $300 million yearly. Over half of these, however, will actually pay no taxes at all and over an average adult productive life span of 30 years, a total of $5 billion in tax revenue will be lost from the cerebral palsied. It is quite clear that if all the neurological and sensory disorders could be resolved as publichealth problems, so would the problems of the national budget. Personal costs
To the individual patient and his family, the costs of the neurological and sensory disorders are not calculable in economic terms alone, though certainly these will frequently be tragic. The loss of productivity, as already indicated, where adults are affected over long periods of time, if not permanently, simply means cessation of income and the consequent impoverishment of the entire family.
Where the family income producer is not affected, the costs of medical care, of doctor, nurse, hospital, or custodial homes are still extremely high. Just what their average might be it would be impossible to say; in those disorders which can be controlled in some measure by various drugs, the total costs might run as low as $1,500; but the costs of rehabilitation and care of cerebral-palsied children over a long period of time have frequently run as high as $100,000.
Economic costs and the resultant social and psychological pressures which they cause are ironically enough aggravated by the fact that these disorders, once developed, are incurable and in most cases uncontrollable. But no neurological patient will accept this verdict and the painful history of the multiple sclerotic, for example, or the parents of a muscular-dystrophied child is the record of a pilgrimage from physician to physician (or indeed to any) until personal and family funds are exhausted.
Just as frequently, however, the patient does not receive an immediate diagnosis and before his disturbance is identified for what it is, he has visited various physicians and paid for services not relevant to his condition. It takes an average of 6 years before the multiple sclerotic is diagnosed as such by a qualified specialist; and 9 out of 10 victims of myasthenia gravis, if they live, are misdiagnosed for a similar period. The myasthenic may be treated for neuro
asthenia, poliomyelitis, muscular dystrophy or atrophy, or even hysteria, and undergo psychological treatment or be placed in a sanitarium. Dearth of specialists
There is good reason for this situation. The specialists available who are capable of diagnosing or treating the neurological disorders is discouragingly small. Of the more than 190,000 practicing physicians in the country, less than 250 specialize in medical disorders of the nervous system. In some areas of the country, there is only 1 such specialist to over 900,000 persons in the population, and the best ratio sees only 1 per 650,000.
The possibility of immediately enjoying a responsible increase in the number of these specialists seems remote. Of the 79 medical schools in the Nation, only 21 have complete neurological units for the training of personnel in this field; and there are only 151 available positions in the entire country which may properly be called neurological training posts.
The dearth of specialists in the field is not only responsible for inadequate diagnosis but, more important, for inadequate or no treatment at all. Today, for example, where 80 percent of the 142 million epileptics could receive successful therapy for the control of seizures, only 20 percent or about 300,000 are able to do so. Another 30,000 epileptics receive treatment through medical mail-order houses, a poor means of therapy at best and always a dangerous one.
Of the 1,800,000 victims of the cerebral vascular diseases (stroke), only a fraction receive the rehabilitation services which could train them to some degree of independent self-care or employment. They become the permanent occupants of hospital beds at tremendous cost, or, at home, they become permanent burdens on their families who must feed, dress, wash, and nurse them, and when this becomes intolerable, they are sent to custodial homes. (It is estimated that 25 to 50 percent of the occupants of custodial homes are neurological victims.) Dearth of facilities
Inadequate facilities for the treatment of the neurological patient is closely correlated with the dearth of specialists in the field. There are just a handful of clinics throughont the United States concerned with these problems from a medical standpoint and those few which do exist are, in the majority of cases, fundamentally associated with one research program or another.
In two areas, most notably in cerebral palsy and blindness, voluntary health agencies, the State and Federal Governments have made extensive funds available for treatment facilities, and indeed more than for all other neurological disorders combined. But even those facilities are far from suflicient. In the State of Connecticut, for example, which is extremely conscious of the problem of cerebral palsy, it is estimated by State authorities in 1951 that of 420 children who needed occupational therapy, only 60 received it; of 580 children needing physical therapy services, only 220 had been served ; speech therapy was needed by 260, 70 received it; less than half of those needing extensive treatment given in special hospitals could obtain it; and for every child then in a custodial institution, there was at least 1 more for whom such care was desirable. Another 120 children needed special educational classes ; 30 needed a home instruction program and there was considerable need for further vocational guidance serv. ices, medical social work, and other premedical support.
The needs set forth by the State of Connecticut do not present the entire picture, sorry as it is. The above statistics were based only on the known cases of cerebral palsy. But for every 10 cases that were known, State authorities acknowledged that 7 were not.
These facts barely adumbrate the situation and no data can present the picture of personal despair which most of these disorders bring with them. More than a third of the 60,000 yearly deaths of new-born children are due to brain injury; and for half of the parents of the 100,000 muscular dystrophied children, the pain of their children's death is even worse; they must watch their children grow paralyzed slowly, knowing that only a few will reach adolescence and almost all will die before maturity.
For those who are crippled and do not die-those suffering, say, from multiple sclerosis, amyotrophic lateral sclerosis, Parkinsonism, myasthenia gravis, hemiplegia, paraplegia, blindness—these, while living, can scarcely be called alive. Incapacited, committed to the isolation of their homes, rooms, or beds, they are far beyond the boundaries of a normal physical, social, and economic life. A burden to themselves, they become also a burden to their families and frequently only the profoundest love can salvage the splintering of the most intimate ties.
THE ATTACK ON THE PROBLEM
It is clear that this situation can be alleviated. There is, however, it should be noted, good reason for the inadequate attack on the neurological and sensory disorders prior to the past few years. Such an attack is almost always contingent on the insistence of public demand that something be done about the problem; but the crippled neurological patient, the epileptic, the cerebral palsied, has always been reluctant to press for aid where this disease for centuries has been synonymous with embarrassment, shame, and hopelessness.
In addition, the fact that the central nervous system has presented science with its most complex problems has not encouraged a vigorous offensive in the laboratory devoted to understanding the growth, structure, and action of the nervous system and to the finding of new methods of prevention, diagnosis, and cure of the neurological and sensory disorders. It should be noted here that the human brain alone is composed of some 20 billion nerve cells and while each of these may seem more or less alike, each serves a special function, each contributing in some singular manner to all our movements, actions, thinking, smelling, hearing, and breathing. How they do so constitutes one of the major medical challenges of our time and one to which we have just begun to devote ourselves. The present
That both the medical and medical research attack on the neurological disorders is gaining strength there can be no doubt. The past decade has seen & stirring of public and professional interest in this field, and the establishment of the various voluntary health agencies, the development and growth of various professional groups, and finally the creation of the National Institute of Neurological Diseases and Blindness by act of Congress in 1950 is testimony to the recognition of the neurological and sensory disorders as a major public health problem. No social or economic history written from this time on can fail to see that the 1940's and 1950's were the beginning of a new medical era.
The attack on the problem so far as largely been directed to immediately meeting the medical and welfare needs of the victims of the neurological and sensory disturbances wherever possible. In no category among these disturbances has this been entirely successful, and it is obvious that certain measures, such as the establishment of diagnostic, treatment, rehabilitation, and educational centers in key geographical areas throughout the United States must be expedited.
Steps to meet all the possible needs which exist, however, are clearly impossible. The financial drain on the country militates against such a solution, mainly because treatment of these disorders is never ultimate; in no case do they restore the human being to his normal status or to a normal state of productivity. The services of a full medical program is contingent upon the success of the therapies which can be brought to bear against disease; and in the neurological and sensory disorders, these therapies have yet to be fully realized. Research accomplishments
Nevertheless, extremely significant medical advances have been made in the partial control of certain neurological and sensory disorders, and these are all the more noteworthy for having been achieved under minimum financial support. At the present time, 80 percent of all epileptic seizures can be controlled by a variety of new drugs and new surgical procedures; new drugs have also been found to alleviate the muscular weakness of myasthenia gravis and partially control the symptoms of Parkinsonism. The development of total rehabilitation procedures has helped restore the cerebral palsied and other victims of brain and spinal injury to some degree of independent self-care. And the electroencephalograph, the electromyograph, and air encephalography procedures have not only revolutionized our ability to diagnose such disorders as epilepsy, hrain tumor, and other neurological conditions, but has provided an invaluable research armamentarium for studving the activity of the brain.
In ophthalmology, ACTH and cortisone have been responsible for preventing blindness from a variety of disturbances; new surgical procedures cataract and glaucoma. have helped retard the insidious progress of these conditions; and the development of corneal transplant methods has been able to restore sight in some cases which would have been irrevocably lost.
We may congratulate ourselves on these advances, and they must especially command respect in view of the limited facilities at the disposal of the scientists responsible for their achievement. In 1951, for example, of the $33 million
which was devoted to all medical research grants, as recorded by the National Research Council, less than 3 million was allocated by all agencies, public and private, for investigation of the neurological and sensory disturbances. Less than $900,000 was spent on research into blindness, in contrast to the $150 million spent for care and services to those already blind. Research ahead
In the full perspective of the problems facing us, those achievements already made will represent only a small fraction of those which we must cover. Such disorders as cerebral palsy, muscular dystrophy, multiple sclerosis, paraplegia, and hemiplegia are still incurable. And even though therapies have been developed for Parkinsonism, myasthenia gravis, and epilepsy, these suffer from severe limitations. The drugs for the treatment of myasthenia gravis, for example, may cause serious side effects, may require frequent administration (usually every 2 hours) and eventually their ability to control the terrible muscular weakness which characterizes may fail. While agents for the treatment of epilepsy are relatively more successful, only a cure which can guarantee the complete disappearance of the disorder will dissipate the social and economic prejudices which are the peculiar fate of the epileptic. For even those whose seizures are controlled (they may suffer but one seizure a year), once they are identified as epileptics, they become virtually unemployable, in many States they may not yet married nor may they have children. The child who is an epileptic may not be admitted to his community's schools, in spite of the fact that his intelligence will be normal or even above it. The social fate of the epileptic-and indeed the cerebral palsied, the muscular dystrophied, and the blind-is often that of the outcast and patronizing acceptance drives them even further into their private worlds. In passing, it should be said that education of the public in the understanding of these disorders must be carried far beyond present efforts.
The major research achievements in the neurological and sensory disorders, therefore, lie in the future. With a broad research attack, considering previous scientific successes, there is no reason to believe that they will not come. Such research, even under present weak financial support, shows the sure signs of progress, and the vast complexities of the nervous system are being unraveled. Among the more basic laboratory developments has been our increased ability to define both the microscopic and enzymatic structure of nervous tissue, an ability to measure the cerebral circulation of the brain; the development of the oxygen electrode has permitted the quantitative measurement of oxygen tension at microscopic points in the brain and through new microchemical techniques and the development of the microelectrode, the metabolism, and electrical activity of single nerve cells are rendered susceptible to experimental determination.
These basic studies on the nervous system are intricately related to those disorders of the nervous system with which the public is concerned. While the value of this research may be disguised until the fruitful moment of application has arrived, it may not be too difficult to see where such investigations frequently form the basis of the ultimate benefit of treatment or cure. For example, this year one scientist has formed a method for growing nerve cells outside of the body so they will conduct electrical impulses. At this stage of neurological invesigation, this finding provides a highly useful method for studying nerve tissue and nerve impulse. Visionary as it seems and indeed it may be, it also clearly signals another possibility that damaged nerve tissue may be replaced or regenerated. Damage to nerve tissue
Damage to nerve tissue is one of the central issues in the consideration of our possible success in attacking the neurological and sensory disorders. In the majority of these disturbances, nerve tissue on the brain or spinal cord has been or is in the process of being destroyed. Such destruction makes it impossible for nerve impulses to pass from the areas affected to those muscular junctions which they ordinarily activate, and the consequence is partial or total disfunction or paralysis. If more damage, therefore, can be prevented, or again, if this damage can be reversed, then a large number of neurological problems will be resolved.
The work in prevention has already made partial progress. Research evidence has clearly established the effects of contingencies occurring during pregnancy and labor on the development of brain injury in the new-born child, and these facts have already been absorbed into medical practice. We do not X-ray a pregnant woman around the third month, unless absolutely necessary, for example, and we are especially careful in keeping the prospective mother ont of contact with certain infectious diseases, especially German measles. And to further prevent brain damage to the child, our obstetrical procedures have become more and more refined.
Valuable as these measures are and will increasingly become, it is clear that only a fraction of all the deaths occurring as a result of natal and postnatal brain and spinal injury can be prevented. Damage done prior to birth, for example, is irrevocable; let the brain be deprived of the nourishment of oxygen for just 3 minutes during the 9 months of gestation and the precious cells of the brain's cortex have begun to deteriorate and the patient is rendered a permanent cripple. Regeneration of nerve tissue
The main hope of research, therefore, lies in somehow reversing nerve damage already committed. While it is classical theory that nerve tissue cannot be regenerated, yet there is good evidence recently that such is probably not the (ase. An investigator now at the National Institute of Neurological Diseases and Blindness, who was working on another problem entirely a few years ago, (ame up with a finding which may lay the groundwork for an absolute rebuttal of this belief.
These investigators injected some cats, whose spinal cords had been severed, with a certain type of dead, heat-producing bacterial agent. On autopsy, these investigators found to their amazement that nerve fibers had grown across the severed spinal cord and that they were capable of carrying nerve impulses. These were later to determine that the substance which had been injected had prevented the formation of scar tissue at the place of damage and this scar tissue ordinarily created a dense barrier through which the nerve ends could not grow together.
While later investigations showed that this bacterial agent could only restore minimum movement to the injured cat, and that it was most effective only if administered rather shortly after the spinal cord was cut, one factor of overwhelming importance emerges—there is good probability that nerve tissue can be regenerated and the medical texts will have to be revised to this effect.
This is not to say that its achievement in terms of a successful therapy for the neurological disorders lies within the near future. It is, of course, possible that some already known agent, other than those presently being tested, will prove more effective on humans, but it seems likely that the successful treatment will develop out of our ultimate understanding concerning the growth of nerve cells and the biochemistry and metabolism of nerve tissue. Broadening of the research effort
The research effort which should be devoted to these and other promising lives of investigation is, however, at a minimum. Many areas of research, moreover, must be opened up to investigation which have never been brought under attack before. In the many links of fact which constitute our understanding of the functions of the nervous system there are now many gaps to be filled. Important as cerebral vascular disease is to the Nation, the Public Health Service, which supports about one-third of all medical research, is devoting approximately $110,000 to support of investigations in this field. The Multiple Sclerosis Society alone, for example, lists 28 major problems which should be followed up or initiated, each of which should be the object of several different studies.
In many areas, even exploration of the obvious has been neglected and useful results have been postponed indefinitely. There is good reason to believe, for example, that cataracts may occur as a result of changes in the composition of the eye due partially or wholly to the growth and aging process. We have believed this for some time, but in spite of this fact no specific investigation of this problem has yet been initiated—though it is now being planned at the National Institute of Neurological Diseases and Blindness.
Such research, of course, is expensive; and it may be a number of years before we can see concrete results. Numerous laboratory animals at every stage of growth must be examined and analysis of protein changes in the lens, its water content, weight, specific gravity, and other factors must be checked, and finally if such changes do indicate that cataract in animals is due to aberrations of the normal growth process, the changes which occur in humans must be studied with the same care.
While the costs of such research are high, the costs of not performing it are a good deal higher. Approximately 20 percent of all blindness is due to cataract50,000 of the totally blind, 200,000 of those blind in 1 eye, and 68,000 of those