Dr. TRAEGER. Mr. Chairman, may I crave your indulgence for just another few minutes to give Dr. Bailey an opportunity to tell the committee something about some of the other neurological diseases and the research and training program at the National Institute? The CHAIRMAN. Certainly.

Dr. TRAEGER. Thank you, sir. Dr. Bailey.

STATEMENT OF DR. PEARCE BAILEY, DIRECTOR OF THE NATIONAL INSTITUTE OF NEUROLOGICAL DISEASES AND BLINDNESS

Dr. BAILEY. Mr. Chairman, I realize that time is very short, but I think these diseases should be mentioned. I do not think they are considered as a group under any written statement.

That is, we have heard a lot of testimony from various voluntary agencies which are interested in diseases. We at the National Institute of Neurological Diseases and Blindness are very intent on pursuing the research attack on all those diseases, but we also have the national responsibility for diseases that are not represented by any organized group. Some of these diseases take a very shocking toll in death and economic loss to the country.

I will just mention these diseases. If you would like, a short statement could be prepared for the record.

The first one is apoplexy or stroke, which accounts for about 170,000 deaths a year in this country. For this disease, so far as I know, not much over $200,000 a year is being spent in research. A stroke has such neurological aspects that have never been investigated that they should be undertaken because of the death toll as soon as possible. In addition to the death toll, there are present in this country 1.8 million hemiplegics resulting from stroke or apoplexy. As you know, this disease hits big people and little people. It is nonpartisan in its approach.

A second disease is Parkinson's disease, or the shaking palsy, which is a progressive disease involving a certain part of the brain, with several causes. It is a very disabling disease; it is common.

The research effort, for instance, from the entire Public Health Service, only amounts to about $90,000.

A third element is accident and injury to the nervous system, which is injured in about 6 to 10 percent of all accidents. You might say that you could bring that up with regard to any organ, but I bring that up particularly because the central nervous system when damaged causes a loss which is irreparable-a fact we brought up before. The importance of continuing research into regeneration of nerve fibers is involved.

Let us take one example: Paraplegia, which, you all know, means paralysis from the waist down, is a good case in point. In World War I there were 400 paraplegies. Within 6 months 50 percent of them were dead.

Now, due to improved methods, about 2,500 paraplegics survived out of some 3,000 plus in World War II. The estimate of the paraplegic population in the United States is between 80,000 and 100,000 people completely paralyzed from the waist down.

An insurance company has estimated that 1 paraplegic in indemnity and hospital cost will amount to $100,000 for that insurance company. That is under a custodial-care program.

I particularly mention paraplegia because as work in nerve regeneration is successful, it is probable it will be applied first to the spinal cord which is a lot simpler in its structure than the brain.

Thank you.

The CHAIRMAN. Doctor, I would like for you to feel free to add to your testimony whatever you might wish to prepare to be made part of the record. I note that there is a general statement prepared on neurological and sensory disorders by the National Institute of Neurological Diseases and Blindness of the National Institutes of Health; but if there is anything in addition to that you wish to make a part of this record please feel free to do so.

Dr. BAILEY. Thank you, Mr. Chairman.

(The prepared statement of Dr. Bailey follows:)

NEUROLOGICAL AND SENSORY DISORDERS

(Prepared for hearing of the House Committee on Interstate and Foreign Commerce, October 7, 1953, by the National Institute of Neurological Diseases and Blindness, National Institutes of Health, Public Health Service, United States Department of Health, Education, and Welfare)

THE PROGRAM OF THE NATIONAL INSTITUTE OF NEUROLOGICAL DISEASES AND BLINDNESS The National Institute of Neurological Diseases and Blindness is the newest of the National Institutes of Health of the Public Health Service, having been created in response to public and professional demand by Public Law 692 in August 1950. No appropriation, however, was made available to activate the Institute until 1951 when $1,250,000 was appropriated to initiate a program of research.

The National Institute of Neurological Diseases and Blindness leads and coordinates the research and training programs in neurological and sensory disorders in the National Institutes of Health under the Public Health Service. It directly administers these programs of research and the support of research and training in universities and other non-Federal institutions. It also serves as a focal point for research and training in rehabilitation activities throughout the National Institutes of Health.

NATURE AND SCOPE OF THE PROBLEM

The relative youth of the Institute does not truly reflect the size and nature of the problem with which it is faced. As a distinct group of disorders, neurological and sensory diseases do create an extremely serious public health problem. They affect approximately 20 million persons in the United States alone, of whom at least one-half endure gravely disabling conditions. While only the third cause of death (after heart disease and cancer), it is probable that no other group of disorders causes such permanent crippling, and this crippling is usually so severe as to cause profound psychological, social, and economic dislocation for the individual sufferer. In general, these are disorders of the nervous system and of the critical sense organs-vision and hearing. More specifically, they include a broad spectrum of different disturbances, such as cerebral palsy, multiple sclerosis, epilepsy, muscular dystrophy, Parkinsonism, and injuries to the brain and spinal cord. Among the sensory disorders are glaucoma, cataract, and many other conditions causing partial or total blindness and deafness.

The problem posed by neurological and sensory disabilities is a difficult one. The nervous system is the most complex and widely dispersed system of the body and until recently the most inaccessible to study. But, in spite of its relative inaccessibility to study, it is, unfortunately, particularly vulnerable to disease and injury.

Moreover, neurological disabilities once developed are frequently permanent disabilities for central nervous system tissue, which unlike other tissue of the body, such as the skin or liver, when once definitively damaged never repairs spontaneously. For this reason, victims of neurological disorders constitute a tremendous drain on the economy of the country--not only in terms of manpower,

wage losses, productivity, and tax revenue, but as an additional burden placed on local community and family resources. At present, a survey of the economic drain on the country's resources resulting from these disorders is being conducted by the National Committee for Research in Neurological Disorders.

RESEARCH IN NEUROLOGICAL AND SENSORY DISORDERS

Before the discovery of sulfonamide drugs and antibiotics neurological research was concerned chiefly with clinical descriptions and autopsy studies. Nothing further was accomplished-neurology during those times was not much more than a scientific cogitation of disability and death.

With the discovery of new drugs and penicillin, many of the infectious diseases of the nervous system were capable of being controlled. Neurosyphilis, and bacterial infections of the nervous system such as epidemic meningitis were practically wiped out. At the same time brilliant advances were made in surgery on the nervous system and the eye-advances which gave to this country leadership in brain surgery and which comprise one of the most dramatic chapters in the history of surgery.

These achievements in infectious diseases and surgery led to the development of new precision instruments to make the nervous system and the eye more accessible to investigation and to new experimental methods in fundamental neurological sciences to probe deeper into the basic nature of the structure, development, chemistry, and physics of the nervous system and its sensory endings. To illustrate, we can point to the development of air encephalography, a technique for outlining the ventricles of the brain; to the development of angiography, by means of which the blood vessels of the brain become visible in an X-ray picture; to the discovery of the electroencephalograph, a precision instrument which records the electrical beats of the brain; and to electromyography which registers the electrical potential of neuromuscular action. development of these precision instruments, together with the discoveries in biophysics and biochemistry, opened up new vistas for research in neurological and sensory disorders.

The

These new discoveries, encouraging as they were, still left large areas of crippling neurological and sensory disorders untouched. Still unsolved were some of the worst neurological disorders of mankind-cerebral palsy, apoplexy (or stroke), multiple sclerosis, muscular dystrophy, Parkinson's disease, the effects of brain and spinal cord injuries (including paraplegia), and loss of language functions. Among the sensory disorders are cataract, glaucoma, and a type of early blindness of prematurely born infants called retrolental fibroplasia.

The tremendous toll in suffering, disability, and cost exacted by these disabling conditions eventually led to a surge of public interest in this relatively neglected field. New voluntary health agencies bound to categorical neurological diseases were formed and for the first time many neurologic patients were able to shed the cloak of social shame, behind which they had hidden for years, and were able to have their stories heard. It was at about this stage in the history of neurologic research that the National Institute of Neurological Diseases and Blindness was formed.

OBJECTIVES

The broad objectives of the Institute's program are: (1) To search for and find improved methods for the diagnosis, prevention, treatment, and rehabilitation of neurological and sensory disorders; (2) to improve professional competence in these fields in order to reduce the suffering, disability, death, and economic loss caused by these disorders; and (3) to participate in the national collaborative effort to combat neurological and sensory disorders.

To achieve these objectives the Institute has developed extramural research and training programs to support research projects and training programs in non-Federal institutions; and an intramural laboratory and clinical research program to be conducted in the laboratories and at the Clinical Center in Bethesda.

RESEARCH GRANTS PROGRAM

This program supports research on neurological and sensory disorders in universities and other non-Federal institutions. The largest part of this research project support has concerned the major disease categories such as multiple sclerosis, epilepsy, muscular dystrophy, cerebral palsy, glaucoma, cataract, and retrolental fibroplasia. In addition to these distinctly clinical projects, the

Institute also supports other projects dealing with the processes fundamental to the understanding of many of the pathophysiological processes of the nervous and sensory systems. This latter type of research support is focused toward providing clues to the basic mechanisms underlying many of these disorders.

In the fiscal years 1951 through 1953, the Institute was able to support from its approved applications 268 projects in the amount of $2,280,000. A classification of the various types of projects supported by the Institute, together with a corresponding financial breakdown, is set forth on pages 1 through 3 of the appendix. Because of the multiplicity of neurological and sensory disorders, the requests for research grant support in these areas far exceed the present resources of this Institute. For example, the estimated demand for the current year was $4,500,000 against an available appropriation of $2,700,000. There is every indication that approved applications during fiscal year 1954 will exceed that forecast. (For explanation of estimates see p. 4 of the appendix.)

There is general agreement that subsequent to the initiation of this Institute's research grants program there has been a mounting interest in research in the neurologic and sensory disorders, not only in the programs directly sponsored by this Institute but also in the grants-in-aid provided by voluntary health organizations. Apparently the development of the Institute's broad research grants program has stimulated additional support for foundations, voluntary health organizations, and private philanthropies dedicated to combating these crippling diseases.

TRAINING PROGRAMS

A difficult problem for the program of this Institute to meet has been the urgent need for better facilities in the graduate training of clinical teachers and researchers in neurological and sensory disorders. It is a generally accepted principle that research and training are merely different points on the same assembly line. Both points must be continuously active if a constructive research program is to endure. Unless the scientist in the laboratory can rely on a pool of young scientists-in-training, his program will not survive for long. Similiarly, if there is not a source of young clinical researchers-in-training, important laboratory discoveries may remain concealed for years before they can be tested in the clinic.

With minor exceptions, the current facilities in our medical schools for postgraduate training of teachers in neurological and sensory disorders are seriously inadequate. Only about a third of all the country's medical schools have complete neurological units for teaching physicians and scientists. Many of our neurological teachers are not qualified neurologists, and many States in the United States do not have a single qualified neurologist.

Funds have been made available to this institute for the support of graduate medical training grants for the first time in fiscal year 1954. This sum ($400,000) will serve to support 20 programs among the total that may be submitted from eur country's 80 medical schools. We have already received requests amounting to $300,000 more than the total available to us.

Besides the training grants program, the institute has a research fellowship program which supports 39 postdoctorate and special fellows in the broad fields of neurology, ophthalmology, otology, rehabilitation, and neurological surgery. At present we are able to support about 1 of every 6 highly qualified applicants for training in this important field of investigation.

The final part of our postgraduate training program concerns stipends (traineeships) to increase the number of highly trained personnel who will develop into competent teachers of the clinical and rehabilitation aspects of neurological and sensory disorders. Currently, we are supporting 20 such trainees. An additional 20 highly qualified individuals could be placed immediately.

SPECIAL PROJECTS

The development of diagnostic techniques and of treatment in any medical field constitutes a major problem. This is particularly true in relation to the neurologic and sensory disorders. Because of the chronic, long-term nature of these disorders, fundamental findings from the laboratory must be translated into clinical application at the earliest possible moment. There is an acute need for special projects designed for the clinical testing, evaluation, and establishment of diagnostic methodologies and approved treatment schedules. Projects of this type are usually located in a clinic and then typically proceed not only on the clinical level, but also exist as demonstration projects. Techniques developed in

the project are taught to specialists, general practitioners, and allied medical personnel. After observing and perfecting themselves in the new techniques of diagnosis and therapy of these diseases, they later incorporate these added skills into their own private practice. In the field of neurologic and sensory diseases, these demonstration projects are urgently needed now for such disorders as multiple sclerosis, epilepsy, cerebral palsy, muscular dystrophy, leprosy, bulbar poliomyelitis, glaucoma, and retrolental fibroplasia. These demonstrations are valuable not only in advancing diagnosis and therapy, but in improving rehabilitation techniques. Until recently the extent to which lareg groups of these patients could be rehabilitated had been grossly underestimated, and as techniques are improved the proportion who can be rehabilitated will increase.

RESEARCH ACCOMPLISHMENTS

When the National Institute of Neurological Diseases and Blindness was founded in 1950, a number of new discoveries in the field of neurological and sensory disorders had secured the scientific beachhead indispensable to an effective large-scale research offensive. The creation of air encephalography, electroencephalography, and electromyography provided new diagnostic tools, without which much further work would have been impossible. The introduction of radioisotope tracer techniques for the diagnosis of tumors, and other lesions of the brain marked another advance whose potentialities are far from exhausted. The discovery of new chemical complexes in the nervous system provided a clue, not yet tracked down, to the basic mechanisms of multiple sclerosis. Recent studies on pregnant mothers may help unravel the mysteries of cerebral palsy. The creation of this Institute, through its direct or indirect support, has given impetus to the exploitation and elaboration of these lines of research. As an example, new antiseizure drugs have been developed so that 80 percent of all epileptic seizures can be controlled. Prior to the use of neostigmine, myasthenia gravis was often rapidly fatal-about half of the patients died within weeks or months after the diagnosis was made. Now 80 percent of these patients at all ages, if adequately maintained on neostigmine, may expect to survive the disease.

In the 21⁄2 years during which the Institute's research grants program has been actively in existence, not only have current ideas been more effectively exploited but additional findings of great potential significance have been made. Grantees at the University of Utah, for example, have found that the adrenal hormone, desoxycorticosterone, greatly increases the effectiveness in animals of antiepileptic drugs presently in use, in some case extending their antiseizure activity more than 10 times the usual period. If these same results obtain for humans, another significant step toward the practical control of epilepsy will have been made.

At the University of Tennessee, investigators under Institute support have been establishing the normal brain activity of newborn infants through the use of the electroencephalograph. This technique has already permitted the investigation of those factors occurring during labor and delivery which might adversely affect the brain of the child.

Further investigations at the Harvard Medical School under a grant from the National Institute of Neurological Diseases and Blindness have cast light on when various parts of the developing nervous system of the embryo are most liable to damage and the exact nature of the damage incurred. Such findings may lead to further modes of prevention of such disorders as epilepsy and cerebral palsy. As further information concerning the biochemical and metabolic changes occurring during embryonic development is derived, new modes of treatment may evolve.

At Columbia University researchers have been able to successfully grow outside of the body nerve tissue capable of carrying electrical impulses. This technique provides an invaluable method for studying the composition of nerve cells. More significant, it offers promise that the functional regeneration of nerve tissue will become a reality.

In the field of ophthalmic research, substantial research accomplishments have also been made under the Institute's support.

At Georgetown University, substantial evidence suggests strongly that prolonged and high oxygen normally given to premature infants in hospital nurseries plays the most significant role in the development of retrolental fibroplasia, the leading cause of blindness in children. (The work at Georgetown has stimulated the establishment of a broad research project under the support of the