ern University Medical School, Chicago, Ill., and clinical professor of Neurology and Neurosurgery, Bowman Gray School of Medicine, Winston-Salem, N.C. I am also the editor of a neurosurgical journal known as "Surgical Neurology." I appear before you on behalf of the National Committee for Research in Neurological Disorders regarding the budget for 1976 of the National Institute of Neurological and Communicative Disorders and Stroke.

NINCDS is the Institute in NIH which is concerned with research in the neurological and communicative disorders and in the basic sciences related to those disorders. It is concerned with a wide variety of diseases which not only affect approximately 20 percent of our citizens but which are the third (stroke) and fourth (injury to the brain and spinal cord), most common causes of death. In addition and, in fact, much more importantly, these diseases are those which cripple and disable chronically more of our citizens than any others. These diseases are also among the most obscure and difficult to investigate and understand. This is true not only because the nervous system is enclosed within bony walls where it cannot be readliy seen or examined but because of its intricacy. Even more important, the central nervous system in man is that part of the body which differs most from the comparable organs in animals. As a result, although animal research is important, much of the investigation of human disease must be conducted on man himself, and all research findings made on animals in the laboratory must be confirmed in man before we can be confident that the observations are true for man.

During the brief 25 years that the Neurological Institute has been in existence it has made great contributions to the understanding and treatment of neurological and communicative disorders. In 1950 the specialty of neurology was literally dying on its feet. It was an erudite diagnostic specialty which had little in the way of prevention and treatment to offer its patients. As a result there were very few neurologists in this country and there were many medical schools with no one specially trained in neurology on their faculties to teach their medical students. In the past 25 years that has changed remarkably, and largely as the result of the activities of this Institute. All medical schools have neurologists on their faculties. Many of them have independent departments of neurology. The laboratories in basic neurosciences have increased in numbers and expanded fantastically. Practically all of these teachers and investigators have received their training in programs supported by NINCDS and the laboratories have been created and in large measure operated through funds awarded by NINCDS.

Until 2 years ago NINCDS had operated with decreasing allotment of funds ever since 1968, and with a decreasing staff. In the past 2 years the funds available to NINCDS have increased and the Institute has been able to expand its activities into necessary areas which had been neglected because of the lack of funds in prior years. The President's budget for fiscal year 1976 calls again for a decrease in funds for this Institute of approximately 20 percent. If such a decrease were to occur the Institute would be forced to cut back on the important programs which it has recently instituted and to discontinue its expansion into new areas. What are the most outstanding needs of the Institute and in the areas of neurological and communicative disorders?

First, NINCDS must have a larger staff. The reducton of staff from 649 to 515, a reduction of 20 percent, is completely unrealistic. The Institute cannot develop and operate the new programs so badly needed if it is not permitted to have a staff large enough to deal with its problems. Instead, the Institute should be permitted to increase its staff by a very modest 10 percent or by 52 positions. Even such an increase would not allow the Institute to return to the level which formerly existed, namely a staff of 649. Numbers alone are not enough. The grade level of the members of the staff must also be permitted to rise to that required to meet the need of the Institute.

For the past several years the policy of destroying the training programs of the Institute has been disastrous. The teachers and investigators in neurology, neurosurgery, otolaryngology, and basic neurosciences which the Institute helped to create over the past 25 years are for the moment carrying the burden. But it takes years to train teachers and investigators. The number now being trained will not be sufficient to supply the needs of the existing and newly formed medical schools, of the enlarged body of medical students, and to replace those teachers and investigators who will retire or die in the next 5 years. First. the policy of the administration destroyed the training programs and substituted for them an inadequate program of individual scholarships. This policy has many

disadvantages and inadequacies, the greatest of which is the fact that no one can train men without a well-developed on-going program. Second, the administration abolished support for the training of clinical teachers and investigators. The one neid of medicine in which clinical investigators is of the greatest mportance is that of the nervous system because the nervous system of man is so vastly different from that of all animals. This policy of the administration was developed, so it was said, because the Government should not contribute to the training of men who were going to go into the practice of medicine and make hundreds of thousands of dollars a year. This excuse was false on two grounds. The training was for teachers and investigators and not for private praculuioners of medicine. And teachers and investigators working in our medical schools and laboratories do not make the incomes suggested by those who destroyed these training programs. Third, now the administration is seeking to destroy all training programs. Conduct of research and the dissemination of knowledge about neurological and communicative disorders will not be possible it the training programs for teachers and investigators are not reestablished. Because improvement in the understanding, diagnosis, and treatment of neurological and communicative disorders is of importance to all individuals in all parts of the United States, the expense for both research and training should be borne by all of the people. This can only be done through the Federal Government. It is not only unjust to expect research and training to be supported by a few individuals, or a new municipanties or States, but it is unrealistic. If it is not done by the Federal Government, it will not be done.

This past year the level of support for research grants increased. The percentage of applications which were approved was essentially the same in fiscal year 1975 as in fiscal year 1974 and fiscal year 1973, but the percentage funded increased in fiscal year 1975 to 46 percent as compared with 31 percent in fiscal year 1974 and 34 percent in fiscal year 1973. However, if the appropriation for NINCDS is not increased in fiscal year 1976 over what it was in fiscal year 1975 and greatly over what the President has recommended, the number of funded research grants will again decline. In the opinion of NCRND even to have 46 percent of all applications funded is inadequate. Of all applications for research support which were submitted the review committees and the Advisory Council of NINCDS found 70 percent worthy of approval. All of these should have been financially supported, but 35 percent of them were not. The Director of NINCDS, Dr. Donald Tower, has told this committee that if the Institute is supported at the level of the President's budget, only 19 percent of new research applications will be funded. And in addition, the support for other research activities will be decreased. This is not the way to abolish crippling, disabling neurological and communicative disorders.

The National Committee for Research in Neurological Disorders has carefully surveyed the needs of the National Institute of Neurological and Communicative Disorders and Stroke. It strongly recommends that the necessary steps be taken to increase the staff of NINCDS by 60 positions and to survey the grade level of all appointments and increase the grade wherever necessary. NCRND also strongly recommends an appropriation of $193 million for NINCDS for fiscal year 1976. The categories to be supported in that appropriation are indicated below. In addition NCRND has heard that the appropriation at this time may be for 15 months rather than the usual 12 months. If the appropriation is for 15 months it should be $241,250,000.

Grants:

Recommendation for fiscal year 1976 for 12-month period

STATEMENT BY JAMES B. SNOW, JR., M.D., PROFESSOR AND CHAIRMAN, DEPARTMENT OF OTORHINOLARYNGOLOGY AND HUMAN COMMUNICATION, SCHOOL, OF MEDICINE, UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA, PA.

Unprecedented progress has been made in the prevention and amelioration of disorders of human communication and in the rehabilitation of our people with communicative disorders. This progress has been achieved i nlarge measure through the support of research and training in the communicative sciences by the National Institute of Neurological and Communicative Disorders and Stroke. This progress has occurred in many areas. Not only have new developments led to new and effective treatment, but our fundamental understanding of the structure and function of the body in the communicative processes has been enhanced and provides the basis for the practical application of new knowledge to those with communicative handicaps. The combination of new information from the fields of biology, electronics, electrical engineering, computer science and radiation has improved diagnosis, therapy and rehabilitation.

In recent years significant progress has resulted from research in the surgical treatment of common causes of hearing loss such as otosclerosis, serious otitis media and chronic otitis media. Major progress has occurred in the prevention of sensorineural hearing loss due to the ototoxicity of drugs, rubella, measles, mumps, syphilis and noise induced hearing loss.

The survival of patients with malignant tumors of the voice box and throat has been improved by imaginative combinations of radiation therapy and surgery. Likewise new developments in the early detection of tumors of the vocal tract have led to higher cure rates with less disability secondary to the treatment.

Much of he information upon which the levels of control of environmental noise to prevent noise induced hearing loss incorporated in the Occupational Safety and Health Act was developed in research supported by the National Institute of Neurological and Communicative Disorders and Stroke.

The number of people in the United States who are afflicted with disorders of human communication is quite great. Indeed, there are over 20 million Americans who are disadvantaged by hearing loss and speech, language and voice disorders. New information has reached a sufficient stage of development so that new breakthroughs can result from further research in many of the problem areas afflicting these 20 million Americans. These areas include serous otitis media (a common cause of childhood hearing loss), hearing loss from head injury, vestibular disorders which result in recurrent and persistent vertigo and imbalance, laryngeal cancer, laryngeal papillomatosis (a devastating disease of the upper airway in young children), stuttering, aphasia (the loss of speech, one of the most profound and persistent disabilities resulting from stroke), language development (critical for early childhood) and voice disorders (a prominent cause of economic disadvantage for those so afflicted). For example, experts in the problem of serous otitis media who are meeting at Ohio State University, Columbus, Ohio, later this month believe that we are on the threshold of discovering the secret to the prevention of this common childhood problem. Although a satisfactory means of surgical treatment of this form of hearing loss has been developed through research, the importance of discovering the means of prevention cannot be overemphasized because of the anguish it causes and the economic impact of it. It has been estimated that more medicaid funds are spent on the treatment of this condition than any other single disease process. Serous otitis media is another area requiring additional research which is likely at this time to have a large payoff.

Likewise, recent progress in the implantation of auditory devices has reached a state of art in which additional research may make the difference between isolation and communication for the large segment of our population (60,000 persons) who are profoundly deaf. The scientific community concerned with auditory prostheses has made a cogent statement supporting a major research effort in implantable devices to restore hearing at this time. The rewards of this endeavor for the profoundly deaf defy quantification in economic or human terms. An area of great importance to the hard of hearing (2 million persons) is the development of the miniaturized master hearing aid which allows alteration of acoustic characteristics to fit the individual's needs. It provides hope through research of making hearing aids useful to persons who previously had not obtained satisfactory improvement.

Another example of an impending breakthrough is the immunotherapy of laryngeal papillomatosis. Preliminary data suggest that this form of therapy offers the most rational approach to this tragic childhood disease. In the area of communi

cative disorders, it is possible to cite many leads like this one which are well worth pursuing with urgency and determination.

At the operative level of the fiscal year 1975 National Institute of Neurological and Communicative Disorders and Stroke budget ($142 million), only 42 percent of the research projects dealing with the medical problems of human communication (hearing, speech, and language) were awarded. At the level of the President's 1976 budget ($114.5 million), only 19 percent of the new proposals addressed to the exploitation of this new research knowledge can be funded. The magnitude of this tragedy becomes apparent when one recognizes the high scientific merit and social significance of the projects that cannot be awarded at this level. The National Committee for Research in Neurological Disorders urges the appropriation of $193 million for the National Institute of Neurological and Communicative Disorders and Stroke so that the work so vital to the communicatively impaired may continue with renewed vigor.

Not only are additional funds needed to support currently proposed research by outstanding investigators, but funds are needed to support research training in the communicative sciences to provide a steady infusion of young creative investigators to pursue the problems evolving along the road of our progress. There is currently a manpower shortage in the research areas of the communicative disorders. These professional fields include the medical specialties of otorhinolaryngology (ear, nose, and throat) and neurology, the allied medical disciplines of audiology and speech pathology and the basic sciences of biochemistry, developmental neurobiology, immunology, electrophysiology, biophysics, and virology. Support for training programs and individual fellowships are of the highest priority in the opinion of experts in the fields of the communicative sciences. The termination of the "old" training grant program was particularly detrimental to the development of research manpower in the communicative sciences. These training programs provided support for the academic environment and training and for the individual trainees. The new program supports the trainees in selected research areas including the communicative sciences and will help meet the national need. However, the level of support must be significantly increased over the operating level for fiscal year 1975 in order to make the necessary impact on the national manpower shortage in the communicative sciences.

Now is a propitious time to increase support for the National Institute of Neurological and Communicative Disorders and Stroke in research in view of the research leverage provided by impending scientific breakthroughs and in training in view of the national manpower shortage in the communicative sciences.

STATEMENT OF DOCTOR THOMAS W. LANGFITT

My name is Thomas W. Langfitt, M.D. I am chairman of the division of neurosurgery and vice-president for health affairs at the University of Pennsylvania. In my testimony last year before your subcommittee, I provided some background for the current research efforts of NINCDS in the areas of head injury and stroke. In this report I will address some concepts and purposes of the NINCDS Clinical Research Centers, how these concepts have been put into practice and the purposes served, then discuss some problems that have to do with the application of information and clinical expertise that have been developed in these centers to patient diagnosis and management throughout the country.

CONCEPTS AND PURPOSES OF THE NINCDS CLINICAL RESEARCH CENTERS The principle goal of neuroscience research in general and of the neuroscience Clinical Research Center in particular is to generate new information potentially applicable to the diagnosis and treatment of neurological diseases and at the same time application of existing knowledge to the management of those diseases. The establishment of clinical research centers was stimulated by recognition of a gap between the generation of knowledge and its application to patient care. The gap has been bridged by combining the basic neurosciences, clinical neurosciences, and direct patient care within the centers. Hypotheses are developed and tested in animal experiments; those hypotheses that offer promise in patient management are then tested in the clinical setting with meticulous attention to the safety and the rights of the individual patient. Conversely, hypotheses are also developed from patient management and tested in the laboratory. Oftentimes in the past the personnel and facilities to test the new hypoth

eses were not available to the research team. Colleagues in other parts of the university had the expertise to do so, but they were busy with their own work. They did not have the time to understand this new application of their own research area. The research center has ameliorated this age old problem, because it is multidisciplinary; most importantly it contains both basic and clinical research scientists who can relate well to their colleagues in other fields. A neurochemist can communicate with a physical chemist who has something to offer the research center as the neurologist or neurosurgeon ordinarily cannot do.

The neuroscience trauma center is but one example of the effectiveness of this approach. In the early part of this century both experimental and clinical head injury research was concentrated in neuropathology. Neuropathology had emerged as an exciting and productive scientific discipline due to the development of tissue staining techniques that permitted a detailed description of the morphology of the brain, and at the same time neuroanatomists were continuing to define the tracts and anatomical connections within the central nervous system. The study of neurophysiology followed as techniques for recording the electrical activity of the brain became more accurate and sophisticated. Thus, until the mid 1950's most research on trauma was directed toward defining the neuropathology and the electrical events produced by a traumatic injury to the brain or spinal cord, and much of the research was conducted by neurosurgeons and neurologists who had special training in these disciplines. Wide application of the strain gage transducer to measure pressures in blood vessels and the intracranial cavity, and the introduction of isotopes to study brain and cerebrospinal fluid chemistry came in the late 1950's. The metabolism of oxygen and glucose by the normal brain was defined. The stage was now set for the investigation of central nervous system trauma with a degree of sophistication and understanding that was at the same time exciting, challenging, and mind boggling. Again neurologists and neurosurgeons took special training in these fields, but for the most part they could not aspire to the competence of basic scientists who had spent their professional lives in these areas of research. Furthermore, the equipment was expensive and required large amounts of new research space.

The neuroscience Clinical Research Center emerged from this background of need. The challenge was not so much to develop new technology; rather the challenge was to develop specific hypotheses regarding the effects of trauma on the brain and spinal cord, then gather together the scientists to apply this technology to specific issues. The principle investigators found themselves wallowing in a sea of plenty; the challenge was to select imaginative and realistic hypotheses to be pursued to a logical conclusion, often over many years, using whatever scientific resources that were required. The goal of all of this effort was clear, reduction in the morbidity and mortality of head and spinal cord injury; therefore, the clinicians and particularly the principle investigators in the Clinical Research Centers had to avoid being so mesmerized by the inevitable excitement of the pure research going on in their laboratories that they lost sight of the primary goal of the Center. The Head Injury Centers have fulfilled these requirements well. The Spinal Cord Centers are younger but are progressing well. Each head injury center has developed a program based on the strengths of the principle investigator and his immediate colleagues in neurosurgery and the basic neurosciences as well as strengths of the institution in basic and clinical sciences that had not been applied to head injury research in that university or. frequently, anywhere else. Some head injury centers concentrate on the pathophysiology of brain injury, others on the effects of trauma on brain metabolism, and still others on the electrical prop erties of the brain. All head injury centers incorporate a neurosurgery intensive care unit where acute head injuries are managed and where ultimately hypotheses are both developed and tested.

There are problems. As the field of head injury research has expanded geometrically since the establishment of Head Injury Centers was approved less than a decade ago, it has been more and more difficult for even the most sophisticated research team to grasp the significance of all of the information that has been generated in recent years. Attractive new hypthoses and technologies tend to divert the team from their primary purpose and create a diffusion of effort. Sometimes there are organizational problems, because the clinician and the basic scientist do in fact speak a different language, and communications between them can be difficult.

Nevertheless, in my opinion, the NINCDS Clinical Research Center offers the greatest single opportunity to apply the vast quantity of information that has