prevent the development of decubitus (q. v.) and efforts made to avoid urinary tract infections. Urinary frequency may be lessened by the use of tincture of belladonna, 10 drops 3 times a day (R 30). Belladonna should be used for as long as there is evidence of urinary frequency and evidence that the belladonna is effective. The presence of dryness of the throat, slight delirium, severe nausea, and constipation should lead to either a discontinuance of, or a reduction in, the amount of the drug.

Physiotherapy.-Massage and passive movement of the weakened, spastic limbs are of some value. Muscle training is beneficial to the patient both physically and psychologically.

Psychotherapy.-Encouragement and reassurance are essential, and the hopeless outlook should be minimized. Invalidism should be postponed as long as possible,

and some form of therapy maintained constantly.

Pharmacotherapy. None of the recommended modes of drug therapy has proved to be of definite value. However, for their psychotherapeutic and tonic effects, drugs such as arsenic and quinine may be worth a trial. Arsenic may be given in the form of one of the arsphenamines (R 71), I. V. at weekly intervals for a period of 4 to 6 weeks. The course may be repeated every few months. Fowler's solution (R 72) can be given by mouth, beginning with 1 drop in water 3 times daily and gradually increasing the dose to 10 drops 3 times a day for a period of 6 weeks. There should be a rest period of at least equal extent before the course is repeated. Arsenic also may be given in the form of sodium cacodylate (R 73) up to 60 mg. (gr i) daily for 1 month; subsequent monthly courses of therapy may be given every other month for an indefinite period. Quinine (R 74) usually is given as the hydrochloride in a dose of 0.3 Gm. (gr. v) once or twice a day for several weeks. Use of anticoagulants such as dicumarol and heparin still is in the experimental stage and may cause severe hemorrhages. Massive doses of all the vitamins have been given, particularly vitamin B and its components.

Climatotherapy. Since multiple sclerosis is relatively uncommon in the subtropics, it has been recommended that patients with this disease move to such a climate if possible.

Miscellaneous. Fever therapy, produced artificially or by the use of typhoid vaccine, is sometimes followed by a remission of symptoms. However, this treatment is debatable, since an acute exacerbation may follow it, or the condition of the patient may become worse.

Mr. TEAGUE. We will hear first from Mr. Donald C. Knapp, of the Office of Legislation of the Veterans' Administration, who will present the Veterans' Administration position, and then from Dr. Leonard Kurland of the Public Health Service, who has spent some 2 years in study of this dread disease.

Representatives of the veterans' organizations-the American Legion, Veterans of Foreign Wars, Disabled American Veterans, and AMVETS are here to testify and we will be glad to hear them upon completion of the testimony of Dr. Kurland.

Mr. Knapp.

STATEMENT OF DONALD C. KNAPP, OFFICE OF LEGISLATION, VETERANS' ADMINISTRATION

Mr. KNAPP. Mr. Chairman, I have with me this morning Dr. R. L. Jenkins, Chief of the Research Section of the Psychiatry and Neurology Division of the Department of Medicine and Surgery of the Veterans' Administration.

Dr. H. A. Kildee, Assistant Chief of the Neurology Section of the Psychiatry and Neurology Divisions; and Mr. Henry Q. Brooks, Assistant Director of Veterans Claims Service, of the Veterans' Administration.

I would like to read the report filed this morning by the Administrator on this bill, following which the doctors with me and Mr.

Brooks will be glad to answer any questions with respect to this matter. This report is addressed to the Honorable John E. Rankin, chairman of the Committee on Veterans' Affairs [reading]:

Reference is made to your request for a report by the Veterans' Administration on H. R. 3205, Eighty-second Congress, a bill to amend the Veterans Regulations to provide that multiple sclerosis developing a 10 percent or more degree of disability within 3 years after separation from active service shall be presumed to be service-connected.

The purpose of the bill is to extend from 1 year to 3 years after separation from active wartime service the period during which recourse may be had to the rebuttable presumption of service-connection for the chronic disease of multiple sclerosis.

Veterans Regulation Numbered 1 (a), part I, paragraph I, subparagraph (c), as amended, provides that a chronic disease (other than pulmonary tuberculosis) becoming manifest to a degree of 10 percent or more within 1 year after the date of separation from active service, as defined in subparagraph (a) of said regulation, shall be considered to have been incurred in or aggravated by such service, notwithstanding there is no record of evidence of such disease during the period of active service, if the person suffering from such disease served 90 days or more in the active service, except where there is affirmative evidence to the contrary, or evidence to establish that an intercurrent injury or disease which is a recognized cause of such chronic disease has been suffered between the date of discharge and the onset of the chronic disease, or the disability is due to the person's own willful misconduct. The presumptive period provided for active pulmonary tuberculosis was increased from 1 to 3 years by Public Law 573, Eighty-first Congress, June 23, 1950.

Public Law 748, Eightieth Congress, approved June 24, 1948, provided that the term "chronic disease" as used in the mentioned paragraph of Veterans Regulations shall include certain specified diseases. Among such diseases specified are "organic diseases of the nervous system" and the specific disease of multiple sclerosis is in that category.

The present 1-year presumptive period does not preclude the granting of direct service-connection for the condition of multiple sclerosis when first diagnosed more than 1 year after discharge from service when the evidence of record is deemed adequate to warrant a finding of service-connection. In such cases the provisions of Public Law 361, Seventy-seventh Congress, December 20, 1941, authorizing consideration of places, types, and circumstances of service as factors in the matter of granting service-connection are liberally applied.

In

Multiple sclerosis is a disease marked by an induration or hardening, occurring in sporadic patches throughout the brain or spinal cord, or both. Although the exact cause of the disease is unknown, there is nothing in the circumstances of military service in time of war which from a medical and scientific standpoint would warrant a presumption of fact that a manifestation of the disease 3 years after discharge is in any way related to the fact or circumstances of service. this connection, it does not appear that the disease is any more prevalent among the veteran population than the nonveteran population. Because of the difficulty of determining the exact cause of multiple sclerosis it would rarely be possible to secure affirmative evidence to rebut the presumption of service-connection proposed by the bill.

Singling out multiple sclerosis as a disease which should be accorded a further presumptive period of service-connection of up to 3 years, as proposed by the bill, would be discriminatory and could be urged as a precedent for extending the presumptive period for many other chronic diseases. It should further be considered that a statutory directive which may require a finding of service-connection contrary to fact results in placing cases without merit, from the standpoint of serviceconnection, on a par with cases of veterans having medically proven serviceconnected conditions.

In addition to granting service-connection for compensation purposes, the bill, if enacted, would confer the same priority right in such cases to hospitalization by the Veterans' Administration which is now afforded by law to veterans having service-connected conditions. Under existing law, the Veterans' Administration is required to furnish hospital care to eligible veterans needing such care for serviceconnected conditions, and this may be provided in hospitals under the direct control of the Veterans' Administration, through bed allocations in other Government hospitals, or in appropriate cases by contract with State, municipal, or private institutions. By contrast, veterans suffering from non-service-connected

83289-51-2

disabilities may be furnished hospital care by the Veterans' Administration only if beds are available in Veterans' Administration or other Federal Government hospitals. Further, admission of non-service-connected cases is generally conditioned on the inability of the applicant to defray the cost of hospitalization as established by an affidavit procedure. The bill would also have the effect of providing out-patient treatment for the group affected because of the serviceconnected status which would be granted to them under the bill. Existing law and regulations generally limit out-patient treatment to those requiring such treatment for service-connected disabilities.

The Veterans' Administration has no available data upon which to base an estimate of the cost of the bill, if enacted. However, as of June 30, 1950, there were 1,640 veterans of World Wars I and II and the Spanish-American War in receipt of disability pension because of nonservice-connected multiple sclerosis, permanently and totally disabling, a substantial number of whom would probably be eligible for the benefits of the bill. An unknown number of World War I and World War II multiple sclerosis cases having a disability of less than total in degree, and therefore not pensionable under existing legislation, would also qualify for service-connection under H. R. 3205.

Advice has been received from the Bureau of the Budget that the enactment of the proposed legislation would not be in accord with the program of the President.

Sincerely yours,

O. W. CLARK (For Carl R. Gray, Jr., Administrator).

Mr. TEAGUE. Mr. Knapp, the first point that if this bill was passed that it would be a precedent for extending the presumptive period for many other chronic diseases at this time, what diseases are covered by presumptive periods? What different diseases have we that are covered today?

Mr. KNAPP. At this time, Mr. Chairman, there is a presumptive period of 1 year for wartime cases of chronic and tropical diseases. The law specifies a number of these chronic diseases by name and then states that the Administrator may add to that list, which he has done. In the administrative regulations of the Veterans' Administration we have listed all of the chronic diseases which have available to them this 1 year presumptive period. I have the list, Mr. Chairman. Would you like me to read it?

Mr. Teague. Yes. I would.

Mr. KNAPP. Anemis, primary; arteriosclerosis; arthritis; atrophy, progressive muscular; brain hemorrhage; brain thrombosis; bronchiectasis (effective June 24, 1948); calculi of the kidney, bladder, or gall bladder (effective June 24, 1948); cardiovascular-renal disease, including hypertension. (This term applies to combination involvements of the type of arteriosclerosis, nephritis, and organic heart disease, and since hypertension is an early symptom long preceding the development of those diseases in their more obvious forms, a disabling hypertension within the 1-year period will be given the same benefit of service-connection as any of the chronic diseases listed.) Cirrhosis of the liver (effective June 24, 1948). Coccidioidomycosis (effective June 24, 1948); diabetes mellitus; encephalitis lethargica residuals; endocarditis (this term is intended to cover all forms of valvular heart disease); epilepsies, Hodgkin's disease; leprosy, leukemia, myasthenia gravis, myelitis, myocarditis, nephritis; other organic diseases of the nervous system (effective June 24, 1948); osteitis deformans (Paget's disease); osteomalacia (effective June 24, 1948); palsy, bulbar; paralysis agitans; psychoses; purpura idiopathetic, hemorrhagic (effective October 19, 1949); Raynaud's disease (effective June 24, 1948); sarcoidosis (effective August 31, 1950); sclero

derma (effective June 24, 1948); sclerosis, amyotrophic lateral; sclerosis, multiple; Syringomyelia; thromboangiitis obliterans (Buerger's disease) (effective September 26, 1947); tuberculosis, active (other than pulmonary); tumors, malignant, or of the brain or spinal cord or peripheral nerves (effective June 24, 1948, as to tumors of the peripheral nerves); ulcers, peptic (gastric or duodenal) (effective June 24, 1948).

In addition to the above active pulmonary tuberculosis has now been granted a 3 year presumptive period.

Mr. TEAGUE. With that list would you say that passing this bill would form a precedent for other diseases? It looks to me as though the precedent has already been established.

Mr. KNAPP. They are all uniformly under the 1-year provision except pulmonary tuberculosis. I believe the administrator pointed out in his report on the pulmonary tuberculosis bill last year that it, similarly, might be regarded by proponents of other particular diseases as a precedent. It is always the possibility. It does not necessarily follow.

This list includes many very serious, very appealing conditions. Certainly, one of the most appealing ones in that category is multiple sclerosis.

Mr. TEAGUE. Well, of course, Mr. Knapp, the thing that brings on legislation is situations and the particular situation that caused me to introduce this bill was a young fellow who went into service in 1943. He has a wonderful service record. He was a paratrooper in combat. All through the service he was having trouble. He went into Georgia hospital in the first 6 months and the diagnosis was pleurisy. After a few weeks he was released. Then he had a very severe case of influenza and he continued to have trouble all during the service.

He came out of the service, a little later started college. He had trouble with his eyes and other troubles no one could diagnose. Finally, after a year and a half it was diagnosed as multiple sclerosis.

We fought the case through your appeal board and it was turned down. That was the reason for introducing this bill. It just seems to me that a kid who had the service record he had ought to be covered. The doctors say they do not know what causes these diseases. There are never symptoms to indicate a service connection and the Administrator had the power to take this case for treatment if he wanted to.

Mr. KNAPP. I might ask Mr. Brooks if, in connection with the adjudicatory procedure, if there were of record in service conditions or symptoms which from medical experience and judgment might have been deemed as the forerunner of this particular disease. This would have been taken into consideration and given very serious weight?

Mr. BROOKS. They would have and if the particular symptoms were identifiable as the forerunner of this disease I should think it would establish service connection of the disease. What these symptoms are I would have to refer to the doctors.

Mr. TEAGUE. This is a disease they do not know too much about. You get four or five different theories and, according to the theory, that is the treatment the doctor gives you.

Mr. BROOKS. I presume that is right.

Mr. TEAGUE. I realize you people have your troubles so far as service-connection is concerned. But this one case is a case where I think there has surely been something wrong with the boy shortly after he went into the service. You said in your report there would be about 1,600 men who would be covered by this bill.

Mr. KNAPP. That represents, Mr. Chairman, the only figures we have of record of any group or groups that might clearly be affected. Those are the figures of our totally disabled non-service-connected cases for this condition. The portion of that group in which the disease first became manifest within 3 years after separation would be accorded service-connection under this bill. Then, of course, there is the unknown number of less than totally disabled non-serviceconnected cases, of which we have no record. A number of those would become service-connected.

Dr. JENKINS. I have been doing a little arithmetic.

On the basis of the best guess I can make, the 2-year addition would add 1,000 to 1,800 cases as a minimum that would be made service-connected cases by a presumption which is, in effect, nonrebuttable.

Mr. TEAGUE. What other diseases might be added if this was to set a precedent?

Dr. JENKINS. There are a number of these diseases that are very slowly developing. Some of these diseases have remissions as multiple sclerosis may have. Peptic ulcer is an example.

Mr. TEAGUE. There are not many others that might be brought up to 1 year but there might be a precedent to bring those up to a 3-year presumptive period?

Dr. JENKINS. It would be less subject to possible difficulty if the condition were clearly related to service in some way other than that it developed during service. But here we are dealing with a condition that is not known to be related to the effect of service.

Mr. TEAGUE. Haven't you people just taken the stand that this disease is likely to start at any time and there are as many veterans as nonveterans and you have just called them all non-service-connected?

Mr. KNAPP. No. If it develops in service or can be traced to the period of service or 1 year thereafter it is considered service-connected. Mr. TEAGUE. Well take this boy who went into service and had these troubles. He had the flu, a high fever, and soon after he came out of the service he had trouble with his eyes and had to completely drop out of school and it was about 2 years before they could diagnose his trouble as multiple sclerosis.

Dr. JENKINS. You mentioned illness in service with pleurisy and influenza, neither one of which is related to multiple sclerosis. I do not know the nature of his trouble with the eyes. Simple conjunctivitis can give trouble with the eyes. Other causes can do it also.

Mr. TEAGUE. He had dizziness, nausea, and had trouble in class. You will have some doctors who will say these are symptoms. Isn't that true? You have some theories that multiple sclerosis is evidenced by these symptoms?

Dr. JENKINS. The matter of correcting problems of adjudication by a legislative presumption is a method of correcting a situation with which many people would differ.