proposed bill, and the question of interpretation of the controlling legislation. Basically what we seek is to have conferred upon the Administrator the authority to grant an equitable rate to any veteran who has profoundly disabling diseases or disabilities which are far greater than a total disability rating but which are not now already covered in this specific statutory rate that this committee recommended and the Congress has previously enacted.

Three bills to be heard, H. R. 9671, 9710, and 11801, propose an increase of the Veterans' Administration burial allowance from $150 to $250. We seek approval of H. R. 9671. It was introduced by request of the American Legion and would allow payment of the increased allowance with respect to deaths occurring on or after the date of enactment.

There is a positive need for enactment of this legislation in the present session. Congress provided the burial allowance, wanting to make certain that recognition of honorable service in the Armed Forces would be extended through assurance of burial of eligible wartime and peacetime veterans befitting the character of their service to the Nation. The allowance today will not serve the purpose.

The burial allowance was last increased from $100 to $150, 12 years ago. It will be immediately recognized that costs of burial services have increased so substantially in this period that the allowance is now far from realistic. Except where death occurs in a Veterans' Administration facility to which the deceased was properly admitted for hospital or domiciliary care, the allowance is granted for burial and funeral expenses and the expense of preparing the body and transporting it to the place of burial. Where death occurs in a VA facility, the agency is authorized to pay within certain prescribed limitations, in addition to the $150 maximum allowance, for transporting the body to place of burial.

Before the increase to $150 was granted July 24, 1946, we understand that the Veterans' Administration was experiencing the same difficulty with which it is confronted today, that is, while it has authority to contract with burial firms for burial and funeral expenses for eligible veterans, many firms must refuse contracts because of costs. We hope that a $250 allowance will make these contracts possible, even though only a modest burial can be provided.

Where burial in a national cemetery is possible, the costs of the grave plot and of opening and closing the grave are borne by the Government and are not items chargable against the burial allowance. Otherwise, the present $150 might not even cover these costs and the cost of a concrete vault or grave liner now required in many cemeteries. To be considered also are costs of preparation of the body, a casket, transportation by hearse or common carrier, slumber room, chapel, and services of a clergyman.

We recognize that most bereaved families in respect to the deceased will want to provide final services, costs of which will exceed the $250 which we ask be allowed. We actually think that an allowance of $250 would not be excessive for items other than the grave site and have proposed in H. R. 290, a bill before this committee not scheduled for hearing today, that there be an additional allowance for acquisition of a burial site of not to exceed $75.

We do urge increase at present to $250, as this sum will help better to defray the burial and funeral costs which are normally borne

by widows, children, and parents who may bear also hospital and medical expenses of the last illnesses of veterans which often create burdensome debts.

Two bills listed for hearing, H. R. 3973 and H. R. 9896, introduced by request of the American Legion, have an identical purpose; namely, to liberalize the basis for establishing wartime service connection for multiple sclerosis and the chronic functional psychoses. Introduced in the first session, H. R. 3973 proposed amendment of the pertinent veterans regulation then in effect, since repealed. H. R. 9896 will amend appropriately the Veterans' Benefits Act of 1957, the existing law, and so I will speak only to this bill.

H. R. 9896 would provide that, when multiple sclerosis or any of the chronic functional psychoses develop a 10 percent or greater disability within 3 years from the date of a veteran's separation from active wartime service, they shall be deemed to have been incurred in or aggravated by such service in the absence of affirmative evidence to the contrary.

Where evidence shows the existence of a psychosis or of multiple sclerosis during active service, there is a basis for wartime service connection of the resultant disability either by incurrence or by aggravation. Notwithstanding the fact that there is no record of evidence of certain chronic diseases during the period of active service, the law provides a basis for their wartime service connection upon manifestation subsequent to active service during specified periods. The factual basis may be established by medical evidence, competent lay evidence, or both. A direct service connection is established just as though the disability had been manifested during active service.

The service connection is the basis for establishment of the entitlement of the disabled veteran not only to compensation but to hospital and medical, including outpatient, treatment as well. Such a service connection also serves as a basis for determining a wartime veteran's eligibility to vocational rehabilitation and to service-disabled veterans' insurance under a national service life insurance program. Veterans of wartime service may benefit by this provision for service connection, only if they were in active service for 90 days or more and released from such service under conditions other than dishonorable. Service connection will not be in order for such a chronic disease where disability is due to the veteran's own misconduct. Where there is affirmative evidence to show the disability could not have resulted from active service or where there is evidence that an intercurrent injury or disease, which is a recognized cause of such disease, has been suffered between the date of separation from active service and the onset of the chronic disease, service connection will not be conceded.

It should be emphasised that the Government has the right of rebuttal. Evidence which may be considered in rebuttal of service incurrence of a chronic disease will be any of a nature usually accepted as competent to indicate the time of inception of disease; also, medical judgment will be exercised in making determinations relative to the effect of intercurrent injury or disease. or disease. The American Legion adheres to the belief that the sound basis for the service connection for a chronic disease for all purposes upon manifestation subsequent to separation from active wartime service lies with the Government retaining the right rebuttal.

In providing a basis for presuming the direct service connection of certain chronic diseases initially manifest within stated periods subsequent to separation from active wartime service, Congress wisely provided, upon recommendation of this committee, that nothing relating to such provisions shall be construed to prevent the granting of service connection for any disease or disorder otherwise shown by sound judgment to have been incurred in or aggravated by active military, naval, or air service.

As the result of painstaking consideration of the subject by this committee over a period of years, initial manifestation to a compensable degree of chronic diseases within 1, 2, or 3 years from separation from active wartime service provides the basis for service connection with which we are here concerned. Accepting sound medical testimony advanced on behalf of veterans of wartime service, the committee reported the legislation which the Congress enacted. A 1-year period applies to the specified chronic diseases except active tuberculosis, 3 years, and multiple sclerosis, 2 years, where the service connection is established for all purposes.

We seek extension from 1 to 3 years for the chronic functional psychoses and from 2 to 3 years for multiple sclerosis.

I now defer to Dr. Shapiro, who will speak on H. R. 9896, to which I have just spoken.

Mr. DORN. Go right ahead, Doctor.

STATEMENT OF DR. H. D. SHAPIRO

Dr. SHAPIRO. I am grateful for again being afforded the privilege of appearing before you to give medical testimony on the subject matter in this bill; namely, the diseases of multiple sclerosis and the functional psychoses.

Under dates of March 20, 1951, April 1, 1954, and March 22, 1956, I appeared before your committee and gave detailed reasons for the enactment of similar legislation. Inasmuch as this is a matter of record I will not reiterate most of this testimony, which is found on pages 4718-4727, hearings before the Subcommittee on Compensation and Pension of your committee, 83d Congress, 2d session, April 1, 1954, when you were considering H. R. 6931. However, if the committee desires, I will be glad to submit a copy of the testimony for the record of this hearing.

on

I again want to stress that multiple sclerosis is a chronic organic rule a very slow disease of the central nervous system that has as a set, with often fleeting and variable signs and symptoms, which may frequently clear up rapidly, only to return months or years later in a more extensive and permanent picture. Because of this, the patient will often not seek medical attention until the disease is well established, or often, if he does seek early medical attention, the disease is frequently overlooked or misdiagnosed as being a temporary harmless condition, or it may be erroneously diagnosed as an emotional upset, a psychoneurosis, or at times, especially where monetary or other benefits may accrue, mislabeled as malingering.

The most common early symptoms are fleeting or temporary dizziness, fatigability, transient numbness, tingling, pains, temporary weakness of a limb, temporary mild to severe visual disturbances, bladder symptoms, emotional disturbances, and other temporary or fleeting

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symptoms. In addition the medical examiner may find hyperactive deep tendon reflexes, questionable haziness of the optic nerve heads, and some temporary pathologic reflexes such as the Hoffman, Babinski, or Oppenheim signs or ankle clonus (which are typical of this disease). However, as I have previously stated, because these signs may vary from day to day and clear up in a matter of days, the attending physician may think they are of no significance and fail to make any diagnosis, or make a diagnosis of neuritis or neuralgia, sciatica or a disc condition, or rheumatoid or muscular involvement, error of refraction of the eye, or a psychoneurosis (conversion reaction), a temporary bladder condition, etc. These diagnostic errors, which are very frequent in this disease, are not confined to the general practitioner, but very skilled physicians, even those who are very familiar with this disease, the neurologist, may often fail to recognize the disease in its early stages.

We find in the case of the veteran who does not seek medical attention in the first 2 years after discharge, or is not properly diagnosed within that time limit, that he often has a difficult time in establishing a valid claim. This also happens all too often where the veteran has these fleeting signs and symptoms, even on the medical records in service. Too often very definite and pertinent lay affidavits receive inadequate consideration by rating boards. This because all too often the rating board members, including the physician, know too little about the disease.

Despite numerous conferences with the Veterans' Administration on this subject and the release by them of issues calling the rating board's attention to the fact that in many diseases, especially multiple sclerosis, symptoms in the early stages of this disease may appear of little significance at the time, but later when the disease is definitely diagnosed they may appear to be of major significance and importance, rating boards continue to deny too many cases, unless the disease is well established or diagnosed within the present 2-year legal or regulatory period.

Over the years I continue to see cases where, in my opinion as a certified neurologist, there should be no question as to the manifestations of multiple sclerosis either in service or within the 2-year period; yet these cases are denied service connection In many instances I am happy to report that the Board of Veterans' Appeals or central office claims services, representatives of which are here this morning, do eventually allow the claims, often after a request for opinion by the Chief Medical Director. However, I can see only a very few of these cases. When I appeared before your committee on March 22, 1956, I cited a number of such cases.

Due to the limitations of time I would like to insert in the record extracts from two outstanding recent textbooks of medicine which verify a great deal of the testimony I have given and cover, I think, our arguments very well.

Mr. DORN. Without objection it is so ordered.

(The material referred to follows:)

The following is quoted in Bernard J. Alpers' Clinical Neurology, third edition : Page 694: "Multiple sclerosis is a peculiar and unpredictable disease. It is not surprising, therefore, that its clinical manifestations are extremely variable. All in all, therefore, the disorder is characterized by great complexity in both diagnosis and prognosis."

Page 703: "II. Symptons.-The clinical features of multiple sclerosis vary so widely that a description of a typical form of the disease would fail to include many variants where are equally characteristic.

"The 'onset' of sympotoms is usually slow and gradual, but in some forms is acute and apoplectiform. The specific complaints at the time of onset vary with the area affected. The duration of symptoms varies as greatly as the onset and is often inaccurate. Distinction must be drawn clearly between the immediate symptoms, which may extend back for a few weeks to a few years, and those which have developed in the dim past and have been completely forgotten. Often, such symptoms have been encountered during the life cycle of the patient, have disappeared after a varying length of time, and have been forgotten in the past history unless they are specifically sought after. Transient first symptoms of the type described were found in the thirty-two or fifty-two cases of multiple sclerosis (Brown)."

Pages 704 and 705: "The symptoms, chronic or acute, may have been present for a variable length of time before help is sought. As a rule, they have persisted for months or years, with intervals of freedom from symptoms or 'remissions.'

"Such remissions are an important feature of the disease and are characteristic of multiple sclerosis. They occur in many but not in all cases. No good statistical studies are available of the percentage of remissions. Complete remissions were found in seventeen percent of 516 cases (von Hoesslin): The remission of individual symptoms, however, is undoubtedly more frequent.

"The remission of symptoms may be complete, with total freedom from symptoms of any sort, and may last for years, or it may result only in an incomplete remission of symptoms without total disappearance at any time. Remissions of twenty-seven and thirty-nine years are known personally to the author. In the former instance, transient weakness of the left leg of one week's duration was followed by fully developed signs of multiple sclerosis twenty-seven years later." Page 710: "III. Diagnosis.—The diagnosis of multiple sclerosis presents many difficulties. In advanced cases recognition of the disease is easy, but early instances are more difficult to detect and sometimes hard to establish definitely, until further evidences of the disease are apparent. Early diagnosis is desirable in order to provide what relief may be expected from purely symptomatic treatment. Because of the disseminated nature of the disease, no permanent constellation of symptoms is found. Variety and variability are probably the outstanding features of multiple sclerosis."

Page 714: "VI. Course and Prognosis.-The 'course' of symptoms in multiple sclerosis varies almost as much as the symptoms themselves. ***

"Repeated attacks of symptoms at varying intervals may be followed by complete or almost complete recovery with each episode and may be associated with few or no residuals. Instances of this type are not infrequent."

The following is an excerpt from Wechsler's Textbook on Clinical Neurology, 7th edition.

Page 539: "The disease is characterized essentially by a variety and multiplicity of signs and symptoms which ill fit into any one entity. Multiple sclerosis, therefore, is a congeries of syndromes."

Page 540: "These symptoms are frequently overlooked or no significance attached to them by the patient, so they are only elicited by a careful history." "All these symptoms are already evident of mild scattered involvement of the nervous system but they pass unobserved or are grouped under the designation of psychoneurosis, especially hysteria."

"These symptoms usually recede, however, and it is only as the whole clinical picture (signs of multiple involvement) develops that their meaning becomes clear."

Page 543: "Emotional disturbances, especially impulsive laughter, more seldom crying, occur in multiple sclerosis and, if present early, lead to the mistaken diagnosis of hysteria."

Page 544: "Remissions may last a long time or the disease may even remain stationary-But a complete recovery is extremely rare."

Page 545: "Early in its course, multiple sclerosis, especially if it is accompanied by emotional changes and impulsive laughter, "may be mistaken for" hysteria." Dr. SHAPIRO. At the hearing on March 22, 1956, a specialist in neurology representing the American Medical Association appeared, and the record will show that in his testimony he agreed that most of the cases cited by me should have been service connected even without the