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between the third and ninth week after discontinuance of the drug.

In other words, the mean interval to the first attack is somewhere in the neighborhood of 40 days. In one group of about 5,000 men with delayed primary attacks, this interval was borne out. Well over 90 percent of the men will have the first attack within 120 days of the discontinuance of suppression. It is true that some cases of 13 and 14 months have been reported, the first attack following discontinuance of suppression.

If you bear in mind the fact that a certain interval elapses between the time a man leaves an endemic area overseas and his discontinuance of suppression and final separation from the service, that this interval of 1 year is a very fair interval with regard to malária. The one rare individual, representing a fraction of 1 percent, could be handled on an administrative level, on the basis of its own merits.

With regard to other diseases, I think they are not adequately covered in this bill, because such diseases as schistosomiasis, which may not have been diagnosed during service. We had approximately 2,000 cases on Leyte diagnosed, and we had probably an equivalent number undiagnosed. The manifestations of this disease may come on relatively longer than a year.

As to filariasis, while it is a negligible problem, a rare case may develop some manifestations later than a year. So I feel with some modifications, this bill provides fairly well for the medical benefits of a veteran of World War II, with a tropical disease, principally malaria.

Mr. Mathews. May I ask you this question, Doctor! You feel this bill 3650, which provides for 1 year only for a presumptive period, sufficiently protects the man who might have contracted malaria while in the service?

Dr. Most. Yes; I do. Actually this provision of 1 year provides for a period from the time of the man's separation until the time he develops malaria, for example.

Mr. MATHEWS. That is right.

Dr. Most. The interval from the time a man arrives from overseas from an endemic area and his separation is one which usually is long enough to permit the development of the disease in a significant number of men.

Mr. MATHEWS. Suppose he continues this, what do you call it, suppression?

Dr. Most. Suppression.

Mr. MATHEWS. Suppose he continues this suppression treatment after he gets out of the service, what is going to happen then?

Dr. Most. He is not advised to do it. It is not in the interest of good medicine to continue suppression indefinitely.

Mr. MATHEWS. No, not indefinitely, but suppose he is subject to it, has attacks, and couldn't connect them up with the service, but while in the service he received some of this treatment just before he got out. How long do you think the treatment should be continued after the first indications of the existence of the disease?

Dr. Most. You mean after a man has had an attack, how long should the interval be during which he should be considered to have service connection?



Dr. Most. Well, we studied possibly 10,000 attacks and found that depending on the origin of the infection. Just for example, take vivax Malariae. That has a high relapse rate. A man will have an attack, then another attack, then another one. Of all of the men who will have attacks, more than 90 percent of the men will have that attack in 120 days. That is an accepted face based on extensive studies in the Army and Navy.

Mr. MATHEWS. You mean within 120 days after subjected to the

Dr. Most. No; after 120 following treatment for that attack, 90 percent of the men will have their next attack, regardless of what treatment it is, except, possibly curative treatment. If a man is treated with quinine, the interval to that attack may be as short as 2 weeks.

Group 2 or group 3 men, the mean interval is 3 weeks. If it is atabrin, it may be 50 days. There is a new drug, chloroquine, which has now been recommended. The average interval is about 60 days. Regardless of the drug, 90 percent of the men will have that next attack within 120 days. That is only 4 months.

Mr. Mathews. How long, in your opinion, Doctor, does it usually take from the inception of the disease, the period of incubation, until the first evidence of it?

Dr. Most. Without suppression?
Mr. MATHEWS. Without suppression; yes.

Dr. Most. From the initial infection, without suppression, depending on what the species of parasite is, it would be roughly from 12 to 24 days. With plasmodium vivax, it would be 12 to 14 days. Falciparum may be from 9 to 11 days. With quartau malaria, as long as a month. Without supression, if an individual is infected, the primary attack develops in a short time. With suppression, on the other hand, that is modified.

Mr. MATHEWS. Do they give suppressive treatment to men who have been exposed to malaria, whether they show any evidences of the disease or not?

Dr. Most. Yes, sir; the indications for suppression are during combat, or during operations in the military area, or to keep up effective strength of military troops or laborers in endemic areas, or even if they are infected or not infected, the principle for suppression is to keep the man free of clinical symptoms of malaria. But following the separation of removal from an endemic area, it is not in the interest of good medicine for longer than 3 weeks after leaving that area. The reason for the 3 or 4 weeks of suppression after leaving the area is that it not only suppresses, but it controls falciparum malaria, which is the potentially bad type of malaria. But to continue suppression indefinitely following removal from an endemic area, is not recommended, because potentially the drug is poisonous and there is no point in it.

Mr. MATHEWS. Do the same statements apply to all tropical disseases?

Dr. Most. No, sir.

Mr. MATHEWS. Do you want to proceed on those? You see this bill says that where a tropical disease is diagnosed within 1 year from separation from active service; it doesn't say just malaria.

Dr. Most. I pointed out this bill would not cover such diseases as leprosy, for example, in which the incubation period is unknown; 5 or 10 years would not cover an individual who served on Leyte, was infected with schistosomiasis, was not hospitalized because he wasn't sick, and 4 years later developed signs of a brain tumor, was operated on, a lesion found in his brain to be due to schistosomiasis.

In the same disease, a man might develop a large liver, or spleen, or bleed from the mouth or rectum, which had not been diagnosed. These later things might take years to manifest themselves. This bill, as it reads now, would not cover such diseases as leprosy, amebiasis—they would not be covered. Rare cases of filariasis would not be covered. Schistosomiasis, as I have said, would not be covered.

Even during my experience with the war, we had a small number of patients with kala-azar, which is relatively rare, and infrequent, a disease occurring in the Mediterranean and India, in which the first manifestations occurred 13 and 19 months afterward.

Mr. MATHEWS. What suggestions would you make, if any, with reference to those particular diseases !

Dr. Most. I think to avoid a blanket bill to cover all the diseases, perhaps they could be enumerated, and a reasonable time put down for the most prevalent ones on the basis of the experience we have. If this bill were limited to malaria, I think it would be adequate, then either an amendment to it or another bill, or in the same bill, enumeration of the other diseases which would be relatively infrequent and not make a time limit on them.

Mr. MATHEWS. How would you cover it? On what basis?

Dr. Most. Well, I would enumerate the diseases and say that if these diseases were diagnosed and established, just name them by name, that they would be considered to have been service connected.

Mr. MATHEWS. Within what period ?
Dr. Most. At any time.
Mr. MATHEWS. At any time?
Dr. Most. Yes, sir.
Mr. MATHEWS. The diseases you have named ?
Dr. Most. Yes, sir,
Mr. MATHEWS. Outside of malaria?
Dr. Most. Outside of malaria.
Mr. BIRDSALL. May I be recognized for a moment?
Mr. MATHEWS. Just a moment. Have you any questions?
Mr. PRICE. Do you want to contribute something here at this point?
Mr. MATHEWS. Do you have any questions?
Mr. PRICE. No.

Mr. MATHEWS. We will hear from you, then. We will continue on with the doctor.

Mr. BIRDSALL. I am quite certain the doctor did not have made available to him the complete report of the Veterans' Administration on the bill, to review from the standpoint of the policy of the Veterans' Administration. This is his own testimony as contultant, rather than the Veterans' Administration.

Mr. MATHEWS. We are glad to have him, whether he testifies strictly as to the Veterans’ Administration policy, or as a medical man. If he wants to clarify that on the record, I will be glad to have him do so, so he won't be in an uncomfortable position.

Mr. BIRDSALL. The reason I raised the question, there appears in the bill a conclusive presumption of service connection, which is not the existing law. It is commented on in our report. We indicate it should be handled administratively by regulations.

Mr. MATHEWS. I don't have a copy of the record, but in the last hearing we read into the record the regulations on that, which covered all tropical diseases as they were enumerated in the regulations.

Mr. BIRDSALL. Yes, sir.

Mr. Mathews. I raised the question at that time as to whether or not those regulations as they now exist were not more broad and more beneficial to the veteran than this bill, because my thought was, if this bill were passed as is, the Veterans' Administration might reàsonably say, "That discards our regulations. It is the intent of Congress to only have a presumptive case within 1 year of any tropical disease of whatever character."

That was the fear I had if this bill were passed as is.

Mr. BIRDSALL. With the consent of the American Legion, if there is an authorized representative here, I would like to give to the chairman a copy of the tentative reply of the Veterans' Administration to the American Legion on this subject.

Dr. SHAPIRO. I may state, if a man demonstrated he had the disease before service, we don't want him on the rolls, unless clear aggravation is shown.

Mr. MATHEWS. Suppose he would get it after he was separated from the service?

Dr. SHAPIRO. There are two things, if the man traveled in tropical or endemic areas after the war, or could have picked up the disease or showed evidence of the disease prior to service, that should be used by the Government in rebuttal.

Mr. MATHEWS. In other words, speaking to Dr. Shapiro, now, you feel in these cases there should be an open question of fact !

Dr. SHAPIRO. That is right.

Mr. MATHEWS. To be determined—I will put it this way, put this in, myself, then-with all reasonable doubts resolved in favor of the veteran?


Mr. MATHEWs. But where the preponderance of the evidence is that he did not get the disease while in the service, then you think the Government ought to be in position to rebut the claim that he did?

Dr. SHAPIRO. Absolutely, sir.

Dr. Most. It wasn't my intention in discussing this bill to supersede or contradict any existing legislation or policy of the Veterans' Administration. I was speaking directly on the basis of what I have before me here.

Mr. MATHEWS. The question was this, Doctor, the regulations which were read into the record at the last hearing, set forth specific periods of incubation for these various tropical diseases. From what I gather from your testimony, that aside from malaria, the man should be able to prove a presumptive case of service connection with any of these diseases, no matter when the evidences manifest themselves.

Dr. Most. I think if the incubation periods are liberally established, that would be all right.

As a matter of fact, the total number of cases which one can expect of these exotic diseases is negligible, aside from malaria; they can be handled on a policy basis, individually, under the existing regulations which they do have.

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Mr. MATHEWS. Would it be your thought that if this bill as it stands were amended by striking out "tropical disease" and inserting "malaria", that then with the present regulations of the Veterans' Administration, the veteran would be properly protected, if he contracted any other tropical disease ?

Dr. MOST. Yes, sir.
Mr. MATHEWS. Are there any further questions?
Mr. PRICE. No.
Mr. MATHEWS. Is there anything further, Doctor?
Dr. Most. No, sir.
Mr. MATHEWS. Thank you, Doctor.
Dr. Most. Thank you, gentlemen.

Mr. MATHEWS. We would like to finish up this 3650, if we can. I think Captain Sapero is here. Are there any others here who want to testify, who haven't testified on 3650, outside of Captain Sapero? If not, we will hear the captain.




Captain SAPERO. My name is James J. Sapero, Medical Corps, United States Navy, of the Bureau of Medicine and Surgery, Navy Department.

Mr. MATHEWS. Have you seen a copy of this bill?

Captain SAPERO. Yes; I have seen it and had opportunity to read it over.

Mr. MATHEWS. Proceed.

Captain SAPERO. The bill as written here, to my mind, is entirely too broad and seems to me that doubtlessly will cause a major injustice to many veterans.


Captain SAPERO. In the first place, the term “tropical disease” is used in the bill, without defining it, which would make it administratively very difficult and open to question as to what are tropical dis

We are, in the medical profession, not in entire agreement on that. Certainly the bill should define what disease it is speaking of.

In the second place, the 1-year proviso in the bill, covering all of these diseases, does not recognize the medical peculiarities of each one of these diseases, some of them which might adequately be covered within the 1-year period, and many of which would not be covered in the 1-year period.

Furthermore, it doesn't recognize the medical fact that diseases do not manifest themselves in the individual in the same way every case, that exceptions to the rule may occur.

I have nothing in particular to add to it, Mr. Chairman, unless there is some question.

Mr. MATHEWS. Let me ask, under the conditions which existed during the last war, and some of the same conditions existed in World War I, don't you think that it is only fair to the veteran that certain periods, reasonable periods, should be allowed within which the manifestation of the disease might lead to a conclusive presumption of service connection, because of the fact that when these things happen, they don't always get on a medical record? Many, many times they don't get there. I am sure the captain knows that. We all know that.


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