to warmer climates, they can be helped. Dr. Freeman and I-and so have other neurologists have indicated that that should be done. If you get an acute case of multiple sclerosis sometimes you can arrest the disease with complete bed rest and use of vitamins. We do not know what we are treating. It is what we call, Dr. Long, empirical treatment, but I have had some acute cases that have been able to stay in remission for a long period of time.

Mr. LONG. May I ask a question?

Mr. RADWAN. Surely.

Mr. LONG. Doctor, the fact that you could not tell or might not tell when a man was admitted into the Army, leaves grounds for the suspicion that he might have had it before he went in?

Dr. SHAPIRO. That is right.

Mr. LONG. But not necessarily that he did have it?

Dr. SHAPIRO. No, sir. Then I would say that subjecting this man to military rigors is the worst thing that you could do to him.

Mr. LONG. Do you not think that there are other diseases which are handled similar to this, sometimes?

Dr. SHAPIRO. Yes, sometimes there are certain slow chronic diseases of the nervous system that may be overlooked for a long period of time, but none of them has the same peculiarities of this, because they come and go. You see a man and he complains that he can hardly see. Then the neurologic signs change, and you say, "What does this man have?"

Mr. LONG. The bad part that I see about it is that a fellow might go into the Army and then comes out sick and they might diagnose that he had this disease before he went into the Army and he would be unable to get compensation.

Dr. SHAPIRO. That is the case in this instance I cited, but they are going back here 12 years after the diagnosis was made.

Mr. GENTRY. What is the term that the Veterans' Administration uses to indicate that he had it when he went in but it got worse?

Dr. SHAPIRO. Aggravation. Aggravation has to be, however, beyond the natural progress of the disease. Just the progress that you expect will not be considered aggravation for the purposes of compensation.

Mr. GENTRY. Now, Doctor, of course you are not a tubercular man, but what about tuberculosis? You get it many times, and then you get over it and go about your business.

Dr. SHAPIRO. I think tuberculosis can be aggravated.

Mr. GENTRY. It can be aggravated, yes; but I would not think natural progress of tuberculosis, because many times you get well not even knowing you ever had it, so the experts say.

Mr. LONG. Doctor, this may be kind of out of line, but it is a thing that is bothering me. Do you think that when a man is taken into the Army and after he has gone through examination by all the experts and taken in as perfect, do you not think that that should be the end of that and they should not be able to go behind that?

Dr. SHAPIRO. We did have in the old Warld War Veterans Act a conclusive presumption at time of enlistment, but when the Economy Act went in, the American Legion did feel that the Government should have the right of rebuttal, and as we bring out in our statements, this rebuttal must be clear and conclusive rebuttal, not any offhand opinion unsubstantiated by facts.

But where you have good, sound medical facts to show preexistence of the disease, then the only question should be the one of aggravation. Mr. LONG. But this case that you have, that was based on history. Dr. SHAPIRO. That is why we would like to service connect him on history within 3 years.

Mr. RADWAN. Go ahead, Doctor.

Dr. SHAPIRO. We also have under consideration the 3-year period for psychosis in this H. R. 33. Mr. Stevens has already submitted a statement showing the two different bases for determining service connection for psychosis. Under one law, for compensation purposes, a psychosis must be manifest to a compensable degree within 1 year from the date of separation from active wartime service and the Government can rebut such service connection.

For hospital and medical care, including out-patient treatment, another law passed by the last Congress provides for the service connection of an "active" psychosis upon manifestation within 2 years, and the Government may not rebut the service connection or deny it, even though it is of misconduct originally.

Again, I shall confine myself to medical arguments which favor service connection upon such showing of a psychosis within 3 years after discharge.

H. R. 33, as I see it, would limit itself to the psychoses of "functional" origin, that is, those where no definite organic cause is ascertainable. In the case of the organic psychosis, the question of service connection must depend on whether the organic disease causing or contributing to the psychosis was, in itself, service connected.

The American Legion, while advocating service connection on a manifestation within 3 years, wants this done on the basis of adequate medical reasoning and background. We believe the Government should have the full right of rebuttal.

If it is shown that an individual develops a psychosis due to a specific cause, such as an injury or an infection or an aging or degenerative organic process such as organic brain disease, which arises subsequent to discharge, and which is not otherwise connected with military service, then I think that we could not properly ask the Congress to include that type of disability within the proposed 3-year period. Likewise, even in the case of the functional psychosis, if it is clearly shown that the psychosis actually arose prior to service, then the Government should have the right to rebut unless, of course, the condition is shown to have been aggravated by service.

Finally, if the functional psychosis arose subsequent to discharge, clearly as a result of some factor or factors in no way related to service, then of course the Government should have the clear right of rebuttal of service connection. In all cases we believe this rebuttal should be based upon clear and convincing evidence and not merely upon an opinion, without adequate supporting data.

With this as a background, I shall proceed with a discussion as to why I believe that the functional psychosis, subject to the rebuttability above mentioned, should be considered as having been incurred in, or aggravated by, service, if the same has developed to a 10-percent degree, or more, within the period of three years following separation from active military service, in wartime.

If one excludes the known causes of these psychoses such as the organic psychoses that I have mentioned, we find that no one today

can tell with certainty the cause or date of onset of most psychoses. We know that strong emotional factors or long-continued emotional and mental stresses can bring about a psychosis. In most cases, however, the development of a psychosis is so slow and insidious, that it can be present to a disabling degree for months or years before the condition is recognized.

Your committee in the past, after hearing expert testimony on the subject, recommended passage of the World War Veterans Act of 1924, at which time a "presumptive period" was extended from the termination of World War I, November 11, 1918, up to the date of January 1, 1925. This is the "presumptive period," still applicable to World War I veterans, far greater than the 3 years now proposed for service connection in the pending bill, H. R. 33.

In discussing this bill, it is to be noted that we are pleading for the veteran who is "insane" and not for the veteran having merely a nervous affliction like neurasthenia or hysteria (psychoneurosis). When a psychotic individual presents himself to the doctor, private or Government, he is usually brought in by relatives or friends. At that time he generally shows an advanced mental state. Very rarely does he personally seek medical attention.

When did this psychosis start? In attempting to trace the onset of his illness we have to obtain data usually from his family, and occasionally from his friends. We find, as a fact, that most relatives and friends are loath to recognize the mental ailment of a relative or friend. Unfortunately, mental disease is still regarded as a stigma by most people. If the individual's behavior becomes abnormal, an attempt is made to explain this away on the basis of personal peculiarity or eccentricity. Often the individual keeps his troubles to himself and may not outwardly manifest obvious symptoms of mental disease.

Only later, often after a matter of years, following a suicidal attempt or an assault, or very bizarre behavior, the individual is brought to the doctor or hospital by his relatives or friends. He rarely voluntarily presents himself for treatment. He then often is in an advanced state of mental disease (psychosis). It is then, in developing the history that the relatives look back and begin to realize that the peculiarities, eccentricities, personality changes, and so forth, that they attempted to excuse were actually early manifestations of the serious mental disease for which now they are attempting to have the individual hospitalized and treated.

All too frequently affidavits of these relatives, those closest to the afflicted person, and in the best position to testify, are given scant consideration, usually on the grounds that these relatives have a personal interest in the outcome of a claim for compensation. Yet, these very individuals are in the best position to know of the changes in the veteran. These are the very persons who have attempted to either blind themselves to the development of the illness, or to shield the patient until often he is considered no longer safe to be at large. How much can the afflicted veteran help us in tracing the onset of his illness? Too often by the time he comes to the doctor or hospital, he is unable to be helpful in this regard. During the period of devel

opment of his illness he may have been entirely unaware of the fact that he had a mental disease. So he frequently made no claim and his condition was unknown to the Government until a date outside of the present 1-year period allowable for compensation purposes. His mental condition has prevented him from looking out for his own interests in the manner that a nonpsychotic veteran might follow. Not having presented himself for examination within the 1-year period, he is frequently now considered a non-service-connected case for compensation purposes.

Who is there to state with certainty that the condition did not have its roots in the individual's war service? Prior to his war service he probably had no problems greater than the average man in his community. He was perfectly happy, and contented there in the warmth and protection of his family. The war rips him out of his environment and places him in a rigid situation, and very often in a situation that is intolerable to the individual. He is no longer able to plan his life as before. Of military necessity his life becomes regimented. He is no longer an individual. He is also faced with the possibility of armed conflict. I need not dwell on other rigors of military service, with its attendant physical hardships. Any one or all of these factors might well have contributed to or have been precipitating factors in the development of his psychosis.

Unless we can show definite factors arising either before or subsequent to service of sufficient import to reasonably cause the psychosis, then the burden of resolving the doubt as to service connection for all purposes, if a doubt exists, because of our inability to find the cause of the psychosis, should be resolved in favor of the war veteran. Mr. RADWAN. Any questions?

Thank you very much, Dr. Shapiro, for your presentation here. The Chair realizes that we have yet to hear the DAV and the AMVETS. We are sorry that we will not have a chance to have the benefit of their testimony today. I thought for a moment that perhaps we could have one of the members testify, but Mr. Patterson suggests that it might be unfair because we might be limited to 15 or 20 minutes. So under the circumstances it would perhaps be better to defer that testimony until the next meeting of the subcommittee. If there is no objection I will insert a letter from the National Tuberculosis Association.

(The letter referred to reads as follows:)

Hon. EDITH NOURSE ROGERS,
House of Representatives,

NATIONAL TUBERCULOSIS ASSOCIATION,
New York 19, N. Y., March 30, 1953.

United States Capitol, Washington, D. C.

DEAR SIR: This is to acknowledge your telegram of March 30 and to inform you that in compliance with your suggestion, we are sending a statement of the National Tuberculosis Association regarding the legislation now being considered by your committee.

We would appreciate the entering of this statement into the permanent record upon its arrival in Washington.

Sincerely yours,

FLOYD M. FELDMANN, M. D.

Assistant to Managing Director.

NATIONAL TUBERCULOSIS ASSOCIATION,
New York 19, N. Y., March 31, 1953.

Hon. EDITH NOURSE ROGERS,
Chairman, Committee on Veterans' Affairs,
House of Representatives, United States Capitol,

Washington, D. C.

DEAR MADAM: The National Tuberculosis Association wishes to offer the following comments on certain bills which are now before your committee for consideration.

It is our impression that H. R. 33, H. R. 46, and H. R. 310 have as their common purpose the extension of the provisions of present law to include all other forms of active tuberculosis as well as pulmonary. Such provision seems just and reasonable and we would favor such amendments.

However, in our considered opinion the enactment into law of H. R. 157 and H. R. 340 would not serve the best interests of the veterans or the citizens of this country. The automatic provision for life compensation or for a "permanently and totally disabled" classification is unrealistic and contrary to our experience in dealing with tuberculosis patients. Only a small proportion of persons who have active tuberculosis are permanently and totally disabled. Usually those without extensive lung damage recover and become normal, responsible members of society. To place a premium on disability would undoubtedly delay and might even prevent full rehabilitation of those veterans who are perfectly capable of returning to useful and satisfying occupations. Money spent on improvement and increase in rehabilitation services would undoubtedly be of more lasting benefit and would eventually be more than repaid in savings.

We would also like to comment briefly on H. R. 2097, which would extend the presumptive period of service connection from 3 to 7 years. From a medical standpoint such an extension cannot be supported. From such studies as are available it is quite clear that most patients who develop active tuberculosis do so within 3 years of the time of contracting the infection or undergoing some specific hardship. It is true that some patients have relapses in later years and some cases develop from an infection incurred many years before. However, these are in the minority and concurrent environmental influences cannot be ruled out. Considering these facts, it would seem that the present limit of 3 years is reasonable and should be retained.

We are wholly in accord with the adequate provision of treatment and compensation for those veterans who have active tuberculosis and who are definitely disabled. Because the number of such veterans is small compared to the total number who have active tuberculosis at some time we would recommend that they be considered on an individual basis, according to need, and that every effort be made to return those without active disease to a normal life.

Another factor which must be considered is the cost of providing compensation on a blanket basis for the thousands of veterans who have a small tuberculous lesion at some time during their service, or shortly thereafter. Although no accurate estimate is possible, it is obvious that tremendous sums of money would be necessary. Such sums would be better spent on tuberculosis control programs which would benefit veterans and nonveterans alike. The veteran suffers the same risk from tuberculosis as do others in the civilian population and so long as tuberculosis continues to be a major problem it will be wiser to support community efforts to control tuberculosis than to distribute funds on automatic compensation to many who really do not need it.

Sincerely yours,

FLOYD M. FELDMANN, M. D.,
Assistant to the Managing Director.

Mr. RADWAN. Let us now stand adjourned until 10 o'clock April 15, 1953.

(Whereupon, at 11:50 a. m., the subcommittee recessed to reconvene at 10 a. m. April 15, 1953.)