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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.

I again want to stress that multiple sclerosis is a chronic organic disease of the central nervous system that has as a rule a very slow onset, 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 80 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

benefit of any presumptive period. However, as was brought out at the time, they were not, and it was only after long periods of time that we were successful in securing a grant of service connection. Nevertheless, the difficulties encountered in service connecting these cases, even with a 1-, and later a 2-year presumptive period, were very evident.

I know the time is short, but to show the continuing difficulty, here are two cases I came across recently in reviewing them. I will give the C number and not identify the veteran by name.

The first case is C-7956093. Here the man had two periods of service. The first period of service was from December 13, 1938, to 1945, in World War II. He remained out of service 311⁄2 years and reenlisted for the Korean war, serving from March 15, 1949, to March 11, 1953.

In this case the man had evidenced many of these signs I have mentioned during his first period of service. During his second period of service many other signs were evidenced which were thought to be functional. Although these signs were noted during his first period of service, yet he was allowed to serve from March 15, 1949, to March 11, 1953. The Board holds the view that signs of multiple sclerosis were noted in his first period of service but his condition was not aggravated during the 4 years in his second period of service. Since this man had the symptoms of multiple sclerosis during his first term of service, I think the 3-year provision would take care of him.

Yesterday, I reveiwed a case Senator Russell was interested in, C-4932694, where a man during military service from April 10, 1943, to February 24, 1945, was treated for shingles and later they gave him a test for psychoneurosis hysteria. The Veterans' Administration had a field investigation made as to the doctors who treated him and people who knew him, and in this field investigation, on February 3, 1948, within a 3-year period, a private physician who was contacted told of operating on the man before service and treating him in April and May 1947, just 2 months outside the present 2-year presumptive period, for impotency. Impotency is often an early sign in multiple sclerosis. The Veterans' Administration investigator got that from the doctor. Yet this man was examined by the Veterans' Administration over the year and even had a period of hospitalization in a VA hospital in Georgia in 1951, when his condition was erroneously diagnosed as neuritis. The man, after many examinations, did not have his condition correctly diagnosed by the Veterans' Administration until 1955, but it is admitted when he was in the VA hospital in 1951 he had classical symptoms of multiple sclerosis. A 3-year presumptive period would take care of this man.

I have read the Veterans' Administration's report on a number of these bills that have to do with presumptive service connection, and at this time I would like to call attention to Print No. 203, Committee on Veterans' Affairs, House of Representatives, to a letter from the Administrator of the Veterans' Administration dated June 3, 1958, giving his comments on these diseases which would include multiple sclerosis. In the next to the last paragraph on page 3, here is what the Veterans' Administration recommends:

From a medical viewpoint, present provisions of the law and regulations on this subject are considered quite liberal and ample provision is made for those diseases that have a long incubation period. In addition, there are administrative provisions whereby chronic diseases generally incurred within a reasonable

time after the present presumptive period following active military service can be and are handled on an individual basis where there is a likelihood that the condition or disease had its inception during military service. Accordingly, the Veterans' Administration does not recommend favorable consideration of these proposals by your committee.

As a specialist in both neurology and psychology, I desire to take issue with the fact the present regulations and present law are liberal, and I do not think the Veterans Administration intended to be misleading, but they are actually misleading. What they are trying to say here, as I see it, and representatives from the Veterans' Administration are here and can correct me if I am wrong, if a man served in the Philippines, say, where leprosy is endemic, where he comes in contact with it, years later if he shows up with leprosy the Veterans' Administration will give him a direct connection. What they are talking about here is that where conditions warrant it they give direct service connection. This has nothing to do with presumption. The presumptive periods are to take care of the cases I have mentioned.

Going back to this last case that I cited, this case that Senator Russell is interested in, C-4932694, I would like to call attention to the fact that I have commented upon the fact that the rating board members, even the doctors, frequently do not know what multiple sclerosis is. This case also illustrates that point. When this man was rated on September 16, 1955, even in view of the fact multiple sclerosis is listed as a ratable disease in the rating schedule, they rated him as Sydenham's chorea. There is as much dissimilarity between these two diseases as day and night. That is what we are up against. If they do not know what the disease is when they rate it, how can they rate it? And I am citing a case I reviewed yesterday.

I, again, want to direct your attention to the hearings on H. R. 3205, before this committee on March 20, 1951, a bill to extend the then 1-year period of presumption for multiple sclerosis, from 1 to 3 years. At that time the committee called for testimony from Dr. Leonard Kurland, epidemiologist, National Institute of Mental Health, United States Public Health Service. His extensive testimony (pp. 130 through 182 covering his report on a 3-year study of multiple sclerosis) supported the American Legion stand for a 3-year presumptive period. It is my understanding, that following the testimony presenated at that time, your committee reported favorably on the proposed legislation for a 3-year presumption, and it was then passed by the House. The Senate however, acted favorably on an extension of presumption to 2 years and in conference a 2-year presumption was agreed upon and that is the legislation that was then subsequently enacted and is the current law-a 2-year presumptive period.

Our experience, since then has indicated, because of the difficulties encountered, that many worthy cases of multiple sclerosis are still being denied service connection. We feel that we have repeatedly presented aedquate evidence, based on sound medical principles, why this legislation should be enacted. We hope you will give these bills favorable consideration.

The time is short and without objection I will ask that my testimony on chronic functional psychoses be made a part of the record, and also the testimony of Dr. Winfred Overholser, who is an outstanding authority.

Mr. DORN. Without objection it is so ordered.

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