who can give you decidedly more information than I can. They are unquestionably more competent to speak on the subject than Ï. I have given you my fair and impartial opinion, without any personal sentiment at all. It represents the bureau's point of view as we see it from personal contact with claimants. It may be that the difference in my point of view to that of the other physicians here is because the perspective is different. The bureau can not think simply of tuberculosis cases; we have other diseases-heart disease, insanity, amputations, etc. We naturally feel every man is entitled to sympathy and justice. We do not feel that the tuberculosis claimant is entitled to more than any other. We try to get coordinated ratings, not ratings that would represent salients pushed out beyond the general alignment of the schedule of ratings. We see this problem from that perspective, and those gentlemen see it from their point as tuberculosis specialists.

Mr. MILLIGAN. It is your opinion that the apparently cured case has no handicap at all?

Doctor COOLEY. A potential rather than an evident handicap. Mr. MILLIGAN. That is the opinion of the bureau under the present rating policy?

Doctor COOLEY. Yes; and it appears in line with the policy of other schedules toward disability from arrested tuberculosis. I have here the French schedule. Our schedule is decidedly more elaborate. The bureau's schedule is more extended and detailed than those of any State or foreign government. We attempt to visualize, to evaluate each condition as justly as we can, so as to get uniform application. The French schedule of pulmonary tuberculosis includes simply "light cases," "medium cases," and "advanced cases with cavities." No mention of arrested cases. The relative values are 10 to 20 per cent in the light case, 20 to 70 per cent in medium cases, and 70 to 90 per cent, less than 100, for advanced cases with cavities. Of course, our ratings for pulmonary tuberculosis are much higher than those all along the line.

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Mr. MILLIGAN. Have you any other classifications than those three? Doctor COOLEY. I have not.

Mr. MILLIGAN. The French have three classes?

Doctor COOLEY. That is all.

Mr. MILLIGAN. They have not the apparently cured case?

Doctor COOLEY. No. The schedule of the California Industrial Commission, which, like our new schedule, is occupationally devised, does not include pulmonary tuberculosis as such, but simply chronic affections of pulmonary tissue due to injury." We attempt to define pulmonary tuberculosis here on the lines that recognized national organizations outline, and our thought is to make the ratings on the basis of our practical experience in following up those cases. The evidence is that they seem to go back to work and stick on the job; and, accordingly, we feel that the disability is apparently one which is essentially potential in character.

Mr. BULWINKLE. What is the date of that report that you have there?

Doctor COOLEY. The National Tuberculosis Association? 1922. Mr. BULWINKLE. What is the date of the report of the Metropolitan Life Insurance Co.?

Doctor COOLEY. 1922, the eighteenth annual meeting.
Mr. BULWINKLE. This ran from 1914 to 1920.

Doctor COOLEY. Yes.

Mr. BULWINKLE. So it was only a year or two, not much more than a year when this report was first made, or probably two years at the outside, so that they did not have six years to try it like you had afterwards?

Doctor COOLEY. They represent cases admitted from 1914 to 1920. Mr. BULWINKLE. Will you explain to me why it is that any insurance company on the application asks you to answer the question, Have you had tuberculosis, and if you have had an arrested case of tuberculosis, why are their premiums higher?

Doctor COOLEY. Of course, they are protecting their stockholders. Mr. BULWINKLE. Do they not?

Doctor COOLEY. It is a greater risk. But that does not stand by itself; the same is true if you have a history of Bright's disease, or heart disease; it is not peculiar to pulmonary tuberculosis.

Mr. BULWINKLE. I am just asking you about tuberculosis. How many cases of Bright's disease have you in the Veterans' Bureau? Doctor COOLEY. I could not tell you off hand.

Mr. BULWINKLE. How many cases of tuberculosis?

Doctor COOLEY. I could not tell you the exact figures on this either. I can give you the sanitorium cases. It would take time to look that up.

Mr. BULWINKLE. Are there 45,000 cases of tuberculosis? Doctor COOLEY. I think that would be about right, at least. Mr. BULWINKLE. Will it reach 1,000 cases of Bright's disease? Mr. COOLEY. I think so, possibly exceed that.

Mr. LUCE. You say there are 45,000 cases under treatment? Mr. BULWINKLE. Homes or in Government hospitals and private institutions, that is about correct, 45,000 to 47,000.

Doctor COOLEY. I would not say for certain. I would have to look it up.

(There are 46,432 cases of tuberculosis.)

Mr. BULWINKLE. Have you been able to find out the occupations of these men that have tuberculosis?

Doctor COOLEY. No; but the plan contemplates that before a man can be rated under our new schedule we must ascertain his occupation.

Mr. BULWINKLE. I am not talking about the rating. You testified as to the Metropolitan men who are practically all office men. Doctor COOLEY. I think so.

Mr. BULWINKLE. They were not laborers?

Doctor COOLEY. Possibly some outside employees.

Mr. BULWINKLE. They are practically all office men or agents? Doctor COOLEY. The contention has been made that office people are rather prone to tuberculosis. But any personal opinion which I advance should be understood as not the opinion of an expert in tuberculosis.

Mr. BULWINKLE. A man suffering with tuberculosis, an arrested case at home in an industrial or manufacturing community where his only occupation has been manufacturing, and he has to go back to that let me ask you if his chances are not greater of the

disease coming back on him than a man in the office of the Metropolitan?

Doctor COOLEY. I think so, generally speaking. There is a curious variation about it.

Mr. BULWINKLE. I am asking for information for the record. Do you not think it would be a great thing if they did find out what the occupations of these men are that have tuberculosis so that we can approach this proposition from the committee's standpoint?

Doctor CooLEY. In our rating schedule we will attempt to determine that because it necessarily arises in the rating.

Mr, BULWINKLE. We are trying here to pass legislation or not pass legislation, and that is what we want to know.

Doctor COOLEY. You want a cross-section of the total number to determine the occupations in which it occurs?

Mr. BULWINKLE. Yes.

Doctor COOLEY. I am afraid we have not the data. It would have to be looked up. Certainly we will try to do it.

Mr. MILLIGAN. As I understand it every case you rate as tuberculosis you have the occupation?

Doctor COOLEY. Yes.

Mr. MILLIGAN. You know his occupation when you make a rating, and you take that into consideration. Is that correct?

Doctor COOLEY. That is correct. The occupation will determine the rating.

Mr. BULWINKLE. We have not such a section in this bill, but I want to know what effect it will have.

Doctor COOLEY. I wish to say, finally, that in our schedule we have a proposed rating for apparently cured cases, and the application of that particular rating will depend on how the arrested case carries on for two subsequent years. If your committee decides on a provision for a flat statutory rating for arrested cases, that will affect this proposed rating for apparently cured cases. In reading the hearings of this committee prior to the March, 1925, amendment there seemed to be a sentiment among some of the members for the payment of the statutory award for arrested tuberculosis over a certain period of time, and not for life payments. That sentiment seems to be an approach to our position, that disability from arrested tuberculosis is not a handicap which persists indefinitely, but is a handicap which could be relieved economically by giving the men a certain sum of money until he had been habituated to his old job. May I suggest that if the committee reports this provision out favorably, it be defined whether it is to cover only a certain period of time, or be given for life of the beneficiary.

Mr. BULWINKLE. Last year I had an amendment on that.
Mr. COOLEY. I think it was your amendment.

Mr. BULWINKLE. Personally, I want to find out as an experiment the principles of how it should be done.

Doctor COOLEY. Whichever way a statutory provision is drafted, the bureau's rating for apparently cured cases will be affected. If you make a provision for life, our rating will be wiped out; if you make it for a certain term of years, that will also necessitate change in our rating for apparently cured cases.

The CHAIRMAN. Then you can make a study of it.

Doctor COOLEY. Yes.

Mr. LUCE. The immigration law provides that no person who has ever been under treatment in an institution for mental disease shall be admitted to the United States. That is affirmatively an official declaration on the part of the Government that the treatment in such an institution is a handicap. I am told that last year more than 13,000 men were discharged from treatment for neuropsychriatric troubles from our hospitals. Assuming that the immigration declaration is accurate, would you venture any estimate as to the comparative economic handicap of a man who has been in an institution of that sort and one who has been treated for tuberculosis?

Doctor CooLEY. Certainly, I think the handicap is at least equal. Mr. LUCE. At least equal.

Doctor COOLEY. Yes; and I feel this way, that so far as any social or business ostracism is concerned I am inclined to think there would be more sentiment against the recovered insane man.

Mr. LUCE. Is it possible for you to give us any opinion as to the proportion of neuropsychiatric cases that are reactivated? Doctor COOLEY. No; I could not at once.

Mr. LUCE. Could your statistical department furnish that?
Doctor COOLEY. I think so, possibly.

Mr. LUCE. Will you not secure that and put it in the record?
Doctor COOLEY. Yes.

The CHAIRMAN. Together with the data concerning reactivation of tuberculosis cases?

Doctor COOLEY. Of course, the particular argument on reactivation will apply not only to pulmonary tuberculosis. It is not peculiar to pulmonary tuberculosis, but is true of Bright's disease, or heart conditions, or diabetes, or recovered insane. Under the stress of overexertion, where there is also likelihood of a breakdown in them. Mr. BULWINKLE. You only had last year 265 cases of Bright's disease. That was in your report.

Mr. LUCE. That is true, but let us have the figures of neuropsychiatric cases along with that.

Of a total of 9,764 neuropsychiatric patients discharged from hospitals, as recovered or cured or improved, 1,591 or 16 per cent have had a relapse which necessitated rehospitalization.

There have been 8,446 psychotic patients discharged as improved of whom 1,408 or 16% per cent were furnished further hospitalization as a result of a relapse.

There have been a total of 8,009 deaths from tuberculosis in hospitals under the control or jurisdiction of the Veterans' Bureau as opposed to 1,134 deaths from neuropsychiatric disease or conditions.

Mr. BULWINKLE. You had 1,700 deaths last year from tuberculosis in Government hospitals.

Mr. RANKIN. Is there any provision on in this bill or any proposed amendment to put neuropsychiatric cases that are what you might call arrested, on the same basis as provided for the tubercular cases?

The CHAIRMAN. No; there is no such provision, but it would be germane to the bill, and, perhaps, the gentleman from Massachusetts may have in mind such an amendment. It would be entirely apropos. Mr. LUCE. I have no such intention.

Doctor COOLEY. The bureau has for years of its own accord granted a so-called convalescence rating for the insane. In the case of a man discharged from hospital, recovered from insanity, it is our practice to carry him for six months on a total temporary rating on the ground that it is difficult for this man to get back into employment.

Mr. RANKIN. I realize a man who has been insane, no matter what his degree of recovery might be, is under a psychological handicap for the rest of his life almost.

Mr. LUCE. I have had personal experience with it and I have no doubt every member of the committee has, that the reactivation of mental disease is more difficult and a person who has once suffered with it encounters economic inefficiency all through life.

Mr. RANKIN. If you were trying a man for commiting a criminal offense and his defense was temporary insanity and you could show that he had ever been declared insane, it would certainly have a great weight with the average jury in America, which constitutes the average citizenship, and my opinion is that men who have suffered from mental disability certainly as a rule never recover their full strength, at least, from a psychological standpoint, with the public, sufficiently to enable them to perform their duties or receive the same renumeration or have the same degree of confidence and efficiency with the public that they had before; and it seems to meI do not know what the gentleman from Massachusetts has in mind-but it seems to me that right there is a discrimination in this bill that ought to be taken care of in some way.

The CHAIRMAN. This is the last opportunity the committee will have to hear Doctor Dunn, as he is compelled to go back to his home, and I would like to have his testimony now. If anyone desires to recall Doctor Cooley the opportunity will be given.

Doctor COOLEY. You may want to recall me when you get down to the discussion of the schedule proper, section 202 (4) second paragraph. As to further questions on tuberculosis, while I shall be pleased to assist you as best I can, I am not a specialist in tuberculosis. The physicians who will follow me to-day are much more competent to give you information regarding tuberculosis.

STATEMENT OF DR. WILLIAM LE ROY DUNN, ASHEVILLE, N. C.

The CHAIRMAN. Doctor Dunn is one of the well-known specialists on the treatment of tuberculosis in the United States. Will you state your present position and your experience in the treatment of tuberculosis?

Doctor DUNN. I have been very largely and almost entirely interested in the care of tuberculosis for about 30 years. For a number of years I was a member of the executive committee of the National Tuberculosis Association.

The CHAIRMAN. State your other connection. Do not be modest for the moment; I want to know your connection with these different organizations and your experience.

Doctor DUNN. I am at present a member of the advisory council of the United States Veterans' Bureau, serving particularly in the tuberculosis division. I have held various offices in tuberculosis