[DECISION ASSESSMENT DOCUMENT]{.underline}

[DOCKET NO.]{.underline}: 91-1036 [ACTIVITY:]{.underline} RATING

[NAME:]{.underline} Santiago v. Brown

[ISSUE(S)]{.underline}: Medical opinions

[ACTION BY COURT]{.underline}: Remand [DECISION DATE]{.underline}:
7/20/93

[Significant Point(s)]{.underline}:

\(1\) The Board may not base its decisions on its own unsubstantiated
medical conclusions;

\(2\) In some cases, SMRs alone may constitute sufficient medical
evidence upon which the Board may base a legal determination about the
onset of a disorder;

\(3\) Although a treatise may not properly form the sole basis for a
decision of the Board, the BVA should use treatises to clarify the
clinical evidence in the record and to assist the veteran and the Court
in understanding clinical terminology and in interpreting medical
evidence in the record.

[Facts]{.underline}: While on active duty, appellant complained of
dizziness, stomach pains, excessive spitting, and tongue cramps. She
also complained of jaw pain, difficulty with speech, and loss of control
of her tongue and sputum. While being observed, she was noted to be
three months pregnant. In December 1986, she accepted a discharge
because of this. At discharge, a diagnosis had not been established for
her condition. Appellant filed a claim for compensation in October 1987.
In January 1988, a diagnosis of Graves\' disease was made. Symptoms
reported included heat intolerance, increased appetite, easy weight
loss, increased sweating, tachycardia, nightmares, palpitations, and
anxiety. Service connection was granted for Graves\' disease and organic
mental disorder effective from the date of her hospital admission,
January 8, 1988. She was also adjudged to be incompetent for VA
purposes. A Notice of Disagreement with the effective date was
submitted. Appellant also felt that service connection should have been
established on a direct basis rather than on a presumptive basis. The
Board found that symptoms of Graves\' disease noted in service are more
easily explainable as being due to other causes. The RO decision was
affirmed.

[Court Analysis]{.underline}: The Court noted that the issue presented
in this case, is whether the Board\'s opinion that the onset of Graves\'
disease did not begin any earlier that November 3, 1987 was an
unsubstantiated medical determination, or whether it was a legal
determination, i.e., a finding of fact which the Board, as fact finder,
derived from a review of medical evidence which is sufficiently
conclusive as to the underlying medical issues to enable the Board to
render the legal determination.

The Board, citing a medical treatise, listed common symptoms of Graves\'
disease and then noted that certain appellant\'s symptoms in service
paralleled them. It then cited another medical treatise to support the
general proposition that signs and symptoms in a number of nonthyroid
disorders may simulate certain aspects of thyrotoxic syndrome. The Court
noted that the Board concluded that the parallel symptoms were due to
astigmatism and myopia for the eye complaints, and to the rigors of
military life for progressive weakness and shortness of breath upon
exertion. No medical evidence was cited to support this conclusion, but
apparently, SMRs were relied on to substantiate the conclusion as to the
eye problems. The Court further noted that, \"A veterans SMRs may
constitute, in some cases, sufficient medical evidence to demonstrate
that symptoms exhibited in service, which are typical of both a
condition for which a veteran is entitled to service connection and one
for which the veteran is not so entitled, were caused by the latter.\"

The Court held that, in this case, appellant\'s SMRs did not provide a
plausible basis for the Board\'s conclusion. The Court further noted
that, \"although a treatise may not properly form the sole basis for a
decision of the Board, the BVA should use treatises to clarify the
clinical evidence in the record and to assist the veteran and this court
in understanding clinical terminology and in interpreting medical
evidence in the record.\" Medical treatises might have been used to
support the Board\'s conclusion that the symptoms were more readily
attributable to other disorders than to Graves\' disease. Additionally,
because of the Court\'s recent holding in
[Thurber v. Brown]{.underline}, U.S. Vet. App. No. 92-172 (May 14,
1993), a remand is necessary to afford appellant reasonable notice of
the evidence to be considered and an opportunity to respond to such
evidence. On remand, the Board is to provide reasons or bases for its
assignment of an effective date so that appellant may understand the
Board\'s decision.

[RECOMMENDED VBA ACTION(S)]{.underline}: This decision is consistent
with the Court\'s decision in [Thurber]{.underline} and requires no
change to current regulations, policies, or procedures.

APPROVED

J. Gary Hickman, Director

Compensation and Pension Service