Citation Nr: 0005097 Decision Date: 02/28/00 Archive Date: 03/07/00 DOCKET NO. 96-02 824 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a hiatal hernia, claimed as secondary to a left inguinal herniorrhaphy scar with chronic skin ulcer. 2. Entitlement to an evaluation in excess of 40 percent for a service-connected left inguinal herniorrhaphy scar with chronic skin ulcer. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARINGS ON APPEAL The appellant and his spouse ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The veteran served on active duty from October 1942 to November 1945. In a rating decision of June 1995, the Regional Office (RO) granted a 40 percent evaluation for the veteran's service-connected left inguinal herniorrhaphy scar with chronic skin ulcer, which had previously been evaluated as 20 percent disabling. The veteran voiced his disagreement with that decision, and the current appeal ensued. FINDINGS OF FACT 1. Service connection is currently in effect for a left inguinal herniorrhaphy scar with chronic skin ulcer, evaluated as 40 percent disabling. 2. The veteran's hiatal hernia is as likely as not the result of, which is to say, aggravated by, his service-connected left inguinal herniorrhaphy scar with chronic skin ulcer. 3. The veteran's service-connected left inguinal herniorrhaphy scar with chronic skin ulcer is not more than large, and not well supported by a belt under ordinary conditions, with no evidence of massive, persistent, severe diastasis of the recti muscles, or extensive diffuse destruction or weakening of the muscular and fascial support of the abdominal wall, so as to be inoperable. 4. The veteran currently suffers from a chronic draining fistula at the site of his previous surgery for a left inguinal hernia, analogous to a scar which is superficial, poorly nourished, and subject to repeated ulceration. CONCLUSIONS OF LAW 1. The veteran's current hiatal hernia is proximately due to and/or the result of his service-connected left inguinal herniorrhaphy scar with chronic skin ulcer. 38 U.S.C.A. § 1110 (West 1991 and Supp. 1998); 38 C.F.R. §§ 3.102, 3.310(a) (1998). 2. An evaluation in excess of 40 percent for the veteran's service-connected left inguinal herniorrhaphy scar with chronic skin ulcer is not warranted. 38 U.S.C.A. § 1155 (West 1991 and Supp.1998); 38 C.F.R. Part 4, Code 7399-7339 (1998). 3. A separate compensable (10%) evaluation for a draining lesion at the site of the veteran's previous left inguinal hernia surgery is warranted. 38 U.S.C.A. § 1155 (West 1991 and Supp. 1998); 38 C.F.R. §§ 4.3, 4.20 and Part 4, Code 7803 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background Service medical records, including a service separation examination of November 1945, are negative for history, complaints, or abnormal findings indicative of the presence of a hiatal hernia. During a period of Department of Veterans Affairs (VA) hospitalization from December 1946 to March 1947, it was noted that the veteran had been well until September 1943, at which time, while in the Army, he underwent a bilateral herniorrhaphy. Reportedly, the veteran made an uneventful recovery, and was subsequently discharged. However, in December 1943, he developed a small rash around the upper pole of his left herniorrhaphy scar. This subsequently broke down to form a small fistula tract. Since that time, the "tract" had healed over and broken down at various intervals. In January 1945, the entire fistula was excised in an Army hospital. The wound subsequently healed well, until three weeks prior to the current admission, at which time a rash again appeared, followed by a weeping, crusted ulceration. Following removal of this crust, an ulceration was again disclosed. This lesion responded well to daily Furacin dressings, and the veteran made an uneventful recovery. The pertinent diagnosis was chronic ulceration in a herniorrhaphy scar, the cause of which was undetermined, and which had healed with treatment. In a VA surgical clinic evaluation of November 1988, it was noted that the veteran had undergone four operations on his left groin, the last in 1946, and that, since that time, he had experienced recurrent infections. Physical examination revealed the presence of a healed wound, with no tenderness, no erythema, and no drainage. No treatment was recommended. During the course of a VA ambulatory surgery consultation in February 1989, the veteran gave a history of a bilateral hernia repair in service in 1943, following which the left side had "broken down," and been "redone" four times. According to the veteran, this was "not really causing him a lot of trouble now," but, in the past, the left-side scar had "broken open and drained periodically." On physical examination, there was a well-healed hernia scar on the veteran's right side, and a deep, somewhat retracted solid scar on the left side. On strain and cough, no hernia on the left could be demonstrated, either in a reclining or standing position. Reportedly, the veteran had recently been seen at another VA facility, at which time there was no drainage. However, from the veteran's history, it seemed "highly likely" that he did have a chronic sinus or even a fistula in the area of his old scar. The pertinent diagnosis was of a recurrent draining sinus and an old left inguinal hernia scar. During the course of a period of VA hospitalization in April 1989, there was noted a 3.5- by 1.5-centimeter necrotic-appearing ulcer in the upper scar of the veteran's left lower quadrant, with no gross drainage and no hernia. The pertinent diagnosis was chronic recurrent ulcer(ation) of the skin of the right (sic) lower abdomen, post hernia surgery while in service. In October 1989, a VA medical examination was accomplished. At the time of examination, the veteran gave a history of "frequent infections, usually at least four times a year," in the area of his previous left inguinal herniorrhaphy. According to the veteran, these episodes required that he take antibiotics for a long period of time. Nonetheless, the incision would "always break open" and "start draining again," resulting in chronic pain and soreness in his left groin. On physical examination, the veteran's abdomen was moderately protuberant. The liver, spleen, and kidneys were not palpable, and there was no evidence of either enlargements or masses. The upper end of the veteran's left inguinal herniorrhaphy scar was open, and there was an open wound approximately three-quarters of an inch long which was draining a purulent, bloody material. At the time of evaluation, the entire area of the veteran's left groin was tender to palpation. The pertinent diagnosis was of chronic recurrent infection (with recurrent drainage) of the left groin at the left inguinal herniorrhaphy site. In late April 1994, the veteran was admitted to a VA medical facility complaining of severe pain with swallowing, and an inability to take anything solid. He was subsequently evaluated, and found to have dysphagia, most probably due to acute esophagitis. An endoscopy was subsequently scheduled, but the veteran refused to undergo the examination. The pertinent diagnoses noted at the time of discharge were dysphagia secondary to acute esophagitis; and reflux esophagitis. In June 1994, the veteran was admitted to a VA medical facility due to the appearance of "some kind of drainage" in the area of his previous left inguinal hernia surgery. According to the veteran, he had no pain, but only "drainage and discomfort." On physical examination, the veteran's abdominal wall was soft and obese, with no masses, and no bruits. In the left inguinal area, there was some drainage of a purulent material. The pertinent diagnoses were drainage from the left inguinal area; and status post left inguinal repair "years ago." During the course of multiple VA examinations in May 1995, the veteran stated that he continued to have problems with periodic infections in the area of his left lower quadrant scar. Reportedly, these infections were formerly controlled with oral antibiotics, but of late, required treatment with intravenous antibiotics "in the hospital." The last time this was done was in June 1994, at which time the veteran "stayed in for a month." According to the veteran, he had had "three of these infections in the past year." Additionally noted were problems with "constant pain in the abdomen," made worse when the veteran's infection "flared up." On physical examination, the veteran's abdomen was soft, though diffusely tender to palpation, even minimal palpation, in particular, in the left lower quadrant, which was "exquisitely tender." Further examination revealed an open draining wound measuring approximately 2 centimeters in length which appeared "indented, with some pus draining out of it." A gauze bandage had been utilized to cover this area. During the course of the evaluation, the veteran commented that, almost every night, he had some acid "come up into his throat" which caused him to cough. Reportedly, this was sometimes "quite bad," and kept the veteran from sleeping. The pertinent diagnoses were chronic recurrent left lower abdominal ulceration, status post herniorrhaphy; and symptoms consistent with gastroesophageal reflux with a hiatal hernia. During the course of a period of VA hospitalization for an unrelated medical problem in May 1995, the veteran complained of "continuous drainage" from his left inguinal area where a hernia repair had been performed years ago. On physical examination at the time of admission, the veteran's abdominal wall was soft and slightly obese, with no masses, and no bruits. The right inguinal area was not remarkable; however, in the left inguinal area, there was a cavity discharging thick, yellowish-gray pus-like material. The pertinent diagnoses noted at the time of admission were drainage from the left inguinal area "for many years;" and status post left inguinal hernia repair years ago. In July 1995, the veteran was once again hospitalized at a VA medical facility with a nonhealing fistula-like formation in the left inguinal area, where he had undergone operation and repair of a hernia years ago. According to the veteran, "so far, there was no healing." On physical examination, the veteran's abdominal wall was slightly obese and soft, with no masses and no bruits. However, in the left inguinal area, there was a longitudinal "area" in the Poupart ligament, from which a thin bloody material was oozing. The veteran was subsequently evaluated by a surgical consultant, who was of the opinion that there might be a sinus in the left inguinal area. Following treatment, the area in question was reduced to the size of less than one-quarter of an inch. The pertinent diagnoses noted at the time of discharge were of a nonhealing area in the operated left inguinal area; and status post left inguinal hernia repair. VA outpatient treatment records covering the period from December 1995 to February 1996 show treatment during that time for recurrent drainage in the area of the veteran's prior left inguinal hernia repair. At the time of a VA medical examination in April 1996, the veteran gave a history of a left herniorrhaphy in 1942/1943, with repeat procedures in 1945 and 1946. According to the veteran, he experienced episodes of infection 2 to 3 times per year, which would often clear up with penicillin after 4 or 5 days. However, since May 1995, he had suffered from an open wound in the area of his left lower quadrant. While in July, the veteran had been hospitalized for treatment, the area in question had "never healed up completely." On physical examination, the veteran's abdomen was soft, with positive bowel sounds, and no masses or organomegaly. There was tenderness to the touch in the area of the left mid and lower quadrants, with the veteran "almost coming off the table" when the examiner began to palpate his left lower quadrant in the area of a previous left inguinal herniorrhaphy. The veteran's left inguinal herniorrhaphy scar was indented, and the medial aspect of it was open and minimally draining clear fluid. The pertinent diagnosis was of a poorly healing left herniorrhaphy scar, with an open portion of the wound which was draining. In September 1996, the veteran underwent gastroscopic examination at a VA medical facility. That examination revealed a Zenker's diverticulum, as well as a hiatal hernia, but no esophagitis. During the course of a period of VA hospitalization in December 1996, the veteran complained of dysphagia which had been progressively worsening for the past 6 or 7 months. On physical examination, the veteran's abdomen was obese and nontender, with normal bowel sounds, and no masses. Additionally noted was that the veteran's left inguinal hernia wound was "well healed." The pertinent diagnoses were dysphagia and Zenker's diverticulum. VA radiographic studies conducted in late June 1997 were significant for the presence of a small sliding hiatal hernia, with possible esophagitis. In October 1997, a VA medical examination was accomplished. At the time of examination, the veteran stated that, for the past several years, he had been experiencing "lots of abdominal gases, burning sensation in the abdomen, and problems with swallowing his food." According to the veteran, while in service, he had experienced no problems with a hiatal hernia. Reportedly, the veteran's "main problem" was his left inguinal hernia. According to the veteran, his left inguinal area wound would repeatedly "open up," and drain. Over time, the veteran had received treatment at the local VA medical center, for the most part, for chronic drainage, and an exacerbation of his chronic left inguinal infection. According to the veteran, this caused "lots of stress and worrying," and his "stress medication" caused "lots of precipitation of abdominal gases," with accompanying pain. Up to the present, the veteran continued to experience drainage in his left inguinal area. Additional complaints consisted of abdominal pain, abdominal gases precipitated by stress and chronic drainage of his left inguinal hernia repair, and recurrent infection in the left inguinal area. On physical examination, there was tenderness in the epigastric and abdominal area, more so in the hypogastric area. Additionally noted was an approximately 1-centimeter opening in the left inguinal area, with some whitish mucus drainage. Around the opening, there was noted some erythema. At the time of evaluation, the veteran complained of vomiting "3 to 4 times per week." The pertinent diagnoses were hiatal hernia; peptic ulcer; and chronic and recurrent infection of the operated site in the left inguinal area. In the opinion of the examiner, there was a connection between the veteran's hiatal hernia and his left inguinal hernia repair, which was somewhat complicated by chronic and recurrent infection. The examiner further commented that the veteran's abdominal pain was a manifestation of hyperacidity, "which was precipitated and aggravated by the stress produced by the nonhealing lesion in his left inguinal area." In the opinion of the examiner, the veteran's inability to perform the activities of a normal person his age contributed to his stress and hyperacidity. The presence of all of the veteran's conditions, and, mainly, his hyperacidity, was also a contributory factor "for the formation of the weakness in the walls of the esophagus, aggravating the hiatal hernia symptoms he (was) currently experiencing." In early January 1998, another VA physician, specifically, the Chief of the Compensation and Pension Department in Temple, Texas, commented that, while the aforementioned VA physician's statements made a "good point," they ignored the fact that the veteran's hernias were developmental lesions, which had been present since birth, and which typically became manifest at various times during a given individual's life. Additionally noted was that the veteran's hyperacidity no doubt aggravated the reflux symptoms from which he suffered, but that hyperacidity "did not cause the hernia in the first place." On subsequent VA medical examination in August 1998, it was noted that the veteran was being seen "in connection with applying for compensation concerning a complaint of a hernia." At the time of examination, the veteran gave a history of chronic drainage and recurrent infection in the area of a previous left inguinal herniorrhaphy. Additional complaints included a hiatal hernia, with a history of epigastric discomfort, recurrent indigestion, heartburn, esophageal reflux, vomiting, bloating, and excessive gas. According to the veteran, he experienced difficulty in swallowing, as well as occasional vomiting. The veteran stated that, in his opinion, the chronic mental anguish associated with his inguinal hernia repair and subsequent chronic infections had been the cause of his hiatal hernia, or, at the very least, aggravated his condition. On physical examination, there was noted a draining lesion approximately 1 centimeter in length in the left lower quadrant of the veteran's abdomen, at the site of the previously-described chronic draining fistula. Additionally noted was a brownish-appearing drainage, as well as mild tenderness in the area of the veteran's fistula, and in the epigastric area on palpation. The pertinent diagnoses were hiatal hernia; history of bilateral inguinal hernia repair; and fistula of the left lower quadrant with chronic recurrent infection and Zenker's diverticulum. Following examination, the examiner noted that the veteran was currently taking Trazodone, which "might or might not" contribute to his problems of bloating and excessive gas. He further commented, were the veteran to, in fact, be experiencing side effects from his medication, the medication could easily be changed, and "would not appear to pose a permanent disability." Concerning the question of the veteran's old inguinal hernia being a source of his "problems" with a hiatal hernia, the examiner was of the opinion that the two problems were "not related," and were, in fact, "separate entities." While the veteran claimed that excessive distress and concern over his inguinal hernia and infected abdominal sinus had created his hiatal hernia by causing excessive acidity in the stomach, the veteran's symptoms, as stated above in October 1997, were consistent with a diagnosis of hiatal hernia and Zenker's diverticulum. His history was not consistent with the usual developmental history of a hiatal hernia, as noted by a previous VA physician in January 1998. The veteran's symptoms, as stated, were symptoms of a hiatal hernia which had developed; however, such symptoms were "not the cause of the hernia." Analysis As to the issue of service connection for a hiatal hernia, the Board is of the opinion that the veteran's claim is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991 and Supp. 1998); see also Caluza v. Brown, 7 Vet. App. 498 (1995). That is, the Board finds that he has presented a claim which is plausible. The Board is also satisfied that all relevant facts have been properly developed. No further assistance to the veteran is required in order to comply with the duty to assist him mandated by 38 U.S.C.A. § 5107(a) (West 1991 and Supp. 1998). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 1991 and Supp. 1998). Moreover, service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (1998). Finally, where there is aggravation of a nonservice- connected condition which is proximately due to or the result of a service-connected condition, the veteran must be compensated for the degree of disability (but only that degree) which is over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). In the case at hand, the veteran argues that the hiatal hernia from which he currently suffers is the result of hyperacidity resulting from "chronic mental anguish" precipitated by recurrent infections related to his service-connected left inguinal herniorrhaphy. In that regard, a review of the record discloses that, over a considerable period of time, the veteran has suffered chronic and recurring infections of the surgical site of his left inguinal herniorrhaphy. At the time of a VA medical examination in October 1997, the veteran complained of problems with "abdominal gases," as well as some difficulty in swallowing his food. He further noted that the wound in his left inguinal area had "never healed completely," and that, as a result, he had experienced both chronic drainage, and an "exacerbation" of chronic infection. According to the veteran, this resulted in "lots of stress and worrying," with accompanying pain. Physical examination conducted at that time revealed the presence of tenderness in the epigastric and abdominal areas, as well as in the hypogastric area. Additionally noted was a 1-centimeter opening in the left inguinal area, surrounded by some erythema, and with some whitish mucous drainage. In the opinion of the examiner, there was a "connection" between the veteran's hiatal hernia and his left inguinal hernia repair, which had been complicated by chronic and recurrent infection. Further noted was that the veteran's abdominal pain was a manifestation of hyperacidity, which was "precipitated and aggravated" by the stress produced by a nonhealing lesion in the veteran's left inguinal area. According to the examining physician, the veteran's hyperacidity was a "contributory factor" for the formation of weakness in the walls of the veteran's esophagus, thereby aggravating the hiatal hernia symptoms he was presently experiencing. The Board is cognizant of the various opinions of two VA physicians to the effect that the veteran's service-connected left inguinal hernia, or complications thereof, are not in fact the cause of his current hiatal hernia. However, those opinions do not rule out the possibility that the veteran's left inguinal hernia, and, in particular, his recurrent and chronic infections, have resulted in a hyperacidity which has, at a minimum, aggravated his hiatal hernia. Under such circumstances, the Board is of the opinion that the veteran's service-connected residuals of left inguinal herniorrhaphy, including infection, have as likely as not resulted in an increase in severity of his hiatal hernia. Under such circumstances, a grant of service connection for that hiatal hernia is in order. See Allen v. Brown, 7 Vet. App. 439 (1995). Turning to the issue of an increased rating for the veteran's service-connected left inguinal herniorrhaphy scar with chronic skin ulcer, the Board notes that disability evaluations, in general, are intended to compensate for the average impairment of earning capacity resulting from a service-connected disability. They are primarily determined by comparing objective clinical findings with the criteria set forth in the rating schedule. 38 U.S.C.A. § 1155 (West 1991 and Supp. 1998); 38 C.F.R. Part 4, (1998). In evaluating the severity of a particular disability, it is essential to consider its history. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. §§ 4.1, 4.2 (1998). However, where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Though a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). In the present case, a review of the record discloses that the veteran has suffered repeated infections and drainage at the site of his service-connected left inguinal herniorrhaphy. However, on VA medical examination in May 1995, the veteran's abdomen was soft, and his bowel sounds positive. On subsequent examination in April 1996, the veteran's abdomen was once again noted to be soft, and bowel sounds were positive. While there was some tenderness to touch in the area of the veteran's left mid and lower quadrants, there was no evidence of masses, or of any organomegaly. As of the time of a recent VA examination in October 1997, pertinent physical findings consisted mainly of the presence of tenderness in the veteran's epigastric and abdominal area, and in the hypogastric area. Subsequent VA examination in January 1998 yielded no findings inconsistent with those previously obtained. The Board observes that the 40 percent evaluation currently in effect contemplates the presence of a large postoperative ventral hernia which is not well supported by a belt under ordinary conditions. In order to warrant an increase, which is to say, 100 percent evaluation, there would, of necessity, need to be demonstrated the presence of massive persistent severe diastasis of the recti muscles, or extensive diffuse destruction or weakening of the muscular and fascial support of the abdominal wall so as to be inoperable. 38 C.F.R. Part 4, Code 7339 (1998). As is clear from the above, the veteran experiences definite symptomatology attributable to his service-connected left inguinal herniorrhaphy. However, it is similarly clear that he does not currently suffer from massive persistent severe diastasis of the recti muscles, or other pathology sufficient to warrant the assignment of a 100 percent evaluation. Under such circumstances, an increased evaluation for the veteran's service-connected left inguinal herniorrhaphy scar with chronic skin ulcer is not in order. Having concluded that an increased rating is not justified for the veteran's underlying inguinal hernia pathology, the Board acknowledges that, over a rather lengthy period of time, the veteran has suffered from recurrent infections and drainage at the site of his surgical incision. While at the time of a period of VA hospitalization in December 1996, the veteran's left inguinal hernia wound was well healed, on various subsequent occasions, and, in particular, on VA medical examinations in October 1997 and August 1998, there was evidence not only of infection at the site of the surgical incision, but also of drainage from that site. The Board acknowledges that, over the course of time, the veteran's chronic fistula has proven resistant to treatment with oral antibiotics, requiring instead, at least on some occasions, the administration of intravenous medication. Under such circumstances, the Board is of the opinion that a separate 10 percent evaluation for the veteran's chronic fistula is warranted by analogy to Diagnostic Code 7803, that is, the code for superficial, poorly nourished scars characterized by repeated ulceration. 38 C.F.R. § 4.20 and Part 4, Code 7803 (1998). In reaching this determination, the Board has given due consideration to the provisions of 38 C.F.R. § 3.321(b)(1) governing the award of extraschedular evaluations. However, based on a review of the entire evidence of record, the Board is of the opinion that such evidence does not present so exceptional or unusual a disability picture as to render impractical the application of the regular schedular standards sufficient to warrant the assignment of an extraschedular evaluation. ORDER Service connection for a hiatal hernia is granted. A separate compensable (10%) evaluation for a chronic draining fistula at the site of the veteran's left inguinal herniorrhaphy is granted, subject to those regulations governing the award of monetary benefits. An increased evaluation for a left inguinal herniorrhaphy scar with chronic skin ulcer is denied. John E. Ormond, Jr. Member, Board of Veterans' Appeals