## Facts

- James R. Cook served on active duty in the U.S. Army from August 1942 to December 1945, including extensive combat service.
- During service, Cook experienced gastrointestinal symptoms (including heartburn, pain, and vomiting) and underwent an appendectomy at a forward aid station.
- After separation, Cook received treatment for stomach complaints beginning in 1946.
- Cook was diagnosed with an ulcer around 1950; in 1951 he was hospitalized and underwent surgery for a perforated ulcer.
- A 1950 military examination for recall found Cook not qualified for active duty because of his ulcer.
- In June 1952, a VA regional office denied service connection for “stomach trouble and nervousness,” finding the ulcer not incurred or aggravated in service and no psychiatric disability shown on examination.
- In 1989, Cook sought service connection again for a duodenal ulcer and a nervous condition, submitting medical and lay evidence asserting continuous stomach symptoms since service.
- In June 1991, the Board of Veterans’ Appeals denied service connection, emphasizing that the first “objective” medical evidence of ulcer disease was the 1950 diagnosis and finding no ulcer shown in service or within the one-year presumptive period.

## Issues

1. Whether the Board erred in denying service connection for a duodenal ulcer by treating the first documented diagnosis as the earliest possible onset and failing to analyze earlier characteristic manifestations and continuity of symptomatology.
2. Whether, in a claim involving a later formal diagnosis, the Board must evaluate lay and medical evidence of in-service and post-service symptoms to determine onset during service or within the presumptive period for peptic ulcer disease.

## Decision

- The United States Court of Veterans Appeals reversed the Board’s decision in part and remanded for further proceedings.
- The Court held that the Board improperly focused on the formal diagnosis date and did not adequately consider evidence of earlier manifestations and continuity.
- The Court directed the Board to reassess the record, including in-service symptoms, post-service treatment beginning shortly after discharge, and lay evidence describing ongoing stomach problems.

## Legal Principles

- In determining service connection for ulcer disease, adjudicators must evaluate characteristic manifestations and the time lapse between symptom onset and formal diagnosis; onset is not fixed by the first documented diagnosis date.
- Lay evidence of observable symptoms may be probative on continuity of symptomatology and onset and may not be rejected solely because contemporaneous records did not label the condition as an ulcer.
- When a chronic disease is potentially subject to presumptive service connection, the Board must address whether symptoms within the presumptive period represented compensable manifestations of the later-diagnosed disease.
- The Board must provide a reasoned assessment of the whole record when weighing medical and lay evidence on onset and continuity.

## Conclusion

The Court required the Board to analyze whether Cook’s documented symptom history and continuity evidence reflected ulcer onset during service or within the presumptive period, rather than relying chiefly on the 1950 diagnosis date, and remanded for readjudication under proper evidentiary standards.


Cook v. Brown, 4 Vet. App. 231 (1993)