cause and effect relationship between the work factors and the disability; and the doctor's medical reason for such opinion. In response, appellant stated that the constant pressures of air traffic control over a period of many years caused tenseness and irritability. He also stated that the irregular hours of service had an adverse effect on his eating and sleeping routine, contributing to insomnia and excessive fatigue.

Appellant's supervisor stated in an October 17, 1973 letter that many of appellant's statements were personal to the extent that he could not support or disclaim them. He indicated that:

"Air traffic control duties do require considerable effort during heavy traffic. I cannot weigh the [relativity] of this to tenseness or irritability. Rotation of shifts is required and this requires adjustment. It should be noted that during the period [appellant] worked [at this tower] no shifts have been assigned between 11 p.m. and 7 a.m. since the tower is closed during that period."

The supervisor further stated that he had observed appellant taking antacids frequently and he had seen exposed ulcers on appellant's ankles.

Appellant submitted several articles which addressed the issue of stress as an air traffic controller and its medical manifestations.

A letter from Dr. Rodenbaugh dated September 26, 1973 stated that: "[Appellant] has been a patient of mine with symptoms of dizziness and some vertigo and postural hypertension, and in addition he has had epigastric burning distress which was awakening him at night. In addition to a Keith-Wagner Grade II hypertension which did respond to medications but which requires medications which are disqualifying for his job as an Air Traffic Controller, he has a hiatus hernia and peptic duodenitis. Since he has two stress-related conditions and his job is a stressful one which at his age becomes increasingly difficult to handle, I do not feel that he will ever be able to resume the duties of an Air Traffic Controller. He would be able to assume an occupation which was not stressful. He will require medications. He is on a diet and has managed to lose approximately 12 pounds and in general is doing quite well since he has been off work. He will require medications for some period of time. These medications disqualify him for his occupation as Air Traffic Controller as well as the near certainty that he would reactivate his peptic disease."

Upon Office request, the employing establishment submitted copies of appellant's employment records. All medical examination records dating from 1966 were reported as normal, qualifying appellant for his position, the only restriction being that he was required to wear correc

tive lenses at work. An August 11, 1971 medical report noted severe headaches and stomach trouble. A July 25, 1972 medical report contained a blood pressure reading of 120/74.

Dr. R. Lawarence Gibson, a Board-certified psychiatrist, submitted a November 20, 1973 report in connection with appellant's application for disability retirement. He stated that, based upon his examination of appellant:

"As far as his mental status goes, [appellant] presented no gross abnormalities. He certainly was not psychotic. He did however, manifest a great deal of anxiety during the interview. He tended to focus on physical symptoms but was able to get away from this and into the psycho-social sphere without much difficulty. Although he did not appear particularly depressed, he certainly gives symptoms thereof."

Dr. Gibson concluded that:

"It is difficult for me to say whether Mr. Fein's depression and anxiety and psychosomatic symptoms are more related to [the] job or to things outside the job. In any case, I think that his depression and physical symptoms certainly have interfered with his job, and if he were to return he probably would experience symptoms similar to what he was experiencing prior to his leave of absence."

Appellant retired on disability effective December 8, 1973. Dr. Rodenbaugh submitted a report to the Office dated November 20, 1975 in which he summarized the situation as follows:

"I saw Mr. Fein initially in April of 1973, with symptoms of dyspepsia, epigastric distress, heartburn, increasing and beginning to wake him at night, noticed particularly when he lay down. I noted at that time that his blood pressure was 175/106. He returned in one week's time, apparently had an upper GI series which showed small sliding type hiatal hernia with gastroesophageal reflux as well as x-ray evidence of antral gastritis and duodenitis consistent with peptic disease. At that time his blood pressure was 160/120 and he did show evidence of Keith-Wagener retinopathy. He was placed on Pamine and Phenobarbital, a bland diet and antacids and in May he was seen again. His blood pressure at that time was 160/94. His symptoms had subsided quite a bit off work. Subsequent blood pressures off work have indicated blood pressure levels in the way of 142/90, 140/90, 152/104 (in May of 1974), 140/90 (August 1974), 130/78 (February of 1975).

"He had been treated with Oreticyl-Forte which is a medication containing rauwolfia derivative as well as a chlorothiazide.

"In summary, the patient has formerly been a tower controller,

he developed peptic disease as well had developed hypertension. He required medications for his hypertension which by federal law keep him from meeting the standards of a second class medical certificate which are required for his job. He is therefore disqualified from his job and disabled by the very requirements of the job itself, i.e. a valid current second class airman's medical certificate. Even were it not for his hypertension, his peptic disease alone should be sufficient and in my opinion is sufficient, to disable him from the job of air traffic controller. Off work he is reasonably asymptomatic but does require medications."

In a letter dated October 28, 1976, the Office notified appellant that, unless he submitted additional evidence to support his claim, it would be disallowed. The letter noted that medical reports of record did not give a rationalized opinion as to the relationship of his disability to his job and stated that the Office must have reports from his internist and psychiatrist as to the reasons why they felt his disability to be related to his work.

Dr. Henry C. Dahleen submitted a letter dated July 11, 1977 in connection with appellant's representative's request for medical records from the clinic where Dr. Rodenbaugh had examined appellant. Dr. Dahleen's letter read as follows:

"Mr. Fein was seen here for FAA physical examinations from 1968 to 1971 August. In 1973, he consulted Dr. Rodenbaugh regarding physical problems. [Two] communications regarding Dr. Rodenbaugh's conclusions are attached. Our only laboratory records are of normal urinalyses-specific gravity, PH. albumin and sugar only. These were done in connection with FAA physicals and all were normal.

"4 Electrocardiograms in connection with his 4 FAA tower exams were normal . .

By compensation order dated December 13, 1977, the Office rejected

appellant's claim for compensation on the ground that causal relation was not established.

Appellant's representative requested reconsideration of the Office's decision. The Office sent the case record and a statement of accepted facts to Dr. William M. Liebman, an Office medical consultant and specialist in gastroenterology. Dr. Liebman, in a report dated April 23, 1981, made the following comments:

"(1) The diagnosis, as can be determined from the available case records, would be: (1) essential hypertension; secondary component— anxiety, (2) hiatus hernia. The diagnosis of peptic duodenitis is a presumptive one, based on the subjective complaints of the patient, but I do not have available for review the specific x-ray report of the UGI series, or, more specifically, an upper endoscopic examination of the esophagus, stomach, and proximal duodenum, which would disclose the area of redness of the duodenal bulb area. Radiological examination is a less than satisfactory manner for the diagnosis of inflammatory lesions of the stomach and/or proximal duodenum, since frequently irritability of the bulb area or presumed irregularity of the lining is taken as evidence for an inflammatory lesion. This is usually not satisfactory, unless excellent air contrast use of the respective areas for a double contrast x-ray examination are performed; most commonly, a single contrast, standard upper UGI series is performed, which is not truly satisfactory.

"(2) The history of hypertension, the K-W grade II retinopathy are probably of longer standing nature, as presumably previous exogenous obesity (with subsequent weight reduction), and these factors certainly can be aggravated by stress, such as from employment. However, this is a subjective relationship, documented by variably controlled studies relating stress to organic illness, and to extrapolate such to this claimant's case is a difficult task. However, this consultant does not find it unreasonable that stress of his type of job could have aggravated the preexisting conditions, previously mentioned in answer no. 1. With reference to ulcers of the lower extremities, this consultant could not find adequate documentation in the available case records to state that such was present, and, therefore, to relate such to the claimant's federal employment.

“(3) The federal employment activity or conditions would have provided temporary aggravation only, subsequently being ameliorated by cessation of this type of job. What permanent effects were done would be quite difficult to state; however, Dr. Rodenbaugh's comments, as well as that of Dr. Gibson, would suggest a temporary effect, and that the claimant could perform desk work, etc.

"(4) The apparent temporary effect of the employment, federal,

would cease at the time that the claimant's performance of work activities as an Air Traffic Controller ceased.

"(5) As in previously mentioned answers, the effects of aggravation would be temporary only."

By compensation order dated November 17, 1981, the Office denied appellant's request for modification of the prior decision.1

The Board finds that appellant has not met his burden of establishing that his disability commencing April 21, 1973 is causally related to conditions of his federal employment.

An award for compensation may not be predicated on surmise, conjecture, speculation, or upon appellant's belief or the belief of his coworkers of causal relation. He has the burden of establishing by reliable, probative, and substantial evidence that his disability from a peptic ulcer was causally related to a specific employment incident or to specified conditions of his employment. As part of such burden of proof, rationalized medical evidence showing causal relation must be submitted. The mere fact that a condition manifests itself or is worsened during a period of employment does not raise an inference of causal relationship between the two.2 Such a relationship must be shown by rationalized medical evidence of causal relation based upon a specific and accurate history of employment incidents or conditions which are alleged to have caused or exacerbated a disability.3

In support of his claim, appellant submitted the reports of Dr. Rodenbaugh, a Board-certified internist, who expressed the belief that appellant's hypertension, peptic disease with duodenitis, and hiatal hernia were stress-related and as such related to his job. However, there was no indication that appellant described to the doctor the employment factors which he believed caused or aggravated his conditions. The doctor's brief reports did not contain such a history and provided little rationale as to why he believed appellant's conditions to be employment related.

The report of Dr. Gibson, the Board-certified psychiatrist, merely stated that it was difficult to say whether appellant's depression, anxiety and psychosomatic symptoms were more related to the job or things outside the job. His opinion was also of little probative value on the issue of causal relation.

With respect to appellant's submission of magazine articles and

Although the November 17, 1981 compensation order stated that the additional evidence did not warrant a review of the prior decision, it is clear from the case record that the Office did, in fact, make a review on the merits, as evidenced by its referral of the case record to a medical specialist for review and a rationalized opinion on causal relationship. The case is therefore before the Board on its merits.

2 See Lawrence Meece, 28 ECAB 87; See William E. Henderson, 26 ECAB 23; Maximo Mandero, 25 ECAB 65; Eloise L. Berry, 25 ECAB 61; Ruth R. Price, 16 ECAB 688; Herbert Fichandler, 16 ECAB 180.

3 See Kenneth W. Kemp, 24 ECAB 152, and cases cited therein.