The opinion of the court was delivered by: WOOD
The claimant in this case filed an application for disability insurance benefits and to establish a period of disability on March 7, 1961, alleging that he had become unable to engage in any substantial gainful activity since September 7, 1960, at age 44, because of anthracosilicosis and a heart condition.
The hearing examiner on September 20, 1962, concluded that the plaintiff was not disabled within the meaning of the Act. The Appeals Council denied the plaintiff's request for review of the examiner's decision on December 20, 1962. Thus, this decision of the hearing examiner became the final decision of the Secretary of Health, Education and Welfare (Secretary). Dupkunis v. Celebrezze, 3 Cir., 323 F.2d 380; and Goldman v. Folsom, 246 F.2d 776, 778 (3 Cir. 1957).
The plaintiff commenced a civil action in this Court to review the Secretary's decision under 42 U.S.C.A. § 405(g) and both parties have filed cross motions for summary judgment which are the subject of this Opinion.
The plaintiff had been a machinist and welder around coal breakers repairing broken machinery parts in the three years before September 7, 1960, when he became unable to work allegedly because of anthracosilicosis. Both jobs required the plaintiff to climb ladders and walk about the premises to get at the particular equipment in need of repair. While climbing up one of these ladders at the breaker, the claimant experienced what was said to be a heart attack in July 1959.
In no report did Doctor Dougherty include detailed clinical evidence such as: (1) specific electrocardiographic discrepancies; (2) specific X-ray findings concerning the condition of plaintiff's lungs, as distinguished from the medical conclusion formed thereon; (3) specific X-ray or fluoroscopic results indicating heart enlargement or other complication; (4) results of ventilation studies giving accurate measurements of plaintiff's residual breathing capacity; or (5) results of exercise tolerance tests indicating the level of activity productive of acute symptoms.
Section 404.1524 of Social Security Administration Regulations No. 4 (20 C.F.R. 404.1524) dealing with the type of medical evidence required to satisfy the plaintiff's burden of proof provides in part as follows:
'Medical reports, copies of medical records or other medical evidence submitted to substantiate an allegation that an individual is under a disability shall include pertinent clinical facts, medical history, results and interpretations of any laboratory and diagnostic tests, and treatment and response. * * * such evidence shall also describe the individual's capacity to perform significant functions such as the capacity to sit, stand, or move about, travel, handle objects, hear or speak, and, in cases of mental impairment, the ability to reason or to make occupational, personal or social adjustments. The clinical and laboratory findings shall be sufficiently comprehensive and detailed to permit the Secretary to make determinations as to the nature and limiting effects of the individual's physical or mental impairment or impairments for the period in question, his ability to engage in physical and mental activities, and the probable duration of such impairment.' (Emphasis supplied)
About March 8, 1961, the plaintiff was examined by Dr. Dessen, a radiologist, who reported after an X-ray examination that heart, mediastinal structures and diaphragm were normal and that the plaintiff's chest was negative except for signs of early second stage silicosis with moderate emphysema.
The plaintiff was also examined by a Dr. Vastine, an internist, who gave the plaintiff a physical examination, laboratory studies, fluoroscopy, electrocardiograph, ventilation studies and clinical observations on exercising. All of these tests caused him to conclude that the plaintiff had only a moderate pulmonary insufficiency due to anthracosilicosis with emphysema and that he did not suffer from any cardiovascular disease of any description.
Some of the clinical findings were as follows: normal blood pressure and pulse; normal eye grounds; no cardiac (heart) enlargement (on physical examination, by fluoroscopy, or by electrocardiogram) no enlargement of aorta (by X-ray or on physical examination) normal heart sounds; normal heart rate and rhythm (on physical examination and by electrocardiogram); no edema; no varicosities; no observable dyapnea, cyanosis or clubbing; no evidence of pulmonary heart disease by electrocardiogram; no evidence of recent or old infarcation (heart attack) by electrocardiogram; no evidence of insufficient supply of blood to the heart by electrocardiogram.
The hearing examiner concluded that the objective medical evidence failed to sustain the existence of a heart impairment. The clinical findings relative to the applicant's heart were all essentially normal and the hearing examiner decided that the plaintiff had failed to meet his burden of proof in that he had failed to establish the existence of any severe functional impairment for the pertinent period during which his application had validity.
Our function at this juncture of the proceedings is to determine whether there was substantial evidence to support the finding of the Secretary that the plaintiff was not prevented by his physical condition from any substantial gainful activity. The test for disability consists principally of two parts: (1) a determination of the extent of the physical or mental impairment and (2) a determination whether that impairment results in an inability to engage in any substantial gainful activity. Klimaszewski v. Flemming, 176 F.Supp. 927, 931 (E.D.Pa.1959); Hodgson v. ...