I f^p . HX641 43490 RC991 Un321916 Instructions to exam Uj^jl'AllTMENT OF THE INTERIOR. RECAP BUREAU OF PENSIONS INSTRUCTIONS TO EXAMINING SURGEONS APPROVED JANUARY 3, 1916 WASHIl,x,TON GOVERNMENT PRINTING OFFICE 1915 V£M COLLEGE OF PHYSICIANS AND SURGEONS LIBRARY Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/instructionstoexOOunit 3—1573 DEPARTMENT OF THE INTERIOR BUREAU OF PENSIONS INSTRUCTIONS TO EXAMINING SURGEONS APPROVED JANUARY 3, 1916 WASHIKGTON GOVERNMENT PRINTING OFFICE 1915 IflC INSTRUCTIONS TO EXAMINING SURGEONS. This book is presented to the examining surgeons of the Bureau of Pensions for their guidance in the performance of their duties. To insure completeness . and uniformity in the examination of applicants and for purposes of record, it is necessary to have a definite and comprehensive method of procedure. This edition supersedes all others and should be carefully read. BOARDS OF SUSGEONS. (1) Surgeons are appointed by the Commissioner of Pensions under authority of the law which provides: That the Commissioner of Pensions is laereby authorized to appoint surgeons wlio, under his control and direction, shall malve such examination of pen- sioners ar.d claimants for pension or increased pension as he shall require ; and he shall organize boards of surgeons, to consist of three members each, at such points in each State as he shall deem necessary, and all examinations, so far as practicable, shall be made by the boards, and no examination shall be made by one surgeon excepting under such circumstances as make it impracti- cable for a claimant to present himself before a board. (2) After appointment the members of the board must organize by selecting a president, secretary, and treasurer. The place of meet- ing should also be determined upon and the bureau promptly notified. The member whose handwriting is most legible should be selected as secretar3\ (3) The place of meeting should not be changed without permis- sion of the Commissioner of Pensions, and such place should be centrally located and readily accessible to claimants, with comfort- able accommodations for those obliged to wait. (4) Boards must endeavor to meet promptly at the time agreed upon, which is usually Wednesday morning at 10 o'clock. When the regular day of examination falls upon a legal holiday, the day pre- ceding it will be considered the regular day. (5) If it be known prior to any regular meeting day of a board that no meeting can be held, all claimants for whose examination the board holds orders should be notified that no session will be held on that day. If on a regular examination day a board holds no valid order for examination, the meeting for that day may be omitted. (6) Under no circumstances can a surgeon delegate to another the work imposed upon himself. If a surgeon is compelled to be absent from the sessions of the board for any extended time, by reason of sickness or other cause, the bureau should be notified. The death of any member should be promptly reported. (7) A surgeon who desires a leave of absence should, if possible, make application therefor at least 30 days in advance of the date he desires it to commence, giving the dates when he wishes such leave to begin and end. 3 4 IIsrSTRUCTIONS TO EXAMINING SUKGEONS. (8) Leave of absence can not be given to two members of a board to cover the same period of time. A leave for a greater time than 60 days will not generally be granted. If the surgeon is compelled to be away for a longer period than 60 days, he should tender his resignation. (9) Change of residence of a member of a board to such distance as will prevent his regular attendance upon the sessions of the board will nullify his appointment. (10) No examining surgeon may act as the attorney or representa- tive of any person in the matter of a pension claim. (11) When no board or single surgeon is accessible, the commis- sioner may authorize the postmaster at the claimant's home to select a civil surgeon to make the examination. (12) Two orders are issued for every examination, one to the board and the other to the claimant. AVhen the claimant presents his order it should be found to agree in name, number, etc., with that in possession of the board. If the board holds no corresponding order, it will generally be found that the claimant's order is directed to some other board, and in such case no examination will be made, and the claimant will be properly advised. If, however, claimant presents himself with a current order properly directed to the board, and no corresponding order is on file, an examination should be made, and in such case the claimant must be questioned as to all of his alleged disabilities in order that none may be omitted in the certificate. (13) If, on the other hand, the board has an order and the claim- ant presents himself without one, the board, after satisfying itself of the identity of the claimant, should proceed with the examination. (14) If a surgeon receives an order for examination which was improperly mailed and was intended for another, he should promptly return the same to the bureau with an explanation. (15) Orders for examination are generally valid for three months from the date of same. They should, however, be kept until the first meeting of the board, following the expiration of the three months limit, when, if the claimant appears, he should be examined. Should he not appear at this session, the order should be indorsed, " Claim- ant failed to appear toithin speci^ed time^'' dated, and returned to the bureau. (16) If an examination is made, the order should be inclosed with the certificate and the voucher. (17) The claimant's order should be dated, signed, and handed to him before he leaves the examining room. (18) No examination made by a single member of a board will be accepted unless such examination is made upon a special order from the bureau. It is desired that all examinations be made by a full board ; but if one member is absent, the examination may proceed if the claimant signs the waiver upon the back of the certificate, con- senting to an examination by two members. (19) If the claimant is unable to sign his name, his mark to the waiver must be witnessed by two persons who can write, one of whom, at least, must not be a member of the board. Under no circumstances must the secretary sign the waiver for the claimant. INSTEUCTIOXS TO EXAMINING SURGEONS. 5 (20) If ii full board is present, the secretary will certify, in the proper form on the back of the certificate, to the presence of the full board and their participation in the examination. (21) "When an examination is made by one member of a board on a special order, or by a single surgeon or expert, it will not be necessary for the claimant to sign a waiver. (22) When an orcTer for examination is marked "Test," it is because there have been differences of opinion as to some pathological sequence, or even as to the existence of the alleged disability. Such examinations should be made with unusual care. (23) If a member of a board can not agree with his colleagues as to their findings in a given case, he may prepare a minority certificate on an entirely separate blank and forward the same. Every effort should, however, be made to reconcile conflicting opinions and avoid the annoyance of a minority report. (24:) Boards may employ a stenographer or clerk, but at their own expense and on their own responsibility. At an examination, mem- bers of the board, one claimant and such clerk may, and no other per- son shall be present, except that a properly accredited special exam- iner as a representative of the bureau, may be permitted to be present. (25) "When the board is in session, all communications relating to the business of the bureau received since the last meeting should be read by the secretary, and the work of the examination should begin promptly. (26) i?he claimants should be taken in the order of their arrival, though if a certain one is very feeble or is obliged to take an early train to get home, those waiting may be asked to waive their turn. (27) Each claimant should be given an opportunity to make a brief statement as to his disabilities and must declare that the dis- abilities named are the only ones contracted in the service that now affect him. (28) All claimants who present themselves on a given day should be examined, nnless the number exceeds twenty, in which case the law provides as follows: And hereafter each member of each examining board shall receive the sum of three dollars for the examination of each applicant whenever five or a less num- ber shall be examined on any one day : Provided, That if twenty or more appli- cants appear on one day, no fewer than twenty shall, if practicable, be examined on said day, and that if fewer examinations be then made, twenty or more having appeared, then there shall be paid for the first examinations made on the next examination day the fee of one dollar only until twenty examinations shall have been made. (Act approved May 28, 1908.) (29) If, therefore, a greater number of claimants appears on a given day than can properly be examined, an adjourned meeting Avill be held on the succeeding day, and the examination will be continued ; and the certificates made under such circumstances must bear the actual date of examination and be indorsed "Adjourned meeting." (30) A board may notify a claimant of the receipt of an order for his examination, but not after the validity of the same has ceased, and may also ask the claimant to return for a reexamination if necessary. (31) \Yhen a claimant furnishes good evidence that he is so dis- abled that he can not present himself before a board, a so-called home examination is ordered, in which case any member of the board, unless some special one is designated, will proceed to the claimant's residence 6 INSTRUCTIONS TO EXAMINING SUEGEONS. at the earliest possible moment and make the examination; but the member who lives nearest to the home of the applicant should gener- ally make the examination. If, however, after such an order is issued, the claimant should pre- sent himself for examination, or it should come to the knowledge of the surgeon that he is able to do so, the home examination should not be made, but he should be examined by two or more members of the board in the one contingency, or notified to appear for examination in the other. (32) "The fee for each examination at the claimant's residence, provided his residence is outside of the corporate limits of the place of the regular meeting of the examining board and of the place of resi- dence of the surgeon making the examination, shall be $5 in addition to the payment of the actual traveling expenses of the surgeon." The fee, however, for a home examination, when the conditions are other than those provided for above, will be $3. (33) If, for any satisfactory reason, no member of a board can make a given home examination, the papers should be returned to the bureau at once with an explanation. (34) No discussion or correspondence should be held with claim- ants who find fault with the rate allowed by the bureau, and under no circumstances should the certificate of examination or any part thereof be shown to a claimant or other person or read in his i^res- ence; nor should the claimant or any other person be told by the examiners or either of them how the claimant has been rated by the board. Dissatisfied claimants may be told that the bureau in all cases reserves the right to fix the ultimate rate. (35) AVhen a claimant for pension requests an examining surgeon to make a private examination and affidavit in support of his claim, he shall refuse to do so; but if the examining surgeon is at the same time the family physician of the claimant, or has attended him pro- fessionally in the past, he may testify, and he should incorporate in his affidavit a statement that he is the family physician. • (36) No examining surgeon shall demand or accept a fee from any claimant for services rendered in connection with his official exami- nation. (37) An examining surgeon who is also a pension claimant should not be examined by a board of which he is a member. If such an order is received, it has been sent out erroneously, and shoiild be returned to the bureau with an explanation. (38) If a claimant has made a long trip to obtain his examination, and through misunderstanding arrives upon the wrong day, if at least two members of the board can be convened, the examination should be made and an explanation forwarded with the certificate. (39) The requisition for blanks (Form 3-116) indicates all the issues for official use, and it will be useless to make request for other blanks. This form should be used only for the purpose intended and should be mailed to the bureau in a separate envelope. EXAMINATIONS. The act of Congress approved May 28, 1908, provides as follows: " That no fee shall be paid to any member of an examining board INSTRUCTIONS TO EXAMINING SUEGEONS. 7 unless personally present and assisting in the examination of appli- cant, and the report of such examining surgeons shall specifically and accurately set forth the physical condition of the applicant, each and every existing disability being fully and carefully described." (40) The necessity of removing all the claimant's clothing before examination must be decided by the board, and will depend, of course, upon the nature of the disability. It is, however, proper for the board to insist upon the removal of the clothing if deemed necessary. (41) The bureau desires in these examinations a concise but clear description of all the disabilities from which the claimant is suffering, whether included in the order or not. Claimants often make obscure allegations, and these are copied, as required by regulations of the bureau, upon the order of examination in the routine of office work. The board can, by judicious questioning, often arrive at the real dis- ability which the claimant means to allege, but does not, and can thus give a clear idea of the actual disabling cause. The certificate must cover all alleged causes of disability, for the claim can not be adjudi- cated in the bureau unless every one is disposed of by the surgeons. (42) Disabilities that are pathologically connected may be grouped together under a single head, but it will assist the bureau if in general the disabilities are taken up in the succession in which they occur in the order and if a separate paragraph is made for every one. (43) It often happens that some member of a board has knowledge of the disability for which the claimant is pensioned or is seeking pen- sion, and it is proper for this member to incorporate in the certificate as a separate paragraph what he may personally know as to the cause and extent of claimant's disability. (44) If such member of a board personally knows that the disabil- ity for which the claimant is pensioned or seeking pension under the general law has been caused or aggravated by some injury or accident occurring outside of the service, or is caused by the claimant's own vicious habits, it will be his duty to state such knowledge. (45) The results of advancing age should be observed, and its effects upon the disabilities should be excluded by the board. Every disability the result of age alone should be described. (46 ) Every certificate should contain a brief report of the condition of the lungs and heart and the results of urinalysis, even though dis- ease of these organs and kidneys is not alleged. (47) Gunshot wounds and injuries. — The site of all wounds and injuries must be indicated on the diagrams on the back of the cer- tificate. {a) The points of entrance and exit of a missile and the point of section of all amputations should also be carefully marked. This is important and should not be neglected. (&) Scars should be fully described and a statement made as to whether they are tender, adherent, or dragging. If there is loss of tissue or atrophy, give comparative measurements. (c) Is there deformity, limitation of motion, lameness, or necessity for artificial aid, such as crutches or canes? {d) If, in the opinion of the board, there are sequelae of either injuries or gunshot wounds, whether alleged or not by the claimant, they should be fully described, and the reasons for considering them sequelae should be stated. 8 HSrSTBUCTIONS TO EXAMINING SURGEONS. (48) Amputations. — In amputations of the leg above the knee cr arm above the elbow it will be necessary to state the length of the remaining portion of bone by measurement from the great trochanter or acromion process to the point of section of the bone. If the claimant states that he is unable to wear an artificial lunb, the stump should be carefully examined to determine whether there is any permanent condition that would prevent the use of a properly fitted artificial limb. (49) If an amputation is near but below the knee, it should be stated whether the point of section is above, through, or below the tubercle of the tibia. (50) Where an amputation is near but below the elbow, state whether the point of section is above, through, or below the base of the head of the radius. (51) In amjDutation of the fingers or toes, use the word proximal or distal joint instead of the word first or last joint to indicate the point of section. (52) In every amputation the condition of the stump as to suffi- ciency of covering, sensitiveness, and painfulness should be given, and the point of section should be indicated on the diagram. (53) In case of injury to an arm or leg, if total disability of the member is alleged or found, great care should be taken in the descrip- tion of the bones, joints, tendons, ligaments, and muscles; and the uses to which the arm, leg, hand, or foot can and can not be put should be clearly stated. (54) Hernia. — Impulse alone can not be accepted as evidence of a hernia. A definite statement should be made as to whether a hernial tumor is or is not present. If there is a tumor, its size and situation with reference to the abdominal rings and Poupart's ligament should be clearly described. If the hernia is inguinal, is it oblique or direct ? In the case of an oblique hernia a statement should always be made to the effect that the mass does or does not pass through the external ring. In other words, state as positively as possible whether the hernia is complete or incomplete. Note all complications, and state whether the tumor can be readily reduced and retained by a truss. Does the applicant habitually wear a truss? The condition of the abdominal rings should be investigated and noted. Has the hernia ever become strangulated? (55) If double inguinal hernia is found, each should be separately and distinctly described. (56) An abdominal, umbilical, or femoral hernia should also receive careful attention and thorough description. Note. — The Bureau of Pensions has nothing to do with furnishing trusses, and all correspondence relating thereto should be addressed to the Surgeon General United States Army, War Department, Wash- ington, D. C. (57) Varicose veins. — Wlien varicose veins of one leg only are alleged, the examination must always include both extremities. Indi- cate on the diagram the extent of surface involved. The names of the affected veins and their size in fractions of an inch, should be given. If there are ulcers, give position, size, and condition. (58) Rheumatism. — When this disability is alleged, the certificate should show the condition of the joints, tendons, and muscles in iisrsTTiucTioisrs to examining suegeons. 9 general, but more especially of those involved in rheumatism. If there is limitation of motion in joints, give degree of same. Show atrophy of muscles by comparative measurements. Crepitation of joints can not be accepted alone as showing rheumatism, but will be estimated by the board, in connection with objective and subjective symptoms, in affixing the rate. When rheumatism is alleged the heart should always be examined. (59) Malarial poisoning ; ehills and fever. — Is the claimant suffer- ing from active malarial disease or its sequelae at the present time? Does he now reside in a locality where malarial diseases are prevalent ? He should be questioned as to the date of his last chill and the fre- quency of such attacks, and should also have full opportunity to explain his subjective symptoms. (60) The general appearance of the claimant, including the color of the skin and conjunctiva, should be described. The areas of hepatic and splenic dullness should be given, and, if abnormality is shown, the areas should be marked on the diagram. To which ribs do the upper and lower borders of the liver correspond? Does the lower border extend below the ribs in the nipple and axillary lines and, if so, how far? Is the spleen palpable? (61) Diseases of the 'brain and spinal cord. — Describe all objective evidence of injury to the cranium and contents and to the spinal col- umn. Describe all motor or sensory disturbances and outline areas of anaesthesia or hyperaesthesia. Is there hemiplegia? If so, describe the same and report the presence or absence of arteriosclerosis. Is there paraplegia or paresis? Are there attacks of vertigo, spasms, or convulsions? If epilepsy exists, secure a statement as to the fre- quency, duration, and violence of the seizures. (62) If insanity is found, describe the mental conditions and state whether there is disorientation in any field. Is the claimant kept under restraint or is restraint necessary? Does he perform any labor ? (63) Are the pupillary and other reflexes normal ? Is there a sense of constriction about the thorax or abdomen or of cushion beneath the feet, numbness of limbs, or incoordination of movements? Is the claimant able to approximate the tips of his fingers and to button his clothes? Can he stand and walk with his eyes closed? Is there muscular tremor ? Is it intentional ? (64) In all cases of disease of brain or spinal cord its possible syphilitic origin must be remembered and investigated. (65) Sunstroke. — ^A detailed statement as to all alleged results of sunstroke should be obtained from the claimant, and all objective symptoms of disease of brain noted. Are there evidences of chronic meningitis, impairment of memory or mental faculties? Is there complaint of habitual headache, vertigo, or intolerance of heat? (66) Diseases of lungs. — Measure the chest at rest, on full inspira- tion and expiration. In cases of asymmetry give bilateral measure- ments. Note all deformities, pleuritic effusions, and adhesions. In tuberculosis determine areas of dullness and whether cavities exist. Has there been haemoptysis ? If so, when and how frequently ? When the board is possessed of the necessary appliances, a micro- scopical examination of the sputum in appropriate cases of disease of lungs will be appreciated. 15614°— 15 2 10 IlSrSTKUCTIOXS TO EXAMIK"IiSrG SUEGEOI^J'S. In all examinations of the lungs the heart must be included. (67) Diseases of heart. — The heart should be examined when the claimant is at rest. The point of apex impulse should be located and a statement made whether it is evident to inspection and palpation. The area and position of cardiac dullness and departures from normal rhythm should be given. If there are murmurs, state with which sound they are heard, where they are most distinct and at which orifice the}^ arise. Is there hyper- trophy or dilatation ? Are there indications of failing compensation ? Is there dyspnoea before or after exercise? Is there cyanosis or oedema % If cyanosis and oedema afe present, state their location and extent. If tachj^cardia without organic lesion is found, determine, if possible, the cause of same. (68) If there is cardiac dyspnoea, do not confound the same with asthma due to other causes. (69) Diseases of the hidneys. — The color, specific gravity, and reaction of the urine should be given, and tests for albumin and sugar made. The tests employed should be named, and any abnormal de- posits should be fully described. Has the skin a normal color and appearance ? Are there local oede- mas ? Are there any uraemic symptoms ? (TO) Diseases of the hlaclder. — Is there incontinence or retention of urine? Is there irritability of the bladder or cystitis? Is there hypertrophy of the prostate gland; if so, is it due to senile causes, and at what age did it develop ? (71) Diseases of genital organs. — Examine the penis for scars, strictures, or discharge. Interrogate claimant for history of gonor- rhea. Are the testicles of normal size and sensitiveness ? (72) If there is hj^drocele, give careful differential diagnosis from varicocele and hernia, state size of sac, frequency of tapping, and com- plications that may be found. (73) In varicocele give size of mass, differentiate from hydrocele and hernia, and state condition of scrotal contents. (74) Syphilis. — If suspicion arises that syphilis has existed, an effort should be made to obtain a history of this disease. Scars of chancres should be sought for, and the lymphatic glands usually in- volved should be examined. The condition of the palate, throat, nasal passages, skin, hair, tibia, and other bones should be stated. Evidences of tertiary lesions in brain, spinal cord, or elsewhere should be sought. (75) Chronic diarrhea. — When this disability is alleged, the claimant should be measured and weighed with unusual care, and his general appearance noted. The condition of the stomach, liver, spleen, rectum, and lungs should be fully described. Examinations for chronic diarrhea should always include a description of the rectum. (76) Diseases of the rectum. — The rectum should be examined either digitally or by the speculum and all abnormalities noted. If there are piles, give their number, size, and condition, and state whether they are internal or external. If there is a fissure, fistula or stricture, a full description is necessary. Is there prolapse of the rectum? If so, is it constant or does it appear only upon straining? Measure its extent and report in inches and fractions thereof the size INSTEUCTIONS TO EXAMINING SUEGEOXS. 11 of the mass. Can it be readil}^ reduced? Is there incontinence of feces? Is a rectal pad or bandage worn or needed ? (77) Diseases of the eyes. — These affections demand extreme care on the part of the surgeons, and the examination should ]Droceed methodically, as follows: {a) The lids should be everted and the conjunctiva carefully in- spected. Is there trachoma, blepharitis, or pterygium? Is there trichiasis, ectropion, or entropion? (6) Is the cornea transparent, or are there opacities or pannus ; and if so, how much of the cornea do they cover ? (c) Are the pupils of the average normal size, and do they respond readily to light ? Are there synechias ? {d) In affections of the deeper structures of the eye, including the crystalline lens, the ophthalmoscope and oblique illumination must be used, and any variation from the normal condition of the parts must be described. (78) In any affection of the eyes, such as cataract, which the sur- geons believe to be a result of senility, it will be their duty to state this opinion. (79) Each board must supply itself with a card of Snellen's test types. This card should be hung in a good light, at a distance of 20 feet from the claimant. Each eye must be covered in turn while the vision of its fellow is tested. The largest type on the card is numbered 200, while the smallest is generally 20 or 15. Eecord the smallest type that can be read at 20 feet with each eye, and make the number of this type the denominator of a fraction in your record, while the distance at which it is read, or 20 feet, will be made the numerator. Thus : If the claimant at 20 feet from the card can read with the right eye the type numbered 50, and can read no farther, record the vision of the right eye as f^. If the left eye under similar circumstances can read only the largest letter, or No. 200, record the vision of the left eye as -^^. If the vision is so poor that none of the letters can be read at 20 feet, bring the card slowly toward the claimant until some of the letters can be seen. The numerator of the recording fraction will then be the new distance of the card from the claimant, while the denomi- nator will be the number of the type, as before. For the sake of uniformity, use only the foot as the unit of measure- ment for recording vision. (80) The test of vision frequently employed by examining sur- geons, viz, reading from a book or newspaper, is, by itself, of no value to this bureau. (81) Each board should provide itself with the means of determin- ing refractive defects, and state what kind of anomaly exists, and the record of visual power should be made after such error is cor- rected by 'the proper glasses. If the claimant wears glasses for distant use, as in walking about, the tests of vision should be made while these glasses are over the eyes; but, of course, reading glasses should not be before the ej^es while testing distant vision. (82) The surgeons should differentiate between the loss of sight of an eye and the actual loss of an eyeball. If an eyeball is shrunken or collapsed, the surgeon must state the extent to which it is atrophied, 12 liSrSTKUCTIONS TO EXAMINHSTG SURGEONS. giving exact size of stump. If the eye has been enucleated, it will be necessary to so state. (83) Nasojyharyngeal catcnTh. — Describe condition of anterior and posterior nares and tonsils. Are the Eustachian tubes pervious ? In every case of catarrh an examination should be made for impaired hearing. (See paragraph as to deafness.) (84) Diseases of the ear — Deafness. — In all cases the ear should be thoroughl}^ examined by the speculum after removing any collection of cerumen. The external auditory apparatus, membrana tympani, and nasopharynx should be described, and if deafness exists, the de- gree in each ear must be expressed in terms suggested in the following j)aragraph : (85) Degrees of deafness are to be rated as "slight," "severe," "nearly total," and "total," and will hereafter be described as follows : Slight deafness of one ear. — ^Inability to hear ordinary conversa- tion at 6 feet. Severe deafness of one ear. — Inabilitj^ to hear loud conversation at 3 feet. Nearly total deafness of one ear. — Inability to hear the loudest dis- tinct conversation at 1 foot. Total deafness of one ear. — Inability to hear the loudest conversa- tion. 4^86) In every case it will be necessary for the board to state the distance at which the claimant can hear the standard tones indicated above., as well as the distance at u-hich he can not hear thenfi. Thus, in a case of slight deafness it should be certified that claimant can not hear ordinary conversation at 6 feet, but can hear same at 1 or 2 feet, as the facts may warrant, etc. (87) Let each ear be tested alone by occluding the opposite ear as thoroughly as possible, and by directing the conversation from various . points "and from such positions that the claimant ma}^ not see the movements of the lips. Make a separate and distinct report for each ear in conformity with the above definitions. (88) If artificial means, such as trumpets, conversation tubes, etc., are necessary to assist the sense of hearing, the board will state this fact. (89) In cases of alleged total deafness the surgeon should state the method of communicating with the claimant. (90) It is expected that your examination will be conducted with such tact that you will not 'be deceived by the claimant's statements, and so that you may state positively that such degrees of deafness as you describe actually exist. Let all your conversation with a claimant for deafness be conducted while he is off his guard, with a view to test the correctness of your report. CERTIFICATES OE MEDICAL EXAMINATION. (91) The preparation of the certificates is an important part of your duty and should not be slighted. These certificates remain per- manently attached to the cases and are a sort of record of vour pro- fessional work. They should be written in a legible hand, with undi- luted black ink, though typewritten work is much preferred. Crowd- INSTEUCTIONS TO EXAMINING SURGEONS. 13 ing of words, interlineations, abbreviations, and use of the margins for writing upon should be avoided. (92) A continuation blank is provided m case a single sheet is not sufficient for the certificate ; and if used, it should be attached to the certificate blank, properly briefed, dated, and signed. (93) These blanks must never be used for any purpose other than •official certificates. (94) The blank spaces at the top of each certificate must be filled, taking care that the date is that of the examination and not that of the construction of the certificate. The date upon the back of the certificate and that upon the face should be the same. (95) The certificate should close with a statement to the effect that except as described no other disability is found and that the disabili- ties are not due to vicious habits, where such a statement is applicable. (96) When a certificate of medical examination does not cover all of the disabilities or is otherwise defective a call will be made for amend- ment. The amendment blank should receive the date of the original certificate, the amendment bearing the current date, be signed by each member who participated in the original examination if ]3rac- ticable, copied in the record, and forwarded as promptly as possible. If the record book is in the possession of the bureau, a copy of the amendment should be forwarded in order that it may be inserted. (97) A photograph or skiagraph is always acceptable and fre- quently aids the bureau in the proper understanding of a case; but there is no fund that can be used for this purpose, and such picture, if made, must be at the claimant's expense. (98) Certificates must have the signatures of the surgeons on both the face and back. If the names are affixed by a stamp or written by proxy, the certificate will be returned. If there is a vacancy on the board or a member is absent, the space for the signature should be filled by the word " vacant " or " absent," as the case may require. (99) Certificates must never be signed in blank, but the signatures should be appended after the certificate is otherwise complete and .after it has been carefully read. (100) No member of a board should sign a certificate unless he has been present during the examination and has actually participatecl in the same by assuming his share of the work. (101) Every member of the board will be held responsible for promptly constructing and forwarding certificates. When the secre- tary is absent or unable to prepare the certificates, the other mem- bers must assume the duties ordinarily performed by this officer. (102) The certificates should be folded from the center in four ■equal folds, the red order placed within, and mailed in the penalty envelope provided for that purpose. (103) Certificates of examination for every daj^'s work should be forwarded to the bureau, as a rule, within a week or 10 days from the date of the examination, never later than one month thereafter. (104) Every certificate of examination, including those made by a full board or member thereof, at the claimant's home or in an asylum, or elsewhere, must be copied in the record. (105) The record of examinations must be a veritable transcript of the certificate, and the signatures of the members of the board must appear as in the original certificate, but a transcript of the 14 IlSrSTEUCTIOXS TO EXAMINING SURGEONS. claimant's waiver in the record book, in case the full board is not. present, will not be necessary. (106) The record book must not be open for the inspection of any- one not properly authorized to see it. Except in this record book, the surgeon will not make and retain for his own use or the use of another a copy of a certificate or any part thereof. Before a record book is entirely filled requisition for a new one should be made, and the old book, when completely filled, should be mailed to the bureau, under the frank of a penalty envelope attached to the package. RATING. (107) By statute it is mandatory upon the boards an-d single sur- geons to " specifically state the rating which, in their judgment, the applicant is entitled to." A rate should, therefore, be suggested for each disability. (108) The order for examination will show the act of Congress under which the application is made. The different methods of rat- ing under the various acts are described in the succeeding paragraphs.. (109) Bates for certain disabilities under the general law are es- tablished either by law or rulings of the department, and they will be found in the appended tables. Under this law each disability should be rated separatel5^ (110) Eatings for enlisted men for other than specific disabilities will be expressed in dollars, and $17 is the highest rate allowed, ex- cept in grade cases hereafter provided for. Since anchylosis of a wrist or ankle joint is rated $8, disabilities; compared therewith that are less in degree are rated $2, $4, or $6 ; dis- abilities equivalent thereto receive the same rate, viz, $8. A disability greater in degree than that caused by anchylosis of a wrist or ankle^ joint, but less than one equivalent to the loss of a hand or foot, is there- fore rated $10, $12, $14, $16, or $17. Except in the case of certain degrees of deafness mentioned in the table of rates, the total for the rank of captain and certain fractional rates for officers of higher rank, there are no rates between $17 and $21, the latter being the rate for a disability equivalent to the loss of a hand or foot. (111) Officers whose disability is less than total will be rated in fractions of their total of rank, |-, |, |, as the case may seem to require. The total of rank of officers will be found in the table of rates. For the same degree of disability that would entitle an enlisted man to a rate of $8 a month, which is an enlisted man's total, the officer would receive the total of his rank. A lieutenant colonel in the Army or any officer of higher rank would, therefore, receive $30 ; a major, $25 ; a captain, $20 ; a first lieutenant, $17 ; a second lieutenant, $15. For a degree of disabilit}^ that would entitle an enlisted man to $2 one of these officers would receive ^ total of his rank ; $4 for an enlisted man ' would correspond to J- for an officer ; $6 for an enlisted man would cor- respond to f for an officer. In this connection read paragi-aph 119. (112) The rate will be placed upon the certificate immediate^ fol- lowing the description of the disability, and where there are several disabilities the same course shall be followed for each of them. IISTSTKUCTIONS TO EXAMINHSTG SURGEONS. 15 (113) Besides these rates there are grade rates provided for by law, as follows : (114) First grade. A permanent disability in a degree requiring the regular aid and attendance of another person, $72 a month. When the board or surgeon finds and describes a disability of this degree, the certificate must clcse with these words : This claimant is " so totally i'Tid permanently helpless from (here name the disability) that he re- quires the regular personal aid and attendance of another person," and is entitled to $72 a month. (115) An intermediate rate of $50 is provided by Congress in the :act of July 14, 1892. This rate is granted for a disability in such a degree as to require " the frequent and periodical, though not regular and constant, personal aid and attendance of another perscn." When this degree of disability is found and described, the certifi- cate must close with the words: This claimant is so disabled from as to require " the frequent and periodical, though not regular and constant, personal aid and attendance of another person," and is entitled to $50 a month. In recommending this rate, you will please state whether the claim- ant requires aid in such daily acts as dressing, undressing, and attend- ing to the calls of nature. (116) Second grade. A disability in a degree incapacitating for the performance of any manual labor, $30 a month. When this degree of disability is found and described, ths C3rtiiicate must close with the words : This claimant is " so disabled from as to be incapaci- tated for performing any manual labor," and is entitled to $30 a month. When it is claimed that the soldier is unable to perform any manual labor, it is important to learn his occupation and to state the condi- tion of his muscles and of the hands, whether indicating the perform- ance of labor cr not. (117) Third grade. A disability in a degree equivalent to the loss of a hand cr foct for the purposes of manual labor, $24 a month. When this degree of disability is found and described, the certificate must close with the words : This claimant is " so disabled from as to be incapacitated in a degree equivalent to the loss of a hand or foot for the purposes of manual labor," and is entitled to $24 a month. (118) The conditions under which grade rates are allowed are ex- actly the same for both commissioned officers and privates. (119) Before a pensioner can receive an increase to a grade rate or to a higher grade rate, it must be clearly shown that the disability is due to the cause or causes for which pension has been allowed and the degree of disability must be permanent. (120) Grade rates can not be made by adding together the rates for minor disabilities, and the surgeons will not make such additions. It is, however, proper to state at the bottom of the certificate that, in the opinion of the board, the sum of the disabilities (not the sum of the rates) is equivalent to the loss of a hand or foot as far as manual labor is concerned, or that the sum of the disabilities totally disquali- fies the claimant for manual labor, etc., as the case may require. Such a statement must not, however, exclude a separate rating for •each disability. (121) In rating an increase claim, you are expected to rate the disa- bility and recognized sequelae thereof precisely as though it were an 16 INSTEUCTIOXS TO EXAMINING SURGEONS. original case, and without regard to the present rating. You will, therefore, rate such cases strictly upon the disabilities found, as your judgment dictates. (122) Rating under act of June 27^ 1890. — The rate under the act ot June 27, 1890, as amended by the act of May 9, 1900, is based upon inability to earn a support by manual labor, due to any mental or phj^sical disability or disabilities of a permanent character net the result of the claimant's own vicious habits, and will be determined b}^ giving due weight to each and every infirmity, including these due to advancing years, and excluding those clearly the result of vicious habits. The sum total of such disabilities and infirmities, as hindrances to manual labor, will be estimated by the board and rated collectively at the end of the certificate at $6, $8, '$10, or $12, as the case mav wan-ant. (123) The rate ultimately granted in all cases will be determined by this bureau in accordance with the law and with the degree of disa- bility shown to exist, (124) The boards will receive orders marked, "Act of May 11, 1912." The disability clause in this act requires that in order to re- ceive ihQ only rate provided ($30) the applicant shall be unable to perform manual labor by reason of the causes for which pension has alreach^ been granted under the general law. The" examinations under this act will not differ from those made under the general law; but since the rate, if allowed, is practically the second grade, they should be made with as great care as those demanding the second grade under the general law. VOUCHERS. (125) The fiscal year is divided into four quarters, ending on Sep- tember 30, December 31, March 31, and June 30, respectively, of each year. Examinations made in different quarters must not be listed on the same voucher. (126) Form 3^163 is for the use of boards of surgeons. Form 3-164 for the use of single surgeons, experts, and others, and Form 3-168 for services and traveling expenses when an examination is made at the claimant's residence. Special instructions made necessary by the law and by departmental regulations are printed on each of these blanks. (127) Each examining surgeon who prepares a voucher for serv- ices (3-163) should enter therein the date of the close of the quarter after the words, " Fpr medical exammation of applicants for pension during the quarter ending — ," on both the voucher and the memorandum voucher, (128) Care should be taken in making the entries indicated by the printed portions of the voucher, and the totals must be entered by the surgeon. (129) The schedule entries in the voucher and memorandum voucher must agree in all respects. The memorandum is retained in the Bureau of Pensions, while the voucher, after approval, is for- warded to the Chief Disbursing Clerk for payment. Vouchers of boards of surgeons are considered with a view to settlement as soon as practicable after the ending of each quarter. HSrSTEUCTIONS TO EXAMINING SURGEONS. 17 (130) The signature of each surgeon must be personal. Signatures by stamps or by proxy will not be accepted. Each surgeon must sign the certification corresponding with the column in which his fees are entered and his post-office address in full, including the number and street, must appear beneath his signature,. The names of cities ]nust not be abbreviated. Signatures and post-office addresses should be jDlainly written in order that checks may be correctly drawn and properly mailed. Accuracy and legibility in the preparation of accounts will facilitate their settlement. (131) If there is a vacancy on the board, the word "vacant" should be written in the sjDace provided for the signature of the missing member. When a member of the board is not present, the word " absent " should be written in the space provided for his signa- ture, unless there is an ad interirro member. In the absence of the secretary, another member of the board must not sign as " acting secretary." The ad interim member should sign in the space provided for the member whose place he takes. (132) The voucher and memorandum voucher should be mailed with the certificate or certificates to which they refer.^ (133) Vouchers for examinations made at an adjourned meeting should bear the words, "Adjourned meeting," and the date when the examinations were made. (134) No entries should be made in the spaces provided for '"''A'pfro'priation: Fees of examinhig surgeons^ pensions.^ 191 — ," " Voucher No. — ," " Symbol — ," and " Class symbol — ." (135) A^^ien no examinations are made on any regular meeting day, the fact should be reported to the bureau on penalty card (3-347). (136) In case of a home examination, Form 3-168 is sent to the surgeon with the order directing that the claimant be examined at his residence. The instructions on the blank should be carefully read before the surgeon incurs any expense in connection with the exami- nation. (137) Each item of expense must be entered separately. A charge for subsistence must be itemized by meal in every instance (each pay- ment for breakfast, dinner, or supper for each person), the amount paid for lodging, and for each feed for horses. (138) Wlien the surgeon uses his own conveyance he is entitled only to actual expenses that can be definitely ascertained, such as for horse feed, gasoline, and oil, and the cost of each should be itemized. No charge should be made for wear and tear on tires. (139) When a railroad, trolley, steamboat, or other public con- veyance is available it should be used, and the name of the same and the fare paid should be entered in the voucher. Eeceipts for such ex- penditures are not required. (140) When a public conveyance is not available, a definite state- ment to that effect should appear in the voucher or subvoucher, and the surgeon must state the special conditions which warranted the use of a private conveyance and whether an automobile or livery was hired, with or without a chauffeur or driver. When transportation other than by rail, trolley, or steamboat is used, a receipt must be taken for each item of expense in excess of $1. This receipt must be signed by the person to whom the money is paid, and his post-office address must be given beneath his signa- 18 INSTRUCTIONS TO EXAMHSTHsTG SUEGEONS. ture. Blanks for receipts to serve as subvoiichers (3-165) are for- warded with each order for a home examination. (141) In form 3-168 the certification or oath must be completed by inserting the proper words, " is " or " is not," in the spaces pro- vided therefor. (142) When reimbursement is claimed for any item of actual ex- pense, surgeons must swear to their vouchers. No fee for adminis- tering an oath to a voucher will be allowed. The voucher may be sworn to before a postmaster, assistant postmaster, or other officials designated, without charge. (143) When reimbursement is not claimed the voucher should not be sworn to, but the surgeon should erase the words " and solemnly swear," and the italicized words, and personally sign the certifica- tion. When a home examination is made outside of the corporate limits of both the place of regular meeting of the board and the resi- dence of the surgeon who makes the examination, the fee is $5 ; other- wise the fee is $3. If no expense is charged, the surgeon should indicate on the voucher the places from and to which he traveled and the total distance covered. (144) There is no law which warrants the payment of a fee for an amendment to a certificate. (145) An examination made on an order through a special exami- ner should be listed on the regular voucher for that day, and it should be noted on the memorandum side of the voucher only that the certifi- cate was delivered to the special examiner. With the above exception, vouchers should be mailed wit,h the certificates to which they refer. TABLE OF RATES. Rates fixed by law for officers for disahilities ichich ivould entitle a private or other enlisted man to $8. ARMY. Per month. Lieutenant colonel and all officers of higher rank $30. 00 Major, surgeon, and paymaster 25. 00 Captain, provost marshal, and chaplain 20. 00 First lieutenant, assistant surgeon, deputy provost marshal, and quarter- master 17. 00 Second lieutenant and enrolling officer 1.5. 00 All enlisted men 8. 00 NAVY AND MARINE CORPS. Captain, and all officers of higher rank, commander, lieutenant com- manding, and master commanding, surgeon, paymaster, and chief engineer ranking with commander by law, lieutenant colonel, and all of higher rank in Marine Corps 30. 00 Lieutenant, passed assistant surgeon, siargeon, paymaster, and chief en- gineer ranking with lieutenant by law, and major in Marine Corps 25. 00 Master, professor of mathematics, assistant surgeon, paymaster, and chaplain, and captain in Marine Corps 20.00 First lieutenant in Marine Corps 17. 00 First assistant engineer, ensign, and pilot, and second lieutenant in Marine Corps 15. 00 Cadet midshipmen, passed midshipmen, midshipmen, clerks of admirals, of paymasters, and of officers commanding vessels, second and third assistant engineers, master's mate, and warrant officers 10. 00 All enlisted men, except warrant officers 8. 00 Rates and dlsahUities specified hy laiv. Loss of both hands 100. 00 Loss of both feet 100. 00 Loss of both eyes 100. 00 Loss of an eye; the other lost before enlistment 100. 00 Regular aid and attendance (first grade) 72.00 Total disability in both hands 72. 00 Loss of one hand and one foot 60. 00 Total disability in one hand and one foot 60. 00 Amputation at shoulder or hip joint, or so near joint as to prevent use of artificial limb 55. 00 Frequent aid and attendance ,50. 00 Total disability of arm or leg 46. 00 Arap'Utation at or above elbow or knee 46. 00 Loss of a hand or a foot 40. 00 Total disability of one hand or one foot 40. 00 Total deafness 40. 00 Inability to perform manual labor (second grade) 30.00 Disability equivalent to loss of hand or foot (third grade) 24.00 19 20 IN-STEUCTIONS TO EXAMINING SURGEONS. Table of rates fixed by the Commissioner of Pensions for certain disabilities not specified by law. Per montli. Anchylosis of shoulder $12- 00 Anchylosis of elbow 10. 00 Anchylosis of knee 10. 00 Anchylosis of ankle 8- 00 Anchylosis of wrist 8- 00 Loss of sight of one eye 12. 00 Loss of one eye I'''- 00 Nearly total deafness of one ear 6. 00 Total deafness of one ear 10. 00 Slight deafness of both ears 6. 00 Severe deafness of one ear and slight of the other 10. 00 Nearly total deafness of one ear and slight of the other 15. 00 Total deafness of one ear and slight of the other 20. 00 Severe deafness of both ears 22. 00 Total deafness of one ear and severe of the other _ — 2.5. 00 Deafness of both ears existing in a degree nearly total 27. 00 Loss of palm of hand and all the fingers, the thumb remaining 17. 00 Loss of thumb, index, middle, and ring fingers 17. 00 Loss of thumb, index, and middle fingers 16. 00 Loss of thumb and index finger 12. 00 Loss of thumb and little finger 10. 00 Loss of thumb, index, and little fingers 16. 00 Loss of thumb 8- 00 Loss of thumb and metacarpal bone 12. 00 Loss of all the fingers, thumb and palm remaining 16. 00 Loss of index, middle, and ring fingers 16. 00 Loss of middle, ring, and little fingers 14. 00 Loss of index and middle fingers 8. 00 Loss of little and middle fingers 8. 00 Loss of little and ring fingers 6. 00 Loss of ring and middle fingers 6. 00 Loss of index and little fingers 6. 00 Loss of index finger 4. 00 Loss of any other finger without complications 2. 00 Loss of all the toes of one foot 10. 00 Loss of great, second, and third toes 8. 00 Loss of great toe and metatarsal 8. 00 Loss of great and second toes 8.00 Loss of great toe 6. 00 Loss of any other toe and metatarsal 6. 00 Loss of any other toe 2. 00 Chopart's amputation of foot, with good results 14. 00 PirogofC's modification of Syme's 17. 00 Inguinal hernia which passes through the external ring 10. 00 Inguinal hernia which does not pass through the external ring 6. 00 Double inguinal hernia, each of which passes through the external ring_ 14. 00 Double inguinal hernia, one of which passes through the external ring and the other does not 12. 00 Double inguinal hernia, neither of which passes through the external ring 8- 00 Femoral hernia 10. 00 Thos. Featheestonhatjgh, Medical Referee. Approved : January 3, 1916. , G. M. Saltzgaber, Commissioner. II^DEX. Paragraphs. Adjourned meeting, voucher for, how made 133 when to hold 29 Age, effects of, when excluded 45 effects of, when included 122 Amputation, how to describe ' 48-52 Applicants, number to be examined in one day 28 privileges of 26 statements of 27 Asthma 68 Bladder, diseases of 70 Blanks, requisition for 39 Boards, absence or death of a member 6-8" adjourned meeting of 29 appointment of 1 change of residence of member 9 communications to, how to be treated 25 correspondence with dissatisfied claimant not to be held 34 legal holiday 4 majority and minority reports of 23 employment of clerk for 24 one member not to make an examination 18 organization of 2 place of meeting, change of 3 secretary being absent, duty to be performed by another member 101 time of meeting of 4, 5 vouchers of - 125-145 Books, record- 106 Brain, diseases of 61-64 Catarrh ( naso-pharyngeal ) 83 Certificates, abbreviations in, not allowed 91 must be copied in record book 104 amendment of 96 construction of 91 copies of, must be verbatim 105 copies of, not for personal use 106 correction of 96 date of 94 date of adjourned meeting 29 disabilities to be entered in order 42 folding of 102 heart and lungs to be described 46 legibility of; typewriter may be used 91 marginal entries on, not allowed 91 not to be signed in blank 99 prompt forwarding of 103 use of additional blank 92 use of stamp for signature prohibited 98 undiluted ink should be used 91 when not accepted as valid 18 Claimant, citation of 30 failure to appear within specified time 15 not to be examined by board of which he is a member 37 signature by mark must be witnessed 19 when to be examined at other than specified date 38 21 22 INDEX. Paragraphs. Claims, increase, how to rate 121 Clothing, when to be removed 40 Deafness 84r-90 Deformities . 47 Diarrhea 75 Disabilities, arrangement of, in certificate 42 degree of, not to be discussed with claimant 34 all existing, to be described 41 the result of age 45, 122 Ears, diseases of 84 Epilepsy 61 Examinations, at adjourned meeting 29 by civil surgeon 11 fees for 28 home, when made or not to be made 31 home, fees for 32 not to be made by one member of a board 18 of a member of a board not to be made by board 37 only members of board and clerk to be present when made (except as provided) 24 orders for 12, 18, 14 orders for, when to be returned 15, 16 results of, not to be revealed 34 special examiner may be present 24 test, when ordered and how to be made 22 through special examiner 145 Examining surgeons, can not make an affidavit unless claimant's family physician 35 can not accept fee for official examination 36 must participate in examination to be entitled to fee_ 100 must not act as attorney in pension claims 10 must read certificate before signing 99 should make a statement if they have personal knowledge of a claimant's disability 43, 44 Expenses for home examinations , 136-148 Eye, loss of sight of 82 Eyes, diseases of . 77-81 Fees 28, 32, 86, 143 Foot, total disability of 53 Genital organs, diseases of 71 Grade rates 113-120 Gunshot wounds 47 Hand, total disability of ' 53 Hearing, impairment of 84r-89 Heart, diseases of 67 Hemorrhoids (diseases of rectum) 76 Hernia 54-56 Holidays, legal 4 Hydrocele 72 Impaired vision 79-81 Injuries 47 Insanity 62 Kidneys, diseases of : 69 Limbs, total disability of 53 Liver, diseases of 60, 75 Lungs, diseases of 66 ' Malarial poisoning 59, 60 Nervous system, diseases of 61-64 Photographs, when desirable and how to be furnished 97 Quarters, ending of 127 Rates, act June 27, 1890 122 allowed, will be determined by bureau 123 basis for 110 for disability, act May 11, 1912 124 for enlisted men 110 INDEX. 23 Rates, act June 27, 1890 — Continued. Paragraphs. fixed by orders, rulings, and law 109 grade 113-120 grade, not to be made by adding rates together 120 in increase claims, how to make 121 must not be discussed in claimant's hearing 34 ofRcei-s 111 should follow description of disability 112 Records, how to keep 104 not to be open to inspection 106 their return, and requisition for record book 106 Rectum, diseases of 76 Rheumatism 58 Signatures on certificates 98 Skiagraphs , 97 Spinal cord, diseases of 61-64 Sunstroke and results 65 Surgeons, can not delegate power 6 change of residence of 9 civil, when and how selected 11 inability to perform duty, to notify bureau 6, 33 leave of absence of 7, 8 Syphilis 74 Tables of rates Appended Truss, correspondence relative to (note) 56 Typewriter, use of 91 Urinary organs, diseases of 69, 70 Urine, analysis of 69 Varicose veins 57 Varicocele 73 Venereal diseases 71, 74 Vicious habits 71, 74, 95, 122 Vision, impairment of 79-81 Vouchers and subvouchers 125-145 approved at ending of quarter 129 addresses on, to be plainly written 130 ending of quarter to appear on 127 expenses to be itemized on 137 for home examinations 136-143 forms for 126 for examinations at adjourned meetings 133 for expenses when surgeon's conveyance used 138 for amendments, not to be made 144 for examination through special examiner 145 " is " or " is not," when to be used in oath or certification to 141 oath to, when required and when not required 142, 143 schedule entries on, how made 129 signatures on, must be personal 130 spaces on, reserved , 134 statement on, when public conveyance is used 139 subvouchers, when to be used 140 totals, to be entered on 128 to be mailed with certificates 132 " vacant " and " absent," how used in 131 o COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C2e(i i40)M 100 COLUMBIA UNIVERSITY LIBRARIES nil 0052833330 1916 ^Mr