mm m^D- r> ',l- » ARMY MEDICAL LIBRARY FOUNDED 1836 WASHINGTON, D.C AUSCULTATORY PERCUSSION CHART. THOEAX. ANTERIOR. 1. 1. Clavicular Regions. 2. i. Sub-Clavian. 3. 8. Mammary. 4. 4. Infra-Mammary. 5. 6. The Sternal. 7. The Lower Sternal. LATERAL. 8. 8. Axillary Regions. 9. 9. Lateral do. 10. 10. Lower Lateral. POSTERIOR. 11. 11. Acromial Regions. 12. 12. Scapular do. 13. 13. Inter-Scapular do. 14. 14. Dorsal. ABDOMEN". 1» Epigastric. 2. 2. Right and Left Hypochondriac. 3. Umbilical. 4. 4. Right and Left Iliac. 5. Hypogastric. 6. 6. Eight and Left Inguinal. 7. Pubic. MANUAL OF INSTRUCTIONS MILITARY SURGEONS, EXAMINATION OF RECRUITS AND DISCHARGE OF SOLDIERS. With an. Appendix, CONTAINING THE OFFICIAL REGULATIONS OF THE PROVOST-MARSHAL GENERAL'S BUREAU, AND THOSE FOR THE FORMATION OF THE INVALID CORPS, ETC., ETC. PREPARED AT THE REQUEST OF THE UNITED STATES SANITARY COMMISSION, JOHN ORDRONAUX, M. D., PROFESSOR OP MEDICAL JURISPRUDENCE IN COLUMBIA COLLEGE, NEW YORK. NEW YORK: D. VAN NOSTRAND, 192 BROADWAY LONDON: TRUBNEE, & CO. 1863. \ J'>'' f ' / \ nb O Cow W| Entered according to Act of Congress, in the year 1863, By D. YAN NOSTRAND, In the Clerk's Office of the District Court of the United States, for the Southern District of New York. O. A. ALVORD, STEREOTYPER AND PRINTER. DEDICATED BRIGADIER-GENERAL WILLI A? 1 A. HAMMOND, SURGEON-GENERAL, T7NITED STATES ARMY. W<> PREFACE. The accompanying manual was prepared at the request of the United States Sanitary Commission, as a contribu- tion to Military Medical Jurisprudence, a department whose importance is second to none in the domain of mili- tary medicine. And while aware that it would amply justify an enlarged treatise of its own, the Commission, in accordance with their usual practice in issuing medical monographs, have selected this as the most condensed and practically useful form, in which to present surgeons with a complete aide-memoire upon the subject of which it speci- ally treats. In undertaking the duty of its preparation, the single point kept in view, therefore, has been that of embodying in a form of succinct exposition, the whole of the vast and complex subject of physical disabilities in their relation to the military service. It has been my aim, at the outset, to be ♦ brief without being obscure—to omit nothing of indispen- sable, or even ordinary importance—and to draw my ma- terials from the best accredited sources of information, and the highest authorities of the old world, because of the ages of experience possessed by European nations, and the largo 8 ' PREFACE. amount of knowledge preserved in their medical annals upon this branch of military hygiene. Selecting France and Prussia as the representative mili- tary nations of Europe, I have followed and adopted, as closely as possible, their codes of instruction on the sub- jects of the enlistment or discharge of soldiers. The Prussian code of 1858, entitled as follows : "Instruction fur M'ditair-Aerzte zur Untersuchung und Beurtheilung der Diensbranchbarkeit oder Unbranch- barkeit Jfilitaitpfichtiger Ilekruten resp. Soldaten, so wie zur Beurtheilung der Invallditat im Dienst b<'findlich>r oder entlassener versorgungsberechtighter Soldaten." Berlin den 9 Dez. 1858, per Dr. Grimm, General-Stab Arzt der Armee und Chef des Militair-Medizinal- Wesc/is, contains only thirty-six pages, while the French code of 1862, entitled, "Instructions pour les officiersde Santc sur les Infirmitcs ou Maladies qui rendent impropre au service Militaire" Approuve par le Marcchdl de France, Ministre Secretaire d'Etat de la Guerre, le 2 Avril 1862, d'apres la proposition du Conseil de Sante des Arrnees, contains one hundred and forty-five pages. This latter be- ing not only the most recent, but also the most ample and exhaustive, was accordingly selected as the foundation of my manual. With the exception of the introduction, and the leading sections treating of generalities, which imme- diately follow it, the manual is, for the most part, a, free translation of the French code. It was at first intended to have translated it literally, and to have thus adopted it without alteration, but on discussing the subject in a com- PREFACE. 9 mittee of medical gentlemen, it was deemed advisable, and as likely better to meet the wants of American surgeons, to entirely reconstruct certain parts, and to alter so many others in various Avays, as to render it more of a paraphrase than, strictly speaking, a translation. The diffuse and dis- cursive style so common to French writers, together with other idiomatic and professional peculiarities which need not here be mentioned, all conspired to justify the wisdom of this decision. Brief notes have also been added, whenever the subject under discussion seemed to require further illustration, and, if few in number, both their paucity and brevity must be charged to the single desire, expressed at the outset, of making the work a simple manual, rather than an expanded treatise like those of Coche, Marshall, or Fallot. In the preparation of a work of this kind, involving as it does a special and accurate knowledge of so many depart- ments of medical science, no single, unaided mind could safely venture to trust to its own resources. And I am happy in this connection, therefore, to acknowledge my great and lasting obligations to Dr. William H. Van Btjren, Professor of Anatomy, in the University of the city of New York, for his patient and critical revision of my manuscript, and the many valuable suggestions offered by him in the course of its preparation. Nor am I the less under obliga- tions of an equally lasting character to Dr. Cornelius R. Agxew, one of the surgeons of the New York Eye Infir- mary, who has not simply revised, but largely reconstructed the section on Diseases of the Eye. Many passages in the manual bear an impress of obscurity, 10 PREFACE. which, it is almost needless to say, has been purposely given them, in order not to furnish any instruments of deception • to those, who might seek here for assistance in accomplish- ing themselves in the art of malingering. While keeping this possibility constantly in view, it is believed that nothing of real importance to surgeons has been omitted. I have embodied in the form of an appendix, the code of instructions relating to the United States Army, adopted by the Board of Medical Officers, convened in Washington for that purpose, on the 15th of April, 1863, to which I have fur- ther added the Regulations governing the formation of our Invalid Corps ; the Prussian list of disqualifying diseases, and the Regulations governing the formation of their In- valid Corps. The following pages are now committed to the candid judgment and impartial criticism of the profession, in the hope that they will both subserve the interests of those for whose benefit they were written, and be found worthy of the subject they are intended to illustrate. J. O. New York, June, 1863. TABLE OF CONTENTS. INTRODUCTION. SECTION PAGE I.—Duties of Medical Examiners ; Instruments for Special Diagnosis............................•......... 19 II.—Generalities of Examination—General Bodily Appearance 20 III—Observations upon Feigned, Artificially Produced, and Concealed Diseases.............................. 25 IV.—Rules for the Examination of Suspected Malingerers.. 30 V.—Constitutional Diseases............................ 31 VI.—Diseases of Tissues.............................. 38 VII.—Diseases of the Cellular Tissue..................... 41 VIII.—Diseases of Serous Membranes..................... 42 IX.—Diseases of the Arteries.......................... 43 X.—Diseases of the Lymphatic System.................. 43 XL—Diseases of the Nervous System.................... 44 XII.—Diseases of the Muscles, Tendons, &c............... 48 XIII.—Diseases of the Osseous System.................... 49 XIV.—Pathology of Regions; Diseases of the Scalp........ 51 XV—Diseases of the Skull............................. 53 XVI.—Diseases of the Encephalon and Nervous System, Mania, Epilepsy, &c................................... 54 XVII.—Diseases of the Ears.............................• 64 XVIII.—Diseases of the Face.............................. ?4 t» XIX.—Diseases of the Eye.................•............. 76 XX.—Diseases of the Nose and Nasal Fossae.............. 102 XXL—Diseases of the Facial Sinus....................... 106 XXIL—Diseases of the Maxillary Bones.........,.......... 106 XXIIL—Diseases of the Mouth............................ 109 XXIV.—Diseases of the Neck............................. 12° XXV.—Diseases of the Larynx and Trachea................ 125 12 TABLE OF CONTENTS. SECTION PAGE XXVI.—Diseases of the Pharynx........................... 127 XXVII.—Diseases of the (Esophagus........................ 129 XXVIII.—Diseases of the Cervical Vertebras................... 131 XXIX.—Diseases of the Chest and Back.................... 132 XXX.—Diseases of the Ribs and Sternum.................. 136 XXXI.—Diseases of the Clavicle and Clavicular Region........ 131 XXXII.—Diseases of the Mammas........................... 137 XXXIII.—Diseases of the Thoracic Organs.................... 138 XXXIV—Diseases of the Spine............................. 148 XXXV.—Diseases of the Lumbar Region and Abdomen........ 153 XXXVL—Diseases of the "Pelvis............................. 162 XXXVII.—Diseases of the Anus and Rectum................... 163 XXXVIII.—Diseases of the Urinary Passages and Organs......... 168 XXXIX.—Diseases of the Genital Organs...................... 178 XL.—Diseases of the Limbs............................ 186 APPENDIX. (official.) UNITED STATES ARMY. 1. Official Instructions from the Bureau of the Provost Marshal- General for the Physical Examination of Drafted Men......... 209 2. Diseases or Infirmities which Disqualify for Military Service...... 211 3. Invalid Corps—Regulations for its Formation.................. 217 4. Invalid Corps—Physical Qualifications and Disqualifications for Admission into.......................................... 221 (official.) PRUSSIAN ARMY. 5. Diseases and Disabilities causing Permanent Unfitness for Military Service.................................................. 227 6. Invalid Corps—Physical Qualifications for Admission into........ 231 MANUAL OF INSTRUCTIONS FOR EXAMINING- SURGEONS. INTRODUCTION. RECRUITING AS A BRANCH OF MILITARY HYGIENE. The profession of arms is of all others that which re- quires in its followers the highest degree of physical perfection. Unlike any of those connected with the civil arts, it constantly subjects the soldier to those vi- cissitudes of life, which are disturbing shocks to the rliythm and harmony of vital functions. From a state of passive inactivity, it suddenly calls upon him to per- form long and fatiguing marches, to carry unaccustomed loads, to endure " fierce extremes" of heat, cold, and moisture, without adequate protection against their effects; to dispense with sleep when at times most ex- hausted, to take food at irregular and protracted inter- vals, and to subsist upon that which is often ill-cooked, inferior in quality, and unseasonable in character, or become unpalatable from monotony of repetition. Yet. such is the elasticity of nature in youth, that these vicissitudes, although depressing in their immedi- ate influences, are easily recovered from, if, with a due II MANUAL OF INSTRUCTIONS regard to hygienic laws, the recruit is gradually broken into acquiring the habit'of encountering them. While originally weak men may thus be hardened, it will always rest with commanding officers to see that due re- gard be had to the constitutional tendencies and the re- cuperative powers of their men, while inuring them to the hardships of the life they are to follow. The young may be as strong as the middle-aged, but they always differ from them in powers of endurance. Endurance, therefore, is the result of an acquired habit of muscular activity imparting tone to the whole system. And it is the culminating point in Military Hygiene, to cultivate the physical powers of young men by a daily practice operating within the limits of their strength, and never pushing exercise beyond fatigue, nor fatigue into prostration, but pursuing its course in such a manner, as to secure a progressive development in the foundation of those powers, as well as a gradual evolution of muscular activity, so that " he who has once carried the calf may be brought to carry the ox.'' No one understood this physiological law better than Napoleon, nor practised more faithfully upon it, and in illustration it is only necessary to cite the great victory of Dresden, which has been well designated a triumph of Military Hygiene.* On the afternoon of the second day of the battle, when the French army had been fre- quently repulsed in its attempts to cross the Elbe, the Young Guard arrived after a protracted march, beneath a sweltering heat. The moment seemed auspicious for deciding the fate of the day—the allies had lorn* been * OorER, Cours d'Etudes sur l'Ad.ninistr. Militaire, vol. iii., p. HO. Revolat, Hygiene Militaire. FOR EXAMINING SURGEONS. 15 harassed by the French artillery, yet still their batteries defied the passage of the river. All eyes were now turned towards the great chief in momentary expecta- tion of that word of command which was to dash this im- petuous young host upon their obstinate foes. But the modern Caesar understood the human constitution better than to call upon jaded troops to storm intrenchments. They were ordered to bivouac under the shade of the trees bordering the river. They were permitted to rest and refresh themselves with food and sleep until late in the day. And when at sunset they rose, a refreshed and recuperated corps, and were hurled like a thunderbolt against the enemy, the energy with which they crossed the stream, stormed the heights, and swept the Russian cannoneers from their hundred guns, testified to the wis- dom of that homage which had been paid to the pow- ers of nature. Had our generals, at the first battle of Bull Run, remembered this lesson of a great master, they too might have changed the fate of the day, and possibly shortened the life of the rebellion. How much of this wisdom of Napoleon was due to the considerate forethought of Larrey is not told us, but that he was consulted on the subject we can entertain no doubt. In ancient no less than in modern times the selection of recruits has always been made from the most virile of the population. If a state of physical integrity be essential to the soldier at the start, that integrity must be satisfactorily ascertained beyond a peradventure, before he is admitted into the ranks. Stature and harmony of form do not alone constitute vigor of body. All modern nations understand the truth of the principle laid down by one of the earliest writers on Military Science. " Utilius est enim fortes milites esse 16 MANUAL OF INSTRUCTIONS juam grandest and from whatever class in society taken, the recruit is always measured by his strength rather than by his size.* It may be stated as a problem immemorially de- monstrated by physiology, and deserving of consider- ation by economists, if only on the score of material cost, that an army recruited from the agricultural population of a country is, caiteris paribus, a cheaper, and at the same time more effective one than any collected from large, commercial communities. Having more physical stamina, it possesses a higher power of resistance to the causes of sickness and mortality, and presents fewer candidates for those forms of invalidism, and consequently exemption, which come from what are technically termed broken constitutions, or constitutions in which the original fund of reserved force has been exhausted—either by hereditary taints, improper educa- tion, diet, habits of occupation and life—in a word by the thousand circumstances in the midst of which civilized man lives. The ancients understood that thoroughly, and endeavored whenever possible to en- force this physical dogma. Yegetius,f writing in the * STATURE OF THE FRENCH ARMY. M. C. Ft. I. L. Infantry..............1. 561 =-497 i—French measure Riflemen..............1. 701=5 5. Artillery ■> Engineers}..........L 733 = 5 4- Dragoons ) Lancers }............1.706 = 5 3.' Chasseurs i Hussars f.........'" == Persons are exempt whose stature is below 1 mill. 506 cent, or 4 ft. 9 in.—Rossignol. Iraite d1 Hygiene Militaire. \ De Re Militari, lib. I., cap. iii. 1-OR EXAMINING SURGEONS. 17 time of the Emperor Yalentinian, and when the in- fluences of Asiatic conquests and the general introduc- tion of Eastern effeminacy had enervated the Roman youth, expresses himself in the following unequivocal terms : '' On which account I think no one can doubt that the rural population is best suited to bear arms, be- cause it ha"s been reared under the open sky and in the midst of labor. It is patient under heat—indifferent to shelter—ignorant of baths and luxuries—frugal in taste —content with little, and possesses limbs inured to every species of labor. Rural life itself accustoms men to' handle implements, to dig trenches, and to bear loads. But, on the other hand, since necessity also requires that dwellers in cities should perform military duty, ere their enrolment as militia, they should be taught to run—to labor—to bear loads, and to endure heat and toil; let them also learn to live on coarse, homely fare, and to dwell now under tents, now under the sky. For I know not why it is that death is dreaded less by him who has known the least luxuries in life." So, too, in the distribution of duties, the considerations due to age and relative strength were regarded with a scientific accuracy, and an appreciation of physiological laws which the moderns have never excelled. It would not be amiss for us to begin something similar in this respect, by distributing enlisted men among the various arms of the service according to their degree of physical vigor. Thus, instead of allowing to arbitrary and per- sonal caprice the selection of that arm of the service in which the recruit is to enter, make it a question of phys- ical adaptation of means to ends. Let his powers and their reach determine where he can be most useful to 18 MANUAL OF INSTRUCTIONS • the country, and least exposed to fall as a sick man upon her care. Use the instruments which science has invented to disclose the latent energies that slumber out of sight, and to indicate whether his constitution fore- ordains him for a stout footman—a swift skirmisher— an agile horseman—a ready artificer, or a sturdy can- noneer. It is skill to be able to read his undeveloped future of power, as well as the undeveloped future of disease, which some lurking predisposition suggests. Let him be developed and improved, as well as accepted and enrolled. FOR EXAMINING SURGEONS. 19 SECTION I. DUTIES 0? MEDICAL EXAMINERS. § 1. The duties which devolve upon •the examining surgeon are both delicate in their nature and of difficult performance. Intrusted with the responsibility of de- ciding some of the most perplexing questions in medical science upon only a few moments reflection, he cannot approach the discharge of his office without feeling how essentially important to the right understanding of every case, are the smallest apparent details of which it is made up. The causes of disease, the catenation of symptoms, their usual and ordinary progress, the results now present and visible, now unseen and latent, which they have produced in the human system—age, temper- ament, and occupation—all these are data which must be weighed and considered in every instance, before he can correctly form an opinion. When, in addition to the incertitude of natural phenomena, the accidents of fraud by simulation, or concealment, enter into the problem, it is not difficult to see that with all the skill possible, and all the readiness of observation employed, cases of deception will at times escape detection. Instruments for Special Diagnosis. § 2. There are certain instruments of indispensable importance to examining surgeons, and without which none should undertake a methodical exploration of the human system. These are— A watch (to test deafness, pulse, breathing, &c.) 20 MANUAL OF INSTRUCTIONS Magnifying-glass (to examine the eyes and cutaneous diseases). Spatula. Measuring tape. Catheter and sound. To these may be added, for greater precision, and when time is abundant—the following, viz : A Stethoscope. Laryngoscope. Speculum auris. " ani. Ophthalmoscope. SECTION II. GENERALITIES OF EXAMINATION. § 3. The law requiring that the recruit should be examined naked, standing, and in the day-time {vide Appendix), the following general rules will be found of service in beginning an examination. General Bodily Appearance. § 4. The first glance at the anterior and posterior portions of the body will give the tout ensemble, or aggregate appearance of its conformation, and serve to answer the first irrterrogatory of, faulty, or not ? The general constitutional vices, or anatomical deformities to be looked for as causes of disqualification are, maras- mus, obesity, extensive deformities of the face larqe Uvid, hairy spots, extensive loss of substance of the FOR EXAMINING SURGEONS. 2] cheeks, loss of one or both eyes—of the nose—of the whole or a portion of a limb—of the testicles, deform- ities of limbs, club-foot, bandy-legs, knock-ktiees, &c* § 5. Inasmuch, however, as a simple glance is not always sufficient, a more particular and minute ex- amination must be made, in order that whatever may have escaped the sight, may be discovered by the touch, a sense whose assistance is of infinite service in the diagnosis of many external affections. The surgeon will therefore begin a systematic and successive examination of-the various portions of the body, from the head downward, proceeding in each region from the exterior to the interior. Each organ should be specially interrogated by every known means, in order to ascertain— A. If any thirrg interferes with that freedom and activity of its functions necessary for the performance of military duty. B. Whether any portion of the body is incapacitated from enduring the burthen of clothing, arms, or equip- ments. C. Whether from inherent debility, morbid predis- position, or existing disease, the health, and even the life * The following description of the " good points " which the recruit should present anatomically, is so terse, comprehensive, and scientifically. accurate, and stated with such elegance, and pregnant brevity, that I would not mutilate it by attempting an English paraphrase: . " Sit ergo udolescens martio operi deputandus, vigilantibus oculis, erecta cervice, lato pectore, humeris musculosis, valentibus brachiis, digitis hngioribus, ventre modicus, exilior cruribus, suris ac pedibus non super- flua came distentis, sed nervorum duritia collectis. Cum haec in tyrone signa deprehenderis, proceritatem, non magnopere desideris. Utilius est enim fortes milites esse quam grandes.—Vegetius, De Re Militari, lib. I., cup. vi. 22 • MANUAL OF INSTRUCTIONS of the individual would be endangered by the circum- stances attendant upon the duties of a soldier. D. Whether the party is suffering from any infirmity which, while not sensibly impairing organic functions, is yet so disgusting in character as to render him repul- sive and uncompanionable. § 6. Head. Examine this closely for deformities, loss of substance of bones, extensive cicatrices, and cutane- ous diseases. Pass the hand through the hair and ascertain whether the scalp be hot, and humid, or dry. § 7. Neck. Fulness in the region of the splenii muscles, is generally an indication of strength of bod}r. § 8. Thorax. The thorax, particularly in its upper (clavicular and subclavian) portions affords a better index of the constitutional vigor of the individual than any other part of the body. When there is fulness, hardness, and symmetrical development of these regions and base of the neck, a presumption of constitutional soundness can safely be indulged.* On the other hand, *Mere lack of symmetry between the sides of the chest, is not, in itself, an indication of structural change in internal organs (e. g., hypertrophy, phthisis, &c), but may be due to a variety of causes occasioning flatness of the pectoral muscles. Constantly using the right arm, or sleeping on that side, by depressing the shoulder, may give rise to this defect of uni- formity. Dr. Wm. H. Thompson, of New York, one of the State Medical In- spectors of Recruits, in his Report to the Surgeon-General, states, that "taking the whole of 5,000 observations, the right side was flatter than the left in 75 per cent, nearly; and out of the more marked cases of 2,000, the right side was flat in 87 per cent. ... In 10.05 per cent., how- ever, the left side was the flattest, though the persons were right-handed." —Annual Report of the Surgeon-General of the State of New York, trans- mitted to the Legislature, January 27th, 18G3, p. 60. Vid Woillez, Recherches pratiques sur l'lnspection et la Mensuration de la roitrine FOR EXAMINING SURGEONS. 23 sinking or depression of these parts, particularly on the left side, should always suggest the necessity of auscul- tation, as it is well known that the left lung suffers more commonly than the right, and that the apices and poste- rior parts of the upper lobes of the lungs are points of election for tubercular deposit. Having noted these things, now measure the circum- ference of the chest, in its ordinary condition of inter- mediate expansion, by passing the tape around on a line with the nipples. This measurement should not fall below thirty-one and a half inches, nor be less than one-half of the stature of the individual. The expan- sive mobility of the chest should be from two to three inches. The following table will explain this at a glance: MINIMUM CIRCUMFERENCE OF THORAX TOLERABLE IN RECRUITS.* HEIGHT. CIRCUMFERENCE OP THORAX. Feet Inches. Inches. 5 3...............................31* 5 4...............................32 5 5...............................32* 5 6...............................33 5 7...............................33* 5 8...............................34= 5 9...............,..............'-34* 5 10...............................35 5 11...............................35* 6 00...............................36 6 1..............................36* 6 2...............................37 6 3...............................37* 6 4...........s...................38 § 9. Abdomen. In health the abdomen is soft, slightly convex, and its walls elastic. The regions to be exam- ined by palpation are the right hypochondriac and epigastric, for diseases of the liver usually manifested by enlargement; left hypochondriac, for enlargement of * Military Hygiene, by Brigadier-General W. A. Hammond, Surgeon- General United States Army, p. 38. -1 MANUAL OF 1NSTKUCTIONS spleen, manifested by tumor and projection of the lower left ribs. Mesenteric disease reveals itself through gen- eral enlargement; while faeculent accumulations, most common in the large intestines, are shown by rough prominences in both the iliac regions. § 10. Limbs. The limbs should be free from all de- formities in size, form, or relative proportion, e. g., atrophy, rickets, bandy-legs, knock-knees, or differences in length. § 11. Feet. The feet should be arched, without de- formity, or loss of substance of any of the toes, particu- larly the great ones. § 12. Stature* and Weight. The stature should not fall below five feet, three inches, nor the weight below Jliat marked as its minimum accompaniment in the sub- joined table: HEIGHT. MINIMUM WEIGHT. Feet. Inches. lbs. 5 3...............................115 5 4...............................120 5 5...............................125 5 6...............................130 5 7...............................135 5 8...............................140 5 9...............................145 5 10...............................150 5 H...............................155 6 00...............................160 6 1...............................165 6 2...............................170 6 3...............................175 6 4...............................180 6 5.............•---•............185 6 6. 6 7. .190 .195 * Wherever there is suspicion of an attempt to decrease stature by curving the spine, the recruit should be measured supine. FOR EXAMINING SUEGEONS. 25 SECTION III. GENERAL OBSERVATIONS UPON FEIGNED, ARTIFI- CIALLY PRODUCED, AND CONCEALED DISEASES. * § 13. By the term feigned disease, is to be under- stood a train of symptoms provoked by artificial means, for the purpose of simulating a real disease. An artificially or self-provoked disease exists in fact, but it is the result of criminal manoeuvres performed upon the person, to avoid the discharge of some duty. A dissembled or concealed disease, is one which, although existing in fact, is purposely concealed with an intention to defraud observation. The military surgeon should always be oh his guard against feigned diseases, as well among soldiers seeking for a discharge, as among recruits; and also be vigi- lant to detect dissembled or concealed diseases in substi- tutes and volunteers. * For exhaustive details on this subject, the surgeon will do well to con- sult, Zacohias, Quaestiones Medico-Legales, lib. III., tit. II.; Fodere, Medecine-Legale, vol. 2, p. 457; Mahon, Medecine-Legale, vol. 1, p. 324; Deveroie, Medecine-Legale, vol. 1, p. 605; Beck's Medical Jurisprudence, vol. 1, art. " Feigned Diseases;" Casper, Medecine-Legale, vol. 1, p. 238 ; Percy and Laurent in Diet, des Sciences-Medicales, art. "Simulation;" Cyclopaedia of Practical Medicine, art. "Feigned Diseases;" Copland's Dictionary of Practical Medicin*, art. "Feigning Disease;" Dunglison'S Medical Dictionary, art. " Feigned Disease." 2 26 MANUAL OF INSTRUCTIONS Artificially Produced Diseases. § 14. Artificially produced diseases which, as we have seen, are diseases in fact, occasion the greatest perplex- ity to the surgeon, by reason of their rarely disclosing the sources of their origin ; and in general it is only when recent, that their origin can at all be discovered. In doubtful cases the surgeon will have to resort to all the questions enumerated below. (§ 23.) Dissembled, or Concealed Diseases. § 15. The duty of the surgeon in exploring a party to discover dissembled or concealed diseases, is always a difficult one, for many diseases- having their seat in internal organs, when they have not produced constitu- tional, nor sympathetic disturbances, will often escape observation. This is particularly the case with inter- mittent affections, which may exist undiscovered so long as the surgeon does not himself witness a parox- ysm. Feigned Diseases. § 16. In treating of simulation in connection with the various diseases which are hereafter to be enumerated, the methods of detecting fraud will alone be given.* It cannot be necessary to a surgeon experienced in the phy- siognomy of disease to be told what and how many are * As these pages cannot be restricted in their circulation to the hands of surgeons alone, it has been deemed judicious to exclude from them all enu- • meration of the pharmacopoeia and the enginery from which simulators draw, their means of deception. The sources of information touching these practices are well known to all physicians, and elsewhere pointed out and aside from policy, it would oMy augment the size of this manual without adding to its usefulness to enter into the pathogeny of feigned diseases FOR EXAMINING SURGEONS. 27 the particular agencies which criminal design employs to impose upon his credulity. The differential diagnosis of the real and the feigned disease will rarely fail to expose the incongruity existing between the actual and the al- leged malady. The ignorance of symptomatology—of sympathetic, and consequential manifestations—of the law of periodicity—of the co-ordination of vital forces and functions—in a word, of anatomy and physiology, renders the majority of simulators mere physical clowns. The rationale of simulation being a travesty of natural phenomena anda violation of truth, in its details, gener- ally exposes itself at a glance to the prying, skilled eye of science. Nevertheless, we must not despise the class entirely. There are some experts in it, and even phy- sicians have been found in other countries selling their knowledge in this way, and prostituting their skill to the basest of purposes, by instructing malingerers in the use of harmful drugs, and in the performance of crim- inal manipulations, calculated to impair, temporarily, their vigor of body. But in all cases the surgeon must be prepared to meet the simulator on his own ground, and if need be, superare malitiam malitia, by artfully circumventing him. § 17. For obvious reasons, chronic forms of disease are of preference feigned by malingerers. As it is known among recruits that the examination of the surgeon must, of necessity, be brief—that it cannot be repeated, but must terminate his inquiry once for all, it is naturally supposed that the more numerous the symptoms they can present the greater will be the bias of a first impres- sion in favor of their disability. Others select milder forms of diseases whenever they mistrust their ability to simulate their acute type, alleging with much reitera- 28 MANUAL OF INSTRUCTIONS tion, that they have been worse even than they now arc, and that the surgeon sees their malady under its most favorable aspect. This is commonly the case when rheu- matism, neuralgic pains, chronic piles, lumbago, diseases of the bladder or kidneys, constant severe headache, ulcers, deafness, old sprains, &c, &c, are feigned. § 18. The following synoptical table exhibits feigned diseases under three pathogenetic classifications, viz. : A. Such as depend upon the influence of the will upon muscles of voluntary motion. B. Such as are excited by artificial agents without lesion of tissues. C. Such as are similarly excited with lesion of tissues. A. Class First. § 19. Feigned diseases depending upon the influence of will upon muscles of voluntary motion, and an im- paired state of the animal functions. Epilepsy, idiocy, loss of memory,* mania, deafness, ptosis of right eyelid, involuntary and convulsive movements of the eyes, or their lids, strabismus, dumbness, aphonia, stammering, torticollis, curvature of the spine, voluntary vomiting, rumination, re- tention, and incontinence of urine, general or partial tremor, paralysis, retraction, or continuous flexion of fingers and limbs, lameness, unnatural elevation of one shoulder, partial or complete anchylosis of a limb, in- version or torsion of one foot. B. Class Second. § 20. Feigned diseases imitated by artificial means and presenting as yet no alteration of tissues nor important lesion of functions. FOR EXAMINING SURGEONS. 29 Jaundice, ecchymosis, phthiriasis, purulent discharge from ears, haemoptysis, haematemesis, hsematuria, internal piles, prolapsus ani, excretion of vesical calculi, varices, hemorrhoidal flux. C. Class Third. § 21. Feigned diseases, voluntarily excited, and imi- tated by the internal or external use of agents, capable of producing an unnatural change in the form, volume, integrity, continuity, and sensibility of different parts of the body. Wounds, mutilations, ulcers, cutaneous diseases, and petechiae, ophthalmia, scurvy of gums, caries, partial or total loss of teeth, vertigo, mania, emphysema, ascites, tympanites, hydrocele, vomiting of food, syncope, fee- bleness of pulse, palpitation of heart, amaurosis, fever, emaciation. Diseases which may be Concealed. § 22. Incontinence of faeces, rheumatism and neural- gic pains, prolapsus ani, retention or incontinence of urine, shortening of an inferior extremity, loss of memory, epilepsy, somnambulism, periodical haemoptysis, asth- ma, taenia, habitual vomiting, gravel or hemorrhoidal flux, chronic catarrh of bladder, intermittent fever, syphilis. 30 MANUAL OF INSTRUCTIONS SECTION IV. RULES FOR THE EXAMINATION OF SUSPECTED MALINGERERS. § 23. Whenever a disease is alleged to exist, by a recruit, the first duty of the surgeon is to determine whether it be of such a character as admits of being feigned. This is the starting point of all subsequent inquiry. A. In cases of doubt, it is always safest to assume the disease as feigned, rather than as real, and to pro- ceed to a minute and detailed examination of the party with all possible delicacy and moderation, and without an}7 seeming suspicion. B. If the history and symptoms of the alleged disease, and the changes wrought by it in the economy, are at variance with the regular and ordinary course of the true disease, simulation may be suspected. C. The party should be questioned in relation to symptoms, in order to test their correspondence with those usually present in similar diseases, and by leading him on vaguely, with irrelevant inquiries touching other disorders, he will often, if a malingerer, expose himself by confounding symptoms belonging to dissimilar and opposite diseases. D. In investigating an internal malady, assume to believe in the existence of all the symptoms narrated; then apply the rule contraria contrariis, and ask leading and suggestive questions touching the presence of in- congruous symptoms, such as amblyopia, haemorrhage from the left ear, swelling of the thumbs (Casper), cold- ness of the tongue, &c. The simulator will often entrap FOR EXAMINING SURGEONS. 31 himself by an affirmative reply, based upon the suppo- sition that he had mis-stated the symptoms of his malady and can now correct his mistake by adopting new ones.* E. By calling attention away from himself, the party may often be made to perform acts entirely in- compatible with the existence of his alleged disease, and thus expose his deception. SECTION V. CONSTITUTIONAL DISEASES. § 24. Whatever may have been said in favor of, or against temperaments, and whatever the disputes in re- lation to their classification, it is an admitted fact, that in every age, and among all men, they have been re- cognized as influencing the predisposition to disease, f On this account, therefore, if no other, the surgeon should interrogate them as sources of aeteological influence. For, the physical aspect presented by the body in this particular expresses the predominance or exaggeration of either the sanguineous, lymphatic, or nervous systems, and the consequent predisposition to those diseases * Ut ergo prudens Medicus ad decernendum ab ipsis Jurisconsultis de veritate vocatus, non decipiatur, plura in consideratione adhibeat necesse est; et primo partem quae dolet, vel quae dolore simulatur; secundd doloris speciem; tertio causam doloris, et maxime siquam enarravit patiens ex procatarcticis et externis; quarto doloris ipsius durationem; quinto remedia adhibita seu adhibenda.—Zacchias, Op. cit., lib. III.,tit. II., q. IV. f Military Hygiene, by Brigadier-General W"m. A. Hammond, Surgeon General U. S. A, page 78. Q>9 MANUAL OF INSTRUCTIONS having their origin in one of these three great centres. Hence, in the lymphatic, we look for diseases of the glandular system; in the sanguine, for diseases of the circulation; and, in the nervous, for diseases reflected from preternatural irritability of the cerebro-spinal sys- tem upon large organs, like the stomach, brain, or heart. But, inasmuch as there are no pure or unmixed tem- peraments, no absolute deductions can be drawn from the foregoing classes, though in each case, taking tem- perament only as a relative element in the computation, we shall still find it acting as an important postulate to predisposition. Sources of Indication. § 25. There are three sources through which radical constitutional impairment ever exhibits itself exter- nally, viz.: 1st. Through the glandular system, producing the true strumous diathesis. 2d. Through the osseous system, giving rise to rickets and rickety deformities. 3d. Through the skin, giving rise to obstinate cuta- neous diseases. Whenever these manifestations have plainly existed to such a degree and for such a length of time as to in- dicate a chronic impairment of the functions of nutri- tion and secretion, it is evident that such a state bor- ders on actual disease, and unfits the party for military service. Feebleness of Constitution. § 26. Without the existence of special disease in any organ or tissue of the body, there may yet be presented by an examination of the person, such proofs of a want FOR EXAMINING SURGEONS. 33 of tone and of powers of endurance, and such an absence of recuperative force and of vigor in vital functions, as to show that the constitution could not rally against causes of depression, nor promptly re-establish itself with the spontaneity due to plenitude of original vigor. This condition, popularly designated as feebleness of constitution, cannot always be defined with precision, because in each individual, the circumstances of ab- solute and reserved vigor express . themselves through different physical phenomena, and what might be rela- tive weakness in one, born of habits of life, and occupa- tion, temporary and remediable, would in another indi- cate congenital absence of tone. It is idle to suppose that constitutions can be re-cast. Original nature may be modified, but never entirely altered. We must judge of the vigor of the human edifice by the character of its foundation, for where this is weak, the super- structure, however beautiful, is only calculated to de- ceive us. The following are manifestations which gen- erally accompany feebleness of constitution : Excessive stature without corresponding breadth of person ; long, thin neck; narrow chest, sunken or flattened / shrunken abdomen ; faccidity, without development of the belly of large muscles ; limbs larger at the joints than in the centre, articulations coarse; skin soft and flabby, and ' almost barren of hair ; lips pale, and a general indica- tion of want of activity in the'vital functions. Although many of these conditions are presented during convalescence from acute affections, yet the skil- ful surgeon will readily detect, by the degree to which the constitution is affected, whether the diathesis pre- sented by the party be radical or merely accidental in its character. 2* 34 MANUAL OF INSTRUCTIONS Anaemia. § 27. Anaemia,.characterized by general debility, emacia- tion, flaccidity, and pallor of tissues, sometimes even infil- tration of the cellular tissue and souffle in the carotids, can only justify the rejection of a recruit when it is of the gravest character. Misery, certain professions fol- lowed in dark and damp places, labor disproportioned to strength, venereal excesses, scurvy, convalescence from acute diseases, are all determining causes of this diathe- sis, which is removable under proper hygienic and therapeutic treatment. Bejection in such case must rest upon the question of extent of disease, and proba- ble time required to recover from it. Anaemia may be artificially produced, but not feigned. Scrofula. § 28. Scrofula, when unmodified by the influences of puberty, and characterized by glandular enlargements, or ulcerations in the cervical or submaxillary regions, is a dis- ease of sufficient gravity to j ustify rejection. When, how- ever, this diathesis, united to an otherwise tolerable state of health, is little developed -and constitutes more of a predisposition than a positive disease, and in particular when this predisposition seems to arise rather from the bad hygienic conditions in the midst of which the party has lived, it often happens that the change of habitation, diet, and occupation, essentially improve the waning constitution, and convert into a healthy soldier a civilian, whose mode of life otherwise doomed him to the infirmi- ties born of scrofula. This constitutional vice is indicated by slight puffi- ness of the face, thin, transparent skin, through which FOR EXAMINING SURGEONS. 35 the veins appear prominent, the alee nasi are smooth and tumefied, the upper Up thickened, the limbs are rounded, the flesh soft and flaccid, and the abdomen slightly enlarged. In a more advanced stage, the eyelids are swollen, red, everted (blear-eyed) with discharge from the meibomian glands, and the ears surrounded by sup- ^ purative crusts. Although malingerers sometimes attempt to simulate scrofula, by making irritating applications to the eye- lids, nose, and upper lip, the absence of all constitu- tional complications readily exposes the cheat. Besides which scrofulous ulcers and scars have a .specific char- acter, the former having pale and flabby borders, with thin edges, and discharging a serous matter, mixed with grumous, cheesy clots ; and the latter being deep, adherent to the subcutaneous tissue, bluish colored when recent; white when old, irregular with trans- verse bridles, and being found in the track of the lym- phatic ganglions. The same degree of scrofula which justifies rejection, likewise justifies discharge. Syphilis. § 29. Primary or local syphilis does not justify rejec- tion, unless accompanied by extensive ulcers, calculated to leave large, feeble, irregular cicatrices, and much loss of substance. The same is not the case with sec- ondary syphilis, which denotes a true venereal saturation of the constitution, and is marked by profound .altera- tion of the vital functions, engorgement of the cervical, axillary, inguinal, and lymphatic ganglions, ulcerations of the mucous membrane of the nose, caries of the bones, &c, in those whose constitutions are seriously affected by it. This condition of body, although cura- 36 MANUAL OF INSTRUCTIONS ble under skilful treatment, yet indicates such impair- ment of the constitution, as renders it certain that the party cannot withstand the duties and hardships of a military life. He must be rejected. Scurvy. § 30. Scurvy, which is. never congenital, but always acquired, presents itself under different degrees of in- tensity.^ The judgment of the surgeon will accordingly be guided by the peculiar phases it reveals, in deter- mining the questions of rejection or discharge. In slight cases, and where the morbid- manifestations are simply local, improved hygienic conditions will usually suffice to produce a rapid recovery. But when the dis- ease has assumed a serious form, and is accompanied by fungous gums, falling of the teeth, oedema of the limbs, discoloration of the tissues, serous infiltration, pete- chise, passive haemorrhage, and muscular pains, the re- cruit must be rejected. Cachexies. § 31. Various cachexies resulting from malarious, lead, or mercurial poisoning, or others arising from the practice of certain avocations, may also come under the notice of the surgeon. So long as there is no manifest impair- ment of the constitution, and a change of habits and occupation seems likely to insure a recovery, rejection is unjustifiable. But when alterations in structure have resulted, or organic functions are so unsettled as to fall readily into morbid conditions under slight exciting causes, the recruit must be rejected. The same rule will apply to discharges. FOR EXAMINING SURGEONS. 37 These cachexies may be artificially produced, but can- not be feigned. Tuberculosis. § 32. Tubercles, although most commonly exhibit- ing themselves in the lungs, or peritoneum, are yet often found in other tissues. Their deposition depends upon a peculiar diathesis, which manifestly impairs the constitutional vigor necessary for the military service. In their second stage (that of softening and suppura- tion) their diagnosis is easy. But in their first stage, where they remain in the form of a hard, indolent, iso- lated deposit, producing no sensible disturbance of any of the organic functions, they may escape observation. It is different with masses of tubercles which even in their first stage are generally appreciable. It is through the constitutional manifestations that the sur geon must seek for revelations of this diathesis where- ever he suspects its existence. Melanosis. § 33. Melanosis which is a deposit of black pigment in the tissue of diseased organs, does not differ greatly from cancer, and when occurring in encephaloid struc- tures, constitutes true melanoid cancer. At times it occurs in organs not essentially diseased. Any attempt at feigning this affection by introducing coloring pigments beneath the skin, is of so gross a nature as to readily expose itself. • Cancer. § 31. Several morbid conditions of structure essentially different in their anatomical elements, are confounded under the common designation of cancer—such, for 38 MANUAL OF INSTRUCTIONS example, as scirrhus, encephaloid, and colloid cancer. Whatever its seat or nature, cancer ever presents itself under the form of a fungous growth, tumor, or of open ulcerations. Being always a serious affection, with dis- position to recurrence when locally extirpated, its diag- nosis becomes of the greatest importance to the surgeon, and as this is at times extremely difficult, all his sagacity will be required in arriving at a conclusion in the premises. The first thing to be remembered is that cancer is of rare occurrence in youth, and, secondly, that it cannot be feigned. In recruits, therefore, the presumptions are against it; in old soldiers it is different; but in both classes rejection or discharge must follow upon its de- tection. The liability to alteration of the lymphatic glands in the vicinity of the suspected cancerous disease is to be borne in mind as a characteristic sipect of traumatic lesions, but also with relation to various diseases, such as spasmodic stric- ture, either a purely nervous disease, or symptomatic of inflammation, stricture, partial dilatation, paralysis, softening (analogous to that of the intestine), ulcer- ations, cancer, &c. These diseases, although rarely en- countered by examining surgeons, are frequently seen in hospitals, and ever afford a cause for discharge. Dysphagia, from whatever cause arising, is always accompanied by an impairment of the general health. An examination of the bodily condition must always be made, whenever any suspicions of the reality of this affection arise. Paralysis. § 243. Paralysis of the pharynx and of the oesopha- gus, is an affection rarely occurring, except as a symp- 6* 130 MANUAL OF INSTRUCTIONS torn of serious nervous disease, and occasioning as a con- sequence, whenever prolonged, marked emaciation, pro- found debility and general prostration,—results, whose absence would set at defiance all such attempts at feigning as contortions during deglutition, efforts to vomit, to cough, to sneeze, by means of which an ob- stacle would be put to the entrance of food or drink into the pharynx, or those nervous spasms causing solid or fluid substances to be rejected through the nostrils, during deglutition. It is needless to remark that this affection is always a cause for rejection or for discharge, when incurable. Coarctation, (Stricture). § 244. Difficulty of swallowing may arise from stric- ture of the oesophagus, without any appreciable external sign of this alteration. It may be discovered, however, by introducing into the oesophagus, a gum elastic sound. A urethral catheter of largest size, provided with a sty- let, and slightly curved, will answer for this purpose. By the obstacle encountered, and the sense of friction transmitted, it is easy to establish the existence, the situation, and the degree of contraction, of the stricture. This latter always affords a cause for rejection. A dis- charge should, likewise, always be granted, even though, by the employment of dilating instruments, a cure seems to have been obtained ; because, in the first place, such a cure is never complete, and secondly, because the dis- ease has a tendency to return in a more aggravated form under the influence of army diet, however good it may otherwise be. Feigning can be discovered by prac- tising catheterism. FOR EXAMINING- SUKGKONS. 131 SECTION XXVIII. DISEASES OF THE CERVICAL VERTEBRA. Articular Torticollis.—Cervical Sprain. § 245. Diseases of the cervical vertebrae, require a critical examination, either by pressure with the fingers in the posterior region of the neck, or by exploring the posterior fauces, and particularly the pharynx. Touch will also enable us to discover certain congenital defor- mities or deviations of the bony structure of those parts (articular torticollis), or among anatomical lesions, cervi- cal sprain, recent or of long standing, varying according to the degree of pain, the extent of deviation, and the immobility of the vertebrae, whose ligaments had suf- fered distension or partial rupture. The peculiar and persistent attitude of the head, well known to surgeons, is a pathognomonic sign of the disease, in its early stage. These diseases are always a cause for rejection. Feigned cervical sprain is of too easy discovery to require any special notice. The means to be employed by the sur- geon in ascertaining its reality, require prudence and careful manipulation. Fracture. § 246. Fracture or incomplete luxation of the cer- vical vertebrae, occasioning more serious effects than sprains, and creating danger of compression of the cord, leave no room for doubt as to the decision which should be made. Other Diseases. § 247. Diseases of the cervical vertebral, or their articulations, impairing permanently, or seriously, the 132 MANUAL OF INSTRUCTIONS motions of the neck, whether arising from wounds, rheumatism, or scrofula, are a cause for rejection. There is a serious condition sometimes resulting from one of the foregoing, which must not be overlooked in this connection. It is a form of white swelling, occipre- vertebral caries, which may suddenly complicate itself with spontaneous or symptomatic luxation, and thus produce instant death. Hence the necessity of carefully examining every one, presenting any appearance of this disease. Feigning of this would be almost impossible, before any practised surgeon. SECTION XXIX. DISEASES OF THE CHEST AND BACK. General Considerations. § 248. The chest contains the principal organs of respiration, and of circulation, whose continuous and regular play is essentially necessary for the maintenance of life or health. It also acts as a point of support in the performance of many movements, and particularly of extraordinary efforts. And lastly, in a military point of view, it directly supports the hardest and heaviest portions of the equipment, such as the knapsack and other accoutrements. Under these various aspects the condition of the chest in recruits should receive the most attentive examination. An external examination of the chest, enables us to appreciate its general confor- mation, and the different lesions which may exist upon FOR EXAMINING SURGEONS. 133 its exterior walls, such as wounds, ulcers, scars, tumors, &c, &c. Mensuration of the chest with a tape measure, will also afford valuable indications touching the dimen- sions of this cavity, in its relations to the size of the body, as well as to the volume of the important organs within. Internal examination by means of auscultation* and percussion, reveals the principal diseases of the respira- tory organs, and of the heart. Diseases of the chest having a melancholy frequency in the army, make it in- cumbent upon examining surgeons, to carefully scruti- nize all recruits in this particular, with relation to latent predispositions. The form of the chest may disclose through its vari- ous peculiarities, the state of the contained organs, and thus acquire great importance in every examination of a recruit. In a well-built man, the thorax is broad and prominently convex ; the ribs are long and symmetrical- ly arched ; the shoulder-blades not prominent, and well covered by the muscles which move them and fill their cavities. In this portion of the trunk, many causes for rejection may be found. DISEASES OF THE THORAX. Deformities. § 249. Congenital deformities of the chest have their origin more particularly in its bony walls, but first of all, in the spinal column, whose deviations and curvatures * It is a good plan, in auscultating a party, to place him with his back against a wooden door or partition. The greater resonance of the pectoral sounds obtained by this process, will surprise those who have never be- fore availed themselves of this simple acoustic medium. 134 MANUAL oF INSTRUCTION'S ordinarily produce relative deformities of the ribs and sternum. Kachitis is. moreover, a complex disease, and not restrained to the vertebral column alone, however great may be its deviations. Deformities of the chest may be enumerated as follows, viz.: Prominence of the thorax, in the shape of a ship's kee (pigeon-breast). The cartilages of the ribs being straight, instead of prolonging the arched curve of the ribs. Depression, at times considerable, of the lower portion of the sternum, and the ensiform cartilage, with inversion or eversion of it. Extreme narrowness of the sterno-costab walls, best proved by mensuration. Every one whose chest does not measure thirty-one and a half inches in circumference, should be rejected, as unfit for military service ; for rarely are such chests large or strong enough t6 enable the contained viscera to per- form their functions without hindrance, and in particular, for the lungs to have full play. Among other causes for rejection may be noted, cur- vatures of different kinds, partial deviation of the ribs and sternum, exaggerated mobility of the floating ribs, defective ossification of some portions of the sternum, which with a bifid state of this bone, are both of rare occurrence. Wounds. § 250. Wounds of the chest may occasion consequences which often, but not invariably, afford causes for rejection or discharge. Foreign Bodies. § 251. Foreign bodies of various kinds, such as pro- jectiles and splinters, may be lodged in the walls of the FOR EXAMINING SURGEONS. 135 chest, and again extracted, or may penetrate its cavitv. No general irule can be laid down touching the im- portance of such lesions. An attentive examination of each case is necessary to enable the surgeon to arrive at a correct decision. Lesions of the Lungs. § 252. Contusions, lacerations, wounds, or hernia of the lungs, generally constitute serious lesions. The last named may be produced by other causes than a penetrat- ing wound—may be congenital, or arise from an effort of coughing. Hernia of the lung, through the cicatrix of a wound, exhibits itself in the form of a soft, circumscribed tumor, which rises and falls with the respiratory move- ments. It is easily reducible, and then exposes the cavity into which the pulmonary parenchyma has escaped, to view, through the cicatrix. Auscultation reveals the presence of air in the cells of the tumor. Traumatic Emphysema. § 253. Traumatic emphysema of the lung—pneumonia, and traumatic pleuritis—traumatic effusions, whether san- guineous, serous, or purulent, into the pleura or pericar- dium, paracentesis thoracis, and its consequences—all these surgical affections afford a cause for rejection, but not always for discharge. 136 MANUAL, OF INSTRUCTIONS SECTION XXX. DISEASES OF THE RIBS AND STERNUM. mechanical Lesions. §254. The structure of the solid framework of the chest composed of bones and cartilages, imparts to this portion of the trunk an elasticity, which enables it to resist very considerable violence. Nevertheless, all the lesions pecu- liar to its several tissues, may at times be observed : such as depression of the ribs, fracture of these bones, or of their cartilages, when non-consolidated or imperfectly consolidated. This form of fracture is always a cause for rejection, but its cure is so easy, whenever it is free from complications, that these alone can authorize the granting of a discharge. Fracture of the sternum, and sterno-costal luxation, are rare; still, the foregoing rules will apply to them also. Defective ossification of this bone, or an undue mobility of its different segments, constitute a disqualification for military service. The same rule should obtain where the cartilage of one or more ribs is wanting. Sterno-costal Ostitis. § 255. Ostitis and exostosis, caries and necrosis, and osteo-sarcoma of the ribs, or of the sternum, are of fre- quent occurrence in the army, and entail the conse- quences, already enumerated, as belonging to such dis- eases. Whatever may be the results of resecting one of these bones, they, still, always afford a cause for rejection and frequently for discharge. FOR EXAMINING SURGEONS. 137 SECTION XXXI. DISEASES OF THE CLAVICLE AND OF THE CLAV- ICULAR REGION. Aneurism of the Subclavian Artery. § 256. The clavicular region may be the seat of va- rious tumors, of which, one in particular—aneurism of the subclavian—exhibits a special character, and pro duces the consequence already stated of such diseases. Deformity of the Clavicle. § 257. The clavicle may suffer an arrest of develop- ment, or may have been subjected to irregular or faulty curvature, either through organic causes, or the results of non, or badly united, fractures; in this latter case, it often exhibits a voluminous callus, which, with the foregoing lesions, affords a cause for rejection, but not necessarily for discharge. Unreduced luxations are an absolute disqualification for military service. SECTION XXXII. DISEASES OF THE MAMILE. Hypertrophy. § 258. Diseases of the mammary gland are sufficiently frequent to merit the attention of the surgeon. Hyper- trophy of this gland, coincident or not, with atrophy of the testicle, is sometimes noticed. This abnormal de- 133 MANUAL OF INSTRUCTIONS velopment constitutes, when well marked, a cause for rejection, and sometimes even for discharge. Mammitis. § 259. Inflammation of the mammary gland is not in- frequent among young soldiers. It may occasion hyper- trophy, or induration, and justify a discharge. Phlegmonous Tumor. § 260. Phlegmonous tumors, developed within the tissue of this gland, may be extensive enough to justify the discharge of a party, but rarely his rejection. These tumors are sometimes the result of tattooing, a per- nicious practice of common adoption in the army. SECTION XXXIII. DISEASES OF THE THORACIC ORGANS. § 261. The large number of young soldiers who suc- cumb to pulmonary diseases in military hospitals, par- ticularly to phthisis, owing to the careless manner in which they have been allowed to pass before Boards of Enrolment, should impart additional watchfulness to surgeons when examining them. Deformity of the Thorax, from Internal Causes. § 262. Faulty conformations of the thorax, resulting from internal diseases, which interrupt either respira- tion or circulation, or prevent the bearing of arms, are absolute causes for rejection or discharge. Thus, for FOR EXAMINING SURGEONS. 139 example, old pulmonary emphysema, imparts to the chest a bulging globular form ; in its early stages, how- ever, this disease produces only partial bulging in the subclavian and sterno-mammary regions. Pleuritic effusions often reveal themselves by analogous bulgings of the posterior walls of the thorax. Resorption of these effusions is, on the other hand, frequently followed by retraction of one of the sides of the chest. Bronchitis and Chronic Pneumonia. § 263. Bronchitis and chronic pneumonia, accom- panied by wasting, always justify either rejection or dis- charge. Pulmonary Emphysema. § 264. Pulmonary emphysema necessarily requires rejection. This disease, of frequent occurrence in the army, justifies a discharge only when sufficiently exten- sive to produce spasms of suffocation. Phthisis. § 265. Threatened consumption and, for still stronger reasons, the fully developed disease, in any stage, well recognized, are disqualifications for military service. This sad predisposition reveals itself through features that are unmistakable to the physician. The chest is narrow, and only slightly muscular around its superior periphery; the shoulder-blades are prominent and de- tached ; the neck is long ; the countenance pale or flushed about the cheek-bones; the voice husky, speech hurried, and frequently interrupted by the necessity of breathing; the skin is fine and transparent, or presents a sallow look, and an unnatural dryness ; the limbs are emaciated, and covered by lean and flaccid muscles. 140 MANUAL OF INSTRUCTIONS In addition to the impressions produced by these in- dicia, judgment must be further enlightened by recourse to percussion, auscultation, and mensuration. Too many proofs cannot be accumulated, on a subject in- volving such important consequences. Unusual dulness over any part of the chest; absence or modification of the respiratory murmur ; inordinate development, or retraction of either side of this cavity, will leave no doubt as to the state of the lungs, or the pleura, and the necessity for a rejection or discharge of the individual. We must not expect to find all these symptoms united in any one person. The presence of a few characteristic ones should suffice to justify a rejection whenever they establish, not only the confirmed disease, but even a strong predisposition to it. The fingers and the ear serve for immediate percus- sion and auscultation. Mensuration should be effected by a tape measure, as described in section 8 ; but in order to render this element of diagnosis valuable, it is indispensable for the surgeon to bear in mind the differ- ent dimensions and relative proportions of a well-formed chest. See section 248. An important sign, and one too, which, in the midst of the difficulties surrounding percussion and auscultation, can always be determined, is the comparison between the number of respirations and pulsations. The normal standard in adults is about twenty respirations to sev- enty-two pulsations per minute, or as 3 ~ 1 —. At a more advanced stage of the disease, uncertainty is impossible, so highly accentuated are all the morbid phenomena. Sometimes recruits feign weakness of chest by round- ing the back, bringing their shoulders forward, and pre- FOR EXAMINING SURGEONS. 141 senting the sternum, apparently depressed; they also affect a dry, frequent cough, and reply to questions with a hurried breath. But it is only necessary to straighten the individual, and to throw back his shoulders, to dis- cover the good development of the thorax; while at the same time the color and elasticity of the integuments, and the volume and firmness of the muscles, will all con- spire to expose the cheat. The presence or absence of physical signs will determine the question. Haemoptysis. § 266. Haemoptysis, as a symptom of pulmonary dis- ease, is always a cause for rejection. It is also a cause for discharge, when it returns frequently, is accom- panied by a psrsistent cough and marked emaciation, with or without the other physical signs of tuberculosis. A soldier attacked for the first time by haemoptysis should be subjected to close observation, for this form of haemorrhage is often observed to be followed by a rapid development of phthisis, not alone among delicate per- sons disposed to scrofula, or whose chests are badly formed, but also—and this point cannot be too much dwelt upon—in apparently strong persons having a dark skin, black hair, and a well-developed muscular system. In rarer cases, haemoptysis is a symptom of heart dis- ease, particularly of hypertrophy. A thorough and dif- ferential examination of the heart and lungs will enable us to establish this diagnostic point. At all events, by reason of its being the result of cardiac lesion, hsemop- tysis is not the less serious, and should entail similar consequences to any other symptom of phthisis. In order to feign it, some persons prick the finger, fore- arm, or any other part of the bod}7 accessible to the lips, 142 MANUAL OF INSTRUCTIONS and by suction, fill the mouth with blood, which they void immediately after having feigned a spasm of cough- ing. Others prick the gums and pharynx,—while some conceal under the tongue or the hollow between the teeth and cheeks, Armenian bole, or a sponge saturated with blood, from which they express variable quantities, and thus redden the saliva. The cheat is easily discovered by passing the fingers through the mouth, and rinsing it out with acidulated water. Moreover, the blood of haemoptysis is distinguishable by its bright and frothy character; at the termination of the attack it mingles itself with and tinges the bronchial secretions of a more or less deep color, and finally, the real attack always leaves a pallor and prostration, which cannot be simu- lated any more than the anxious expression, which ever marks the face of the real sufferer. Pleuritic Effusions. § 267. Pleuritic effusions are always a cause for rejec- tion. They do not, however, justify a discharge, until they have resisted all treatment or produced constitu- tional alterations. Contraction and impaired mobility of one side of the chest, resulting from pleurisy, consti- tutes a cause for rejection. Organic Lesions of the Heart. § 268. In common with organic lesions of the lungs, those of the heart and large blood-vessels are of difficult detection in their incipient stage. Yet the obstacles they present to the discharge of a soldier's duties, through the rapid development they undergo under the efforts inci- dental to military life, and the dangers they occasion in FOR EXAMINING SURGEONS. 143 their subjects, render it of great importance that all such persons should be kept out of the army. No means of exploration should be omitted. Recourse must be had to palpation, in order to discover the fre- quency, force, extent, and rhythm of the motions of the heart, and the prominence or bulging of the thorax; to auscultation, for indications of the nature and intensity of abnormal sounds ; and to mensuration and percussion, which disclose increase in volume and limits of size. At the same time it will be necessary to search out, and to analyze attentively, the disturbances which these lesions may excite in the play of other organs; such as shortness of breath. Slowness or acceleration, or disturbance of the circulation, will reveal themselves through dyspnoea, often one of the first symptoms of heart disease; by the feebleness, force, irregularity, or intermission of the pulse; by the red or livid injection of the capillaries, particularly of the face, and by the distension or pulsa- tion of the jugular veins, etc. Besides the signs by which to distinguish dilatation of the heart, and of its sac when distended by dropsy—that is to say, besides the extension of precordial dulness, which normally does not cover more than two and a-half square inches,—the other phenomena, viewed by them- selves, are far from furnishing precise or irrefragable indications. This statement applies to palpitations, to abnormal sounds, when they are slight and ephemeral, to variations of the pulse, coloration of the counte- nance, and the other already recited symptoms of car- diac lesion. In such perplexing cases as these, it is only by the resemblance and the harmony of general and local symptoms, that the physician can arrive at any cer- 144 MANUAL OF INSTRUCTIONS tain conclusions. His attention should, above all, be fixed upon the sounds of the heart, upon the relation between the strength of the pulse and the ventricular impulsions, upon the power of these, and finally upon the extent of the region occupied by the organ itself. If any uncertainty still remains, he may clear up all doubts by questioning the party upon his subjective observations of his own condition, in connection with mode of sleeping, violent exercise, and emotional excite- ment, &c, Arc. Displacement of the Heart.—Transposition. § 209. The heart may be displaced, or even totally transposed. This latter condition, which is manifestly congenital, is rare yet occasions no disorder of function ; circulation and respiration going on as well with the heart on the right, as on the left side. But the same is not the case when this organ is displaced by a hepatized, or emphysematous lung, a pleuritic effusion, or the de- velopment of a morbid growth, or tumor. The simple announcement of these serious conditions suffices to indi- cate the opinion which the surgeon should form of their consequences. Endocarditis.—Pericarditis. § 270. Acute inflammation of the heart (endocarditis), or of its sac (pericarditis), is always a cause for rejection, and often for discharge, on account of the structural alterations which it induces. Hydro-pericardium is always a cause for rejection or discharge. Hypertrophy. § 271. Hypertrophy of the heart is an absolute dis- FOR EXAMINING SURGEONS. 145 qualification in a recruit, and also requires the discharge of a soldier, when ordinary means of treatment have proved unavailing. During an examination the recruit is generally excited, and the motions of the heart increased, so as to mislead one into the belief that hypertrophy is present. It may not therefore be out of place to repeat some of the phys- iological and pathological details, applicable to a diag- nosis of this disease. In health, the intercostal muscles situated between the fifth and sixth ribs, are raised by the apex of the heart during systole, over an extent of from half an inch to one inch. In hypertrophy, these move- ments are much more extensive, and may include several ribs and intercostal spaces. Precordial dulness, which, in a normal state, occupies a space of two square inches, may extend itself over one of four. Adhesion of the Pericardium. § 272. Friction murmur of the pericardium, indicat- ing an altered condition of the surface of this membrane, should always cause rejection, whenever recognizable by auscultation. It should also occasion the discharge of a soldier, if accompanied by disturbances in the heart's action, and irregularity or intermission of the pulse. Narrowing, or Insufficiency of Valves. § 273. Valvular sounds ordinarily announce serious lesions ; rough sounds, accompany contractions of the auricular-ventricular orifices; soft ones, valvular insuf- ficiency. Lesions of Cardiac Orifices.—Dilatation, with Thinning. § 274. Purring murmurs reveal a lesion of the cardiac 1 146 MANUAL OF INSTRUCTIONS orifices. Increase of precordial dulncss, accompanied by feebleness of the heart's contractions and without strong impact of this organ against, nor raising of the intercostal muscles, indicates dilatation with thinning of its walls. The foregoing different conditions, as also the succeeding ones, necessarily require the rejection, or discharge of a party. Cyanosis. § 275. Cyanosis, which is often an indication of the persistence of the foramen ovale, is, when congenital, beyond the reach of art. Facial cyanosis may be produced by the application of a ligature about the base of the neck, and hidden among the folds of the skin. But in such cases there is injection and not true cyanosis, and the cheat is too clumsy to require any further notice. Lesions of the Thoracic Aorta. § 276. Diagnosis of lesions of the thoracic aorta, is in most cases obscure. Yet aneurism may be suspected from the whistling of the voice, flatness of sound, on percussion over the middle and superior portions of the sternum, by the feebleness and irregularity of the pulse, and its inequality between one arm and the other. All these are indicia of a tumor, compressing arterial trunks, or their branches. It may also be recognized by a thrilling, or purring tremor, felt by the hand when applied to the sternum, and particularly by the simple pulsations, accompanied by a bellows murmur heard in the track of the artery. When the aneurism is situated in the ascending aorta, the pulsations are detected be- neath the sternum and the cartilages of the ribs, with a FOR EXAMINING SURGEONS. 147 distinctness corresponding to the volume of the tumor. They differ from the first sound of the heart by a greater intensity, besides which, their true initial point may be recognized in passing the naked ear, then the stethoscope, successively from the point where the sound is heard, up to the heart, and back again. If the pulsation arises from aneurism of the aorta, it will grow weaker as we approach the heart, and vice versa. Aneurism of the descending aorta, may be recognized by a simple, strong pulsation, distinct from the double pulsation of the heart, and from the fact that this latter never extends itself with similar intensity, as far as the back, besides which a rasping or bellows murmur will be heard and abnormal dulness perceived. Asthma. § 277. Shortness of breath, produced by certain dis- eases of the pulmonary or circulatory organs, sometimes extends to the degree of asthma, a disease which in itself, is a disqualification for the military service. When asth- ma is thus dependent upon organic lesion, it is ordinarily continuous, although varying in intensity according to circumstances. The examining surgeon can consequently witness its manifestations, and comparing its symptoms with the other signs of visceral alteration, he will find, in their combination, the basis for his opinion. He should above all things, not omit an examination of the lungs, heart, and aorta. There is, however, a species of asthma (nervous asthma), which belongs to no organic lesion, and which only reveals itself, ordinarily, by noc- turnal paroxysms of variable frequency. Among soldiers the reality of this disease, which cannot be feigned, may be ascertained in the hospital; but it should never be 148 MANUAL OF INSTRUCTIONS admitted in the case of recruits, except upon proof obtained for that purpose. SECTION XXXIV. DISEASES OF THE SPINE. Deformities. § 278. Deformities of the spine originate either in an organic alteration of the vertebras themselves, or in a defective equilibrium between the different motor forces, which act upon the column which they compose. Curvatures of the Spine. § 279. These deformities may be either congenital, acquired, or symptomatic of Potts' disease. The spinal column, under the influence of the forces which move it, may be curved forward, backward, or laterally. Such deformities involve absolute incapacity for the duties of a soldier, either because they may compress the spinal cord, and give rise consecutively, to altera- tions in functions over which this organ presides; or they may interrupt the action of the thoracic viscera, and predispose them to serious lesions; or finally, be- cause they deprive the soldier of the freedom and pre- cision of those movements which are necessary, and be- cause they also occasion great hindrance to equipments. But the different curvatures spoken of may be feio-ned or artificially produced. Men occasionally present themselves with excessive curvature of the spine, the FOR EXAMINING SURGEONS. 149 chest hollowed in, and pretending that they are unable to straighten themselves. This cheat may be exposed, either by placing the man on the floor, face downwards, tightly compressing his loins with a belt, and then stretching his arms out over his head; or else, placing him upon his back, and removing all points of support for his extremities. Lateral curvatures are more easily feigned. They may be imitated through muscular action alone, by assisting this with mechanical agents, tending either to curve directly the vertebral axis, or to displace the rela- tions of the pelvis, and consequently those of the flexible column which it supports, together with the centre of gravity. Such may be the success, that the simulator, contrary to his intention, remains permanently hump- backed, and this, too, without any advantage, for it is not impossible to distinguish feigned or artificially-pro- duced curvatures from spontaneous ones. The latter, as a first characteristic, have a tendency to attack a va- riety of points, and to assume a variety of forms, and being as diversified as the particular cases themselves, may occupy any region of the spine. Again, no real deformity of any extent is ever seen having but one curvature; there are always two or three, and sometimes four alternately, when they are produced in order to maintain, by counterbalancing, the axis of the trunk in the line of gravity. Each curvature is always accompa- nied by a twisting movement of the vertebra?, propor- tional to its arc and chord. This torsion impresses upon the muscular prominences, on either side of the median line, at the projections of the ribs and shoulders, a notice- able want of symmetry, according to the number, the seat, and the degree of the curvatures. At each curva- 150 MANUAL OF INSTRUCTIONS ture, there is a corresponding elevation of the muscles of the ribs and of the shoulder-blade o[' the convex side, while the concavity is marked by a depression of all its included parts. There are no furrows formed by the wrinkling of the skin, unless the deformity is very ex- tensive, and then they are ordinarily shallow, on account of the retraction of the skin, which in the end always effaces them. These furrows occur in the majority of instances, just below the axilla, and then the chief cur- vature has its convexity on the opposite side, and in the dorsal region. If, as an extraordinary thing, they are located between the floating ribs and the crest of the ilium, there will be a dorso-lumbar curvature, with ex- tensive uplifting of the ribs and muscles, corresponding to the convexity. There may finally exist a well-marked furrow on a level with a lumbar curvature, without extensive torsion of the vertebrae included in that region, while another furrow corresponds on the opposite side to the dorsal curvature. In such an exceptional case, the dorsal curvature is extensive, descends to the last verte- brae of this region, and is accompanied by a high degree of torsion which raises the last ribs, and produces a de- pression, with wrinkling of the skin, above the crest of the ilium. Hence, in those rare cases where the real deformity is accompanied by wrinkles of the skin, there is necessarily extensive curvature, and torsion of one or the other side, with consecutive bulging of the muscles and ribs, and lateral, dorsal, or lumbar deformity. Fi- nally, if the hips are no longer on a level, one never dif- fers from the other by more than a few lines, unless there be proportional inequality in the length of the lower limbs. When the disease is feigned, whatever may be the FOR EXAMINING SURGEONS. 151 means employed, the same external appearance is always remarked, viz.: a single lateral curvature, describing a regular arc, which invariably includes the dorsal and lumbar regions, with lateral inclination of the column upon the pelvis; and such is the sameness and uniformi- ty with which these effects constantly reproduce them- selves, that it is next to impossible not to recognize the fraud. The trunk is more or less inclined to the side opposite the convexity, according as the pelvis is more or less elevated on this side, or depressed upon the other. The degree of curvature, which takes place on a large radius, is not in harmony with the degree of inclination of the trunk, whose superior extremity departs widely from the vertical line, this inclination not being counter- balanced by any counter curvature. Within this curva- ture, and between the floating ribs and the crest of the ilium, the skin of the hip exhibits two or three parallel folds, the shoulder of the side corresponding to the con- vexity is much more elevated than the other, but both exhibit the same prominence in the rear, together with the ribs, and the two surfaces of corresponding muscles; in other words, there is no trace of torsion. The hips, according to the means employed, may remain on a level, or that of the concave side be raised from two to three and a half inches, and in such case, the corresponding limb appears proportionally shortened; there is also a semblance of limping, Avhich does not occur in the real deformity. These curvatures can only be maintained by the exclusive power of the will, during standing, sitting, or marching. They may also, when long maintained by mechanical agents, continue permanent, and constitute a real exciting cause whose effects vary, according to the agencies em- I-'j MANUAL OF INSTRUCTION'S ployed in its production, and which it is here needless to enumerate. It suffices to say that: 1st. When it has not been protracted, the action of these agencies, impresses upon the spine none of those characteristics of multiple or alternative curvature, and of torsion of the vertebrae, which distinguish true de- formities. 2d. Even after their application, and their long-con- tinued use, the most ingeniously combined means of provocation, although they may have occasioned alter- nating curvatures, yet do not produce torsion, and reveal through this fact, and the special, always identical form of the curvature, the means of distinguishing the feigned from the real disease. The diagnosis being established, if the deformity, whether of spontaneous or provoked origin, has now become permanent, the party must be rejected or dis- charged. Potts' Disease. § 280. This affection is one of very serious conse- sequence, in a military point of view. It reveals itself by a prominence and bulging of the spinous process, corresponding to the vertebra which is its seat, and some- times by the presence of cold abscesses, at varying dis- tances from this point. In its incipient stage patients are themselves often ignorant of the existence of local lesion, and do not complain of these secondary effects. In order to discover the disease, the patient must be made to bend forward, while the hand is passed over the spine, to test its sensibility, and to examine critically any abnormal protuberances or depressions which may be encountered. There can be no doubt as to the decision proper in such cases. FOR EXAMINING SURGEONS. 153 Abscess. § 281. Large dorsal abscess, if it does not terminate by resolution, may occasion the most serious consequences, by reason of the suppuration which accompanies it. It should always be a cause for rejection, and often for dis- charge. Carbuncle. § 282. Of the various tumors which may occur in the back, we shall only mention anthrax, or ca'rbuncle, as among those often seen, and which should cause re- jection, when extensive; but would only justify a dis- charge through its possible consequences. SECTION XXXV. DISEASES OF THE LUMBAR REGION AND OF THE ABDOMEN. § 2S3. Partly connected with diseases of the back, especially with its deformities, diseases of the loins are vet, on many accounts, entirely distinct from them, in a military point of view. Spina Difida. § 284. The only deformity deserving of notice, on account of the special character of its seat, is hydro- rachitis, or spina bifida, which is congenital, and some- times continues up to puberty, though very rarely, up to adult age. It constitutes an absolute disqualification for the duties of a soldier. 7* 154 MANUAL OF INSTRUCTIONS Lumbago. § 285. Lumbar rheumatism, or lumbago, is usually a trifling affection, yet it sometimes masks serious disease, either of the spinal column, of the cord, or of the kid- neys. It becomes therefore necessary to explore its seat with the greatest attention, in order to establish a correct diagnosis, and not to confound these pains with ostitis, caries, necrosis, or disease of the kidney. The surgeon should always remember, that chronic rheumatism is often feigned ; whence the greater reason for examining carefully the region in which it is alleged to exist. When the disease is real, whether it be a rheumatism, or a more serious lesion, the lower limbs are frequently wasted, with more or less paralysis of sensation or motion, and traces of the external treatment, to which they have been subjected, by leeches, cups, moxas, cauterizations, dissolved in the excess of alkali, forming a dark blue solution. If this be gently heated to ebullition, a dense deposit of red suboxide of copper takes place. FOR EXAMINING SURGEONS. 171 Hematuria. § 326. Hematuria, or bloody urine, is rather a serious disease whenever it originates in the kidneys or in the bladder, and is not simply of a temporary character. It is of rare occurrence, however, among young men. Besides traumatic causes, hematuria may result from the suppression of an habitual haemorrhage, epistaxis for example, or depend, although more rarely, upon a scorbutic affection, or the haemorrhagic diathesis. In these cases, rejection or discharge must follow. Albuminuria. § 327. Albuminuria, which can be certainly ascer- tained by the use of proper means, is an absolute dis- qualification for the duties of a soldier.* Urinary Calculi. § 328. Urinary calculi, whether originating in the kidney, under the form of gravel, or whether formed in the bladder, or lodging themselves in the prostate or the urethra, present ordinarily very characteristic signs, but which nevertheless require an attentive examination. Their presence, when well established, requires the re- jection of a party, and even his discharge, if he will not submit to the necessary operations. Urinary Abscesse§. § 329. Urinary abscesses and fistulas, whatever may be their seat, always require the rejection of a party, and his discharge, when the complications of the fistula necessitate a long treatment whose results are uncertain. * Hoat, nitric acid, and microscopical examinations of the urinary sedi- ments, will determine the existence of this disease. 172 MANUAL OF INSTRUCTIONS Mechanical Lesions of tbe Kidneys. § 330. Diseases of the kidney require practical expe- rience in palpation and percussion, the sources which, together with microscopical examinations of the urinary sediments, furnish the principal signs of their existence. Congenital lesions of the kidney are not amenable to examination. These organs may, in common with the others, be the seat of various mechanical lesions, such as contusions and concussions, which it is often difficult to discover, and wounds or lacerations, which frequently require the rejection of a party, though more rarely his discharge. Foreign bodies, introduced by external violence, may remain lodged in their substance. Whenever their presence is recognized, they constitute an absolute inca- pacity for the duties of a soldier. Nephritis. § 331. Inflammation of the kidneys, of which it is important to establish the diagnosis, in order not to mis- take it for diseases of less gravity (such as lumbago), may be simple, traumatic, albuminous, calculous, rheu- matic, gouty, or purulent (the result of resorption), in character. These all constitute causes for rejection, and often for discharge. Renal Calculi. § 332. Urinary calculi, which are suspected, for the most part, only from the-violent pains attending them, particularly in their passage through the ureters, but of which no certainty exists until their escape from the urethra, are always a cause for rejection or discharge.* * The fact of having once passed a urinary calculus does not afford pre- sumptive evidence that another is likely to follow, or the diathesis to con- tinue, upon which its existence depends. FOR EXAMINING SURGEONS. 173 A bscesscs.—Fist ulas. § 333. Renal abscesses and fistulas, tumors, cysts, and cancer, are causes for rejection, but not necessarily for, discharge. Diseases of the Bladder. § 334. The importance of the bladder is such, that all diseases capable of affecting it are of a serious character, and deserve particular attention; nor are they the less worthy of study on account 06 their extreme frequency. An examination of this organ by direct palpation will reveal its condition of fulness or emptiness ; catheterism alone can give correct ideas of some of the lesions of which it is the seat; while examination of its excretions is indispensable as a means of diagnosis. Absence of the Bladder.—Estrophia (extroversion). § 335. Complete absence of the bladder is very rare; yet it has been observed. Extrophia, or extroversion, of this organ, exhibits itself in the form of a loss of substance of the inferior portion of the walls of the abdomen, and by the presence of a red, moist surface, on which the ureters are sometimes seen, allowing the urine to escape directly. Atrophy of the bladder has occasionally been mistaken for its absence. The foregoing diseases are all manifest disqualifications for the military service. Dy per t roph y. § 336. The bladder may also be hypertrophied, and occupy a large space in the abdomen. It may also open into various abnormal localities through imperforationsof 174 MANUAL OF INSTRUCTIONS the ureters, as for example, through the umbilicus with persistence of the urachus, or through the rectum. These cases are extremely rare; still, it is well to be apprised of their possibility. It is almost needless to add, that they constitute a cause for rejection. Traumatic Lesions. § 337. The bladder may be the seat of contusions, of compressions, if full, of rupture, and of wounds of various nature, particularly gunslfot. These lesions are so im- mediately serious in their nature as rarely to come before examining surgeons. If any should present themselves, they would constitute a cause for rejection, but not of discharge,until surgical treatment had proved unavailing. Foreign bodies sometimes find their way into the blad- der, either through wounds or catheterism (fragments of a sound). These form constant causes for rejection, but not of discharge, until all attempts at extraction have proved abortive, or serious disorders have been produced by such bodies. Vesical Calculi. § 338. Vesical calculi reveal their presence by pain, a sense of weight at the lower part of the bladder, turbid urine, sometimes purulent, sometimes sanguinolent, in- termission in the flow of the urine, and pain at the*ex- tremit}r of the penis; but the only true pathognomonic sign is furnished by the sound. Paralysis. § 339. Paralysis of the bladder, of which atony con- stitutes the first stage, arises nearly always from lesion of some other organ, particularly of the spinal cord. FOR EXAMINING SURGEONS. 175 This disease, of easy recognition, by its own character- istics, and those of its parent source, derives all its im- portance from the diseased condition of the latter. Cystitis. § 340. Inflammation of the bladder, whether acute or chronic, is always a sufficiently serious disease to require the rejection of a party. Nevertheless, it must be borne in mind that this disease may be artificially produced by partaking of certain substances well known to phy- sicians. It is, therefore, important to assure one's self that the inflammation is not due to this cause, for in such case it is trifling, and occasions no disqualification. Hydatids. § 341. Hydatids, although rare, are at times met with in the bladder. Their presence, when duly established, constitutes a disqualification for the duties of a soldier. Vesical Fistulas. § 342. Gangrene, wounds, operations for puncture, or lithotomy, sometimes leave behind them urinary fistulas, which are always a cause for rejection. Hernia. § 343. Hernia of the bladder may occur in various directions, constituting either abdominal, inguinal, or perineal cystocele. These are all causes for rejection or discharge. The same rule will apply to a varicose state of the neck of the bladder, to polypi, fungous growths, etc., which are at times observed, though very rarely in young men. 176 MANUAL OF INSTRUCTIONS Diseases of the Urethra. § 344. It is more particularly to diseases of the urethra, that catheterism applies as a means of diagnosis. Direct examination by the hand must not be neglected, as it enables us to discover foreign bodies lodged in the corpus cavernosum, together with any protuberances formed by structural alterations. Simple inspection suffices to detect diseases situated in the vicinity of the meatus; while a catheter or sound is necessary to explore the deeper portions of this canal. Anomalies. § 345. The urethra may be entirely wanting, imper- forate, or turned from its normal direction. The two first anomalies would require the rejection or discharge of a party, while a simple deviation might not. Hypospadias. § 346. The urine may be voided in an abnormal way, as, for example, in hypospadias, epispadias, and fistulas. In hypospadias, the opening occurs either at the fossa navicularis, near to, or corresponding with, the fnenum of the prepuce, or between this point and the scrotum, or in the scrotum itself. In epispadias, the orifice is near the root, and on the dorsum of the penis, which organ is slightly developed, and most often cleft throughout its entire length. Hypospadias is not a disqualification for military ser- vice, whenever the opening is situated at the extremity of the penis, beneath the gland, and the urine can be ejected to some distance; when, in fact, the opening is large enough to permit the escape of a stream of urine of normal size, which may be ascertained by a bougie, FOR EXAMINING SURGEONS. 177 or causing the subject to pass water before the surgeon. In all other cases, there is a total disqualification for the military service. A person, laboring under such infir- mities, cannot avoid soiling his garments during every passage of water, and these soon become offensive, to an intolerable degree, to all about him ; while the humidity itself is a source of constant danger to his health. The same rule necessarily applies to urinary fistulas, with this difference, that when they occur in soldiers, an operation should first be resorted to, wherever the case justifies it, before granting a discharge. Foreign Bodies. § 347. Foreign bodies are occasionally introduced into the urethra either accidentally or through design ; these bodies, not admitting of being extracted without a sur- gical operation, afford a cause for rejection. Calculi, lodging themselves there, would produce a similar dis- qualification, not only as being foreign bodies, but be- cause they would create fears of the presence of other calculi in the kidneys or bladder. On the other hand, they would afford a cause for discharge, only in excep- tional cases. Stricture. § 318. Strictures of the urethra, recognizable by the bougie, or by causing the subject to pass water in one's presence (the stream of urine is often in such cases forked or twisted) is a disease of difficult cure, and pro- ductive of consequences incompatible with the discharge of a soldier's duties. Nevertheless, whenever it occurs in a soldier, no discharge should be granted until all curative means have failed. 8* . 178 MANUAL OF INSTRUCTIONS Urethritis. § 349. Inflammation of the urethra, whether acute or chronic, never is a cause for rejection or discharge. Diseases of the Prostate. § 350. Diseases of the prostate are very rare among young men. This gland may be the scat of hypertrophy, either congenital or acquired, of various mechanical lesions, or of calculous disease. The decision to be ar- rived at in each case must be determined by the nature of the lesions, which may be either trifling and without importance, or seriously endanger the functions of the oro-an. Young men often believe themselves the sub- jects of serious diseases of the prostate, when, in fact, none exist. In such cases, they should always be sub- jected to a manual examination by the rectum. SECTION XXXIX. DISEASES OF THE GENITAL ORGANS. § 351. The frequency and variety of the diseases of the genital organs in man, require the closest attention, and a certain amount of practical experience, when viewed in the light of causes for rejection or discharge. Some of these diseases exhibit forms or degrees at times incompatible with the discharge of a soldier's duties. Traumatic Lesions. § 352. Accidental mutilations of the genital organs, FOR EXAMINING SURGEONS. 179 occasioning complete or almost entire loss of these parts, whether arising from criminal acts, particularly with cutting .instruments, or from gunshot wounds, require both the rejection and the discharge of a part}'. In fact, the loss of these parts becomes at once a cause of physi- cal infirmity (with obstacle to passing water or compli- cation of fistulas) and a cause of moral infirmity, through the depressive influences which belong to this infirmity. But the same is not the case in partial lesions, or such as are capable of being cured. DISEASES OF THE PENIS. Phymosis and Paraphimosis. § 353. Phymosis and paraphymosis, existing without complication, are not a cause either for rejection or dis- charge, since they can always be readily cured. The simple operation for phymosis has sometimes sufficed to remove symptoms which were attributed to the presence of vesical calculus. Atrophy. § 351. Atrophy of the penis, however marked, is not a cause for rejection, unless accompanied by simulta- neous atrophy of the testicles. But extensive hyper- trophy of this organ, to the degree of constituting ele- phantiasis, would be a disqualification in itself, as well on account of its tendency to invade the scrotum, as of interfering with marching. L.©ss of the Penis. § 355. Total, or almost entire, loss of the penis, whether resulting from voluntary mutilation, accidental ISO MANUAL OF INSTRUCTIONS wounding, or surgical amputation, requires the rejection or discharge of a party. The same rule obtains in cases of crushing of the penis, followed by deformity, rupture of the corpora cavernosa, laceration, fistula, and stric- ture of the urethra. Various Affections. § 356. As to ulcers, chancres, and syphilitic warts, they do not, in the majority of cases, require any men- tion here; but it will be different if the penis has been partly destroyed by a phagedenic ulceration, the cure of which would not restore the organ to its natural shape. DISEASES OF THE SCROTUM. Wounds.—Laceration s. • § 357. "Wounds or lacerations sufficiently extensive to expose the testicles, may afford causes for rejection. It is well to bear in mind, however, that cicatrization oc- curs nearly always without adhesions. Contusions.—Hematocele. § 358. Yiolent contusions, or contused wounds, often give rise to hematocele by infiltration or extravasation. In the former case (infiltration), the blood is ordinarily absorbed with facility, and rejection is not called for any more than by other forms of ecchymosis, provided there are no complications. This state counterfeits gangrene in a gross way, but the least attention will expose the fallacy. In the latter case (extravasation into the tunica vaginalis), the manifestations bear a strong resemblance to those of hydrocele, and demand a like decision. FOR EXAMINING SURGEON8. 1S1 Cutancons Affections. § 359. The scrotum may be the seat of various cu- taneous affections which spread to the neighboring parts, the internal and superior surface of the thighs, the perineum, and the margin of the anus. These dis- eases, which are often of difficult cure, and ordinarily provoke an. intolerable itching, are aggravated by the friction occasioned by marching, ano by the contact of woollen clothing. They constitute a cause for rejection and discharge, under all the conditions mentioned in the chapter devoted to the consideration of these diseases. Care should be taken, however, not to confound them with simple chafing, and other trifling diseases, which do not deserve special mention in this connection. Swellings and Abscesses. § 360. Swellings and abscesses never are a cause for rejection, unless the latter are symptomatic of, or asso- ciated with, scrofula. Urinary Abscesses. § 361. Urinary abscesses of the scrotum, are of suffi- cient importance to constitute a disqualification for the military service. Emphysema. § 362. Air never accumulates in the scrotum. When- ever, therefore, parties present themselves with this re- gion tumefied, light, when compared with its volume — distended, elastic, and resonant under percussion, there is certainly fraud, and the emphysema has been arti- ficially produced. 182 MANUAL OF INSTRUCTIONS CEdcina. § 363. (Edema of the scrotum acquires its importance from the general bodily condition of its subject, and the cause which has originated it. It is never uncompli- cated, and this circumstance enables Tis always to dis- cover the deception, whenever any person has caused water to be injected, through a small opening, into the cellular tissue of the scrotum. Varicocele. § 364. Varicocele, which is a tumor formed by the distension of the spermatic veins, occurring between the external orifice of the inguinal canal and the epididymis, is not a cause for rejection, unless it occasions, by its size, a marked impediment to marching, or the perform- ance of other movements. Nor should a discharge be granted therefor, until curative treatment has proved unavailing. Even then a soldier, if unable to march, may be made useful in some less active capacity.* * The differential diagnosis of varicocele, and inguinal hernia, is easily established by noticing the following distinctions in their symptoms. In Hernia, the tumor is uniformly round, soft, and compressible, and often emits a gurgling sound on pressure; when reduced, it returns on removal of the support and resumption of the upright position, or coughing. In Varicocele, the tumor is pyramidal in form, its base resting upon the testis, and its apex ascending into the external ring; it feels like a knot of earth- worms (cirsocele), and when reduced, and the patient resumes the upright position, it returns, despite pressure upon the abdominal ring, owing to the circulation continuing in the spermatic veins. This was the test proposed by Sir Astley Cooper. In cases of hernia, the extremity of the finger should be pushed as far as possible into the external abdominal ring, by thrusting the skin of the scrotum before it. Under which circumstances the contact, or impulse of the descending hernia can almost invariably be recognized, when it exists, if the suspected party be made to cough, when in the upright position. FOR EXAMINING SURGEONS. 183 Hydrocele. § 365. Hydrocele of the spermatic cord, and that of the tunica vaginalis, are causes for rejection; but not for discharge, inasmuch as its radical cure can be obtained by surgical treatment. It is impossible, in whatever way attempted, to feign, with any degree of probable success, either of these diseases. Encysted Tumors.—Fistulas.—Calculi. § 366. Encysted tumors, of any notable size, by reason of their tendency to increase; fistulas communicating with the tunica vaginalis, or the testicle; calculous con- cretions of the scrotum, which are rare, are causes for rejection, but not generally for discharge. Elephantiasis. § 367. Hypertrophy of the scrotum and of the subja- cent cellular tissue, known as elephantiasis, is extremely rare. But whenever present, would always constitute a cause for rejection. DISEASES OF THE TESTICLES. § 368. The influence exercised by the functional ac- tivity of the testicles upon the constitution, the physical and moral courage of individuals, requires that the in- tegrity of these organs should be unimpaired. Hence their loss, atrophy, or the degeneration of either of them, constitutes an absolute incapacity for the military service. Anorchidia.—Ectopia. § 369. Absence of the testicles, or anorchidia, is only apparent; it is often only ectopia, or malposition. Some* times the testicles have not descended; sometimes. 1S4 MANUAL OF INSTRUCTIONS though rarely, they are in the perineum, but more fre- quently they are lodged in the inguinal canal. Ectopia may be slight, and the testicles capable of being pushed down and maintained there; in which case no cause lor rejection would exist. But if they were strongly com- pressed in the ring, it would be well to reject the party, by reason of the pain they occasion, their tendency to become atrophied, or the hernias to which they often give rise. It is safe to believe in the retention of the testicles in the abdomen, and consequently in the capa- city of a party, whenever he exhibits in general, all the other signs of virility, and no credible testimony, nor external signs afford any presumption that these organs have been removed by a surgical operation, or destroyed by wounds. Atrophy and Loss. § 370. Atrophy of the testicles is more often acquired than congenital. It frequently results from premature ex- cesses or mechanical injuries. This condition would not afford any cause for rejection, unless existing to a great degree. Atrophy of one of these organs, the other being healthy and well developed, is not a disqualification for military service; but where the remaining one is attack- ed, and in an incipient state of atrophy, the party should be rejected. Orchitis. § 371. Inflammations of the testicle may require the rejection of a party, whenever they are the result of con- siderable violence; and if the disease has become chronic it may also require that a party be discharged. The same rule will apply to syphilitic orchitis, which may FOR EXAMINING SURGEONS. 1S5 be complicated with various consequences, and evince a tendency to degeneration. Gonorrheal epidydimitis, which must not be confounded with the preceding, is not a serious disease, and not likely to lead to any con- sequences, rendering a party unfit for the duties of a soldier. Fistulas. § 372. The like rule will apply to non-adherent fis- tulas of the testicles. Enchohdronaa. § 373. Enchondroma, or cartilaginous degeneration of the testicle, and the other forms of degeneration, of which these organs are frequently the seat, are manifest causes for rejection, and most frequently for discharge. Diseases of the Spermatic Cord. § 371. Chronic inflammation of the spermatic cord, independent of, or complicated with, disease of the tes- ticle, and occasioning either infiltration, or more serious disorders, is a cause for rejection, and sometimes, even for a discharge. The same rule will apply to hydrocele and degeneration, arising from those of the testicle. Spermatorrhoea. § 375. Spermatorrhoea, even if its existence, in an aggravated form, could be demonstrated, should not be a cause for rejection, unless the general health were manifestly broken down, and it were accompanied by evidences of organic disease. 186 MANUAL OF INSTRUCTIONS SECTION XL. DISEASES OF THE LIMBS. § 376. Soundness of the limbs, in all their parts, is assuredly one of the most important of all prerequisite conditions for the duties of a soldier. Their shape should exhibit no extremes, either of size, or want of development—the cutaneous functions should be per- formed with regularity—the perspiration be moderate— the sensibility of touch be normally developed. It is also indispensable that the bony structure should furnirdi a sufficient fulcrum of resistance to the action of the muscles, and the play of the articulations. Some diseases of the limbs might be concealed and overlook- ed, if the surgeon neglected to examine in detail the play of all the articulations of the arms, hands, and, in particular, the fingers; and if care were not taken to make the recruit wTalk. Anomalies. § 377. It is indispensable that both the upper and lowrer limbs should be mutually alike;* every anomaly of organization, therefore, in their number, shape, and relations, is an absolute disqualification for the military service. Inequality of Limbs. § 378. Congenital inequality of the limbs, carried to a marked degree, is very rare. It may be limited to the upper or lower limbs, or extend to both. For example, all the parts of one side have been seen longer, and lar- FOR EXAMINING SURGEONS. 187 ger, than those of the other. From such an anomaly there results incapacity for the duties of a soldier; on the one hand, because the manual of arms could not be performed with regularity, by limbs of unequal length and strength; and on the other, because there neces- sarily results lameness in the lower limbs, with curva- ture of the spine, and all the inconveniences attendant upon it. Incurvation of Eimbs. § 379. Incurvation of the arms is not rare—the fore- arm instead of continuing, in its articulation with the humerus, the almost straight line which the whole arm should make, forms a larger angle, opening outwardly. This deformity may render it impossible to perform, with regularity and precision, certain motions in the handling of arms. The same is the case with bow-legs, which are a disqualification, because they prevent junc- tion of the heels, and occasion an impediment and an irregularity in walking, which extends almost to lame- ness when the deformity is restricted to one leg. This deformity is, in the majority of cases, associated with scrofula. Atrophy of the Eimbs. § 380. "Whether atrophy be congenital or acquired, whether it involve all the limbs or be confined to one, the relative weakness which it occasions necessarily constitutes an absolute disqualification for the military service. Contractions. § 381. Contraction, or rigidity, and shortening of cer- tain muscles, with diminution or loss of their normal ex- 188 MANUAL OF INSTRUCTIONS tensibility, occasions, sometimes flexion, and more rarely permanent extension, of a portion of a limb, and always constitutes an absolute disqualification for the military service. Contraction of limbs is often feigned—a fact which may be suspected whenever it is declared to be of long standing, and vet the limb is not emaciated. There are persons who, for a long, while, keep the fore- arm and leg continually bent, and thus succeed in inter- rupting the nutrition of their limbs. Others habituate themselves to wearing a high heel, in order to compel flexion of the knee while walking; others, as is most commonly the case, keep the thumb and index finger of one hand in a state of absolute repose, by flexion, or compress the hand with a band, in order to diminish the size of the fingers and to crook them, allowing perspira- tion and dirt to accumulate beneath them for the pur- pose of rendering the curvature more probable, and sometimes even burn themselves, in the direction of the tendons of the flexor muscles, to make the retraction appear more natural. All these frauds will fail in the presence of a surgeon enlightened by experience, since the phenomena of nature can never be perfectly im- itated by art. In each of the foregoing cases suspicion should be awakened not, properly speaking, when the muscles feel hard and tense alone, as has been said; but when their belly presents, along with hardness, that swelling which accompanies every contraction, and when too there may be felt, within their thickness, those slight jerkings which betray the incessant repetition of contractile efforts on the part of the muscular fasciculi, resisting action imparted to the limb in a different direction. In order to expose the cheat, or to cause sus- pension of its effects, the simulator must be met by FOR EXAMINING SURGEONS. 189 artifice: his attention must be strongly distracted, while at the same time an effort is made to surprise him, and to suddenly overpower resistance. At other times be- lief must be pretended in his assertions, and he must be led to acts in contradiction with them. Fraud may be discovered by making the suspected man stand on one foot, upon a post slightly elevated, and compelling him to balance himself upon the sound leg; fatigue will soon oblige him to extend the limb artificially contracted. Finally, a more direct and potent expedient offers itseff, which consists in applying upon the limb a tight, and well-rolled bandage made of new linen, and afterwards wetting it, in order to increase its compressive power. The limbs being no longer able to contract beneath this uniform impediment, soon cease to resist motion. "When the party is in hospital, it will suffice to wait until he is asleep in order to straighten the limb and to expose his deception. This last method of verification is applicable to cases of feigned anchylosis. The use of an anaesthetic will, in general, speedily determine the question. Supernumerary Eimbs. § 382. This anomaly is of rare occurrence, so far as it relates to a whole limb. It is sometimes observed, how- ever, with regard to the lower extremities. It is more frequent when partial and limited, for example, to fingers and toes. Thus, certain persons are born with supernumerary fingers or toes ; these may be either rudimentary or possess the complete organization of true fingers or toes. Both these deformities con- stitute a disqualification for the military service. 190 MANUAL OF INSTRUCTIONS ITIechanical Lesions. § 383. The various mechanical lesions which affect the limbs either in their continuity or their contiguity, deserve serious attention, as well on account of the weak- ness to which.they give rise, as of the deformity which they may occasion. The decision to be given in each case will rest necessarily upon the importance, extent. seat, and nature of parts involved, as also upon the con- sequences produced. A superficial and slight wound is trifling; a deep wound, however slight in extent, may have occasioned persistent troubles. "Wounds of the joints are always serious. Exsections and Amputations. § 381. Exsections applied to the bones of the limbs, whether in their continuity or in their contiguity, are always causes for rejection and often for discharge. The same rule, for a still stronger reason, will apply to loss of limbs by amputation. Fractures. § 385. Fractures of the limbs, simple, recent, or uni- ted by a small non-prominent callus, without deformity, are not a cause for rejection. But the same will not be the case when the fracture is of long standing, badly united, or has occasioned a false articulation, or again, when union has taken place with an exuberant callus, angular and voluminous, with or without shortening of the limb. All such cases afford causes for rejection or discharge. Sprains and Luxation*. § 386. Recent sprains are generally recovered from without serious consequences, but the possibility of con- FOR EXAMINING SURGEONS. 191 secutive disability, should lead the examining surgeon to bestow the greatest care upon the examination of those individual cases, concerning which his decision is required. Old sprains, when accompanied by swelling, pain, and difficulty in walking, are always a cause for rejection. If the sprain is of an upper limb, its consequences are less serious, and it often justifies a favorable prognosis. Congenital luxation, particularly of the femur, justifies the rejection of a party; the same rule does not obtain, however, when it is accidental, and properly reduced, unless it has given rise to injurious consequences, such as partial paralysis, with atrophy of the limb, which are sufficient causes of disqualification. Old and properly reduced luxations do not justify re- jection, unless they have been followed by serious con- sequences which interfere with the play of the articula- tion. — Badly reduced luxations, together with unreduced lux- ations, are always a disqualification for military service. Arthritis and Hydrarthrosis. § 387. Arthritis," and even hydrarthrosis, when simple and recent, justify neither the rejection nor the discharge of a party, whatever may have been their origin, whether accidental or gonorrhceal, with the exception, however, of inflammation of the shoulder or hip joint, which are often serious, and demand all the attention of the sur- geon. These diseases, when chronic, are, on the contrary, always causes for rejection, and sometimes for discharge. The same rule, for still stronger reasons, will apply to well-marked white swellings of the joints, complicated or not with sinuses or ulcerations. 192 MANUAL OF INSTRUCTIONS Varices. § 388. Varices which are fluctuating, knotty, and livid tumors, formed by the permanent distension and elonga- tion of the veins, may be considered as exclusively con- fined to the lower limbs, so rarely are they encountered in the arms. Their existence in young men, whenever they cannot be explained by any local cause or profes- sional influence, may be referred to some obstacle to the flow of the blood, either from compression of some venous trunk by a tumor, or by some lesion in the central organs of circulation or respiration. It is therefore under this aspect that investigations should be made, and whenever the presence of varices is added to other signs, even ob- scure, of any of the foregoing diseases, the decision should lean towards the side of rejection. Except in such in- stances, no attention need be paid to scattered and su- perficial varices which are without importance. But when they are deep seated, and detached, in knotty clusters, extending to the thigh, and even to the groin, they must be considered a disqualification for the mili- tary service. Sometimes swelling of a lower limb is no- ticed, which springs from no other cause than deep-seated varices often associated with serious internal disease. Such cases justify rejection. Among soldiers, it must not be forgotten that varices which might be troublesome when men are forced to make long and rapid marches, do not prevent them from serving in some sedentary capacity. Abscess. § 389. Acute abscess occurring in the limbs, if large, diffused, and situated beneath the deep fascia;, may occasion copious suppuration and extensive scars, and FOR EXAMINING SURGEONS. 193 must be considered a cause for rejection. But if only superficial, and of slight extent, it would not be so. Chronic and indurated abscess is always serious enough to constitute a disqualification. Whitlow of the fingers is unimportant when super- ficial ; but if deep seated, it is well to bear in mind the possible consequences which it may occasion, such as multiple and extensive incisions, deformity, stiffness, and even loss of the phalanges. In such cases rejection must follow. (Edema of the Limbs. § 390. (Edema of the limbs, which is often suggestive of organic disease of the heart and kidney, may be arti- ficially produced by the application of ligatures imped- ing circulation. The possibility of such things should always awaken the attention of surgeons. Elephantiasis of the limbs when present, always con- stitutes a cause for rejection. Neuralgia.—Rheumatism. § 391. Chronic neuralgias, like sciatica and chronic rheumatic pains, which occasion a real impediment to the discharge of a soldier's duties, are too easily feigned not to be often alleged, although young men are much less subject to them than persons of more mature age. When the pains are very intense, and have lasted for some time, they always produce an emaciation, and sen- sible weakness in the strength of the limbs, whose mus- cles, diminished in volume, become flaccid, and whose form sometimes undergoes alteration. Where no ap- parent symptom reveals the presence of these affections, the surgeon may draw some conclusions from the pro- 9 194 MANUAL OF INSTRUCTIONS fession of the party and his local habits. It is well known that country people are more subject to these diseases than city people, and that there are modes of living where they are most easily contracted. In uni- ting these various data, and in combining and comparing them, the surgeon will nearly always be able to distin- guish the real from the feigned disease. "Whenever this diagnosis cannot be established, the Board of Enrolment has no other resource than proofs derived from public notoriety. Among soldiers a powerful auxiliary will be found in those active medicines which these diseases, when real require, and which, in cases of imposture, finally succeed in wearying, or intimidating malingerers. Yet experience forces us to admit, that there are men whom the longest and most severe treatment fails to over- power. It is therefore justifiable to incline towards severity, rather than towards leniency, for fear of the contagiousness of example; but this severity should immediately cease, at the first intimation of a real im- pairment of health. Gout. § 392. Gout is extremely rare in youth, being gen- erally found only in old age. It is also of infrequent occurrence among soldiers and non-commissioned of- ficers, whatever may be their age. It would, if present, constitute a disqualification for the military service. Professional Deformity of the Hands. § 393. Certain manual avocations impress upon the hands modifications of more or less extent, amounting sometimes even to real deformities. It is unusual, how- FOR EXAMINING SURGEONS. 195 ever, to find them existing to such a degree as to require the rejection of a party; for it must not be forgotten that a change of occupation most generally suffices to diminish sensibly these alterations, or even to obliterate them entirely. The surgeon need not spend much time upon them, unless they are very strongly marked, since the manual of arms will of itself tend to restore the hand to its normal condition. MUTILATIONS OF THE FINGERS AND TOES. § 391. Mutilations of the fingers and toes are a dis- qualification for military service, whenever they consist in any of the following lesions: Hands. 1st. Total loss of either thumb or one of its phal- anges. 2d. Total loss of the index finger of the right hand or of one of its phalanges. Total loss of the index finger of the left hand or of two of its phalanges. 3d. Total loss of any two fingers or coexisting loss of two phalanges of two fingers. 4th. Coexisting loss of one phalanx of the three last fingers. Feet. § 395. 1st. Total loss of either great toe or of one of its phalanges. 2d. Total loss of two of the lesser toes. 3d. Coexisting loss of one phalanx of all the small toes. It is particularly in relation to these mutilations that the serious question of bow they occurred arises. For it is doubtless true that, both before and after admission 196 MANUAL OF INSTRUCTION.-. into the army, parties do voluntarily mutilate them- selves, either with cutting instruments or fire-arms. The extreme difficulty under which an examining sur- geon labors, in such cases, can readily be conceived, as also how great must be the certainty of his conviction before making an allegation of fraud" against any one. The examination, made with the greatest possible care, should bear upon the antecedents of the party and all the circumstances of the accident ; but, generally speak- ing, the question can only be solved when the mutila- tion is recent, and even then often gives rise to many doubts. Permanent Flexion, or Contraction of the Fingers. § 396. Permanent flexion of the fingers may be either congenital or accidental, and arise from very different causes, involving the integuments, the cellular and fibrous tissues, the muscles and tendons, the nerves, and the phalanges, in their continuity or contiguity. At- tention should be directed to the skin, which may be the seat of a retraction caused by cicatrices ; to the mus- cles, and*fibrous tissues, which may be shortened by loss of substance; to the nerves, whose lesion may have caused local paralysis ; or to articular and bony tissues. Permanent flexion of the fingers, unless existing in a slight degree, is a disqualification for the duties of a soldier. It may be looked upon as feigned, whenever we fail to find a reason for it in the causes, or tissues, above enumerated. Permanent Extension of the Fingers. § 397. The same considerations apply to well marked permanent extension of the fingers, which may affect one or more of them. FOR EXAMINING SUROJiONS. 197 DEFORMITIES OF THE FEET. Club-Foot. §398. The extremities of the limbs present deformi- ties known, when belonging to the feet (where they are more common than to the hands) under the designation of club-feet. Whatever may be their variety, and ap- preciable degree, whether eguinus, talus, varus, or val- gus, they constitute an evident disqualification for the military service. A mild form of club-foot may be simulated by a false position of the foot, being either voluntary, and mo- mentary, or permanent by reason of a faulty mode of walking. It requires no special mention. Flat Feet. § 399. The bony framework of the feet is, in most per- sons, so constituted as to present on its inner side a hol- low, whose concavity faces the ground, while its convex- ity forms the instep ; wrhence it follows that, standing or walking, that portion of the sole of the foot which forms the summit of this hollow does not. touch the ground. The generic term fiat feet, is given to those who do not possess this conformation. A very important distinction must, however, be made in this connection ; for at times there may be simple flatness, and again there may be flatness with deviation of the foot.*. Feet that are sim- ply flat, do not prevent marching, and are not a cause * The deviation alluded to here consists in a twisting of the foot on its own axis, so as to bring its inner border in contact with the ground, while its outer border fails to receive its due proportion of the weight of • the body. 198 MANUAL OF INSTRUCTIONS for rejection ; but flat feet with deviation, are, on the contrary, always a disqualification. If we limit our- selves, however, to an examination of the sole of the foot, and there discover no hollow, and if, finding its whole surface uniformly callous, and soiled, from con- tact with the ground, we reject the party, we at times run the risk of committing a great error. This false ap- ■ preciation is founded upon the opinion that the difficulty of walking, under such circumstances, arises from com- pression of the nerves, and soft parts of those regions. Experience contradicts this assertion. Many' country- men, and more particularly mountaineers, have the soles of the feet flat, without hollow, and touching the ground through their whole extent, and yet these men are, in general, good walkers. The flat foot, with deviation, which constitutes a disqualification for the military ser- vice, consists not only in an absence of the hollow of the foot, and a flatness of its dorsum, but also in an unnatu- ral inclination of it. In such cases the internal malleo- lus descends low down, and is prominent; the astraga- lus is inclined inwardly, and the axis of the leg does not fall directly upon the centre of the foot, whence it fol- lows that the inner side of either ankle is prominent, and the corresponding malleoli exposed, to interfere painfully in walking, or to be bruised by contact with a rough soil. The lateral ligaments of this region are stretched, weakened, and, during protracted marches, this part being strained, suffers and becomes inflamed and swollen.- Xone of these troubles arise when, al- though the surface of the feet be flat, the leg and the foot are in their natural relations. The shape of the foot in these cases often arises from the fact that the hollow is filled by the muscles of the plantar surface, which • FOR EXAMINING SURGEONS. 199 have acquired unusual size through habitual exercise. This circumstance, far from indicating any impediment to inarching, proves, on the contrary, the extent of the locomotive power. Hollow Feet. • § 400. An opposite deformity to this, and which might be called hollow feet, is sometimes met with. This is characterized by a more or less extensive hollow- ing of the foot, with a corresponding arching of its in- step. This last feature is not witnessed when the hol- lowing arises from traumatic lesion, with loss of sub- stance. This deformity affords a cause for rejection, whenever it is sufficiently marked to cause an impedi- ment in walking. Faulty Direction of the Toes.—§ub-Luxation. § 101. The natural direction of the toes may be altered in different ways, and by different causes. One of them may have changed its normal place and direction, and ascended laterally, in such a way as to cross and override the one immediately adjoining; and as soon as this de- viation becomes chronic, the articular surfaces themselves alter their direction, and a cure becomes next to impossi- ble. This overriding of one or more toes, when it exists to an extreme degree, has become permanent, and yields with difficulty to mechanical pressure, interferes more or less with walking, and may, on this account, require the rejection of a party. Some persons produce it purposely. The cheat may be discovered by noticing whether, to the cushion of the displaced toe, a corresponding hollow on the other affords * a lodging place. 200 MANUAL OF INSTRUCTIONS Walking on the Nail. § 402. In other cases, the first phalanx of one of the toes, and it is commonly the third, turns up by degrees, in such a way, as to form, with the metatarsus which sustains it, an obtuse angle approximating more or less to a right one, while at the same time the second and third toes incline themselves in an increasing flexion, so that the extremity of the toe pointing downwards rests upon the ground, when the person stands or walks. The toe is thus compressed between the upper and the sole of the shoe. This pressure causes more or less pain, the skin becomes inflamed, red, and often ulcerates on the prominent side, and walking becomes painful. Persons laboring under this infirmity, when strongly marked, cannot endure a long march, particularly when the third phalanx bonds upon the second to such an extent that the toe, instead of-resting upon its cushioned end (ham- mer-toe), rests upon the nail itself, which is then called " walking on the nail." This latter condition is an abso- lute disqualification. When the cushioned extremity of the toe rests upon the ground, the party can still walk, and no cause for rejection exists. Web Fingers and Toes. § 403. Sometimes the fingers and toes are united by a prolongation of the skin, extending for a variable dis- tance from their root towrard their extremities, and which is designated a web. When this abnormal membrane is found between all the fingers of one hand, although*, it should not extend beyond the first or proximal phalangeal articulation, the party must be rejected. Two fingers alone united throughout their extent would justify a similar disposition of him, whereas, if united through a FOR EXAMINING SURGEONS. 201 space of about an inch, disqualification would only arise if the web existed between the thumb and forefinger, or between this last and the middle one. As for the toes, with the exception of the great one, they must all be united, and throughout their whole extent in order to afford a cause for rejection. The great toe must always be free throughout its whole extent. Subungual Exostosis. § 401. Subungual exostosis of the great toe, although not a serious affection, is a cause for rejection, because of the painful operation which it requires. But it would afford no cause for a discharge, unless in very excep- tional cases. Bunion. § 405. The tumor affecting the internal aspect of the metatarso-phalangeal articulation of the great toe, varies in importance. When it does not extend beyond the epidermis, or true skin, no attention need be paid to it; but if the fibrous tissues, the periosteum, and the bony tissues are themselves altered, which is most frequently the case, the party must be rejected. A discharge, in like manner, is called for, whenever this tumor has suc- cessfully resisted all curative treatment. Corns. § 406. Corns on the feet are in general a trifling affection. Nevertheless, they may have acquired a suf- ficient size to interfere very sensibly with walking. Ex- cision is only an imperfect remedy, and under very peculiar circumstances, therefore, they might afford a cause for rejection. But a discharge could only be granted under extraordinary circumstances. 9* 202 MANUAL OF INSTRUCTIONS Perforating Ulcer of the Foot. § 407. Perforating ulcer of the foot, a disease but re- cently known, attacks chiefly the sole of the foot, the surface of the metatarso-phalangeal articulations, the cushion of the toes, and the heels. This affection mani- fests itself in a thickening of the epidermis which covers an ulcerated surface, whence exudes a small quantity of viscid, colorless, and fetid matter. These ulcerations heal with difficulty and tend to increase in depth. They constitute an absolute disqualification. Fetid Perspiration from the Hands and Feet. § 408. It is particularly at the points of union be- tween the trunk and the limbs, and where the latter are in permanent contact with it, that cutaneous exhal- ation occurs with the most constancy and abundance. These are the chief sources of the smell which it emits. Now this odor may habitually be of so fetid a character, as to constitute a good cause for the rejection of a party. But it can be readily conceived that much caution is needed in forming a decision, for there are individuals in whom this serious inconvenience only manifests itself during exercise. They can therefore readily conceal it, or even if they disclose it, it is difficult to establish its reality. On the other hand, it is often feigned, notwith- standing the fact that when real, this odor is so entirely-m* generis, as to be readily distinguished. It should not then be admitted as a cause for rejection until authenticated by reliable testimony, or unless it persistently showed itself after subjecting the individual to repeated washings with soap and water. Nor should it l)e forgotten, either, that it sometimes depends upon the avocation followed, and that consequently it may be removed by change of cir- FOR EXAMINING SURGEONS. 203 cumstances, such, for example, as entrance upon a sol- dier's life and an observance of those rules of cleanliness, to which military men are subjected. Diseases of the Nails. § 409. The nails, particularly of the feet, may be the seat of a form of hypertrophy, rendering them similar to horny growths. This condition would not constitute a disqualification for the military service, unless it had acquired enormous proportions, and given evidence of being remediless. The same rule will apply to extensive curvature of the nails, which often accompanies hypertrophy. In-growing Nail. § 410. The great toe is sometimes the seat of a disease known as in-growing nail. In this state, the nail either grows in an abnormal direction, or else encroached upon by the soft parts around it, which have themselves been compressed by too tight a shoe, it burrows into the flesh beneath its lateral edge. Irritation of the parts ensues; ulcers.are formed which occasion the develop- ment of soft, sometimes fungous flesh ; and lancinating pains, always aggravated by walking, accompany the disorder. In-growing nail, being susceptible of cure, does not justify rejection, unless it should exhibit an exceptional degree of severity, and be complicated with a fungous state of the surrounding flesh. It can only rarely afford a cause for discharge. Syphilitic Affection of the Nail. § 111. Syphilitic ulcer of the nail, which may coun- terfeit in-growing nail, does not, of necessity, constitute a disqualification for the military service. 2 »1 MANUAL OF INSTRUCTIONS DISEASES OF THE BTJRS.2E MUCOSA AND SYNOVIA! MEMBRANES. Hygroma.—Cysts. § 412. Hygroma, or dropsy of the subcutaneous bursre mucosae, and more particularly of that of the knee, may be sufficiently voluminous to impede walking, and thus afford a cause for rejection. If its development is only slight, it merits no attention. The same rule applies to synovial tumors, and to the cysts formed in the wrist or calf of the leg. Small syno-' vial cysts, or ganglia, such as are frequently met with on the extensor tendons of the hand, are not a disquali- fication for the military service, unless exceedingly volu minous. Foreign Bodies in the Articulations. § 113. There are often formed within the capsular ligament of joints, hard, round, or flat bodies, mostly cartilaginous, which give rise to pain and impede the freedom of motion. These non-adherent bodies may be formed in any of the movable articulations ; but it is in the knee that they are most often found, and where they occasion consequences which are a disqualification for the duties of a soldier. Lameness. § 414. Lameness may be the consequence of most of the foregoing lesions, when they are situated in the lower limbs. Hence, it may arise from congenital de- formity, from obliquity of one of the sides of the pelvis, from pain, or from swelling of the limbs. Whatever its cause, unless it be an acute disease, which is known not FOR EXAMINING SURGEONS. 205 to constitute a disqualification for the military service, it should afford a cause for rejection or discharge. But this infirmity is often feigned, and the fraud then demands the closest attention on the part of the surgeon. It is only by a correct measurement, that we can assure ourselves of the inequality in length of the lower limbs, and consequently of the reality of the lameness ascribed to this cause. For this purpose the subject should be laid horizon- tally on his back, and a comparative measurement, on both sides, be made of the space between the most prom- inent point of the crista ilii and the external malleolus, in passing the tape directly in front of the trochanter major. Conclusions. § 415. The foregoing instructions can hardly be consid- ered in the light of a code of absolute prescriptions. Yet the pathological indications which they describe, when judiciously combined with the results of individual examination, will generally be found sufficient to guide examining surgeons, as also to enlighten Boards of Enrolment in confirming the decisions of their medical advisers. It is also necessary in this connection to establish, as a leading principle, the propriety of the surgeon not resting satisfied with convincing himself alone of the existence of the fact to which his attention is called, but seeking also to impart a like conviction to his colleagues in the Board. It is well, therefore, whenever possible, to sustain his opinion by a sensible, material, and evi- dent demonstration, instead of limiting himself to a sim- ple declaration of it. But in following this course one 200 MANUAL OF INSTKtVTIONS, KTC. danger must be avoided, and that is the tendency to be captivated by the ease of explaining external affections, to the neglect of internal diseases, which are nearly always of more serious character. Boards of Enrolment are in general disposed to reject parties for visible and palpable infirmities, although often of a trifling charac- ter, while they are much more strictly disposed towards visceral lesions which they cannot perceive. It be- comes the duty of the examining surgeon, under such circumstances, to unfold the great importance of these structural alterations, and to explain the consequences to which they may give rise. In conducting the personal examination of a party, kindness, forbearance, and patience of attention to his statements should be exhibited ; he should be saved from indiscreet curiosity, and proper precautions be ob- served to spare the becoming sensitiveness of families, on the score of hereditary diseases. In conclusion, examining .surgeons should remember the double duty they are called upon to discharge, in se- curing healthy recruits for the army, and in protecting the interests of the infirm. Whenever, therefore, they entertain any serious doubt of the physical capacity of an individual, they must act conscientiously, and as the law directs, by advising his rejection. APPENDIX. APPENDIX. [official.] Provost-Marshal General's Bureau. INSTRUCTIONS FOR THE PHYSICAL EXAMINATION OF DRAFTED MEN. I. The duty of inspecting drafted men, and of determin- ing whether they are fit or unfit for the military service of the country, requires the utmost impartiality, skill, and cir- cumspection on the part of the Examining Surgeon and Board of Enrolment, for upon the manner in which this duty is performed, will depend in a very great degree the efficiency of the Army. II. In the examination of drafted men, the Examining Surgeons will bear in mind, that the object of the Govern- ment, is to secure the services of men who are effective, able-bodied, sober, and free from disqualifying diseases. III. The Examining Surgeons will also remember that the object of the drafted men in elaiming exemption may be to escape from service by pretended, simulated, or factitious diseases, or by exaggerating or aggravating those that really exist, and that the design of substitutes frequently is, to con- ceal disqualifying infirmities. IV. The examination of a drafted man by the Examining Surgeon is to be conducted in the day-time, in the presence 210 APPENDIX. of the Board of Enrolment, and in a room well lighted, and sufficiently large for the drafted man to walk about and ex- ercise his limbs, which he must be required to do briskly. V. The man is to be examined stripped. The principal points to be ascertained are as follows: 1. Whether his limbs are well formed and sufficiently mus- cular ; whether they are either ulcerated or extensively cica- trized ; Avhether he has free and perfect motion of all his joints, and whether there are no varicose veins, tumors, wounds, fractures, dislocations, or sprains that would impede his marching or prevent continuous muscular exertion. 2. Whether the thumbs and fingers are complete in number, are well formed, and whether their motions are unimpaired. 3. Whether the feet are sufficiently arched to prevent the tuberosity of the scaphoid bone from touching the ground; whether the toes are complete in number, do not overlap, are not joined together, and whether the great toes are free from bunions. 4. Whether he has any inveterate and extensive disease of the skin. 5. Whether he is sufficiently intelligent; is not subject to convulsions, and whether he has received any contusion, or wound of the head that may impair his faculties. 6. Whether his hearing, vision, and speech, are good, and whether the eye and its appendages are free from disqualify- ing diseases. 7. Whether he has a sufficient number of teeth in good con- dition to masticate his food properly, and to tear his car- tridge quickly and with ease. The cartridge is torn with the incisor, canine, or bicuspid teeth. Whether his chest is ample and well formed, in due pro- portion to his height and with power of full expansion. 9. Whether there is any structural or serious functional disease of the heart. 10. Whether the abdomen is well formed, and not too pro- APPENDIX. 211 tuberant; whether neither the liver or spleen are consider- ably enlarged ; and whether the rectum and anus are free from disqualifying diseases. 11. Whether the spermatic cords and testes are free from diseases which would impair his efficiency, whether the testes are within the scrotum, and whether he has any rup- ture. 12. Whether there is any organic disease jof the kidneys or bladder, or permanent stricture of the urethra. 13. Whether his physical development is good, and consti- tution neither naturally feeble, nor impaired by disease, hab- itual intemperance, nor solitary vice; whether he is free from phthisis, scrofula, and constitutional syphilis; and whether he is epileptic, imbecile, or insane. DISEASES OR INFIRMITIES, WHICH DISQUALIFY FOR MILITARY SERVICE. 1. Manifest imbecility or insanity. 2. Epilepsy. For this disability, the statement of the drafted man is insufficient, and the fact must be established by the duly attested affidavit of a physician of good standing; who has attended him in a convulsion. 3. Pkrah/sis, general, or of one limb, or chorea—their ex- istence to be adequately determined. 4. Acute or organic disease of the brain or spinal cordy of the heart or lungs y of the stomach or intestines y of the liver or spleen y of the kidneys or bladder—sufficient to have impaired the general health, or so well marked as to leave no reasonable doubt of the man's incapacity for military service. 5. Confirmed consumption y cancer y aneurism of the large arteries. G. Inveterate and extensive disease of the skin, which will necessarily impair his efficiency as a soldier. 212 APPENDIX. 7. Decided feebleness of constitution, whether naturally, or acquired. 8. Scrofula, or constitutional syphilis, which has resisted treatment, and seriously impaired his general health. 9. Habitual and confirmed intemperance, or solitary vice, in degree sufficient to have materially"enfeebled the consti- tution. 10. Chronic rheumatism, unless manifested by positive change of structure, wasting of the affected limb, or puffi- ness or distortion of the joints, does not exempt. Impaired motion of joints, and contraction of the limbs, alleged to arise from rheumatism, and in which the nutrition of the limb is not manifestly impaired, are to be proved by exam- ination, while in a state of anaesthesia, induced by ether only. 11. Pain, whether simulating headache, neuralgia in any of its forms, rheumatism, lumbago, or affections of the mus- cles, bones, or joints, is a symptom of disease so easily pre- tended, that it is not to be admitted as a cause for exemption, unless accompanied with manifest derangement of the gen- eral health, wasting of a limb, or other positive sign of dis- qualifying local disease. 12. Great injuries, or diseases of the skull, occasioning impairment of the intellectual faculties, epilepsy, or other manifest nervous or spasmodic symptoms. 13. Total loss of sight y loss of sight of right eye y cata- ract y loss of crystalline lens of right eye. 14. Other serious diseases of the eye, effecting its integ- rity and use, e. g., chronic ophthalmia,fistula lachrymalis, Ptosis (if real), ectropion, entropion, &c. Myopia, unless very decided, or depending upon some structural changes in trie eye, is not cause for exemption. 15. Loss of nose ; deformity of nose so great as seriously to obstruct respiration. Ozoena, dependant upon caries in progress. APPENDIX. 213 16. Complete deafness. This disability must not be ad- mitted on the mere statement of* the drafted man, but must be proved by the existence of positive disease, or by other satisfactory evidence. Purulent otorrhoea. 17. Caries of the superior and inferior maxillary, of the vasal or palate bones, if in progress ; cleft palate (bony): extensive loss of substance of the cheeks, or salivary fistula. 18. Dumbness y permanent loss of voice, not to be ad- mitted without clear and satisfactory proof. 19. Total loss of tongue ; mutilation or partial loss of tongue, provided the mutilation be extensive enough to in- terfere with the necessary use of the organ. 20. Hypertrophy, or atrophy of the tongue, sufficient in degree to impair speech or deglutition. Obstinate chronic ulceration of the tongue. 21. Stammering, if excessive, and confirmed; to be es- tablished by satisfactory evidence, under oath. 22. Loss of a sufficient number of teeth, to prevent proper mastication of food, and tearing the cartridge. 23. Incurable deformities, or loss of part of either jaw, hindering biting of the cartridge, or proper mastication, or greatly injuring speech : anchylosis of lower jaw. 24. Tumors of the neck, impeding respiration or degluti- tion : fistula of larynx, or trachea; torticollis, if of long standing and well marked. 25. Deformity of the chest, sufficient to impede respiration, or to prevent the carrying of arms and military equipments. Curies of the ribs. 26. Deficient amplitude, and power of expansion of chest. A man 5 feet 3 inches, (minimum standard height for the Regular Army,) should not measure less than thirty inches in circumference, immediately above the nipples, and have an expansive mobility of not less than two inches. 27. Abdomen grossly protuberant; excessive obesity; Hernia, either inguinal or femoral, ventral, umbilical, Lymphatic..................... 43 l Albuminuria........................ 171 Amaurosis......................... 85 f Differential Diagnosis of Blind- . • ness from, and Cataract...... S6 | Aneurism, of Subclavian...........*137 Anorchidia......................... 183 Antenna............................ 34 Anus and Rectum, Diseases of....... 163 Traumatic Lesions.............. 164 Foreign Bodies.................. 164 Worms......................... 164 Syphilitic Diseases of............ 1(54 Fistulas of...................... 165 Cancer......................... 166 Anus, Artificial..................... 157 Anchylosis, of Lower-jaw........... 108 Angeioloceiitis...................... 43 Anasarca............................ 41 ' Aneurism.......................... 43 Aorta, Lesions of Thoracic........... 146 Appearance, General Bodily......... 20 Aphonia........................... 126 Articulations, Foreign Bodies in .. .. 204 Asthma........................... 147 Astigmatism........................ SI Atresia............................. *2 Atrophy of Penis.................... 170 Baldness.....................■..... 51 Bladder, Traumatic Lesions.......... 174 Paralysis.................'....... 174 Hypertrophy................... 173 Diseases of...................... 173 Absence, Extrophia............. 173 PA«« Bladder, Hydatids of................. 175 Fistulas of..................... 175 Blepharospasm...........,.......... 95 Bones, Diseases of....................49 Breath. Fetor of....................Ill Bronchitis.......................... 139 Bunion............................. 201 Bursa; Mucosa;, Diseases of.......... 204 Cachexies......................... 36 Calculi............................. 172 Biliary ........................ 161 Vesical....................... 174 Urinary........................ 171 Cancer............................. 87 Carbuncle, dorsal................... 153 Catalepsy........................... 62 Cataract........................... 83 Cervical sprain..................... 131 Vertebra?, Diseases of........... 131 " Fractures of.......... 131 Chemosis........................... 90 Chest, Diseases of................... 132 Chorea............................ 62 Clavicle, Deformity of............... 137 Cicatrices___«..................... 40 Of Scalp....................... 52 Coccygis, Sprain or Luxation........ 162 Conjunctiva, Diseases of............ 90 Ecchymoses of.................. 90 Cysts and Tumors of............. 91 Constitution, Feebleness of.......... 82 Contractions, Permanent............ 47 Cornea. Diseases of.................. 80 Wounds, and Foreign Bodies in.. 80 Ulcerations of.................. 80 Opacities of.................... 80 Corns.............................. 201 Coryza, Chronic.................... 104 Crystalline Lens, Diseases of........ 83 Cutaneous Diseases of Face ......... 75 Cyanosis.......................... 140 Cystitis........................... 175 Deafness............................ 70 Delirium Tremens................. 63 Dementia.......................... 55 Diabetes........................... ll9 Diphtheria......................... 128 Diplopia............................ &a 230 IN DUX. Disqualifying Diseases, U. S. A...... 211 Prussia...........1..........T . 227 Diseases, Artificially produced...... ->'< Dissembled.................... 2H Feigned........................ 2(! Constitutional................. 81 Sources of Indication of........ 82 Of Skin..................... .. 3s Dropsy............................ 42 Duinbness.......................... 116 Dysphagia.......................... 120 Kara, Diseases of................... 64 Ear, Loss of Pavilion................ 64 Atrophy and Hypertrophy...... 6fi Polypi of....................... 66 Obliteration of Meatus.......... 65 Foreign Bodies in............... CO Middle, Diseases of............. (IT Internal, Diseases of......:..... 6S Purulent Discharges from...... 69 Eczema...........................38, 51 Etliisiuns. Pleuritic................ 142 Emaciation........................ 41 Emphysema, Traumatic............. 135 Pulmonary..................... 139 Of Scrotum..................... Enc-phalMii, Diseases of............. 54 Encli.uidnima...................... Endoearditis........................ 144 Epilepsy........................... 57 i:piphora........................... 99 Epistaxis........................... 104 Erysipelas.......................... 89 Examination, Generalities of........ 20 Of Malingerers, Rules for........ 80 Exanthemata, Artificially produced... 89 Exophthalmos...................... 7s Exostosis, Subungual............... 201 Eye, Diseases of.................... 76 Mechanical Lesions gf Ball...... 77 Foreign Bodies in............... 78 Atrophy of Ball................. 78 Diseases of Internal Parts....... s4 Atrophy of.................. 85 Hyperemia.................... 85 Choroid congestion............. 86 Eyelids, Diseases of................. 94 Deformities of.................. 94 Adhesions of.................... 94 Wounds of..................... 95 Occlusion of.................... 97 Granulations of................. 96 Paralysis of..................... 96 Tonic contraction of............. 06 Face. Diseases of.................... 74 Cutaneous Diseases of........... 75 Fistulas of...................... 75 Ulcers of........................ 75 Mutilations of................... 75 Facial Sinns, Diseases of............. 106 Occlusion of............. 106 Faeces, Incontinence of............... 167 Feet, Generalities of Examination--- TAOR Feet, Club-foot...................... 197 Flat............................. in: Hollow........................ l'.ni Mutilations of................... 195 Feigning........................... 25 Bibliography of (Note)........... 25 Fingers. Permanent Flexion of....... 1 :ni Contraction of.................. 1S"> Permanent Extension of.......... llMi Web............................ 2u.) Fistulas, of Face..................... 76 Abdominal ..................... 157 Lachrymal...................... 100 Of Keetum...................... 1l2i Renal........................... 1,3 Salivary......................... Ill) Vesical".......................... 175 Forehead, Deformities and Exostosis of 71 Fractures of Skull.................. Glands, Diseases of Salivary......... 1 IS Glaucoma........................... 79 Goitre.............................. 121 Gout............................... 194 Gums, Diseases of................... 112 Inflammation of................. 112 Scorbutic Condition of........... 112 Ilornatemesis........................160 Ihemotocele......................... 1^> Hematuria.......................... 171 Ha-moptysis......................... 141 I hemorrhoids....................... 106 Hands, Deformities of............... 194 Mutilations of................... 195 Hare-lip, Accidental................ 110 Heart, Narrowing of Valves.......... 145 Dilatation with Thinning........ 145 Organic Lesions of............... 142 Displacement of................. 144 Hypertrophy of................. 144 Hemeralopia........................ 89 Hemiopia.......................... M Hernia............................ 15G Of Bladder...................... 175 Lumbar......................... 151 Hordeolum.......................... 9(1 Hydrocele........................... 1 Invalid CoTps U. S.. how formed. ... 217 Physical Qualifications and Dis- qualifications for............ 221 Invalid Corps, Prussia.............. 231 Degrees of Invalidity....... 232 Medical Certificates for.......... 2-J3 INDEX. q«' PAGE Instructions for Examination of Draft- ed Men, U. S...............209 Instruments for Examination........ 19 Iris, Congenital Fissure, and Lacera- tions of..................... 81 Absence of..................... 81 Detachment of.................. 82 Diseases of...................... 81 Loss of Color .................. 81 Iritis................................ 82 Jaundice............................ 161 Keratitis............................ 80 Kidney, Mechanical Lesions of....... 172 Lachrymal Gland, Tumefaction of___ 98 Tumor.......................100 Caruncle, Diseases of............ 101 Lameness.......................... 204 Larynx, Diseases of.................. 125 Lesions of................ ...... 125 Laryngitis.......................... 125 Lichen.............................. 88 Limbs, Generalities of Examination.. 24 Diseases of...................... 186 Anomalies of.................... 186 Inequality of.................... ls>6 Incurvation.....'................ Is7 Atrophy........................ 1S7 Contractions.................... 1 s7 Supernumerary................. 1S9 Mechanical Lesions.............. 190 IXsections and Amputations..... 190 Fractures........................ 190 Sprains and Luxations........... 190 Arthritis, Hydrarthrosis......... 191 Varices...."................... 192 Abscess......................... 192 tEdema ....................... 193 Neuralgia....................... 193 Lips, Herpetic Diseases of............ 109 Hypertrophy of................. 109 Lumbago........................... 154 Lungs, Lesions of................... 135 Lymphatic System, Diseases of...... 43 Mamnne, Hypertrophy.............. 137 Phlegmonous Tumor............ 13s. Mammitis........................... 138 Mania............................. 55 Mastoideal Cells, Suppuration of .... 70 Maxillary Bones, Superior, Diseases of 106 Congenital Fissure of............ 107 Accidental Lesions............•.. 107 Inferior, Diseases of.............. 107 " Contraction............ ins " Anchylosis of.........10s Medical Examiners, Duties of........ 19 Melanosis ...................*...... 87 Mouth, Diseases of.................. 109 Muscles. Hupture of................. 48 Myopia............................. !>7 PAGE Na?vi Materni....................... 40 Nail, Walking on the................ 200 Nails', Diseases of................... 2u3 Ingrowing...................... ifliS Syphilitic Disease of............. 203 Necrosis and Caries.................. 5U Neck, Deformities of................ 120 Ulcers of........................ 120 Cicatrices....................... 120 Scrofulous Enlargements......... 120 Glandular Tumors of............ 121 Nephritis........................... 172 Nervous System, Diseases of......... 44 Neuralgia of Face .................. 76 Neuroma........................... 49 Nose, Polypus of.................... 104 Nose, Diseases of................... 102 Deformities of................... 102 Herpetic Affections of........... 103 Nostalgia.... ...................... 63 Nostri Is, Obliteration of..............103 Perforation of Septum........... 103 Foreign Bodies in............... 103 Nyctalopia........................ 90 Nystagmus........................ 93 Obesity............................. 41 Q3dema .......................... 41 Oesophagus, Malformation of......... 129 Paralysis of..................... 129 Stricture of...................... 130 Ophthalmia ...... ................ 78 Orbit, Diseases of.................... 91 Fractures of..................... 92 Foreign Bodies in............... 92 Tumors of...................... 92 Orchitis........................... 184 Ostitis, Sterno-costal................ 136 Ossification, Incomplete of Skull___ 53 Otitis. Acute..... .................. 68 Chronic........................ 63 Ozoena..........:................... 104 Pannus............................. 91 Paralysis.......................... 44 Paralysis, Lead..................... 45 From Fatty Degeneration........ 46 Traumatic...................... 46 General Progressive............. 46 Of Bladder...................... 174 Diphtheritic.....................117 Of Eyelids....................... 96 Of Face.......................... 76 Of Lips...................... .. 110 Of (Esophagus.................. 129 Penis, Diseases of................... Atrophy of...................... Loss of.......................... Pelvis, Congenital Deformities ...... 162 Relaxation of Symphyses........ 162 Fistulas of...................... 103 Tumors of....................... 163 Pericarditis....................... 144 Pericardium, Adhesion of............ 14") Perineum, Wounds of................ 162 238 INDEX. PAGE Perioslosis and Exostosis........... 50 Peritonitis. Traumatic.............155 Perspiration. Fetid of Feet........... 202 Pharynx, Diseases of................ 127 Traumatic Lesions of............. 127 Anomalies of................... 127 Foreign Bodies in............... 127 Pharyngitis........................ 128 Phthisis.......... ................ 189 Phymosis, and Paraphimosis......... Pleuritic Effusions................. 142 Photophobia___................... 89 Pneumonia, Chronic................. 139 Pott's Disease....................... 152 Prostate Gland, Disease of............ Presbyopia........................ 88 Pseudoblepsia..,.................... 89 Psoas Abscess....................... 154 Pterygion......................... 91 Puncta Lachrymalia, Obliteration of.. 100 Deviation of.....................100 Pupil, Dilatation of................. is2 Rnnula.............................. 119 Rectum, Procidentia of Mucous Mem- brane...................... 167 Prolapsus of..................... 167 Rheumatism........................ 193 Ribs, Diseases and Mechanical Lesions of.......................... 136 Salivary Fistulas.................... Saliva, Involuntary Flow of......... Salivary Glands, Diseases of......... Enlargement and Degeneration of Sclerotic, Diseases of ............... Scrofula ........................... Scrotum, Wounds, &c.............. Cutaneous Diseases of.......... Scrotum, Encysted Tumors.......... Fistulas of.........."............ Elephantiasis of................ Scurvy............................ Skull, Diseases of................... Somnambulism................... Spermatic Cord, Diseases of......... Spermatorrhoea..................... Spina Bifida........................ SpiLe, Curvatures of................ Stammering....................... Staphyloma....................... Statuw, of French Army............ Stature ai.d Weight, Minima of...... Sternum, Diseases and Lesions of.___ Stomatitis.......................... Strabismus......................... Stricture, of Rectum................ Of Urethra..................... Of Oesophagus.................. Syphilis........................... Tenia......................... 161 Teeth. Loss of ................... 112 Xerosis Congenital Absence of............ 113 Teeth, Anomalies of................ Supernumerary.............. Deviation and Fistulas.......... Tendons. Retraction and Rupture of.. Tendinous Ganglia, Affections of .... Testicles, Diseases of................ Thorax, Generalities of Examination. Minimum Circumference..... Deformities of...............133, Wounds of...................... Foreign Bodies in............... Tinea capitis..................... Toes, Faulty Direction of............ Tongue. Diseases of................. Prolapsus of.................... Division and Hypertrophy. ..... Mechanical Lesions of........... Partial Loss..................... Retraction ..................... Adhesions....................... Tonsils, Atrophy and Hypertrophy... Torticollis........................... Articular........ ............... Trachea, I Mseases of................ Tremor, Habitual.................... Trichiasis........................ Tuberculosis........................ Tumors, Cancroid and Fibro-Plastic . Erectile......................... Of Face ..................... Fatty and Encysted............. Inguinal........................ Lachrymal...................... Of Neck....................... Of Orbit........................ Of Pelvis....................... Of Scalp........................ Of Skull....................... Steatomatiuis................... Tympanum, Perforation of........... agr 114 114 114 1>8 22 28 138 184 134 51 199 114 115 115 115 115 115 115 119 123 131 125 47 94 87 38 40 75 42 15 •> 1.0 121 Ulcers.............................. 89 Of Face....................... 75 Of the Pharynx................. 123 Perforating of Foot.............. 2o2 Urethra, Diseases of................. 176 Anomalies of................... 176 Inflammation of................. 17S Urine, Incontinence of............... 103 Retention of................... 169 Uvula, Diseases of................... 118 Varicocele........ .................. 1^2 Varices............................. 192 Velum Palati, Diseases of............ 117 Absence, Division, Loss of Sub- stance..................... 117 Vertebrae, Diseases of Cervical....... 131 Vertigo, Epileptic................... 01 Vomiting at Will................... 160 Weight, Relation to Stature......... 24 91 APR 4 J247 V.v^&gj