[These notes are not to be considered as in any way superseding the Navy Regulations and Naval Instructions, or the instructions In the Manual for the Medical DepartMent.]

The recruiting surgeon stands at the door, and none enters unless pronounced physically fit.
Your duty is to safeguard the interests of both the service and the candidate. You should be of an open mind, and not allow either a sudden dislike or sympathy to affect the impartiality of your judgment.

A fixed routine of examination should be early established and rigidly followed, as this prevents confusion, saves time, and is the only way to insure a complete examination.
A good plan is to have a  strong light with a reflector so arranged that it will throw a cone of bright light on the candidate, allowing the examiner to stand in the shadow.

Common varieties of attempted fraudulent enlistment which the examining surgeon should keep in mind:
(a) Age falsely sworn with intent to deceive.
(b) Men who have been previously rejected physically by the naval or other military service and who deny the fact.
(c) Deserters or men. with dishonorable, or medical discharges who deny the fact. These men usually give an assumed name.

The recruiting line officer will be vigilant in detecting these frauds, but the medical officer should be on the alert for them also, and he has many opportunities for detection that are not open to the recruiting officer. A fraudulent enlistment is almost certain to be followed by detection, and entails a loss of time and money to the Government. Even if undetected, most of this class of recruits will prove worthless, with the possible exception of the boy who lies about his age in order to pass the minimum legal age limit. And perhaps even in his case his relatives will turn up and demand the annulling of his enlistment.

A man who has previously had a thorough physical examination will often betray a familiarity with the routine. In inspecting the anal region, if such a candidate, be told to present his back to the examiner and stoop over, he will often pull his buttocks apart without further instruction. Then, if asked in a casual voice, " Where were you examined before?" he may be caught off his guard and admit a previous examination. . With his back to you, say in a tone of command, "Turn around." If he does an "about face," the inference is obvious.

The command to draw back the foreskin will frequently be followed by milking the urethra by the sophisticated.

" Head" is a shipboard term for toilet. If a man is asked how long since he was at the head, and he understands it, he has probably been to sea, and in the Navy. Of course, he may have heard it from some naval relative or friend.

An explanation of the infallibility of finger-print identification, and a display of careful plotting of marks of identification may be followed by a sudden withdrawal of the candidate. If a candidate requests permission to leave for a moment before being sworn in, don't expect him back. Sometimes at an inland station a man will try to enlist in order to obtain free transportation to the coast. Examiners on Marine Corps recruiting duty should be especially careful, as marine recruits are not sworn in until they reach the recruit depot.

Tattooing Ninety-five per cent of the men who enlist in the Navy fraudulently by concealing previous military service that is discoverable are tattooed in a manner characteristic of the naval or military service.    This fact has been demonstrated by a close observation of the records for the last five years in the identification office of the Navy. As a result, it has been found that men with certain tattoo marks will almost invariably be identified as having served previous enlistments in some branch of the military service. A list of the tell tale tattooing follows:

• Shoulders tattooed with female heads or figures, birds, animals, grotesque figures, butterflies, and stars.
• Butterflies on any part of the body.
• Eagle and globe.
• "C. A. C." U. S. N. U S. A," and U.S.M.C."
• "Death before dishonor, "In memory of my mother," " In memory of my father."
• Tombstone and weeping willow.
• Pig tattooed on foot. (In olden times it was believed by sailors that if they had a pig tattooed upon   the instep of the left foot it would be impossible to drown.)
• Men who have "Manila, P. L," or the name of any foreign port tattooed on their person have invariably been found to have had military service.
• Sailor's head.
• Eagle and shield. Crossed guns.
• Apprentice knot (figure of eight). Star or other marks over umbilicus. Tattooing on penis.
• Tattooing below waist. Obscene tattooing.
• Tattooing on buttocks.
• Designs such as dragons, flowers, butterflies, animals, and Japanese women tire used almost exclusively by the tattooer in the Orient.

Applicants for enlistment who are tattooed in the above-named manner should not be enlisted until finger prints have been forwarded to the Bureau of Navigation to determine whether they have had prior service. Such men will apply in most cases for enlistment in the ratings of coal passer, fireman, ship's cook, baker, seaman, and ordinary seaman.

An obviously altered tattoo mark should cause suspicion. The identification experts in the Bureau of Navigation have found that tattoo marks, especially butterflies, on the shoulders are more distinctively naval in origin than any other. Extensive tattooing does not necessarily indicate a naval or even a maritime experience, but even though he be cleared of suspicion as a repeater," the young idler who has his skin covered with tattooing is often an undesirable frequenter of saloons and dives.

When the examination is nearly completed and the confidence of the suspected candidate has been won by kindly treatment and friendly conversation, he will be off his guard, and inquiries as to birthplace, age, previous residence, previous illness, family history, etc., may elicit a truthful answer where a false statement was made before.

Get an actual chest measure, without exaggeration due to muscular action and posture. Cheek up your tape, measuring rod, and scales frequently. The tape stretches, and sometimes a measuring rod will become bent, and show as much as a half-inch error.

Do not depend upon milking the urethra. Have the man urinate in your presence.. Many are sophisticated enough to urinate just before examination. Examine the underclothing f or pus. If the meatus is red keep them in the office long enough to show whether there is suppuration.

Identification - Be careful to mark the missing teeth correctly. The space left by a tooth extracted during childhood may be entirely obliterated by a lateral movement of neighboring teeth, creating a gap at another place. Be sure you understand the nomenclature in recording complexion, eyes, and hair.     

Get as many well-defined marks of identification as possible, and plot and record them accurately. Careful search will nearly always reveal at least five marks. Many descriptive lists are worthless as a means of identification. Scars about knees should, of course, be recorded, but they are so common as to be of but little value as identification. The same may be said of vaccination scars.

Temperature. - In cases where the skin feels unduly warm the temperature should, of course, be taken. A fact noted by recruiting surgeons is that applicants very frequently display a slight elevation of temperature, as high as 99.6 degrees, with no discoverable cause, unless it be due to nervousness or excitement. According to some authorities this may be a normal temperature in some individuals, with a maximum normal diurnal range of 1.8 degrees F. In these, cases, if the man is otherwise desirable, he should be allowed to dress and sent to the outer office to talk to the men, or on some trivial errand, so that he regains his composure, and the temperature be taken again after two hours, or on the following day. If the diurnal maximum remains high, be cautious.

In case of a disability which may be temporary, such as bronchitis, or insufficient weight, encourage the man to return again, and perhaps offer him advice as to how to overcome the defect. It has been found that the bronchitis of cotton-mill workers does not clear up. Many applicants are below weight simply because of insufficient nourishment. In many cities the aid of charitable organizations may be obtained for these men in the way of obtaining teinporary employment or food and shelter.

If you have reason to inquire about possible symptoms, do not say "Do you feel so-and-so"  but ask leading questions, as if the possession of such symptoms were a matter of course, as "How many times do you get up at night to urinate?" How much weight have you lost?", "How much do your ears discharge?"

In cases where it is possible to remove disqualifications by surgical means, in many cities arrangements can be made with local hospitals to admit these cases for early operation upon a note or card from the examining surgeon. There may be retired naval medical officers or Medical Reserve Corps officers in the vicinity who practice a specialty or are connected with hospitals who could be of assistance in this respect. In any case, make it clear to the candidate that enlistment can not be guaranteed after the operation. Inform applicant of probable time of convalescence and time before he could be enlisted if operation proves a success. Capable dentists may be found who would do work for a reduced fee to remove disqualifications. A local hospital may be found to make laboratory examinations.

It sometimes happens that an examiner will become impressed by some particular defect, especially if some recruit passed by him was later invalided for that defect, and will get into the habit of being too exacting concerning it.

Try to get the strong, active men. Many will have no organic defects and may be able to squeeze past the height and weight requirements, and still not be nearly as desirable physically as another who may be robust and vigorous, but has some minor disqualification, which might be waived by the department. As an instance, relaxed external inguinal rings should not be too severely considered.

When a report or survey is sent to the recruiting surgeon, he should profit by the knowledge gained, but he should not allow it to make him too timid. It does not necessarily indicate implied inefficiency or carelessness, except, of course, in the case of some such obvious defect as an ankylosed joint or grossly defective vision or hearing.

If a man gives Arizona, Colorado, or other well-known locality for tuberculous invalids as a previous residence, be especially careful in the chest examination.

The attitudes of the candidate, and of the same man after he becomes a recruit, may be diametrically opposed. The shiftless, lazy individual while being examined for enlistment will endeavor to conceal the same defect that he may be exaggerating in a short time, after he has become tired of a regulated life and of regular work. The pinch of winter or of hard times will diminish the rheumatic twinges or sharpen the hearing at the recruiting station, but the advent of spring and the lure of the road will have an opposite effect upon the same man after he has become a coal passer.

Do not forget that your candidate is undergoing an experience probably unique to him, and his embarrassment and desire to appear self-possessed may cause him to appear surly and flippant, when such traits may ordinarily be foreign to his disposition. A candidate treated with kindness and consideration becomes an aid to recruiting, whether accepted or not, and will be the cause of other applications being made, and it takes a great many applications to furnish the needed good material. Be searching in your examination, but patient and considerate.

The regulations prescribe that a man shall be examined only when clean and sober. If he is drunk, he should not be examined, then or subsequently, as he is undesirable. If his body is unclean, the circumstances should be taken into consideration, as they may be beyond his control. Some of these men come long distances to reach the recruiting station, and many have had to travel without money, riding on freight trains, sleeping in haystacks, and cleanliness may have been impossible, especially in cold weather. Unless a man shows signs of long-continued dirt, and is unashamed of it, he may not be undesirable. The most unclean man may be desirable, if he voluntarily apologizes and can give an acceptable explanation.

In many cities inquiry will usually reveal some place to which a man may be sent for a free bath, if there are no bathing facilities in the recruiting office.

The examination of the skulls of men with long hair should be careful. A most marked asymmetry, or depression, or extensive postoperative scar may be concealed by the hair.

Real bromidrosis is a sufficient cause for rejection. Aboard ship the men sleep very near each other, head to feet, sometimes in a close atmosphere, and the man with ill-smelling feet will be a general nuisance, and will be made miserable himself by his neighbors' wrath.

Heart murmurs.- If after careful examination you are convinced that a murmur is functional, do not hesitate to recommend a waiver if the candidate is otherwise sound.

Hearing test  - Use whispered voice, with residual air. Use numbers instead of sentences, as one or two words heard may enable the candidate to guess at the others in a sentence. Many recruiting stations will not afford a room of sufficient size and quietness to make an accurate voice test. In such case, if a room is available where the watch test may be more accurately applied, this should be used, but the change should be indicated on the record. The watch used as the standard at the Naval Academy, at 40 inches, is the Ingersoll-Trenton.

It is easier to deceive the examiner in the watch test than with the voice. The eyes must be kept carefully covered, and the candidate should not be allowed to cover his own eyes. Of course, the briefest, most indirect glance will suffice to inform the man whether he should hear the watch. The movement of the examiner's arm as he raises and lowers the watch may be perceptible to the candidate through friction of clothing, etc., and enable him with luck to make three or four accurate guesses. It is better not to ask "Do you hear it now?" every time you move the watch, but better have him tell you the instant he hears it or loses it. Do not be too brief, as even random guesses may hit the mark two or three times in succession.

Some examiners use two watches, one ticking and the other silent. In this case the eyes need not be considered, and the test becomes also one of veracity.  

A man may be confused by the ticking, of his own watch.

If you use the voice test, try your voice on a person with known good hearing, as it may be indistinct.

Always use a speculum in examining ears. Get a clear view of the eardrum in every case. During the 10-year period 1905-1914 middle ear disease ranked seventh in frequency as a cause for medical discharge.

Vision test.- Look  out for the peeper. See that the eye not being tested is thoroughly and continuously covered. Do not let the candidate eover his own eye. Cover the unused eye with something which does not touch the eye, as the pressure of a towel may blur a good vision. Have a card with a slot only large enough to show five or six letters of the test card. Be careful that the margins of the opening do not cast a shadow on the type. To be sure of uniformly good illumination it is best to have a 32 candlepower light, with reflector, above the card.

The Grow cards are recommended for several reasons:
These cards all have a uniform type, fulfilling Snellen's principle, while the ordinary commercial Snellen's cards in this country show wide divergence in size and shape of letters.

The greater number of letters makes possible many more combinations, with less chance of deception.

The ordinary Snellen card with large letters at the top gives a cue to the candidate who may have memorized that card.

Be thorough in the examination of the eye. Trachoma is more prevalent in this country than is generally believed, as shown by a survey made by the United States Public Health and Marine-Hospital Service in certain sections of the South.

Beware the "weak sister" of effeminate mannerisms. He will probably sink under the fire of his shipmates' raillery and sarcasm. The sailor man is unmerciful in his jibes at a man so unfortunate as to possess any marked peculiarities, either of person or manner. For the same reason the candidate with huge, outstanding ears or other very prominent features should cause reflection, unless he possesses the physical size and disposition to enforce respect.

Drug Habitues.- Always look for the hyperemia or ulceration of the nasal mucosa due to cocaine or heroin snuffing, and marks of needle punctures in the skin.

Every recruiting station has a laudable ambition to secure as high a percentage of recruits as possible, but the medical examiner should not allow this desire to interfere with his judgment.

Extracts from "Weak Foot," by Surg. R. C. Holcomb, United States Navy, reproduced from United States Naval Medical Bulletin:
Weak foot, commonly called pes planus, flat foot, and splay foot, is a frequent cause for rejection of applicants for enlistment In the Army and Navy. The condition is of sufficient importance for a careful examination Into the subject with a view to determining its full significance, not only as a cause for rejection among applicants for enlistment but also as a cause of disability.

The Navy statistics for weak foot or flat foot as a cause for rejection are not available before 1912. For this year, however, out of a total of 78,180 applicants .for enlistment 4,534, or 57.99 per 1,000, were rejected on account of flat foot. In 1914 the ratio was 108 per 1,000, and In 1915 It was 79 per 1,000.

Bearing in mind the normal low arch in savage races, the diagnosis of weak foot must be judged not only by the appearance of the foot but largely from Its function. The main symptoms as pointed out by Whitman (Orthopedic Surgery) group under the following heads:
1. Attitude.
2. Distribution of weight and strain.
3. Contour.
4. Height of arch.
5. Bearing surface.
6. Range of motion.
7. Pain.

Attitude.- (a) The heel walk; (b) Exaggerated turning out of the foot.
These two symptoms are not of necessity early symptoms. The cause of the heel walk with Its tendency to take the weight off the arch of the foot Is not alone the result of the weakness, but also an effort to case the arch. The exaggerated turning out of the foot needs little comment. * * * A weakness of the structures which tie the arch would result in the sinking of the astragalus and its wedging more deeply between the articular surface of the calcaneum and navicular, thus turning the anterior structure outward. There is also an effort of the individual to ease the inner arch by throwing as much weight as possible on the outer arch of the foot. Have the patient walk and note if the foot is properly used, whether the great toe points to the median line or turns away. Note where the line of the tibia falls, whether over the second toe or inside the great toe.

Distribution of weight and strain.- (a) Examine shoe.
(1) Observe signs of bulging inward at the arch (look for the impress of mechanical arches, or the clean area in contrast with the rest of the lining in those who have worn arches).
(2) Observe wearing away of the inner sole of the shoe.
(b) Compare the shoe, with the bare foot.

The wearing of the heel and sole of the shoes, and the misshape, a result of strain on the uppers, are valuable bits of evidence which will show in a good measure the strength or weakness of the foot that has been incased within the shoe.

Contour.-With the applicant standing, observe the feet placed side by side, the two internal malleoli and the metatarso-phalangeal joints touching. In normal feet a slight interval remains between them due to the concavity along the inner border. In weak feet the concavity is replaced by a convexity and an attempt at adduction is accompanied by an inturning of the patella and crests of the tibia. According to Whitman, "This change of contour is the earliest and sometimes the only evidence of weakness."

Height of the arch.-The height of the arch is measured as the distance from a line drawn between (a) the lower border of the Internal malleolus and (b) the lower tubercle on the head of the first metatarsal (Feiss line) to (c) the tubercle of the scaphoid, which distance should not exceed one-half inch.

It should he understood that this measurement is relative, and is simply a measurement of proportion in the average foot. A small foot might well have a measurement less than this and still lie within normal limits, while a foot larger than the average will give a proportional measurement of much greater than one-half inch. About 5 per cent of the cases examined seem to show a deficiency in this measurement, and this conforms very closely to the Army and Navy average of rejections for flat foot.

Bearing surface.- An imprint taken with the finger-print apparatus will show the shape of the bearing surface of the foot. While this may, when present in a normal degree, serve to assist in forming an opinion, on the other hand if the imprint is flat, in, the absence of other symptoms it would not be sufficient to warrant a diagnosis of weak foot. The fatty pad under the arch which is normally present in the young, the highly developed plantar muscles in the savage tribes, or in those not bred to the shoe, all serve to discount the value of this imprint as an aid to diagnosis. According to Whitman: "Of all the tests, this, so often used to demonstrate the height of the arch and thus confirm a diagnosis of flat foot, is of least importance."

 Range of Motion - The range of motion in examining the foot should Include flexion, abduction and adduction.
Under normal circumstances the foot will show a concavity along its inner surface, and a line along the crest of the tibia continued over the foot falls over the second toe. Voluntary dorsal and plantar flexion is accomplished by the movement of the astragalus upon the leg bones between the internal and external malleoli. Dorsal flexion is normally between 100 and 200 less than a right angle between the foot and leg. Plantar flexion is much greater and is between 50 degrees and 60 degrees more than a right angle between the foot and leg.

During voluntary abduction and adduction the astragalus is practically fixed between the internal and external malleoli, and the foot moves on the astragalus. The actual range of adduction, while difficult to measure, is about 30 degrees from the line continued from the crest of the tibia; abduction is about 15 degrees from this line.

Voluntary adduction or inversion of the foot, is the most important test of all motions to show the weakness of the foot. Extend the leg; keep the crest of the tibia fixed in the median line, then have the patient turn the foot inward as far as possible without rotating the leg. According to Whitman: "Even mild and early cases of weak foot usually show some limitation of this most important motion, and in many instances it is completely lost, the patient turning the entire limb In the effort to adduct the foot."

The question naturally presents itself: What degree of weak foot may be accepted for service?
It is certain that a large number of cases of weak foot are enlisted without being recognized. I think, as a general rule, any man in whom the scaphoid tubercle is not depressed beyond one-half inch below the Feiss line, and who can adduct the feet each between 25 degrees and 30 degrees from the line continued along the crest of the tibia, may be accepted as attaining a standard. It is well also to observe the contour of the inner border of the foot, the feet being placed side by side, noting any beginning downward and inward displacement of the astragalus.

What degree of flat foot should constitute a disability?
I think this must. depend largely upon the man's rate. We would naturally expect less disability for this cause in the yeoman than in the marine, whose duty is largely a question of feet.

In examining the teeth, look for proper occlusion. Even though few or no teeth are missing, many of them may be useless because of lack of occlusion. In young men with evident general disintegration of the teeth, they may be poor risks even if repaired sufficiently to meet the requirements. Naval dental surgeons are not authorized to do crown or bridge work.

A row of clothes hooks, mirror, and a buttonhook are recommended.

It is well not to allow any doubt you may have in your mind about passing a defect to be apparent to the candidate. He may possibly make capital of it later in an attempt to get a medical discharge for cause existing prior to enlistment.

In filling out rejection report, regardless of whether waiver be or be not recommended, be sure to describe every defect even though some may be of such minor importance that if any one existed alone it would not be considered a disqualification. In considering a recommendation on these reports it is necessary that the bureau should have a clear, composite picture of the physical, mental, and moral status of the candidate. In forwarding telegraphic requests for waiver of deficient height, weight, or chest measurement, always include all three.

Have the men at substations forward the addresses of men rejected by them if there is any possibility that they may be accepted by the medical officer. Have the substation men encourage these men to go to the main office for examination, or to present themselves at the substation on the next visit of the medical officer, if such visits are made. Recommend that men before going to duty at a substation be given a thorough course of instruction at the main office

The medical officer is assisted by an enlisted man of the Hospital Corps, who records the findings dictated by the medical officer. The Hospital Corps man should give the necessary instructions to candidates to facilitate smoothness of procedure. He should be on the alert during the presence of the candidate in the office for any incident that may escape the notice of the examiner. He may be allowed to make the finger-print records, after he has demonstrated his competence to do so. The prints should be carefully examined by the medical officer in all cases. He may be given the care of the instruments and apparatus. He may assist in the vision and hearing tests. In case of illness among the personnel of the office, he may act as nurse in so far as it does not interfere with the primary duty of the station to secure recruits.

The recruiting medical officer has the medical care of the officers and men of the Navy and Marine Corps attached to.the station and in that vicinity, unless otherwise provided. Medicines and necessities, except as above noted, are not furnished by the department, but are procured from local sources on prescription.

In the event of necessary hospital treatment, the patient shall be sent to a suitable local hospital, as provided in article 4532 (1), Navy Regulations, as follows:
- Officers and enlisted men of the Navy and Marine Corps when on duty at a place where there is no naval hospital, may be sent to other hospitals upon the order of the commander In chief, or the senior officer present, and the expenses of such persons shall be paid from the naval hospital fund, and no other charge shall be made against their accounts than such as are made for persons under treatment at naval hospitals.

Bills for medical attendance upon enlisted men, for medicines and surgeon's necessaries, and for treatment in hospital shall be properly made out and certified to by the medical officer and submitted promptly to the Bureau of Medicine and Surgery before payment, accompanied by a letter of advice giving the disease or injury on account of which the expenses were incurred. Upon all copies of public bills for such expenses the medical officer will certify that Navy medical supplies were not available, or that the services of a Navy medical officer could not be had, or that treatment in hospital was necessary. (Art. 4534, Navy Regulations.)

No expenses for medicines for or medical attendance upon a naval officer will be included in the account current.

The original recruiting outfit is as follows: Vision test set, urinary test set, stethoscope, thermometer, otoscope, ophthalmoscope, tapeline, and wooden tongue depressors.

Additional supplies of these articles are obtained by requisition, Form 4. The stethoscope, otoscope, and ophthalmoscope are not expendable, and must be accounted for, and if lost or damaged must be surveyed. The other articles are expendable.