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3-155
[Old No. ​3-111]

SURGEON'S CERTIFICATE

Insert character and number of claim. Increase
Pension claim No. 981343
Name of claimant. Charles F. Stokey
Pvt Company H 195 Reg't O V Inf.
Claimant's post-office address.  #907 West 9th St. Canton, Stark Co. Ohio
Address of Board. Massillon, Ohio
Date of examination October 17th, 1900
Cause of disability Disease of digestive organs and rectum.  Disease of
       liver + bowels + any other disabilities found
He receives a pension of 8 dollars per month.
Here give the claimant's statement (briefly and consistently as possible) in regard to the origin of his disabilities and the manner in which they affect him.
He makes the following statement on which he bases his claim for Increase.
I am especially disabled during the hot months, + I get better except with asthma in the winter time.  I have great pain.

Attention is invited to the outlines of the human skeleton and figure upon the back of this certificate, which should be used to indicate precisely the location of a disease or injury, the entrance and exit of a missile, an amputation, etc.

We hereby certify that upon examination we find the following objective conditions:
Pulse rate, [sitting, standing, after exercise] 100 112 124, respiration [sitting, standing, after exercise] 20 22 28, temperature, 98.4 , height, 5 feet 5 inches; actual weight, 130 pounds; age, 56 years.

Here give a full description of the disabilities, in accordance with Back of Instruction.
Occupation - Teacher.  Tongue slightly coated with yellow coating + marked with a few fissures.  State of nutrition fair.  Abdominal walls are thin + weak.  There is marked tenderness + tympany over the stomach.  There is marked tenderness over the liver.  Area of hepatic dulness is not increased.  Spleen is normal.  Sphincter muscles are weak + relaxed.  There are two external hemorrhoids 1x1/2 in.  No internal hemorrhoids.  Rectum is red, tender, and relaxed.  Mucous membrane is redundant.  Hearts action very rapid, weak, with impulse diminished.  There is a roughened termination of the first sounds.  There are no murmurs.  Area of cardiac dulness + location of apex beat normal.  No Oedema, Cyanosis, or Dyspuoca.  Inspiration 36 in Expiration 33 in. Rest 34 1/2 in.  Respiratory murmur.  Clear over all portions of both lungs.  No moist rales, no areas of dulness on percussion.

Urine Straw color, acid. Sp gr 1022 +o Albumin.  No sugar No Deposits.

The actual [or probable] origin of every existing disability must be fully set forth.

Whenever a disability is shown or is believed to be due to or aggravated by vicious habits the opinion of the board must be stated.  When not due to such habits this need not be stated.

​Each disability must be rated separately, the act of Congress of March 3, 1895, requiring "that the report of such examining surgeons shall specifically state the rating which, in their judgment, the applicant is entitled to."

When rates are recommended solely on subjective evidence the strongest reasons must be given therefor.
Claimant should have $10 per month because of Disease of digestive organs, rectum.  Piles.  Which we consider permanent + not the result of vicious habits.

We find no other disability + no evidence of vicious habits.

A. B. Campbell , Pres.  H.B. Garrigues  , Sec'y  A.G. Seei Pease , Treas.

N.B. Do not use backs of certificates for any purpose other than indicated by printed matter thereon.  When additional space is needed to complete report of examination use blank certificate (3-111g) properly numbered, and attach it to the back and upper margin of this sheet.  Marginal entries must never be made.

The examination must not be made by one member of a board except upon a special order of the Commissioner of Pensions.

(This certificate to be filled in and signed by the secretary when the full board is present.)
I hereby certify that Dr. Campbell, Dr. Garrigues, and Dr. Pease were personally present and actually participated in the examination of Chas. F. Stokey, the claimant in this case, on 17th day of October, 1900

(Signature) H.B. Garrigues sec

​(This certificate to be filled in by the member of the board acting as secretary, and signed by the applicant, when a full board is not present.)

"I, _________, the applicant for (increase or original) pension referred to in this medical certificate, hereby consent to be examined by Dr. ___________ and Dr. ___________, the examining surgeon here present (waiving examination by full board). on this _________ day of ______, 190_."
(Signature) _______________

COVER AREA

SURGEON'S CERTIFICATE
IN CASE OF
Charles F. Stokey
Co A, 195th Reg't Ohio Vol Inf.
APPLICANT FOR Increase
No. 981,343
DATE OF EXAMINATION:
October 17th, 1900

A.B. Campell, Pres. |
H.B. Garrigues, Sec'y |  Board
[H.G.See Pease], Treas |

Post office, Massillon
County, Stark
State, Ohio
P.S. Write your post office address plainly and in full.

[stamp]
MIDDLE DIV.
NOV 1 1900
RECEIVED


BACK AREA
​
[human skeleton and figure]

Single surgeons will use this blank, changing "we" to read "I."  They will erase the words "Pres.," "Sec'y.," "Treas.," and "Board" where the words appear, and sign at the bottom of the certificate, and also on the back of the same.

"All examinations shall be thorough and searching, and the certificate contain a full description of the physical condition of the claimant at the time, which shall include all the physical and rational signs and a statement of all the structural changes."  [Extract from Section 4, Act of Congress approved July 25, 1882.]
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1900-10-17: ​​​tour stops---images---audio---transcript---~NOTES~---links---site navigation
1.
3-155
[Old No. ​3-111]
I didn't see any difference between the old form and the new form other than the date change from 1800s to 1900s.  Y19C?

​2.
Whenever a disability is shown or is believed to be due to or aggravated by vicious habits the opinion of the board must be stated.  When not due to such habits this need not be stated.
I googled "vicious habits" and got various answers.  Maybe it was just one of those useful things so that if they wanted to deny an increase and didn't have an objective reason, they could claim vicious habits.

3.
Papa Charles was not pleased with the results of this medical examination.  See:
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