APPENDIX B
Mobilization Regulations
Pertaining to Mental and Nervous Diseases and Neurological Disorders
The following are extracts from MR 1-5, 5 December 1932, and from MR 1-9, 31 August 1940 and 15 March 1942, respectively, pertaining to mental and nervous diseases and neurological disorders:
MOBILIZATION REGULATIONS
WAR DEPARTMENT,
No. 1-5
Washington, December 5, 1932
STANDARDS OF PHYSICAL EXAMINATION DURING THOSE MOBILIZATIONS FOR WHICH SELECTIVE SERVICE IS PLANNED
SEC. 215. MENTAL AND NERVOUS DISEASES.
a. Registrants who on examination show the following conditions shall be unconditionally accepted for general military service:
(1) A normal nervous system.
(2) Who appear to have normal understanding, whose speech can be understood, who have no definite signs of organic disease of the brain, spinal cord, or peripheral nerves, and who are otherwise mentally and physically fit.
(3) Hysterical paralysis or hysterical stigmata and local muscular spasms which do not cause mental or physical defects disqualifying for general military service.
(4) Muscular tremors of moderate degree.
b. Registrants who on examination are found to suffer from the following defects of the nervous system, who are otherwise mentally and physically fit, may be accepted for special and limited military service.
(1) Stuttering and stammering of a degree disqualifying for general military service but which has not prevented from successfully following a useful vocation in civil life.
(2) Hysterical paralysis or hysterical stigmata of a degree disqualifying for general military service, but not of a character to prevent the registrants from successfully following a useful vocation in civil life.
(3) Tremors of such marked degree that they disqualify for general military service but have not prevented the registrants from following a useful vocation in civil life.
(4) Drug addiction, including the habitual use of opium and its derivatives and cocaine.
c. Registrants who on examination are found to suffer from the following defects shall be unconditionally rejected for all military service:
(1) Insanity.
(2) Epilepsy.
(3) Idiocy.
(4) Imbecility.
(5) Chronic alcoholism.
(6) Stuttering or stammering to such a degree that the registrant is unable to express himself clearly or to repeat commands or to demand the countersign.
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(7) Constitutional psychopathic state.
(8) Chronic essential chorea.
(9) Tabes (locomotor ataxia).
(10) Cerebrospinal syphilis.
(11) Multiple sclerosis.
(12) Paraplegia or hemiplegia.
(13) Syringomyelia.
(14) Muscular atrophies and dystrophies which are obviously disqualifying.
(15) Hysterical paralysis or hysterical stigmata so serious that these defects are disqualifying for military service.
(16) Neuritis or neuralgia which is not temporary in character and which has progressed to such a degree as to prevent the registrant from following a useful vocation in civil life.
(17) Brain tumors.
* * * * * * *
SEC. 223. NOTES ON MALINGERING.
a. Malingerers may be divided into three general groups:
(1) Real malingerers with nothing the matter with them, who injure themselves, or make allegations respecting diseases or such condition as drug taking, or who counterfeit disease with full consciousness and responsibility; all for the purpose of evading military service. Many of these have been coached.
(2) Psychoneurotics who are natural complainers and try to get out of every disagreeable thing in life. Perhaps only partially conscious of the nature or the seriousness of what they do and only partly responsible. In many the motives are not persistent and many can be made into good soldiers.
(3) Confirmed psychoneurotics with long history of nervous breakdown and illnesses who behave like group (1) but more persistently and from whom not much can be expected in the way of reconstruction.
b. The detection and management of medical cases depend upon the absence of positive findings in one who presents the general characteristics of the malingerer. There is especial need for the physical examination to be thorough in this group. Some of the cardiac cases at first regarded as malingerers were pronounced later by the cardiovascular board to have mitral stenosis, and similarly proper tests have shown the existence of gastric ulcer in cases which were under suspicion of fraud. The estimation of the reality of rheumatic pains is always a difficult matter.
c. Surgical.-Under this are included old scars and injuries of the bones, fractures, and orthopedic conditions.
d. Artificially created conditions.-Men shoot or cut off their fingers or toes, practically always on the right side, to disqualify themselves for service. Sometimes they put their hands under cars for this purpose. Many men have their teeth pulled out. Retention of urine is simulated. Egg albumin is injected into the bladder or put in urine. Glucose is added to urine. Digitalis, thyroid gland preparations, and strophanthus are taken to cause disturbance of the heart and cantharides to cause albuminuria. The skin is irritated by various substances which are also injected under it to create abscesses. Various substances are taken to bring about purging. An appearance of hemoptysis may be produced by adding blood, either human or that of animals, to the sputa. Sometimes merely coloring matter is added. Those who can vomit voluntarily what they swallow use the same means to create the appearance of hematemesis. Similarly, coloring matters may be added to the stools. Mechanical and chemical irritants are made use of to cause inflammation about practically all the body orifices. Jaundice may be simulated by taking picric acid. Crutches, spectacles, trusses, strappings, etc., are made use of to create the appearance of disability.
e. Detection.-Wounds are rarely self-inflicted when witnesses are present, con-
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sequently it is almost impossible to be certain of the motive behind these. Artificial jaundice is to be recognized by the demonstration of picric acid in the urine.
f. Bed wetting.-A frequent complaint among registrants for military service but not a cause of rejection.
g. The surest means of detecting malingering is a thorough understanding by the examining physician of the types of people who actually do it-and the way they behave. It is only in the feigned diseases of the eye and ear that special tests are required. Observation in hospital is necessary in difficult cases. The vast bulk of malingerers are those who exaggerate some actual defect, and the problem for the examining physician is to decide whether the defect complained of is sufficient cause for rejection for service. Persons of intelligence and education have more difficulty in deceiving, as they are bound to express themselves freely. If they are reticent in these matters they arouse suspicion by their reticence. Those who talk freely may be counted on to say things at variance with the existence of the disease of which they complain.
h. Whenever it shall appear to an examining physician that a registrant is endeavoring to escape service by malingering, if otherwise mentally and physically fit, he shall be accepted. A full statement of the facts shall be prepared and forwarded to the Director of Selective Service.
SEC. 224. NERVOUS AND MENTAL.
a. Insanity.-Rarely feigned by registrants and then of an extremely silly, foolish type. In cases of doubt, hospital observation is necessary with verified past records. Mental defects are frequently feigned, especially by illiterates. Organic diseases of the central nervous system cannot be simulated.
b. Pain and hyperesthesia.-The most frequent of all complaints. History inconsistent, ordinary traces of suffering absent. Absence of other symptoms usually accompany types of pain complained of. Absence of objective evidence of localized pains. Note behavior when the registrant believes himself unobserved.
c. Anesthesia.-Complaint of anesthesia itself creates a suspicion of malingering as most patients with anesthesia are ignorant of it.
d. Epilepsy.-Men who have sustained head injury are very apt to claim fits. These complaints may be in reference to grand mal or petit mal. Petit mal attacks are spoken of as fainting attacks. In grand mal attacks there is loss of pupil response to light, knee jerks are lost, and the Babinski reflex may be present.
e. Hysteria.-Not feigned in itself, but its existence creates confusion as to malingering. The question to be decided is whether the registrant is too seriously affected with the neurosis to be useful as a soldier. Often, even when the physical symptoms are most pronounced (paralysis), cure is still possible.
f. Stiff backs.-Stiff back is a frequent symptom of hysteria in mobilization among selected men. In cases of this kind organic disease of the vertebrae can and should be excluded, if necessary, by the X-ray.
MOBILIZATION REGULATIONS
WAR DEPARTMENT
No. 1-9
WASHINGTON, August 31, 1940
STANDARDS OF PHYSICAL EXAMINATION DURING MOBILIZATION
* * * * * * *
SECTION XIX
MENTAL AND NERVOUS DISORDERS
Paragraph
Class 1-A 75
Class 1-B 76
Class 4 77
Diagnostic criteria 78
Sequelae of organic neurological disease 79
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75. Class 1-A.-a. A normal nervous system.
b. Registrants who appear to have normal understanding, whose speech can be understood, who have no definite signs of organic disease of the brain, spinal cord, or peripheral nerves, and who are otherwise mentally and physically fit.
c. Muscular tremors of moderate degree, unless malingering is definitely excluded.
76. Class 1-B.-a. Stuttering and stammering of a degree disqualifying for general military service but which has not prevented registrants from successfully following a useful vocation in civil life.
b. Tremors of such marked degree that they disqualify for general military service but have not prevented the registrants from following a useful vocation in civil life.
77. Class 4.-Any serious mental or neurological disorder such as-
a. Insanity.
b. Epilepsy.
c. Post-encephalitic syndrome.
d. Imbecility.
e. Drug addiction, including the habitual use of opium and its derivatives and cocaine.
f. Chronic alcoholism.
g. Stammering to such a degree that the registrant is unable to express himself clearly or to repeat commands.
h. Psychoneuroses and constitutional psychopathic states providing the diagnosis is clearly established and in the opinion of the medical examiner precludes the successful performance of military duty.
i. Chronic essential chorea.
j. Syphilis of central nervous system.
k. Post-traumatic cerebral syndrome.
1. Multiple sclerosis.
m. Paraplegia or hemiplegia.
n. Syringomyelia.
o. Muscular atrophies and dystrophies which are obviously disqualifying.
p. Hysterical paralysis.
q. Neuritis or neuralgia which is not temporary in character and which has progressed to such a degree as to prevent the registrants from following a useful vocation in civil life.
r. Brain tumors.
s. Cerebral arteriosclerosis.
t. Sexual perversion.
78. Diagnostic criteria.-In arriving at decisions concerning nervous or mental defects, the following criteria may be of assistance:
a. Insanity.-All registrants should be considered insane who are committed, or who have been committed, to a licensed public institution for the care of the insane. The examining physicians may require proof in the form of verified records of commitment by the proper State authorities to verify the statements of the registrants.
(1) Dementia praecox.-Look for indifference, apathy, withdrawal from environment, ideas of reference and persecution, feelings of the mind being tampered with, or thought being controlled by hypnotic spiritualistic, or other mysterious agencies, hallucinations of hearing, bodily hallucinations, frequently of electrical or sexual character; meaningless smiles; in general, inappropriate emotional reactions and lack of connectedness in conversation. There may be sudden emotional or motor outbursts. The history of family life and of school, vocational, and personal career will usually show erratic and more or less irrational conduct.
(2) Manic-depressive insanity.-Look for mild depression, with or without feeling of inadequacy, or mild manic states with exhilaration, talkativeness, and overactivity.
(3) Paresis.-The diagnosis of paresis may be made when at the examination of
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the registrant a majority of the following signs and symptoms are demonstrated: Argyll-Robertson pupil, facial tremor, speech defect in test phrases and in the slurring and distortion of words in conversation; writing defects, consisting of omissions and the distortion of words; apathetic or depressed or euphoric mood. These registrants may show memory loss or discrepancies in relating facts of life; the knee jerks may be plus, minus, or normal.
b. Epilepsy.-The registrant will not be considered an epileptic unless the claim is substantiated by characteristic scars on the tongue, face, or head, or if the examining physician is in doubt, by properly certified proof.
c. Imbecility.-A registrant will be declared an imbecile who has been so defective in mind from birth or early age as to be incapable of earning a livelihood but at the same time is able to guard himself against common physical danger.
d. Chronic alcoholism.-(1) A registrant will be declared a sufferer from chronic alcoholism when he presents a majority of the following symptoms and signs: Suffused eyes; prominent superficial blood vessels of nose and cheek; flabby, bloated face; red or pale purplish discoloration of mucous membrane of the pharynx and soft palate; muscular tremor of the protruded tongue and extended fingers; tremulous handwriting.
(2) The history of evidence presented that the registrant has been frequently and grossly intoxicated is not of itself sufficient proof for the diagnosis of chronic alcoholism.
e. Tabes.-The diagnosis of this disease should be made when, at the examination of the registrant, several of the following signs and symptoms are present: Argyll?Robertson pupil; absent knee jerks; positive Romberg, ataxic gait (especially when the eyes are closed); hypotonia; and anesthetic areas of the skin. The history of tabes is usually that of slow progression, of failing sexual power, and pains in the legs or back which are often described as rheumatism.
f. Cerebrospinal syphilis.-The prominent diagnostic signs and symptoms are headaches, varying deep and superficial reflexes, pupillary changes, ptosis, ocular palsies, facial weakness; the mental state may be normal, dull, or apathetic. Comparative motor weakness may involve one side of the body or one extremity.
g. Multiple sclerosis.-The diagnosis of this disease rests upon the following signs and symptoms: Intention tremor, nystagmus, absent abdominal reflexes, increased tendon reflexes, and scanning speech; in cases of this kind the history obtained is not characteristic, but sometimes there may be a history of urinary disturbances.
h. Paraplegia.-The diagnosis of paraplegia from whatever cause will rest upon weakness of the lower extremities, associated with loss of or increased knee jerks, Babinski reflex, or disturbance of the sphincters of the rectum and bladder, with or without girdle sensations. Sensory disturbance of the skin may or may not be present. Muscle sensibility may be diminished.
i. Syringomyelia.-Syringomyelia is usually evidenced by more or less loss of power and atrophy of groups of muscles of one or more extremities; disturbance of the sensations of the skin, more especially in the form of analgesias, and diminution of the temperature sense; if in the upper dorsal cord, often associated with stooped shoulder posture; if in the lower dorsal, with weakness in one or both lower extremities.
j. Muscular atrophies and dystrophies.-The signs and symptoms of muscular atrophies and dystrophies are: Atrophies of the small muscles of the hand and of the muscle groups of the shoulder; fibrillary twitchings. The history of these defects rarely furnishes reliable data, although it will usually be found that the registrant has shown evidences of awkwardness. There is never a history of pain in the affected muscles.
k. Multiple neuritis.-The chief manifestations are more or less pain in the course of the affected nerves, with tenderness over the trunks of the nerves and of the muscles supplied by them; lessened muscular power of varying degrees; more or less atrophy of muscles, with or without contraction, and evidences of trophic changes of the skin. The reflexes, deep and superficial, may be diminished or absent; the sphincters are not involved.
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79. Sequelae of organic neurological disease.-Certain after-effects of organic nervous disease need not be causes for rejection, provided-
a. That the disease is no longer active and is not likely to recur.
b. That the effect left by it does not prevent a satisfactory fulfillment of military duties. Examples of such conditions are paralysis of a few unimportant muscles following poliomyelitis, slight unilateral hypertonicity as a result of an infantile hemiplegia in a man now robust, and various traumatic conditions.
SECTION XX
PURPOSELY CAUSED PHYSICAL DEFECTS
Paragraph
Report of apparently purposely caused defects
80
80. Report of apparently purposely caused defects.-Whenever it shall appear to an examining physician that a registrant is suffering from self-inflicted or purposely caused physical defects which, under the standards of physical examination prescribed herein, would render him disqualified for military service of any kind, a full statement of the facts and of the condition of the registrant and of the examining physician's recommendation will be prepared and submitted to the Director of Selective Service or other designated authority for a waiver of the physical defects, if recommended, so that the registrant may be compelled to render military service.
SECTION XXI
NOTES ON MALINGERING
Paragraph
Types of malingerers 81
Feigned medical diseases 82
Feigned surgical conditions 83
Nervous and mental feigned illness 84
* * * * * * *Bed wetting 87
General considerations 88
81. Types of malingerers.-Malingerers may be divided into three general groups.
a. Real malingerers with nothing the matter with them, who injure themselves, or make allegations respecting diseases or such condition as drug taking, or who simulate disease with full consciousness and responsibility-all for the purpose of evading military service. Many of these will have been coached.
b. Psychoneurotics who are natural complainers and try to get out of every disagreeable thing in life; perhaps only partially conscious of the nature of the seriousness of what they do and only partly responsible. In many the motives are not persistent and many can be made into good soldiers.
c. Confirmed psychoneurotics with long history of nervous break-downs and illnesses who behave like group a above but more persistently and from whom not much can be expected in the way of reconstruction.
82. Feigned medical diseases.-a. The detection and management of malingerers simulating medical diseases depend upon the absence of positive findings in an individual who presents the general characteristics of the malingerer. There is especial need for the physical examination to be thorough in this group. Some of the cardiac cases at first regarded as malingerers may later be found to have mitral stenosis or bacterial endocarditis. Similarly, proper tests may show the existence of peptic ulcers in those suspected of feigning digestive abnormalities. The estimation of the reality of rheumatic pains is always a difficult matter.
b. Tachycardia and thyrotoxicosis may be temporarily induced by ingestion of drugs, such as thyroid extract. Egg albumin or sugar may be added to urine. Undiluted canned milk may be made to simulate urethral discharge. Cantharides may
781
be taken to cause albuminuria. Digitalis and strophanthus may be taken to cause abnormal heart findings. The skin may be irritated by various substances. Cathartics may be taken to bring about purging or to simulate a chronic diarrhea. An appearance of hemoptysis may be produced by adding blood, either human or that of animals, to the sputa. Sometimes merely coloring matter is added. Those who can vomit voluntarily what they swallow use the same means to create the appearance of hematemesis. Similarly, coloring matter may be added to the stools. Mechanical and chemical irritants are made use of to cause inflammation about practically all the body orifices. Jaundice may be simulated by taking picric acid. Crutches, spectacles, trusses, strappings, etc., are made use of to create the appearance of disability. Artificial jaundice is recognized by demonstration of picric acid in the urine.
83. Feigned surgical conditions.-Under this are included old scars and injuries of the bones, fractures, and orthopedic conditions. Men may have teeth extracted in effort to evade military service. Others may shoot or cut off their fingers or toes, practically always on the right side, to disqualify themselves for service. Some may put their hands under cars for this purpose. Retention of urine may be simulated. Substances may be injected under the skin to create abscesses. Crutches, braces, strappings, or trusses may be used to give the appearance of disability. Wounds are rarely self-inflicted when witnesses are present; consequently it is almost impossible to be certain of malingering in some cases.
84. Nervous and mental feigned illness.-a. Insanity.-Rarely feigned by registrants and then of an extremely silly, foolish type. In case of doubt, hospital observation is necessary, with verified past records. Mental defects are frequently feigned, especially by illiterates. Organic diseases of the central nervous system cannot be simulated.
b. Pain and hyperesthesia.-The most frequent of all complaints. History inconsistent, ordinary traces of suffering absent. Absence of other symptoms usually accompanies types of pain complained of. Absence of objective evidence of localized pains. Note behavior when the registrant believes himself unobserved.
c. Anesthesia.-Complaint of anesthesia itself creates a suspicion of malingering as most patients with anesthesia are ignorant of it.
d. Epilepsy.-Men who have sustained head injury are very apt to claim fits. These complaints may be in reference to grand mal or petit mal. Petit mal attacks are spoken of as fainting attacks. In grand mal attacks there is loss of pupil response to light, knee jerks are lost, and the Babinski reflex may be present.
e. Hysteria.-Not feigned in itself, but its existence creates confusion as to malingering. The question to be decided is whether the registrant is too seriously affected with the neurosis to be useful as a soldier. (See par. 77h.)
f. Stiff back.-Stiff back is a frequent symptom of hysteria in mobilization among selected men. In cases of this kind, organic diseases of the vertebrae can and should be excluded, if necessary, by X-ray.
* * * * * * *87. Bed wetting.-Enuresis, either real or simulated, may be a frequent complaint among registrants for military service, but it is not a cause for unconditional rejection. Bed wetters may be placed in class 1-A or 1-B depending upon the apparent significance or severity of the disorder.
88. General considerations.-a. The surest means of detecting malingering is a thorough understanding by the examining physician of the types of people who actually do it, and the way they behave. It is only in the feigned diseases of the eye and ear that special tests are required. Observation in hospital is necessary in difficult cases. The vast bulk of malingerers are those who exaggerate some actual defect, and the problem for the examining physician is to decide whether the defect complained of is sufficient cause for rejection for service. Persons of intelligence and education have
782
more difficulty in deceiving, as they are bound to express themselves freely. If they are reticent in these matters they arouse suspicion by their reticence. Those who talk freely may be counted on to say things at variance with the existence of the disease of which they complain.
b. Whenever it shall appear to an examining physician that a registrant is endeavoring to escape service by malingering, if otherwise mentally and physically fit, he will he accepted. A full statement of the facts will be prepared and forwarded to the Director of Selective Service.
MOBILIZATION REGULATIONS
WAR DEPARTMENT,
NO. 1-9
WASHINGTON, March 15, 1942.
STANDARDS OF PHYSICAL EXAMINATION DURING MOBILIZATION
* * * * * * *
SECTION XIX
NEUROLOGICAL DISORDERS
Paragraph
Methods of examination 82
Class 1-A 83
Class 1-B 84
Class 4 85
Diagnostic criteria 86
82. Methods of examination.-a. In order to detect the presence of certain common neurological diseases, particularly epilepsy, post-encephalitic and post-traumatic syndromes, multiple sclerosis, drug addiction, and hysteria, information regarding the life history of the individual is essential. The following should therefore be inquired into: Convulsions, fainting spells, attacks of unconsciousness, routine use of any medicines, hospitalization, severe head injury, and educational and occupational history.
b. The neurological examination will be conducted as follows: The individual will be examined stripped. He will walk a straight line at a brisk pace with his eyes open, stop, and turn around. He will then return in the same manner with his eyes closed, stop, and turn around. Look for spastic, ataxic, incoordinate or limping gait; absence of normal associated movements; deviation to one side or the other; the presence of abnormal involuntary movements; undue difference in performances with the eyes open and closed. The individual will then stand erect, feet together, arms extended in front. Look for unsteadiness and swaying, deviation of one or both of the arms from the assumed position, tremors or other involuntary movements. With eyes closed he will then touch his nose with the right and then the left index finger. Look for ataxia, tremors, overshooting, particularly at the end of the movement. Examine joint and spine movement and muscle condition. Look for muscular atrophy or pseudohypertrophy, muscular weakness, limitation of joint movement and spine stiffness. As to pupils, look for irregularity, inequality, diminished or absent contraction to light; movements of eyes, facial muscles, and tongue. Look for strabismus, ptosis, sustained nystagmus, tremors of retracted lips, asymmetry or tremors of face or tongue. Sensation will be examined by pricking lightly each side of the forehead, bridge of nose and chin, across the volar surface of each wrist, and dorsum of each foot. Look for inequality of sensation right and left. If these sensations are abnormal, vibration sense should be tested at ankles and wrists by tuning fork. With the eyes closed, he will run each heel from the opposite knee to the ankle. Test sense of movement of great toes and thumb. Look for diminution or loss of vibration and sense of position, and ataxia. Knee jerks and plantar reflexes should be tested. When indicated, appropriate laboratory tests and X-ray examinations will be made.
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83. Class 1-A.-These registrants present-
a. A healthy nervous system as manifested by absence of signs of disease of the brain, spinal cord, cranial and peripheral nerves.
b. Certain variations clearly within physiological limits such as minor tremors.
c. Inconsequential paralyses resulting from old poliomyelitis or lesions of the peripheral nerves not likely to interfere with military duties.
84. Class 1-B.-Individuals who present muscular tremors or local paralyses due to old poliomyelitis or nonprogressive disease of the spinal cord or peripheral nerves of such marked degree that they disqualify for general military service but have not prevented the individual from successfully following a useful vocation in civil life.
85. Class 4.-Any serious neurological disorder such as-
a. Neurosyphilis of any form (general paresis, tabes dorsalis, meningo-vascular syphilis).
b. The epilepsies.
c. Paralysis agitans, post-encephalitic syndromes, athetosis, chorea, spasmodic torticollis, familial ataxia.
d. Post-traumatic cerebral syndrome.
e. Multiple sclerosis, encephalomyelitis.
f. Diffuse muscular atrophies or dystrophies of any type (with the exception of extremely mild residuals of poliomyelitis).
g. Chronic or recurrent neuritis or neuralgia of an intensity sufficient to prevent the individual from following a useful vocation in civil life. Multiple neuritis.
h. Cerebral arteriosclerosis, vascular accidents of all types.
i. Spina bifida, if associated with neurological manifestations. Meningocele, even if uncomplicated.
j. Other chronic degenerative diseases of the brain and spinal cord.
86. Diagnostic criteria.-The following brief summary of diagnostic criteria is intended as a general guide for examiners. It includes the common manifestations of the more usual neurological disorders, but it is not intended to cover all diagnostic criteria or all neurological disorders.
a. Syphilis of central nervous system.-(1) General paresis or meningo-encephalitic syphilis.-Look for unequal, irregular or sluggishly reacting pupils or Argyll?Robertson pupil; facial tremor; speech defect in test phrases and in the slurring and distortion of words in conversation; writing defects consisting of omissions and distortions of letters; defective memory; discrepancies in relating facts of life; inability to perform quickly and accurately simple problems of addition and subtraction in mental arithmetic. Knee jerks may be normal or overactive or underactive. The mood may be apathetic, depressed or euphoric; other psychiatric symptoms may be of a schizophrenic or neurasthenic type.
(2) Meningo-vascular or cerebrospinal syphilis.-The prominent diagnostic signs and symptoms are headaches, history of mood changes or convulsions, varying deep and superficial reflexes, pupillary changes, ptosis, ocular palsies, and facial paresis. The mental state is normal, dull or apathetic. Motor weakness may occur on one side of the body or in one extremity.
(3) Tabes dorsalis (locomotor ataxia).-Look for unequal, irregular or sluggishly reacting pupils, or Argyll-Robertson pupil; absent knee jerks; positive Romberg; ataxic gait, especially when the eyes are closed; hypotonia; and anesthetic areas of the skin. The history, usually of slow progression, may show failing sexual power or sphincter disturbances and pains in the legs or back, usually an irregular series of short, identical attacks of pain coming at intervals.
b. The epilepsies.-Look for deep scars on tongue, face and head. Since no physical findings are pathognomonic, it is necessary to discover if the individual has had
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spells of unconsciousness, convulsions, 'fits,' 'falling out' spells, 'lapses,' 'dizziness,' or 'fainting.' The individual should be disqualified on a verified history of such spells or of multiple attacks of loss of consciousness especially with incontinence or twitching or of frequent momentary episodes of being dazed, or of uncontrollable outbursts of rage or irrational conduct, or fugues, or treatment with anticonvulsive drugs over a long period of time. Such a history should be verified, if practicable, by a confirmatory medical record from a trustworthy source. When a registrant is rejected for epilepsy a statement will be made by the examining board giving the basis for the diagnosis. In the absence of stigmata or a verified history and diagnosis is based wholly on the registrant's statement, it will be so stated.
c. Paralysis agitans.-Paralysis agitans is recognized by frozen facies, unwinking stare, rigidity of the muscles, stooped posture, slowness of movement, tremors, slow, monotonous speech, etc. It may be unilateral. A history of encephalitis or influenza is obtained in only about one-half of the cases. Even mild manifestations disqualify.
d. Athetosis, dystonia, torticollis, chronic chorea.-These are names given to various types of irregular, intermittent involuntary movements, affecting various parts of the body, often associated with evidence of spastic paralysis. Simulation is possible and in doubtful cases previous medical records should be sought. Even mild manifestations disqualify.
e. Post-traumatic cerebral syndrome.-A history of head injury followed by headache, dizziness, loss of initiative or change of personality is suggestive; but independent confirmation of such alterations should be sought if possible. A dull apathetic expression, slight nystagmus, fine tremors, vasomotor changes, abnormal sweating, etc., are confirmatory evidence. If the syndrome is definite, even though mild, the individual should be rejected. The presence of signs indicating a focal lesion, even though mild, is also cause for rejection.
f. Multiple sclerosis.-A history of transitory weakness, numbness, ataxia of one or more extremities, transient diplopia, scotomata or bladder disturbances should arouse a suspicion of multiple sclerosis. The presence of optic atrophy, scotomata, definite nystagmus, corneal hypesthesia, absence or irregularity of abdominal jerks, exaggerated deep reflexes, a Babinski or similar signs, or ataxia and euphoria are common manifestations.
g. Muscular dystrophies.-There is atrophy of the muscles in some forms, hypertrophy in others, and, in general, decrease or loss of muscle power. In the pseudohypertrophic form some muscles are atrophied, others hypertrophied. In myasthenia gravis there is rapid fatigue of muscle power, appearing first in the facial and extrinsic eye muscles and later becoming generalized.
h. Chronic neuralgias.-A history of severe constant or recurrent pain, confirmed to the area of distribution of a single nerve or segment, without objective changes, suggests this diagnosis. Clearly defined entities are sciatic and trigeminal neuralgias. Less common are suboccipital, brachial and glossopharyngeal neuralgias. Neuralgias of other nerves are extremely rare and the diagnosis should be made with extreme caution. Neuritis, arthritis, bursitis, sinusitis, etc., and also hysteria and malingering must be considered in differential diagnosis. Evidence of previous treatment and the injection of procaine into the nerve presumably affected are important diagnostic aids.
i. Multiple neuritis.-This may be associated with the dietary deficiencies, infection or intoxication. The symptoms depend upon the cause and duration. They consist of pain, various combinations of diminution or loss of motor power most marked in the distal part of the extremities, sensory diminution or loss, tenderness of the muscles and nerves, loss or diminution of reflexes.
j. Cerebral vascular accidents.-Characteristically, the onset is acute, with or without unconsciousness. Almost any focal disturbance may result. Evidence of peripheral arterial disease may be inconspicuous. The diagnosis disqualifies.
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SECTION XX
PSYCHOSES, PSYCHONEUROSES, PERSONALITY DISORDERS
Paragraph
General considerations 87
Routine procedure 88
Minimum psychiatric examination 89
Class 1-A 90
Class 1-B 91
Class 4 92
Diagnostic criteria 93
87. General considerations.-The detection of disorders of the personality is often most difficult and the general fitness of the individual for military life should be considered at the end of the medical investigation. At the time of examination there may be no obvious defects such as present themselves in other pathological conditions. Each examiner should constantly be on the alert throughout his contact with the individual to detect any sign of such disorders and should promptly report suspicious symptoms he may note to the chief examiner. (See par. 2b.) Every effort must be made to reject the mentally deficient and those showing evidence of nervous instability. The mentally deficient and unstable are always a detriment to the Army from the day they are accepted until they are separated from the service. Such men should under no circumstances be accepted.
88. Routine procedure.-a. The diagnosis of most psychiatric disorders depends in the first place upon the examiner's estimate of the person's behavior and response to the situation of the examination and in the second place upon an adequate history, supplemented if necessary by information gathered from the individual's own physician, courts, hospitals, social service or welfare agencies, etc.
b. Routinely, examiners should be on the watch for any of the following personality deviations: inability to understand and execute commands promptly and adequately, abnormal negativistic attitude, abnormal anxiety, silly inappropriate laughter, instability, seclusiveness, sulkiness, sluggishness, discontent, lonesomeness, depression, shyness, suspicion, overboisterousness, timidity, personal uncleanliness, stupidity, dullness, resentfulness to discipline, a history of nocturnal incontinence, sleeplessness, lack of initiative and ambition, sleep-walking, recognized queerness, suicidal tendencies either bona fide or feigned, and homosexual proclivities.
c. Abnormal autonomic responses (fainting, blushing, excessive sweating, shivering or gooseflesh, excessive pallor or cyanosis of the extremities) are also occasionally significant. Note also the lack of such normal anxiety or autonomic responses as might reasonably be expected under the circumstances.
89. Minimum psychiatric examination.-a. Mental and personality difficulties are most clearly revealed in the subject's behavior toward those with whom he feels relatively at ease. The most successful approach is often one of straightforward professional inquiry coupled with real respect for the individual's personality and due consideration for his feelings-which does not mean diffidence.
b. The psychiatric examination should be made outside of easy hearing of other men. Matter of diagnostic significance is often concealed when the individual feels that he must be impersonal and give replies that will not impress listeners with his peculiarity.
c. Questioning should begin with something that is obviously relevant to the immediate situation. One tries to elicit the difficulties which the individual has been experiencing in his relations with others and himself in his work and in his spare time activities. The examiner pays close attention to content and implication of everything said and to any other clues and, in a matter-of-fact manner, follows up whatever is not self-evidently commonplace.
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d. The probable presence of some types of psychiatric disorders-in particular the major psychoses and marked degrees of feeble-mindedness-may often be suspected by alert observation of the individual's behavior if the examiner knows what to look for and what to regard as significant. In other cases one would not be able to suspect the presence of any morbid condition without some knowledge of the individual's history.
90. Class 1-A.-a. The range of personalities usually classed as 'normal.' Evidence of ability to get along tolerably with family, friends, casual acquaintances, authorities in school or society, employers and fellow workers. Conventional attitude toward sexual problems. Sufficient intelligence to graduate from grammar school unless prevented by external circumstances. Sufficient stability and ability to obtain and keep, or at least to seek, a job.
b. Marginal intelligence, if compensated for by better than average stability.
c. Men whose speech can readily be understood, even though there is a moderate degree of stuttering or stammering, if otherwise physically, intellectually and emotionally fit.
91. Class 1-B.-a. Moderate degrees of compulsiveness or obsessiveness.
b. Stuttering and stammering of a degree disqualifying for general military service but which has not prevented the man from successfully following a useful vocation in civil life.
92. Class 4.-Individuals who are found to have any serious mental or neurological disorder such as-
a. Mental deficiency.
b. Psychopathic personality.
c. Major abnormalities of mood.
d. Psychoneurotic disorder.
e. Pre-psychotic, post-psychotic and schizophrenic personalities.
f. Chronic alcoholism and drug addiction.
g. Syphilis of the central nervous system. (See par. 85a.)
h. Sexual perversions.
i. Stammering to such a degree that the registrant is unable to express himself clearly or to repeat commands.
93. Diagnostic criteria.-a. Mental defect or deficiency.-(1) Manifested by lack of general information concerning native environment; inability to learn, to reason, to calculate, to plan, to construct, to compare weights, etc.; defect in judgment, foresight, language, output of effort; suggestibility, untidiness, lack of personal cleanliness, anatomical stigmata of degeneration, muscular awkwardness. History of school life, vocational career, and disciplinary report will assist materially; then classify according to psychometric standards.
(2) Examiners will use extreme care and judgment in reporting their findings on enlistment records. Such terms as 'imbecile' and 'moron' will not be used, but an approximate psychometric scaling will be listed as cause for rejection, as 'mental age, eight years.' Elaborate psychometric estimation is not necessary and any accepted abbreviated method will suffice. Intelligence cannot be definitely estimated and there is no test that is infallible. They are all only approximations and must be evaluated only in conjunction with accompanying factors and circumstances. Illiteracy per se is not to be classified as mental deficiency.
b. Psychopathic personalities.-In this ill-defined, more or less heterogeneous group are placed those individuals who, although not suffering from a congenital defect in the intellectual sphere, do manifest a definite defect in their ability to profit by experience. They are unable to proceed through life with any definite pattern of standardized activity. They are unable to respond in an adult social manner to the demands of honesty, truthfulness, decency, and consideration of their fellow associates. They are emotionally unstable, not to be depended upon; act impulsively with poor judgment;
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are always in difficulties, have many and various schemes without logical basis, lack tenacity of purpose, are easily influenced and oftentimes in conflict with the law. They do not take kindly to regimentation and are continually at variance with those who attempt to indoctrinate them in the essentials of military discipline. Such an individual has a decided influence upon his fellow associates and the morale of his organization, for he will not conform himself to organized authority and he derives much satisfaction in cultivating insubordination in others. Quite frequently he presents a favorable impression, is neat in appearance, talks well, and is well mannered. However, under this veneer the real defect is evident by past irresponsiveness to social demands and lack of continuity of purpose. Among this general group are to be placed many homosexuals, grotesque and pathological liars, vagabonds, wanderers, the inadequate and emotionally unstable, petty offenders, swindlers, kleptomaniacs, pyromaniacs, alcoholics, and likewise those highly irritable and arrogant individuals, so-called pseudoquerulents, 'guardhouse lawyers,' who are forever critical of organized authority and imbued with feelings of abuse and lack of consideration by their fellow men. All such men should be excluded from the services as far as possible, both because of the difficulties which these symptoms themselves cause and because of the fact that such individuals ultimately may develop fullfledged psychotic states.
c. Major abnormalities of mood (affective psychoses, manic depressive psychosis).-Major abnormalities of mood are shown by episodes of unreasonable elation or depression which have tended to recur without obvious connection with events. People who are known to be so mercurial in their reactions that their judgment is seriously impaired during the up or down swing of their moods should be rejected. Individuals known to have received medical or nursing care because of a morbid excitement or a depression should be rejected.
d. Psychoneurotic disorders.-(1) Symptoms.-These conditions, often having no objective signs, may easily escape notice. Such individuals may show-
(a) Conversion symptoms such as hysterical fits, absences, trances, hysterical deafness, blindness or loss of voice; hysterical paralyses or anesthesias, and vasomotor disturbances such as sweating, palpitation and dizziness, and other dysfunctions of internal organs. In evaluating all of these conditions, the history of interference with progress in civil life is of utmost importance.
(b) Excessive concern with minor or imaginary bodily ailments as manifested by multiple vague complaints, multiple operations for obscure disorders, unusual fatigability, vague pains, pressure feelings, distorted head sensations, etc.
(c) Obsessions, compulsions, phobic manifestations such as specific terrors of harmless objects or situations, food phobias, dirt and germ
phobias, inflexible rituals of behavior about food, sleeping, dressing, compulsive acts, tics, obsessional thoughts, obsessional indecision, etc.
(d) Emotional disturbances such as chronic depression, mild elation, irritability and chronic or episodic insanity.
(2) Physical disorders which may furnish important clues to psychoneurotic disabilities.-Neurotic tensions may be manifested not only by frank psychoneuroses and behavior difficulties but also by manifestations of a variety of physical disturbances and organic disease processes. Such conditions as peptic ulcer, pylorospasm, mucous colitis, spastic constipation, neurocirculatory asthenia, paroxysmal tachycardia, vascular hypertension and hypotension, Raynaud's disease, fainting, convulsions, som?nambulism, narcolepsy, migraine, glaucoma, eczema, psoriasis, enuresis, cardiospasm, impotency, and asthenia may have important emotional components and may therefore furnish important clues to the neurotic aspects of the individual. The presence of such conditions, if not in themselves disqualifying, should always lead to further study. Look for a close relationship.
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e. Schizophrenic group.-(1) This category comprises the grave mental or personality handicaps. Pre-psychotic and postpsychotic personalities and those actually suffering a schizophrenic ('dementia praecox') mental disorder manifest their condition by obscurely motivated peculiarities of behavior and thought. Of these, the so-called deteriorated states are the most obvious. Here belong the numerous shiftless, untidy, perhaps morose, sometimes nomadic individuals, who have had what was regarded as quite a normal childhood. Somewhere between the ages of 12 and 25 they underwent a change, acute or insidious, with dilapidation of their social interests and the habits in which they had been trained. They may or may not have received treatment in hospitals for mental diseases.
(2) The paranoid personalities are another large division. These persons cling to fantastic beliefs in their overwhelming importance, and often feel that people are persecuting them or otherwise interfering with their career or well-being. Some of them believe that they are in communion with supernatural beings. Others believe that they are victims of plots, secret organizations, spy rings, or religious or fraternal groups. They are often plausible in supporting these delusions by clever misinterpretation of facts. Some of them are very evasive and skillful at concealing the pattern of their disorder. A morbid suspiciousness of anyone who takes an interest in them is frequent. They may become tense and hateful when interrogated. An attitude of unusual cautiousness or suspiciousness toward the examining physician or toward fellow individuals should suggest the possibility that the individual may be paranoid.
(3) The catatonic and prepsychotic states may present great difficulty in diagnosis. Perhaps the only sign of these conditions is the impression of queerness which the person makes on anyone who seeks to get acquainted with him. The actual oddities of behavior or thought may be subtle; it may be difficult, in retrospect, to point to any particular instances of the unusual. The most striking signs of these conditions may in fact come out in connection with the physical examination. The physician, at some state of the physical examination, may observe a peculiar reaction which upon questioning may awaken a suspicion of a prepsychotic state. These individuals frequently entertain unfounded convictions as to bodily peculiarities or disorders which they attribute to excessive sexual acts of one sort or another. These beliefs, sometimes hard to elicit, are often medically incredible and bizarre. Questioning them on intimate personal matters often leads to great embarrassment, confused speech, or actual blocking of thought-so that they do not know what to say. Get history of family life and of school, vocational, and personal career.
f. Chronic alcoholism and drug addiction.-(1) Chronic alcoholism.-An individual will be regarded as a chronic alcoholic if he habitually uses alcohol to the point of social or physical disablement, as evidenced by loss of job, repeated arrests, or hospital treatment because of alcoholism. Such a history, if obtained, should be verified. Look for suffused eyes, prominent superficial blood vessels of nose and cheek, flabby, bloated face, red or pale purplish discoloration of mucous membrane of pharynx and palate; muscular tremor in the protruded tongue and extended fingers, tremulous handwriting, emotionalism, prevarication, suspicion, auditory or visual hallucinations, persecutory ideas.
(2) Drug addiction.-An individual will be regarded as a drug addict if he is or has recently been a habitual user of any of the opium preparations, cocaine, or cannabis indica (marijuana). A history of arrests for narcotic law violation is important; recent needle marks are suggestive; discolorations along the line of blood vessels on the arms, or scars from needle abscesses on the arms, shoulders, buttocks, or thighs are very important evidence but are not always present. The condition of the pupils is not important in active addicts.
g. Syphilis of the central nervous system.-See paragraph 85a.
h. Sexual perversions.-Persons habitually or occasionally engaged in homosexual or other perverse sexual practices are unsuitable for military service and should be
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excluded. Feminine bodily characteristics, effeminacy in dress or manner, or a patulous rectum are not consistently found in such persons, but where present should lead to careful psychiatric examination. If the individual admits or claims homosexuality or other sexual perversion, he should be referred to his local board for further psychiatric and social investigation. If an individual has a record as a pervert he should be rejected.
SECTION XXI
PURPOSELY CAUSED PHYSICAL DEFECTS
Paragraph
Report of apparently purposely caused defects
94
94. Report of apparently purposely caused defects.-Whenever it shall appear to an examining physician that an individual is suffering from self-inflicted or purposely caused physical defects which under the standards of physical examination prescribed herein would render him disqualified for military service of any kind, a full statement of the facts and of the condition of the individual and of the examining physician's recommendation will be prepared and submitted to the Director of Selective Service.
SECTION XXII
MALINGERING
Paragraph
Definition 95
Differentiation 96
Feigned medical diseases 97
Feigned surgical conditions 98
Feigned nervous or mental illness 99
* * * * * * *Bed wetting 102
General considerations 103
95. Definition.-The malingerer is one whose complaints of bodily disorders and whose behavior or acts are in simulation of some physical or mental disease for the definite purpose of attaining a particular end which is more satisfactory to him or of seeking an escape from a fear-infested situation. Malingering is encountered in a number of situations but most frequently during the preliminary examinations and early training periods of military service. The simulation of neuroses and of physical disorders includes a wide variety of problems which must be differentiated from the ordinary neuroses as well as from physical illnesses; however, simulation is always in keeping with the extent of the knowledge possessed by the individual regarding the particular disorder from which he pretends to suffer and therefore constantly changes its methods and its maladies. A person gifted with histrionic talent and who has a considerable degree of knowledge and skill at his command may be able to simulate physical or mental conditions to such perfection that physicians may sometimes be deceived.
96. Differentiation.-a. For a disorder to be classed as true malingering, it must fulfill three conditions:
(1) That no obvious or frank disease or personality disorder is present.
(2) That the individual is consciously aware of what he is doing and of the motive responsible for his attitude.
(3) That he is fixed in carrying out a purpose to a preconceived result.
b. When confronted with a case of malingering the observer should try to ascertain how much of what constitutes the total picture is well acted drama and consciously done and how much is true in part and more or less unconscious. For practical purposes these reactions may be divided into the following:
(1) Malingering for the purpose of attaining a definite end by simulation of a
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disease by one who has no past history of similar patterns of reaction but who is making an attempt to escape in an emergency (temporary reaction); one who feigns his symptoms as a bluff and hopes to get away with it.
(2) Malingering to the extent of exaggerating or 'capitalizing' conditions or symptoms that are present for the purpose of avoiding service. This includes an enlargement on minor physical ailments or on relatively insignificant diseases, emphasizing mild personality problems or neuroses, and over-emphasis on symptoms of fatigue, etc.
(3) Malingering as a manifestation of psychopathic personality with a suggestion or definite history of previous psychopathic behavior. In intelligence the psychopath may be retarded, of average endowment, or superior but he is incapable of adjustment under ordinary life conditions. The ranks of psychopathic personality contain many persons having an irresistible tendency to alcoholism, drug addiction, sex perversion and criminality including numbers of cranks, extremists, eccentrics, hobos and queer social misfits.
(4) The psychoneurotic suffering with hysteria, who believes in the reality of a disability which on the surface appears to be a definite simulation, requires a special investigation. The confusion of hysteria with true malingering is not infrequently made by those who consider nearly all hysterics as malingerers with symptoms that could be controlled voluntarily. Some of these psychoneurotics exaggerate more or less unconsciously their symptoms to gain their ends, thus emphasizing the questions of how much is neurosis, how much is simulation and how much is associated with a change in personality.
(5) Malingering or reactions considered to be malingering may appear in those basically psychoneurotic, insecure and apprehensive, or physically ill as well as in those suffering from psychosis, epilepsy and organic brain disorders where there has been a definite change in personality. These reactions frequently confused with pure malingering may become much worse during investigation or attempted correction.
c. Among these five groups the typical members are readily distinguished but intermediate and doubtful cases which resist differentiation do occur. It should be kept in mind that it is even more difficult for a healthy person to feign disease than it is for a diseased person to simulate health and that a malingerer may be able to simulate and accentuate single symptoms but he is practically always unable to feign the entire picture of the disease he has selected and thus the expert can usually detect omissions, discrepancies and contradictions in the situation.
97. Feigned medical diseases.-a. The detection and management of malingerers simulating medical diseases depend upon the absence of positive findings in an individual who presents the general characteristics of the malingerer. There is especial need for the physical examination to be thorough in this group. Some of the cardiac cases at first regarded as malingerers may later be found to have mitral stenosis or bacterial endocarditis. Similarly, proper tests may show the existence of peptic ulcer in those suspected of feigning digestive abnormalities. The estimation of the reality of rheumatic pains is always a difficult matter.
b. Tachycardia and thyrotoxicosis may be temporarily induced by ingestion of drugs such as thyroid extract. Egg albumin or sugar may be added to urine. Canned milk may be utilized to simulate urethral discharge. Cantharides may be taken to cause albuminuria. Digitalis and strophanthus may be taken to cause abnormal heart findings. The skin may be irritated by various substances. Cathartics may be taken to bring about purging or to simulate a chronic diarrhea. An appearance of hemoptysis may be produced by adding blood, either human or that of animals, to the sputa. Sometimes merely coloring matter is added. Those who can vomit voluntarily what they swallow use the same means to create the appearance of hematemeses. Similarly, coloring matter may be added to the stools. Mechanical and chemical irritants may be used to cause inflammation about practically all the body orifices. Jaundice may be
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simulated by taking picric acid. Artificial jaundice is recognized by demonstration of picric acid in the urine. Crutches, spectacles, trusses, strappings, etc., may be used to create appearance of disability.
98. Feigned surgical conditions.-Under this are included old scars and injuries of the bones, fractures, and orthopedic conditions. Men may have teeth extracted in an effort to evade military service. Others may shoot or cut off their fingers or toes, usually on the right side, to disqualify themselves for service. Some may put their hands under cars for this purpose. Retention of urine may be simulated. Substances may be injected under the skin to create abscesses. Crutches, braces, strappings, or trusses may be used to give the appearance of disability. Wounds are rarely self-inflicted when witnesses are present; consequently it is almost impossible to be certain of malingering in some cases.
99. Feigned nervous or mental illness.-a. Psychosis.-Rarely feigned by individuals and then usually a silly, foolish type. In case of doubt, hospital observation is necessary, with verification of past records. Mental deficiency is frequently feigned, especially by illiterates.
b. Pain and hyperesthesia.-The most frequent of all complaints. History inconsistent, ordinary indications of suffering absent. Absence of other symptoms usually accompanies types of pain of which complaint is made. Absence of objective evidence of localized pains. Note behavior when the registrant believes himself unobserved.
c. Anesthesia.-Complaint of anesthesia itself creates a suspicion of malingering as most patients with anesthesia are ignorant of it.
d. Epilepsy.-Men who have sustained head injury may claim fits. These complaints may be in reference to grand mal or petit mal. Petit mal attacks are spoken of as fainting attacks. In grand mal attacks there is loss of pupil response to light, knee jerks are lost, and the Babinski reflex may be present.
e. Hysteria.-Not feigned in itself but its existence creates confusion as to malingering. The question to be decided is whether the individual is too seriously affected with the neurosis to be useful as a soldier.
f. Stiff back.-Stiff back is a frequent symptom of hysteria in mobilization among selected men. In cases of this kind, organic diseases of the vertebrae can and should be excluded if necessary by X-ray.
102. Bed wetting.-Enuresis either real or simulated may be a frequent complaint among individuals for military service, but it is not a cause for unconditional rejection. Men claiming to be bed wetters may be placed in class 1-A, unless enuresis is substantiated by a physician's affidavit or other acceptable documentary evidence.
103. General considerations.-a. All men suspected of malingering should be immediately subjected to a thorough psychiatric survey which should include a careful history of their previous behavior and adjustment record and a complete physical, neurological and laboratory evaluation. Observation in hospital may be required. If simple genuine malingering exists, the man should be confronted with the situation and given time to reconsider his attitude. Those malingerers whose past record is not unfavorable and who are otherwise acceptable should not be rejected. Suspected malingerers found suffering from definite psychoneuroses and others in whom signs of mental disorders are detected should be rejected for military service.
b. Whenever it shall appear to an examining physician that an individual is endeavoring to escape service by malingering, if otherwise mentally and physically fit, he will be accepted.
