APPENDIX D
Report of the Special Committee to the Secretary of War on Induction
21 SEPTEMBER 1943
Major General NORMAN T. KIRK, USA
The Surgeon General
Washington, D.C.
SIR:
Pursuant to authority granted by the General Staff the following were appointed special consultants to the Secretary of War for the purpose of serving on a committee to study the procedures currently followed at induction stations with particular reference to the subject of rejections for mental causes, and to make recommendations concerning possible improvement: Doctors Karl M. Bowman, Titus H. Harris, Frederick W. Parsons, Arthur H. Ruggles, Edward A. Strecker and Raymond W. Waggoner. Doctor Winfred Overholser, Superintendent of St. Elizabeths Hospital, was detailed by the Federal Security Agency to serve on the committee and Col. Roy D. Halloran, MC, of the Office of The Surgeon General was assigned to serve with the committee. The committee met in Washington on 31 August 1943 and elected Doctor Overholser chairman. Meetings were also held in Washington on 1 and 2 September and on 18, 19 and 20 September 1943. The necessary travel was authorized, and all possible facilities have been extended by the staff of The Surgeon General's Office in Washington and in the field. Inasmuch as the report was called for on or before 23 September, much work had to be compressed into a short period; had time permitted, more details might profitably have been studied.
Interviews with a number of officials who were able to cast light on certain aspects of the problem have been very helpful to the committee. In addition to Lt. Col. Malcolm J. Farrell and Lt. John W. Appel of the Division of Psychiatry in the Office of The Surgeon General, the following have been interviewed: Col. Richard H. Eanes, Executive Assistant to the Director of Selective Service; Col. Leonard Rowntree, Chief, Medical Division of Selective Service; Brig. Gen. Frank T. Hines, Administrator of Veterans Affairs; Hon. Paul V. McNutt, Manpower Commissioner; Maj. Harold C. Bingham, Personnel Division, Adjutant General's Office; Maj. Margaret C. Craighill, MC; Lt. Col. Esmond R. Long, MC; Capt. Harold Dorn, SnC, of the Statistical Division, Surgeon General's Office; and Lt. Col. Cornelius Gorman, MC, Physical Standards Branch. On 1 September the committee took advantage of the meeting of eight of the psychiatrists from replacement training centers who were meeting in the Office of The Surgeon General and had an opportunity to discuss with them the various psychiatric problems as found in the field. The committee was also fortunate at that time in hearing Capt. Herbert X. Spiegel, MC, recently returned from service as a battalion surgeon in North Africa.
In the field an attempt was made to gain an idea of the practices actually being followed at the induction station. Each member visited one or more stations, spending a large part of the time with the psychiatrist, being present during his examination of inductees and also discussing with him and with the senior medical officer the methods followed. The induction stations at thirty-five points widely scattered throughout the United States were visited as follows:
First Service Command-Boston, Mass.
Second Service Command-New York City, Albany, Buffalo, and Rochester, N.Y.; Camden and Newark, N.J.
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Third Service Command-Baltimore, Md.; Philadelphia, Pa.; and Richmond, Va.
Military District of Washington-Fort Myer, Va.
Fourth Service Command-Forts Benning and McPherson, Ga.; Fort McClellan, Ala.; and Camp Croft, S.C.
Fifth Service Command-Columbus and Toledo, Ohio; Indianapolis, Ind.; and Huntington, W. Va.
Sixth Service Command-Detroit, Mich.; Milwaukee, Wis.; and Chicago, Ill.
Seventh Service Command-Fort Snelling, Minn.; and Omaha, Nebr.
Eighth Service Command-Shreveport, La.; Tulsa and Oklahoma City, Okla.; Lubbock, Dallas, San Antonio, and Houston, Tex.
Ninth Service Command-San Francisco, Sacramento, and Los Angeles, Calif.; and Salt Lake City, Utah.
In addition, three station hospitals, Fort Benning, Ga., Fort Custer, Mich., and Fort Benjamin Harrison, Ind.; six general hospitals, Valley Forge, Halloran, Billings, Brooke, Lawson, and Letterman; and the First, Second, Fourth, Fifth, Sixth, Seventh and Eighth Service Command Headquarters were visited.
It is hardly necessary at this late date to labor the point that psychiatric problems constitute perhaps the largest single group of medical problems in the present conflict. This can be readily demonstrated by statistics as well as by the experience of both medical and line officers. Detailed statistics are readily available in the Office of The Surgeon General; they are extensive and there is no need to quote them at length here. As a result of the painful experiences of World War I with psychiatric problems, a considerable amount of attention was given to the question of the psychiatric selection, conditioning and disposition of men from the time that the Selective Service Act was first discussed. Certain criteria of psychiatric and neurological acceptability were set up and the Army standards as contained in MR 1-9 were adopted after consultation with a committee of the National Research Council, as was the case with the various other sections of that pamphlet. Provisions for the mental examinations of registrants, both at the local board level and at the stage of induction were contemplated and extended plans were made in the early days of Selective Service for the indoctrination of the local boards and of the medical advisory boards, as well as of the examiners on Army induction boards regarding the type of disqualifying mental symptoms.
About January 1942 the primary selective function of the local boards regarding physical standards was to a great extent given up, with the result that an increased load was thrown upon the induction board. Inductees were presented to the induction boards without accompanying information concerning facts which perhaps would have been well known to the examining physician of a local board regarding the inductee's history, family, economic and social. An attempt was made in several areas, notably Connecticut, Maryland, and more recently in New York, as well as in a number of other states, to provide significant data for the benefit of the psychiatric examiners at the induction boards. At the present time a country-wide plan is being set up by the National Headquarters of the Selective Service System and Medical Circular No. 4, which will be published very soon, will prescribe a plan whereby this type of information may be made available. The importance to the psychiatric examiner of having at hand significant data of this sort cannot be overemphasized. In February, 1943, the Navy was obliged to draw candidates from the induction lines and accordingly Naval medical officers have since that time been assigned to the induction boards.
At the beginning of the Selective Service activities the Adjutant General's Department developed a classification procedure which has gradually widened to include not only tests of education as such, but tests of native intelligence. Rejection is authorized on the basis of failure to meet these tests and under existing regulations
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the findings of the psychologist are reviewable only by the commanding officer of the induction station and not by the medical personnel. Since 15 June 1943 all inductees failing to meet the standards are classified for rejection under the heading of educational, whereas previously some of these men were charged to the medical examination as rejected for mental deficiency or for other mental reasons. It was originally planned to have each psychiatrist examine not more than fifty inductees per day. Psychiatric examination is time-consuming compared with many of the other examinations called for, and it has been found that justice cannot really be done to the psychiatric requirements if the psychiatrist is required to see more than fifty men per day. However, in many areas the scarcity of psychiatrists has made it impossible to observe this limitation; we have found stations at which one psychiatrist had to carry a daily load of three hundred (300) or more, and in several stations, particularly in the Eighth Service Command, no psychiatrist whatever was on duty.
The rate of rejections during World War I was approximately 21 per 1,000 or 2.1%. The figure has consistently been higher during the present conflict. For the months of June and July, 1943, the percentages of rejections for mental conditions, not including rejections by the psychologist, was 8.87% and for neurological conditions 1.36%, or a total of 10.23%. This figure represents the average for the entire country. There are, however, some remarkable fluctuations as between different stations. At Boise, Idaho, for example, the rate was 0.6% whereas at Oklahoma City it was 23%. Some of these inequalities are perhaps accounted for by the educational standards and the standards of intelligence of the population in the particular area. They are also attributable to the skill of the psychiatrists (or the lack of it) and to the extent to which the psychiatrist is aided in his judgment by a history of the registrant. The load thrown upon the individual psychiatrist makes much difference, a large load promoting carelessness and the development of routine habits often resulting in the acceptance of undesirable material. The physical conditions of examination differ but, in general, the circumstances under which the psychiatrist must operate are reasonably satisfactory.
One of the principal forms of mental disorder which is cause for rejection is the condition known as psychoneurosis. This is a mental condition which embraces a wide variety of symptoms, no one of which may be disabling but the sum total of which may interfere with the efficiency of the individual when he is living a life which makes relatively few demands upon his ability to adjust. Placed in an unusual situation or called upon to make an unusual adjustment, as is the case in Army camps or in combat, the symptoms may increase to the point of complete incapability for any useful work. In a substantial number of instances, resumption of a life relatively free from stress may bring about improvement in the condition. It should be borne in mind that psychoneurosis is the result of unconscious mechanisms beyond the control of the individual, that it is an illness, but that it does not constitute what is generally termed 'insanity' and that it is frequently unrecognized by the casual observer. These men may be extremely useful persons in the community and yet a total loss from the military point of view, not only being unable when ill to fulfill their military duties, but having an undesirable effect on the morale of a group, occupying hospital space, and calling for the time and attention of others who must care for them. The rejection of men of this type is therefore beneficial to the Army and to civilian manpower. The demands of warfare today, by reason of speed, increased mechanization, the greater amount of individual responsibility, and the development of means of destruction and terrorization, are far more intense than in previous wars. They call for a high degree of adjustability on the part of the soldier and render comparison with the data of previous wars somewhat misleading.
In spite of the efforts to weed out initially those who are poor risks from a psychiatric point of view, the rate of psychiatric breakdown is substantial and has caused alarm in some circles. There were on 28 August 1943 in the psychiatric wards
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of the hospitals of the Army over 16,600 patients, and during that week there were admitted to those wards approximately 5,000. The rate of admission for July 1943 per 1,000 strength per year in the continental United States was 40, whereas in 1917-1918 the rate was 30; in the overseas combat theaters the rate for the same period was 60 as compared with the 1917-1918 rate of 16.5. The rate of discharge on Certificate of Disability is higher than for any other single cause. For the first six months of this year such discharges for neuropsychiatric reasons constituted 41.9% of the total number. In addition, a large proportion of the men discharged on what is known as Section VIII are discharged fundamentally for psychiatric reasons which existed prior to their enlistment or induction, such as mental deficiency or psychopathic personality. This group constitutes about 13% of the total number separated from the service.
Statistics furnished by the Veterans Administration indicate that since the declaration of war 4,737 men have been admitted to Veterans hospitals for neuropsychiatric reasons. This constituted 34% of the total. Of this number 1,257 were admitted during June and it may be expected that the number will increase month by month. Of the total group admitted since December of 1941, 2,158 or very nearly one-half have been ruled to be non-service-connected. In other words, every one of these men has been found to be suffering from a psychiatric or neurological condition which existed prior to his induction. In some of these instances it is not questioned that the condition might have been recognized upon induction had more time been available, had a history been available or had the skill of the examiner been greater. Whatever the reason, an error of omission was made.
In our studies of the functioning of selective service as it pertains to the induction stations we have found some disharmony in the National Headquarters. It seems clear to us, from our personal interviews and from reports from the field, that Col. Richard H. Eanes, Executive Assistant to the Director, holds opinions, undoubtedly sincere, regarding the place of psychiatry in the selective process which are nevertheless at great variance with the officially accepted principles of the Army and of Selective Service. These opinions are so fixed that we doubt seriously whether the most efficient psychiatric procedure can be carried out while Colonel Eanes occupies an official position in Selective Service Headquarters.
The committee found that throughout the country there was considerable variation in the psychiatric rate. Along the Eastern seaboard where the supply of civilian psychiatrists is adequate the rejection rate at induction centers tends (with some fluctuation) to be about 10%. In sections of the country where trained civilian and military psychiatrists are not available the rejection rate is lower.
In considering the rejection rate for psychiatric reasons two questions seemed to merit special consideration of the committee. They are:
1. Is suitable military material being unjustifiably rejected?
2. Is the Army accepting individuals who will not render satisfactory service? In answer to the first question the committee reports that its members have sat with examining physicians, civil and military. In no case did the members find that individuals were excluded without good reasons therefore. Observation on the second point indicates that where the psychiatric personnel was inadequate selectees who should be excluded were being inducted. It is the committee's opinion that the psychiatric rejection rate, far from being too high, is actually lower than is warranted by the facts of the situation.
The committee included in its study a consideration of the psychological test procedure at the induction station because of its overlapping with psychiatry. Maj. Harold C. Bingham of the Personnel Division, Adjutant General's Office, was interviewed by the committee and a general discussion of the methods employed in the psychological tests was held. Major Bingham gave his opinion of the validity of these tests.
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While in the field the committee studied the actual procedures carried out in giving psychological tests, the degree of cooperation and interchange of opinions between psychologists and psychiatrists, and the opinions of both psychologists and psychiatrists as to any method of improving procedures. It should be noted that the psychological tests are carried out independently of all other examinations at the induction centers; that the commanding officer of the induction center is the only person with authority to review and overrule the findings of the psychologists; and that interpretation of these tests is too separated from the rest of the examination. In actual practice considerable variation was found in the amount of interchange of opinion which occurred between psychologists and psychiatrists. In some centers psychologists never referred problems to psychiatrists and vice versa. In other centers it was found that psychologists might ask the psychiatrists for special study in individual cases, and the psychiatrists in turn would refer cases back to the psychologists for further examination and study. In some centers it was also found that there might be a general discussion of an individual case in which both psychologists and psychiatrists participated, while in other centers this never occurred.
At most centers the physical examinations, including the psychiatric, are carried on even after inductees were rejected on psychological grounds, but a few isolated instances were found where no further examination was given after inductees were rejected by the psychological test.
Some variation was found in the procedure in giving psychological tests. Practically always, some preliminary psychological tests were given as the first tests, but there was variation at different centers. Some centers carried out the entire psychological study before the inductee went on for further examinations, while at other stations part of the psychological examination was given first and the inductee later returned for other psychological tests. This means that there was considerable variation in the psychological report which accompanied the inductee when he appeared before the psychiatrist. In some cases the final result of the psychological test was available to the psychiatrist, and in other cases it was not.
The problem of malingering was discussed with Major Bingham who stated that the psychologists were well aware of the possibility of an attempt at malingering and had specific instructions concerning procedures for detecting it. He stated, however, 'The question of malingering is a mooted question on which there is a good deal of different opinion. Personally, I have always thought it a psychiatric problem. It has seemed to me that a prevailing definition of a malingerer is that there is something abnormal about him.'
In view of the high psychiatric discharge rate among the members of the Women's Army Corps, the committee studied the problem of WAC induction. The psychiatric discharge rate of this group is very high, namely 44.7% of the total discharge rate, largely for psychoneuroses. Our investigation disclosed several important induction factors.
1. The upper age limit for WAC enlistment is fifty years which is the age epoch of very high incidence of neuropsychiatric disability in women.
2. Induction boards do not regard the examination of WAC enlistees as being as important as for male inductees; they often do not have sufficient psychiatric personnel or facilities to make adequate examinations and, in some stations, no psychiatric examination of Wacs has been made.
3. At some induction stations women civilian psychiatrists are being satisfactorily used in the examination of WAC enlistees.
4. The criteria for the diagnosis of psychoneurosis in women usually are not so clearly defined by induction boards as in males.
The committee's investigation disclosed that the Navy is now represented on induction boards and in some induction stations the ranking medical officer is a Navy medical
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officer. An overall study of the problem, as far as the Navy is concerned, indicates four categories of psychiatric patients:
1. The disabilities are obvious; they are usually detected at induction and account for 15% of all rejections in the induction centers.
2. A 'questionable fit' group. Here further information and observation, and often trial duty, are needed. About 4% of all recruits are found to be unfit.
3. A 'potentially unfit' group, not obvious. These men are apt to do fairly well for about six months, then a considerable number break under increased stress between the sixth and ninth month of service. This group is not separated from the service without hospitalization before survey. Approximately 30% of all medical discharges from the naval service each month constitutes the personnel of this group.
4. This group contains the men who are reasonably well integrated and who break only under greater than average stress-usually combat conditions. They are admitted to hospitals here and abroad and make up 6% of the monthly total of medical surveys for neuropsychiatric reasons.
The Navy stresses the usefulness of time and observation under actual training camp conditions and feels it has demonstrated its importance notably in groups 1 and 2. The psychiatric discharges from 'boot' camps average about 4%. Usually 50% of the men are given the test of observation under actual training conditions and in a few training areas the proportion is as high as 90%.
CONCLUSIONS
Your committee finds that in the past too large a number of psychiatrically vulnerable men have been inducted into the armed forces only to become psychiatric casualties, many within two months of induction. These men have been of no service value and instead have been consumers of manpower in the service. We find that instead of being too high the overall psychiatric rejection rates are at the present time too low, as demonstrated by the number of cases in the psychiatric wards, at the psychiatric out-patient departments, and those being separated from the service through Section II, Section VIII, and otherwise.
Many of these vulnerable men can function in civilian work and make valuable contributions to the manpower supply whereas in service they promptly go on sick call or enter hospitals and thus add to the burden of care without having contributed anything of value to the armed forces. The psychiatric work at induction stations has improved in the past year, but there are still areas in the country where there are no psychiatrists to function, and in these areas neuropsychiatric cases are being taken into service in large numbers. A continuing rejection of the present 8% to 10% of neuropsychiatric cases, or even higher rates, should reduce the present high percentage of discharges for psychiatric reasons.
We find no evidence to support a belief that the evasion of service through malingering occurs in any considerable degree. We further believe that most evasion of service through malingering is confined primarily to those men who would not in any event make a satisfactory adjustment in the armed forces.
RECOMMENDATIONS
The committee respectfully recommends that the present procedure at the Armed Forces Induction Stations as concerns neuropsychiatry be continued, with the following modifications:
1. Wherever feasible, the psychiatrist be required to examine not more than fifty inductees per day.
2. That the psychiatric examination be the last examination in the line.
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3. That the completed results of the psychological examination accompany the inductee when he is examined by the psychiatrist, and that consultations between the psychiatrists and psychologists be encouraged.
4. That the psychological examination be considered as contributory to the psychiatric examination, and that it be subject to medical review as are all other parts of the examination.
5. That every effort be made to provide trained psychiatrists for those induction stations which are now undermanned, especially in the Eighth Service Command.
6. That, so far as possible, Army psychiatrists be rotated in service between induction stations and the psychiatric wards of Army hospitals.
7. That privacy and quiet be provided so far as possible for the psychiatric examination.
8. That more frequent use be made in doubtful cases of the employment of special diagnostic techniques, such as the electroencephalograph, and wider application of the provision for three days' observation.
9. That the procedure for furnishing an adequate social and medical history as prescribed in the forthcoming Medical Circular 4, Selective Service System, be put into general use as promptly as possible.
10. That, in accord with present plans of the Surgeon General's Office, each Service Command be supplied at regular intervals with information showing the place of induction of men who have been discharged for disability, as a means of evaluating the efficiency of the screening process at the induction stations.
11. That the upper age limit of WAC enlistees be lowered to the present Army age of thirty-eight years; that a uniform examination procedure as employed in the psychiatric examination of male inductees be followed, and that an effort be made to secure the services of a larger number of qualified women civilian psychiatrists to make psychiatric examinations of WAC enlistees.
12. That a change be made in the assignment of the liaison officer between the Surgeon General's Office and Selective Service Headquarters.
13. That each service command be provided with a psychiatric consultant.
This report and recommendations represent a summary of a large amount of factual data collected by the various members. All of this information is available to your Office should it be desired. The Committee wishes to express its appreciation of the courtesies extended to it, and its readiness to be of further service should such service be of assistance to the War Department.
Respectfully yours,
WINFRED OVERHOLSER,
Chairman.
KARL M. BOWMAN,
TITUS H. HARRIS,
FREDERICK W. PARSONS,
ARTHUR H. RUGGLES,
EDWARD A. STRECKER,
RAYMOND W. WAGGONER,
R. D. HALLORAN,
Colonel, MC,
Chief, Neuropsychiatry Branch.
