CHAPTER VIII
Selection and Induction
Ivan C. Berlien, M.D.. and Raymond W. Waggoner, M.D.
HISTORICAL NOTE
One of the most important lessons learned from World War I was the high cost of medical care for veterans suffering from nervous and mental disorders which, by the time of World War II mobilization, had reached approximately $1 billion. Psychiatrists, in general, as well as others in responsible positions in Government, believed that this staggering expenditure emphasized or highlighted an urgent need for preventing the induction of mentally unfit registrants. Further, World War I experience had demonstrated that it was also uneconomical, both from the standpoint of manpower wastage and from the expenditure of money and time, to induct men unsuited for military service because of their tendency to break down with mental illness under stress and strain of military life. It was also believed that it was rare for any soldier with nervous or mental disease to be susceptible of improvement or cure by treatment in military service. Indeed, as stated in the history of the Medical Department in World War I,1 such soldiers constantly reported at sick call, or were suddenly seized with nervous or mental collapse, or became involved in repeated military delinquencies. Moreover, while such men were ultimately discharged, they had nevertheless consumed the time and money necessary for their period of training, maintenance, and equipment in addition to the expense of their care in military hospitals. The World War I history also pointed out another unfortunate feature of inducting such men. Not only was such induction fruitless from the standpoint of obtaining an effective soldier but it was also a loss to the war effort on the homefront where, had these men been allowed to remain, they might have maintained their marginal adjustment and contributed something of value to the war effort.
From these World War I experiences and their aftermath, it seemed evident that a major objective in the procurement of large numbers of men during the mobilization period of World War II was, on the one hand, to select men who would be capable of being good soldiers and, on the other, to reject those unsuited because of mental illness or character disorder. Perhaps the most oft-quoted evidence to support such selection was the
1The Medical Department of the United States Army in the World War. Neuropsychiatry. Washington: U.S. Government Printing Office, 1929, vol. X, p. 57.
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famous telegram sent by Gen. John J. Pershing, American Expeditionary Forces commander in France, to the Chief of Staff, on 15 July 1918, as follows:
Prevalence of mental disorders in replacement troops recently received suggests urgent importance of intensive efforts in eliminating mentally unfit from organizations [of] new draft prior to departure from the United States. Psychiatric forces and accommodations here inadequate to handle a greater proportion of mental cases than heretofore arriving, and if less time is taken to organize and train new division, elimination work should be speeded.2
For the record, however, it should be noted that the program for screening out prospective service personnel with potential psychiatric problems during World War I had been extremely variable and by no means consistent. Of the nearly 70,000 men eliminated for neuropsychiatric reasons, only 40 percent had been rejected at the time of their entrance into the Army (pp. 6-8). Faced with these facts, it would have seemed important to have undertaken new research promptly after World War I to develop methods and techniques for the collection and screening of men for a fighting Army. Unfortunately, practically nothing was done in terms of such research and very little more in the development of plans.
1939-41 PHILOSOPHY OF SELECTION
From the foregoing background data, it should be apparent that, during this period before World War II, the prevailing professional and lay opinion argued for psychiatric screening as of vital necessity to avoid the errors of World War I. This was well stated by Baganz3 who said: 'Future mobilization plans will require each draft board to include a psychiatrist.' In his article, Baganz estimated that somewhat more than 1 percent of individuals examined would have some form of mental disease and that it was vital that such persons be kept out of service by some kind of screening process.
Psychiatric literature.-Other important influences supporting the philosophy of screening were the viewpoints expressed in the psychiatric literature of the time. During this period, many psychiatrists devoted considerable time and thought to the problem of psychiatric screening. One saw in their writings a rainbow of opinion, as it were, reflecting at one end an enthusiasm for psychiatric screening which overevaluated the effectiveness of such a program, believing that most of the psychiatric ills of the Army would be obviated by careful selection, shading over to the other end, reflecting a more conservative view. For the most part, writers were in a
2It is noteworthy that General Pershing's request referred to a need for eliminating unsuitable personnel before oversea shipment. It made no mention of total rejection for service as seemed to be interpreted or utilized by the proponents of psychiatric screening.-A. J. G.
3Baganz, C. N.: The Importance of a Proper Psychiatric Survey in the Enrollment of the Personnel of Military Forces. Mil. Surgeon 86: 471-477, May 1940.
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middle ground position, counseling the rejection of those who were obviously mentally unfit and, at the same time, realizing that selection would not, indeed could not, be so efficient as to obviate the breaking down of considerable numbers of men in the stress of combat, or from other strains incidental to military service.
In an excellent presentation of the problem, a Canadian Army psychiatrist4 who had reviewed some 200 neuropsychiatric cases, in October 1940, stated: 'In our estimation, the unsuitability should have been obvious in 68, or 34 percent, on enlistment.' He concluded: 'It is suggested that a short form of neuropsychiatric examination be part of the man's medical examination on enlistment.'
That serious pyschiatrists were alarmed over the overenthusiasm of certain advocates of screening may be deduced from the following:
There may be enthusiasts who would carry psychiatric scrutiny of recruits to extremes, or who would sell to the Government infeasible mental hygiene schemes. Such promotions sometimes emanate from nonmedical sources. They tend to discredit the real service which the psychiatrist can render. That all unsuitable cases should be discovered at the beginning, no one could expect or require, nor would it be advocated that all potentially neurotic or border cases should be indiscriminately rejected. All material which can be fitted into the military organization should be utilized.
Conservative opinion might be formulated somewhat as follows:
1. With adequate psychiatric instruction it should be possible for medical boards to recognize and reject on application for enlistment a high proportion of candidates who are unsuitable by reason of mental or neurological conditions.
2. Doubtful or border cases might be accepted for probationary training under special observation, their fitness or unfitness to be determined reasonably early as results of such special observation.
3. Those judged unfit during preliminary training period should be eliminated; others might be assigned to special training or duty as indicated.
4. Psychopaths as such should not necessarily be discharged from the service. They should be assigned to special duty in special units under special discipline-Spartan discipline.
5. There should be scrupulous avoidance of any attitude which would suggest or encourage the idea that minor psychiatric findings, vague nervous conditions or complaints, are grounds for rejection or discharge.
Porter,6 in his paper, cited the cost of the care of neuropsychiatric cases from World War I, but took a moderate view as to the efficacy of the psychiatric screen imposed at induction stations. He stated:
* * * it will probably be impossible to eliminate from the Army at either the enlistment or the training stage all soldiers who will neurotically break down under conditions of extreme combat stress. But if the examiner will scrutinize carefully and give due weight to a history of neurotic-like breakdown prior to entry into service-a large percentage of those who might develop neurosis will be eliminated.
4Baille, W.: A Summary of Two Hundred Neurological and Psychiatric Admissions From the Canadian Army Service Forces. Am. J. Psychiat. 97: 753-779, January 1941.
5Comment: Psychiatry and the War. Am. J. Psychiat. 97: 975-976, January 1941.
6Porter, W. C.: The Military Psychiatrist at Work. Am. J. Psychiat. 98: 317-323, November 1941.
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On the other hand, Kiene and his associates,7 writing of their experiences in an Army induction station, said:
Since the armistice terminating the First World War in 1918, the Government of the United States has spent approximately one billion dollars for compensation and hospital care of nervous and mental casualties suffered by our fighting forces. Many of these casualties could have been prevented by the elimination of the actual and potential sufferers from nervous and mental disease by neuropsychiatric examination at the time of their induction into the service.
Leigh,8 writing of his experiences as a regimental medical officer in the British Army, came to these conclusions:
There is no place in the Army for men with effort syndrome, chronic stress, dyspepsia, anxiety neurosis or anxiety hysteria, or for mental defectives. Most of these cases show a bad family history or evidence of previous breakdown, which should be detected by the civilian board and should lead to rejection. Rapid neuropsychiatric examination should be made of every recruit by an experienced psychiatrist.
Orr,9 writing of the importance of psychiatric screening, also quoted statistics from World War I and pointed out that every three cases rejected, which would become psychiatric casualties, would save the Government $100,000 in a period of 20 years. Orr went on to say that the principal task of the local board examiner was to reject existing manifest neuropsychiatric disabilities. However, speaking of the induction board psychiatrist, he made this statement:
With the more obviously psychopathic men eliminated, they are asked to eliminate further: (1) those men with more subtle personality disorders missed by previous examiners; (2) men whose present personality makeup suggests that they may break under the special stresses and strains of camp life; and, even beyond these, (3) men who may be expected to develop some type of neuropsychiatric disorder at any time during the next eleven years, the period of camp training, plus the period of liability to military service as a member of the Organized Reserve. It is even suggested that the induction board psychiatrist should endeavor to pass only men who are, in a positive sense, 'vocationally suitable' for Army life, rejecting all those who, in no sense mentally ill, are nevertheless better adjusted to civilian jobs than they could ever be in the Army.
The foregoing statement summarized in brief the problems confronting the induction board psychiatrist and suggested the impossibility of completely accomplishing that which the overenthusiasts solemnly advanced as the goal of psychiatric screening.
Bowman,10 writing on psychiatric examination in the Armed Forces, also cited the famous Pershing cablegram and the figure of a billion dollars that had been spent since the close of World War I on the care of veterans who had nervous mental disorders and pointed out that, in the last draft during World War I, approximately 2 percent of the candidates were ex?
7Kiene, H. E., Hassel, A. S., and Miller, H.: Neuropsychiatric Examination at the R. I. Army Induction Station. Am. J. Psychiat. 98: 509-514, January 1942.
8Leigh, A. D.: Neurosis as Viewed by Regimental Medical Officer. Lancet 1: 394-396, 22 Mar. 1941.
9Orr, D. W.: Objectives of Selective Service Psychiatric Classification. Bull. Menninger Clin. 5: 131--133, September 1941.
10Bowman, K. M.: Psychiatric Examination in the Armed Forces. War Med. 1: 213-218, March 1941.
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cluded from military service because of nervous or mental disease or defects and that later 3 percent more were discharged because of similar disabilities. He stated:
With these figures in mind, it is apparent that approximately 5 percent of those chosen under the present draft either will have some neuropsychiatric disability at the time of induction or will show it shortly thereafter. The problem, therefore, from the standpoint of psychiatry is to pick out and exclude this 5 percent.11
Bowman then called attention to the advisory system of specialist consultation which was then being practiced; namely, a complete examination by Selective Service System examiners who, when encountering a disorder or disability which referred to a special system, such as the nervous system, referred the registrant to a psychiatrist on the medical advisory board, who then gave the draftee a complete mental examination. He believed that the first step in psychiatric screening was that of education-that it would be necessary to educate the regular board examiners to the fact that about 5 percent of all registrants were suffering from mental disorder or defect of such a degree that they should be excluded, but warned: 'While men with marked feeblemindedness and clear-cut psychoses should be eliminated rather easily, it will be extremely difficult to pick out the more nearly normal persons who are sufficiently unstable mentally to make their induction undesirable.'
Yet Bowman made the point that, from a study of World War I material, it had been determined that many draftees who later broke down in the service could have been 'spotted' by the psychiatrist if a complete and accurate history had been obtained. He recommended, therefore, that local draft boards secure adequate social records and utilize as much as possible the files of hospitals and courts, the social service records of the community, the school records, and any material which the public health nurses might have. One of his concluding statements is significant and reflects the philosophy of taking only the best in view of the fact that a small army was being contemplated at that time:
If an army of approximately one million men is contemplated, there is no necessity for inducting men who are not entirely qualified in every way to become good soldiers, and there is every reason for not doing so. The inductive service must not be considered a punitive measure, with its main responsibility that of preventing persons from escaping just punishment. Rather, the psychiatrist must be considered a vocational adviser, who considers carefully all of the material which passes through his hands and sees to it that only those who are vocationally fit and who will make
11Quite fortuitously, the quoted 2 percent rejection rate for neuropsychiatric reasons, which was erroneously derived, agrees with the actual World War I rejection rate. The quoted discharge rate of 3 percent is grossly overstated; the discharge rate for neuropsychiatric reasons in World War I was around 1 percent. Consequently, the quoted combined 5 percent is also exaggerated. Furthermore, the quoted combined rate was obviously obtained by directly adding the rejection and discharge rates in this case-an improper statistical procedure. These rates were computed from different population bases and, therefore, are not directly additive. Even by using the quoted rejection and discharge rates, the combined rate would be about 4 percent. The correct combined rate would be about 2.8 percent. See appendix A for a comparative evaluation of World War I and World War II disqualifications and discharges for neuropsychiatric reasons.-A.J.G.
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the best type of soldiers are allowed to enter the Army. In this way, the United States will have an army of high intelligence, great ability, and unsurpassed morale.
Expressing an opposite viewpoint, Kardiner,12 on the basis of his work with patients suffering from neurosis connected with World War I, stated:
Though I have seen many hundreds of the chronic forms of these neuroses and have studied the psychopathologic picture, course, treatment, and previous personality in many cases, I should hesitate to offer any criteria that can be used to predict that a given candidate will have a traumatic neurosis.
And with what must be regarded as prescience, he went on to state:
Closely related to this question is the question whether an existing psychoneurosis of the usual type, hysteria or compulsion neurosis, is a contraindication to military service, and the answer to this is decidedly that it is not, I have seen many severely neurotic persons who were most uncomfortable and maladjusted in their premilitary life who accommodated themselves excellently to the military routine and who lost all their neurotic symptoms-for the time being at any rate.
Although Kardiner advised the rejection of men who were obviously suffering from a severe mental disorder, such as psychosis or psychoneurosis, he had this to say with regard to predisposition:
Therefore, with regard to predisposition to neurosis and fitness for service, I should rule out positively only men with a history of convulsions, tiqueurs, stammerers, and men who have shown persistent disturbances of the autonomic nervous system over a long period. These, however, can be inducted and assigned to noncombatant duties.
In the same vein, Aita,13 writing on the basis of experience gained in examining 9,652 men at the Fort Snelling Induction Station, Minn., noted the accuracy of prognosis, as follows:
However, if examiners are to consider men carefully, they must not become too subtle through obscure reference to varied psychologic hypotheses in their establishment of prognostic data, because psychiatry is not ready for this. For the present Army, one must not attempt more than to deal with established facts and figures. It is not known how subtle or how objective the Selective Service examiners or the in?duction center board may become before accuracy is imperiled.
Similarly, Menninger,14 at a seminar on practical psychiatric diagnosis for psychiatrists of medical advisory boards and Army induction boards, held in Dallas, Tex,, on 16-17 June 1941, pointed out that, in Kansas, of the 17 local draft boards, 7 had general practitioners designated to serve as the 'psychiatrist' on the advisory board, With this in mind, he stated, referring to Medical Circular No. 1 (p. 164), as revised:
It should be pointed out, as is done in the Circular, that it is incorrect to assume that any of the various kinds of behavior or items of personal history outlined in the examination are absolutely or definitely diagnostic of any condition in every case. Positive findings are to be regarded as suggestive, often highly and importantly so,
12Kardiner, A.: The Neuroses of War. War Med. 1: 219-226, March 1941.
13Aita, J. A.: Neurologic and Psychiatric Examination During Military Mobilization; Results and Suggestions Derived From a Study of 9,652 Men. War Med. 1: 769-780, November 1941.
14Menninger, W. C.: Condensed Neuropsychiatric Examination for Use by Selective Service Boards. War Med. 1: 843-853, November 1941.
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of the presence of a morbid condition. Such suggested findings, can, at least, be the basis for calling the man back for more complete examination; pending this, some social investigation might be made.
ORGANIZATION OF PSYCHIATRY DURING MOBILIZATION
As early as August 1940, Dr. Winfred Overholser,15 Superintendent, St. Elizabeths Hospital, Washington, D.C., wrote President Roosevelt, setting forth the imperative need for psychiatric evaluation of the potential serviceman. In October 1940, the Director of Selective Service, Dr. Clarence A. Dykstra, and representatives of some divisions of the War Department, met with Drs. Overholser, Harry A. Steckel, and Harry Stack Sullivan at Selective Service National Headquarters. As a result of this meeting, plans were developed to have a psychiatrist on each of the 660 selective service medical advisory boards, since it was obvious that there were not enough psychiatrists available to have one on each of the 6,403 local boards.
Dr. Harry Stack Sullivan was appointed as psychiatric consultant to Selective Service in early 1941, and an advisory board for psychiatry to the Selective Service System was appointed to aid Dr. Sullivan in developing a program. In June 1941, a psychiatrist from the Army, Capt. Philip S. Wagner, MC, was assigned to National Headquarters, to assume responsibility for the Psychiatric Section of the Medical Division of the Selective Service System, National Headquarters.
Through Dr. Sullivan's influence, a plan for the psychiatric examination of draftees was incorporated in Selective Service System's Medical Circular No. 1, issued on 7 November 1940, containing 'A Minimum Psychiatric Examination of Registrants,' which was designed to aid medical examiners (nonpsychiatrists) of the 6,403 draft boards in the evaluation of draftees.16 Medical Circular No. 1 advised local board examiners to suspect the presence of neuropsychiatric problems in five categories, as follows:
Type I: Mental defect or deficiency.
Type II: Psychopathic personality.
Type III: Major abnormalities of mood.
Type IV: Psychoneurotic disorders (the hysterical; the morbidly anxious; the obsessional).
Type V: Prepsychotic and postpsychotic personalities.
The circular also advised local examining physicians to refer regis?trants, whose mental fitness or unfitness they could not definitely determine, to the appropriate member (psychiatrist) of the medical advisory board.
At this time, it was evident that the proponents of rigid psychiatric screening had prevailed, as witness the following statement of Dr. Dykstra, in his letter of 7 November 1940, to which was appended Medical Circular No. 1:
15Overholser, Winfred: Early Steps in Psychiatric Mobilization. [Unpublished manuscript.]
16Physical Examination of Selective Service Registrants. Special Monograph No. 15. Volume II. Appendices D-E. Washington: U.S. Government Printing Office, 1948, pp. 92-96.
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Military life requires that the soldier shall be able to live comfortably in continued close contact with a variegated group of other men. He cannot depend on any self-evolved protective mechanism that sets him apart from his fellows. Military and naval experience is in favor of excluding from the Armed Forces all persons discovered to have mental or personality handicap of any material degree.
With the beginning of the draft in November 1940, all candidates were examined by physicians in their own communities. These local examiners had the authority to reject those men whom they believed were not quali?fied to meet the standards set forth in mobilization regulations. Registrants found to be fit were then referred to the nearby Army induction station for a second complete examination (including psychiatric evaluation) which determined final acceptance or rejection for service.
Indoctrination of Psychiatrists
In order to orient psychiatrists in their function at the local board level or at the Army induction, station, a program was planned for a series of seminars to be conducted in various parts of the country. This program was developed to a large extent as a result of the initiative and stimulation of Dr. Sullivan. Eventually, a series of 2-day seminars were held in nine large cities in the country for the medical advisory board and Army induc?tion station. psychiatrists.
The first of these seminars, held in Washington, D.C., on 2-3 January 1941, was designed to be a kind of pilot program which could then be utilized for subsequent programs throughout the country. The second was held in Boston, Mass., on 30-31 January 1941; and the third, in. Atlanta, Ga., on 5-6 February 1941. Others which followed were held in New York, N. Y., on 5-6 April; in Chicago, Ill., on 19-20 May; in Dallas, Tex., on 16-17 June; in Los Angeles, Calif., on 19-20 June; in San Francisco, Calif., on 20-21 June; and in Buffalo, N.Y., on 21-22 July.
The attendance of selective service psychiatrists of 45 States and the District of Columbia was authorized. Corps area commanders were encouraged to facilitate the attendance of psychiatrists working with Army induction stations. All members of the American Psychiatric Association, or physicians designated as interested in neurology, neuropsychiatry, or psychiatry by the American Medical Association, were invited. Of the 584 physicians serving as psychiatrists on medical advisory boards, 312 participated in at least one of the seminars. At least 106 of those in attendance indicated that they were serving at least part time on some Army induction board.
The first day of each seminar was organized to include as essential features a presentation of military psychiatry, the experience of the Veterans' Administration in providing medical care and other benefits for those who had served in World War I, and an outline of the practical diagnostic possibilities and procedures which could be used to exclude from induction
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a considerable proportion of those who would probably become psychiatric casualties.
The first day's presentation on military psychiatry was handled by Medical Corps officers, Lt. Cols. William C. Porter, Patrick S. Madigan, or
George E. Hesner. Drs. Martin Cooley, John H. Beard, Harry H. Rubin, William A. Jones, Percival G. Lasche, or Neathe V. Bolen spoke for the
Veterans' Administration. Dr. Harry Stack Sullivan handled the session on practical diagnosis.
On the second day of each seminar, a group of outstanding specialists discussed diagnostic procedures and implications pertaining to registrants' falling within the various groups as outlined in directives from the Office of The Surgeon General and the Selective Service System.17
The Army Medical Corps and Veterans' Administration representatives actively participated and added greatly to the enthusiastic discussion by psychiatrists of the selective service and Army induction boards. Evening sessions were devoted to problems of local board examining physicians. An especially distinguished contribution in this connection was made by Dr. C. Macfie Campbell18 at the Boston seminar. His talk was reprinted and 18,000 copies were distributed throughout the Selective Service System.
By the end of July 1941, the nine seminars were concluded, and the first phase of the psychiatric program for military mobilization was completed.
Concepts Developed
In early 1941, it was fairly well assumed by various psychiatrists that those factors which might identify the potential neuropsychiatric casualty were known. Furthermore, at this time, military plans called for an army of approximately 1 million men to be a well-selected nucleus of personnel for the Military Establishment, which could, after a period of training, be placed in reserve and returned to active duty if the need arose.
In such circumstances, it seemed not unreasonable to err on the side of rejecting a fairly large number of men who might not become neuropsychiatric casualties in order to eliminate the largest percentage of potential problems. At the seminar held in Washington, D.C., on 2-3 January 1941, this viewpoint was stated: 'The effect of mental diseases on a militarized individual is different from that on the same individual in civil life. Military training intensifies the defects of weaklings instead of 'making men out of them'.' The philosophy expressed was that service?aggravated conditions are a loss to the State and to the individual as well as to the service:
17(1) Circular Letter No. 19, Office of The Surgeon General, U.S. Army, 12 Mar. 1941. (2) Medical Circular No. 1, Selective Service System, 7 Nov. 1940 (revised 19 May 1941).
18Campbell, C. M.: Selective Service and Psychiatric Issues. J.A.M.A. 116: 1883-1887, 26 Apr. 1941.
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Since the Army cannot promise any soldier what job he is to have, and since the service is now highly mechanized, great emotional stability is required of conscriptees. Low-grade morons are entirely unsuitable! Peacetime disabilities in the Army with no service history at all amounted to 33,440, of which 20 percent, 6,638, had diseases of nervous system. One-half of those receiving treatment from Federal facilities throughout the country were psychoneurotics * * * * . The great value of a social history of the registrant before examination would require that records of organized welfare groups of the Red Cross and so forth be opened for inspection by local and medical advisory boards.
Psychopaths are those vocationally unfit for service and include the eccentric, the leader in subversive activities, the emotionally unstable, the sexually perverse, those with inadequate personalities that do not adapt readily, and those who are resentful of discipline. All are not assimilable in service. The inability to escape from circumstances over which they have no control causes explosive behavior which disappears as soon as they are restored to their homes. The aggressive type also shows up within this group. He stands monotony and discipline poorly. The passive type and those having mood disorders are not suitable to the teamwork which is necessary in modern training in warfare. The psychiatrists of the medical advisory boards would expect to have referred to them for further examination 5 percent of the number of registrants in each locality not definitely recognizable as belonging to the type of unfit enumerated in Medical Circular No. 1.
This, then, was the general thinking expressed by psychiatrists, by the Selective Service System, and by the military service as it became apparent that war was imminent.
Albeit the aforementioned reasons for psychiatric screening appeared valid, nevertheless one heard them quoted ad nauseam and repeatedly used as a 'cliche' to rationalize the tendency of examiners to reject not only those who were obviously unfit but also those who were thought to possess a predisposition to mental disease. Since the great shortage of manpower was not experienced until later in the war, the philosophy of skimming off the cream-'when in doubt reject'; 'if we're building only a small Army let's make it of the best men available'-appealed to line officer and medical examiner alike. In induction stations, one not infrequently heard the remark when considering whether or not to reject a registrant, 'if there is any doubt, reject him, there'll be another better one along in a few minutes.' Thus, as a result of this concept and procedure, many registrants were screened out, who, later upon reexamination, were inducted and subsequently made excellent service records.19
Disagreement
Some exception to the program planning and to the various categories of individuals who should be excluded from service was taken by a number of psychiatrists and was voiced by one of the authors (R. W. W.) to Col. Leonard G. Rowntree, Chief of the Medical Division, Selective Service System, National Headquarters, 27 January 1941, as follows:
19Eagan, J. R., Jackson, L., and Eanes, R. H.: A Study of Neuropsychiatric Rejectees. J.A.M.A. 145: 466-469, 17 Feb. 1951.
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In view of the large number of Draft Boards and the relative scarcity of psychiatrists, it would seem to me that the screen should perhaps be as fine as suggested in Medical Circular No. 1 for the local draft boards, but most certainly not for the psychiatrists of the Medical Advisory Boards. The men thus selected (at the local board level) as having some deviation should be referred to a psychiatrist of the medical advisory board. The psychiatrist should be allowed to use his own judgment in determining the fitness of a man for service. I am convinced that many men will be unjustly treated if fixed categories, such as included in Medical Circular No. 1 are used to automatically exclude a man for service * * * psychiatric patients might make far better than average soldiers if they would not be more or less automatically excluded because they had received psychiatric treatment * * *. There are persons who could easily pass the examining boards who would undoubtedly make a poor adjustment as a soldier. It boils down to the fact, then, that the examining psychiatrist must use his own judgment in a large degree to determine those who are psychiatrically fit or unfit for service * * *. The history of his school, work, and social adjustment is far more important than is evidence of tension during a medical examination.
The warning expressed in this letter and similar comments from a number of other psychiatrists received relatively little attention, as is so strongly emphasized in the reply written over Colonel Rowntree's signature, dated 3 February 1941:
True, none of us can be sure that very grave demands on American manpower may not be made in the future. There is no such emergency in immediate prospect, however, and even if there were, the major characteristics of total warfare would probably indicate much the same policy as that now in force * * *. It is equally evident that we cannot depend solely on the undirected judgment of any particular psychiatrist to select those who will be inducted. It is perhaps reckless to try to induct people with great ability associated with unusual personality. A consideration of best untilization seems to indicate their finding a place elsewhere in the total defense picture.
PHYSICAL AND MENTAL STANDARDS
Mobilization Period
As the Army first began to build up, the physical standards which were to be applied for selective service registrants were contained in MR (Mobilization Regulations) 1-5, dated 5 December 1932. (See appendix B, pp. 775-777). The standards of physical examination subsequently set forth in Selective Service Regulations (physical examination) were identical with those prescribed in MR 1-5, even to the numbering of the paragraphs and sections. MR 1-5 was to be used during any mobilization for which selective service was planned; also, it was to govern the retention or discharge of members of the National Guard drafted into Federal service and the acceptance or rejection of applicants for voluntary enlistment before the operation of selective service, with certain exceptions. One of the exceptions was that 'no applicant for voluntary enlistment whose mental age is less than ten years will be accepted. Any member of the National Guard whose mental age is found at the time of being drafted into the Federal service to be less than ten years will be discharged.'
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On 31 August 1940, MR 1-5 was superseded by MR 1-9 (appendix B, pp. 777-782). These were the mobilization regulations which governed at the time selective service registrants were first called for examination and induction into the Army of the United States. Changes in standards which occurred with the publication of MR 1-9 were as follows:
Under MR 1-5, men having hysterical paralysis or hysterical stigmata and local muscular spasms 'which do not cause mental or physical defects disqualifying for general military service' were acceptable as general or unlimited service. This qualification for general service was deleted in the August 1940 edition of MR 1-9. Similarly, whereas MR 1-5 allowed the induction for limited service of men with 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,' the edition of MR 1-9 deleted this qualification for limited service. Drug addiction was another condition which under MR 1-5 was acceptable for special or limited service but which was deleted in MR 1-9.
As previously stated, Selective Service Medical Circular No. 1 provided guidelines and standards for local draft board physicians and their advisory psychiatrists relative to psychiatric criteria for selection or rejection. Before the publication of The Surgeon General's Circular Letter No. 19, in March 1941, there had been a considerable hiatus between the standards underlying the Selective Service psychiatric screen and the Army induction screen. Selective Service physicians, following their Medical Circular No. 1, were using an implied standard that was more general than the seemingly rigid and specific criteria, established by section IX of MR 1-9, which guided psychiatrists of the induction stations.
Circular Letter No. 19 brought the expressed and implied standards of the induction stations into substantial agreement with selective service standards; thereupon, the Selective Service System revised its Medical Circular No. 1, on 19 May 1941,20 to remove any possibilities of divergence of views between the two groups of psychiatrists and other physicians by enlarging group IV to include so-called psychosomatic disorders and by adding three other groups; that is, chronic inebriety, syphilis of the central nervous system, and other organic neurological disorders.
Before this report was accomplished, however, a radical remedy had been suggested for the dissatisfaction which was growing in the country at large over the high rate of rejections at induction stations. It was then proposed that there be a joint Army-selective service examination, In some of the great cities, for instance, real bitterness existed over the rejection at the Army induction station of those selectees believed by the local boards to be malingering. Forgetting that the question of malingering was one which had been brought up at seminars repeatedly and had been
20Physical Examination of Selective Service Registrants. Special Monograph No. 15, op. cit., pp. 96-102.
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discussed thoroughly, many men brought forth the accusation that malingering to evade duty by affecting symptoms of a mental disorder were the result of these seminars and the publicity attendant thereupon. These accusations were made despite general acceptance that the first increment of selectees would become the source of many officer and noncommissioned officer leaders for the subsequent expansion of the Army should it become necessary, and therefore, it was imperative to enforce high standards of physical and personal as well as mental fitness. Moreover, it was obvious that, should this country become involved in war, it would become necessary to enlarge the Army rapidly, building upon the nucleus obtained through selection and voluntary enlistment during the early days. For this reason, the philosophy of accepting only the cream and rejecting those who not only were obviously unfit, but also those who might be classified as borderline, continued to be that which governed in the minds of most examiners.
Viewed historically, it is probable that this philosophy was a healthy one21 and did indeed result in providing a nucleus of physically and mentally fit and alert young men upon whom later developed the tremendous responsibilities of rapidly enlarging and training an army for severe combat.
Wartime Period
With the onset of war, acceleration of the draft, and continued dissatisfaction with the dual system of medical processing of registrants, local draft board examination by Selective Service physicians was abandoned in favor of a single routine complete examination at the induction station; not, however, without a good deal of controversy and recrimination and with the resignation of Dr. Sullivan as psychiatric consultant to Selective Service.22 Also, physical standards for induction, including the psychiatric and neurological criteria, were changed and, subsequently, underwent repeated revisions as the war progressed, in response both to the need to eliminate errors found by practical experience and to the demands based upon manpower availability.
In addition, the War Department, from time to time, issued instructions relative to the interpretation or application of the standards then in effect. Such instructions were obviously a reaction to manpower needs, at the par?ticular time; difficulties in the assignment and utilization of limited-service personnel; shortages of psychiatrists; and the rise and fall of the tides of war. These instructions also corrected obvious errors but, at times, would completely reverse instructions issued only several weeks previously. On such occasions, induction examiners, including psychiatrists, were under?
21Unfortunately, a precedent was provided and values for mental health were established which were not susceptible of radical change with the onset of war and the need to develop rapidly large military forces from the available manpower resources.-A. J. G.
22(1) See chapter I, p. 22. (2) Menninger, William C.: Psychiatry in a Troubled World: Yesterday's War and Today's Challenge. New York: The Macmillan Co., 1948, pp. 269-270.
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standably confused and exasperated in their efforts to develop and maintain a consistent professional viewpoint toward selection for military service.
First revision
The first revision of MR 1-9 was issued on 15 March 1942. In general, the new edition tended to liberalize previous standards for induction, no doubt to facilitate the raising of a large wartime army. The revision included a separate section (XIX) on neurological disorders, in which methods of examination were described and a class of individuals possessing a neurological disorder was made acceptable for special or limited duty; namely, '* * * those 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.' Diagnostic criteria for disqualifying neurological defects were described briefly.
The section on mental disorders was revised and entitled 'Psychoses, Psychoneuroses, Personality Disorders' (section XX). A routine procedure for examination was described, and the minimum psychiatric examination was outlined. A significant change in acceptability for class 1-A, or general military service, was that men of 'marginal intelligence, if compensated for by better than average stability' were, for the first time, made acceptable for general military service. Likewise, whereas the first edition of MR 1-9 accepted for only limited service those who had stuttering and stammering to any material extent, such disorders were now placed in the acceptable category for general military service, as follows: '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.' It made acceptable for limited service those possessing 'moderate degrees of compulsiveness or obsessiveness.'
The paragraph entitled 'Diagnostic Criteria' was enlarged considerably, and more adequate descriptions were included. The psychopathic personalities were described and defined. The old subheading 'Manic-Depressive Insanity' was revised and entitled 'Major Abnormalities of Mood.' Psychoneurotic disorders were described for the first time, and criteria for acceptance and rejection were given. It is interesting to note that the first edition and all successive editions of MR 1-9 continued to reject unconditionally drug addicts.
Changing instructions
On 1 August 1942, The Adjutant General, in a radiogram to all service commands, stated that, because of the extreme difficulty which selective service was experiencing in filling its quotas, it directs 'active medical
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supervision of Army examining boards at recruiting and induction stations to the end that no individual physically qualified for general military service is rejected for physical reasons.'
On 11 August, another radiogram was dispatched to all commanding generals of service commands. In this radiogram, instructions were given that the standards for acceptance for induction as prescribed in MR 1-9 would be considered by the examining personnel as a guide to their discretion and would not be construed strictly or arbitrarily. The radiogram further stated:
The possibility that some individual soldiers may have to be discharged for disability or that others may eventually make claims on account of disability is of minor importance compared to necessity of immediately inducting the maximum number of qualified registrants into our wartime Army.
MR 1-9 was again revised without any particular changes, and the new edition was issued on 15 October 1942. Nevertheless, on 22 October 1942, only 1 week later, another radiogram rescinded the instructions on standards for acceptance as set forth in the radiogram of 11 August and substituted the following:
The objective of MR 1-9, standards of physical examination during mobilization, is not only to procure men who are physically fit for the rigors of general military service or limited service, but also to avoid burdening medical facilities with unqualified personnel. Examining personnel will consider these standards as a guide, to be followed with discretion without arbitrary adherence to technicalities. The examination will be carried out with the utmost care in order that no individuals who are obviously unfit for service will be accepted, only to be discharged within a short time on certification of disability.
This succession of radiograms, uncorrelated with the changes of MR 1-9, with conflicting instructions and ambivalence of intention and meaning could only be due to a lack of coordination between line officers in the War Department and those in the Surgeon General's Office. For instance, it is likely that the radiogram of 11 August was dispatched without prior clearance with the Surgeon General's Office and the radiogram of 22 October, 2 months later, was dispatched because The Surgeon General, having learned of the 11 August instructions, succeeded in having them rescinded. The lesson here is plain-staff action and directives from the War Department must be correlated with all interested agencies.
Later revisions
On 22 January 1943, Changes No. 1 of MR 1-9 were issued. This revision reflected a conservative trend consistent with the instructions of 22 October 1942 and, apparently, was a reaction to the increasing number of neuropsychiatric problems that were appearing at the various camps. Changes No. 1 rescinded the acceptance of individuals for limited service with local paralyses due to old poliomyelitis, or nonprogressive dis?
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ease, which had been established in the October 1942 revision of MR 1-9, stating: 'There are no neurological disorders which warrant initial selection for limited service.' Likewise rescinded was paragraph 91a, which formerly made acceptable 'moderate degrees of compulsiveness or obsessiveness.' In the same vein, before Changes No. 1, bed wetting was not considered to be a psychiatric problem and was not a cause for unconditional rejection. According to the previous edition of MR 1-9, 'men claiming to be bed wetters may be placed in class 1-A unless enuresis is substantiated by physician's affidavit, or other acceptable documentary evidence.' Changes No. 1, however, made a more final statement: 'Bona fide enuresis substantiated by physician's affidavit or other acceptable documentary evi?dence is cause for unconditional rejection.'
Another revision of MR 1-9 issued on 19 April 1944 continued the conservative viewpoint. There were no material changes in standards for psychiatric examination as described in section XXI. Minor changes, however, were made in terminology. For example, instead of designating major abnormalities of mood and prepsychotic, postpsychotic, and other schizophrenic disorders as separate entities, the new revision included these under a single head; namely, psychosis. Instead of 'psychoneurotic disorder,' the new edition utilized 'psychoneurosis.'
This revision considered certain behavior disorders to be nonacceptable, as follows: 'Primary behavior disorders of sufficient degree to indicate predisposition to more serious disorders.' The subparagraphs of 'Diagnostic Criteria' were further revised and enlarged, and a description of primary behavior disorders with a breakdown of the various types, such as simple adult maladjustment, neurotic traits, enuresis, emotional immaturity, and stammering and stuttering, were included for the first time.
Also, for the first time, MR 1-9 contained a section on intelligence (XXII). Under 'General Service,' the following statement was made:
Individuals who are graduates of standard English-speaking high schools are acceptable. Individuals who are not graduates of standard English-speaking high schools will be given prescribed objective tests of intelligence. A man achieving the critical score, or a higher score on one or more of the authorized tests is acceptable for induction.
Under the heading 'Limited Service,' it was stated: 'There are no intelligence criteria to warrant initial selection for limited service.' Under 'Nonacceptable' was stated:
Failure of a nongraduate of a standard English-speaking high school to achieve a score in one or more of the prescribed tests equal to or higher than the critical score will be accepted as evidence of low intelligence. Such persons are nonacceptable.
Some liberalization was made in neurological disorders. Under section XX, it was again provided that men with 'local paralyses such as due to poliomyelitis or nonprogressive disease of peripheral nerves * * *' were again made acceptable for limited service.
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Experience Induces Liberal Trends
With over 2 years of wartime experience and with the accumulation of reports and observations from training centers, oversea garrisons, and combat divisions, a gradual but surprising optimistic change in philosophy occurred relative to the ability of the ordinary individual to withstand stress and strain. It has been frequently observed that times of stress are apt to produce a leveling effect as far as man's thinking is concerned. The conviction that it was a man's job to fight until he could fight no longer grew in the minds of both line officers and medical officers. Also, at this time, there was an acute shortage of manpower, and it became increasingly more apparent that a larger proportion of draftees than hithertof ore would have to be inducted. It also became known that the exhibition of nail biting, tremor, and 'nervousness' did not necessarily indicate that a person with such traits or signs could not fight effectively or that he could not serve effectively in some noncombat capacity, either in the Zone of Interior or in a communications zone. Therefore, as evidence began to accumulate that many individuals with minor symptoms could be of service in the Armed Forces, this newly acquired knowledge was conveyed to induction station examiners and others concerned with screening procedures.
War Department Technical Bulletin (TB MED) 33
This information, therefore, was published in TB MED 33, 'Induction Station Neuropsychiatric Examination,' and issued on 21 April 1944.23 In this bulletin, it was pointed out that, from accumulated evidence, many individuals with minor personality defects and neurotic trends could be of service, but that it was believed that, on the basis of previous directives sent out from the War Department, many such men were being rejected at induction stations on neuropsychiatric grounds. Attention was called to the acute need for manpower with the subsequent necessity of admitting all individuals into the Armed Forces who had a reasonable chance of ad?justing to the service. It emphasized that the neuropsychiatric study 'should be made on a longitudinal basis and not on a cross section' because from observations on inspection tours and information garnered from various sources, the Surgeon General's Office was aware that many rejections were being made after a short examination, which consisted in many instances of leading and suggestive questions, such as "Do you worry?"
23Is noteworthy that TB MED 33, which laid down liberal guidance for screening, was issued only 2 days after the publication of a revision of MR 1-9 (p. 168) which continued the previous conservative trend. Clearly, information for technical medical bulletins originated in the Office of The Surgeon General, and no doubt, TB MED 33 reflected the work of Menninger and his associates in the Neuropsychiatry Consultants Division of the Surgeon General's Office. Apparently, the Neuropsychiatry Consultants Division took this technical means of bringing about realistic guidance to induction station examiners after having failed to influence the staff agency responsible for the 19 April revision of MR 1-9. It should be further noted that TB MED 33 superseded previous guidance by stating: 'Previous directives in conflict herewith are rescinded.'-A. J. G.
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'Are you nervous?' or 'Do you have headaches or stomach trouble?' It pointed out that such an examination was inadequate. Attention was focused on the fact that rejection for neuropsychiatric reasons 'should be made only in those cases in which the history and examination clearly indicate the existence in the past and/or present of a personality disorder of partially or completely incapacitating degree.' Further, it pointed out that an individual's normal concern over the prospect of induction, as manifested by moderately moist palms or tenseness, should not be regarded as evidence of such an incapacitating disorder.
The bulletin further stated that information and time were often inadequate to establish an accurate diagnosis and that, in many instances, the symptomatology or behavior, or both, although not sufficiently well crystallized to warrant the diagnosis of a clinical disease entity, might make disqualification of the registrant necessary. Thus, labeling a registrant with a diagnostic term in so brief an examination without adequate data available was unscientific and unfair to the individual. It directed, therefore, that each clinical diagnosis as outlined in MR 1-9 would be based on adequate historical and examinational evidence. Further, that in those instances 'where insufficient data are available to arrive at a diagnosis and where it is the neuropsychiatrist's considered opinion that the registrant is not acceptable, he will indicate that the individual is disqualified as 'not suited for military service,'' amplified by some qualification, such as 'due to severe antisocial tendencies' or 'due to severe neurotic symptoms.' Thus, although the primary purpose of the neuropsychiatric examination would be served, that is, rejecting those not fitted, the registrant would not receive a stigmatizing label which might prove embarrassing to him upon. his return to his community or his job.
Results of TB MED 33
That TB MED 33 had, to a certain extent, the desired effect in reducing the rejection rate and in making available for induction more men who were capable of becoming soldiers was evidenced by both statistics and comments by interested official observers. An example of this was the survey of registrants, previously rejected for psychiatric reasons, conducted at the Armed Forces Induction Station, Fort McPherson, Ga., on 12 June 1944. The investigators of the survey commented that it was apparent in the instructions in TB MED 33 that some relaxation in the rather severe standards heretofore followed was indicated. They also stated:
Upon receipt of news of the contents of this bulletin, the chief medical examiner and the psychiatrists at the induction station, Fort McPherson, felt that many men previously disqualified for psychiatric reasons might be salvaged for military service. * * * volunteered to reexamine a group of 50 such registrants, but only 25 were forwarded for reexamination. Of this number, over 50 percent were found acceptable. * * * again volunteered to reexamine a larger group.
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In the larger group, consisting of 732 Georgia registrants previously disqualified for psychiatric reasons, 413 were found acceptable and 319 were again rejected. This was an example that, with a change in philosophy and with adequate direction to the field, a larger number of men previously thought to be disqualified could have been obtained for service.
After this survey, a study was made at the Detroit Armed Forces Induction Station. A total of 248 men who previously would have been rejected as borderline cases were accepted for service. The status of these men was determined 12 months after induction. At that time, 209 of the 248 were still on duty; 32 had been discharged; and 5 had died in the service. It is interesting to note that two were discharged to accept commissions as officers.
Later changes
On 8 September 1944, Changes No. 2 of MR 1-9 were issued. These changes again were of little moment and only provided for a neurological examination to detect late complications of syphilis and a spinal fluid examination for such cases. Further, that each individual requiring such a spinal fluid examination would be hospitalized for that purpose as au?thorized in another section of the regulations.
Because verbal instructions issued in 1944 (p. 222) were misinterpreted by induction station examiners and authorities to mean that emphasis was now being placed on the rejection of inductees, clarification was considered necessary. Accordingly, on 18 December 1944, a radiogram was dispatched to the commanding general of each service command and to the oversea departments. This radiogram stated:
It is the intent of the War Department that emphasis be placed on the acceptance of men who meet the requirements of MR 1-9 for general service. * * * The medical examination personnel of Armed Forces Induction Stations will be cautioned to follow carefully the provisions of MR 1-9 for general military service and to consider acceptable any man who meets those physical requirements. * * * Any enlisted men who, after being profiled at the reception center is considered below minimal physical induction standards for limited military service as prescribed in MR 1-9, will not be discharged, but his physical profile will be confirmed by a board of three medical officers appointed by the post commander. Those found below profile C will be assigned to the nearest ASF [Army Service Forces] training center for which best qualified, unless designated by current instructions for training at a special training unit, or unless the medical board finds that the defect is progressive or likely to be aggravated by military service. In the latter case the individual will be hospitalized for consideration for discharge under the provisions of AR 615-361.
Final revision
After the cessation of hostilities in Europe, and with the end of the war clearly in sight, the last wartime revision, that is, Changes No. 3 of MR 1-9, was issued on 4 June 1945. This revision finally incorporated not
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only the instructions laid down in TB MED 33 but also other hard-won lessons learned by World War II psychiatrists and provided comprehensive and practical guidance for psychiatric screening. The change consisted almost exclusively of a revision of the entire section XXI (Psychoses, psychoneuroses, personality disorders). Herein was stated that the primary object of the psychiatric examination was to procure men who were without psychiatric disorders of such a degree of severity as to make impossible their rendering effective military service. Again, following the principles of TB MED 33, the ideation expressed was that of acceptance, rather than that of rejection, with emphasis upon accepting as many men as possible who would make effective soldiers. Also stressed again was that acceptance or rejection should be based not only upon the findings present at the time of examination but also upon the careful consideration of the longitudinal history of the registrant and the absence of previous maladjustment, as follows:
Attention will be given not only to unfavorable or negative data in the history, but also to the favorable or positive data, since the history of good adjustment in the past may be reasonably accepted as favoring a good adjustment in the military service as well.
For the first time, the category of chronic psychoneurosis was made acceptable for limited service. Likewise, acceptable for limited service were moderate transient psychoneurotic reactions. Also acceptable for the first time were mental deficiencies, mild in degree, as manifested by completion of the fourth grade in school, unless prevented by external circumstances, if there was evidence of ability and stability in the home, in the community, and at work.
Guidance in the area of primary behavior disorders was clarified as follows: In the last previous edition of MR 1-9 (19 April 1944), it was stated that such disorders may or may not be cause for rejection, depending upon their severity, followed by: 'They are cause for rejection either because they indicate predisposition to more serious mental disorder, or because the symptom itself interferes with military efficiency.' Changes No. 3 read as follows: 'They are cause for rejection if it is considered that the symptom itself will interfere with the performance of effective military service.' Thus, attention was focused sharply on the problem at hand; namely, that of obtaining effective soldiers and not upon rejection.
Following in this enlightened vein, as in TB MED 33, Changes No. 3 provided that, because of time limitations or when information was often inadequate to establish accurate diagnoses, to label a registrant with a diagnostic term in so brief an examination, without adequate data available, was unscientific, and unfair to the individual. Thus, psychiatrists were enjoined to-
* * * carefully avoid unscientific methods which give inadequate or inaccurate data. Thus, a neuropsychiatric examination consisting of a few leading and suggestive questions, such as 'Do you worry?' 'Are you nervous?' or 'Do you have headaches or
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stomach trouble?' is inadequate, and positive answers to such questions are not in themselves justifiable cause for rejection. Isolated signs, such as nail biting, slight tremor, or vasomotor symptoms, are not disqualifying.
Further, as also contained in TB MED 33, in those instances where insufficient data were available and where the neuropsychiatrist deemed the registrant not acceptable, the examiner would indicate that the individual was disqualified as 'not suited for military service.' The clause 'not suited for military service' would then be amplified by one of several qualifications (p. 170).
Shortage of Psychiatrists
By the end of 1942, the shortage of psychiatrists was beginning to become a matter of urgency. Psychiatrists were especially difficult to secure for outlying induction stations not near enough to a center of population to draw upon civilian specialists in psychiatry. In order to make the most economical use of the time of the psychiatrists attached to these induction boards, a radiogram from The Adjutant General was dispatched on 7 December 1942 to the commanding general of each service command, of the Hawaiian, Panama, and Puerto Rican Departments, and of the Alaska Defense Command. This radiogram instructed these officers that, where sufficient psychiatrists to examine all inductees were not available, the lack of psychiatric examiners would be overcome by utilizing medical examiners to sift out suspected mental cases for detailed study by available psychiatrists, instead of the latter attempting abbreviated examinations of all inductees. It further directed 'additional and continuous effort will be made to obtain the required number of psychiatrists at each induction station.'
Navy Participation
When the Navy could no longer obtain sufficient recruits by voluntary enlistment, it was determined to conduct joint Army and Navy inductions. On 9 January 1943, by airmail, a notice of such intent was sent to the commanding generals of all service commands, of the Puerto Rican and Hawaiian Departments, and of the Alaska Defense Command, stating that such plans were underway and that operation would begin on 1 February 1943.
On 22 January 1943, detailed instructions were mailed to the commanding generals of all the service commands on the subject of joint induction procedure of the Army, Navy, Marine Corps, and Coast Guard. The joint operation did not materially affect psychiatric examiners or standards. However, the psychiatric personnel problem of the induction stations was aided materially by this joint operation inasmuch as the Navy furnished 20 percent of the personnel of these stations, supplying 48 psychiatrists for duty in induction centers about 1 February 1943.
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Because the Navy had always maintained a more rigid and more exacting standard for enlistment than had the Army for either enlistment or induction, Navy psychiatric examiners were prone to reject many more registrants than were Army psychiatrists, as a general rule. It was necessary to visit various induction stations and secure the cooperation of all the psychiatrists in trying to establish uniform criteria. In a few instances, it was necessary to request that certain examiners of both branches of service be transferred to other assignments, because of their unduly high rejection rates.
Correction of Neuropsychiatric Statistical Reporting
In evaluating the statistical data relating to the neuropsychiatric rejections, it must be realized that certain preferential procedures obtained with respect to reporting, on the monthly report, primary disqualifying causes. When more than one medical disqualifying cause was present, one of which was a neuropsychiatric cause, the procedure called for reporting the neuropsychiatric disorder as the primary disqualifying cause in preferance to the other medical disqualifying cause(s). Thus, upon compilation of statistics, the psychiatric disorder was found to be listed as the primary cause for rejection, and accordingly, the psychiatrist appeared to be responsible for the greatest number of rejections even though many were actually joint rejections; that is, rejections also for some other defects. Often, these other irremedial defects were found simultaneously but were given a number two spot on the rejection statement.
In order to bring statistics into a more equitable relationship, on 4 November 1943, a letter was dispatched to the commanding generals of all service commands, as well as to departments overseas, on the subject of listing of disqualifying defects of rejected registrants. In short, this directive instructed that all defects found would be reported fully and accurately on the report of physical examination. Furthermore, that 'defects would be listed in the summary of the physical examination in the order of their importance.' It was specified that the 'irremediable, disqualifying permanent defects should be listed as #1 and the others in order of their importance.' It was specifically directed that the principal defect should be that which was most permanent and irremediable. It is believed that this action resulted in a fair statistical report insofar as it did something to equate psychiatric rejections with other types of rejections.
Procedure for Suspect Cases
Frequently, registrants, reporting for induction and later for preinduction examinations, would state that they had some disorder which was disqualifying but for which there were no subjective symptoms or discernible signs. For instance, a man would state that he was an 'epileptic'
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or an 'enuretic.' Frequently, such men were rejected upon their statements, and in many instances, it was later determined by the local board of the Selective Service System that the registrant had malingered and had misrepresented facts or through ignorance had given a diagnosis which was not substantiated by any reputable physician,
On 27 November 1944, a letter from The Adjutant General's Office, on preinduction physical examination and induction of registrants, was sent to the commanding generals of all the service commands and to oversea departments. This letter provided that no registrant would be rejected upon his own unverified statement of a disqualifying disorder or defect, but that he would be rejected only if documentary and substantiating evidence were provided at the time of the examination. Further, that registrants, previously accepted at the time of preinduction examination, who upon presenting themselves for induction presented documentary evidence of a disqualifying disorder or defect, would be rejected only if the disorder was substantiated by objective signs or when such documentary evidence had been forwarded with the records by the Selective Service local board, or after the local board had been given an opportunity to verify or refute such evidence. It also stated that, if such evidence was provided and it was not substantiated by objective signs, the man would be held over for a period not to exceed 3 days in order that such evidence might be verified or refuted through the local board by telephone or telegram. Then, if at the end of a 3-day period, verification had not been received through the local board, the registrant would be allocated to the Army or Navy and inducted.
PHYSICAL PROFILE SERIAL SYSTEM
As the war progressed, it became apparent that it would be extremely helpful in the utilization of available manpower to develop a method of physically classifying individuals according to their functional capacities. Such a method, the 'Physical Profile Serial,' issued on 22 May 1944, was devised and published as a supplement to MR 1-9. The Physical Profile Serial was patterned on the PULHEMS System which had been developed in the Canadian Army and which represented functional capacity, as follows:
P: General bodily functions, including the various major physical systems of the body, such as cardiovascular, respiratory, and genitourinary.
U: Upper extremities.
L: Lower extremities.
H:Hearing.
E: Vision.
M: Intellectual capacity.
S: Emotional stability.
In the American version, M, or the intellectual factor, of the serial
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was deleted, leaving the letter S to represent all neuropsychiatric factors, including emotional stability, intelligence, personality, and mental illness or defect, if present. In concept, PULHES was based primarily upon a numeral scoring of the functions of the various organs and bodily systems. Under all categories of PULHES, with the exception of S, a numeral scoring from 1 to 4 was utilized, the numeral 1 representing normal function and the numeral 4 representing below minimum standards for induction. For the psychiatric factor, 5, numeral 2 was omitted. To obtain ease of application, the first two numeral ratings were equated with a high level of physical and mental fitness and thus represented the general military service category. Numeral 3 identified individuals with defects which prevented the individual from being classified for general military service, but which considered the person acceptable for limited service. Numeral 4 represented incapacities that were below minimum physical or mental standards for induction.
The PULHES supplement of MR 1-9, issued on 22 May 1944, stated that the initial profile would be accomplished by medical officers at the reception center from the physical inspection which was required for all new personnel reporting to the training camp. The information concerning the upper and lower extremities and the visual and auditory acuity could readily be obtained and transcribed from the DSS Form 221 (Report on Physical Examination and Induction), which form accompanied the inductee to the reception center. It was not intended that the special examination would be repeated at the reception center level, other than in the exceptional cases. It was to be understood that if a registrant successfully passed the induction station examination he was neuropsychiatrically acceptable as class 1. As a check upon the induction examination and the physical inspection at the reception center, it was provided that 'at or near the completion of a basic training, each enlisted man will be given a physical inspection by one or more medical officers and his profile verified, or revised upward or downward as the findings were.'
The supplement further provided that (1) a profile would be accomplished on all enlisted men not previously profiled, who were returned to duty from hospitals; (2) a profile would be accomplished on all enlisted men not previously profiled, who were assigned to units or installations by personnel reassignment centers and redistribution stations; and (3) if it was believed that an individual's profile should be revised either upward or downward at some later date, the unit commander was charged with the responsibility of having the soldier examined by a profile classification board of three officers, consisting of a line officer, a medical officer, and a classification officer.
In mental cases, it was stipulated that a psychiatrist would replace the classification officer. If the profile classification board found that a change in the profile was warranted, such a change could be made by the board without the necessity of hospitalization. After a profile had been verified
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or revised, it was not subject to review until a period of 3 months, unless the individual concerned suffered some illness or injury resulting in a marked deterioration, which would indicate that a review was necessary.
On 30 June 1945, the Physical Profile Serial was revised in another supplement to MR 1-9. Whereas, formerly numeral 1 under S (neuropsychiatric) designated personnel who were 'emotionally stable and those with transient mild psychoneurotic manifestations incident to imminent departure for oversea assignment,' in the revision, numeral 1 simply included individuals who had no psychiatric disorder. The revision also added a numeral rating of 2 under S, which included: 'Mild transient psychoneurotic reaction. Mild psychopathic personality. Borderline mental deficiency.' Numeral rating 3 under S was enlarged by adding 'Mental deficiency, mild in degree.' Numeral 4 was changed from 'Below minimum standards for induction. Disqualifying except for those who had performed adequately in current assignment,' to 'Psychosis (or authenticated history of). Moderate or severe chronic psychoneuroses. Severe transient psychoneuroses (situation). Marked degrees of psychopathic personalities. Marked mental deficiency.'
Under the heading 'Factors to be considered,' the revision required modifying statements relative to-
Type, severity, and duration of the psychiatric symptoms or disorder existing at the time the profile is determined. Amount of external and precipitating stress. Predisposition as determined by the basic personality makeup, intelligence, performance, and history of past psychiatric disorders. Impairment of functional capacity.
MEDICAL SURVEY PROGRAM
Establishment
As the war progressed and the need for manpower grew more imperative, it became more apparent to all concerned that a method of selection which depended solely upon a brief examination at the induction station that obtained only a cross sectional view of a registrant's personality was an ineffective screening procedure. To facilitate more efficient selection, a longitudinal section or history of the individual's past experiences was needed. The only national organization that was in a position to undertake the task of providing the necessary historical data was the Selective Service System. Thus, after considerable groundwork and research, the Medical Survey Program came into being. The organization and operation of this program was outlined in Medical Circular No. 4, of the Selective Service System, issued on 18 October 1943. As was stated in the introduction of that circular:
The Selective Service System has provided this Medical Survey Program to furnish the Armed Forces induction stations with adequate medical, social, and educational histories on each registrant. The Selective Service System and the Armed Forces want
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to make certain that the greatest possible care is taken, (1) to accept those registrants whose previous medical and social history indicate their ability to adjust themselves under situations of stress, including those who may be termed 'borderline' cases; and (2) to reject those registrants whose condition is such as positively indicates physical or mental breakdown, or failure to adjust themselves to the responsibilities of military service after being inducted.
The circular further stated:
Information regarding a registrant's medical and social history as revealed in health, education, employment, and social records is important in properly determining whether a registrant should be accepted or rejected.
Under section 623.33 (d), Selective Service Regulations24 local boards were charged with the responsibility of assembling pertinent information concerning the medical and social history of registrants. In order to provide the necessary personnel to carry out the gathering of such information, an amendment was made on 4 October 1943, to part 603, of the Selective Service Regulations (section 603.85, Appointment and Duties). These regulations provided for a field agent in each local board and, further, provided: 'States may request permission to continue using an established medical survey program.'
Details of the Medical Survey Program, as described in Medical Circular No. 4, dealt with procedures for obtaining information on the educational background and the medical and social history of the registrants; also, the forms to be used therefor. For the educational history, the form to be used, DSS 214 (Special School Report), contained space for comments by the registrant's past teachers as to his conduct in school, his adjustment or maladjustment in the school community, and other pertinent facts regarding his school career.
Deficiencies
Of the various forms, DSS Form 212 (Medical and Social History) was the most valuable. The completion of this form depended upon the activity of the medical field agent concerned. Although many field agents, especially in the Eastern States, were well qualified and turned in a creditable job, the vast majority were not prepared to accomplish this mission effectively either from the standpoint of training or from a standpoint of their own educational background. Clearly, trained social workers were needed to perform this task, but such personnel were extremely limited in number, and most were already occupied in either governmental or private enterprise. This scarcity of trained social workers constituted the greatest single handicap to the program.
As a direct result of this deficiency, it became apparent that a ma?
24The procedures followed by Selective Service were detailed in Selective Service Regulations under the 1940 act. These were issued in two editions. The first was by Executive order of the President and covered the period of 23 September 1940 to 1 February 1942. The second edition, issued in three printings, was for 1 February 1942 to 31 March 1947.-A. L. A.
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jority of forms received at induction stations did not contain much useful information. There seemed to be a marked tendency on the part of schoolteachers to indicate their own appraisal of the individual and to make recommendations. For instance, it was not uncommon to receive a school form with a notation, 'I don't think John would make a good soldier.' Because even under the best conditions it was rarely possible for a psychiatrist to see a registrant at the induction station for a time longer than 4 or 5 minutes, except for questionable cases, the examining psychiatrists came to believe that it was not worthwhile, from a time standpoint, to open the sealed envelopes and sort out the various forms, only to discover, after reading them, that the information sought for was not to be found. Not only were many blank forms received, obviously without any information whatsoever, but examiners objected to the type of data that were forwarded. In this regard, examiners repeatedly stated that factual material was wanted, not opinions of untrained persons who gather the information. This lack of capable field agents was scarcely amendable to correction as time, funds, and facilities were not available for their training.
Efforts Toward Improvement
As time went on, the Medical Survey Program did improve somewhat in quality and quantity of forms received. A stimulus in this respect was the publication of TB MED 33 (p. 169) which directed attention of all psychiatric induction examiners to the Medical Survey Program. The bulletin pointed out that one or more trained psychiatric social workers could be of much assistance to the neuropsychiatric examiner in obtaining and organizing such historical data. However, because of the various factors already outlined, there continued to be much frustration and difficulty connected with the utilization of the medical survey forms at the induction stations.
On 22 September 1944, a conference was held at the National Headquarters, Selective Service System, on the subject of the Medical Survey Program. Officers and representatives from the Selective Service System, the Office of The Surgeon General (Army), the Bureau of Medicine and Surgery (Navy), the National Committee for Mental Hygiene, the Social Security Administration, and the American Association of Psychiatric Social Workers met and discussed the program.
The representative from the Surgeon General's Office reported on the results of a survey which had been initiated at the request of The Surgeon General. On 11 March 1944, a letter had been forwarded from the Surgeon General's Office to all service commands, requesting information relative to the effectiveness of the individual medical and social histories as obtained through the Medical Survey Program. Most of the replies received were markedly critical of the value of the reports. (See
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also pp. 181-183). It was pointed out that the crux of the problem lay in the lack of trained medical field agents. Also, that the examining psychiatrists were almost unanimous in stating that they desired positive statements in the histories. The outstanding need from their standpoint was for answers to such questions as: 'Did or did not the registrant ever have epilepsy, enuresis, somnambulism, history of arrest, previous nervous breakdown or other definite disease entity?' It was also pointed out that the forms as they were constructed stressed only pathology. It was suggested that it would be desirable, in cases of individuals who were adjusted and valuable citizens in the community, to make some positive statement to that effect on the DSS Form 212.
Inasmuch as one of the chief criticisms aimed at the program by induction station psychiatrists was that they did not have sufficient time to thumb through the many forms, a suggestion was made that the solution to this problem would be to install a trained psychiatric social worker in each induction station to review the form and summarize the information on a face sheet, which would then be forwarded to the psychiatrist in the examining line. This idea was unanimously approved, and it was agreed that steps would be taken to put this plan into action. A representative of the Director of the Budget stated that the money could be provided. Representatives of the Federal Security Agency and the American Association of Psychiatric Social Workers stated that perhaps private agencies could spare, on a part-time basis, some trained workers for this important job.
On 23 September, a committee, consisting of Dr. Winfred Overholser, Dr. Raymond W. Waggoner, Col. Louis H. Renfrow, and a representative from the Surgeon General's Office, met to take up the question of revision of forms. Certain recommendations as to alterations, deletions, and additions to the forms were made.
The Surgeon General's Office remained firmly convinced of the value of such a longitudinal history and believed that even with its deficiencies the Medical Survey Program was superior to no program at all. Consequently, on 14 March 1945, a letter on the utilization of medical survey forms, sent to each service command and oversea department, stressed the value and objectives of the Medical Survey Program. Cooperation was directed, and it was provided that, if available, a competent male psychiatric social worker would be stationed in each induction station for the purpose of opening, evaluating, and passing on to the proper examiner at the proper time the various forms dealing with the registrants.
Further Modifications
In order to further facilitate the program, the Army and the Selective Service System jointly agreed that, at the end of each day of induction processing, the forms would be stamped either 'pertinent' or 'not perti?
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nent.' The forms would then be forwarded to the State headquarters of the Selective Service System, from which State the registrant had originated. The Selective Service System, on its part, agreed to have a trained social worker on duty in each of its State headquarters, whose duty it would be to select the forms stamped 'not pertinent,' determine which medical field agent had prepared the form, and then, in order to improve the quality of work in the future, visit and help instruct that agent in his or her duties.
This practice of stamping 'pertinent' or 'not pertinent' was continued until the spring of 1946, after the war had ended. On 25 March 1946, a letter to each service command and oversea department, also on the utilization of medical survey forms, ordered the discontinuance of the stamping of 'not pertinent' and 'pertinent,' as the case might be, and the substitution therefore of stamping 'acceptable' or 'rejectable.'
Evaluation
In an attempt to evaluate the helpfulness and efficiency of the Medical Survey Program, the Surgeon General's Office, in the spring of 1945, requested the various service commands to render a report on the program. Replies varied considerably in the estimate of the degree of helpfulness of the program. For instance, the First Service Command reported that forms were submitted on only 50 percent of registrants and that, of the forms submitted, only 20 percent contained positive information. However, they evaluated it as follows: 'Reports considered definite aids in formulating decisions in all stations.'
The Second Service Command, exclusive of New York City, reported that forms were submitted on 50 percent of the registrants. However, they stated: 'Social and medical information generally valuable, but frequently received after examination.'
The induction stations in the Fourth Service Command gave varying reports on the number of forms submitted and indicated that positive information was contained in the forms in 1 to 75 percent. They stated that sometimes 100 percent were negative or blank and of no value. Camp Shelby Induction Station, Miss., reported that 10 percent were valuable. Fort Jackson Induction Station, S.C., reported 'value of survey forms extremely small.' Fort Bragg Induction Station, N.C., reported 'valuable information rarely obtained.' Fort McClellan Induction Station, Ala., reported 'very small.' For example, of 225 forms submitted, only 70 contained positive information, and of these, only 6 contained valuable information. Fort Benning Induction Station, Ga., reported 'helpful on rare occasions.' Fort Oglethorpe Induction Station, Ga., reported 'occasionally helpful in rejecting men,' Camp Blanding Induction Station, Fla., reported 'bulk of forms are valueless.'
In the Fifth Service Command, it was reported that from 20 to 25
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percent of all registrants had forms submitted and that of these 51/8 percent contained positive information. However, they also reported that from 95 down to 92 percent were negative or blank. The opinion in the Fifth Service Command varied. For instance, the Cleveland, Ohio, Induction Station's general impression was 'if forms were utilized to their fullest extent they would be of considerable help to the psychiatrist.' The Fort Hayes Induction Station, Columbus, Ohio, stated: 'The general utilization of all examiners indicates forms are not worthwhile.' The Huntington, Ind., Induction Station reported 'only a few forms have significant information.'
In the Seventh Service Command, only 15 percent of the registrants had forms submitted. The Minnesota-St. Paul area, however, received forms on 50 percent of the registrants. The Seventh Service Command surgeon estimated that 15 percent of the forms contained positive information.
In the Ninth Service Command, the figures and opinions reported varied widely. For instance, Seattle, Wash., claimed that forms were received on only 2 percent of registrants, while Portland, Ore., reported that forms were received on 22 percent of the registrants. However, the percent of positive information contained was a varying figure, the lowest being 2 percent, the highest 8 percent. The estimate at Portland was 'actual use is disappointing.' The San Francisco, Calif., Induction Station reported that they received forms on 14.4 percent of their registrants, but that only four-tenths of the forms contained positive information. It was estimated, by the San Francisco station, that the forms were of practically no value. Phoenix, Ariz., Induction Station received forms on 14 percent of their registrants, but only 5 percent of the forms contained positive information and 95 percent were received blank or negative. The Phoenix station stated that the information was of no value. Butte, Mont., however, stated that they received forms on 60 percent of their registrants and that 75 percent of the forms received contained positive information and that only 25 percent were received blank or negative. They claimed, however, that only 2 to 3 percent of the forms contained information of value. The State as a whole claimed that only less than 1 percent contained information of value. The Los Angeles, Calif., Induction Station received forms on 28 percent of the men, 20 percent of which contained positive information and 80 percent of which were negative or blank. However, their estimate was 'no value at present.' The Sacramento, Calif., Induction Station stated that information of value was obtained on less than 1 percent of the registrants. The Fort Douglas, Utah, Induction Station, receiving registrants from Utah, Montana, and Idaho, stated that only 1 percent of the forms contained information of value. Thus, as judged by the men who were actually making use of the forms of the Medical Survey Program, this program was disappointing
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in its operation. As has been previously outlined, the reasons for this were all too apparent.
Reduction in Scope of Program
By the summer of 1946, it was possible to reduce the scope of the Medical Survey Program. This could now be accomplished, as stated in a local board memorandum25 on the subject of medical survey, because of the reduction of calls by the Armed Forces and of the recruitment of a number of men through voluntary enlistments.
This memorandum stressed, however, that it was still incumbent upon local boards, with the assistance of the local board examining physician and such agencies as were designated by the State Director, to obtain from all possible sources information relating to a registrant's qualification; further, that the fundamental principle of exercising care in the selection of men free from mental conditions of a disqualifying nature remained the same. It pointed out that the desired information might be secured from other local social agencies, school systems, hospitals, training schools for the handicapped, or any other available service. It was decided to continue the use of DSS Form 210 and DSS Form 212, the identity verification and medical and social history forms, respectively. However, the educational verification, the cooperative school report, and the special school report (DSS Forms 211, 213, and 214, respectively) were all discontinued.
It was again provided that States having their own established programs of obtaining such information might request and receive permission to continue their own programs. The amended memorandum described the procedure for securing medical and social histories, substantially, as follows:
When the local board knew or had reason to believe that there existed a history of mental disease in the family of a registrant, or that the registrant was socially maladjusted, had a poor work record, or possessed other mental or personality disorders, or any physical condition which might cause the Armed Forces ultimately to reject him, it would prepare DSS Form 212 (part 1) and add a statement giving the reason for requesting the investigation. After completing part 1, the local board was to transmit the form to the medical field agent.
The medical field agent, upon receipt of Form 212, with part 1 completed, was to obtain the information necessary for completing part 2. When this part was completed, the medical field agent was to return the form, in a sealed envelope, to the local board, addressed to the medical examiner of the Armed Forces induction station, with the name, address, and order number of the registrant on the envelope. This envelope and
25Local Board Memorandum No. 186, Selective Service System, issued on 2 Oct. 1943; amended on 8 Aug. 1946.
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its contents were to be available to no one except the medical examiner at the Armed Forces induction station, or subsequently to the Selective Service medical advisory board, if the registrant was deemed by the local board to have been erroneously rejected for, or discharged from, the Armed Forces.
When the registrant for whom the forms had been obtained was forwarded for induction, the local board was to forward such forms, in the sealed envelopes to the induction station to which registrant was sent. At the end of the day at the induction station, the forms were stamped as accepted or rejected as the case might be, and forwarded to the State Director of the Selective Service System, in the State from which the registrant had originated.
Summary
The Medical Survey Program was designed to meet a very real need in the proper selection of men suitable for service. The shortcomings of this program were:
1. The shortage of trained psychiatric or other social workers in the positions of medical field agents, with the consequent result that the histories were, for the most part, inferior and lacking in the required factual information.
2. The lack of trained personnel, including social workers, in the induction station and in the military forces to provide for the opening, evaluating, and proper handling of the material obtained through the program. In order to have made the program function properly, obviously, there should have been an arrangement which, as has been shown was presumably provided for by directive, whereby only factual material of value would have been presented to the examining psychiatrist at the time he examined the registrant in question. When time is at a premium, as it is in a busy induction station, it is not practicable for the examining psychiatrist to open and evaluate the material himself.
3. There was a deficiency in the overall supervision of this program, both on the part of the Selective Service System and on the part of the Armed Forces. In the first place, the Selective Service System should have provided experienced and adequately trained personnel, to its State headquarters, to supervise and help medical field agents in properly carrying out their part of the program. In the second place, the Armed Forces should have provided more adequate supervision in the induction station, as has been outlined.
4. It would seem that, to obtain the most out of such a program, it would be advisable to make available to the medical advisory board psychiatrist the information gathered by the Medical Survey Program and to allow the psychiatrist to make a personal examination of the registrant before actual induction.. If indicated, the psychiatrist could
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request further information, When the examination was completed, the psychiatrist could submit a summary of his findings and recommendations regarding the desirability of inducting such a registrant.
5. Despite this program's shortcomings and its disappointing showing, psychiatrists are united in their belief that such a program, effectively carried out, would be of the greatest value in the selection of men for the Armed Forces.
NEUROPSYCHIATRIC SCREENING ADJUNCT
During the mobilization period, and certainly with the onset of war, it became apparent that there were an insufficient number of psychiatrists to conduct a reasonably thorough routine psychiatric evaluation of each inductee. Initially, 15 minutes was sought as a minimum time for the psychiatric induction examination. However, with the heavy workload for each induction station, it soon became evident that even 5 minutes was an overly optimistic expectation for the psychiatric examination and that, in actual practice, 2 minutes or less was the most time that could be allotted. Even then, the number of psychiatrists was insufficient, and many nonpsychiatric physicians were pressed into service as induction psychiatric examiners. It seemed evident that a solution for this problem could be a screening device of a paper-and-pencil type, to be group administered, and thus economize upon the utilization of psychiatrists by reducing the number of inductees who required an individual examination. To be effective, such a screening test would permit the majority of inductees who were free of overt or latent mental disorders to enter the service without an individual psychiatric examination, but would identify a large minority, perhaps one-third of inductees, in whom were contained the potential psychiatric problems. Thus, the screening test would not replace the psychiatric examination but would select the group most likely to have sufficient psychopathology as to constitute a hazard or risk for military service.
Screen paper and pencil tests of a 'homemade' type, empirically constructed, were already being used by some of the induction station psychiatrists. These tests consisted of a series of questions which could be readily answered by the inductee, sometimes aided by an enlisted assistant, and which referred to the existence, past and present, of psychosomatic manifestations, psychiatric symptoms, antisocial behavior, and the like. Such tests saved the time of the examiner, particularly for those individuals who would admit having positive symptomatology.
An effort to construct a valid screening adjunct was initiated by Maj. John W. Appel, MC, Chief of Preventive Psychiatry, Neuropsychiatry Consultants Division of the Surgeon General's Office. He requested the Research Branch of the Information and Education Division, Army Service Forces, to construct the test. Since most of the psychiatric problems of
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World War II were demonstrated to be of the psychoneurotic type, efforts were made initially to identify mainly this group. Research was conducted for the purpose of comparing the responses of a cross section of Army personnel with that of a sample of psychoneurotic patients in Army hospitals. Eventually, a questionnaire was evolved which, in addition to background information, inquired into 15 major areas of the individual's past and present experience and current attitudes as follows:
1. Childhood relations with parents.
2. Childhood fears.
3. Childhood neurotic symptoms.
4. Childhood school adjustment.
5. Childhood fighting behavior.
6. Childhood participation in sports.
7. Emancipation from parents.
8. Mobility.
9. Sociality.
10. Identification with the war effort.
11. Acceptance of soldier's role.
12. Worrying.
13. Oversensitivity.
14. Personal adjustment.
15. Psychosomatic complaints.
The questionnaire was necessarily incomplete for induction screening since it was only based upon the identification of psychoneurotics. Further questions were needed to detect psychotics and psychopaths. For this reason, there were added 8 specific questions which were not consolidated with the many questions under the 15 original items. These separate questions were treated qualitatively, and even a single affirmative answer was to be considered a critical sign and sufficient reason for referral for individual psychiatric evaluation. Thus, the final test result consisted of two parts: a numerical score obtained from the psychoneurotic test battery and a series of yes-or-no answers for the eight separate questions. Men with scores considered critical in either respect, that is, low numerical scores under the psychoneurotic scale or the possession of one or more affirmative answers to the separate questions, were to be considered screened by the test and referred to individual psychiatric evaluation. Those with passing numerical scores for psychoneuroses and negative critical signs for the other questions were to be passed by the test as not requiring individual psychiatric examination.26
26The exact questions, to be answered by a simple 'yes' or 'no,' were:
1. Have you ever had stomach ulcers?
2. Do you ever take dope?
3. Have you ever had fits or convulsions since you were ten years old?
4. Did you ever have a nervous breakdown?
5. Were you ever a patient in a mental hospital (because of your nerves)?6. Were you ever sent to reform school?
7. Have you ever gotten into serious trouble or lost your job because of drinking?8. Do you ever wet the bed? (This means urinate in bed, not wet dreams.)
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Official adoption.-The NSA (Neuropsychiatric Screening Adjunct) was ordered officially adopted for use at all induction stations beginning on 1 October 1944, by WD (War Department) Memorandum No. 40-44, issued on 19 September 1944. By this time, however, the extreme need for the NSA to relieve pressure on the psychiatrists had diminished, and it was never considered necessary to make full use of the test in passing certain men without individual examination. For example, according to WD Memorandum No. 40-44, 'men who score 18 or above on the NSA and who have no critical signs, regardless of score may, at the discretion of the psychiatrist, be considered neuropsychiatrically acceptable for induction without further examination.' Further in the memorandum, however, it was stated: 'Nothing herein will be interpreted as restricting the responsibility of the neuropsychiatrist for examining registrants in accordance with the provisions of MR 1-9, 19 April 1944 * * *."
Results.-As stated by the authors of NSA: 'It would not be surprising if by a good many clinicians it was either treated with tolerant amusement or completely ignored, even though their own clinical examination hardly could be more than perfunctory in the majority of cases.'27 The test scores, however, were available to the examining physicians who were free to use them or discard them.
It should be recognized that the NSA was not designed to predict success or failure in the Army but rather to predict the professional opinion of the examining psychiatrist as to rejection or acceptance for military service on the basis of the absence or presence of mental disorder. For this reason, a basic difficulty in the standardization of the NSA was the extremely wide variation in the frequency of psychiatric rejections, ranging from 0.5 percent at Camp Beale, Calif., to 50.6 percent at Manchester, N. H. Also, there were marked differences in specific diagnoses. For example, there were 29 stations in which the dominant tendency was to classify men as psychoneurotic, 16 in which psychiatric rejectees were most often diagnosed as psychopaths, and 10 in which neither of these labels was used. It is difficult to believe that Pittsburgh, Pa., had three times the proportion of psychiatric rejects as Philadelphia, Pa.; Detroit, Mich., three times the number of Chicago, Ill.; New Orleans, La,, three times that of Dallas, Tex.; and Seattle, Wash.-Portland, Oreg., three times that of San Francisco, Calif. Further, that New Haven, Conn., had 3 times as many psychopaths as Boston, Mass.; Pittsburgh, 5 times as many as Baltimore, Md.; and Camp Shelby, Miss., 35 times as many as Fort McClellan, Ala.28
27Stouffer, Samuel A.; Guttman, Louis; Suchman, Edward; Lazarsfeld, Paul F.; Star, Shirley A.; and Clausen, John A.: Studies in Social Psychology in World War II. Volume IV. Measurement and Prediction. Princeton: Princeton University Press, 1950, p. 549.
28Ibid., pp. 550-555.
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Despite the aforementioned considerable variations in both the number and the cause for psychiatric rejections at the different induction stations, the NSA was successful in selecting four out of five men, approximately 80 percent, subsequently diagnosed as psychoneurotic at a cost of screening, as unfit, approximately 20 percent of men subsequently passed as fit for military service. However, the test was not so successful in people diagnosed psychopathic, screening approximately 70 percent, Even less successful were other diagnostic categories for which there were wider variations from one station to another.
The authors of the test concluded that NSA could have served as a useful signal to point out the man who needed a thorough examination and to point out another who needed only cursory inspection. If practiced earlier in the war, the savings in efficiency and manpower might have been enormous. On the other hand, they commented: 'Until, however, psychiatric diagnosis is better standardized than it is today, it is likely that the predictability of psychiatric screening tests will fall far short of ideal.'29
In another study,30 comparing the efficiency of the Cornell Selectee Index, Form N, and the NSA with the findings of two psychiatrists doing their customary screening examinations and not seeing the screening forms, the results were as follows:
Form N of the Cornell Selectee Index and the NSA both screened approximately 80 percent of the individuals found by the psychiatrists to be militarily unfit. In essence, these screening devices were approximately 80 percent as effective as the individual psychiatric examination. However, the NSA was considered to be superior to the Cornell Selectee Index form, for its phraseology was simpler and the results were more easily perused by the examiner.
EFFECTIVENESS OF THE NEUROPSYCHIATRIC SCREENING
Early in 1944, an attempt was made by the Surgeon General's Office31 to evaluate the effectiveness of neuropsychiatric screening in identifying potential neuropsychiatric casualties.32 Toward this end, 10 induction stations were selected which had been rated beforehand as 'good,' 'fair,' and 'poor,' with respect to the quality of their neuropsychiatric prescreening examination.33 Data were then obtained on disqualifications for neuropsychiatric reasons of men examined for military service at these stations
29Stouffer, et al., op. cit., p. 567.
30Leavitt, H. C., and Graham, H.: A Comparison Between the Neuropsychiatric Screening Adjunct (NSA) and the Cornell Selectee Index (Form N). Am. J. Psychiat. 103: 353-357, July 1946-May 1947.
31The information in this section is based on material furnished by Dr. Bernard D. Karpinos, Special Assistant for Manpower Studies, Medical Statistics Agency, Office of The Surgeon General, Department of the Army, 4 Mar. 1964.-A. L. A.
32The neuropsychiatric screening was aided at that time by the NSA (p. 185) and special backgroundmaterial (Medical Survey Program, p. 177) obtained before the psychiatric examination.-A. L. A.
33The rating was done by Lt. Col. Malcolm J. Farrell, MC, Neuropsychiatry Division, SGO.-A. L. A.
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and on disability discharges for neuropsychiatric conditions of persons inducted from these stations. The apparent objective was to relate these types of data-the assumption obviously being that the induction stations rated qualitatively higher and showing higher disqualification rates should show lower discharge rates, and vice versa. In other words, a negative association was presumed between the disqualification and the discharge data. The obtained data are presented in table 1.
Rating1 and induction station | Rate | Rating1 and induction station | Rate | ||
Disqualification, per 1,000 examined2 | Discharge for disability, per 1,000 inducted3 | Disqualification, per 1,000 examined2 | Discharge for disability, per 1,000 inducted3 | ||
Good: | Fair-Continued | ||||
| Detroit, Mich. | 108 | 15 | Camp Croft, S.C. | 59 | 16 |
| New York, N.Y. | 107 | 18 |
| 62 | 17 |
| Boston, Mass. | 133 | 11 | |||
| 112 | 16 | Poor: | ||
Fair: | Shreveport, La. | 79 | 15 | ||
| Fort Benning, Ga. | 59 | 16 | Tyler, Tex. | 109 | 21 |
| Fort McClellan, Ala. | 70 | 18 | Lubbock, Tex. | 11 | 18 |
| Santa Fe, N. Mex. | 144 | 16 | |||
| 92 | 18 | |||
1'Rating' relates to the quality of the neuropsychiatric examination, as evaluated beforehand by the Neuropsychiatry Division, SGO.
2Based on neuropsychiatric disqualification data of men examined at these induction stations during the 7-month period from June 1943 through December 1943.
3Based on data for men from these stations discharged for disability. The rates were computed by relating these discharges that occurred during the 6-month period from May 1943 through October 1943 to the number of individuals inducted from these stations during the 6-month period from January 1943 through June 1943.
Source: Memorandum, Director of the Medical Statistics Division, SGO, for Director of the Neuropsychiatry Division, SGO (dated apparently early in 1944), subject: Neuropsychiatric Discharge Rates.
The data on disqualification for neuropsychiatric reasons deal with men who were examined for military service at these selected stations during the 7-month period, from June 1943 through December 1943. The data were taken from the monthly reports (SG Form 366) submitted by the induction stations to the Surgeon General's Office. These disqualifications may reflect the effect of two directives of that period. The first was The Adjutant General's letter, in May, which abolished the quota for illiterates and made all men who could meet the minimum intelligence standards acceptable for induction into the Army. The second was a directive from the Surgeon General's Office which instructed that all men who failed to meet the minimum intelligence standards be classified under mental
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deficiency (counted, obviously, as psychiatric rejections) on the monthly reports, starting with the October (1943) report. It is impossible to determine to what extent these two directives variably affected the reports of the selected stations. But, whatever these effects, the data clearly indicate wide variation among these stations in the disqualification rates for neuropsychiatric reasons (table 1, col. 1). With the exception of Tyler (Tex.) and Sante Fe (N. Mex.) which were rated 'poor,' higher disqualification rates for neuropsychiatric reasons were associated with the stations rated 'good.'
The data on disability discharges (table 1, col. 2) deal with individuals from these stations discharged for neuropsychiatric reasons during the 6-month period, from May 1943 through October 1943. The data were based on medical discharge reports received by The Adjutant General. The discharge rates were computed by relating these discharges to individuals inducted from these stations during the 6-month period, from January 1943 through June 1943. These figures are obviously incomplete, since some of the men inducted in the first 3 months of 1943 were, undoubtedly, discharged previous to May, and some of the men who were inducted during the first 6 months of 1943 could have been discharged after October 1943.
Irrespective of the variation in their rating and in their disqualification rates, these stations indicated only slight differences in their discharge rates-clearly not commensurable with the variations in their disqualification rates. It must be recognized, however, in evaluating these data, that these stations do not represent homogeneous populations. Whereas the 'poor' and 'fair' stations obviously drew their examinees primarily from rural and semirural areas, the examinees of the 'good' stations came chiefly from urban areas. These differences also involve, of course, regional as well as ethnic factors. The initial prevalence of the neuropsychiatric conditions could have been different at the various stations.
The evaluation is further complicated by the fact that the study was limited to disability discharges which dealt presumably with more serious and, consequently, more easily recognizable neuropsychiatric conditions, but it left out all those men who were administratively discharged for unsuitability or unfitness (sec. VIII, AR 615-360) or for the convenience of the Government (sec. X, AR 615-360). These pertinent data were apparently not available by station.
If these data were only suggestive, without providing conclusive evaluative evidence as to the effectiveness of the neuropsychiatric screening in World War II,34 a series of followup studies35 published after the war
34A comparative analysis of these data showed a very low negative association between these data; namely, a rank correlation of -.15 (Karpinos).
35(1) Egan, J. R., Jackson, L., and Eanes, R. H.: A Study of Neuropsychiatric Rejectees. J.A.M.A. 145: 466-469, 17 Feb. 1951. (2) Brill, N. Q., and Beebe, G. W.: Psychoneuroses; Military Applications of a Follow-Up Study. U.S. Armed Forces M.J. 3: 15-33, January 1952. (3) Brill, N. Q., and Beebe, G. W.: Some Applications of Follow-Up Study to Psychiatric Standards for Mobilization, Am. J. Psychiat. 109: 401-410, December 1952. (4) Glass, A. J., and others: Psychiatric Prediction and Military Effectiveness. U.S. Armed Forces M.J. 7: 1427-1443, October 1956; 7: 1575-1588, November 1956; 8: 346-357, March 1957.
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clearly demonstrated its various difficulties and shortcomings. These studies led to a general recognition that the psychiatric standards and procedures of World War II were obviously overcautious and, hence, caused a considerable and unnecessary loss of potential military manpower. They also indicated that psychiatric and psychological criteria at the time of examination for military service generally have not proved a reliable index for efficiently predicting future behavior and, furthermore, that greater proficiency can be accomplished by observing individuals with psychiatric difficulties under military conditions, rather than by psychiatric screening, at the time of their examination. As a result, both the psychiatric standards and the psychiatric processing procedures of World War II were modified.
In line with this new orientation, psychoneurosis of any degree is now considered acceptable if it had not incapacitated the person in civilian life, or if the person has otherwise clearly demonstrated stability. The current psychiatric evaluation at the Armed Forces examining station is done by the examining physician as a part of the general medical examination. (The NSA and other routine supplementary psychiatric aids have been eliminated.) The examining physician or the medical officer of the station determines the necessity for a psychiatric evaluation by a qualified psychiatrist. Some of the larger stations employ full-time psychiatrists for this purpose. Most of the stations, however, avail themselves of a psychiatrist's service on a consultation basis. Basically, the current psychiatric screening is intended to eliminate only gross psychiatric conditions.36
36As a result of this liberalized policy, the current disqualification rate for psychiatric reasons is 1.9 percent per 1,000 examinees, as compared with the 5.5 percent of psychiatric disqualifications in World War II. See (1) Karpinos, B. D.: Qualification of American Youths for Military Service, Medical Statistics Division, Office of The Surgeon General, Department of the Army, 1962; (2) appendix A, table 10; and (3) Voth, H. M.: Psychiatric Screening in the Armed Forces. Am. J. Psychiat. 110: 748-753, April 1954.-A. L. A.
