History

Part III

MILITARY PSYCHIATRY IN PRACTICE

CHAPTER IX

Hospitalization and Disposition

Norman Q. Brill, M.D.

From the standpoint of hospitalization in the United States, World War II can be divided into two periods: One, the period of mobilization which extended from September 1940 to the latter part of 1942; the other, the period of combat, from the latter part of 1942 until the end of the war. During the first period, the major medical activities were centered, mainly, in the station hospitals. In the second period, emphasis shifted to general and convalescent hospitals.

INITIAL PROBLEMS

During the mobilization period, the Army was expanding rapidly, new organizations were being activated, training was hurried, and outfits were being prepared for oversea shipment. The Allied military situation looked dark and the future uncertain.

From the beginning, large numbers of men were admitted to the various station hospitals because of psychiatric disorders. Many were frankly psychotic or psychoneurotic; others were immature, mentally defective, or had personality or character disorders which interfered with their adjustment. The hope that had been nourished by some, that induction screening would leave the Army free of neuropsychiatric problems, soon waned.

Generally, if a soldier consistently did not adjust at duty, he was referred to the hospital. Dispensary medical officers did little in the way of therapy. They were kept busy screening the many men who reported daily on sick call, trying to get as many as possible back to their duties promptly. Outpatient specialty clinics had not yet been organized.

While the types of psychiatric syndromes seen in the Army were, for the most part, the same as those seen in civilian life,¹ the fact that specific dispositions had to be made with patients in the Army led to certain difficulties and complications which were not experienced in civilian practice. In the service, an arbitrary distinction was made between the type of discharge for those who were considered ill by virtue of mental disease and for those who had personality or intellectual disorders. Psychoses and psychoneurotic disorders were included in the category of illness while the

¹Many psychiatrists would take issue with this statement on the grounds that rarely would such immature, personality, or neurotic disorders be self-referred or sent to civilian psychiatrists. No doubt, such cases in lesser numbers were seen by general practitioners.-A. J. G.

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various types of psychopathic personality, mental deficiency, enuresis, and the like were not.² Personnel who were incapacitated for service by 'illness' were given medical discharges while those who 'were inapt' or 'did not possess the required degree of adaptability or who had habits or traits of character which served to render retention in the service undesirable' were to be given administrative (nonmedical) discharges upon the recommendation of a board of line officers appointed to consider their cases.³ The Medical Department, therefore, had no direct control over the retention or discharge of this latter group. Its function was merely to make recommendations.

The criteria for medical discharge were laid down by War Department directives. At one time, it was directed that all men with psychoneurotic disorders be discharged medically while, at another time, it was directed that if a man were capable of performing any duty he was to be retained in the service regardless of diagnosis.⁴

It was extremely difficult, in many instances, for medical officers to decide about the type of discharge that should be recommended. Many times, individuals who were mentally defective or emotionally immature would develop anxiety or conversion reactions as a result of the minimal stress of entering military service. Their acute symptoms would subside when placed in the protective environment of the hospital, but recurrence could be expected if they were returned to duty. Many such individuals could be salvaged with job assignments which were appropriate to their capabilities but, unfortunately, such assignments were not always available.

Similarly, many individuals were seen with neurotic symptoms or histories of maladjustment which could be related quite definitely to some specific situation in the military service. There were conflicting opinions about whether such cases should be called psychoneurotic disorders or instances of lack of adaptability.

From the beginning of mobilization, psychiatrists were impressed with the poor motivation of many patients who found their way into hospitals. It was difficult to define exactly how much of such patients' ineffectiveness was due to illness and how much to lack of desire to do their part. Seemingly conscious exaggeration of existing defects was not uncommon.

As the war progressed, an increasing number of men who had been returned to the Zone of Interior after having served overseas showed overt evidence of maladjustment. They complained; were not as cooperative as

²It is pertinent to note that such a distinction was not made in World War I. Mental deficiency, chronic alcoholism, constitutional psychopathic states, or personality disorders, and even drug addiction, were usually given discharges for disability if persons having such defects were considered unfit for service. See appendix A, table 8.-A. J. G.
³As provided by section VIII, AR 615-360, the company or unit commander was responsible for initiating such administrative discharges, including the gathering of necessary evidence to support the action for discharge. Line (nonmedical) officers generally constituted the board which considered the case, and the next higher commander (the convening authority) was responsible for processing the action. A reviewing authority, usually a general officer, implemented the actual discharge.-A. J. G.
⁴Appel, J. W.: Incidence of Neuropsychiatric Disorders in the United States Army in World War II (Preliminary Report). Am. J. Psychiat. 102: 433-436, January 1946.

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they had been previously; and were irritable, somewhat tense and restless, subject to emotional outbursts and admittedly unwilling to continue to serve. They frankly proclaimed that they had done their share and felt under no compulsion or obligation to continue contributing their efforts. Medical officers who struggled with this problem for a long time received little help or guidance from the War Department-until it was too late in the war effort. There was considerable difference of opinion concerning the significance of these altered attitudes. Some psychiatrists insisted that they represented psychoneurotic disorders which justified disability discharges. Others, admitting that these attitudes were evidences of maladjustment, were nevertheless reluctant to categorize them as psychoneuroses. The problem was an important one for, if the former view were adopted, it would imply that defective motivation in general was an evidence of illness and that its manifestations were to be treated medically and not administratively.

Psychoneurosis was difficult to define, and apparently, it could not be clearly differentiated from other psychiatric diagnoses of transient reactions or personality disorders which were in use, such as simple adult maladjustment, emotional instability, and inadequate personality. It was not uncommon to see the same case given three different diagnoses by three different psychiatrists. The same patient might have been recommended by one psychiatrist for disability discharge and for return to duty by another.

LIBERAL DISCHARGE POLICY

The War Department policy concerning discharge of soldiers with neuropsychiatric disorders varied from time to time, the variation for the most part being based on manpower needs. In the early days of mobilization, registrants who qualified for limited service were not inducted. Consequently, there was no such classification, or duty assignment, in the Army. After evaluation in a hospital, patients were either discharged from the Army for disability or returned to full military duty. Often, patients who were not fit for strenuous field duty were returned to their outfits (not infrequently with a medical report which could not be used by their commanding officers as a basis for reassignment) where the medical officer had hoped that they could be utilized in some assignment. Occasionally, medical officers in hospitals upon their own initiative sent a note to commanding officers pointing out some physical limitation of the patient being returned to duty, but such a practice was by no means standard or required. Over a period of time, a considerable number of below-par men accumulated in all types of units.

Shortly after the beginning of hostilities, efforts were made to rid the field forces of those men who were not physically qualified for general service. The War Department directed all branches of the Army to transfer

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such personnel to garrison-type duties, such as post and station complements, military police, and cadres of the replacement training centers. Many commanders of field units seized this opportunity to rid themselves of all undesirable personnel, not confining their transfers to those who were physically unfit. Steps had to be taken to stop this abuse. For example, in the Fourth Corps Area (later Service Command),⁵ a letter was sent to the commanding officers of all posts drawing attention to the abuse of transferring personnel, other than those physically disqualified for field service, to the control of station commanders. Specific reference was made to deserters, men AWOL (absent without leave), absent sick in hospitals, malingerers, men who should be discharged on CDD (certificate of disability for discharge), and similar cases. This problem of disposing of noneffective personnel was one which was to plague the Army during the entire duration of the war.

A considerable percentage of the men who were transferred from field force units to garrison installations were transferred as a result of neuropsychiatric disorders, chiefly psychoneurosis. They were transferred in such large numbers that it soon became impossible for the overhead installations to absorb them, and commanders were directed⁶ to discharge all men 'with epilepsy, psychosis, and definite psychoneurosis.' Borderline psychoneurotic cases and cases of mental deficiency who were considered useful for some limited assignment could be retained. It was also directed that 'cases of constitutional psychopathic states uncomplicated by psychoses and cases of mental deficiency, with mental ages lower than 8 years, be disposed of administratively (in contrast to medically) under the provisions of Section VIII, AR 615-360.'

Problems of the Psychiatrists

While many psychiatrists concurred with the spirit of Circular Letter No. 77, in the belief that the Army was no place for individuals with any clearly defined neuropsychiatric disorder, others were not of the opinion that all psychoneurotics were a total loss to the Army. The diagnosis of 'borderline psychoneurosis' was not an acceptable entity to either medical officers or psychiatrists. A man either had psychoneurosis or didn't have it. Consequently, some psychiatrists, when confronted with a soldier who had a mild psychoneurotic disorder and who was thought capable of doing duty, did not record a diagnosis of psychoneurosis. If the diagnosis of psychoneurosis were made, such a patient had to be recommended for a medical discharge, which some psychiatrists did not believe to be indicated or warranted. Often, in order to return such patients to duty, the use of other diagnoses was resorted to, such as gastric neurosis, functional back?

⁵Letter, Headquarters, Fourth Corps Area, to Commanding Officers, Posts and Stations, 28 Feb. 1942, subject: Disability Discharges.
⁶Circular Letter No. 77, Office of The Surgeon General, U. S. Army, 29 July 1942.

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ache, and cephalalgia for cases of stomach and back disorders and headache which were obviously psychogenic.

Those who agreed with the policy of discharging all individuals with psychoneurotic disorders used the diagnosis freely and recommended for disability discharge practically everyone who manifested any degree of nervousness or maldajustment regardless of its cause.

Problems of Administrative Discharge

It was one thing for higher headquarters to direct the administrative discharge of individuals with psychopathic personalities or severe mental deficiency and another to get it accomplished. Many company commanders with little military experience were unfamiliar with the complex administrative procedure involved. Others, familiar with the administrative procedure, were reluctant to initiate an administrative discharge because of the considerable time that was involved and because of the unpleasantness of testifying before an individual that he had undesirable habits or traits of character or was inapt or unadaptable. In some regiments or divisions, it was felt that a good officer should be able to make a soldier out of any one and that each 'Section Eight Board' represented a failure on the part of the company commander. However, there was no such adverse reflection on the officer's ability when he arranged either for a transfer of a problem soldier to another outfit or, if possible, for a medical discharge. In those cases where there was a history of frequent hospitalization or sick call visits, the officers involved, including the reviewing authorities, often held to the opinion that such persons were sick, contrary to medical testimony, and urged disposition through medical channels.⁷ In some posts, the impression existed that only malicious troublemakers and behavioral problem soldiers should be discharged under 'Section 8' and that other character or personality disorders did not fall in the administrative discharge category. The overall effect of this attitude was to liberalize and stimulate medical discharges.

Maj. (later Lt. Col.) Malcolm J. Farrell, MC, in a memorandum of 11 August 1942, to The Surgeon General, on the findings of an inspection of the Station Hospital at Indiantown Gap, Pa., on 6 August 1942, commented as follows:

Considerable difficulty is met with in the disposal of Section VIII cases (all administrative discharges). The main difficulty appeared to be in convincing line officers of the need for the separation from the service of psychopathic, mentally defective individuals, and chronic alcoholics. Repeatedly, cases studied at the hospital have been sent before Section VIII Boards where their discharge would be disapproved, mainly because the line officers of the Board could not understand the reasons for the psychiatrist's recommendations. * * * Many posts apparently felt that Section VIII (discharges) had been discontinued altogether. * * * Many line officers hesitate to request

⁷In this connection, a memorandum dated 30 December 1943 from Gen. George C. Marshall, Chief of Staff, to Maj. Gen. Alexander D. Surles is of great interest (p. 131).

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Section VIII Board proceedings in the case of unfit soldiers feeling that it is an admission of failure on their part because they cannot train and develop good soldiers in individuals of these types.

Major Farrell recommended consideration of giving these individuals disability discharges since they were psychiatric problems. Hecker and his associates⁸ also suggested this be done routinely because company commanders lacked the time to accomplish the rather complicated procedure required for section VIII (AR 615-360) boards.⁹

It was not unusual for a medical officer to succumb to the friendly overtures of a company commander 'to get rid of so and so' who was a problem in the company. 'Getting rid of' generally meant sending him to the hospital. When a liberal discharge policy was in effect, sending a man to the hospital for a psychiatric disorder was practically tantamount to giving him a medical discharge.

In oversea theaters where the question of discharges was not one of primary concern, it was a matter of evacuating such cases to the United States. In the Pacific theaters where the manpower situation did not permit liberal evacuation policies, there was relatively little such abuse of medical channels. There and in the North African-Mediterranean theater, directives had been issued which restricted such abuses. In the European theater where the major portion of the oversea Army was located, patients with mental deficiency and those with psychopathic personalities were often, if not routinely, admitted to hospitals and medically evacuated to the United States. Upon arrival in the Zone of Interior hospital, disposition was extremely difficult. Evidence of lack of adaptability, and so forth, which was contained in the abbreviated accompanying medical records was not sufficient in most instances to convince a board of line officers that administrative discharge was appropriate for a soldier who had served overseas and had been evacuated as a patient.

Discharge for the Convenience of the Government

In December 1942, additional efforts were made to dispose of marginal personnel. It was directed¹⁰ that limited-service enlisted personnel who could not read or write the English language as commonly prescribed for the fourth grade in grammar school and who did not meet one of the following qualifications be discharged for the convenience of the Government (sec. X, AR 615-360), when in the best interests of the military service:

1. He must possess a civilian occupational skill which is needed by the Army and which the man is physically capable of performing, or

⁸Hecker, A. O., Plesset, M. R., and Grana, P. C.: Psychiatric Problems in Military Service During Training Period. Am. J. Psychiat. 99: 33-41, July 1942.
⁹The recommendations of Farrell and of Hecker and his associates were never seriously considered because of the experience after World War I when a disability discharge carried with it an excellent chance of receiving disability compensation from the Veterans' Administration although, in the opinion of physicians, it was not warranted in many instances.-N. Q. B.
¹⁰War Department Circular No. 395, 5 Dec. 1942.

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2. He must possess sufficient intelligence and education to absorb instructions and attain a skill rapidly and to be physically capable of performing the duties attendant to such skill, or

3. He must be physically capable of performing manual labor day after day.

The same criteria were adopted for the induction of limited-service personnel.

Trend Toward Elimination

Reports were received from oversea commanders to the effect that too many men who were mentally unsuited for ordinary military duties were arriving overseas. They indicated that in many instances these individuals had been observed in Army hospitals in the United States only to be returned to duty. Accordingly, on 25 March 1943, the following directive was issued:¹¹

Great care will be taken by all medical officers at induction stations, hospitals, replacement training centers, tactical units, staging areas, and ports of embarkation to make certain that everything possible is done to prevent * * * misfits from entering the service and especially from being sent overseas. Every effort will be made to detect and eliminate these individuals before they reach the staging area. These cases are disturbing to the morale and discipline of a unit. They present a problem and an unnecessary burden to unit commanders, often requiring that they be returned to this country after a brief period of service overseas.

All concerned will give careful consideration to the detection and the prevention of return to duty for service overseas of cases of psychoneurosis, mental deficiency, epilepsy, constitutional psychopathic state, and psychoses. The detection of these mentally abnormal cases before their shipment out of this country is an extremely important duty of each medical officer, since the elimination of such individuals will enhance materially the efficiency of oversea organizations.

This directive was superseded by a stronger one¹² about a month later, to the following effect:

1. Greater care will be taken by all medical officers at induction stations to make certain that everything possible is done to prevent all individuals predisposed to or suffering from psychoneurosis, mental deficiency, constitutional psychopathic state, epilepsy, psychosis, organic disease of the nervous system or having a proven history of these conditions from entering the military service. Attention is invited to the fact that there is no classification for duty of military personnel with such mental diagnoses as psychoneurosis, mental deficiency, epilepsy, constitutional psychopathic state, and psychosis.

2. Medical officers of all units, especially those at training centers, hospitals, tactical units, staging areas, and ports of embarkation, will increase their efforts to detect individuals with the conditions mentioned in paragraph 1 with a view to the discharge of those who cannot be expected to render full military duty.

¹¹War Department Memorandum No. W600-30-43, 25 Mar. 1943.
¹²War Department Memorandum No. W600-39-43, 26 Apr. 1943.

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Solution by Medical Discharge

From the foregoing, it seemed that the decision relative to which neuropsychiatric patients were capable of performing duty was taken out of the hands of the medical officers and assumed by higher authority. The directives by higher authority literally invited a witch hunt for the elimination of all persons with any taint of an emotional disorder, contrary to the recommendation of the Neuropsychiatry Consultants Division, SGO (Surgeon General's Office), and made their discharge (generally for disability) mandatory. Also, articles written by psychiatrists, civilian and military, pointed to World War I experience, and General Pershing's famous telegram (p. 154) (requesting that no one with any evidence of emotional instability be sent overseas) was often quoted. Reference was made to the large amount of money which was spent by the Government to provide care for neuropsychiatric patients after the war, and pleas were made to avoid getting involved again. The effect of this announced War Department policy was to increase greatly hospital admissions and disability discharges for psychoneuroses. Dr. Eli Ginzberg, a special assistant to The Surgeon General and chief of the Resources Analysis Division, SGO, commenting on this, stated:

Problems of morale, induction and separation and rotation were handled by officers of the line who were so oblivious to the psychiatric aspects of their problems that they failed to seek, no less follow, professional advice.¹³

Impact of Liberal Disposition Policy

Although not documented, there were medical officers, including psychiatrists, who were of the opinion that many individuals with psychoneuroses were capable of performing effective duty and who by various subterfuges tried to prevent their discharge. These psychiatrists would avoid making a diagnosis of psychoneurosis whenever possible. They would first decide whether or not a man was capable of doing duty and then supply a diagnosis which would permit such a disposition. If the case happened to be one of psychoneurosis, a term such as 'simple adult maladjustment' or 'situational maladjustment' might have been employed.¹⁴ To repeat, free use was made of such diagnoses as gastritis for cases of functional vomiting, lumbosacral strain for cases of functional backaches, and cephalalgia for cases of tension or hysterical headaches. Other medical officers often did not request psychiatric consultations for fear the psychiatrist would make a diagnosis of psychoneurosis.

Strangely enough, the psychiatrists came in for a great deal of indirect criticism and blame for the policy which they had no part in initiating. It

¹³Ginzberg, E.: Logistics of the Neuropsychiatric Problem of the Army. Am. J. Psychiat. 102: 728-731, May 1946.
¹⁴One wonders whether the diagnosis of a transient type of disorder was not correct and indeed not a subterfuge.-A. J. G.

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was felt that they were using the diagnosis of psychoneurosis too freely when all they were trying to do was to apply the criteria which they had been taught in civilian life. From the beginning, the Neuropsychiatry Consultants Division had opposed the policy of indiscriminate discharge of patients with neuropsychiatric disorders, but their efforts were in vain. It seemed that many medical officers (and the Army, in general) were not aware of the prevalence of emotional disorders, and they could not understand the phenomenon which was before them-the increasing number of individuals who were hampered or crippled by their emotions.¹⁵

Elimination of Limited Service

Up until this time, the major emphasis had been placed on preventing men with neuropsychiatric disorders from going overseas (although the Medical Department was encouraged to eliminate as many as possible from the service). Despite the directive which emphasized the fact that there was no classification duty for patients with neuropsychiatric disorders (p.

CHART 1.-Discharge rates of enlisted men on certificate of disability for discharge for neuropsychiatric conditions, U.S. Army, by year and month, 1942-45

¹⁵In retrospect, some of the criticisms directed toward psychiatrists seem justified. Many Army psychiatrists could not alter their attitudes based on civilian experience and considered situational maladjustments and immature reactions to be identical with the fixed neuroses of civilian life.-A. J. G.

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201), large numbers of men had been returned (and were still being returned) to limited duty in overhead installations. As more and more men were transferred from field force units for limited duty, more than could be utilized accumulated in the United States.

In July 1943, the War Department completely eliminated the category 'limited service.'¹⁶ It was ordered that all those who did not meet the minimum standards for induction would be discharged. Exceptions could be made in those cases where men were physically qualified to perform their present assignments provided their commanding officers desired to retain them. While commanders of all echelons were directed to 'exercise close personal supervision in appraising the soldier's physical qualifications, prior training, skills, intelligence, and aptitude to assure the fullest utilization of the soldier's potential capabilities,' the effect of this circular was to initiate an Army-wide house cleaning. Thousands of men who had been classified as 'limited service,' in many instances for disabilities which were

TABLE 2-Disability discharges for neuropsychiatric conditions, by diagnosis and year, U.S. Army, worldwide, 1942-45

[Rate expressed as number of individuals separated or discharged per 1,000 mean strength per year]

Diagnosis	Total 1942-45		1942		1943		1944		1945
Diagnosis	Number	Rate	Number	Rate	Number	Rate	Number	Rate	Number	Rate
	Total U.S. Army Personnel
Neurological disorders:
Epilepsy	15,103	0.6	2,589	0.8	5,398	0.8	3,940	0.5	3,176	0.4
Other	37,097	1.5	2,214	.7	11,608	1.7	9,176	1.2	14,099	1.9
Total	52,200	2.1	4,803	1.5	17,006	2.5	13,116	1.7	17,275	2.3
Psychiatric disorders:
Psychosis	62,062	2.5	7,013	2.2	15,831	2.3	19,279	2.5	19,939	2.7
Psychoneurosis	268,744	10.6	14,149	4.4	105,544	15.4	66,757	8.5	82,284	11.1
Character and behavior disorders	3,163	.1	401	.1	1,021	.1	1,006	.1	735	.1
Disorders of intelligence	2,653	.1	709	.2	1,250	.2	467	.1	227	.0
Other psychiatric disorders	337	.0	1	.0	71	.0	164	.0	101	.0
Total	336,959	13.3	22,283	6.9	123,717	18.0	87,673	11.2	103,286	13.9
Total neuropsychiatric disorders	389,159	15.4	27,086	8.4	140,723	20.5	100,789	12.9	120,561	16.2
	Enlisted Men
Neurological disorders:
Epilepsy	14,633	0.6	2,559	0.9	5,258	0.8	3,735	0.5	3,081	0.5
Other	35,472	1.6	2,162	.7	11,328	1.9	8,571	1.3	13,411	2.0
Total	50,105	2.2	4,721	1.6	16,586	2.7	12,306	1.8	16,492	2.5
Psychiatric disorders:
Psychosis	59,935	2.6	6,859	2.3	15,320	2.4	18,542	2.7	19,214	3.0
Psychoneurosis	259,432	11.4	13,806	4.6	102,737	16.4	63,320	9.0	79,569	12.3
Character and behavior disorders	2,930	.1	357	.1	931	.2	952	.1	690	.1
Disorders of intelligence	2,650	.1	709	.2	1,249	.2	465	.1	227	.0
Other psychiatric disorders	281	.1	1	.0	55	.0	141	.0	84	.0
Total	325,228	14.2	21,732	7.2	120,292	19.2	83,420	11.9	99,784	15.4
Total neuropsychiatric disorders	375,333	16.4	26,453	8.8	136,878	21.9	95,726	13.7	116,276	17.9

NOTE.-A rate of 0.0 denotes less than 0.05.
Source: Individual Medical Records. The presented data for enlisted men somewhat differ from those published in 'Health of the Army,' vol. 1, Report Number 2, 31 Aug. 1946, which were preliminary data based on individual reports received from the Office of The Adjutant General. (See also appendix A, table 9.)

¹⁶War Department Circular No. 161, 14 July 1943.

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not serious and often for psychoneuroses which may have been transient, were admitted to hospitals and discharged from the Army on certificate of disability for discharge. Many others, not previously classified limited service, were placed on limited service (for psychoneuroses more often than any other condition) and then discharged. Competent medical technicians in station hospitals who, although classified 'limited service,' were doing superior work got caught in the increasing stream of discharges and soon found themselves out of the Army as 'disabled soldiers.' WD (War Department) Memorandum No. W615-64-43 (26 August 1943) called attention to the fact that commanders were authorized to retain individuals not meeting standards, whose services were such as to warrant retention.

The effects of these changing policies with respect to neuropsychiatric patients are clearly reflected in tables 2 and 3, where the discharge rates for disability because of neuropsychiatric disorders are presented for

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World War II by year and month, respectively. Some 389,000 military persons were discharged during World War II for neuropsychiatric disorders. Some 375,000 of these persons were enlisted men, discharged on certificate of disability for discharge. From a yearly disability discharge rate of 8.8 per 1,000 mean strength per year (enlisted men) in 1942, the discharge rate rose to 21.9 in 1943; it declined to 13.7 in 1944, and rose again to a rate of 17.9 in 1945 (table 2). These wide fluctuations in the discharge rates appear even more conspicuous when viewed on a month to month basis. The discharge rate reached alarming heights in September 1943, when it rose to a rate of 35.6 per 1,000 mean strength per year (table 3). (See also chart 1 for discharge rates by month.)

TABLE 3.-Discharge rates¹ of enlisted men on certificates of disability for discharge for neuropsychiatric conditions, by broad diagnostic categories and month, U.S. Army, worldwide, 1942-45

[Rate expressed as number of enlisted men discharged per 1,000 mean strength per year]

Year and month	Diagnosis
	Total neuropsychiatric	Neurological	Psychiatric
	Total neuropsychiatric	Neurological	Total	Psychosis	Other
1942
January	5.7	1.2	4.5	2.0	2.5
February	5.5	.9	4.6	1.9	2.7
March	7.0	1.2	5.8	2.2	3.6
April	7.3	1.4	5.9	2.0	3.9
May	8.4	1.6	6.8	2.4	4.4
June	8.4	1.5	6.9	2.2	4.7
July	7.6	1.3	6.3	1.8	4.5
August	9.7	1.5	8.2	2.7	5.5
September	8.6	1.5	7.1	2.0	5.1
October	10.2	1.7	8.5	2.7	5.8
November	9.9	1.8	8.1	2.3	5.8
December	11.0	2.1	8.9	2.5	6.4
1943
January	10.9	2.1	8.8	2.2	6.6
February	11.3	1.9	9.4	2.3	7.1
March	14.3	2.2	12.1	2.6	9.5
April	15.2	2.5	12.7	2.5	10.2
May	17.0	2.0	15.0	1.9	13.1
June	21.2	2.0	19.2	2.1	17.1
July	24.0	2.1	21.9	2.1	19.8
August	28.8	2.4	26.4	2.0	24.4
September	35.6	2.9	32.7	2.1	30.6
October	34.6	2.8	31.8	2.4	29.4
November	27.1	1.9	25.2	2.1	23.1
December	21.7	1.6	20.1	2.0	18.1
1944
January	20.3	1.7	18.6	2.2	16.4
February	14.3	1.3	13.0	2.3	10.7
March	12.3	1.3	11.0	2.7	8.3
April	11.0	1.0	10.0	2.8	7.2
May	11.0	1.0	10.0	2.5	7.5
June	11.0	1.0	10.0	2.6	7.4
July	12.2	1.1	11.1	3.3	7.8
August	13.0	1.2	11.8	3.0	8.8
September	16.8	1.2	15.6	2.5	13.1
October	16.6	1.2	15.4	2.3	13.1
November	15.5	1.4	14.1	2.5	11.6
December	12.8	1.2	11.6	2.3	9.3
1945
January	10.8	1.4	9.4	2.4	7.0
February	12.2	1.5	10.7	2.5	8.2
March	16.5	2.0	14.5	3.1	11.4
April	13.9	1.8	12.1	2.6	9.5
May	17.4	2.2	15.2	2.3	12.9
June	19.6	2.6	17.0	2.3	14.7
July	18.4	2.7	15.7	2.4	13.3
August	20.3	3.7	16.6	2.2	14.4
September	22.2	4.9	17.3	2.0	15.3
October	26.1	6.5	19.6	2.3	17.3
November	18.9	5.9	13.0	2.5	10.5
December	14.2	5.8	8.4	1.7	6.7

¹Based on individual reports of discharges for disability furnished by the Office of The Adjutant General. (See 'Health of the Army,' vol. 1, Report No. 2, 31 Aug. 1946.)

These data are particularly significant in view of the fact that the CDD's (enlisted men) for neuropsychiatric disorders constituted between 40 percent (in 1943) and 49 percent (in 1944) of all CDD's (table 4, 'Enlisted Men').

REVERSAL OF LIBERAL DISCHARGE POLICY

It became apparent that a continuation of the policy of discharging limited-service personnel would be disastrous. The pendulum then did swing in the opposite direction, clamping down on all discharges. On 3

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TABLE 4.-Relationship between discharges for disability for neuropsychiatric conditions and disability discharges for all nonbattle diseases and injuries, U.S. Army, worldwide, 1942-45¹

[Rate expressed as number of individuals separated or discharged per 1,000 mean strength per year]

Diagnosis	Neuropsychiatric disability discharges as percent of all disability discharges, by year
Diagnosis	Total 1942-45	1942	1943	1944	1945
	Total U.S. Army Personnel
Neurological disorders:
Epilepsy	1.7	4.1	1.5	1.9	1.2
Other	4.2	3.5	3.5	4.5	5.2
Total	5.9	7.6	4.8	6.4	6.4
Psychiatric disorders:
Psychosis	7.0	11.1	4.5	9.5	7.4
Psychoneurosis	30.3	22.3	30.1	32.9	30.6
Character and behavior disorders	.4	.6	.3	.5	.3
Disorders of intelligence	.3	1.1	.4	.2	.1
Other psychiatric disorders	.0	.0	.0	.1	.0
Total	38.0	35.1	35.3	43.2	38.4
Total neuropsychiatric disorders	43.9	42.7	40.1	49.6	44.8
	Enlisted men
Neurological disorders:
Epilepsy	1.7	4.1	1.5	1.9	1.2
Other	4.1	3.5	3.3	4.4	5.1
Total	5.8	7.6	4.8	6.3	6.3
Psychiatric disorders:
Psychosis	6.9	11.1	4.4	9.6	7.3
Psychoneurosis	30.1	22.3	29.8	32.7	30.4
Character and behavior disorders	.4	.6	.3	.5	.3
Disorders of intelligence	.3	1.1	.4	.2	.1
Other psychiatric disorders	.0	.0	.0	.1	.0
Total	37.7	35.1	34.9	43.1	38.1
Total neuropsychiatric disorders	43.5	42.7	39.7	49.4	44.4

NOTE.-A rate of 0.0 denotes less than 0.05.

Source: Individual Medical Records. The presented data for enlisted men somewhat differ from those published in 'Health of the Army,' vol. 1, Report Number 2, 31 Aug. 1946, which were preliminary data based on individual reports received from the Office of The Adjutant General. (See also appendix A, table 9.)

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November 1943, the following War Department radiogram was sent to all service commands:

Pending imminent publication of War Department circular covering subject of utilization of military manpower based upon physical capacity provisions * * * (of previous War Department directives) are suspended. Discharges and processing for discharge under the provisions of these publications will cease immediately and will be resumed only on receipt of and under the provisions of forthcoming circular mentioned above. Desire you advise commanding officers of all stations within territorial limits your service command by most expeditious means.

The revised policy was issued 8 days later, on 11 November 1943, in WD Circular No. 293, entitled 'Enlisted Men-Utilization of Manpower Based on Physical Capacity.'

All previous instructions were rescinded, and emphasis was placed on the salvaging and utilization of every man possible. (This was approximately 2 months after Allied Forces had invaded southern Italy and at the time when there was heavy fighting around the Volturno River, south of Cassino.) It was pointed out: 'Classification, assignment, reassignment, and training are command functions which must be exercised energetically and continuously so that the skill, aptitude, physical qualifications, and capacity for development of the individual are used to the utmost.'

Salvage and Utilization

The circular also pointed out that many positions in the Army (including combat units) do not require men of unusual strength and physical ability. In line with the new policy of conserving manpower, enlisted men who were in assignments which demanded more physical endurance than they were capable of were to be reassigned jobs within their capacities. It was recognized that many men were extremely valuable to the Army because of their training and experience despite the fact that they were below the physical standards for induction. The discharge of an enlisted man for physical reasons because he was incapable of serving in a physically exacting position when he was able to render adequate service in a less exacting assignment was prohibited. Such men were to be retained in the service and given appropriate assignments even though they did not fulfill the minimum physical standards for induction under MR (Mobilization Regulations) 1-9.

The unnecessary removal of trained enlisted men from units immediately before departure for overseas was pointed out as a flagrant example of wastage of military manpower and training, destructive alike to the morale of the individual and the efficiency of the unit.

The existence of a nonprogressive or remediable defect or disease which would disqualify a man for dispatch overseas was not considered sufficient reason to return him to the United States from an oversea theater. Men whose defects were such that they could be remedied within the

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oversea command and those who could serve usefully in any assignment in an oversea theater, despite their defects, were to be retained.

The discharge of men who were able to render effective service was prohibited. On the other hand, the retention of men unable to perform a reasonable day's work for the Army was considered wasteful. Commanders and surgeons were advised to exercise extreme care and judgment in arriving at a decision to discharge an enlisted man on physical grounds. It was directed that commanders exercising discharge authority give this matter their closest personal supervision so as to obtain the maximum benefit from available manpower.

Enlisted men were to be assigned to the most active type of duty appropriate to their physical qualifications with due consideration to their civilian training and experience, education, intelligence, aptitude, leadership ability, and acquired military occupational qualifications. The need for all commanders and those staff officers concerned with personnel to study this matter continuously was emphasized.

The use of the term 'limited service' pertaining to enlisted men was discontinued. (This term was to be used only at Armed Forces induction stations where similar terminology was used by Selective Service and the Navy.) Discontinuance of the term 'limited service,' however, did not mean that men who were classified as limited service were to be discharged or that the Army would not continue to induct and use men who do not meet the full standards for general service.

No longer were individuals with neuropsychiatric disorders to be discharged routinely. Any man capable of performing any type of duty was to be retained, and the responsibility for the proper assignment of men with limited capacities was placed on command. Pronounced psychiatric disorders were, however, still considered disqualifying for oversea service, and men with other psychiatric disorders, except mild psychoneuroses, transient in character, although eligible for oversea service were not to be assigned to combat organizations.

Surgeon General's Office Policy

Up until this time, the views of the Neuropsychiatry Consultants Division, SGO, had not been accepted or included in the formulation of War Department discharge policies. With the change in policy to one of 'conservation of manpower,' they were accepted and published as a Surgeon General's circular letter¹⁷ which stated that separation from the service would not be recommended merely because a man has or has had a psychoneurosis or similar psychiatric disorder. Going even further than the policy announced by the War Department, it said that men with psychoneuroses could be recommended for combat service if they were believed capable of it. The importance of evaluating each case individually was stressed. Where

¹⁷Circular Letter No. 194, Office of The Surgeon General, U.S. Army, 3 Dec. 1943.

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the psychiatric disorder was believed to arise more from indifference toward the war than from fundamental instability of personality, the individual was to be retained for service. It was pointed out that a large proportion of men developing psychiatric disorders, particularly in combat zones, if properly treated and promptly returned to duty, recover entirely and render valuable service.

The significance of this directive cannot be overemphasized. It was the first time that The Surgeon General had expressed a policy which varied from the old concept that 'all NP's were no good.' Much effort was to be expended later in maintaining its principles.

Army Service Forces Policy

On 8 January 1944, to emphasize the new policy, Lt. Gen. Brehon B. Somervell, Commanding General, ASF (Army Service Forces), issued the following letter on the utilization of available manpower:

1. The following personal directive of the Chief of Staff (General Marshall) is quoted:

Reports are continually being received that large numbers of men are being discharged for physical or mental reasons, that units are discarding considerable percentages of their strengths on similar ground, and that physically qualified personnel are being used in limited service positions. The serious wastage resulting must in part be charged to a failure on the part of commanders to exercise a rigid personnel economy. Since physically perfect men are not available in the quantities desired, the Army must be maintained with the personnel at hand and it rests with the commander to do so. A unit commander who permits the discharge of an enlisted man in preference to making the necessary effort to properly place and train him fails to meet his responsibilities.

There are also indications of failure to place sufficient emphasis upon the preventative maintenance of the individual. Training in mental and physical hygiene, sanitation, and other preventive measures must be intensified. Unit commanders whose inadequate leadership is reflected in a high preventable sick rate, or a high rate of discharge, or transfer for physical or mental reasons must be replaced.

The present manpower situation is critical. Industrial as well as armed force requirements are pressing and must be met. We are now receiving from Selective Service men who hitherto have been deferred for dependency reasons. The country cannot afford, nor can the Army tolerate, any wastage of suitable manpower. The solution lies in the proper exercise of command functions and it is desired that this matter be given personal and continuing attention.

2. You will furnish copies of this letter to each officer under your jurisdiction. Further, you will require each commander of a lower echelon to study this letter and to take every necessary measure to comply energetically and continuously with the letter and spirit of the instructions contained herein and in Circular 293, War Department, 11 November 1943. As an additional means of indoctrinating our commissioned personnel, this headquarters will schedule instruction in the proper utilization of manpower in the program for each officers' school and officer candidate school.

3. You are charged with close supervision of this program.

The recognition that health was a responsibility of command was an extremely significant development. As long as it remained the sole responsibility of the Medical Department, there were great limitations on what could be done in a preventive way.

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This was reemphasized in WD Circular No. 164, issued on 26 April 1944, subject: Enlisted Men-Use of Manpower Based on Physical Capacity (as amended by WD Circular No. 212, 29 May 1944).

Reaccumulation of Marginal Personnel

The immediate effect on all these directives was apparent. Discharges dropped off precipitously. In some instances, the provisions of the directives were followed so rigidly that men who were capable of performing only a few hours' work a day in sedentary jobs were returned to or retained on duty.

From its peak in September 1943 (a rate of 35.6), the disability discharge rate for neuropsychiatric disorders dropped to 11.0 per 1,000 mean strength per year in April 1944; it stabilized at that level for at least two more consecutive months (May and June, 1944) (table 3). In absolute numbers, from 19,500 enlisted men discharged for neuropsychiatric disorders in September 1943 and again in October of that year, the number gradually declined to 6,400 in April 1944.

Once again, men with limited capacities accumulated in the Army in increasing numbers. In 1944, the war was progressing favorably. The Russians were advancing westward, Cassino fell to the Allied forces, and in June, Normandy was invaded. Paris was liberated in the latter part of August, and in September, U.S. troops entered Germany. A wave of optimism spread over the country, and rumor in the War Department set November as the time Germany would surrender.

By April through June 1944, the neuropsychiatric discharge rate was somewhat less than one-third of what it was at its highest level in 1943. However, as a result of the invasion of Normandy and the subsequent heavy fighting, hospitals in the European theater were beginning to fill up.¹⁸ Increasing numbers of patients were expected to start arriving in the States in the fall of 1944. Indeed, the expected increase started in December 1944. From 4,200 patients evacuated from overseas in November 1944, the number rose to about 7,800 in December 1944, and reached its high point in May 1945 when somewhat over 9,500 patients were evacuated from oversea theaters to the United States. During this period, the evacuation rate for neuropsychiatric disorders fluctuated between 12 and 23 per 1,000 mean strength per year. The evacuees for neuropsychiatric disorders constituted during this period between 25 and 17 percent of all evacuees. For the entire World War II, the percentage of neuropsychiatric evacuees was about 21 percent of all evacuees-an unquestionably high percentage. (See table 5.)

In addition, rigid adherence to the policy of salvaging manpower resulted in the retention of many men who were not capable of performing effective duty. Since there were a limited number of jobs in garrison

¹⁸The total number of neuropsychiatric patients remaining in hospitals overseas (all theaters) rose from 7,904 in January 1944 to a peak of 18,834 in December 1944.

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installations in the Zone of Interior to which they could be assigned, increasing numbers of those who were returned to duty from hospitals in the Zone of Interior were readmitted after short periods of inactivity or trial at duty and, again, pressure began to be exerted to lower the discharge standards.

TABLE 5.-Neuropsychiatric patients evacuated from overseas, by month, 1943-45

[Rate expressed as number of evacuees per 1,000 mean strength per year]

Year and month	Neuropsychiatric patients evacuated			Year and month	Neuropsychiatric patients evacuated
Year and month	Number	Evacuation rate	Percent of total evacuees	Year and month	Number	Evacuation rate	Percent of total evacuees
1943				1944-Con.
January	477	5.8	18.7	September	4,125	13.0	23.2
February	211	2.4	9.2	October	2,657	8.0	15.2
March	345	3.6	13.9	November	4,200	12.1	23.5
April	1,105	10.8	22.2	December	7,792	21.4	24.9
May	842	7.7	16.0	Total	43,658	12.5	26.9
June	780	6.5	15.1	1945
July	957	7.3	18.7	January	6,699	17.5	20.0
August	1,566	11.0	19.9	February	7,023	17.5	18.6
September	1,996	13.3	20.8	March	7,792	19.2	17.3
October	1,416	8.5	18.9	April	8,371	20.2	19.9
November	2,109	11.7	24.0	May	9,549	22.8	16.9
December	937	4.7	12.1	June	6,389	15.7	15.1
Total	12,741	8.2	18.4	July	6,923	18.0	18.6
1944				August	5,975	17.2	23.1
January	2,370	11.2	31.7	September	4,762	15.6	26.1
February	3,050	13.6	31.0	October	3,167	11.4	16.6
March	3,100	12.6	35.1	November	2,878	12.6	21.1
April	¹19,730	11.7	36.3	December	1,733	10.7	19.0
May				Total	71,261	17.2	18.7
June				Grand total	127,660	13.9	20.9
July	3,084	10.4	27.1
August	3,560	11.1	26.2

¹No monthly data are available for neuropsychiatric evacuees during this 3-month period.

LIBERAL DISCHARGE POLICY REESTABLISHED

A followup study was made in June 1944 by the Surgeon General's Office to determine the effectiveness, as reported by their commanding officers, of neuropsychiatric patients who were being returned to duty from general and station hospitals in the Zone of Interior, with recommendations for special assignments. The findings, based on 47 percent of the entire group on whom reports were recorded, were as follows:

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In 26 percent of the patients, the adjustment was considered excellent. About 42 percent were rated satisfactory, and the remaining 32 percent were rated poor. In 30 percent of all cases, commanding officers believed that discharge from the service was indicated. There was evidence to indicate that some of the men who were rated unsatisfactory were improperly assigned.¹⁹

With these facts in mind, on 23 August 1944, a letter was sent to all service commands by Brig. Gen. Raymond W. Bliss, Chief, Operations Service, SGO, inviting some liberalization of neuropsychiatric discharges. This letter was sent out without the knowledge of the Neuropsychiatry Consultants Division and contrary to the known opinion of that division.

This was followed shortly by a War Department letter, dated 8 September 1944, drawing attention to a forthcoming War Department circular (WD Circular 370) to the following effect: That the retention of personnel who did not meet the minimum physical induction standards for limited service as prescribed by MR 1-9 for whom there were no appropriate authorized positions to which they could be assigned was not desired. Any degree of psychoneurosis was considered below minimum induction standards for limited service at that time.

Also at this time, the Army was criticized by Congress for retaining more men than it needed. Supposedly, it was over its quota. In addition, the directors of the Hospital Division and Resources Analysis Division were of the opinion that liberalizing discharges would reduce the number of readmissions to hospitals and thereby increase the number of available beds.

Again, the plan was to utilize medical discharges to decrease the size of the Army. War Department Circular No. 370 was issued on 12 September 1944. It authorized the discharge and the return from overseas for discharge of the aforementioned type of personnel who did not meet the minimum physical induction standards. The determination was to be made in each case whether discharge was to be for disability (CDD) or for the convenience of the Government.

Indiscriminate Medical Discharges Opposed

The Neuropsychiatry Consultants Division was opposed to any liberalization of medical discharges. Its opinion was that the criteria for disability discharges should remain constant. If the War Department wanted to decrease the size of the Army or the size of the limited-service pool, it should be accomplished by administrative procedures. The indiscriminate use of disability discharges which had been experienced the year before had wasted manpower, resulted in abuse of the diagnosis of psychoneurosis, and, in the opinion of many, had undermined morale.

To forestall a repetition of this, an implementing directive²⁰ was is?

¹⁹Monthly Progress Report, Army Service Forces, War Department, July 1944, Section 7: Health.
²⁰Army Service Forces Circular No. 318, 23 Sept. 1944.

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sued, primarily at the insistence of the Neuropsychiatry Consultants Division. It restricted the use of medical discharge to those who were actually disabled for service. It emphasized the need for medical officers to distinguish between defects which did not preclude doing duty and those which were truly incapacitating. Those who were capable of performing limited?service duties were ordinarily to be discharged for the convenience of the Government and not for disability. It was specifically stated that mild

CHART 2.-Admission rates for neuropsychiatric disorders, U.S. Army, by year and month, 1942-45

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TABLE 6.-Admissions for neuropsychiatric conditions, by diagnosis and year, U.S. Army, worldwide, 1942-45¹

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psychoneuroses would not be considered adequate cause for discharge on certificate of disability.

This represented a second and final attempt to prevent the War Department from encouraging the utilization of medical discharges as a means of controlling the size of the Army or the number of men on limited service.²¹ For the first time, it was pointed out that disability discharges were intended for those who were disabled-a concept which apparently had been overlooked previously. It was not uncommon to hear voiced the opinion: 'They'll all get pensions anyway, so what difference does it make how you discharge them.' The psychological effect of discharging a man as 'disabled' seemed to be a matter of no concern. Brig. Gen. William C. Menninger,²² in reviewing the problems confronting psychiatry in the Army convalescent hospital, commented on this, as follows:

In every convalescent hospital there is a basis to state that we are going to have from 15 to 25 percent of the patients on the NP Section that we do not regard as 'sick' * * *. We still do not believe he should be rewarded for his noneffectiveness by the award of a certificate of disability. We must face realistically the mental hygiene aspect of the problem when the man is discharged from the hospital as an 'invalid' and then is subsequently paid to stay sick.

As a result of WD Circular No. 370 (September 1944), the hospital admission and admission rates for neuropsychiatric disorders reached another peak, in the late months of 1944 and the early months of 1945. (The first peak occurred in the second half of 1943, tables 6, 7, and 8, and chart 2.) Although there was also at that time an increase in the disability discharge rates for neuropsychiatric disorders (table 3 and chart 1), it did not parallel the increase in neuropsychiatric admissions and admission rates. Large numbers of men who were below the minimum induction standards and for whom there were no suitable assignments available were discharged for the convenience of the Government (section X, AR 615-360).

But here too, abuses crept in. Many commanders used this opportunity to rid themselves of men whom for one reason or another they did not wish to retain. Such individuals were referred to dispensaries, clinics,

²¹Uhler, C.: Perpetuation of Nervous Disorders by Army Psychiatric Procedure. J.A.M.A. 131: 652-656, 22 June 1946.
²²Menninger, W. C.: Problems Confronting Psychiatry in the Army Convalescent Hospital. Am. J. Psychiat. 102: 732-734, May 1946.

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and hospitals in the hope that medical officers would find some condition which placed the men below minimum induction standards. It appeared that many medical officers obligingly found disqualifying defects; commanding officers would then declare the men surplus and order them to separation centers for discharge. A survey at one separation center by representatives of the War Department revealed that a majority of the men sent to the separation center for discharge were not found to have disqualifying defects and a considerable number of these were labeled with psychiatric diagnoses.

The end of the war did not come in November. On 16 December 1944,

TABLE 7.-Admissions for neuropsychiatric disorders, by broad diagnostic categories, month, and year, U.S. Army, worldwide, 1942-45¹

Month and year	Diagnostic categories
	Total neuropsychiatric	Neurological	Psychiatric
	Total neuropsychiatric	Neurological	Total	Psychosis	Other
1942
January	4,598	956	3,642	475	3,167
February	4,641	1,008	3,633	476	3,157
March	5,877	1,262	4,615	673	3,942
April	6,248	1,237	5,011	703	4,308
May	6,981	1,381	5,600	718	4,882
June	8,189	1,536	6,653	820	5,833
July	9,498	1,830	7,668	902	6,766
August	10,802	2,101	8,701	968	7,733
September	11,895	2,287	9,608	1,142	8,466
October	13,544	2,616	10,928	1,309	9,619
November	14,470	2,894	11,576	1,400	10,176
December	17,312	3,351	13,961	1,724	12,237
Total	114,055	22,459	91,596	11,310	80,286
1943
January	18,413	3,687	14,726	1,508	13,218
February	18,197	3,376	14,821	1,378	13,443
March	23,295	4,297	18,998	1,478	17,520
April	24,940	4,174	20,766	1,301	19,465
May	26,173	4,418	21,755	1,432	20,323
June	28,702	4,778	23,924	1,466	22,458
July	33,798	5,644	28,154	1,525	26,629
August	38,970	6,093	32,877	1,553	31,324
September	36,163	5,727	30,436	1,300	29,136
October	34,842	5,402	29,440	1,531	27,909
November	30,568	4,938	25,630	1,484	24,146
December	27,026	4,644	22,382	1,571	20,811
Total	341,087	57,178	283,909	17,527	266,382
1944
January	27,030	4,315	22,715	1,825	20,890
February	24,695	4,230	20,465	1,790	18,675
March	25,305	4,455	20,850	1,935	18,915
April	22,960	3,840	19,120	1,975	17,145
May	27,830	4,165	23,665	2,255	21,410
June	27,170	4,010	23,160	2,050	21,110
July	33,150	4,095	29,055	1,920	27,135
August	31,165	4,010	27,155	1,535	25,620
September	37,010	4,365	32,645	1,570	31,075
October	37,595	4,650	32,945	1,765	31,180
November	37,775	4,115	33,660	1,595	32,065
December	36,130	4,295	31,835	1,685	30,150
Total	367,815	50,545	317,270	21,900	295,370
1945
January	35,780	4,675	31,105	1,975	29,130
February	29,690	3,835	25,855	1,700	24,155
March	31,595	4,240	27,355	1,920	25,435
April	31,205	4,085	27,120	1,770	25,350
May	29,830	4,400	25,430	1,550	23,880
June	26,930	4,120	22,810	1,585	21,225
July	24,985	4,250	20,735	1,355	19,380
August	22,910	3,735	19,175	1,200	17,975
September	16,275	3,340	12,935	1,130	11,805
October	13,470	3,170	10,300	1,070	9,230
November	10,305	2,500	7,805	1,000	6,805
December	7,135	1,890	5,245	650	4,595
Total	280,110	44,240	235,870	16,905	218,965

¹The diagnostic nomenclature and classification used for the presentation of World War II data on morbidity, separation, and mortality are those adopted by the Army in 1944 and used for 1944 and 1945 records. Therefore, the data for diseases which in 1942 and 1943 were differently named or classified, or both, were translated and, in effect, reclassified or renamed in equivalent or closely equivalent terms of the 1944-45 diagnostic classification and nomenclature. In certain cases, this involved a major relocation. With respect to psychiatric diagnoses, cases of 'alcoholism,' for instance, while separately identified prior to 1944 as 'alcoholism with psychosis' and 'alcoholism without psychosis,' appeared in the broad class of 'General Diseases' and not in the 'Nervous System' class, where neuropsychiatric disorders have been shown. Under the 1944-45 classification, alcoholism with psychosis was included under 'psychosis,' and the other cases of alcoholism were classified under 'Character and Behavior Disorders,' separately by acute and chronic alcoholism. Similarly, cases of 'Drug Addiction,' previously classified under 'General Diseases,' are shown here under 'Character and Behavior Disorders.' 'Enuresis' presented in this respect a more complex problem, as no distinction was made prior to 1944 between 'enuresis'-a 'habit' reaction symptomatic of immaturity-and 'enuresis'-a symptom of some organic disorder. (Prior to 1944, all cases of enuresis were listed in the 'Genitourinary Disease' class.) The 1944-45 nomenclature provided for such a differentiation, listing 'enuresis' symptomatic of immaturity under 'Character and Behavior Disorders,' and the other type of enuresis under 'General and Miscellaneous Diseases.' Inasmuch as no differentiation could be made with respect to the data on enuresis prior to 1944, all cases of enuresis in 1942 and 1943 were translated to the 1944-45 class of 'General and Miscellaneous Diseases.' (The table carries, therefore, for 1942 and 1943 the symbol NA-not available-for enuresis.) But, even for the 1944-45 data, this differentiation seems to have been of questionable accuracy, showing a much lower proportion in the psychiatric category than has been observed in later experience. As is seen from the table, only 1,030 cases of enuresis were classified in 1944-45 under 'Character and Behavior Disorders.' However, additional 19,055 cases of enuresis were counted during the 1942-45 period under 'General and Miscellaneous Diseases.' Thus, altogether some 20,000 individuals were admitted to treatment facilities with a diagnosis of 'enuresis,' in World War II, indicating an annual admission rate of 0.8 per 1,000 mean strength per year.

the Germans started their offensive which resulted in the Battle of the Bulge, and again, there was a tightening of discharge policy. On 27 January 1945, the provisions of WD Circular No. 370, dealing with discharge policy, were rescinded.

Oversea Psychiatric Returnees

As already stated, in the latter part of 1944, when WD Circular No. 370 was still in effect, patients were being returned to the Zone of Interior

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from overseas in large numbers (table 5).²³ There was a critical shortage of general hospital beds, and the convalescent hospitals were still unprepared to receive the very great load. A mechanism of discharging, for the convenience of the Government, had not yet been developed for psychiatric patients who were evacuated from overseas and who had recovered sufficiently to be returned to limited-duty assignments. By virtue of having had psychoneuroses, such patients were below the minimum induction standards, and there were very few available jobs to which they could be assigned. It was not known who could officially declare these men surplus. Authority for discharge from the service was not given to

²³In the Mediterranean theater, evacuation out of Fifth U.S. Army had been greatly reduced by improved organization of psychiatric combat services.-A. J. G.

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TABLE 8.-Admission rates for neuropsychiatric disorders, by broad diagnostic categories, month, and year, U.S. Army, worldwide, 1942-45¹

[Rates per 1,000 mean strength per year]

Month and year	Diagnostic categories
	Total neuropsychiatric	Neurological	Psychiatric
	Total neuropsychiatric	Neurological	Total	Psychosis	Other
1942
January	30.6	6.4	24.2	3.2	21.0
February	30.3	6.6	23.7	3.1	20.6
March	31.0	6.7	24.3	3.6	20.7
April	30.4	6.0	24.4	3.4	21.0
May	30.4	6.0	24.4	3.1	21.3
June	33.8	6.3	27.5	3.4	24.1
July	35.6	6.9	28.7	3.4	25.3
August	37.0	7.2	29.8	3.3	26.5
September	38.2	7.4	30.8	3.7	27.1
October	37.8	7.3	30.5	3.7	26.8
November	36.6	7.3	29.3	3.5	25.8
December	38.6	7.5	31.1	3.9	27.2
1943
January	37.9	7.6	30.3	3.1	27.2
February	39.2	7.3	31.9	3.0	28.9
March	42.4	7.8	34.6	2.7	31.9
April	45.5	7.6	37.9	2.4	35.5
May	44.9	7.6	37.4	2.5	34.9
June	50.0	8.3	41.6	2.6	39.0
July	55.2	9.2	46.0	2.5	43.5
August	63.5	9.9	53.6	2.5	51.1
September	60.6	9.6	51.0	2.2	48.8
October	56.5	8.8	47.7	2.5	45.2
November	50.9	8.2	42.7	2.5	40.2
December	43.3	7.4	35.9	2.5	33.3
1944
January	43.0	6.9	36.1	2.9	33.2
February	41.6	7.1	34.5	3.0	31.5
March	39.8	7.0	32.8	3.1	29.7
April	36.5	6.1	30.4	3.1	27.3
May	42.0	6.3	35.7	3.4	32.3
June	42.1	6.2	35.9	3.2	32.7
July	49.1	6.1	43.0	2.8	40.2
August	46.3	6.0	40.3	2.3	38.0
September	56.4	6.7	49.7	2.4	47.3
October	56.2	7.0	49.2	2.6	46.6
November	57.9	6.3	51.6	2.4	49.2
December	54.0	6.4	47.6	2.5	45.1
1945
January	54.3	7.1	47.2	3.0	44.2
February	45.1	5.8	39.3	2.6	36.7
March	47.2	6.3	40.8	2.9	37.9
April	46.5	6.1	40.4	2.6	37.8
May	43.5	6.4	37.1	2.3	34.8
June	40.1	6.1	34.0	2.4	31.6
July	37.3	6.4	30.9	2.0	28.9
August	34.6	5.7	28.9	1.8	27.1
September	25.3	5.2	20.1	1.8	18.3
October	22.9	5.4	17.5	1.8	15.7
November	21.4	5.2	16.2	2.1	14.1
December	19.1	5.1	14.0	1.7	12.3

the hospitals, and their only recourse was to send these men to duty. This involved sending such patients to a reception station where they were given 30 days' oversea leave. Following this leave, they were sent to a redistribution station where they generally remained for about 2 weeks, were then reexamined, and if no change was found were ordered to a station for duty. However, some of these men were returned to hospitals from the redistribution stations. Others were returned to hospitals after reaching their duty stations.

The attitude of most neuropsychiatric patients evacuated from overseas was that they had done their part. Almost all of them, without exception, wanted to get out of the Army. Very often, their psychiatric

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symptoms were complicated by defective attitudes and feelings of resentment toward the Army. These feelings were intensified when they were returned to duty and resubjected to military discipline and basic training. They objected to being given combat instruction when they had just come from combat-and especially by officers, commissioned and noncommissioned, who had never experienced actual battle, as was often the case. To add to the difficulties, there were few assignments available in which they could do productive work. With histories of having been returned from overseas as patients, it was easy for commanding officers to explain all of such persons' difficulties in terms of illness and refer them to hospitals.

Conflict Within the Surgeon General's Office

A vicious circle was developed of hospital to duty to hospital. It was easier to discharge patients from the service than to correct the inherent defects in personnel, training, and assignment policies. Representatives of the Surgeon General's Office took it upon themselves, contrary to the advice of the professional consultants in the same office, to solve the problem for the War Department (and at the same time to make much needed hospital beds available for others who were returning from overseas) by personally encouraging hospital commanders and medical officers (during visits to hospitals) to discharge by CDD practically everyone who returned as a patient from overseas. It seemed to matter little that this action was directly contrary to expressed War Department policy.²⁴

At the same time, representatives of the Neuropsychiatry Consultants Division continued to encourage medical officers to return to duty all those patients whom they felt were capable of doing duty. Their expressed policy and viewpoint was not to assume that a man was incapable of performing duty merely because he did not want to do duty. Hospital psychiatrists were confused by the conflict in verbal instructions they received from the professional consultants on the one hand and, on the other, from commanding officers of hospitals and other representatives of the Surgeon General's Office who were primarily concerned with making hospital beds available and avoiding public criticism.

An attempt was made to solve this problem in December 1944. A conference was arranged by General Menninger which was attended by representatives of other interested divisions of the Surgeon General's Office. The following considerations were presented by General Menninger:

1. The basic purpose of the Medical Department of the Army has always been to conserve manpower. In accordance with this, our principal objective should be to treat all those who need treatment and to return to duty as many men as possible.

2. The decision concerning a man's ability to do duty should not be based solely upon his ability to do full combat duty. Individuals vary considerably in their physical

²⁴A personal opinion from the experience of the author who was on duty in the Surgeon General's Office at this time. No documentation is available.-A. J. G.

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and mental (or emotional) capacities and it should be recognized that inability to perform combat duty over a long period of time does not necessarily imply illness. Stated in another way, those who are capable of performing limited service only are not necessarily sick. Extra demands placed upon an individual by combat service may produce symptoms of illness which disappear when an individual returns to activities which are more like those he has performed in civilian life. Therefore, the conclusion that those who had to be relieved from combat services are temporarily or permanently ill in a non-combat situation is not justified.

3. In determining whether or not a soldier is capable of performing duty, the Army as a whole and all its jobs should be considered. In general, an individual should not be discharged for disability when he is capable of performing limited service. The criteria or standards for disability discharges should remain consistent and fixed and only those who are actually disabled by disease or injury should be so discharged. This concept should not be confused by matters concerning compensation. Just because a soldier has incurred a condition or defect in the service and is therefore entitled to compensation, should not be adequate reason for his being discharged for disability. The Medical Department should be the only agency to determine who shall be discharged for disability. The criteria for such discharges should not be manipulated because of changing manpower needs.

4. The Medical Department should, therefore, be charged with the responsibility of returning to duty all those who are capable of doing duty. If there is no need for men with limited capacities at any given time, they should be released through administrative channels and perhaps return to a reserve status. It is conceivable that if the war were to last long enough, individuals with limited capacities might be required for full combat service, as apparently is now the case in the German Army. Discharging people for disability who are not really disabled, in addition to certifying them incorrectly as being incapable of performing any military service, is bad from a psychological standpoint. Many such individuals find it necessary to perpetuate their symptom upon return to civilian life in order to save face in their communities and to justify compensation, which they are not entitled to, on the basis of ill health. If the country feels indebted to such men for their military service, the compensation system should not be geared to the point where it is necessary for people to be invalids in order to obtain such compensation.

5. We are faced with the fact that the discharging of relative noneffectives had a bad effect on morale of those who remain in the service. Unfortunately, the present system of discharging has the effect of rewarding noneffectiveness. The use or abuse of medical channels to effect such discharges serves to aggravate the situation.

6. In relation to Paragraph I, it is the opinion of this office that any individual suffering from a psychoneurotic disorder, whether he be a Zone of the Interior or an overseas case, should receive treatment with the objective being to return to duty. When the Convalescent Hospital program was first developed, two considerations were paramount: 1.-That psychoneurotics did poorly in hospitals, where, because of lack of facilities and personnel, therapy could not be given, and, 2.-To make beds available in hospitals for those who were much more in need of hospital type care. The convalescent hospital then was to be a place where psychoneurotics could be treated, with the idea in mind that as many as possible would be returned to duty. It was on the basis of such an orientation that this office concurred in the plan which was proposed by the Hospital Division and Operations Service.

7. The opinion is expressed that no individual should be discharged from the service because of a psychoneurosis until he has been given the benefit of all the treatment we can give him in a Convalescent Hospital. Only those individuals who are too ill to be capable of performing limited service (and this should apply equally as well as to medical and surgical cases) should be CDD'd. In this connection, revision of MR 1-9 is indicated for the sake of consistency. If, for example, some psychoneu?

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rotics are retained in the service for limited duty, then all psychoneurotics should not be rejected at induction.²⁵ The flow into the Army of men with defects which qualify them for limited service only can be regulated according to the demands for such personnel. Those who are not needed at any one time can be accepted for service but kept on a reserve status in civilian life.

8. The present system of using discharges via medical channels to control the size of the Army leads to the abuse of medical channels. It is generally known that medical officers have obligingly placed labels on individuals in order to cooperate with command in getting men out of the service. ASF Circular 318 directs that careful consideration should be given to whether or not an individual's defect is disabling to a degree that warrants discharge on a certificate of disability. Clear distinctions should be drawn between defects which do not preclude duty and those which are incapacitating for service. The presence of a defect does not necessarily constitute adequate cause for discharge on CDD. This principle has not been followed except with regard to some psychoneurotic patients.

9. We feel strongly that men who have recovered from wounds or illness and are still ineffective as a result of defective attitude, or because 'they want to get out,' should not be labeled as psychoneurotics or anything else in order to regulate the size of the Army. To discharge such individuals as sick, even under Section X, is a miscarriage of medical practice.

The difficulties, however, were not resolved, and the abuse of medical discharges continued. In one convalescent hospital where patients returned from overseas with mild psychiatric disorders were sent, 98 percent of all neuropsychiatric patients who were discharged from the hospital were discharged for disability. In another convalescent hospital with similar patients, only 10 percent of all neuropsychiatric patients were discharged for disability. The general hospitals which had been designated as psychiatric centers and which received the more seriously ill psychiatric patients (including all psychoses) were returning a much greater percent of patients to duty than some of the convalescent hospitals. It is quite likely that patients who were discharged for disability from some convalescent hospitals were less sick than many who were returned to duty from other hospitals. Maj. Herbert S. Gaskill, MC, of the Psychiatry Branch, Neuropsychiatry Consultants Division, in his report of 25 July 1945 of a visit to Madigan Convalescent Hospital to the chief of the Operations Service stated that about 10 percent of psychiatric patients arriving from debarkation hospitals required little or no treatment, having largely recovered by the time they reached the hospital.

Restatement of War Department Policy

On 28 September 1944, the Deputy Chief of Staff had sent a memorandum to the Assistant Chief of Staff, G-1, on the subject of psychoneurotics which initiated considerable interoffice correspondence and

²⁵At about this time, perhaps as a result of this conference, a radiogram of 18 December 1944 was dispatched to all service commands (p. 171) which placed emphasis upon acceptance rather than upon rejection at induction stations. Further, it inveighed against indiscriminate discharge of limited-service personnel.-A. J. G.

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resulted in a special survey of the problem. The correspondence and the survey are discussed fully on pages 102-108 and in appendix E.

The outcome of this correspondence and the subsequent investigation was WD Circular No. 81, dated 13 March 1945. This circular was drafted by representatives of the Surgeon General's Office, the Air Surgeon's Office, the Inspector General's Office, and the Office of the Assistant Chief of Staff, G-1, and read as follows:

1. Administrative disposition.-a. The purpose of this circular is to state War Department policy in regard to administrative and medical disposition of noneffective personnel. Medical channels for evacuation, reclassification, and discharge are designed for the disposition of individuals who are sick or injured. Noneffectives who are not disabled are to be disposed of by the command through nonmedical channels.

b. An enlisted man upon maximum benefit of medical treatment whose condition warrants medical discharge will be discharged under the provisions of AR 615-361. Those enlisted men who have demonstrated inadaptability to military service but whose psychiatric or physical condition is not such as to warrant disability discharge will be disposed of as directed by the approved proceedings of a board of officers convened under AR 615-368 or AR 615-369. In such cases the appropriate commander will convene promptly the board of officers required under the appropriate regulation. Only experienced qualified personnel will be appointed to such boards. Commanding officers will make available to these boards such administrative assistance as is necessary.

c. When an officer has demonstrated inadaptability to his assignment, and his psychiatric or physical condition is not such as to warrant placing him before an Army retiring board, prompt measures will be taken to initiate reassignment or reclassification under AR 605-230.

2. Medical disposition.-a. The diagnosis of any type of psychoneurosis implies sickness and disability of some duration. It is not to be applied for reasons of expediency in order to effect a disposition. It will be applied only when its use is justified by the existence of a clinical picture which satisfies the criteria for psychoneurosis as established by good medical practice. The mere presence of psychoneurotic symptoms which do not significantly impair the individual's efficiency or the presence of a predisposition to psychoneurosis does not warrant the diagnosis of any type of a psychoneurosis. Such individuals if otherwise sound will be considered as having no disease.

b. The various types of psychoneurosis such as anxiety state, conversion hysteria, etc., are sufficiently well defined to justify their use without being prefaced by the term 'psychoneurosis.' This term will therefore no longer be used on individual clinical records. Instead the particular type or types of psychoneurosis and the severity will be recorded as the diagnosis. In every case this will be followed by a statement of the degree and nature of the external stress which has precipitated the disorder and an estimate of the extent of the individual's predisposition.

c. The terms 'operational fatigue' and 'exhaustion' are acceptable as working diagnoses for psychiatric disorders incurred as a result of combat or other severe stress until a definitive diagnosis has been established.

d. The diagnosis of psychoneurosis of any type will not be entered on the WD AGO Form 38 or WD AGO Form 63 of any individual being separated from the service except under AR 615-361 unless the diagnosis has been established by a board of at least three medical officers, one of whom shall be a psychiatrist.

e. In determining disposition of cases, it must be clearly understood that there are many causes for noneffectiveness other than sickness. Among these are inaptness, inadaptability due to emotional instability, lack of physical stamina, misassignment,

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defective attitude, and unwillingness to expend effort. Those who are ineffective by reason of any of these causes will be disposed of administratively.

f. There has been a tendency to attribute noneffectiveness to coexistent medical defects such as flat feet, lumbo-sacral strain, or mild psychoneurosis when actually these defects were not in themselves significantly disabling and the primary cause of the noneffectiveness was nonmedical, e.g., inaptness, inadaptability, defective attitudes * * *.

g. It should be clearly recognized that the presence of any type of psychoneurosis should not lead automatically to separation from the service. Many individuals with psychoneurosis recover or even if not fully recovered are capable of performing full duty. The disposition should depend solely upon the degree of incapacity after adequate treatment. In itself a mild psychoneurosis of any type will not be considered adequate cause for disability discharge. When an individual is suffering from a psychoneurosis which is not incapacitating he will be returned to duty.

h. When after careful medical evaluation, including psychiatric examination, it is the medical opinion that an individual has a condition which warrants consideration for discharge under provision of AR 615-368 or AR 615-369, and no condition is present which warrants discharge for disability, a certificate to this effect will be executed and forwarded by the psychiatrist to the individual's commanding officer, through medical channels. The certificate will include a statement specifying and describing the nonmedical condition in detail. Coexisting medical defects which do not warrant medical discharge will not be mentioned.

Abuse of Medical Discharge Continued

It was the first time that such a clear-cut expression of policy was made.²⁶ It was hoped that the problems of disposition of patients would be resolved. There followed some increase in the number of men returned to duty from hospitals, but abuses continued.

Commanders were reluctant to discharge men who had been overseas and in combat as inadaptable when they failed to conform to what was expected of them or in a passive way refused to do duty. There was the fear that the public and Congress would not understand how someone who had served honorably for several years and been in combat was being discharged as inadaptable.²⁷ Therefore, continued pressure was exerted on the Medical Department to dispose of them-and in many places, War Department policy continued to be flagrantly disregarded by medical officers who received support from those who were still primarily interested in the critical shortage of hospital beds.

'A full day's military duty'

The Surgeon General had thus far issued no written instructions concerning the conflicting views and pressures which resulted in confusion in the field. On 28 May 1945, he forwarded a letter entitled 'Medical

²⁶It is evident that General Menninger's views, as stated in pages 224-226, prevailed in the policy established by WD Circular No. 81.-A. J. G.
²⁷This was an understandable reaction on the part of commanders. However, it illustrates the malutilization of psychiatry and psychiatric diagnoses in dealing with problems of morale and motivation which, apparently, could not be realistically faced at that time.-A. J. G.

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Clarification of Disposition Policy' to all service commands. It included the following instructions concerning disposition of patients:

No patient should be returned to duty unless he can be expected to do an effective day's work in the military service. Many patients, especially those with prolonged hospitalization, reach maximum hospital improvement and leveling off but are unable to perform an effective day's duty. Patients in this group usually have not made the physical or psychological compensatory adjustments which are largely a function of time * * *. If a patient at the completion of his hospitalization has not reached a point where he can be expected to perform a normal day's effective work in the military service without probably readmission to the hospital system, he should be discharged on a Certificate of Disability Discharge.

Illustrative of the type of patients to be discharged on Certificate of Disability are,

(1) (Not applicable to NP Patients).

(2) All patients with neuropsychiatric disorders who are not able to perform a full day's military duty.

All patients with residual medical disabilities (reference to previous paragraph) should be discharged on Certificates of Disability Discharge.

Individuals who have no residual medical disabilities but who are found inadaptable for further service by reason of psychopathic personality, adult maladjustment and mental deficiency should be disposed of under the provisions of AR 615-369 (honorable but nonmedical discharge) if their record of service warrants honorable discharge.

To facilitate the discharge of the foregoing group of personnel, all hospital centers, general and convalescent hospitals should utilize appropriate boards * * *.

Where individuals in the [above] group have rendered service which has been other than honorable, they will be returned to duty for administrative discharge and will not be separated from the service, while members of the detachment of patients.

Unfortunately, this letter did not clear up all the confusion. With regard to the psychiatric patients, there were divergent opinions on what to do with the very large group of patients who had been evacuated from overseas, who had mild residual neurotic disorders, but who were judged completely ineffectual because of their poor attitudes toward the Army and their expressed desire to be discharged from the Army. There was wide variation in the interpretation of the phrase 'a full day's military duty.' Many medical officers, cognizant of the unavailability of appropriate assignments in the Zone of Interior and realizing that men sent to duty often were put through basic training or given work which was just designed to keep them busy, were reluctant to recommend many men for duty. The number of CDD's continued to increase although it was generally recognized that a large proportion of the men being discharged for psychiatric disorders were at the time of discharge considered perfectly capable of doing a 'full day's work' in civilian life.

It was the consensus of the service command neuropsychiatric consultants and of the Neuropsychiatry Consultants Division that, of the patients arriving at convalescent hospitals from overseas with psychiatric diagnosis, approximately 25 percent had no psychiatric disability which warranted hospitalization. Yet, only about 15 percent of all the psychiatric patients who were disposed of in all the Zone of Interior

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convalescent hospitals during May and June of 1945 were returned to duty.

Further conflict within the Surgeon General's Office

To make matters worse and in direct conflict with existing War Department directives, The Surgeon General issued the following letter, on 11 September 1945:

On the basis of detailed surveys recently completed of all convalescent hospitals, both by military and civilian consultants, the following clarification is offered concerning the disposition of patients:

a.Type of Disposition: No patient should be returned to duty unless he is general duty.

b. Method of Discharge: All patients with residual medical disabilities should be discharged on Certificates of Disability Discharge.

c. Individuals who have no residual medical disabilities but who are considered inadaptable for further service should be disposed of under the provisions of AR 615-369, if their record of service warrants honorable discharge.

This, in effect, constituted an open invitation to CDD practically every patient who was evacuated from overseas since 'general duty' implied 'combat duty,' and practically none of this group could be so classified because of some limitation-physical or psychological.

The 'military and civilian consultants' referred to in the letter did not include any member of the Neuropsychiatry Consultants Division, nor any of the service command neuropsychiatric consultants, all of whom had on many occasions voiced opposition to such a policy.

The subject was brought up at a meeting of the War Department General Council on 5 November 1945.

On 23 November 1945, a representative of G-1 informed The Surgeon General that the matter of abuse of CDD's in convalescent hospitals had been discussed at the meeting of the General Council, and 6 days later, The Surgeon General's letter of 11 September 1945 was rescinded.

FINAL POLICY

It was not until 29 December 1945, 4 months after the war had ended, at a time when the matter had ceased to be important, that the final chapter was written. On that date, WD Circular No. 391 was issued, with the following instructions:

1. Enlisted personnel hospitalized in the United States will be disposed of in accordance with the provisions of this circular. Every effort will be exerted to return to duty all enlisted hospitalized personnel who can be expected to render effective military service of any type.

2. a. Enlisted personnel physically unfit for further effective service in the Army will be discharged in accordance with the provisions of AR 615-361 after maximum benefit from Army hospitalization has been obtained.

b. Enlisted personnel physically fit for return to limited assignment or general

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service duty (see WD Cir. No. 217, 1944, and WD Cir. No. 196, 1945) but who are eligible for separation from the Army under existing provisions of age, points, service, dependents, etc., will, as soon as maximum benefit from Army hospitalization has been obtained, be transferred on a duty status, direct from the hospital to the separation center, nearest his home.

c. Enlisted personnel physically fit to return to an appropriate duty assignment (general or limited service in accordance with the provisions of WD Cir. No. 217, 1944, and paragraph 4, WD Cir. No. 196, 1945) and who are not eligible for discharge under current directives will be disposed of as follows:

(1) Those likely to render effective service upon return to duty will be returned to an appropriate duty assignment.

(2) Those unlikely to render effective service upon return to duty by reason of likelihood of early recurrence of incapacitating symptoms as a result of continued military service, but who can be returned to civilian life without likelihood of such recurrence, will be transferred to the detachment of patients if not already so assigned, and ordered, on a duty status, to the separation center nearest their homes for discharge under the provisions of AR 615-365, and this circular. This procedure will not be utilized to discharge those individuals who should be discharged under the provisions of AR 615-368 or AR 615-369.

PSYCHIATRIC NOMENCLATURE

Psychiatric nomenclature which was barely adequate for civilian psychiatry was totally inadequate for military psychiatry. Use of the generic term 'psychoneurosis' for all types and severity of neurotic disorders placed all individuals so labeled in a single category, the variations of which were never appreciated by line officers.²⁸ Unfortunately, the term 'psychoneurosis' was often confused with the term 'psychosis,' and many individuals diagnosed as psychoneurosis were looked upon with suspicion of insanity by their associates and officers since both words contained the basic syllable 'psycho' which is, and was, a commonly used lay colloquial term for designating a major mental disorder.

Adding to the difficulties of nomenclature were such blanket statements²⁹ as 'there is no classification duty for patients with neuropsychiatric disorders' and 'greater care will be taken * * * to prevent all individuals predisposed to or suffering from psychoneurosis * * * or having a proven history of such from entering the military service.'

As stated previously, the criteria for the diagnosis of psychoneurosis were not uniform. The Inspector General found in a survey of many medical installations both in the Zone of Interior and overseas that the diagnosis of psychoneurosis was being abused by medical officers-that it was being applied to cases of transient situational maladjustments and of character and behavior disorders.

It appeared that, once a soldier was placed on limited duty or recommended for limited assignment because of an emotional disorder, it was unusual for him to ever revert to general service, because of the possibility

²⁸One could add: Also not understood or appreciated by medical officers, including psychiatrists.-A. J. G.
²⁹War Department Memorandum No. W600-39-43, 26 Apr. 1943.

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of a recurrence of his difficulty. A prevalent misconception was that psychoneurotic disorders would develop in all such predisposed individuals whenever they were exposed to any stressful situation.

Psychoneurosis became practically a household word, and there was hardly a soldier who was unfamiliar with the word 'psycho.' To differentiate between cases of chronic psychoneurotic disorders and those which developed as a result of the stress of operational or combat flying, to minimize the stigma of a psychiatric diagnosis, and to emphasize the situational aspects and lack of permanence of the disorder, the Air Forces adopted the terms 'operational fatigue' and 'flying fatigue' for those cases of psychoneurosis which resulted from the stress of hazardous or combat flying. This concept was quickly and widely adopted by Ground and Service Forces combat units where the term 'exhaustion' and later 'combat exhaustion' and 'combat fatigue' were used for those emotional disturbances which resulted from the stress of combat.³⁰

The use of these terms was remindful of the term 'shell shock' which became the wastebasket for neuropsychiatric diagnosis in World War I. Before long, the terms 'operational fatigue,' 'flying fatigue,' 'combat exhaustion,' and 'combat fatigue' were applied to cases other than those which were combat incurred. In many instances, it was applied to men who had never been in combat and even to men who had never left the continental limits of the United States. Other difficulties encountered were: According to an official ruling, Air Forces personnel hospitalized for 'flying fatigue' could receive flight pay, while hospitalized, similar to personnel with physical injuries or disease. However, if the diagnosis was psychoneurosis, they were not eligible to receive flight pay-on the assumption that it was not the result of an injury or disease.

To effect some standardization in the use of such terms and to dispel the existing confusion, The Surgeon General issued the following directive in October 1943:³¹

In certain theaters it has been found that the term 'psychoneurosis' produced in the patient's mind the idea of war causation and incurability and thus materially interfered with recovery. The term 'exhaustion,' on the other hand, implied to the patient nonspecific etiology, natural occurrence, and speedy recovery. It was also in a measure true, in that in the majority of cases this exhaustion was a strong contributory factor. If it is found expedient to use the term 'exhaustion' as a preliminary diagnosis for combat neuropsychiatric casualties, the term should be employed only on the emergency medical tag and the case rediagnosed with the proper diagnostic term on the field medical record. The use of the term 'exhaustion' for psychoneurosis will be confined to cases developing under enemy action. Cases of exhaustion free from

³⁰The term 'exhaustion' was first used in a II Corps directive issued in April 1943 to designate combat psychiatric casualties. Later, NATOUSA (North African Theater of Operations, U.S. Army) directives continued to direct the use of this diagnosis. In the same sense, the Marine Corps utilized 'fatigue' and 'combat fatigue' for the psychiatric casualties of the Guadalcanal fighting. A full discussion of the origin of the term 'exhaustion' is contained in 'Medical Department, United States Army. Neuropsychiatry in World War II. Volume II. Oversea Theaters' [in preparation].-A. J. G.
³¹Circular Letter No. 176, Office of the Surgeon General, U.S. Army, 20 Oct. 1943.

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psychiatric components and essentially 'physical in nature' will be qualified with an appropriate term in addition to the word 'exhaustion,' for purposes of differentiation.

Change of psychiatric nomenclature.-In September 1944, the Deputy Chief of Staff requested the Assistant Chief of Staff, G-1, to study the entire problem of psychoneurosis (p. 102) for the purpose of 'determining what improvements could be made in Army procedures and publicity in the handling of psychoneurotics.' He stated:

A competent authority has expressed the fear that in their enthusiasm the psychiatrists within the Army are overdoing their diagnosis of psychoneurosis and are overdoing the publicity on this subject. If the War Department builds up a clinical record and a diagnosis that a soldier is a psychoneurotic it will probably impair the individual's future civilian usefulness and may greatly increase the number of men dependent upon Government disability allowance. In many of these cases the individual became a psychoneurotic because he was unable to adjust himself to his position in the Army. Many of these individuals will have no difficulty in returning to their former civilian environment and will be normal in every respect in continuing a way of life to which they were accustomed and adjusted prior to their induction in the Army. If they are labeled as psychoneurotics their former employers will be reluctant to take them and the individual concerned will become convinced that he cannot readjust himself to his previous civilian environment. It is understood that the Navy is now diagnosing these cases as 'No disease. Temperamentally unqualified for Naval service.' It is suggested that the Army may well use a similar diagnosis.

Shortly afterward, the Air Surgeon requested The Surgeon General to call a conference for the purpose of standardizing nomenclature and defining terms which were then in use.

In connection with the request of the Deputy Chief of Staff for a report on the problem of psychoneurosis, The Surgeon General made the following comments in a comprehensive report to G-1:

It has been suggested that the word psychoneurosis be changed to something else that is less imposing and frightening. This office has consistently maintained that the word is an accepted medical term with a specific meaning and that if a new word were substituted, it would soon carry with it all the associations of the present one. Any stigma which is attached to the diagnosis would carry over to any other word used in its place. Cancer or syphilis called by any other name would still be the same. The difficulty is not with the term but rather with the attitude toward and understanding of the term. Furthermore, much of this existing confusion and misunderstanding can be traced to the fact that psychoneurosis was called 'shell shock' in the last war. To introduce still another misnomer at this juncture could not but lead to even further misunderstanding. The solution is believed to be in education rather than evasion of the term.³²

On 25 January 1945, The Surgeon General called a conference which was attended by the civilian consultants in neuropsychiatry to the Secretary of War and by representatives of the Veterans' Administration, the

³²In retrospect, the repeated defense of the term 'psychoneurosis' by the psychiatrists in the Surgeon General's Office was an error as demonstrated later by the successful effort of Menninger et al. (p. 232) in introducing a new psychiatric nomenclature in which two new categories, the 'transient personality reactions' and the 'immaturity reactions,' made unnecessary the wholesale usage of the term 'psychoneurosis.' These new categories have now been used successfully for years, including the Korean War period.-A. J. G.

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Air Surgeon's Office, the Bureau of Medicine and Surgery of the U.S. Navy, the U.S. Public Health Service, and the Surgeon General's Office. It was the consensus of the conferees that, whenever possible, a psychiatric diagnosis should include four parts:

1. The type of disturbance or disorder.

2. The external precipitating stress which caused the disorder.

3. The extent of the predisposition.

4. The degree of impairment of functional capacity resulting from the disorder.

It was also agreed that the term 'psychoneurosis' should be regarded as an inclusive term which could be omitted from the more specific diagnoses, such as anxiety reaction or conversion reaction.

These recommendations were included in The Surgeon General's memorandum to G-1 on the subject of psychoneurosis and were later adopted by the War Department³³ and appropriate instructions issued to the field (see 'Medical Disposition,' a, b, and c, p. 225).

The method of recording the diagnosis of psychoneurosis was elaborated upon in a later publication³⁴ which outlined the criteria to be used in describing the severity of stress, the degree of predisposition, and the amount of incapacity.

War Department Technical Bulletin (TB MED) 203.-The final step in the modernization of psychiatric nomenclature was taken when a markedly revised list of standard diagnoses was published in TB MED 203 and issued on 19 October 1945. The new nomenclature was the work of General Menninger over a period of 14 months. He personally solicited the opinions and recommendations of over 100 of the outstanding psychiatrists in the country and made numerous revisions until the final draft was accomplished. The dynamics of psychopathology was chosen as the basis for the classification of the psychoneuroses.

A new group was added-the transient personality reactions to acute or special stress. It included such disorders as combat exhaustion and acute situational maladjustment. The term 'psychopathic personality' was eliminated and replaced by 'character and behavior disorders' which were subdivided into: (1) Pathological personality types, (2) addiction, and (3) immaturity reactions. The term 'somatization reaction' was also introduced. It included all of the so-called 'organ neuroses.'

All of the needed changes were thereby brought about. No longer did the diagnosis of psychoneurosis appear with annoying frequency. The four-part diagnosis permitted individualization and, in effect, represented a brief description of the case. A more dynamic system was substituted, and some of the undesirable categories were eliminated.

³³War Department Circular No. 81, 13 Mar. 1945.
³⁴War Department Circular No. 179, 16 June 1945.

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LINE-OF-DUTY DETERMINATION OF NEUROPSYCHIATRIC DISORDERS

Initial Criteria

Because of the chronic nature of most neuropsychiatric disorders, peacetime criteria for LD (line-of-duty) determination were continued during the early days of the war. They were based on the knowledge that 'in many chronic diseases and degenerative conditions, symptoms appear only after many months or even years, and that in such conditions incapacitating defects may arise as a natural consequence of the disease and not as the logical incident or probable effect of duty in the service.'³⁵

All cases of dementia praecox, manic depressive psychoses and psychoses of a similar nature, and psychoneurosis developing within 6 months after entry into active military service were to be regarded as having existed prior to service. Cases developing after 6 months' active duty were to be regarded as having been incurred in line of duty '* * * when a careful review of the past history fails to elicit evidence of mental abnormality or functional nervous disorder before the original entrance into active military service or during the first six months of such service.'³⁶ It was permissible to use medical judgment in making the LD determination.

Revision

In May 1944, to conform with Veterans Regulations No. 1 and to facilitate the adjudication of claims for pensions, the criteria for determining line of duty were revised. The new criteria were based on the assumption that, lacking evidence to the contrary, a disease or injury was service connected and, therefore, in line of duty-unless it resulted from misconduct or neglect, or occurred while absent without official permission or out of activities not connected with the service.

The Veterans Regulations provided:

Every person employed in the active military or naval service shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of enrollment or where clear and unmistakable evidence demonstrates that the injury or disease existed prior to * * * enrollment and was not aggravated by such active military or naval service.³⁷

Under this regulation, length of service per se was no longer to be a decisive factor. The important considerations were (1) what was written down in the findings of the induction physical examination and (2) clear and unmistakable evidence concerning the disease or disorder.

All cases of psychosis and psychoneurosis were, therefore, to be con?

³⁵Army Regulations No. 40-1025, Changes No. 1, 21 Aug. 1942.
³⁶Ibid.
³⁷Veterans Regulations No. 1 (a), pt. 1, par. 1 (b), as amended by Public Law No. 144, 78th Cong.

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sidered 'in line of duty' except where there was clear and unmistakable evidence that the disorder existed prior to entry into the service and that it was not permanently aggravated by service.

When these guides were incorporated in AR 40-1025, 12 December 1944, upon the recommendation of the Neuropsychiatry Consultants Division, the following addition was included with reference to neuropsychiatric disorders:

Whenever 'permanency' of aggravation must be established, as in determination of eligibility for retirement benefits, an aggravation (of a psychiatric disorder) will not be considered permanent if it is purely situational and if it is evident that it will be removed, with reversion of the disorder to its previous degree of severity, within a reasonable time upon return to civilian life.

Defects of revision.-While in many induction stations, great care was exercised in performing and recording the results of the medical histories and examinations, there were other stations where, because of the large volume of work and shortage of medical officers, the psychiatric portion of induction physicals was performed in a perfunctory fashion. For example, in one induction station, it was necessary to process 600 men each day and, with just 1 psychiatrist, approximately 30 seconds were devoted to the neuropsychiatric portion of the examination. Here, thorough and intensive study of each man was not possible, neuropsychiatrically or any other way. (This was in contrast to other induction stations located in metropolitan areas where availability of psychiatrists permitted much more careful evaluation.) Therefore, to assume that complete and careful examinations could be performed on every man entering the service during wartime was unrealistic.

In many instances where men related histories of epilepsy, nervousness, headaches, and weakness, but were unable to supply 'proof' that these conditions existed before acceptance into the service and no objective evidence of these conditions were apparent on examination, the men were inducted often without notation being made on their induction records. When these men were later discharged and applied for pensions, there was no clear and unmistakable evidence (if the individual chose to change his story) to prove that the condition existed prior to induction, and nothing to contradict a claim of aggravation.

The effect of a law (Veterans Regulations) which placed the responsibility on the Government for any illness which occurred in military personnel during wartime was (1) to increase the rate of rejections and (2) to cause the Government to pay pensions to men whose conditions existed before entry into the service and were not truly aggravated by service.

A great deal of publicity had been given to the cost of caring for the many neuropsychiatric casualties of World War I, and those psychiatrists who were impressed with the figures undoubtedly rejected many men who were borderline cases, but who might well have made good adjust-

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ments in the Army, in order to avoid the possibility of their becoming responsibilities of the Government. They did this in compliance with directives which were written with those same considerations in mind.

A trial period of duty with administrative discharge for preexisting defects which are discovered during that time would have had the effect of allaying the fears of examining psychiatrists and would have decreased the number of rejections at induction. Further, by such a trial period, the Government would have been spared the responsibility for illnesses which were not truly service connected.³⁸

SPECIAL PROBLEMS

Enuresis

The problem of bed wetting has bothered armies for time immemorial. Bed wetting subjects the individual to the taunts of the others, results in some loss of sleep, introduces the complication of increased linen and bedding requirements if malodorous situations are to be avoided, increases the possibility of exposure to cold or inclement weather when in bivouac, and makes for difficult situations under crowded housing conditions, such as on troop transports.

Traditionally, the Army attitude toward nocturnal enuresis (which was not the result of organic disease) was that of an 'undesirable habit' and handled such cases in several ways. One method was to turn the individual over to a proverbial tough sergeant who by such techniques as having the man awakened every hour throughout the night or pitiless ridicule was supposed to cure him. This, however, was by no means the usual manner of dealing with cases of nocturnal enuresis.

Another method was developed at Camp Abbot, Oreg., where the post commander, in September 1943, established an enuresis tent near the post stockade under the supervision of the provost marshal for all military personnel suffering from enuresis, cause undetermined.³⁹ Its purpose was for 'training in self-regulation and self-discipline.' Company commanders upon learning of repeated bed wetting of any member of their commands were required to report the individual to the post inspector who, if the facts so warranted, would refer the individual to the provost marshal. The individual continued in training with his organization but was not permitted to drink 'cokes,' beer, or soft drinks at any time, was permitted coffee only for breakfast, and received no pass or furlough privileges except in cases of emergency. He was delivered to the provost marshal one-half hour after the evening mess call and was permitted no fluids from supper to reveille. He was awakened every 2 hours during the night and

³⁸This describes the common Navy philosophy and practice of administrative separation of noneffective trainees during the initial training phase (boot camp.-A. J. G.
³⁹Administrative Memorandum No. 25, Camp Abbot, Oreg., 16 Sept. 1943.

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taken to the latrine. Or, discharge for undesirable habits might be recommended and separation from the service effected with either 'blue' (without honor) or 'white' (honorable) discharge, depending upon the individual commander's discretion.

As time went on, the attitudes toward and the management of enuresis became more medically and psychiatrically oriented. Thorough medical workup was given in most posts to exclude the possibility of organic genitourinary or nervous system disease. In some stations, medical discharges were given even when no organic disease was found.

Policy and procedures for dealing with enuresis were not uniform until 1 January 1944 when section VIII, AR 615-360, was modified by changes No. 18, as follows:

It is now a generally accepted medical and psychiatric opinion that enuresis is not necessarily a habit, but rather may be a symptom of some underlying mental or physical condition. Underlying causes of enuresis may be organic disease, psychoneurosis, psychosis, mental deficiency, psychopathic personality or lack of proper juvenile training.

Generally, if the case is studied completely, one of the above diagnoses will be established. Therefore, in each case a complete mental and physical evaluation of the person afflicted will be done by qualified medical officers and a decision made as to disposition. If the individual is to be discharged, decision will be made as to the appropriate section of these regulations to be utilized. The type of discharge should also be decided solely on the merits of each individual case and governed by the nature of the determined underlying cause rather than by the resultant enuresis.

When the conduct of an enlisted man was such as to render his retention in the service desirable except for his enuresis, an honorable discharge was to be given. Relatively few cases of enuresis were found to be due to physical or mental disease; a majority were considered to be due to 'lack of proper juvenile training'-but the practice of penalizing this unhappy group with 'blue' discharges was discontinued.

No differentiation was made before 1944 between enuresis as a habit reaction-symptomatic of immaturity-and enuresis as a symptom of some organic disorder (s). Therefore, no data for admissions for enuresis (in its psychiatric connotation) are shown in table 6, dealing with neuropsychiatric admissions in World War II, for the period before 1944. However, if all types of enuresis were taken into account, some 20,000 persons were admitted with such a diagnosis during World War II, indicating an admission rate of 8 per 10,000 mean strength per year.⁴⁰

Homosexuality

There was a similar evolution in the disposition of homosexuals. Initially, all cases of homosexuality who were not tried by courts-martial (where offenses were involved) were given 'blue' discharges. A man on his own initiative or because of noticeable difficulty in adjusting might

⁴⁰For further details, see footnote 1 to table 6, p. 216.

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visit or be sent to a psychiatrist for consultation. When it was ascertained that the basis of the maladjustment was homosexuality and this was reported to the individual's commanding officer, the subject usually received a 'blue' discharge. Objections to this harsh practice were raised by many homosexuals whose attempts to receive help from a medical officer resulted in their being discharged 'without honor.' Further, confidence in medical officers was undermined by the Army requirement that these officers report even those confidential statements given in a professional consultation. The homosexual was being singled out as a result of irrational prejudices, even though he was no more responsible for his aberration than the mental defective was responsible for his central nervous system pathology. World War II data indicate that some 5,500 persons were admitted to hospitals with a diagnosis of 'pathological sexuality,' primarily 'homosexuality.'⁴¹

Col. Roy D. Halloran, MC,⁴² who was chief of the Neuropsychiatry Consultants Division in the early part of the war, while feeling that the problem of homosexuality had not created serious difficulties, attributed some progress in the handling of the problem to the publication of WD Circular No. 3, issued on 3 January 1944. This directive permitted the giving of a 'blue' discharge to an offender who was not deemed reclaimable, in lieu of court-martial, and provided for hospitalization of those who were deemed reclaimable. Included in the reclaimable category were those who were guilty of first offenses, those who acted as a result of intoxication or curiosity, or 'those who acted under undue influence, especially when such influence was exercised by a person of greater years or superior grade.'

The commanding officer of the hospital at which such an individual was hospitalized was required to transmit to The Adjutant General (and to theater headquarters, if overseas) a full report of the diagnosis, treatment, results of treatment, and recommendation as to disposition, to be kept on file. Depending upon the results of treatment, the individual was returned to duty or separated from the service or tried by court-martial, this decision being made by higher authority. If returned to duty, the reclaimed offender was then assigned to a different organization so that he could start anew.

Actually, there was little in the way of individual intensive treatment that could be given to such men in a military setting.⁴³ Adequate evaluation was possible, however. It is not known just how many homosexual offenders were salvaged for further duty under this system, but probably less than 1,000. The fact that any were salvaged is significant.

⁴¹In regard to statistical data on homosexuality, one can agree with Menninger that such data 'are probably of little if any importance as an indication of either the true incidence or significance of the problem * * * Probably for every homosexual who was referred or came to the Medical Department, there were 5 or 10 who never were detected.' (Menninger, William C.: Psychiatry in a Troubled World. New York: The Macmillan Co., 1948, pp. 226-227.)-A. J. G.
⁴²Halloran, R. D.: Problems of Neuropsychiatry in United States Army. M. Ann. District of Columbia 13: 17-23, January 1944.
⁴³In all fairness, it should be recognized that few homosexuals were or are given individual intensive psychiatric treatment in civil life.-A. J. G.

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Neither Army regulations nor WD Circular No. 3 specified the method of disposition of a homosexual who was not guilty of any offense. It was common practice, however, to give 'discharge without honor' (blue) to any individual discharged because of homosexuality, on the premise that homosexuality constituted an undesirable trait of character.

To correct this practice, the Surgeon General's Office recommended a change in Army regulations⁴⁴ to indicate that only those homosexuals who were guilty of sexual misconduct in the service should be considered for 'blue' discharges. Further, that those who were not guilty of any sexual offense and who had a satisfactory record of service should be given an honorable discharge. Concurrence in this, however, could not be obtained from other War Department agencies because it was feared that many adjusted homosexuals would seek to be discharged and that others might claim to be homosexual for the purpose of being separated from the Army with honorable discharges.

Without prior knowledge of the Surgeon General's Office, a change to AR 615-368 was issued about a month later to the effect that 'the mere confession by an individual to a psychiatrist that he possesses homosexual tendencies will not in itself constitute sufficient cause for discharge * * *."⁴⁵ Provision was made for hospitalization upon the recommendation of the psychiatrist for the purpose of determining if the individual should be restored to duty or separated from the service. The implication was that if separated it would be with a 'blue' discharge.

After a series of conferences with representatives of the major forces of the Army, a memorandum was forwarded in July 1945 by The Surgeon General to the Assistant Chief of Staff, G-1, expressing the opinion that 'personnel who were inadaptable for service by reason of homosexuality were entitled to honorable discharges providing they were guilty of no offense and their service had been honorable and faithful.' It was pointed out that when an individual voluntarily sought medical assistance and this resulted in a 'blue' discharge, faith in medical officers was lost, and in effect, such an individual was given the same consideration as one who had committed homosexual offenses and whose services had not been satisfactory. It was suggested that a person with homosexual tendencies was no more responsible for his condition than was one with mental deficiency. Men in the latter category were given honorable discharges when released because of inaptness.

This memorandum resulted in the preparation of a confidential letter, in the Adjutant General's Office, on the disposition of homosexuals. This letter, dated 31 October 1945, was addressed to all commanding officers

⁴⁴Army Regulations No. 615-368, 7 Mar. 1945. (Section VIII, AR 615-360, was replaced by AR 615-368-Undesirable Habits or Traits of Character, Enlisted Men, Discharge, dated 20 July 1944; and AR 615-369-Enlisted Men, Discharge-Inaptness, Lack of Required Degree of Adaptability or Enuresis, dated 20 July 1944.)
⁴⁵Army Regulations 615-368, Changes No. 1, 10 Apr. 1945.

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having general court-martial jurisdiction.⁴⁶ From the psychiatric standpoint, it represented great progress in the solution of this highly charged problem. It provided for honorable discharges (under the provisions of AR 615-369) of enlisted personnel who were released because of lack of adaptability resulting from homosexual tendencies, and who had committed no sexual offenses while in the service. It did not imply that all confessed homosexuals should be discharged merely on the basis of a confession of homosexuality. Officers who were found to be inadaptable for service as a result of homosexual tendencies were permitted to resign for the good of the service. A report of medical examination, including psychiatric examination, was required to be forwarded with the letter of resignation. Where no sexual offense had been committed and where record of service justified an honorable discharge, upon review, the qualification 'for the good of the service' would be disregarded and resignation under honorable conditions accepted.⁴⁷

Malingering

The subject of malingering⁴⁸ comes to the foreground in every war-but perhaps less in this war than others because of greater understanding of the dynamics of human behavior.⁴⁹ Certain line officers and tough first sergeants would from time to time insist that most individuals with functional disorders were fakers or cowards and initially handle them accordingly. Many others may have had similar opinions but did not translate their thoughts into words or actions. Never during the war did there develop a witch hunt for malingerers. There are no reliable medical statistics available on the frequency of malingering since it was not included as a medical diagnosis. Where an individual was suspected of malingering, a diagnosis of 'No Disease' was usually entered on the clinical record. It was then left to that person's commanding officer to prefer charges, if he so desired. If charges were preferred, the ultimate decision concerning the existence of malingering was resolved by court-martial.

The following figures on the number of cases tried for malingering (excluding self-inflicted wounds) and the number found guilty during the war were obtained from the Office of the Judge Advocate General:

⁴⁶This came out on 23 March 1946 as WD Circular No. 85.
⁴⁷The achievement of a more enlightened management of the homosexual problem during the end phase of World War II was rapidly lost in the postwar years. A revision of AR 615-368, issued on 14 May 1947, deleted any reference to or procedure for reclaiming homosexual offenders and made it increasingly difficult to obtain an honorable-type discharge for the confessed homosexual who had committed no offense in the service. However, the last chapter on Army policy for dealing with homosexuality (AR 635-89, 8 Sept. 1958) provided that self-confessed homosexuals or other homosexuals with no provable offense in the service (so-called Class III) were required to be given an honorable-type discharge.- A. J. G.
⁴⁸This subject (with others in this chapter) is comprehensively reviewed by William C. Menninger, in Psychiatry in a Troubled World. New York: The Macmillan Co., 1948.
⁴⁹Halloran, R. D.: Problems of Neuropsychiatry in United States Army. M. Ann. District of Columbia 13: 17-23, January 1944.

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	Number of cases
	Tried	Guilty
July 1941-July 1942	3	2
July 1942-July 1943	5	3
July 1943-July 1944	10	8
July 1944-July 1945	28	25
July 1945-December 1945	1	1

It was, however, the consensus of medical officers that exaggeration of existing disorders and not malingering-for the purpose of avoiding duty-was not uncommon. This practice, however, was by no means confined to those with neuropsychiatric disorders. Patients with arthritis or sinusitis were as apt to demonstrate this common trait as were those with psychoneurosis. The psychopath with an established pattern of deceitful

TABLE 9.-Percent distribution of admissions for neuropsychiatric disorders and psychiatric disorders, by diagnosis, U.S. Army, 1942-45¹

Diagnosis	Percent
Diagnosis	Total (worldwide)	Continental United States	Overseas theaters
	Neuropsychiatric Disorders
Neurological disorders:
Epilepsy	1.6	2.1	0.9
Other	14.2	13.7	14.9
Total	15.8	15.8	15.8
Psychiatric disorders:
Psychosis	6.1	5.6	7.0
Psychoneurosis	58.8	57.5	60.8
Character and behavior disorders:
Pathological sexuality	0.5	0.6	0.4
Asocial and antisocial personality types	.2	.3	.2
Immaturity reactions	6.1	7.3	3.9
Alcoholism	3.9	3.7	4.1
Drug addiction	.1	.2	.1
Enuresis	¹NA	¹NA	¹NA
Total	10.8	12.1	8.7
Disorders of intelligence	2.6	3.6	1.1
Other psychiatric disorders	5.9	5.4	6.6
Total psychiatric disorders	84.2	84.2	84.2
Total neuropsychiatric disorders	100.0	100.0	100.0
	Psychiatric Disorders
Psychiatric disorders:
Psychosis	7.3	6.6	8.3
Psychoneurosis	69.8	68.4	72.2
Character and behavior disorders:
Pathological sexuality	0.6	0.7	0.5
Asocial and antisocial personality types	.3	.3	.3
Immaturity reaction	7.3	8.7	4.7
Alcoholism	4.5	4.4	4.8
Drug addiction	.1	.2	.1
Enuresis	¹NA	¹NA	¹NA
Total	12.8	14.3	10.4
Disorders of intelligence	3.1	4.3	1.3
Other psychiatric disorders	7.0	6.4	7.8
Total psychiatric disorders	100.0	100.0	100.0

'NA' signifies "Not Available.'

behavior was perhaps the one in whom simulation or true malingering was most consistently found. In combat, cases of suspected self-inflicted wounds and simulated amnesias were seen. It was extremely difficult, however, to definitely prove malingering.

The subject came up for discussion in relation to the prevention of psychiatric disorders. It was reported by the Inspector General, following the survey of the subject of psychoneurosis in the European theater in the spring of 1945, that 'the combined expression of many combat experienced line officers reflects their belief that stronger disciplinary action against malingerers, deserters and individuals proved to be suffering from self?inflicted wounds would greatly decrease the number of psychiatric casualties.' It was therefore recommended to the Deputy Chief of Staff that disciplinary examples should be made and sentences enforced in proved cases. The Surgeon General who concurred in this view was requested to prepare the appropriate directive, subsequently issued on 29 September 1945 as WD Circular No. 298. In preparing the directive, great care was taken to point out the difficulties involved in positively establishing a diag?

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nosis of malingering so that injustice would not be done to those with psychoneuroses who were often looked upon with suspicion by uninformed line officers. Unfortunately, this much needed clarification appeared after the war had ended, and its effect was never determined.

FREQUENCY OF NEUROPSYCHIATRIC DISORDERS

There were somewhat over 1,103,000 admissions with a diagnosis of a neuropsychiatric disorder in World War II. Somewhat over 174,400 admissions were for neurological disorders, and 929,000 admissions for psychiatric disorders (table 6).

Neurological Disorders

The World War II admissions for neurological disorders constituted 15.8 percent of all admissions for neuropsychiatric disorders. These percentages were the same for continental United States and for overseas (table 9). The World War II admission rate for neurological disorders was 6.9 per 1,000 mean strength per year. By year, the highest admission rate (8.3) occurred in 1943 (table 6); by month, the highest rate was in August 1943-9.9 per 1,000 mean strength per year (table 7 and chart 2).⁵⁰

Psychiatric Disorders

Admissions for psychiatric disorders constituted 84.2 percent of all World War II admissions for neuropsychiatric disorders. Among the specific psychiatric disorders, psychoneurosis was the most prominent.

Psychoneurosis

There were some 648,500 admissions in World War II with a diagnosis of psychoneurosis. This diagnosis constituted 58.8 percent of all admissions for neuropsychiatric disorders, or 69.8 percent of the psychiatric disorders (table 9). This admission rate for psychoneurosis for the entire World War II period was 25.6 per 1,000 mean strength per year. As just indicated, this rate fluctuated widely; it rose from a yearly rate of 16.7 in 1942 to a yearly rate of 29.9 in 1944. (See tables 6 and 8 and chart 2; the diagnostic category marked 'other' is mainly psychoneurosis.)

By far, the most common types of psychoneurosis in World War II were the anxiety reactions. Somatization reactions were extremely common with psychogenic gastrointestinal disorders⁵¹ heading the list in this

⁵⁰For a detailed analysis of the neurological disorders by specific diagnoses, see chapter XVIII, 'Neurology.'
⁵¹Halstead, J. A.: Gastrointestinal Disorders of Psychogenic Origin; Management in Forward Areas. Bull. U.S. Army M. Dept. 9: (suppl.) 163-180, 1949; and The Management of Soldier's Stomach Among Combat Infantrymen: Evaluation of Psychiatric and Physical Factors. J. Nerv. & Ment. Dis. 105: 116-123, 1945.

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category and psychogenic cardiovascular reactions being next most frequent. In one survey, 66 percent of an unselected series of psychoneuroses in general hospitals in the Zone of Interior showed some psychogenic somatic disturbances of clinical importance. In 27 percent of the cases, the organic dysfunction was the primary and chief difficulty.

Major conversion reactions manifested by paralyses, convulsions, deafness, blindness, and the like were considered to be much less common than they were in World War I-and were most apt to occur in individuals with limited or defective intelligence.

Predisposition versus stress.-The vast majority of men who were hospitalized for psychoneurosis after a brief period of service were individuals who brought their psychoneurosis with them into the Army.⁵² They were induction errors for the most part. Sometimes, the physician was honestly mistaken because of ignorance or lack of insight, but sometimes he was under pressure to accept defective men against his better judgment. Sometimes, the physician's judgment was reversed with or without his knowledge. Only a small proportion would have required hospitalization in civilian life.⁵³ Symptoms were often temporarily aggravated by the relatively mild stress incidental to induction and training but frequently subsided upon admission to the hospital or with promise of discharge. Unfortunately, some of these individuals as a result of their brief exposure to military service may never again reach the same levels of effectiveness that they maintained before entering the Army. They have been supplied with facesaving, socially acceptable, and sympathy-producing explanations for their difficulties and compensation to maintain a dependent attitude.

Those who broke down in combat and especially after prolonged combat were, for the most part, previously well adjusted persons with no histories of overt psychiatric disorder. Upon careful investigation, however, it was found that there were latent personality and emotional difficulties in many of these men for long periods of time.⁵⁴ In the combat-incurred group, anxiety reactions were again by far the most common, but evidences of depression were apparent in a relatively large portion of these and of the entire group of combat neuroses.

Psychosis

Of all admissions for neuropsychiatric disorders in World War II, psy?

⁵²A typical broad utilization of the term 'psychoneurosis' in World War II, when perhaps 'neurotic predisposition' or 'neurotic personality' was intended.-A. J. G.
⁵³Appel, J. W.: Incidence of Neuropsychiatric Disorders in the United States Army in World War II (Preliminary Report). Am. J. Psychiat. 102: 433-436, January 1946.
⁵⁴It should be noted, however, that similar histories of emotional difficulties could be obtained from combat wounded and successful combat soldiers and that such past or latent difficulties may have no significant relevance to combat psychiatric disorders. See Ludwig, A. O., and Ranson, S. W.: A Statistical Followup of Effectiveness of Treatment of Combat-Induced Psychiatric Casualties; I.-Returns to Full Combat Duty; II.-Evacuation to the Bases. Mil. Surgeon 100: 51-62, January 1947; 169-175, February 1947.-A. J. G.

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chotic disorders constituted 6.1 percent (table 9). Some 67,600 patients were admitted to hospitals and were diagnosed as psychotics, constituting 7.3 percent of the psychiatric admissions. The overall World War II admission rate for psychoses was 2.7 per 1,000 mean strength per year, without showing much fluctuation either by year or by month (tables 6 and 8 and chart 2).

As in World War I, the development of acute transient schizophrenic reactions was not uncommon. These constituted approximately 5 to 15 percent of all the psychoses.⁵⁵ Most of them occurred in combat situations,⁵⁶ but some were seen in the base areas and even in the Zone of Interior. During the acute phase, they could not be differentiated cross sectionally from the chronic psychotic reactions except, perhaps, for the extreme confusion and disorientation which they showed so consistently. In general,

FIGURE 27.-A neuropsychiatric attendant bringing a tray of food to a mental patient in a paranoid state. Patient believes the food to be poisoned. [Posed by professional actors.]

⁵⁵This is the author's own impression; there are no statistical data available.-A. J. G.
⁵⁶In combat, such reactions were diagnosed as 'pseudopsychotic' and were not considered to be schizophrenic. A full discussion of this subject is contained in 'Medical Department, United States Army. Neuropsychiatry in World War II. Volume II. Oversea Theaters.' [In preparation.]-A. J. G.

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FIGURE 28.-A disturbed patient in a seclusion room. [From the film 'Shades of Gray.']

schizophrenic reactions were many times more common than were effective disorders and, not too uncommonly, were seen superimposed on mental deficiency or psychopathic personality (figs. 27 and 28).

As the war progressed and with the increased emphasis upon therapy, the proportion of patients with psychoses who required further hospitalization, upon discharge from the service, steadily diminished. With the introduction of shock treatment and with a comprehensive activities program, only 20 to 30 percent of all those who were hospitalized for psychoses had to be transferred to Veterans' Administration hospitals. The remainder either recovered or were sufficiently improved to be released to their own custody or to the custody of relatives.

Character and behavior disorders, and other disorders⁵⁷

Among the character and behavior disorders, immaturity reaction counted for the greatest number of admissions; it constituted 6.1 percent of all admissions for neuropsychiatric disorders, or 7.3 percent of the psychiatric admissions (table 9). Next to follow are: Alcoholism (3.9 percent of all neuropsychiatric admissions, or 4.5 percent of the psychiatric admissions); pathological sexuality (0.5 percent of all neuropsychiatric admis?

⁵⁷This diagnostic category includes enuresis discussed as a special problem on pages 235-236.

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sions, or 0.6 percent of the psychiatric admissions); asocial and antisocial personality (0.2 percent of all neuropsychiatric admissions, or 0.3 percent of the psychiatric admissions); and drug addiction (0.1 percent of the neuropsychiatric admissions and 0.1 percent of the psychiatric admissions).

Some 29,000 admissions in World War II were diagnosed as disorders of intelligence. They constituted 2.6 percent of all neuropsychiatric admissions, or 3.1 percent of the psychiatric admissions.

Factors affecting psychiatric admission and discharge administrative policies.-As already described, both admissions and discharges were affected to a very considerable extent by changes in administrative policies involving the utilization of manpower.⁵⁸ These policies fostered the use of nonmedical criteria as the basis for defining medical disability caused by neuropsychiatric conditions. For this reason, these fluctuations cannot be considered as evidence of changes in actual incidence of psychiatric disorders even though they were reported as such statistically. For example, the decline in admission rates beginning in November 1943 resulted from WD Circular No. 293 (11 November 1943) and from WD Circular No. 164 (26 April 1944; amended by WD Circular No. 212, 29 May 1944). The discharge of any individual who could render effective service was prohibited except those who were permanently below the minimal physical standards of MR 1-9 as a result of combat wounds. Since it was a common practice for marginal personnel to be hospitalized for the purpose of discharge from the service, such directives strongly influenced admission rates. Thus, the low rate of admissions obtained as a result of these directives was continued until September 1944 when the admissions again rose rapidly as a result of WD Circular No. 370 (issued on 12 September 1944 and modified by ASF Circular No. 318, issued on 23 September 1944) which authorized the discharge of enlisted men in the United States who did not meet minimum physical induction standards for limited service as prescribed by MR 1-9 and for whom there were no appropriate positions reasonably available.

Carded-for-record cases.-Another factor which resulted in an increased admission rate throughout 1944 was the frequent practice of the Army Air Forces to admit, as carded-for-record cases (credited as admissions), large numbers of men passing through the redistribution stations. A very significant number of these cases were never hospitalized but were merely afforded the opportunity of a 30-day sick leave before returning for duty. Annual admission rates resulting from the procedure at various redistribution stations ranged as high as 1,600 per 1,000 strength. These rates were higher than those of divisions in combat.

Outpatient treatment.-The admission rates do not constitute a complete expression of the magnitude of the neuropsychiatric problem in the Zone of Interior because a significant number of men with neuropsychiatric

⁵⁸The following War Department directives and Army Regulations affected admissions and discharges: WD Circular No. 161, 14 July 1943; WD Circular No. 176, 31 July 1943; WD Circular No. 293, 11 Nov. 1943, rescinded WD Circular No. 161; WD Circular No. 164, 26 Apr. 1944; WD Circular No. 217, 1 June 1944; AR 615-369, 20 July 1944; and WD Circular No. 370, 12 Sept. 1944.

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conditions were treated in outpatient status without admission to hospitals. There was an increasing tendency for this practice throughout 1944 and 1945. In addition, with the establishment of mental hygiene consultation clinics in all training centers, many other neuropsychiatric cases were spared hospitalization and were successfully treated on an outpatient status. No statistics are available to indicate the extent of the neuropsychiatric outpatient caseload, but at large camps, it can be stated as a reasonable estimate that the number of consultations equaled or exceeded the number of neuropsychiatric hospital admissions.

Undiagnosed psychiatric manifestations.-A questionnaire study by the Information and Education Division, Army Service Forces, of 5,000 enlisted men returned to the Zone of Interior from overseas indicated a high incidence of potential or undiagnosed psychiatric or mental health problems. The questionnaire included the key questions from the NSA

CHART 3.-Neuropsychiatric patients remaining in hospital: total and by open and closed wards, continental United States, 1943-45

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TABLE 10.-Neuropsychiatric patients remaining in hospital: number and percent of all remaining hospital patients, by year, month, and percent distribution by closed and open wards, U.S. Army, continental United States, 1943-45

Year and month	Neuropsychiatric patients remaining in hospital		Percent distribution by-
Year and month	Number	Percent of all remaining hospital patients	Closed wards	Open wards
1943
January	9,716	6.0	48.8	57.2
February	10,366	5.8	41.5	58.5
March	10,633	6.0	42.1	57.9
April	12,035	6.5	39.6	60.4
May	13,014	7.4	30.5	69.5
June	13,606	7.9	35.8	64.2
July	14,488	7.9	33.4	66.6
August	16,817	9.0	29.6	70.4
September	17,123	8.7	29.8	70.2
October	17,818	9.2	28.5	71.5
November	17,606	9.1	28.6	71.4
December	15,191	8.7	29.8	70.2
1944
January	15,974	8.7	29.0	71.0
February	16,826	9.5	28.2	71.8
March	16,035	10.1	30.9	69.1
April	15,582	10.3	30.3	69.7
May	16,162	10.8	31.1	68.9
June	16,444	11.5	32.4	67.6
July	15,793	10.9	30.9	69.1
August	16,157	10.9	30.2	69.8
September	19,346	11.9	26.0	74.0
October	19,924	11.8	26.0	74.0
November	19,940	11.7	26.4	73.6
December	22,906	13.0	31.1	68.9
1945
January	28,199	12.5	22.9	77.1
February	31,485	13.0	18.3	81.7
March	34,333	12.9	15.0	85.0
April	35,696	12.7	13.7	86.3
May	37,640	12.6	14.1	85.9
June	37,541	11.8	14.2	85.8
July	34,928	11.1	15.3	84.7
August	32,974	11.0	14.7	85.3
September	26,700	10.0	16.3	83.7
October	19,542	8.5	19.4	80.6
November	13,947	7.0	22.4	77.6
December	11,384	6.8	25.3	74.7

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(Neuropsychiatric Screening Adjunct) test which was used at induction.⁵⁹ This study revealed that from 52 to 73 percent of the returnees answered positively as to their having many 'somatic' and 'nervous symptoms.' While it is not to be thought that all or even most of these men had psychiatric illness of any degree, yet it is highly probable that they represented a more than average potential source of psychiatric noneffectives.

Another survey based on the NSA was made in the Pacific Ocean Areas. The results were even more startling than those of the aforementioned study, for 'only 7 percent of all the veterans and only 6 percent of the infantry veterans stated that they were in good physical condition. In other words they felt that they were in 'ill health' and, therefore, not fit for combat.'⁶⁰ It was believed that these findings could be related to the presence of many psychosomatic manifestations of anxiety or psychoneurotic difficulties.

Prevalence of Neuropsychiatric Disorders in Hospitals

The prevalence of neuropsychiatric disorders in hospitals is measured here by the number of psychiatric patients remaining in hospitals at the

CHART 4.-Number of neuropsychiatric patients remaining in hospitals, 1943-45
(as of end of month)

⁵⁹The NSA, a standardized series of questions relative to physical and mental health, was established on 1 October 1944 'to provide a means of rapidly selecting those registrants having indications of psychoneurotic tendencies and who, therefore, require an additional clinical neuropsychiatric examination.' (WD Memorandum No. 40-44, 19 Sept. 1944, 'Psychological Examining for Neuropsychiatric Tendencies.') See also pp. 185-188.-A. J. G.
⁶⁰Kaufman, M. R.: Ill Health as an Expression of Anxiety in a Combat Unit. Psychosomatic Med. 9: 104-109, March-April 1947.

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end of each month. These data are presented in table 10, by month, covering the period from January 1943 through December 1945. This table also shows the proportion of such patients as a percent of all patients remaining in hospital and their percent distribution by closed and open wards. See also chart 3 for the distribution of all neuropsychiatric patients, and separately by closed and open wards.

The prevalence depends, of course, on the number of admissions-it parallels, therefore, to a great extent the trend of admissions as depicted in chart 2, and on the length of hospitalization. It is apparent from table 10 and chart 3 that the number of neuropsychiatric patients remaining in hospitals increased in the latter month of 1944, reaching its peak in May 1945. With this increase in the number of neuropsychiatric patients, the proportion of these patients in open wards also progressively increased. The increase in both instances was due to: (1) The greater number of patients being evacuated from overseas as a result of an increase in combat activity-increasing, thus, the admission rates in continental United States, and (2) the policy of the Surgeon General's Office which throughout 1944 placed greater emphasis on the treatment of neuropsychiatric patients, especially of those falling in the psychoneurosis category.

The utilization of convalescent hospital facilities as treatment centers for patients with psychoneurosis, who did not require individual therapy, afforded an opportunity for retaining patients for treatment for 6 to 8 weeks. Patients receiving treatment under this program constituted an increasingly higher proportion of the neuropsychiatric patients remaining in hospitals. About 45 percent of the total number of neuropsychiatric patients were treated under the convalescent program. (See chart 4 for the distribution of the neuropsychiatric patients remaining in hospitals, for continental United States and overseas, by month.)

Discharges for Neuropsychiatric Reasons

Of the specific diagnoses responsible for the disability discharges of neuropsychiatric disorders in World War II, psychoneurosis was the most prevalent cause of discharge (table 2). Of the total number of persons (389,000) discharged from the Army for neuropsychiatric disorders, some 269,000 persons were discharged for psychoneurosis; in other words, 69.1 percent of all neuropsychiatric disability discharges were due to psychoneurosis. Next in magnitude were the discharges for psychosis (62,000 persons), constituting some 15.9 percent of all disability discharges for neuropsychiatric reasons, followed by discharges for neurological reasons (some 52,000 persons, or 13.4 percent). The remaining discharges were due to character and behavior disorders (0.8 percent), disorders of intelligence (0.7 percent), and other psychiatric reasons (0.1 percent). The same percentage distribution by diagnosis obtained for enlisted men (table 2).

During the period of mobilization, the vast majority of neuropsychi?

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atric disorders for which discharge was recommended was clearly in existence prior to service. An analysis of 200 consecutive case histories of soldiers discharged from the Army,⁶¹ at Camp Lee, Va., because of neuropsychiatric disabilities revealed that in 89 percent the illness had existed in civilian life (in over 50 percent for more than 5 years). Of the 11 percent in which onset had seemingly occurred after induction, all but one patient were psychotic. Almost half were admitted to the hospital within the first month of service and 97 percent within 6 months after induction.

Ebaugh⁶² found that neuropsychiatric discharges constituted 26.5 percent of all discharges from a typical station hospital during the period of 1 December 1942 to 1 June 1943.

Kinsey⁶³ studied 1,000 consecutive unselected cases that were medically discharged from the Army in the latter part of 1942 and early part of 1943 (when any psychoneurotic disorder was cause for discharge). Of the discharges, 53.5 percent were for neuropsychiatric disorders.

The most common diagnosis was found to be psychoneurosis, as indicated by the overall World War II data (table 2). (See also appendix A for a comparative evaluation of World War I and World War II discharges for disability.)

TABLE 11.-Administrative separations of enlisted men for inaptitude or unsuitability, unfitness, reasons other than honorable (excluding unfitness), and dishonorable discharges, and total specified administrative separations, numbers and rates, by year, 1942-45

[Rate expressed as number of separations per 1,000 mean strength per year]

Year	Inaptitude or unsuitability¹		Unfitness²		Reasons other than honorable³		Dishonorable discharges		Total specified administrative separations
Year	Number	Rate	Number	Rate	Number	Rate	Number	Rate	Number	Rate
1942	3,486	1.2	2,153	0.7	2,285	0.8	933	0.3	8,857	2.9
1943	40,165	6.5	14,262	2.3	3,421	.6	3,321	.5	61,169	9.9
1944	41,184	5.8	16,049	2.3	3,653	.5	7,577	1.1	68,463	9.7
1945	37,629	5.7	8,191	1.2	2,915	.4	8,623	1.3	57,358	8.7
Total	122,464	5.4	40,655	1.8	12,274	0.5	20,454	0.9	195,847	8.6

¹Includes enlisted men discharged under section VIII, AR 615-360, prior to July 1944; under AR 615-369 and changes, after July 1944
²Includes enlisted men discharged under section VIII, AR 615-360, prior to July 1944; under AR 615-368 and changes, after July 1944.
³Includes discharges for misconduct and bad conduct (excluding unfitness).

Source: The following sources were used in the preparation of these data: Adjutant General's Reports: ETM-54c and 59c-for the earlier years, and 'Strength of the Army' STM-30, Adjutant General's Office, Machine Records Branch-afterward. In each case, the latest available statistics were used. (See also appendix A, table 9.)

⁶¹Rosenberg, S. J., and Lambert R. H.: Analysis of Certain Factors in the Histories of 200 Soldiers Discharged From the Army for Neuropsychiatric Disabilities. Am. J. Psychiat. 99: 164-167, September 1942.
⁶²Ebaugh, Franklin G.: History of the Eighth Service Command. [Official record.]
⁶³Kinsey, R. E.: Study of 1,000 Cases Separated From the Army on Certificate of Disability Discharge. Bull. U.S. Army M. Dept. 69: 64-75, October 1943.

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Administrative Discharges for Enlisted Men

In addition to military personnel discharged for neuropsychiatric reasons on CDD, some 196,000 enlisted men were administratively separated from the service in World War II for various noneffective behavioral disorders. These administrative separations consisted of 122,000 enlisted men

TABLE 12.-Administrative separations for inaptitude or unsuitability, unfitness, reasons other than honorable (excluding unfitness), and dishonorable discharges, by year and month, 1942-45¹

Month	Year
Month	1942	1943	1944	1945	1942	1943	1944	1945
	Inaptitude or Unsuitability				Unfitness
January	125	1,193	3,886	2,382	77	353	1,620	969
February	124	1,612	3,390	2,176	98	483	1,576	867
March	136	2,591	3,563	2,319	134	653	1,435	743
April	176	2,344	3,177	2,281	144	779	1,326	679
May	214	2,279	3,391	2,055	127	875	1,284	577
June	233	3,235	3,994	3,564	136	1,251	1,645	894
July	284	3,370	2,153	4,094	210	1,456	847	869
August	262	3,672	3,606	5,561	191	1,532	1,385	698
September	276	4,566	4,200	3,700	203	1,774	1,210	494
October	431	5,723	3,624	4,903	227	1,896	1,248	596
November	464	5,264	3,276	2,844	287	1,466	1,238	490
December	761	4,316	2,924	1,750	319	1,744	1,235	315
Total	3,486	40,165	41,184	37,629	2,153	14,262	16,049	8,191
	Reasons other than Honorable				Dishonorable Discharges
January	185	125	55	240	55	90	644	715
February	187	239	201	228	60	136	683	632
March	259	223	169	169	83	165	617	632
April	219	410	106	190	76	223	551	778
May	204	314	174	155	69	223	590	709
June	230	273	172	355	77	286	699	1,150
July	195	265	441	127	85	323	495	619
August	196	185	388	234	81	323	682	627
September	144	268	469	181	73	384	646	625
October	174	385	524	382	84	428	682	664
November	157	417	330	301	93	354	603	789
December	135	317	624	353	97	386	715	683
Total	2,285	3,421	3,653	2,915	933	3,321	7,577	8,623

¹Includes enlisted men discharged under section VIII, AR 615-360, prior to July 1944; under AR 615-369 and changes, after July 1944.

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separated for inaptitude or unsuitability (including enuresis); 41,000, separated for unfitness; 12,000, for reasons other than honorable, including misconduct and bad conduct; and 20,000, dishonorably discharged (table 11). Inaptitude or unsuitability were the main cause of administrative separations (62.5 percent of these separations); unfitness constituted 20.8 percent; discharges for reasons other than honorable, 6.3 percent; and dishonorable discharges, 10.4 percent.

Altogether these administrative separations in World War II showed a discharge rate of 8.6 per 1,000 mean strength per year. As in the case of the disability discharges, the administrative separations indicate wide variations year by year, and month by month, due primarily to changing administrative policies, especially with respect to inaptitude or unsuitability and unfitness (tables 11 and 12).

WORLD WAR II MEAN STRENGTHS

The mean Army strengths in World War II, 1942-45, are shown in table 13. These strengths were used in computing the rates shown in the various tables in this chapter.

TABLE 13.-Mean Army strengths, total Army and enlisted men, by year, 1942-45

Year	Mean strengths		Year	Mean strengths
Year	Total Army personnel	Enlisted men	Year	Total Army personnel	Enlisted men
1942	3,242,710	3,015,620	1944	7,791,006	6,982,533
1943	6,870,616	6,256,936	1945	7,432,042	6,512,699

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