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HISTORY OF THE OFFICE OF MEDICAL HISTORY
Disqualifications and Discharges for Neuropsychiatric Reasons, World War I and World War II
(A Comparative Evaluation)
Bernard D. Karpinos, Ph. D., and Col. Albert J. Glass, MC, USA (Ret.)
Repeated references have been made in several chapters of this volume to the rejection and discharge rates for neuropsychiatric reasons in World War I. During the mobilization and the early phases of World War II, these World War I rates were freely quoted by various civilian and military authorities, including psychiatrists, as evidence to support recommendations for increased or more comprehensive psychiatric screening at the time of examination for military service. Because the quoted World War I rates varied according to source material and, moreover, were frequently erroneously derived, owing to certain difficulties in obtaining statistical data for World War I that could be reliably compared with those of World War II, it was thought essential-for uniform and proper interpretation of these data-to present the following comparative evaluation of the neuropsychiatric selection and discharges in World War I and World War II:
DISQUALIFICATIONS FOR NEUROPSYCHIATRIC
World War I
General considerations.-On 16 April 1917, Congress declared war against Germany. On 17 May 1917, President Woodrow Wilson approved the selective service act providing for the registration of all males between the ages of 21 and 30, both inclusive. Of the approximately 10 million World War I registrants, comprising the first and second registrations, approximately 2.5 million registrants were medically examined at the local boards before 15 December 1917. Some 29.1 percent of these registrants were rejected on medical (including mental) grounds. Of the number who were found medically (physically and mentally) qualified for military service, 516,212 were called and entrained for mobilization camps before 31 December 1917.
On about 15 December 1917, all registrants of the first and second registration, not yet called to service, were placed in five classes on the basis of a special questionnaire obtained from each registrant with regard to his economic (industrial and agricultural) status. Class I included registrants liable for immediate military service (excluding those exempt on economic grounds). At that time, provisions were also made for using men who might not be qualified for full military service but who would qualify for limited military duty; that is, class B, the remedial group, and class C, the limited-service group. With the creation of the "B" and "C" groups, all registrants who had been previously disqualified for full military service, namely, all those included in the 29.1 percent previously rejected registrants, were reexamined, in addition to the examined class I men. As a result, 3,247,888 registrants were medically examined, or
reexamined, by the local boards after 15 December 1917, of whom 549,099 registrants were rejected for any (full or limited) military service. Obviously, the total manpower pool to which these rejected registrants relate includes both the registrants who were examined or reexamined, after 15 December 1917 (3,247,888 men), and the registrants that were found fit for military service and forwarded to mobilization camps (516,212) before that date; that is, a total of 3,764,100 registrants.
After 1 January 1918, a total of 2,150,555 class I men from the first and second registrations were called and sent to mobilization camps. This number, added to the men (516,212) who had been sent to camp before 15 December 1917, gives a total of 2,666,767 men of the first and second drafts who had been found medically (physically and mentally) fit by the local boards and sent to mobilization camps. This number does not include the third registration of 12 September 1918, which consisted of an additional 13 million men, of whom 140,000 were reported to camps for active duty; nor does it include voluntary enlistees and officer candidates.1
To determine his fitness for military service, a World War I registrant actually underwent two complete medical examinations; that is, one given by the local boards and another, if found medically qualified by the local board, at the mobilization camp.
Examinations by the local boards.-The examinations of World War I registrants for military service by the local boards were accomplished much in the same way as in the early days of World War II. The local boards of World War I thus faced similar problems and difficulties as those of World War II. The medical examinations at the local boards were conducted by local physicians. When considered necessary, such examinations included referral for specialist consultation by appropriate members of the medical advisory boards-a system quite similar to that which prevailed during the mobilization phase of World War II. As might have been expected, "the character of the examination varied with different boards and also at different periods of mobilization with changing orders from time to time relative to the standards for rejection and classification."2
With respect to neuropsychiatric evaluation at the local board level, it is highly improbable, except by some coincidence, that there were routine examinations by psychiatrists. However, many of the overt and more severe neurological and psychiatric disorders, such as epilepsy, mental deficiency, chronic alcoholism, and severe behavioral problems, must have been either recognized by the local board physicians or brought to their attention by collateral information from family physicians, family members, correspondence from hospitals, and general knowledge of such cases in the community. It is not surprising, therefore, that most of the neuropsychiatric disqualifications by the local boards were in the aforementioned diagnostic categories which did not require the diagnostic skills of a psychiatrist.
Examinations at mobilization camps.-Upon arrival at mobilization camps, the draftees3 found fit for military service by the local boards were given another complete medical examination, including ordinarily a psychiatric evaluation. Inasmuch as the psychiatric program had not been fully established at the early phase of World War I, not all draftees of the first increments reporting to camps were given a routine neuropsychiatric examination by neuropsychiatrists.
In addition to the more effective psychiatric program that was eventually established, the general caliber of the medical examinations and the use of medical specialists at mobilization camps improved with time. For this reason, the routine examinations
at mobilization camps of men in the second draft were considerably more thorough than those of the first.
Draftees found unfit for military service at the mobilization camp were properly considered as rejections and returned to their local boards. Local boards, however, did not always take the decision of the mobilization camps as final and frequently, when called upon for another increment for men, would include, among the new increments, draftees previously rejected for neuropsychiatric reasons.4
Data relating to medical rejections.-Actually, there are no statistical data which would show, for World War I, the number of draftees who were rejected for military service for any specific diagnosis. The only basic source of such diagnostic data is the publication "Defects Found in Drafted Men."5 But, as its very title suggests, this publication deals with defects, not men. Diagnostic distributions of the defects are shown in this publication separately for the various groups, as follows: A, fit for full military service; B, accepted for remediable treatment; C, accepted for limited service; D, rejected at mobilization camps; and Vg, rejected by local boards (tables IV and V in the publication). The distributions deal, hence, with the prevalence of defects-both nondisqualifying and disqualifying-among these various groups. For some draftees, more than one defect was reported.
Our immediate concern is with the rejected draftees (classes D and Vg), since the closest evaluation that could be made with respect to rejections for any diagnosis has to be based on the prevalence of these defects among these groups. As may be seen from the total given in the aforementioned table IV,6 698,718 defects were recorded for the draftees rejected by the local boards (Vg group), which counted, as previously stated, some 549,099 rejected men. In other words, 1.3 defects (= 698, 718/549,099) were recorded on the average for each draftee rejected by the local boards (Vg group). About the same proportional number of defects per rejected draftee were recorded for draftees rejected at the mobilization camps (class D). One of these defects recorded for rejected draftees must have been a disqualifying defect; the other defects could or could not have been disqualifying.7
Prevalence of neuropsychiatric defects.-The prevalence of neuropsychiatric defects among rejected draftees is presented in tables 1, 2, and 3, for neurological, psychiatric, and total neuropsychiatric disorders, respectively. Each table indicates both the number of recorded defects and their prevalence rates; namely, the number of defects among rejected draftees per 1,000 draftees examined-separately for those rejected by the local boards and those rejected at the mobilization camps. The rates shown under "total" represent "weighted" prevalence rates and not merely summations of the separate prevalence rates.8
In comparing the neuropsychiatric defects found at the local board level with those found at the mobilization camps (tables 1-3), it will be noted that the prevalence rate at the local boards for neurological disorders was 3.7 times as high as that at the mobilization camps; for psychiatric disorders, about twice as high; and about 2.5 times as high for total neuropsychiatric defects. The differences lie primarily in such diagnoses as epilepsy, mental deficiency, and psychoses which are more readily diagnosed
TABLE 1.-Prevalence of neurological defects among draftees rejected for military service, World War I
Source: Adapted from: Love, Albert G., and Davenport, Charles B., Defects Found in Drafted Men. Washington: Government Printing Office, 1920, tables IV and V, pp. 424-433. The diagnoses listed here are shown in the source tables under section "V. Nervous system, diseases of (all)." The deaf and dumb, mute, deaf, and deformities and diseases of the spine, listed under this section, were excluded. The prevalence rates shown in the "Total" column are "weighted" rates and not mere summations of the separate rates of the Vg and D groups. (See op. cit., pp. 55-58, for the method of calculation of these rates.)
at the local board level, no doubt because of information available at the community level. Conversely, for the less overt diagnoses and for those which are more difficult to identify, as psychoneurosis and character and behavior disorders (specifically, constitutional psychopathic states), the mobilization camps indicate higher prevalence rates (table 2).
The total prevalance rates among World War I rejected draftees were as follows: Neurological defects, 9.6; psychiatric disorders, 16.8; and total neuropsychiatric defects, 26.3; for 1,000 examined draftees (table 3).
Analogous prevalence data were published by Rollo H. Britten and George St. J. Perrott.9 Their data were derived from the same source as the data presented here.10 Britten and Perrott, however, confined their calculations to the results of the "second million," including local board examinations.11 Furthermore, their detailed diagnostic distribution deals with the prevalence of defects among both rejected and limited-service men. No separate detailed data were published by them for rejected men. For comparable diagnoses of the neuropsychiatric defects, this report indicates a prevalence rate of
28.0 among rejected and limited-service draftees per 1,000 men examined-versus our prevalence of 26.3 among rejected draftees only. The corresponding prevalence rate for psychiatric reasons is 18.3-versus our prevalence rate of 16.8 for rejected draftees only.
TABLE 2.-Prevalence of psychiatric defects among draftees rejected for military service, World War I
NOTE.-The entry .00 indicates a rate of more than zero but less than .005.
Source: Love and Davenport, op. cit. Except for "Alcoholism" and "Drug Addiction," which are listed in the source material under section "IV. General diseases (other)," these data are as listed under section "V. Nervous system, diseases of (all)," and section "VI. Mental alienation."
TABLE 3.-Prevalence of neuropsychiatric defects among draftees rejected for military service, World War I1
1Derived from tables 1 and 2.
Ginzberg and his associates,12 in comparing World War I and World War II data, indicate that the rejection rate in World War I for emotional disorders and mental or educational deficiency was 14 per 1,000 men examined.13 These authors also used Love and Davenport's data and limited their calculations to the second million men, as did Britten and Perrott. Despite the fact that the second million would show, in general, higher rates, their rates for psychiatric reasons are somewhat lower than ours: 14 as reported by them, versus 17 reported by us for psychiatric disorders (table 3), per 1,000 examined draftees. In all probability, this is due to differences in the diagnoses included in their table.
It seems that these authors also mistook these data as rejection rates (men rejected), instead of prevalence rates of defects among rejected men. In doing so, they naturally overstated their rejection rates.
Rejections for neuropsychiatric reasons.-As previously emphasized, there are no data which would provide rejection rates by diagnosis. However, it may be justifiably assumed that the calculated average number of all defects per rejected draftee, namely, 1.3 defects per rejected draftee, holds for the neuropsychiatric defects.14 On the basis of this assumption, the best estimates with respect to rejection rates for neuropsychiatric defects in World War I would hence be as follows: Neurological defects, 7.4; psychiatric disorders, 12.9; and total neuropsychiatric defects, 20.3 for 1,000 examined draftees-2.0 percent rejections for neuropsychiatric defects and disorders.15
Quoted data on World War I neuropsychiatric rejections.-The primary source for the repeatedly quoted World War I rejection rates for neuropsychiatric rejections is "Neuropsychiatry."16 This publication gives extensive information on 69,394 individuals identified as having neuropsychiatric defects and disorders originating in the U.S. Army home forces. Of these individuals, 27,836 (or 40.1 percent)17 were discovered during the routine examination upon arrival at the mobilization camps. These persons included both draftees and volunteers for enlistment, as well as commissioned officers. It was obviously not a homogeneous group, from the point of view of selection, since the processing procedures were different for these individuals. While only draftees found fit for military service by the local boards were sent to the mobilization camps, no such procedures existed in World War I with respect to volunteers or officer candidates. The latter groups were sent directly to the mobilization camps without any extensive preliminary examination. Naturally, more defects would be found at the mobilization camps among volunteers and officer trainees than among draftees prescreened by the local boards. Indeed, with respect to neuropsychiatric disorders, the total prevalence rate among volunteers was found to be 1½ times as high as that among draftees. The highest differences between these groups were for drug addiction, psychoses, and constitutional psychopathic states, diagnoses more readily eliminated at the local board level.18
At any rate, only the individuals (the 40 percent) discovered on the routine examinations, upon arrival at the mobilization camps, could be properly designated as rejections. The remaining individuals (60 percent of the neuropsychiatrically unfit) were discovered by referral from medical officers, unit commanders, psychologists, and in connection with courts-martial and delinquency. Clearly, the latter group should be considered more rightly as discharges, rather than rejections.
Such a consideration can be supported by the distribution of these individuals by length of service (table 4). This distribution indicates that 21.3 percent of these men were discharged from the service after having between 1 and 3 months of service; 11.6 percent, between 4 and 6 months; 7.9 percent, between 7 and 12 months; 3.1 percent, between 1 and 2 years; and 1.7 percent over 2 years of service. Only slightly over one-half were discharged with under 1 month of service. Yet the quoted World War I rejection rate for neuropsychiatric reasons is based on the total number of these individuals. As stated in that publication:19 "Assuming 3,500,000 as the total number examined, it is found that about 20 out of 1,000 were discovered to have some sort of nervous and mental disease * * *."20 It is this oft quoted statement that has been the origin of the 2 percent figure, constantly quoted as the World War I rejection rate for neuropsychiatric disorders. It is by pure chance that this quoted rate for World War I, erroneously derived, so remarkably coincides with the actual World War I rejection rates.
World War II
Statistical data.-The disqualification rates for military service, especially those for neuropsychiatric reasons, fluctuated widely in World War II. Various rejection rates could be and have been used, depending on the period to which the rates relate. However, certain estimates have been published by Selective Service representing an overall distribution, covering the entire World War II period. These estimates are presented in condensed form in table 5, showing the distribution of the draftees classified as 4F, as of 1 August 1945, by wide causes of disqualification.
These data as reported by Selective Service were modified ("adjusted") by distributing the "obviously disqualifying" defects; namely, the disqualifications by the
TABLE 4.-Distribution of neuropsychiatric cases by length of service prior to discovery, World War I1
1Derived from: The Medical Department of the United States
Army in the World War. Neuropsychiatry. Washington: U.S. Government Printing
Office, 1929, vol. X, table 10, pp. 170-171.
local boards which represent some 11 percent of all rejections, by diagnostic categories.21
These "adjusted" estimates indicate that approximately 38 percent of the disqualified draftees were classified as 4F because of neuropsychiatric defects, as follows: For neurological reasons, 6 percent; for psychiatric reasons ("mental disease"), excluding mental deficiency, 18 percent; and for mental deficiency, 14 percent (table 5). It has been further estimated that some 30 percent of the draftees were classified 4F as of that period (table 6).
On the basis of the foregoing data (tables 5 and 6), the following World War II rejection rates for neuropsychiatric defects and disorders were derived (table 7): For
TABLE 5.-Distribution of registrants, 18-37 years of age, in class IV-F and classes with "F" designation, by major disqualifying cause, as of August 1945, World War II
1Adapted from "Physical Examinations of Selective Service
Registrants in the Final Months of the War." Medical Statistics Bulletin No. 4
(table 4, p. 36). Washington: National Headquarters, Selective Service System,
3Includes (1) registrants with more than one disqualifying
defect who were rejected for educational deficiency before 1 June 1943; (2)
registrants rejected for failure to meet minimum intelligence standards,
beginning on 1 June 1943; and (3) morons, imbeciles, and idiots rejected
November 1940-July 1945.
NOTE.-Figures in parentheses are subtotals.
TABLE 6.-Disqualification for military service of registrants 18-37 years of age, by age, World War II
Source: Report of the National Headquarters, Selective Service System, as appeared in the Congressional Record, dated 8 Jan. 1947, vol. 93, No. 5. This source provides estimated number of men 18-37 years of age on 1 Aug. 1945, who had been physically examined for induction or enlistment and the number accepted and rejected (including percent), by age.
neurological defects, 17.2; for total psychiatric disorders (mental disease, 55.0 percent, and mental deficiency, 43.2 percent), 98.2; and for total neuropsychiatric defects and disorders, 115.4 per 1,000 draftees examined.22
Comparison of World Wars I and II Disqualification Rates
For comparison, the World War I and World War II disqualification rates for neuropsychiatric reasons are both presented in table 7. As may be seen from this table, the World War II rejection rates for neurological defects were 2.3 times as high as those in World War I; the rejection rates for psychiatric disorders were 7.6 times as high in World War II as in World War I. Especially high were the rejection rates for psychiatric disorders ("mental disease"), excluding mental deficiency; they were 15.3 times as high in World War II as in World War I.
DISCHARGES FOR NEUROPSYCHIATRIC REASONS: WORLD WARS I AND II
Detailed diagnostic distributions of the individuals discharged for neuropsychiatric defects and disorders in World War I are presented in table 8; a distribution by diagnostic categories of those discharged for neuropsychiatric disorders in World War II is shown in table 9; and a comparison between these discharge rates for World Wars I and II is presented in table 10. In evaluating these data, it must be recognized that disability discharges in World War I included persons discharged for mental deficiency and character and behavior disorders, such as constitutional psychopathic states, alcoholism, drug addiction, and enuresis, who in World War II were primarily discharged from the service by administrative separations for inaptness, inadaptability, and undesirable habits and traits of character.
World War I Discharges
The psychiatric diagnostic categories of World War I were different from those of World War II. However, these were rearranged in table 8 to correspond as closely as possible to the World War II diagnostic classification.
TABLE 7.-Rejections for military service because of neuropsychiatric defects, World Wars I and II
1Derived by dividing the prevalence rates, as shown in
table 3, by 1.3.
TABLE 8.-Disability discharges for neuropsychiatric reasons, World War I, 1 April 1917-31 December 1919
1Includes both officers and enlisted men.
The presented discharges of World War I (table 8) deal separately with the "Total," which includes both officers and enlisted men, and with "Enlisted men." For comparison with World War II data, only enlisted men are to be considered. In terms of broad diagnostic categories, the World War I disability discharge rates for enlisted men were as follows: For neurological disorders, 2.2; for total psychiatric disorders (psychoses, 2.3; psychoneurosis, 2.4; mental deficiency, 2.7; and character and behavior disorders, 1.5), 8.9; and for total neuropsychiatric defects and disorders, 11.1 per 1,000 mean strength per year, or 1.1 percent.
These data clearly indicate that neuropsychiatric discharges in World War I were only slightly above 1 percent (1.1 percent)-a rate significantly less than the rate of 3 percent disability discharges, cited by Bowman (p. 157). If the neurological dis
TABLE 9.-Disability and administrative separations of enlisted men for neuropsychiatric reasons, World War II (1942-45)
1Based on individual medical records. These data differ somewhat from those published in "Health of the Army," vol. 1, Report No. 2, 31 Aug. 1946, which were preliminary data based on reports received from the Office of The Adjutant General.
2The 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.
NOTE.-The entry .0 indicates a rate of more than zero but less than .05.
TABLE 10.-Discharges of enlisted men for neuropsychiatric reasons, World Wars I and II
1Computed by dividing the World War II rates by those of
World War I.
4"Other" includes character and behavior disorders, disorders of intelligence (mental deficiency), and other psychiatric disorders, as well as the World War II administrative separations for inaptitude or unsuitability, and unfitness (table 9).
charges are excluded, a rate of less than 1 percent (0.89 percent) is obtained for psychiatric discharges in World War I.
World War II Discharges
The World War II discharges for neuropsychiatric reasons include disability separations for neuropsychiatric defects and disorders as well as administrative separations for inaptitude, unsuitability, and unfitness, as previously indicated. The underlying causes of the latter separations are primarily character and behavior disorders. In terms of broad diagnostic categories, the World War II discharges for neuropsychiatric reasons were as follows: For neurological defects, 2.2; for psychiatric disorders (including disability and administrative separations), 21.3; and for total neuropsychiatric defects and disorders, 23.5 per 1,000 mean strength per year.
Comparison of World Wars I and II Discharge Rates
As may be seen from table 10, the total discharge rate for neuropsychiatric reasons in World War II was about 2.2 times as high as in World War I. However, the discharge rates for neurological defects and for psychoses were practically identical in both wars.
The main differences in the discharge rates of World Wars I and II were with respect to the psychoneurosis and "other" psychiatric disorders, which mainly consisted of character and behavior disorders. The discharge rate for psychoneurotic disorders was 4.8 times as high in World War II as in World War I. For "other" psychiatric disorders, the World War II discharge rate was 1.7 times as high as that of World War I.
Many factors were responsible for the higher disqualification and discharge rates for neuropsychiatric reasons in World War II than in World War I. With respect to
the disqualification rates, the foremost factor was, of course, the experience of World War I. That experience led to a philosophy, adopted in World War II, that the neuropsychiatric selection standards and screening procedures should be stricter than they had been. Besides, there have been improvements in the techniques of recognizing neuropsychiatric disorders. But these, and similar factors that obviously contributed chiefly to the increased disqualification rates of World War II, are exogenous factors, not germane to the incidence of neuropsychiatric disorders per se. Yet, these differences have been interpreted often, and unqualifiedly, as an index of increasing incidence of neuropsychiatric disorders in our population during that period. Obviously, such an interpretation is hardly justifiable. It is as misleading as would be an inference, drawn from the decreased disqualification rates for neuropsychiatric reasons during the Korean War period, that the incidence of these disorders is now decreasing. Owing to the liberalized policy with respect to psychiatric standards and screening procedures, which became effective after World War II, the disqualification rates for psychiatric reasons during the Korean War was 1.9 percent, compared with 5.5 percent in World War II; that is, about one-third of what it was in World War II.23
Similarly, in comparing the higher discharge rates of World War II with those of World War I, the relative severity of these wars, their relative duration, the number and geographic locations of their combat zones, and probably, above all, the discharge procedures that prevailed in World War II are all factors which must be taken into account in such an evaluation. (See chapter IX, "Hospitalization and Disposition.")