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MENTAL FITNESS OF U.S. RECRUITS
103
THE LANCET SATURDAY, JULY 26, 1941
LONDON::
MENTAL FITNESS OF U.S. RECRUITS advertisement called for men and women occupational, vocational or educational to psychology enlist in the British Army for the work of selecting personnel. This betokens a somewhat tardy recognition of the assistance to be obtained from psychologists, and of the fact that the soldier’s mental qualities are at least as important as his physical in estimating his efficiency, or placing him in the job where he will be most useful. Examination for mental fitness has hitherto had far less attention than the physical examination of recruits ; it is more difficult to perform, more difficult to assess, more difficult to check, and therefore much more difficult to trust. The doubts and delays which have here hampered its reasonable application, except in special instances, are now showing themselves in the United States, where our tribulations of 1939 are being repeated. There the psychiatric problem has been fully recognised, and excellent instructions have been circulated for the guidance of physicians examining recruits1 ; but art is long (especially the psychiatric art) and time is fleeting, and 50 men a day have to be put through each neuropsychiatrist’s sieve. An informative account of how this is being done comes from the Boston area.2 The physicians concerned have a lively sense of what the problem meant to the United States last time : 2% of the men admitted to the army in 1917-18 were found to be suffering from neuropsychiatric disabilities, hardly any of which were due to war service and most of which had begun at least five years before ; a third of these men had some degree of mental deficiency, a sixth were neurotic, and another sixth were classified as drug addicts, alcoholics or constitutional psychopathic inferiority " ; and by 1927 almost half of all the cases receiving treatment for disorders attributable to war service were neuropsychiatric cases. Each such case has cost approximately 30,000 dollars to date. Nobody wants to incur such avoidable burdens this time, but there are more people to be examined under " Selective Service " than could be given the thorough psychiatric overhaul that might be desired. A compromise has been arrived at. Men are examined in the first instance by general practitioners (the local board) ; dubious cases can be referred to the specialists of the medical advisory boards (of which there is one to each ten local boards) ; all men approved as Al at this stage are called up and examined by the medical induction boards, which are the final barrier before actual entrance into the army. On this board there are a medical director from the A.M.C., and (in the Boston area, which is presumably typical) five civilian neuropsychiatrists and a psychologist (non-medical), the other civilian specialists being a clinical pathologist, an oral surgeon, an otolaryngologist, an ophthalmologist, an orthopaedic surgeon, a general surgeon, and
A
RECENT
trained in
"
1. See
Lancet, May 17, 1941, p. 633. Engl. J. Med. 1941, 224, 890.
2. New
three physicians. The allowance of neuropsychiatrists is therefore generous but not excessive. The number of men examined daily by the induction board has varied from 100 to 250. In a given month
(February, 1941) a third of all rejections were on neuropsychiatric grounds, and they amounted to 5% of all candidates examined by the induction board. If the medical director had not refused to sanction some of the neuropsychiatrists’ recommendations for rejection, the number of candidates rejected on these grounds would have been more than half as high again. The examination by the neuropsychiatrist took from five to ten minutes, the length of time spent on each case being restricted by the number of available psychiatrists and by the necessity to deliver the candidates to the reception centre on the day of induction. In justifying this expenditure of time to those who say it is too little, as well as those who say it is too much, four general principles are stated : (1) Individual interests must for the time being yield
to the collective interests of the nation. (2) The army needs men sound in mind and body, it is not to be considered a corrective institution for
psychopaths. (3) There are
17 million eligible men from whom to choose an army of 2-4 million. (4) The admission of undesirable candidates to the army not only decreases its efficiency but increases the burden on the nation through supporting these men by the army or by the veterans (pensions) bureau.
The first of these
propositions will command universal
assent ; the second is flouted by those misguided among examining doctors who can’t see why bad hat should get away with it " ; the third can As for pensions, arouse in our breasts only envy. the Americans have prudently set up a dam by providingfor further examination and rejection of recruits, if necessary, without providing governmental care or treatment for neuropsychiatric disabilities incurred before entrance into the army or within the first six months after entrance. On this score the difficulty is not to make a sensible enactment but to prevent its being set aside by clamour or political
patriots "
a
pressure. It is instructive to read the proportions of men rejected for the U.S. Army on neuropsychiatric’ grounds by the induction board aftec the local board (which apparently too seldom invokes the aid of its advisory neuropsychiatrist) had passed them Al.
The local board’s neuropsychiatric rejections numbered 209 out of 4405 candidates : 16% of rejections were for mental deficiency, 5% for insanity, 54% for neuroses (including effort syndrome) and abnormal or psychopathic personality, 7% for drug addiction, stammering or enuresis, 4% for epilepsy, and the remaining 14% for neurological disorders. But the medical director on the induction board often (159 times out of 245 in the Boston area during February) quashed the neuropsychiatrist’s rejection. He did this most often where mental deficiency, constitutional psychopathic inferiority, schizoid personality, psychoneuroses, post-traumatic syndromes and epilepsy were the diagnoses, and of 11 men recommended for rejection on account of effort syndrome he reversed the decision in every case. It seems that the army doctor was less particular than the civilian. Light is cast on this by the official plan for " prehabilitation " 3. United States
Army Regulations, Nov. 20, 1939,
para. 2 C
(1).
104
of the
registrants, in which concern high proportion of rejects.
is
shown about
" To date the number of deferments and rejections has been large, so great indeed that considerable concern is evident in SelectiveService, in the Army, and in the country as a whole. It is estimated that less than 20% of the 16,500.000 registrants are being classed available for general military service.... Selective Service local boards at. the present time are classing 20% of those physically examined in class IV-F, as being totally disqualified for military service, 12% in class I-B, as being fit for limited military service only, and 68% in class I-A, as being qualified for general military service. Of the 68% classed as being qualified for general military service and sent to the Army Induction Station, about 12% are being rejected because of physical, mental, moral, administrative and other reasons.... Criticism has been abundant and bitter and is on the increase."4
A plan is therefore put forward to make men aware of the physical standards required by the army, and to encourage them to seek medical advice in advance in order to make themselves fit to serve. Such men will then bring to the examining board a certificate of " prehabilitation the obtaining of which " will tend to indicate character and the possession of desirable qualities-intelligence, forethought, initiative, fitness and a desire to serve-all of which must go into the making of a good soldier.... It should serve to diminish the number of rejections, with all the attendant humiliation and inconvenience involved." Evidently too high a standard of fitness for army service may have unwelcome effects on the civilian population. But it has to be remembered that many unsuitable men cannot be detected as such until they are in the training camp. There is agreement among the American neuropsychiatrists who have lately written on the subject,5 in the light of their experience on induction boards, that a great deal can be done by an experienced neuropsychiatrist in five to ten minutes of wellconducted interviewing, and that another ten minutes would not give much more that is practical and necessary for a decision. The testing of intelligence may be an essential part of the procedure.’ It could not be carried out by the physician limited to ten minutes for his whole examination, but must be regarded as an additional investigation. The Boston induction board has had the advice of a group of Harvard psychologists.** Group tests were looked on as impracticable " for both administrative and technical reasons." These objections are well known here, but it is surprising that they were regarded as decisive against the method. The tests used by the Boston psychologists were, however, less suitable to group testing on the whole than the progressive matrices test of RAVEN which has been much employed in this country. The subjects were referred by the psychiatrist as suspect of being below the mental age of 12 years (the critical level of capacity set by the U.S. Army recently, but questioned by the writers as too high) though it is well recognised that the basic question is not mental age but " is this man equal to the demands that will be made on him by the army ? Very brief examination by the psychologist disposed of the few candidates who were below the 10-year or above the 14-year level ; those in between required more attention. Self-administered tests, "
"
4. J. Amer. med. Ass. 1941, 116, 1777. 5. Aita, J. A. Proc. Mayo Clin. May, 1941, p. 294 and 307. 6. New Engl. J. Med. 1941, 224, 898.
with printed instructions (comparable to those which have also been widely used in the Army here), were found unsatisfactory in Boston because many of the subjects were unaccustomed to reading and were tlrerefore handicapped in grasping what they had to do. The examiners say that they felt keenly the lack of non-verbal material that would be adequate and not time-consuming ; probably our experience with nonverbal tests could be of use in this connexion. The Boston psychologists advise flexibility in the use of individual tests. " It is important," they say, " to have clinicians who are qualified to use their own judgment concerning the techniques that will enable them to give a reasonably accurate approximation of intellectual levels." Out of 5100 men passing through the induction station during 16 days, 199 were referred by the neuropsychiatrist for psychometric examination ; 79 of these were given a rating of less than 12 years, 120 a rating of 12 or over. The regular psychological examination of recruits is deferred until they arrive at the reception station, where a fairly elaborate series of tests is applied.
DRIED PLASMA AND SERUM THE Ministry of Health’s regional blood-transfusion services are now producing significant quantities of blood, plasma and serum, and are planned on a scale to provide these materials in excess of local needs; some of the regions have a surplus already. According to Science of June 13, our American colleagues think in terms of a hundred million quarts. What is to be done with these large volumes, little of which will be required for use immediately after collection ? In this country it is likely that liquid plasma or serum will always be preferred since it is available for instant use, but for overseas or for reserve stores intended to keep more than a few months dried plasma or serum has great advantages ; it is stable, transport weight and space are relatively small, and, so long as there is a proper supply of pyrogen-free distilled water at the receiving end, it can be readily reconstituted by simple solution in distilled water. Numerous methods for preparing dried plasma have been described ; they all aim at distilling off the water without denaturing the proteins and in such a way that the product is easily soluble ; sterility must be maintained
throughout. The most obvious method is simple in-vacuo distillation, allowing the water to be boiled off at a temperature well below 37° C. There is usually an arrangement which allows the liquid plasma to be run into the distillation chamber in a continuous stream or spray without stopping the process. An efficient system of this type was described by AYLWARD, MAINWARING and WILKINSON,1 but although the product was satisfactory they found the method
unsuitable for large-scale production. HARPER, EssEX and OSTERBERG2 used an essentially similar technique which they incorrectly call " spray distillation " ; their account3 of clinical experience with their dried product brings out one of the disadvantages -the residual water content may be as high as 8%, which diminishes its keeping qualities. A second Aylward, F. X., Mainwariog, B. R. S. and Wilkinson, J. F. Brit. med. J. 1940, 2, 583. 2. Harper, S. B., Essex. H. E. and Osterberg, A. E. Proc. Mayo Clin. 1940, 15, 689. 3. Harper, S. B. Osterberg, et al. J. Amer. med. Ass. 1941, 116, 1760. 1.
THE LANCET SATURDAY, JULY 26, 1941
LONDON::
MENTAL FITNESS OF U.S. RECRUITS advertisement called for men and women occupational, vocational or educational to psychology enlist in the British Army for the work of selecting personnel. This betokens a somewhat tardy recognition of the assistance to be obtained from psychologists, and of the fact that the soldier’s mental qualities are at least as important as his physical in estimating his efficiency, or placing him in the job where he will be most useful. Examination for mental fitness has hitherto had far less attention than the physical examination of recruits ; it is more difficult to perform, more difficult to assess, more difficult to check, and therefore much more difficult to trust. The doubts and delays which have here hampered its reasonable application, except in special instances, are now showing themselves in the United States, where our tribulations of 1939 are being repeated. There the psychiatric problem has been fully recognised, and excellent instructions have been circulated for the guidance of physicians examining recruits1 ; but art is long (especially the psychiatric art) and time is fleeting, and 50 men a day have to be put through each neuropsychiatrist’s sieve. An informative account of how this is being done comes from the Boston area.2 The physicians concerned have a lively sense of what the problem meant to the United States last time : 2% of the men admitted to the army in 1917-18 were found to be suffering from neuropsychiatric disabilities, hardly any of which were due to war service and most of which had begun at least five years before ; a third of these men had some degree of mental deficiency, a sixth were neurotic, and another sixth were classified as drug addicts, alcoholics or constitutional psychopathic inferiority " ; and by 1927 almost half of all the cases receiving treatment for disorders attributable to war service were neuropsychiatric cases. Each such case has cost approximately 30,000 dollars to date. Nobody wants to incur such avoidable burdens this time, but there are more people to be examined under " Selective Service " than could be given the thorough psychiatric overhaul that might be desired. A compromise has been arrived at. Men are examined in the first instance by general practitioners (the local board) ; dubious cases can be referred to the specialists of the medical advisory boards (of which there is one to each ten local boards) ; all men approved as Al at this stage are called up and examined by the medical induction boards, which are the final barrier before actual entrance into the army. On this board there are a medical director from the A.M.C., and (in the Boston area, which is presumably typical) five civilian neuropsychiatrists and a psychologist (non-medical), the other civilian specialists being a clinical pathologist, an oral surgeon, an otolaryngologist, an ophthalmologist, an orthopaedic surgeon, a general surgeon, and
A
RECENT
trained in
"
1. See
Lancet, May 17, 1941, p. 633. Engl. J. Med. 1941, 224, 890.
2. New
three physicians. The allowance of neuropsychiatrists is therefore generous but not excessive. The number of men examined daily by the induction board has varied from 100 to 250. In a given month
(February, 1941) a third of all rejections were on neuropsychiatric grounds, and they amounted to 5% of all candidates examined by the induction board. If the medical director had not refused to sanction some of the neuropsychiatrists’ recommendations for rejection, the number of candidates rejected on these grounds would have been more than half as high again. The examination by the neuropsychiatrist took from five to ten minutes, the length of time spent on each case being restricted by the number of available psychiatrists and by the necessity to deliver the candidates to the reception centre on the day of induction. In justifying this expenditure of time to those who say it is too little, as well as those who say it is too much, four general principles are stated : (1) Individual interests must for the time being yield
to the collective interests of the nation. (2) The army needs men sound in mind and body, it is not to be considered a corrective institution for
psychopaths. (3) There are
17 million eligible men from whom to choose an army of 2-4 million. (4) The admission of undesirable candidates to the army not only decreases its efficiency but increases the burden on the nation through supporting these men by the army or by the veterans (pensions) bureau.
The first of these
propositions will command universal
assent ; the second is flouted by those misguided among examining doctors who can’t see why bad hat should get away with it " ; the third can As for pensions, arouse in our breasts only envy. the Americans have prudently set up a dam by providingfor further examination and rejection of recruits, if necessary, without providing governmental care or treatment for neuropsychiatric disabilities incurred before entrance into the army or within the first six months after entrance. On this score the difficulty is not to make a sensible enactment but to prevent its being set aside by clamour or political
patriots "
a
pressure. It is instructive to read the proportions of men rejected for the U.S. Army on neuropsychiatric’ grounds by the induction board aftec the local board (which apparently too seldom invokes the aid of its advisory neuropsychiatrist) had passed them Al.
The local board’s neuropsychiatric rejections numbered 209 out of 4405 candidates : 16% of rejections were for mental deficiency, 5% for insanity, 54% for neuroses (including effort syndrome) and abnormal or psychopathic personality, 7% for drug addiction, stammering or enuresis, 4% for epilepsy, and the remaining 14% for neurological disorders. But the medical director on the induction board often (159 times out of 245 in the Boston area during February) quashed the neuropsychiatrist’s rejection. He did this most often where mental deficiency, constitutional psychopathic inferiority, schizoid personality, psychoneuroses, post-traumatic syndromes and epilepsy were the diagnoses, and of 11 men recommended for rejection on account of effort syndrome he reversed the decision in every case. It seems that the army doctor was less particular than the civilian. Light is cast on this by the official plan for " prehabilitation " 3. United States
Army Regulations, Nov. 20, 1939,
para. 2 C
(1).
104
of the
registrants, in which concern high proportion of rejects.
is
shown about
" To date the number of deferments and rejections has been large, so great indeed that considerable concern is evident in SelectiveService, in the Army, and in the country as a whole. It is estimated that less than 20% of the 16,500.000 registrants are being classed available for general military service.... Selective Service local boards at. the present time are classing 20% of those physically examined in class IV-F, as being totally disqualified for military service, 12% in class I-B, as being fit for limited military service only, and 68% in class I-A, as being qualified for general military service. Of the 68% classed as being qualified for general military service and sent to the Army Induction Station, about 12% are being rejected because of physical, mental, moral, administrative and other reasons.... Criticism has been abundant and bitter and is on the increase."4
A plan is therefore put forward to make men aware of the physical standards required by the army, and to encourage them to seek medical advice in advance in order to make themselves fit to serve. Such men will then bring to the examining board a certificate of " prehabilitation the obtaining of which " will tend to indicate character and the possession of desirable qualities-intelligence, forethought, initiative, fitness and a desire to serve-all of which must go into the making of a good soldier.... It should serve to diminish the number of rejections, with all the attendant humiliation and inconvenience involved." Evidently too high a standard of fitness for army service may have unwelcome effects on the civilian population. But it has to be remembered that many unsuitable men cannot be detected as such until they are in the training camp. There is agreement among the American neuropsychiatrists who have lately written on the subject,5 in the light of their experience on induction boards, that a great deal can be done by an experienced neuropsychiatrist in five to ten minutes of wellconducted interviewing, and that another ten minutes would not give much more that is practical and necessary for a decision. The testing of intelligence may be an essential part of the procedure.’ It could not be carried out by the physician limited to ten minutes for his whole examination, but must be regarded as an additional investigation. The Boston induction board has had the advice of a group of Harvard psychologists.** Group tests were looked on as impracticable " for both administrative and technical reasons." These objections are well known here, but it is surprising that they were regarded as decisive against the method. The tests used by the Boston psychologists were, however, less suitable to group testing on the whole than the progressive matrices test of RAVEN which has been much employed in this country. The subjects were referred by the psychiatrist as suspect of being below the mental age of 12 years (the critical level of capacity set by the U.S. Army recently, but questioned by the writers as too high) though it is well recognised that the basic question is not mental age but " is this man equal to the demands that will be made on him by the army ? Very brief examination by the psychologist disposed of the few candidates who were below the 10-year or above the 14-year level ; those in between required more attention. Self-administered tests, "
"
4. J. Amer. med. Ass. 1941, 116, 1777. 5. Aita, J. A. Proc. Mayo Clin. May, 1941, p. 294 and 307. 6. New Engl. J. Med. 1941, 224, 898.
with printed instructions (comparable to those which have also been widely used in the Army here), were found unsatisfactory in Boston because many of the subjects were unaccustomed to reading and were tlrerefore handicapped in grasping what they had to do. The examiners say that they felt keenly the lack of non-verbal material that would be adequate and not time-consuming ; probably our experience with nonverbal tests could be of use in this connexion. The Boston psychologists advise flexibility in the use of individual tests. " It is important," they say, " to have clinicians who are qualified to use their own judgment concerning the techniques that will enable them to give a reasonably accurate approximation of intellectual levels." Out of 5100 men passing through the induction station during 16 days, 199 were referred by the neuropsychiatrist for psychometric examination ; 79 of these were given a rating of less than 12 years, 120 a rating of 12 or over. The regular psychological examination of recruits is deferred until they arrive at the reception station, where a fairly elaborate series of tests is applied.
DRIED PLASMA AND SERUM THE Ministry of Health’s regional blood-transfusion services are now producing significant quantities of blood, plasma and serum, and are planned on a scale to provide these materials in excess of local needs; some of the regions have a surplus already. According to Science of June 13, our American colleagues think in terms of a hundred million quarts. What is to be done with these large volumes, little of which will be required for use immediately after collection ? In this country it is likely that liquid plasma or serum will always be preferred since it is available for instant use, but for overseas or for reserve stores intended to keep more than a few months dried plasma or serum has great advantages ; it is stable, transport weight and space are relatively small, and, so long as there is a proper supply of pyrogen-free distilled water at the receiving end, it can be readily reconstituted by simple solution in distilled water. Numerous methods for preparing dried plasma have been described ; they all aim at distilling off the water without denaturing the proteins and in such a way that the product is easily soluble ; sterility must be maintained
throughout. The most obvious method is simple in-vacuo distillation, allowing the water to be boiled off at a temperature well below 37° C. There is usually an arrangement which allows the liquid plasma to be run into the distillation chamber in a continuous stream or spray without stopping the process. An efficient system of this type was described by AYLWARD, MAINWARING and WILKINSON,1 but although the product was satisfactory they found the method
unsuitable for large-scale production. HARPER, EssEX and OSTERBERG2 used an essentially similar technique which they incorrectly call " spray distillation " ; their account3 of clinical experience with their dried product brings out one of the disadvantages -the residual water content may be as high as 8%, which diminishes its keeping qualities. A second Aylward, F. X., Mainwariog, B. R. S. and Wilkinson, J. F. Brit. med. J. 1940, 2, 583. 2. Harper, S. B., Essex. H. E. and Osterberg, A. E. Proc. Mayo Clin. 1940, 15, 689. 3. Harper, S. B. Osterberg, et al. J. Amer. med. Ass. 1941, 116, 1760. 1.