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Memorandum for General Surles
December 30, 1943 Washington, D.C.
We have been having increasing difficulty with members of Congress regarding physical rejections of men at induction stations. Since June 1st about 40% of the men reporting have been rejected and during the same period more than 200,000 have been discharged from the Army for physical disabilities. The point of this particular note is that between 25% and 35% of both rejections and discharges were for psychological and neuropsychiatric reasons. The War Department has taken steps drastically to curtail all discharges for disability pending the promulgation of new instructions which it is believed will materially reduce the wastage of manpower.1
In all of this matter the great problem is the handling of the psychoneurotics, and I am of the opinion that we should get out one way or another some additional information on the subject. The following is a rough draft hurriedly dictated by me on which I should like your opinion and which would have to be checked by G-1 and the Surgeon General.
G. C. M.
“The War Department has just completed, under the direction of the Inspector General, whose principal assistant, Major General Howard McC. Snyder, is a medical officer, a comprehensive survey of induction and discharge processes in continental United States relating to physical rejections of inductees and discharges from the service for similar reasons. 137 stations or installations were inspected so as to assure a nation-wide cross-section of the situation. As a result of this survey new instructions have been issued which it is believed will materially reduce the number of rejections.
“However, one problem remains extremely difficult of solution. It pertains to the fact that between 25% and 35% of all rejections and discharges for physical reasons related to psychoneurotics. While in the opinion of the several high ranking and experienced medical officers participating in this inquiry the doctors concerned, Army[,] Navy, and civilian, on duty at induction stations are performing their duties in a manner which precludes any thought of predilection or partiality, this does not mean that the line officers on duty at induction stations always agree with the medical officers or that the doctors do not at times disagree among themselves. Nevertheless it appears that all are doing their utmost to fill required quotas with the best material available.
“The greatest differences of opinion relate to rejections for psychiatric reasons. Most physical defects can be seen and measured and therefore quite accurately diagnosed and appraised. Psychiatric disorders, however, are for the most part invisible and their detection rests with the professional ability and experience of neuropsychiatrists. These specialists at times have appeared either over-enthusiastic or overcautious. In other instances it is evident that medical personnel have been too limited in numbers or too inexperienced in training properly to diagnose the large groups of men which must pass rapidly through induction stations. As a consequence many psychoneurotics have been inducted into the armed forces, with the consequent complications of a later discharge.
“It is this question of psychoneurotics which is least understood and is most difficult to handle. Functional nervous diseases are recognized as entities by neuropsychiatrists but these disorders cannot as a rule be definitely measured nor confirmed by laboratory tests or objective findings. For this reason there is a greater divergence of opinion regarding these cases than in any others. To the specialists the psychoneurotic is a hospital patient. To the average line officer he is a malingerer.2 Actually he is a man who is either unwilling, unable, or slow to adjust himself to some or all phases of military life and in consequence he develops an imaginary ailment which in time becomes so fixed in his mind as to bring about mental pain and sickness. In a sense this might be considered as shirking, yet among the thousands of psychiatric cases in the Army no record exists of any psychoneurotic ever having been convicted for malingering. This is because no doctor is either willing or able to state under oath that the pain complained of by the psychoneurotic is non-existent. The doctor may believe there is no pain. He may even say so—off the record—but he cannot swear to it. For this reason the layman or uninitiated line officer inclines to the belief that a medical officer’s diagnosis of psychoneurosis is either wrong or else that the doctor is influenced by a hyperconsiderate professional attitude.
“This view is emphasized in the light of certain happenings with which line officers in time become familiar. For example, at one general hospital during the course of this recent inquiry there were approximately 85 psychoneurotic patients. Most of these were walking about, performing light duties, and appearing quite content with their lot and with the prospect of an early discharge for physical disability. Shortly after representatives of The Inspector General arrived rumors spread through the hospital that discharges for physical disability, insofar as psychoneurotic disorders were concerned, had been discontinued. Immediately practically all the psychoneurotics became confined to their beds, too sick, by their own testimony, even to get up and go to meals.
“A further example has been handed down from the last World War when on the publication of the Armistice some 8,000 of 10,000 shell-shocked patients were reported to have made an instantaneous recovery.3
“The fact remains that thousands of hospital beds are being occupied by soldiers under observation and treatment for psychoneurosis who require the services of cooks, nurses, doctors, ward attendants, etc., all a burden on the Army and manpower generally. Whether or not the diagnosis in their cases is correct does not appear half so important as does the fact that the men are occupying hospital beds and taking up the valuable time of limited medical personnel. Furthermore, in most cases the primary reason for these men being in hospitals is not because doctors made patients of them but because line officers were unable to make soldiers out of them.
“The desire of commanders to be rid of below-average soldiers is understandable, particularly so when those commanders are necessarily held to rigid training schedules and the accomplishment of objectives according to a time schedule. In addition there is no established method by which psychoneurotics can be adjusted more slowly to military service than are normal soldiers. They all must of necessity, in a huge Army, receive virtually the same treatment and undergo similar training. The standards set for all men are more or less alike, but are based on what is to be expected of the average man. However, the true psychoneurotic is not average; he cannot keep up nor assimilate military life as do the others, whereupon, as a defense measure he discovers some ailment to which he attributes the reason for his inadequacy and immediately begins to go on sick report. This latter action is quite frequently condoned, if not actually encouraged by the officers and non-commissioned officers who have become weary of waging a losing struggle to keep the men up to the standard of other soldiers. We find in some instances that the line officers have importuned medical officers to help rid them of the burden of these particular cases, meaning of course by the method of disability discharge. As one doctor stated: “Conducting sick call is a game of wits; the man says he has it and the doctor says he hasn’t”. In some cases it appears that the men are smarter than the doctors, especially the inexperienced medical officers, while on the other hand the doctors do not care to disregard the possibility that the psychoneurotic does have some organic ailment. In any event the psy[cho]neurotic eventually gets to the hospital. Once there the man’s potential value to the service is either destroyed or seriously impaired. There he exchanges information regarding his ailment with other patients and from them he learns the symptoms most likely to perplex the doctors. He is recognized and treated as a sick man. He wears the clothes of an invalid. His food is brought to him. He is catered to by “grey ladies” and above all, he escapes from those duties which he seeks to evade. He cannot be punished for malingering, therefore the worst that can happen is to be sent back to his organization where he can and will start the same process all over again. In the meantime he enjoys a life of leisure with one great goal ahead, to wit, a discharge for physical disability, a comparatively high paid job as a civilian, a discharge bonus, and eventually a pension from the Veterans Administration Bureau.
“Perhaps the most important factor contributing to the spread of psychoneurotics in our Army has been the nation’s educational program and environmental background since 1920.4 While our enemies were teaching their youths to endure hardships, contribute to the national welfare, and to prepare for war, our young people were led to expect luxuries, to depend upon a paternal government for assistance in making a livelihood and to look upon soldiers and war as unnecessary and hateful. The efforts to change these teachings in a few short years have left millions of our people unconvinced. The burden of changing the minds of such people who are being inducted into the Army has fallen primarily upon the hard-worked young platoon leaders and company commanders of our great war Army and the indications at present are that the problem is not yet being satisfactorily met. This is manifested by the ever-increasing number of psychoneurotic patients crowding into our hospitals. A determined effort is being made throughout the Army to better this situation. It is admittedly difficult, and also it is important that there be a general public understanding of the problem.5
Document Copy Text Source: George C. Marshall Papers, Pentagon Office Collection, Selected Materials, George C. Marshall Research Library, Lexington, Virginia.
Document Format: Typed memorandum signed.
1. “The outstanding medical problem of the Tunisia Campaign was the unexpectedly high incidence of psychiatric disorders,” which “constituted a heavy burden on forward medical units.” (Charles S. Wiltse, The Medical Department: Medical Service in the Mediterranean and Minor Theaters, a volume in the United States Army in World War II [Washington: GPO, 1965], p. 144.) As a result, the army sought to weed out individuals who appeared to be susceptible to “battle fatigue.” By the end of 1943, the War Department’s concern about the manpower loss due to neuropsychiatric rejection at induction centers or discharges for neuropsychiatric reasons led it to place a publicity blackout on the release of information regarding the army’s psychiatric (and also malaria) problems. Discharge rates of enlisted men on certificates of disability for neuropsychiatric conditions had reached a peak in September and October 1943 of 35.6 and 34.6 men per thousand, more than three times the rate for the same time in 1942. In mid-November the War Department reversed its policy of discharging men with neuropsychiatric disorders and sought to use them in various ways. (Robert S. Anderson et al., eds., Neuropsychiatry in World War II, volume 1, Zone of Interior, a volume in Medical Department, United States Army [Washington: GPO, 1966], pp. 130-31, 206, 209. The problem of defining “psychoneurosis” in the military is discussed on pp. 229-32.)
2. George S. Patton’s treatment of two soldiers diagnosed as having psychiatric problems at hospitals in Sicily on August 3 and 10, 1943—the so-called “slapping incidents”—caused considerable press comment in the United States during November and December and focused attention on the causes of emotional problems in combat. Marshall’s office received numerous letters from civilians concerning Patton’s behavior. On these incidents, see Albert N. Garland and Howard McGaw Smyth, Sicily and the Surrender of Italy, a volume in the United States Army in World War II (Washington: GPO, 1965), pp. 426-31.
3. Not only was Marshall’s example “not supported by any known documentation,” according to Colonel Albert J. Glass, one of the editors of the army’s neuropsychiatry history, but the number of hospital admissions of neuropsychiatric patients increased briefly after the Armistice. Moreover, after the fighting stopped, there was a tendency to discharge hospitalized patients more readily and with certificates of less disability than they would have received had the war continued. (Anderson et al., eds., Neuropsychiatry in World War II, 1: 132.)
4. The overall rejection rate for draftees during World War II was 5.7 times higher than during World War I and 15.3 times higher in the category “mental disease.” The rate of discharges of enlisted men for neuropsychiatric causes was 2.2 times higher in World War II. The foremost factor leading to the higher rates during World War II, according to the editors of Neuropsychiatry in World War II, was the experience of World War I, which led to stricter standards and screening procedures. (Ibid., pp. 769, 772-73.)
5. It took three months for this document to reach and be answered by the Surgeon General’s Office; the memorandum and changes suggested by the Division of Neuropsychiatry are printed ibid., pp. 131-36. The memorandum was leaked to the press during January 1944. In part as a result of this, pressure from some reporters and magazine writers, who were becoming suspicious that the War Department was hiding something, and from the American Psychiatric Association forced a liberalization of the policy against public discussion of neuropsychiatry problems beginning in late April 1944. As a result of the lifting of the blackout, Marshall’s proposed press release was deemed unnecessary. Restrictions were not eliminated on publicity concerning the topic until September 1945. (Ibid., pp. 131, 137-42, 148-49.)
Recommended Citation: ThePapers of George Catlett Marshall, ed.Larry I. Bland and Sharon Ritenour Stevens(Lexington, Va.: The George C. Marshall Foundation, 1981- ). Electronic version based on The Papers of George Catlett Marshall, vol. 4, “Aggressive and Determined Leadership,” June 1, 1943-December 31, 1944 (Baltimore and London: The Johns Hopkins University Press, 1996), pp. 221-225.