By Duane Schultz

Eugene Sledge knew a thing or two about combat fatigue. It was September 15, 1944, on a tiny spit of land called Peleliu: the Japanese opened up with heavy mortar fire just as the Marines moved off the beach and started inland. The men hit the deck and took any cover they could find as the barrage of shells exploded around them. They were completely pinned down. The shells fell faster and faster until they sounded like one continuous raging roar. For long agonizing minutes, no one could move.

Sledge, a 21-year-old private, never forgot his first day in combat. He described it 35 years later in his classic book, With the Old Breed at Peleliu and Okinawa. “I thought it would never stop,” he wrote about the barrage that day. “I was terrified by the big shells arching down all around us. One was bound to fall directly into my hole. I thought it was as though I was out there on the battlefield all by myself, utterly forlorn and helpless…. My teeth ground against each other, my heart pounded, my mouth dried, my eyes narrowed, sweat poured over me, my breath came in short irregular gasps, and I was afraid to swallow lest I choke.”

He survived that day and the days that followed, but as the battle for Peleliu wore on, Sledge found that during every prolonged shelling “I often had to restrain myself and fight back a wild, inexorable urge to scream, to sob, and to cry. As Peleliu dragged on, I feared that if I ever lost control of myself under shell fire, my mind would be shattered.”


Yet, despite the horrors and the fearsome memories that haunted him for decades, Sledge was among the fortunate ones. He came perilously close to the breaking point in combat but never quite reached it. He never completely lost control; he did not drop his weapon or try to claw his way deep into the earth with his fingernails, or run screaming and panic stricken to the rear. He never reached the point that he could not take any more, as thousands of men do in every war, for as long as there have been wars.

Combat Fatigue Accounted for 40 Percent of All Medical Discharges

The number of combat fatigue cases in American fighting units in World War II was staggering. More than 504,000 troops were lost due to “psychiatric collapse,” an early term for reaching the breaking point. That was the equivalent of nearly 50 infantry divisions lost to the war effort. Far more men were rendered unfit for combat in World War II than in any previous war, primarily because the battles were longer and more sustained.

Some 40 percent of all the medical discharges in World War II were for psychiatric reasons, the so-called “Section 8s.” In one survey of combat veterans in the European Theater of Operations, fully 65 percent admitted to having at least one episode during combat in which they felt incapacitated and unable to perform because of extreme fear. One out of every four casualties in World War II was attributed to combat fatigue, with more cases reported in the South Pacific than in Europe. On Okinawa alone, 26,000 psychiatric casualties were documented. Overall, 1,393,000 soldiers, sailors, and airmen were treated for combat fatigue in World War II.

The Breaking Point

Historian John C. McManus described what combat fatigue is like. A soldier “starts trembling so bad he can’t hold his rifle. He doesn’t want to shake but he does, and that solves his problem. Involuntarily, he becomes physically incapable. He just plain ‘gives up.’” It was reported that an infantryman in North Africa “went crazy and beat his head against our foxhole till his skin on his forehead was just hanging in strands. He was foaming at the mouth just like a madman.” At Anzio, a sergeant who had been in combat for almost a year started running so fast he had to be tackled and physically restrained. A friend said, “He was the last person in the world you would have thought that would happen to.” Soldiers soon learned that it could happen to any of them.

One truism about the stress of continuous combat is that every soldier, no matter how well trained or how experienced, has a breaking point. “There is no such thing as ‘getting used to combat,’” wrote a group of psychiatrists in a 1946 report titled Combat Exhaustion. “Each moment of combat imposes a strain so great that men will break down in direct relation to the intensity and duration of their exposure.”

In some situations, such as the fierce and sustained fighting on the beaches and in the hedgerows of Normandy, fully 98 percent of those who were still alive after 60 days of fighting became psychiatric casualties. In less sustained fighting, the breaking point is typically reached between 200 and 240 days on the line. In the British Army in Europe, it was found that a rifleman could last for about 400 days, but that was attributed to the fact that the British relieved their troops for four days of rest every 12 to 14 days. American troops remained in battle continuously with no relief for as long as 80 days at a time.

The 1946 Combat Exhaustion report concluded, “Psychiatric casualties are as inevitable as gunshot and shrapnel wounds…. The general consensus was that a man reached his peak of effectiveness in the first 90 days of combat, and that after that his efficiency began to fall off, and that he became steadily less valuable thereafter, until he was completely useless.”

Artist Tom Lea’s iconic painting The 2,000 Yard Stare illustrates the toll that combat may take on the psyche of an individual. Although its manifestations varied from one individual to another, shell shock, or combat fatigue, was bound to affect any soldier to some extent.
Artist Tom Lea’s iconic painting The 2,000 Yard Stare illustrates the toll that combat may take on the psyche of an individual. Although its manifestations varied from one individual to another, shell shock, or combat fatigue, was bound to affect any soldier to some extent.

The experience of reaching the breaking point was given different names in different wars. During the Civil War it was sometimes referred to as “nostalgia” because people thought it was caused by homesickness rather than the experiences of battle. Another name applied at that time was “irritable heart,” also known as “Da Costa’s Syndrome,” after the U.S. Army surgeon, Dr. Jacob Mendes Da Costa. He described the symptoms as shortness of breath, discomfort in the chest, and palpitations, all of which he believed were caused by the stress of combat. By World War I, the condition had become known as “shell shock.”

As long as there have been wars, regardless of the style of combat or the killing power of the weapons, extreme fear to the point of panic and loss of control, exhaustion, numbness, and sheer terror have caused men to collapse, tremble, and run screaming from the field of battle. World War II, with its far more powerful weapons of destruction, was no exception.

Why Combat Fatigue Was Originally Labeled as “Guadalcanal Disorder”

In 1943, the American Psychiatric Association described what it called the “Guadalcanal Disorder” that appeared during the deadly, prolonged, close-quarters combat in capturing the island of Guadalcanal in the Solomons. This was America’s first large-scale offensive operation of the war.

More than 500 Marines were treated for an array of symptoms including “sensitivity to sharp noises, periods of amnesia, tendency to get panicky, tense muscles, tremors, hands that shook when they tried to do anything. They were frequently close to tears or very short-tempered.” When it was thus demonstrated that even an elite force of Marines was susceptible to such breakdowns, the situation became of major concern to the War Department. If it could affect the Marines in that manner, then no troops could be considered exempt.

For the majority of troops, fear is ever-present in combat, but it does not always lead to incapacitation. Sometimes fear can result in an array of symptoms that can temporarily disable a soldier without necessarily leading to a diagnosis of combat fatigue and a forced period of relief from the front line. These symptoms include a frantic heart rate, uncontrollable trembling, sweating, and periods of weakness, vomiting, and involuntary urination and defecation. The last two symptoms are the most dreaded because they are so hard to conceal and cause such feelings as shame, embarrassment, and humiliation. Some soldiers consider them to be the most overt signs of cowardice to their comrades.

Suicide, Self-Injury, and Desertion

Sometimes the stress of combat is so overwhelming that it leads to a collective panic in which whole units show signs of combat exhaustion and simply leave the battlefield together. Charles MacDonald, a company commander in France, watched his entire company collapse under a German attack. “They walked slowly on toward the rear,” he wrote, “half-dazed expressions on their faces.”

Some react to the stress of combat by committing suicide. One American soldier was so exhausted physically and emotionally during the Battle of the Bulge that he thought of killing himself because he was convinced that he would never make it out alive anyway. “I had been living in such miserable, bitter cold, and scared at Bastogne, I didn’t really care what happened. A click of the safety and tug of the trigger and my suffering would be over.” He had to force himself to put on the safety catch on his rifle. “You see, I didn’t want to kill myself [but] I was afraid that I was going to do it on impulse. Suffering does things to you.”

A second extreme reaction to combat stress is a self-inflicted wound. Some men at the breaking point shoot themselves in the hand or foot. Lieutenant Paul Fussell, an infantry officer, found that hundreds of soldiers in the Hürtgen Forest fighting shot themselves to get out of the line. They usually chose the left hand or foot. Fussell said, “For most boys being right-handed, the shooting had to be done with the right hand, working with a pistol, carbine, or rifle. The brighter soldiers used some cloth—an empty sandbag would do—to avoid telltale powder burns near the bullet hole.”

So many men wounded themselves that Army hospitals had to set up special wards to house those soldiers designated as SIWs (self-inflicted wounds). When they recovered, most were tried and convicted of “carelessness with weapons” and given six-month sentences in the stockade.

Another way out for those who could not stand up to the stress of combat or who simply did not like Army life anymore was to desert. This was a lot easier to do in Europe than on some remote Pacific island. The U.S. Army in Europe acknowledged that at least 40,000 men deserted; the British Army lost more than 100,000. Many of those who deserted fashioned new lives for themselves in other countries and were never found. Even the German Army, which had a policy of shooting deserters on sight, lost more than 300,000 soldiers through desertion.

Deficiencies in Addressing Combat Stress

Developing a method of treating the victims of combat stress took some time. In the early days of World War II, the U.S. Army tried several ways of dealing with the problem. At first, psychiatric personnel attempted to screen for it during the induction and selection process, looking for signs of psychological instability, trying to pinpoint those men who might be prone to reaching the breaking point faster than others. It was soon recognized that it was virtually impossible to predict which soldiers would fold under the stress of combat and which ones would not.

In 1943, a committee of 39 psychiatrists, psychologists, and social scientists produced a 456-page manual for soldiers called Psychology for the Fighting Man: What You Should Know About Yourself and Others. The book offered advice on every aspect of a soldier’s life, from morale and training to food and sex. But it devoted only nine pages to the topic of fear in combat.

The book took an optimistic and comforting view about feeling fear in battle, noting, “Every man going into battle is scared, but … as soon as the fighting man is able to go into action—to do something effective against the enemy, especially if it involves violent, physical action —his fright is apt to be dispelled or forgotten because he is too busy to remember it.” In other words, a man could expect to be afraid before a battle, particularly if it was his first, but as soon as the fighting started his fear would vanish and he would be fine.

That advice did not work out well. The fear remained with many soldiers every time they faced the enemy, particularly if the actions involved an especially violent clash. Nor did evacuating combat-stressed soldiers far from the battlefield provide positive results. In addition to losing a trained soldier from future combat, the distance from the field seemed to worsen the condition of combat neurosis.

Captain Hanson’s Treatment Program

Then in 1943, along came Captain Frederick Hanson, an Army neurologist and neurosurgeon, whose assignment was to deal with hundreds of combat-stressed soldiers after the disastrous defeat of American troops at Kasserine Pass in North Africa. Hanson made two major decisions that radically transformed the way victims of combat stress were treated.

As historian Stephen Budiansky wrote, “Hanson’s first step was to emphasize the normality of such reactions. He ordered psychiatric cases to be termed ‘exhaustion.’ The term was not just a euphemism. Hanson found that a significant number of cases were no more than the result of men being driven past their limits of endurance through lack of sleep during days of frontline fighting.”

Hanson arranged for the soldiers to be given a bed and food close behind the lines and then injected them with sodium amytal and other calming drugs, often referred to as “Blue 88,” named after the highly effective German artillery piece, the 88, which was also highly effective in knocking people out. The drugs induced a long, deep sleep lasting up to 48 hours. When the men awoke and the numbing effects of the drugs wore off, they were given hot showers, fresh uniforms, and a pep talk and then sent off to the front. Hanson’s data showed that 50 to 70 percent were able to return successfully to combat within three days.

As he climbs aboard a transport off the island of Eniwetok, a U.S. Marine wears the expression of a fighting man who has endured continued hardship.
As he climbs aboard a transport off the island of Eniwetok, a U.S. Marine wears the expression of a fighting man who has endured continued hardship.

A key aspect of Hanson’s program of rapid rehabilitation was to keep those suffering from combat exhaustion close enough to the front line that they could still hear the sounds of combat when they awoke from their drug-induced sleep. He also insisted that patients adhere to a regular military routine during the recovery period. Hanson’s approach was made official Army doctrine toward the end of 1943 and remained in place for the rest of the war.

The Long Legacy of PTSD in World War II

Still, there were many men who could not be helped even by this program and who never returned to active duty. For others, the fear of reaching the breaking point would stay with them long after the last battles were over; their war did not end in 1945. What we now call post-traumatic stress disorder (PTSD), but which had no name or formal treatment programs during World War II, did indeed affect millions of returning World War II veterans. Most of them struggled on their own to deal with the terrors of their private war, not even confiding in their families or telling anyone else what they had experienced.

“The increasing dread of going back into action obsessed me,” Eugene Sledge wrote in 1981, more than three decades after the war was over. “It became the subject of the most tortuous and persistent of all the ghastly war nightmares that have haunted me for many, many years. The dream is always the same, going back up to the lines during the bloody, muddy month of May on Okinawa. It remained blurred and vague, but occasionally still comes, even after the nightmares about the shock and violence of Peleliu have faded and been lifted from me like a curse…. All who survived will long remember the horror they would rather forget.”