Combat Fatigue

Photograph of Marine suffering from combat fatigue

National Archives #520616. Via Wikimedia Commons

Combat fatigue, also known as combat psychosis or shell shock, was a serious psychological disorder that caused significant casualties during the Pacific War. It manifested itself in various forms. At one extreme, combat fatigue produced an extreme fear of performing one's military duties that differed from the normal fear of combat only in its severity and in its presentation in men who had previously performed bravely. At the other extreme, it presented as complete mental collapse from which the victim never recovered. Between these extremes, combat fatigue might present itself as dangerously irrational behavior or as various forms of hysteria, such as psychological blindness or paralysis.

In a rear-area hospital, O.P. Smith inspected combat fatigue cases, of which Okinawa generated thousands. He watched a doctor treating a Marine in whose foxhole a mortar round had landed. "No man could have portrayed fear as this man did. He kept gurgling 'Mortar, mortar, mortar.' The doctor asked him what he was gong to do now. He replied: 'Dig deeper. Dig deeper.' The doctor told hem to go ahead and dig. The man got down on his knees and went through frantic motions of digging in the corner of the room."

(Hastings 2007)

Western armies had recognized by the end of the First World War that combat fatigue was not simply cowardice or a lack of "moral fiber." However, most of the lessons of the First World War were forgotten by the time of the Second World War, and it took some time to relearn them. Psychological screening to predict which recruits might be subject to combat fatigue was attempted, but proved almost completely unsuccessful. Psychiatrists relearned the lesson that combat fatigue was best treated as close to the front line as possible: The further back the patient was transferred for treatment, the less likely he was to fully recover.

In many cases, the breakdown was transient, and the victim was able to pull himself through, sometimes with the help of his comrades, without leaving his unit. Dick Winters, a reserve airborne officer who reached the rank of major in the European theater, recalled visiting a soldier in his battalion aid station who was suffering from hysterical blindness. After Winters talked soothingly with the man for a few minutes, he abruptly regained his eyesight and was able to return to the front line. Another treatment that proved effective was to heavily sedate the soldier for a couple of days, thereby giving him a prolonged rest. This allowed about 30% of patients to return to combat duty within a day and 70% within 48 hours. Men who broke down were diagnosed with "exhaustion", which may not have been too far from the truth, and which saved the patient from the stigma of mental illness and improved his chances of recovery.

However, as the war wore on, psychiatrists began to recognize a form of combat fatigue dubbed "old sergeant syndrome" that differed from the more transient form and did not respond to treatment. Its victims were often sergeants and officers with long records on honorable combat service. Such men were described as "burned out, all shot, no good" (Cowdrey 1994). It is now fairly well established that even the best soldier will eventually succumb to some form of mental breakdown if he remains in continuous heavy combat long enough. In Europe, it was estimated that U.S. troops reached their peak combat efficiency after about 30 days of combat, and combat fatigue began to be a serious problem for troops who had been in combat for 100 days or more. After 140 to 180 days of combat, a soldier was basically useless for further combat even if he showed no patent symptoms of combat fatigue. It was rare for a campaign in the Pacific to last this long, but the terrible environment and the brutality of the fighting may have worn men down more quickly. It was the opinion of E.B. Sledge, who witnessed  the psychological breakdown of a hardened and previously reliable Marine at Okinawa, that length of combat was more critical than its absolute intensity in producing psychological casualties. However, artillery seems to have been particularly prone to produce combat fatigue, which may help explain why the condition was also called shell shock.

Closely related to "old sergeant syndrome' was that some Marine veterans dubbed the "don't-give-a-damns." This was manifest in troops who remained in intense combat for a prolonged period, as at Peleliu. The troops did not show any obvious signs of breakdown, but they developed an intense fatalism which, together with physical fatigue, resulted in carelessness. They failed to stay alert and to make good use of cover, often with lethal consequences. Marine veteran R.V. Burgin recalled that (Sloan 2005):

Jimmy [Burke] and I had never been excitable types, but on Peleliu, it was different from just being able to stay calm under pressure. There towards the end, we got to the point where we didn't feel much of anything. We still wanted to kill Japs, but there were times when it didn't seem to matter if you lived or died. You were so damned tired and worn-out, you just didn't care. I can honestly say I never felt that way anywhere else. Sometimes I think not caring was the only thing that kept us from going completely nuts.

Since old sergeant syndrome could not be successfully treated, the only hope was prevention. It was claimed that the British practice of systematic rotation of troops doubled their period of combat effectiveness to 400 days. Such rotations were recommended to U.S. field commanders, but there was no mechanism for enforcement, demands for manpower were great, and rotation was little practiced except through the relief of individual soldiers with the longest combat experience. Rotation would be systematized in later conflicts, only to present problems of its own.

The transient form of combat fatigue was most common in troops that were badly trained and led, as seems to have been the case for American troops at New Georgia, where the percentage of casualties from both combat fatigue and friendly fire were much higher than average for the theater.  Curiously, Army doctors on Corregidor saw few cases of combat fatigue. This may be attributed to the fact that the troops were relatively well fed, were not in immediate contact with the enemy, and were not exhausted from constant physical exertion -- and because they all knew that there was no escaping to the rear.

In the Pacific, combat fatigue was often confounded with physical breakdown. Many soldiers reported to aid stations with high fevers of unknown origin. These may have been consequences of heat stroke or of undiagnosed tropical diseases, but they may also have been hysterical. Clifford Fox, a Marine at Guadalcanal, told Bergerud (1995):

A lot of the older guys cracked quicker than the younger ones. The old NCOs just couldn't take it as long as the younger fellows. They just got physically ground down; they didn't have the physical strength of the younger guys. And then they got psychologically worn out. They didn't have the reserve to draw on. A lot of them were in their late thirties and early forties. They probably weren't as dumb as some of the nineteen-year-olds. They had families and so forth. They took it harder.

Given that the regulation ration didn't always make it to front line troops at the end of long supply chains, there were concerns among American nutritionists that bordline malnutrition was also contributing to combat fatigue.

Combat fatigue occasionally manifested itself in subtle ways. It has been suggested that the infamous slapping incident by General George Patton in the Mediterranean Theater was a result of Patton himself suffering from mild combat fatigue. Hornfischer (2011) has discovered documents suggesting that Nimitz relieved Ghormley from command of South Pacific Area because he feared his old friend was on the verge of a nervous breakdown. Li Tsung-jen was briefly hospitalized after the Hsuchow campaign, ostensibly for an old bullet wound, but Peattie et al. suggest it was for depression. It is obvious that subtle combat fatigue in leaders, manifesting itself as irritability or the issuance of irrational orders, can be an extremely dangerous thing in a combat situation.

Combat fatigue was not restricted to soldiers. Airmen who flew too many missions sometimes became careless or lost their aggressive edge, perhaps because prolonged stress reduced their situational awareness. One Japanese pilot recalled widespread combat fatigue while on a combat strike during the Battle of the Philippine Sea (Werneth 2008):

I could not hear my navigator Ensign Nakajima's voice through a voice tube, perhaps because of engine noise. It seemed that he also could not hear me either. I was suffering from a very unusual physical condition caused by prolonged fatigue, and felt I was in a plane being flown by somebody else. I was sure that all of the other aviators were feeling the same way.... I was surprised to see that one Suisei and three Zeros had disappeared. I really wondered if they left the formation due to mechanical trouble or dove into the sea from mental confusion.

An American flight surgeon, Major James T. King, noted (Gamble 2010):

In our group, after the crew has flown from 100 to 130 combat hours or from 10 to 15 missions, they begin to notice that they are losing their natural zest and eagerness for combat flying. As the condition develops, there are manifestations of mental, emotional and physical tiredness, and changes in personality. Variably there is a preoccupation, moodiness, brooding, moroseness and irritability. The flyer is usually tense and appears to always be worried. He notices that he is unable to rest adequately and has trouble sleeping. When he does sleep, he is frequently awakened by dreams and nightmares. The next morning he finds that he is just as tired as when he went to bed. Instead of  taking one day to recover from a combat mission, it takes three or four. There is weight loss on an emotional basis. As an experienced squadron commander put it, he could recognize the condition at a glance by the haggard, hangdog expression in [men's] eyes.

The Japanese ignored this problem, but the Americans rotated a pilot home after he completed a tour of duty.

Combat fatigue was uncommon among the enlisted men of the Navy, since intense combat was infrequent and typically lasted but a few hours, but commanding officers were under continual heavy stress. Halsey suffered a mysterious skin condition after several months' continuous duty following the Pearl Harbor attack, which could not be satisfactorily diagnosed and may have been hysterical. He was sent home, where he was hailed as a hero, recovered from his skin condition, and returned to combat command later in the war. Submarine commanders were under extraordinary pressure and were carefully watched for signs of combat fatigue. After a number of patrols, they were usually rotated to another assignment. This was often the commissioning of a new submarine, which meant an extended stay in a home port.

Allied prisoners of war in Japanese hands were subject to appalling treatment, and this sometimes led to mental breakdown. Prisoners working on the Burma-Siam Railroad were so badly treated that many retreated into elaborate daydreams of home. Sometimes prisoners relived past conversations with old friends out loud, or described their old homes as if they were standing before them. From here the prisoner might slip into the catatonic state the other prisoners called "atap staring", named after the crude atap huts in which the prisoners were housed. Once this stage was reached, the prisoner almost never recovered.

The Japanese warrior ethos of Bushido ignored the reality of combat fatigue. Nevertheless, the Japanese were human beings, and if seemingly cowardly conduct was unthinkable, then combat fatigue took other forms. Japanese troops who had reached their psychological limits often engaged in suicidal tactics known as gyokusai ("shattered jewels"), of which the most common manifestation was the banzai charge. This was essentially a form of "suicide by Marine." Others killed themselves when approached by Allied troops. Ultimately, however, those who did not die in combat or kill themselves with their own weapons suffered the same kind of psychological collapse seen in soldiers of other nationalities. Large numbers of Japanese are reported to have suffered such psychological collapse under the terrible conditions on Guadalcanal, and many were either killed by their comrades (who regarded this as a mercy to them) or left behind to die.

Units composed largely of reservists in China could not escape the reality of combat fatigue. Historian Kawano Hitoshi (in Peattie et al. 2011) reports that 1,287 neuropsychiatric patients were evacuated from China in 1940 and constituted 2.9 per cent of evacuated casualties. He concludes that rates of combat fatigue among units in China was roughly comparable with those in the U.S. Army in the Pacific.

The effects of combat fatigue were also manifest in the fate of FPO 1st Class Matsunaga Hisamatsu (Gamble 2010):

... Matsunaga had advanced rapidly to shotai leader due to attrition. As the death toll rose, he eventually became a chutai leader, responsible for nine aircraft.... In early March, about the time that the Zeros of Air Group 582 advanced to Buin airfield on Bougainville, Matsunaga became withdrawn and refused to fly. He remained at Rabaul, holed up in a senior enlisted man's quarters. The group's commanding officer and vice commanding officer tried to reason with him, but Matsunaga refused to cooperate. There was talk of sending him to Japan for court-martial, which would likely result in his execution, but Matsunaga did not care.

... Realizing that Matsunaga was carrying far too much responsibility on his young shoulders, Tsunoda offered to take him into his own division. "I will kick in the gate of Enma, the Lord of Hell. Follow to the bottom of Hell," Tsunoda said, borrowing a war cry used by his own former division leader. It worked. Matsunaga had been virtually paralyzed by depression but agreed to fly again, though not as a leader; he simply needed someone to remove the yoke of responsibility. "I do not like Hell," he replied, "but with you, I will go there."

... During the approach to the Russells, a gaggle of F4U Corsairs attacked Matsunaga's side of the formation. He charged at them singlehandedly, leaving the rest of the Zeros to protect the bombers. Tsunoda watched in dismay has his friend raced headlong toward the American fighters, knowing instinctively that Matsunaga would not return.

One recognizes the pattern of depression and irritability, to the point of losing the instinct for survival, as evidenced both by the disregard of the threat of execution and the suicidal charge into the enemy.

Men returning from a hard campaign sometimes suffered various forms of breakdown in their first few days off the line. Mark Durley, who led a lengthy and very dangerous reconnaissance patrol on Bougainville, told Bergerud (1995):

All of us were exhausted. For three or four days we were useless. Some of us, myself included, would break out in tears for no specific reason. It is a little hard to remember the period. I tried to stay away from people for a while. After a few days we started to snap out of it.

Not all were able to "snap out of it." During the time 3 Marine Division was stationed on Pavuvu in the Russell Islands, where there was no combat, but living conditions were miserable and the troops felt a strong sense of isolation, several veterans broke down psychologically. One former Marine told Sloan (2005) that:

I knew a guy who blew his brains out with his own rifle while he was on guard duty one night. Other guys just went crazy and started screaming all of a sudden. They'd yell stuff like, 'They're killing me! They're killing me!' and they'd get taken to the Navy hospital for psychiatric treatment. It was really the after-effects of the battles they'd been through but conditions on Pavuvu didn't help any.

Possibly related is the case of Kosono Ammyo, a Navy captain at Atsugi who tried to continue resistance to the Americans in spite of the Emperor's decision to surrender. Kosono was also suffering from relapsing malaria, and this may have contributed to his mental collapse when his plans to continue resistance were thwarted.


Ambrose (2001)

Bergerud (1996)

Collingham (2011)

Craig (1967)

Cowdrey (1994)

Dunnigan and Nofi (1998)

Ellis (1980)

Gamble (2010)

Hastings (2007)

Hornfischer (2011)

Leckie (1962)

Peattie et al. (2011)

Sledge (1981)

Sloan (2005)

Webster (2003)

Werneth (2008)

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