In studying the infantry’s experience in the European Theater of Operations (ETO), we find circumstances that are almost beyond imagining. We learn, for instance, that fear was ever present. The terror “came and went in varying degrees,” sometimes seeming “intolerable” but at others “dissipating entirely” . At times it was such intense fear that an average of one in four soldiers in one ETO division admitted to losing control of their bladders or bowels during a bad shelling . The terror was heightened by horror. Paul Fussell wrote of “the bizarre damage suffered by the human body in modern war,” offering an example of soldiers being hurt not by shell fragments and shrapnel, but by “parts of their friends’ bodies violently detached” . The more we learn, the more we wonder how men could have endured the strain of such an experience. How did they do it?
Sometimes they didn’t.
Whether their breakdown happened immediately or after months of fighting, each man had a limit. There were more than 1.3 million psychiatric casualties during Word War II . In the Army alone in, 929,000 reached their limit and became psychiatric casualties , which was more than twice the number of those killed in action in the entire war . The figure would have been higher had not “other forms of attrition intervened too rapidly for psychiatric attrition to occupy a major role.” In other words, men were far more likely to be killed and wounded before they reached their breaking point . As it was, over half a million were evacuated permanently from the battlefield [8 ]. Although censorship insured that the American public wouldn’t know the extent of the emotional damage until well after the war , infantrymen and field commanders alike were well acquainted with it.
These breakdowns occurred in every war. Indeed, each war’s breakdowns generated new terms to describe them – like ‘soldier’s heart’ in the Civil War or ‘shellshock in the First World War . In World War II they were known as “battle fatigue” or “combat exhaustion” casualties. General Omar Bradley ordered that the term “exhaustion” be used to describe it in the hopes of likening the affliction to a state of tiredness from which troops could recover after a brief rest . It was far from that. Its modern name is “combat stress reaction.” It’s defined as being “any response to battle stress that renders a soldier combat ineffective.” It’s important to note that battle fatigue is not post-traumatic stress disorder (PTSD), although the two are related. PTSD is a persistent and potentially chronic condition that occurs well after the traumatic experience, while combat stress reaction is an acute affliction .
Even though sufferers of battle fatigue were classified as non-battle casualties,  their condition could be just as debilitating as any physical wound and was most certainly brought on by combat. Its symptoms vary widely. Mild cases could exhibit trembling, insomnia, rapid heartbeat, or being easily startled, among others. More severe symptoms might include constant movement, inability to communicate, paralysis, or even hallucinations . One of the most frequently cited symptoms observed by ETO veterans during breakdowns was crying. One officer mentioned how “awful” it was “to see men go into convulsions, froth at the mouth, [and] gibber incoherently.” .
Infantrymen understood it well. They believed the break was brought on by a loss of the ability to deal with the fear any longer. Lieutenant George Wilson observed that he “knew that everyone had their breaking point” . Another officer, Paul Fussell, explained that “normally each man begins with a certain full reservoir, or bank account, of bravery, but that each time it’s called upon, some is expended, never to be regained. After several months, it has all been expended, and it is time for your breakdown” . One veteran “watched men in combat gradually lose their nerve and senses till they went berserk…We also knew they weren’t cowards” . A 1958 study noted that it was “generally believed that every man had his breaking point…Too many men with long and valorous combat experience…were brought to hospitals with disabling mental illness for there to be doubt” .
Some men reached their limit even before entering combat. For instance, the soldiers of K Company, 333rd Infantry Regiment, recorded that a new replacement “was shaky – he wouldn’t even get out of his hole at night to take a leak.” The men in his company determined that they “couldn’t trust the guy,” and he was evacuated as a psychiatric casualty . Others collapsed in their first action. A captain, on his first day in command of a company in the Huertgen, made a mistake that caused significant casualties. Lieutenant George Wilson wrote that he “broke down in tears…blubbering about how it was all his fault. He kept at it, and…I realized he was completely out of control.” He, too, was sent to the rear .
Most soldiers held up far longer than their baptism of fire. Exactly how long depended on the individual, but the “most frequently cited estimate of a of a soldier’s emotional lifespan is between 80 and 90 days in combat” . At 80 days, the average psychiatric casualty rate was 47%. By 140 days it would be 75%. At 210 days the rate would be a full 90% .
For those who kept fighting, several factors were found to make them less or more susceptible to battle fatigue. Among individuals it was found that no variation of personality types had a measurable bearing on when men would break. However, married or less educated men were more apt to become psychiatric casualties . Other factors affected the whole unit. Physical hardship “played a pivotal role” in undermining men’s “ability to cope with emotional stress.” Hunger, fatigue, and extremes of weather all hastened its onset. The character of the unit itself mattered as well. Outfits with greater cohesion, morale, and confidence in themselves and their leaders, tended to result in less cases of battle fatigue, as did better trained units. It was also found that defensive tactical situations were more harmful to soldiers’ resilience than mobile warfare, perhaps owing to the degree of helplessness that is inherent in the former . “Interpersonal and social factors” like “rejection” and “humiliation” motivated men as well  . Put another way, men’s “pride swallowed their fear” . Yet the single greatest determinant of battle fatigue casualties was the “intensity of combat.” The higher the amount of killed and wounded, the higher the occurrences of battle fatigue .
The War Department anticipated the problem and took measures to mitigate its occurrence. They implemented a rigorous screening process intended to weed out potential recruits who may have been more susceptible to battle fatigue, resulting in nearly a million and half potential inductees being denied entry into the service. Nevertheless, psychiatric casualty rates were “notoriously high” in Guadalcanal and North Africa . The army’s response included devising a treatment strategy based on the principles of “proximity, immediacy, [and] expectancy” . Soldiers were to be treated as soon as they became a casualty, close to their unit, and ensuring that they fully expected to recover . Psychiatric resources were added to units’ tables of organization and equipment to implement this “forward psychiatry,” with division-level hospitals eventually having a psychiatric ward with three hundred cots . Still, only half the soldiers taken off the front line managed to return to their units after their first evacuation. 16% did so after their second, third, and fourth evacuations .
PFC Robert Koltowitz’s experience is remarkable in the details of his evacuation from the battlefield and his subsequent treatment. Koltowitz, a 26th Division infantryman in the Alsace-Lorraine, was one of three soldiers who survived his platoon’s ill-fated attack one morning. The forty others in the unit were wiped out by mortars, machine guns, and grenades. He played dead until darkness fell and medics came out to look for survivors, and, after being found, he was evacuated to the division hospital. For several days there he was alternately interviewed by the division psychiatrist and dosed with sodium pentathol – a substance that brought on “the kind of sleep that is like a lost universe in itself.” Eventually, the psychiatrist had him re-assigned to a detail behind the lines in which he guarded and sorted the division’s duffel bags. He never returned to his unit .
Fred Salter, who served in North Africa, Sicily, and Italy, was an example of a soldier who broke down well after combat. He was rotated to the States before the end of the war. He thought it “wonderful to be home,” but “couldn’t get rid of the tensions that plagued my mind.” After a furlough he was hospitalized for malaria and his “shattered nerves.” Following his release, he served briefly as a guard in a disciplinary barracks. After a second hospitalization for combat fatigue he was tasked with guarding German POWs. There he snapped. He loaded and charged a machine gun, then aimed at the prisoners that were “heckling” him. Other guards intervened, and he was arrested. He was charged with attempted murder, but after the court-martial read of his combat record he was discharged. When he wrote his memoir, he said he had “spent almost half a lifetime searching for a solution to heal the festered wounds of my mind” .
The high incidence of battle fatigue had a legacy on the army as well. Given the inevitability of either psychological breakdown, death, or wounding, the authors of a 1958 study reported that most soldiers were in favor of a rotation policy that would fix the number of days infantrymen would have to be in combat. They acknowledged that the lack of a rotation negatively affected morale . Another study concluded that an infantryman’s tenure on the front lines “for the duration” was viewed to be “a bitter injustice” . Individual rotation policies were developed in the Vietnam War that limited an infantryman’s tour to twelve months, and units were afforded rest periods in theater .
The soldiers themselves, of course, also dealt with lasting effects of the psychological trauma of World War II. Lieutenant George Wilson knew well that “some of the poor guys” who broke down “never did make it back to normalcy, even long after the war” . Countless more didn’t, either. A 1951 study estimated that as many as 10% of World War II veterans “still suffered from combat neurosis.” One famous example is Audie Murphy, a highly decorated World War II infantrymen who was “frequently suicidal” and plagued with “nightmares and insomnia.” He said at one point that “the war never really ended for him.” Yet the full extent of PTSD connected to World War II is hard to determine. American culture at the time “didn’t acknowledge the psychological [cost] of war” to the degree it does in the present day . Veterans were, by and large, reticent about their experiences and about any problems they had after returning home, attempting to simply move on with their lives .
One can imagine that at the very least, all of them remembered. One veteran wrote home that “forgetting will be impossible” . Given the horrors of World War II and the psychological impact on so many, he was probably right.
 Radford Carroll quoted in John C. McManus, The Deadly Brotherhood: The American Combat Soldier in World War II (New York: Ballantine Books, 1998), p. 138.
 Paul Fussell, Wartime: Behavior and Understanding in the Second World War (New York: Oxford University Press, 1989), p. 277
 Ibid., p. 270.
 The Perilous Fight: The Mental Toll. PBS Documentary Film, 2003. [https://www.pbs.org/perilousfight/psychology/the_mental_toll/]
 Rick Atkinson, The Guns at Last Light: The War in Western Europe, 1944-1945 (New York: Henry Holt and Company, 2013), pp. 340-341.
 Nese. F. DeBruyne, “American War and Military Operations Casualties: Lists and Statistics” Congressional Research Service, (September 2018), p. 2.
 John W. Appel and Gilbert W. Beebe, Variation in Psychological Tolerance to Ground Combat in WWII (Washington, DC: National Academy of Sciences), 1958.
 David Morris, The Evil Hours: A Biography of Post-traumatic Stress Disorder (Boston: Houghton Mifflin Harcourt: 2014), pp. 134-136.
 James Wright, Those Who Have Borne the Battle: A History of America’s Wars and Those Who Fought Them (New York: Public Affairs, 2012), pp. 118-119.
 Morris, The Evil Hours¸ p. 137.
Russell Glenn and Todd C. Helmus, Steeling the Mind: Combat Stress Reactions and Their Implications for Urban Warfare (Arlington: Rand Corporation, 2005), p. 15.
 Ibid., pp. 2-3.
 Appel, Beebe, Variation in Psychological Tolerance, p. 50.
 Ibid., p. 71.
 George Wilson, If You Survive: From Normandy to the Battle of the Bulge to the End of World War II (New York: Ballantine Books, 1987), p. 138 and 157. Lieutenant Wilson mentions combat fatigue in various segments of the book, with most of them occurring in the Huertgen Forest.
 Ibid., p.156-157.
 Paul Fussell, Doing Battle: The Making of a Skeptic (Boston: Little, Brown, and Company, 1996), p. 138.
 Veteran’s survey response quoted in Appel, Beebe, Variation in Psychological Tolerance, p. 58.
 Ibid., p. 1.
John D. Campbell and Harold P. Leinbaugh, The Men of Company K: The Autobiography of a World War II Rifle Company (New York: Bantam Books, 1986), p. 223.
 Wilson, If You Survive, 138.
 Glenn, Helmus, Steeling the Mind, 34.
 Appel, Beebe, Variation in Psychological Tolerance, p.92.
 Glenn, Helmus, Steeling the Mind, pp. 24-25.
 Glenn, Helmus, Steeling the Mind, p. 27-36; Appel, Beeber, Variation in Psychological Tolerance, p. 166-167.
 Appel, Beeber, Variation in Psychological Tolerance¸167.
 Fussell, Wartime, p. 210.
Appel, Beeber, Variation in Psychological Tolerance, pp.25-43.
 Glenn, Helmus, Steeling the Mind, pp. 13-14.
 Dr. Matthew J. Freidman. “History of PTSD in Veterans: Civil War to DSM-5.” National Center for PTSD: US Department of Veterans Affairs [https://www.ptsd.va.gov/professional/treat/essentials/history_ptsd.asp], Accessed December 2018.
 Erica Goode, “When Soldiers Snap,” The New York Times (7 NOV 2009).
[https://www.nytimes.com/2009/11/08/weekinreview/08goode.html] Accessed December 2018.
 Glenn, Helmus, Steeling the Mind, 15-17.
Appel, Beebe, Variation in Psychological Tolerance, pp. 64-65.
 Robert Koltowitz, Before Their Time: A Memoir (New York: Anchor Books, 1997), pp. 135-171.
 Fred H. Salter, Recon Scout: Story of World War II (New York: Ballantine Books, 1994). Kindle Edition, Loc. 4856 to 5358.
 Appel, Beebe, Variation in Psychological Tolerance, 253-261.
Atkinson, Guns at Last Light, pp. 340-341.
 Glenn, Helmus, Steeling the Mind, pp. 15-20.
 Wilson, If You Survive, p. 157.
 Morris, The Evil Hours, pp. 134-136.
 Wright, Those Who Have Borne the Battle, pp. 131-132.
 Letter, Sergeant Meredith Rogers to his father in Howard Peckham and Shirley Snyder, eds., Letters from the Greatest Generation: Writing Home in World War II (Indianapolis: Indiana University Press, 2016), pp. 186-187.