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Medical Science Publication No. 4, Volume II



I. Introduction

In the limited time I have today I will confine my remarks to only afew aspects of studies conducted by a psychiatric team which operated inKorea at division level between 17 May and 23 October 1953. The membersof this team were myself, a psychiatric social worker, and a psychologytechnician. Dr. David McK. Rioch and Dr. Frederick C. Redlich also actedas consultants, both present part of the time with the team in Korea. Ourintention was to gather data which might be indicative of psychologicalstress in a combat zone, to check the performance and adjustment of psychiatricpatients returned to duty, and to determine the correspondence betweenpsychiatric diagnosis, personality "structures," name-calling,etc., and the actual functioning of men in combat.

Before speaking of these matters, however, I would like to make someremarks about the combat zone in Korea, where our studies were confined.From the psychological point of view the combat zone is two things: Onthe one hand actual fighting (hand-to-hand combat, artillery andmortar shelling), and on the other, life in the combat zone, irrespectiveof fighting. This suggests that there are also two broad psychiatric problems.The combat zone also differs markedly in the types and degrees of stressdepending on whether one is in the rear or the forward areas. Table 1 givessome of these levels of difference as extremes.

With this brief preface I will move on to consider psychiatric patientsthemselves. We will not be particularly concerned with the previously psychoticor neurotic individuals who happen to land in the combat zone. They arerelatively few in numbers and present no major problems. As a matter offact, it is generally conceded that many of the neurotics-in-civil-lifeactually do well in the combat zone-only to revert to their neuroses uponreturn home. The major

*Presented 30 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington,
D. C. This paper is an abstract of a complete report of the studies conducted by the Psychiatric Research Team under the Army Medical Service Graduate School.


Table 1. Differences in Stress in Forward andRear Areas



Extreme danger, more or less constant and often sudden.

Little or no danger; at most intermittent and rarely sudden.

Comrades being mutilated and killed.

Rarely being mutilated or killed.

Little mobility of individuals, and extreme closeness between them.

Much mobility of individuals, and less extreme closeness.

But great isolation otherwise.

Less isolation.

Instability of interpersonal relations (through turnover, rotation, death, injury).

More stability even if not more prolonged.

Direct concern with destruction and killing.

No direct concern with destruction or killing.

Consistent youthfulness.

Mixture of many age-groups.

Rank divergencies less marked (captains to privates).

Rank divergencies greater (generals to privates).

Discomfort of living conditions (foxholes, bunkers, trenches, tents).

Relative comfort of living conditions (prefabs, quonsets, janeways, clubs).

Absence of women.

Presence of women.

Material poverty.

Relative material richness.

Contraction of sense of time.

Less contraction of sense of time.



Quick, important decisions.


Stability and identity of units as teams, with definite demarcation of territory.

Less identity of units as teams, with more indefinite demarcation of territory.

problems of combat psychiatry lie with the more or less severely disturbedpatients (dissociative reactions) from actual combat situations, and onthe other hand with the less disturbed patients from the combat zone butnot from a situation of actual combat.

The dissociative reaction under actual combat appears to be a fairlydistinct entity. In our series of cases it always occurred in associationwith intensive artillery and mortar shelling, never on patrols beyond thefront lines or while performing ordinary duty on the front lines duringrelatively quiet periods. It did occur in rearward areas when these areaswere undergoing heavy shelling. The dissociative reaction usually occurredin men who had been some time with their units, were effective and well-likedsoldiers, to whom the reaction apparently occurred suddenly and came asa surprise both to themselves and their comrades. There is evidence thatin some cases this reaction was contagious to small groups of men. On theother hand, most of them occurred as single, isolated cases. The reactionwas more or less severe, with considerable effacement of reality and oflearned abilities. It was, however, usually transient.


The other category of psychiatric patients are the men who get to thepsychiatrist during periods of relative quiescence, and are usually diagnosedas "character and behavior disorders" (including the "immaturityreactions") or simply as "no disease." It was in this categorythat psychiatric diagnosis most often failed to encompass the actual circumstancesunder which an individual becomes a psychiatric patient.

II. One Battle

Only one battle occurred during our stay which lent itself to study.Thirteen rifle companies from two regiments were directly involved. Thisaction lasted 6 days. Furthermore, one small hill, an outpost in frontof the main line of resistance, took the brunt of the fight throughout.There was, however, during this period greatly increased shelling of therearward elements of the division concerned-and this produced casualtiesof all sorts. Officers had good indications for several days in advancethat this battle was impending, but evidence is that the men did not.

But confining ourselves for the moment to the immediate battle area,the outpost hill, we note some striking phenomena. Approximately 2,000men were committed to this fight at overlapping intervals of time rangingfrom approximately 15 to 50 hours. Of these 2,000 men, 52 were killed,846 were wounded, 164 were missing, and 25 became psychiatric casualties.None of those who became psychiatric casualties in this battle hadever for any reason been to a psychiatrist before. And of 39 men who hadseen the division psychiatrist prior to this battle, who were still presentin Korea, and about whom information could be obtained, 10 were on theoutpost hill and 1 in the vicinity during the battle, 14 were in companyrear areas, 9 had been transferred, and the location of 5 could not bedetermined. These 39 men were classified as 8 neurotics and 31 psychiatricadministrative problems. Also of the 10 who were on the outpost hill, 1was killed, 3 were wounded, and 1 was missing. None of these 39men, however, became psychiatric casualties during the battle. Althoughthis material is scanty, it does have the double element of exclusiveness,such that in this one instance the following statement can be made: Noncombatpsychiatric cases do not become combat psychiatric cases and combat psychiatriccases have not been noncombat psychiatric cases.

I hardly think there was anything special in this battle or in the commandor logistical situation which would account for this phenomenon. It couldconceivably be a result of a really superior system of psychiatric disposition-e.g., where the 10 psychiatric patients who were retained for combat andthe 14 who were disposed


in rear areas were all correctly evaluated and assigned. I feel thatis highly improbable. It could be an entirely spurious phenomenon, thougheven in view of the small number of examples, I do not believe it is achance occurrence. Other observers have reported similar phenomena. Atany rate, the fact that those men who had previously seen the divisionpsychiatrist did not break down, and that those who did break down in thebattle had not seen the psychiatrist goes counter to most of our prognosticnotions, and is worthy of very careful investigation. Furthermore, themen who did break down in this battle were evaluated by their NCO's as"normal," average, or above-average soldiers before their breakdown-whereasthe reverse evaluation was given of men who had seen the division psychiatristin periods of relative quiescence. On the other hand, many of those withprevious noncombat psychiatric history were said to have performed wellin actual combat. This of course by no means excludes the possibility ofevaluation biased according to circumstances, i. e., whether a man breaksin a combat or a noncombat situation.

It is clear that more examples are needed to test the generality ofsuch a phenomenon. Moreover, whether this is found to be general or particular,it should point to the need to know by what processes it is produced.

To me there is one outstanding thing about this battle, which lasted6 days and in which 13 rifle companies directly participated for periodsof 15 to 50 hours each. About half of the men were killed, wounded, ormissing and talk of ending the war was hot. Furthermore, the area to beheld was only an outpost-though I had heard one battalion commander remarklong before the battle: ". . . Hill is tactically not a critical feature,but it is psychologically." At any rate, from my point of view I wouldconsider this a pretty "demoralizing" situation. Yet it producedonly 25 psychiatric casualties in the 13 companies directly involved.

This particular battle, however, produced psychiatric casualties inother than the 13 rifle companies involved. In all there were 40 additionalcases from engineer, artillery, medical, and other units. They were apparentlya result of either the heavy enemy shelling of rearward units or the presenceof individuals from these other units on the outpost hill. That is, engineersand aid men from the regimental collecting companies were brought intothe battle to assist in the operations. Casualties from these other units,however, did not appear to be any different essentially from the ones whocame from the rifle companies.


Characteristic of psychiatric battle casualties at the time they arrivedat the Division Clearing Company were the following phenomena:

They presented a dazed, apathetic, absent, or drawn appearance. (Somewere under the influence of sedatives.)

Physical fatigue was present but not marked.

They appeared to have little interest in their surroundings or in foodor drink, moved slowly, indulged in no spontaneous conversation.

A few mumbled incoherently, and some talked spontaneous nonsense.

There was usually a definite startle response to noises or sudden movement.Most were otherwise passive to stimuli, but a few ineffectually "fought"stimulation.

Some made no response to questions; some would give short, apparentlyirrelevant or hazy answers; and others would begin complaining that theyremembered nothing after a certain event or else began to ask (out of context)what happened to so-and-so. When attempts were made to relate events, theywere in negative terms: "I feel empty; we couldn't move; we calledfor artillery 2 days and didn't get it; so-and-so was blown up; if I'donly knocked him out he'd still be living; I don't remember what happened;I never expected it to be like that," etc.

With all this there was slight to marked disorientation for time andplace. Time sense was blunted.

Some of the outstanding symptoms were muteness, waxy flexibility, andcomplaints of stomachache, backache, and headache.

Example of a dream: "Last night I was dreaming he (a sergeant)was calling me-'Help me!' I was saying 'I can't, I just can't.' I said,'Medic, what you gonna do?' I said it over and over again, 'I can't, Ican't.'" Someone said, "You're next"-at which the patientwakes up.

Example of an expressed attitude: "Now know what it is to live-wantto live at all costs. Maybe it wouldn't have been so bad if I had diedduring the first part of the fight. I would like to go home."

A description of the same men approximately 11/2months after the battle:

All the above had apparently passed-in fact, most of it only a few daysafter these men became patients. In other words, there were no overt symptoms.There were no spontaneous comments about their battle reactions or aboutcontinuing traumatic dreams.

There were references, however, to feelings that their experiences hadaffected them. Some of the comments in reference to these experiences were:"Feel funny-can't describe it; everything was crazy


up there; lost my head; thought I couldn't make it; get most 'nervous'after a fight when you begin to think what a close call it was; thinkingabout dying; the shells and/or the dead bother you; makes a man even nervousto talk about it."

The comment was frequently made that smoking or talking to someone helpedto keep the nervousness down.

There was actually little else clinically observed that marked thesemen off from the majority in the non-patient category. The results of ourpsychometric tests on these patients and their controls have not been completed,so I can give no data on them at present.

III. The Noncombat Psychiatric Patient

In the preceding section we dealt mainly with the dissociative reactionoccurring during a hot battle-a reaction which is characteristically designatedas "combat exhaustion."1 Now I will attempt to delineatethe other broad category of psychiatric patients, i. e., those who breakdown in the combat zone, but not as a result of actual combat. I have mentionedthat these are the patients who get one of the "character and behaviordisorder" diagnoses.2 The "character and behaviordisorders" officially include two main groups: The pathological personalitytypes and the immaturity reactions. I am not concerned, however, with definingand pigeon-holing these different types, for this will not serve my purposehere. Some observations on the circumstances under which they become patientsare more to the point.

These patients generally come trickling one by one to the division psychiatrist.They are either themselves "fed-up" or else somebody is "fed-up"with them. They are usually sent in by their immediate commanding officers.They may even have various symptoms of a sort, but what strikes the psychiatristis their inability to relate, in explicit terms, what their trouble is-this,even when there is no reason for us to suspect a disabling inarticulateness.It might lead us, however, to suspect that perhaps all the trouble is nottheirs. If we are kind, they seem to be victims of chronic misfortuneof one sort or another; if we are not so kind, they may simply be classifiedas "bastards" or "sons of bitches."

1The term "combat exhaustion" was meant originally, however, to cover all kinds of fluid reactions within the divisional area. After evacuation to the rear of the divisional area a definitive diagnosis is in order. It thus serves a limited purpose. This policy, however, does not take into consideration the apparently very important matter of wide fluctuations in actual combat stress on the front lines, e. g., as measured in number of artillery and mortar rounds per unit sector per unit of time.
2See the "Joint Armed Forces Nomenclature and Method of Recording Psychiatric Conditions," Washington, D. C., 1949.


In any case, what frequently happens in such situations is that thepsychiatrist, having no more to go on than the patient can tell him, goesoff on the tangent of examining the patient for present and past evidencesof various immature or deviant personality features. And certainly I believehe can find them in abundance whenever he looks or whomever he looks at-hisonly trouble being a lack of quantitative measures.

Now, I think there are two aspects we should examine here. In the firstplace, our present classification system recognizes these reactions asresults of individual, idiosyncratic psychopathology. With this I haveno objections as far as it goes. But it does not take into sufficient considerationwhat has happened, what may actually be going on, say, back in a particularpatient's rifle company. As an example, several patients from one riflecompany were sent to a division clearing company sporadically and as individualsover a period of several weeks. They had various complaints, none of whichseemed very clear. On a visit to three of the squads in this company itwas found that the men were in a serious uproar about their company commander,who had twice failed them in a battle by sitting down and burying his headin his hands, unable to talk to his men. Furthermore, the regimental commanderhad removed this company commander on the occasion of his first breakdown-butlater had sent him back for a 2-week tour so that he could get his promotion!The men openly feared and hated the company commander. There seemed littledoubt that this situation had produced a number of unnecessary psychiatricproblems.

The second aspect is that the patient apparently has little or no realizationof significant connections between his stimuli and his responses, moreparticularly when he comes alone to the psychiatrist. And becausehe comes alone and because the psychiatrist knows neither how many morein the parent unit may be disturbed nor for what reasons, there is reallyvery little chance of getting together in a meaningful way.

The result is that these patients are sent back to duty with one recommendationor another, the sum total of their psychiatric benefits at most a briefrespite from their troubles. But no understanding has been reached andno course of action has been clarified. The patient goes back to the situationwhere he feels that he does not matter, that it makes no difference tothe others whether he stays or goes, or that he is not worth reclaiming.The same clique that excluded him may still be in operation, the same seductiveness,intolerance, or punitiveness of his commanding officer or sergeant towardhim may still be present, or there may be even more subtle causative factorsin operation. Such predicaments are difficult to verbalize in


isolation, even given a prolonged period in which to do so. Also, becauseof his own inability to communicate, the patient may get the feeling thatthe psychiatrist is not on his side or "doesn't give a damn"-andthis creates further difficulties.

Now, it is with this type of patient that I feel a more direct approachcould be made, such as a frank statement by the psychiatrist to the patientthat it is not clear what is going on, followed by a proposal that thepsychiatrist visit him at an appointed time along with his squad. In afew instances in which I tried this, there seemed to be three factors ofpossible significance in favor of good results. In the first place thepsychiatrist's visit will partly restore the patient's sense of importanceand he will shed any ideas he might have about the psychiatrist's lackof interest. Secondly, the psychiatrist can get an incomparably betteridea of what the difficulties are. And thirdly, the psychiatrist will undoubtedlyhave placed himself in a better position to strike on effective measuresthat can be taken to restore a reasonable balance. Also, I believe thismethod could be developed into a reliable research technic.

IV. The Psychiatrist and the Handling of Psychiatric Patients

It is probably by now clear that combat psychiatry presents unique featureswhen compared to civil psychiatry. One of the problems that faces us isthat we have to draw upon civilian psychiatrists and also upon militarypsychiatrists without combat experience, to supply the needs of fightingforces. And I am inclined to say that the major problem here is the orientationof the psychiatrists called upon to fill these jobs. In turn, the orientationof other medical personnel in more immediate contact with fighting menis also very important.

In this section I will discuss some of these points of orientation inrelation to the combat psychiatric casualty, where, I believe, it is mosteasily observed. In the last section I spoke of a possible method for handling(and also for observing) the noncombat psychiatric patient-but this hasnot been developed and we do not as yet have any well-formulated policyfor it.

So far the most distinctive task of the combat psychiatrist is the handlingof the sometimes large numbers of cases of "combat exhaustion"(mild to severe dissociative reactions), which occur during periods ofactive fighting. This task would be at times overwhelming if the psychiatristdid not possess assistance, in the form of more or less oriented aid menand battalion surgeons out ahead of him.

Ordinarily the company aid men are the first links in the chain of evacuation.They, in fact, decide who will or will not be evacuated. And they havetheir own particular nomenclature for the psychiatric


problems they encounter. For example, they recognize what is calledthe "Gung-Ho" reaction, which occurs in the more experiencedmen, and is characterized by a glassy-eyed stare, a fearsome (not a fearful)expression and a tendency to momentary reckless, but often neverthelesspurposeful, exposure. The aid men may temporarily remove men with thisreaction from areas of greatest danger, but they do not evacuate them.Aid men apparently learn early in their experience who is a poor and whois a good risk, psychiatrically speaking. It is, in fact, rather remarkablehow many things do occur that we would ordinarily think needed psychiatricattention, that do not ever get to the psychiatrist. This means to me thatthere is a good deal of innate or developed understanding that aid menworking under the same conditions as the riflemen use in the support ofthese riflemen. It may also mean that becoming a psychiatric casualty isdistinctly second choice. Such areas are almost totally unexplored.

The battalion surgeons at their posts very near the battle area arein a position similar to but not as favorable as that of the aid men. Theircontact with the immediate situation, however, is superior to that of thepsychiatrist rearward in the division clearing company. Apparently thebattalion surgeon handles many psychiatric problems quite well but evacuatesto the division clearing the overflow or those men he feels he cannot handle.Here, at division clearing, patients can be held longer, observed morecarefully, and presumably treated more definitively. I sometimes think,however, that the division psychiatrist is at a distinct disadvantage ascompared to the aid man or the battalion surgeon. For already, at the clearingcompany, time and distance may be becoming effective as obstacles to therecovery of the patient. Probably a more important way of putting thisis that the psychiatrist, situated at the division clearing company, willnot know or understand the circumstances of the patient as well as theaid man or the battalion surgeon-and hence has difficulty in effectivelycommunicating with him. To the psychiatrist at this distance an isolated,evacuated psychiatric casualty is likely to be viewed in terms of his motivationto go back to duty. But this may well be an end result of two people (patientand psychiatrist) reacting to the results of a prior experienceof the patient on the battlefield. The patient, for one thing, has beenremoved from the battlefield, from the context of his experience. Meaningsmay have changed altogether. At least the nearer the front we get the lesswe hear about motivation, and the further rearward we go the more we hearabout it. Rearward it is "motivation to escape" from combat;forward it seems to be "motivation to stick it out."


What can considerably ameliorate the psychiatrist's position, however,is his expectation that most of his patients after a few days willreturn to duty with their parent units. If he once lets go his expectationof returning a patient to duty, he might as well give up on that particularcase.

The psychiatrist gets his expectations from his orientation-from others'and his own experience he rather quickly learns what the "score"is. I doubt if many patients could ever be returned to duty if the divisionpsychiatrist did not expect it. I think this matter is extremelyimportant, all considerations of combat psychotherapy notwithstanding.3Else why is it, in such difficult circumstances, that the majority of psychiatriccasualties seem themselves to initiate the idea of their returning to theirparent units? There are, of course, within the patient certain attitudesderived from his parent unit that support this tendency to return to duty.But certainly, as a last word on this, neither the patient nor the psychiatristhas time to get involved in any official, elaborate psychotherapy. It is,practically speaking, a problem of the psychiatrist's own orientation andthe means he finds for handling (in contradistinction to what isusually called treating) patients. Most of the rest must be left to theremarkable powers of the individual for adjustment anyway. This is notto say, I remind you, that one best "let things ride." No, thereare good and effective ways of handling patients, and very poor ways indeed.

One well-established policy, the soundness of which, I think, is unchallenged,is the keeping of psychiatric patients as near the front as possible, notfar from their parent units. This probably means several things: It leavestheir loyalties undisturbed; it prevents the idea of serious psychiatricand/or physical disability getting established in the patients' minds andso fixing for future trouble what is a temporary experience; it allowsprimary gain but it offsets most of the problem of secondary gain and self-justification;and it saves manpower. By far the majority of the combat psychiatric casualtiescan be returned within a few days to duty, functioning perhaps not supremelywell, but at least near their former degree of efficiency. This practicedoes not apparently have deleterious effects on the patients, even if itis repeated. I am not certain about this, however. We ourselves had noopportunity to study men who had more than once become combat psychiatriccasualties. Nor did we have an opportunity to check on the long-termadjustment of those who had once broken down in combat. These are studiessorely needed.

3This same phenomenon of expectation is also evident in what is referred to as the "testing" of a doctor-a new battalion surgeon or division psychiatrist. People have a need to know what they can expect.


V. The Performance of Psychiatric Patients Returned to Duty

Psychiatric patients returned to duty were followed up indirectly bymeans of interviews with noncommissioned officers who were personally acquaintedwith them. The object was to obtain some estimate of their performanceon duty. Several control groups were treated in the same way. All groupswere then rated on a 5-point scale: + +, +, 0, -, =. Superior is
+ +, distinctly inferior is = and average is 0. Agreement among three scorerswas 73 percent. The principal difficulty encountered in this study wasthe evaluation of such comments as, "He's excellent in combat, butpoor in the rear," or vice versa. In all such cases we gave the ratingas 0 or - , whichever seemed fitting.

Psychiatric patients and controls fell roughly into three groups, asfollows:

    1. Men returned from R & R in Japan, men with their units continuouslyfor 5 months or longer, and medical and surgical casualties returned toduty. This was the most effective group.

    2. Court-martial (stockade) cases sent over from the United States,and venereal disease cases. This group fell between groups 1 and 3 in performance.

    3. Psychiatric patients (combat and noncombat). This was the least effectivegroup.

Table 2, giving both numbers and percentages, shows the relations betweenthe three groups on the 5-point scale.

Table 2. Follow-Up Classification of PsychiatricPatients and Controls




























































    Control=1. Continuously with company since January 1953.
    2. Medical, surgical, and wounded in action.
    3. Rest and rehabilitation in Japan.

    CMVD=1. Court-martial cases (before Korean tour).
    2. Venereal disease.

    NP=Neuropsychiatric casualties (combat and noncombat).


VI. Psychiatric Research in a Combat Zone

I will close these remarks with a few comments on psychiatric researchin a combat zone. To begin with, it is important to get an overall pictureof the phenomena that take place in a combat zone. This must be done inthe field. For on the basis of the overall picture the details to comelater can be interpreted in their proper perspectives. Getting the overallpicture, however, presents special difficulties. It requires patience andrestraint, which over long periods will seem to be without results; itrequires a great deal of moving around in unfamiliar territory and amongunfamiliar people; and it demands the sacrifice of one's usually comfortablyauthoritarian position in a hospital setting.

In the discussion of the noncombat psychiatric case I have indicatedone advantage of getting a broader picture. This applies equally to thecombat psychiatric casualty. That is, we notice that the combat psychiatricpatient at division clearing company talks and dreams (example on page394) about the real or assumed loss of a buddy. If this detail is studiedin isolation, I don't think it means very much. It will make more sense,however, if from general observations of rifle squads on the front lineswe know about the following facts:

    1. That men are intensely preoccupied with problems of personal invulnerabilityand of assuming that if anyone "gets it," it will be the "otherguy." It was not difficult to elicit this sense of invulnerability-andmarked uneasiness if the reality of it was questioned. And even in talkingabout the "other guy getting it" the self would always be implicated,e. g., "I'd be sorry if another man got it, but I'd be gladit wasn't me."

    2. That an extensive system of "buddying" operates among riflemenand others who must maintain themselves on the front lines. This is muchmore than an official policy or a swimming-partner-like arrangement. Itis intimate and quite exclusive and does not occur in the rear areas. Andfor the vast majority of riflemen it is disturbing to be without a buddy.

    3. That there is a strange and frequent comment that men make abouttheir buddies. It surprises you because it seems to come "out of nowhere."It is that one's buddy can be forgiven for almost any transgression, evenfor "bugging out." Now such "strange" things that seemto come "out of nowhere" nearly always represent significantunconscious processes.


    4. With 1, 2, and 3 we must contrast the fact that riflemen rarely communicatewith buddies who have rotated home or who have been evacuated. Absent buddiescease to be useful.

With these additional facts we can at least produce a hypothesis, namely,that a buddy assures one's invulnerability as long as the buddy is okay,but that as soon as something happens to the buddy the conviction, "You'renext," may occur with disrupting force.

The next steps will be the "testing" of the hypothesis wehave made. In the example I have given above the "testing" canconsist of, say, a search for information on the following points:

    1. How invariably is the loss of a buddy connected with dissociativereactions in combat? It is at least very frequently so connected.

    2. Does it ever happen that both of a pair of buddies become psychiatriccasualties in combat at the same time? I have never encountered such anexample.

    3. What exactly goes on between buddies at the time of a break?

    4. What varieties of buddy systems are there?

    5. Do phenomena other than disruptions of buddy relationships seem tobe necessary for the production of psychiatric breakdowns in combat? Intensiveartillery and mortar shelling appears to be an important factor.

    6. Are lost buddies replaced, and if so, how soon after they are lost?

This list could be expanded but at least these questions give some ideaof the scope of the problem.