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Chapter V

Contents

CHAPTER V

Ophthalmology

James N. Greear, Jr., M.D.

The first Senior Consultant in Ophthalmology in ETOUSA (European Theater of Operations, U.S. Army) was Col. Derrick T. Vail, MC, (fig. 151). Colonel Vail returned to the Zone of Interior on 26 December 1944 for a period of temporary duty in the Office of The Surgeon General. His presence in the Zone of Interior at that time permitted a desirable and indicated exchange of certain key ophthalmologists. Colonel Vail was reassigned permanently to the Office of The Surgeon General as consultant in ophthalmology, relieving the incumbent, Maj. (later Lt. Col.) M. Elliott Randolph, MC. Major Randolph, in turn, relieved Lt. Col. James N. Greear, Jr., MC (fig. 152), as the officer in charge of the rehabilitation program for the blind at Valley Forge General Hospital, thus freeing the author for assignment to the European theater as Senior Consultant in Ophthalmology. Colonel Vail has recorded his experiences and activities as the first Senior Consultant in Ophthalmology in the European theater in the volume, "Ophthalmology and Otolaryngology," of the history of the Army Medical Department in World War II.1

During Colonel Vail's absence, Col. Norton Canfield, MC, the Senior Consultant in Otolaryngology in the European theater, took care of problems in ophthalmology that demanded attention at the theater headquarters. When Colonel Vail had not returned to the European theater by the end of January 1945, Colonel Canfield recommended that Maj. Byron C. Smith, MC, of the 1st General Hospital be assigned temporarily as Senior Consultant in Ophthalmology in addition to his other duties. The recommendation was approved. Major Smith was in charge of an active service in ophthalmology at his own hospital; therefore, he was unable to make extensive visits to medical units in the theater. He did keep in touch, however, with the activities concerning the Senior Consultant in Ophthalmology and gave valuable assistance and advice relative to problems of a specific nature which were constantly arising.

Colonel Greear reported for duty at the Office of the Chief Surgeon, ETOUSA, on 29 March 1945 and began his tour as Senior Consultant in Oph-

1Medical Department, United States Army. Surgery in World War II. Ophthalmology and Otolaryngology. Washington: U.S. Government Printing Office, 1957, Chapter V, "Administrative Aspects of Ophthalmology in the European Theater of Operations," and Chapter VI, "Clinical Policies in Ophthalmology, European Theater of Operations."


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thalmology in the European theater. He devoted the first few days after his arrival to searching the files of Colonel Vail in an effort to determine the established policies of the theater and to familiarize himself with the many problems to be considered.

ORGANIZATION

The original plan for the organization of the Professional Services Division, Office of the Chief Surgeon, as set up early in 1942 by Col. James C. Kimbrough, MC, Director of Professional Services, was still in effect. In brief, the division consisted of a Chief Consultant in Medicine with subordinate senior consultants in neuropsychiatry, tuberculosis, dermatology, and infectious diseases and a Chief Consultant in Surgery with subordinate senior consultants in the specialties of orthopedic surgery, plastic surgery and burns, neurosurgery, anesthesia, transfusion and shock, ophthalmology, radiology, urology, otolaryngology, and maxillofacial surgery.

FIGURE 151.-Col. Derrick T. Vail, MC.

By January 1945, decentralization of all activities had occurred owing to the great number of wounded and the presence in the theater of some 200 hospitals. The larger base sections had consultants in medicine and surgery, who reported on purely professional matters to the Chief, Professional Services Division, Office of the Chief Surgeon, through either the Chief Consultant in Medicine or the Chief Consultant in Surgery. This plan, alone, did not provide adequate coverage of professional activity within the theater. Therefore, in order to maintain close contact with professional work, consultants in medicine and surgery were set up in the hospital centers. These officers in turn re-


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FIGURE 152.-Lt. Col. James N. Greear, Jr., MC.

orted on professional matters through the base section surgeons to the Chief Consultant in Medicine or the Chief Consultant in Surgery. Consultations in the medical and surgical specialties were also decentralized. In each hospital center, officers selected for their superior ability acted as regional or hospital center consultants while carrying on their regular duties. At a high level, and separate from this intimate organization for the supervision of professional work in communications zone hospitals, there always existed a close liaison with the consultants of the various field armies and the air forces. This close liaison with the tactical elements was essential, for it was believed that in any single theater there should be but one professional policy if the soldier, whether sick or wounded, was to receive proper therapy.

POLICIES AND PROCEDURES

The policies of the Professional Services Division as established in 1942 were designed to implement measures whereby personnel of the U.S. Forces would receive promptly the highest standard of medical and surgical care. The condition of all patients reported seriously ill in U.S. Army hospitals as well as British hospitals could be easily and quickly determined. In order to stimulate and maintain professional morale and disseminate recent medical information, it was considered advisable that medical meetings be held regularly at general and station hospitals. The type and frequency of these meetings depended on local conditions at each hospital and on the general situation.


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The specialty senior consultants in medicine and surgery submitted written daily reports of their activities to Colonel Kimbrough through their respective chief consultants, Col. William S. Middleton, MC, in medicine, or Col. (later Brig. Gen.) Elliott C. Cutler, MC, in surgery. These reports were consolidated by Colonel Middleton, Colonel Cutler, and Colonel Kimbrough for transmission to the Chief Surgeon. It was the policy of the Professional Services Division to have consultation service immediately available at all times. Senior consultants for the various specialties in the Office of the Chief Surgeon coordinated the activities relating to their respective areas. They made such recommendations to the appropriate chief consultant as were considered necessary for the instruction of subordinate consultants and specialists in hospitals and other units. Under the guidance of the senior consultants, the consultants for field armies and base sections supervised and coordinated the work of specialists functioned under the direction of the Chief, Professional Services Division, and its members were the responsible advisers to the Chief Surgeon on all professional and technical medical matters.

The specialist senior consultants visited all Medical Department units for the purpose of giving their guidance and assistance with regard to technical and professional matters falling within their fields of activity. They advised on the selection and assignment of junior consultants and specialists and reported from time to time on the standard of professional efficiency maintained by such officers. They collaborated with members of the Operations Division, Office of the Chief Surgeon, in arranging courses of instruction, medical meetings, and training schools and in other measures designed to keep the officers of the Medical Department in touch with the latest developments in medical science. It was their duty to initiate and carry out research and investigations with a view to conserving manpower in the field and restoring to health the sick and wounded. It was their responsibility also to maintain liaison with the consultants and specialists in all branches of medicine of the British Armed Forces and civilian practice. They advised as to the suitability of drugs, instruments, and equipment of a specific nature and made recommendations on other matters pertaining to the health of the U.S. Army in the European theater.

The most important function of the Senior Consultant in Ophthalmology was to see that every U.S. soldier requiring eye care, in the European theater, received the highest possible standard of medical care (fig. 153). The best method of accomplishing this was to determine the capabilities of the ophthalmologists assigned to the general and station hospitals. This information was obtained by personal contact and through the hospital center consultant in ophthalmology. On several occasions, groups of ophthalmologists from both station and general hospitals were invited to meet with the Senior Consultant in Ophthalmology. The meetings were very satisfactory, and many important phases of the handling of patients were discussed. Following the general


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discussion, individual interviews were held with most of the men who had attended the meeting.

It was impossible for the Senior Consultant in Ophthalmology to cover the entire area and to see the work that was being done in each individual hospital. Nevertheless, he made every effort to visit hospitals where the larger number of eye cases were being treated. These hospitals were primarily those treating large numbers of neurosurgical patients and maxillofacial injuries where, naturally, many eye cases would be located. On several occasions, groups of hospital center consultants met at some centrally located hospital or at a base section headquarters, and informal discussions were carried on among these consultants and the Senior Consultant in Ophthalmology. These discussions proved of great benefit to all concerned insofar as the care of patients was concerned. Not infrequently, it was necessary for the center consultant in ophthalmology to have patients transferred from another hospital to his own to assure adequate medical care, and this could be carried out without too much difficulty. The hospital center consultant had no authority to initiate transfers of personnel from one hospital to another; however, it was his duty to report to the Senior Consultant in Ophthalmology when he felt that such transfer was necessary, and the transfer could then be initiated from the Senior Consultant's level.

Regular monthly reports were received by the Senior Consultant in Ophthalmology from most of the ophthalmologists in station and general hospitals in the theater. These reports were informal, but they contained information pertinent to both the type and the number of ophthalmic lesions being dealt with in each particular hospital. This information was valuable to the author in that it kept him acquainted with the needs for personnel and equipment in various units as conditions changed. A monthly report was not received from some of the newer units.

Early policy in the European theater had dictated that newly blinded casualties be sent to St. Dunstan's Institute for the Blind near Shrewsbury, Shropshire, England, for a period of training before evacuation to the Zone of Interior (fig. 154). Since September 1944, however, the established policy in the European theater was to evacuate all blinded patients to the Zone of Interior, at the earliest possible moment after they were transportable. Before his transfer to the European theater, this consultant had learned that patients who had been sent to St. Dunstan's in England for initial rehabilitation before returning to the Zone of Interior were usually critical of the training they received at special rehabilitation centers in the Zone of Interior. They constantly compared procedures carried out in the two places. Therefore, personnel dealing with blinded casualties in the theater were instructed as to the proper psychological approach. The necessity for these blinded patients to become independent as quickly as possible in order to regain confidence in themselves was emphasized.


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FIGURE 153.-Ophthalmological service in a general hospital. A. Examining facilities. B. Perimetry and the determination of distant visual acuity.


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FIGURE 153.-Continued. C. Optometry. D. An eye operation in progress.


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HOSPITAL CENTERS

During November and December of 1944 and the early months of 1945, thirty 1,000-bed general hospitals had arrived in the European theater. In addition, there were 10 new 400-bed evacuation hospitals and 1 new 750-bed evacuation hospital (fig. 155). In some of these hospitals there was no ophthalmologist, and in others the ophthalmologist had received meager training in his specialty. The rapid movement of the armies had necessitated an increased dispersion of hospitals and had thus made the author's personal contacts with the ophthalmologists in the theater much more difficult. This greatly increased the importance of competent and active subordinate consultants.

FIGURE 154.-St. Dunstan's Institute for the Blind, Shropshire, England. A. A blinded amputee learning to type. B. Sir Ian Fraser, founder and director.

Hospital centers were well established in the United Kingdom Base and were well organized. In each center, there was a very competent consultant in ophthalmology who made regular visits to hospitals in the center and who worked, in most instances, in close cooperation with the commanding officer of the center. Thus, the commanding officer was kept advised concerning the care of ophthalmological patients in his center. Shifts in personnel were recommended through the center consultant in ophthalmology wherever it was deemed necessary. The more serious eye problems were concentrated in hospitals where more capable ophthalmological officers were assigned.

On the Continent, hospital centers generally were less well organized, and, while consultants in ophthalmology had been assigned in a few instances, they had not had their functions well defined and were of the opinion that they should not visit hospitals until they were invited. An effort was made to clarify this situation in order that this consultant might be kept informed as to


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the ophthalmic care of patients in widely scattered hospitals. Additional consultants were appointed to new centers which had been organized on the Continent and every effort was made to acquaint them with their duties and responsibilities. An able center or regional consultant was of inestimable value in coordinating the functions of his specialty in his area.

FIGURE 155.-An eye clinic in an evacuation hospital.

The majority of the hospital center consultants in the European theater were captains. This was a great handicap to them in carrying out their duties, since a great many of the eye, ear, nose, and throat men assigned to general and station hospitals were majors and resented an officer of a lower grade inspecting their services and making recommendations as to the care of patients. This situation was common throughout the entire theater. The hospital center consultant had important responsibilities. It was his duty to visit the hospitals in the center at least monthly and oftener if necessary; he certainly had to visit them often enough to ascertain that the patients in the hospitals of his center were receiving the best possible eye care. It was important that he gain the confidence and respect of the ophthalmologists assigned to the hospitals in his center in order that they would freely seek the center consultant's advice on problem patients. A higher rank would have made it easier for him to carry out his responsibilities.

Geographic dispersion of hospitals in each hospital center rarely offered any real problem since most of the hospitals in the centers were situated within


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a relatively small radius and in most instances could easily be reached within less than an hour. The question of transportation was never a serious problem. Most hospital center consultants could obtain transportation from their own units; if not, transportation was available from the hospital center headquarters.

SUPPLIES AND EQUIPMENT

The standard equipment supplied to general and station hospitals in the European theater was extremely deficient in certain items which were essential to accurate diagnosis of many eye disorders. Because of the inability of the medical officer to make early and accurate diagnoses as a result of a lack of diagnostic instruments or because of inadequate equipment, alleviative measures were not instituted until the patient reached another hospital where such equipment was available.

The slit lamp and corneal microscope are indispensable to the accurate diagnosis and treatment of injuries or diseases of the anterior segment of the globe. A good many of these instruments were distributed to hospitals in the United Kingdom Base, but very few ever reached the hospitals on the Continent. In one hospital center, there was not one single such item, and, in another center, there was only one such item-and that was in a rather isolated hospital.

Abnormal fields of vision could be accurately determined only by plotting such changes with the use of a perimeter or tangent screen. Neither of these items was on the standard table of equipment for general or station hospitals. In some instances, through the ingenuity of some medical officers or their technical assistants, both tangent screen and perimeters were constructed. These proved to be very satisfactory and most useful.

It was the opinion of all concerned that every general hospital should have been supplied with a giant magnet as standard equipment since the hand magnet was found to be not sufficiently powerful to remove many of the smaller intraocular magnetic foreign bodies.

OPTICAL SUPPLY

Full credit was given to Colonel Vail for establishing the optical program in the European theater. This program had worked and was thoroughly organized at the time the author arrived in the theater. Late in 1944, one section of the issue branch of the ETOUSA Base Optical Shop was moved from Blackpool, England, to Paris. Col. Silas B. Hays, MC, Chief of the Supply Division, Office of the Chief Surgeon, ETOUSA, was most cooperative in instituting this transfer to the Continent. This unit was designed as the Base Optical Shop and located at the 7th General Dispensary to service the optical requirements of the U.S. Army on the Continent. This facility not only filled prescriptions for glasses arising from the immediate area but also provided all optical supplies to mobile units, both Services of Supply


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FIGURE 156.-A technician in a mobile optical repair unit checking a lens for accuracy of grinding.

and field army, on the Continent. Initially, requisitions were drawn on the Blackpool Base Optical Shop in England to maintain stock levels. Special jobs could be expedited with the use of air courier service to the United Kingdom.

By 1945, there were 2 base optical shops, 27 mobile optical repair units (fig. 156), and 54 portable optical repair units employed on the Continent. In the first 6 months of 1945, 186,000 spectacle requisitions were processed by these units, of which more than 99 percent were processed immediately from available materials. Mobile units processed 102,000 prescriptions, portable units processed 66,000 prescriptions, and 82,000 of the total number of prescriptions were processed by optical units operating in the army areas. Without these units, approximately 10,000 troops each month would have been evacuated because they were visually unfit for duty. Capt. Chester E. Rorie, SnC, commanding officer of the Base Optical Shop, also had the responsibility for compiling information and requisitioning, receiving, storing, and issuing all optical supplies and equipment for all echelons. His work in this field was outstanding.

Soon after plans for redeployment had been announced, a letter was received from Colonel Vail, then Consultant in Ophthalmology to The Surgeon General, outlining the necessity for equipping troops being redeployed with


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spectacles and gas mask inserts. On 18 May 1945, the author was in conference with Colonel Cutler; Colonel Hays; Col. Angvald Vickoren, MC, Chief, Troops and Training Branch, Operations Division; Col. John E. Gordon, MC, Chief, Preventive Medicine Division; Lt. Col. Bernard J. Pisani, MC, Executive Officer, Professional Services Division; and Captain Rorie. The question of supply of eyeglass gas mask inserts and spectacles was the chief topic under discussion. It was proposed that an ETOUSA directive be sent to all unit commanders concerned with the medical processing of troops for redeployment. The following day, a proposed directive dealing with spectacles and gas mask inserts was transmitted to the Deputy Chief Surgeon. The directive was never published on the basis that items covered by the proposed directive were already adequately covered in published ETOUSA command directives on redeployment. On 29 June 1945, this consultant submitted a letter to the Chief Surgeon pointing out the necessity for more specific instructions relative to this phase of redeployment because there was so much misunderstanding.

Accompanied by Major Smith and Captain Rorie, the author visited Twelfth Army Group headquarters and then the headquarters of the Third, Seventh, and Fifteenth U.S. Armies and discussed with the army surgeons the eyeglass and spectacle requirements for troops being redeployed. This information was well received and the army surgeons were quite willing to cooperate.

Despite early planning, after V-E Day (8 May 1945), some critical problems developed which demanded immediate action. Some 2 million troops were to be redeployed either directly or indirectly just as quickly as transportation facilities would permit. All troops having visual error were to be redeployed with their maximum spectacle requirements of two pairs of issue spectacles and, if visual acuity was less than 20/70, one pair of gas mask inserts. Service troops were to be redeployed first, and this was the category that most optical units came under. In practically no time at all, 65 percent of optical facilities had ceased operations in preparation for redeployment. The personnel on temporary duty in the Base Optical Shop had dwindled down to four.

The Commanding General, Assembly Area Command, had demanded six mobile units to serve the assembly area alone. The commanding general of the Le Havre area had requested an extra unit, the Marseilles Port had requested an additional unit there, the armies were demanding additional units to replace those that had ceased operations for redeployment, the Bremen Port had requested a unit, and a unit was requested for Berlin. In short, the requirements had increased to about 20 percent more than they ever had been at any time during the war, and about 65 percent of the optical supply units had ceased operations. This, of course, created temporarily a serious condition and "Immediate Action" was stamped on practically every requisition placed on the operating optical supply units.


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This problem was solved in the following manner. A teletype message was sent to all prisoner-of-war stockades directing that prisoners be screened immediately for experienced opticians. Between 50 and 75 opticians were located and allocated to various units. A 24-hour shift was put in operation in the assembly area, and additional equipment was set up. The stocks of supplies were doubled in all units having a large demand. Nine Belgian civilians were employed in Liége. Twenty-seven French civilians were employed in Paris. A unit was sent to Bremen Port. Two portable units were sent to Berlin. In the last month of operations prior to V-J Day (14 August), 37,000 pairs of glasses were processed. Again, Captain Rorie cannot be too highly commended for the splendid job he did in supplying the entire Army in Europe with instant service on optical supplies under the most difficult circumstances.

TRAINING

Early in May 1945, the Medical Field Service School, ETOUSA, was reestablished near Paris. The Senior Consultant in Ophthalmology, assisted by Maj. Kenneth Fairfax, MC, and Maj. Byron C. Smith, MC, gave lectures on war ophthalmology to the medical officers attending the school. These lectures and demonstrations were designed to impress upon the general medical officers the need to handle patients with injured eyes carefully, particularly patients with perforating wounds of the globe. Lectures were also given to nurses attending the school (fig. 157). These talks emphasized the necessity for nursing care in patients with severe eye injuries. Procedures pertaining to the nursing of newly blinded soldiers were discussed.

During 1944, it was anticipated that there would be a period following hostilities in which some type of training program or refresher courses in the various medical specialties would be of tremendous value to the men in various fields of medicine, either in continued service activities or in civilian practice. Before reporting for duty in the Office of the Chief Surgeon, ETOUSA, the author had conferred with Colonel Vail relative to posthostilities training for the ophthalmologists in the European theater. Colonel Vail had given the subject considerable thought, but no definite action had been taken. Prior to the cessation of hostilities, this subject was discussed with center consultants and with individual ophthalmologists throughout the theater. It was decided that a didactic program in ophthalomology would be inaugurated at Oxford University under the direction of Prof. Ida Caroline Mann, Head of the Department of Ophthalmology at the university.

A conference was held with Professor Mann, and plans were completed for such a program to begin on 17 July and extend through 14 August 1945. This course was to consist of lectures and demonstrations by Professor Mann and her staff, supplemented by a number of invited lecturers from the United Kingdom. Following this lecture course, ophthalmologists who were available were to be assigned to various civilian ophthalmological services in the United Kingdom for a period of 2 weeks. This consultant visited several of these


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FIGURE 157.-Nurses receiving instruction at the Medical Field Service School, ETOUSA, at Chateau du Maurais near Paris, France.

hospitals, and, in each instance, they were willing to have U.S. Army officers attend clinics and observe the activities of the hospital generally. Lt. Col. (later Col.) Einar C. Andreassen, MC, Chief of the Operations Division, Medical Section, Headquarters, United Kingdom Base, assured the author that the 91st General Hospital would be available for billeting and messing the officers attending the course at Oxford University. All financial arrangements for the course were completed with the authorities of Oxford University, utilizing theater information and education funds. Maj. Ferdinand P. Calhoun, MC, of the 2d General Hospital was appointed coordinator of the course and, from 13 June to 30 June, was attached to the Office of the Surgeon, United Kingdom Base. With the cooperation of Professor Mann, eminent British ophthalmologists throughout the United Kingdom were interviewed and worked into a lecture timetable. The coordinator found that the lecturers, all prominent in ophthalmology, were most eager and willing to do all they could, despite the inconvenience of preparing a lecture and of traveling to Oxford from their homes throughout England. Except for Sir Stewart Duke-Elder, who was prevented by his important military duties, every British ophthalmologist who was asked to participate accepted the invitation. This spirit was a great tribute to the friendly and cooperative relationship between the U.S. and British ophthalmologists, established during the war by Colonel Vail.


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The course was eminently successful in providing a taste of academic ophthalmology to men who had been doing military ophthalmology for varying periods of time. The men were unusually and uniformly appreciative and eager to take advantage of the opportunity afforded them and were repeatedly impressed by the education, poise, and affability of the British lecturers, many of whom were internationally known. The scope and duration of the course did not in any way qualify an officer for a certificate, diploma, or degree. The intention of the course was merely to give the officer who had been doing military ophthalmology a review of academic ophthalmology, to refresh and broaden him, and to stimulate his future serious study of opthalmology. Owing to unavoidable redeployment requirements at this particular time, only about half the number of students originally scheduled to attend could attend.

SUMMARY AND CONCLUSIONS

The consultant system made possible the high type of medical and surgical care that was available to the U.S. soldier in the European theater in World War II. A consultant in ophthalmology was always available in the hospital center, and, if it was his belief that the Senior Consultant in Ophthalmology should be called to see any individual patient, the latter could be reached through the base section headquarters. The consultant system was essential for the best surgical care of the Army in the European theater. It did not work perfectly; however, in the event of any future conflict it should work far more smoothly than it did in World War II.

No general or station hospital should have been sent to an oversea theater without adequate equipment to render all the specialized services for which the hospital was formed. Certainly, they should have had the essential equipment for specialties such as ophthalmology. The equipment should have included a perimeter, a giant magnet, slit lamp and corneal microscope, a first-rate ophthalmoscope, and a tangent screen. These items are mentioned because they were not included in the standard equipment of ophthalmological departments in the hospitals of World War II.

In a theater of war, hospital centers should be organized and hospital center consultants should be given very explicit instructions as to their duties and responsibilities. One of the chief responsibilities of the hospital center consultant should be to apprise his senior consultant in ophthalmology of any hospital in which a low grade of ophthalmology is being practiced.

The sole purpose of any system is to provide the U.S. soldier with the very best medical and surgical care, and this purpose certainly was accomplished in World War II. It is believed that the system could be improved in any future conflict with only minor changes. Perhaps the most important advance would be to commission ophthalmologists in ranks in keeping with their professional attainments and previous training. This applies particularly to men who have been selected as regional or hospital center consultants.

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