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ANNUAL REPORT THE SURGEON GENERAL UNITED STATES ARMY Fiscal Year 1960

Annual Report the Surgeon General United States Army Fiscal Year 1960

PREVENTIVE MEDICINE

 Communicable Disease Control

Communicable disease among Army troops during the fiscal year was unusual in only one respect-a marked shortening of the duration of the respiratory disease season. Although the peak incidence of common respiratory disease and influenza occurred at approximately the same time in February 1960 as it did in the previous year and was of the same magnitude, there was a rapid fall off through the latter part of February and in March which brought the rate in April down to levels not usually attained until June. The significance of the shortening of the respiratory season has not been determined. Although influenza vaccine was in use throughout the period and adenovirus vaccine was administered to all incoming recruits, beginning in October at one recruit training post and in February and March at the others, the abbreviation of the respiratory season was also experienced in the U.S. civilian population, among whom the use of influenza and adenovirus vaccine was far less common.

The use of standardized adenovirus vaccine, beginning in February and March 1960, marked the fruition of more than 6 years of studies and trials within the Army.

During the year, the chief of the Communicable Disease Branch the Preventive Medicine Division, OTSG, visited military medical facilities and military assistance advisory groups and missions in Ethiopia, Saudi Arabia, Pakistan, Iran, and Turkey. The result was an increased awareness of the medical problems encountered in these relatively isolated areas, particularly in regard to epidemiologic factors concerned with infectious disease.

 Occupational Health

The Army Occupational Health Program, authorized by Public Law 658, 79th Congress, and implemented by AR 40-557, dated 19 November 1956, is applicable to approximately 900,000 military personnel and 300,000 Army civilian employees. Major emphasis has been placed upon the recognition and control of hazards to health by the utilization of occupational health and industrial hygiene survey activities carried on by USAEHL (U.S. Army Environmental Health Laboratory), Army Chemical Center, Md.


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In addition to the hazards associated with industrial operations and the complexity of the newer weapons systems, other problems arose with the development of "closed ecological systems" (isolated and controlled environment), within which men may have to live and carry out their military tasks. Liaison was established during the year with other technical services concerned to facilities the exchange of technical and medical information and suggested procedures relative to the development of studies concerning these new problems.

The OTSG, in conjunction with the Bureau of Employees' Compensation, initiated action to define more sharply the incidence and the kinds of occupational illnesses for which compensation is being paid to Army Federal civilian employees. As this information is developed, appropriate emphasis can be given to problem situations which are not now recognized and less emphasis to those where fewer problems exist.

Newer approaches to the early recognition and prevention of disease have been studied to determine which produce the best results.

The major occupational health problems continue to be those associated with exposure to chemicals, noise, extremes of temperature, humidity, vibration, and ionizing radiation. Other environmental factors about which the health implications are less well known have come to the attention of the OTSG. These include vibrations of small amplitudes, flicker of certain frequencies, sleep deprivation, and isolation.

Occupational medicine.-During the year, DCSPER requested The Surgeon General to study the Army Occupational Health Program with the view of expanding and emphasizing health education activities and participation in community health programs at installations, as well as the feasibility of conducting "executive health examinations" of civilian employees by means of the resources currently available to the Army Medical Service. This study was made, but a more detailed examination of this problem is being continued in an effort to respond to the needs of management.

It became clear that the Army Occupational Health Program could not be expanded materially without additional resources. In an attempt to obtain more efficient utilization of personnel engaged in this program, two actions were taken. A course in occupational medicine was given twice during the year at USAEHL, to acquaint the medical personnel at the post level with the responsibilities, scope, objectives, and methods of the program. A 30-minute film designed to orient personnel responsible for carrying out the program and for showing at Army posts was approved and the scenario is being written.

Industrial hygiene.-The most frequently recurring deficiencies in the working environment are inadequate ventilation at paint-spraying operations, accumulation of exhaust fumes in areas where automotive


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equipment is being repaired, and the nonuse or improper use of respirators in areas where dusts are generated. Attention was given to the detection and control of hazards arising from the use of such metals as lead, mercury, selenium, and beryllium in the work environment. These are well-known occupational health hazards. The widespread use of new plasticizers, the growing family of industrial solvents, and the broadening exposure of personnel to missile fuels have contributed to the variety of new problems that require study, investigation, and the development of specific industrial hygiene control procedures. It is clear that the most common hazards must be given close attention if they are to be controlled adequately.

Consultation on the conservation of vision was continued through postwide surveys which included classification of the eye hazard potential of each job, the evaluation of illumination for the job, and the screening of employees for visual acuity.

The increasing mechanization of the Army tends to produce a noisier work environment with a resultant potential loss of hearing acuity and the creation of associated physiological and psychological problems. In connection with the periodic industrial hygiene surveys of Army installations performed during the year, emphasis was placed on investigations of industrial and military operations producing excessive noise levels. Also, the Corps of Engineers requested consultation on this subject, and a study was initiated on the problem of altering the design of engines, motors, and generators to reduce the inherent noise from this class of equipment.

During the year, the OTSG was consulted by the Ordnance Corps, by USCONARC (U.S. Continental Army Command), and by the Army Defense School of the U.S. Army Air Defense Command on the  problems of the potential hazards of microwave energy to Army military and civilian personnel. While no proved cases of microwave damage to personnel have occurred, radiofrequency transmitters, especially those in use with radar systems, are now operating at power levels capable of producing free space power densities in excess of permissible levels. In all these consultations, the OTSG has emphasized that practical, inexpensive methods are usually at hand to control excessive exposure to microwave radiation. This is in opposition to the tendency to place the burden of microwave exposure control on the battery commander, whose main tool is exclusion of personnel from high power density areas. Proper site selection and organization of the ground area are important factors in reducing the opportunities for personnel exposure. Shielding, operational stops in elevation and azimuth, and interlocks to deenergize the rotating antennae, when rotation ceases, have also been recommended as useful
methods of control.


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Radiological hygiene.-The Army Medical Service has the responsibility for all matters relating to the effects of ionizing radiation upon the health of personnel under the jurisdiction of the Army. With the rapidly increasing use of radioactive materials within the Army and the increasing number of persons handling them, the exposure to the hazard of ionizing radiation is constantly growing. As a result, a very large portion of the work of the Preventive Medicine Division is now devoted to  dealing with problems of radiation, examples of which follow.

1.  The processing of applications for Atomic Energy Commission Byproduct and Special Materiel Licenses. The radiological hygiene surveys of Army installations, conducted by USAEHL, aid greatly in this processing. There were 87 such licenses granted during the fiscal year.

2.  Reports of film badge readings, which indicate exposures of personnel to ionizing radiation greater than the maximum permissible dose, are followed up as a means of monitoring the Army program. No demonstrable injury resulting from such exposures became manifest. Such a record is indicative of the excellent controls exercised by the Army installations in a broad spectrum of uses of radioactive isotopes.

3.  The plans for such facilities as isotope and X-ray laboratories are reviewed to assure adequate protection of personnel from the potential hazards of ionizing radiation.

4.  Participation in conferences relating to plans for the construction of radiation facilities, such as the Ordnance Corps' Triga reactor to be installed next year at the Forest Glen Section, WRAMC, provides another means for exercising surveillance of ionizing radiation hazards.

5.  The monitoring of the progress being made under the Army Nuclear Power Program in the design, construction, testing, and production of nuclear power plants for the three armed services enables the OTSG to be cognizant of and prepared for the future plans of this program.

6.  Action was taken to correct DA Label 15 for designating containers of radioactivity after the AEC (Atomic Energy Commission) called attention to the fact that it did not conform to the Code of Federal Regulations. The corrected label was submitted to DCSLOG (Deputy Chief of Staff for Logistics) and to the Surgeons General of the Navy and Air Force for review and then recommended to The Adjutant General in time to be included in the next printing of the code. Appropriate action was also taken to revise certain military specifications and standards (MIL-M-1959OB and MIL-STD-129C) to conform to AEC requirements.


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Environmental Hygiene

In the broad field of environmental health, major efforts were devoted during the year to the specialties of entomology, sanitary engineering, toxicology, and environmental physiology as they pertain to the military medical service.

Toxicological clearance on the insect repellent diethyltoluamide was temporarily suspended. Further detailed toxicological investigation on this material is being conducted by USAEHL, and it is anticipated that it may be made available as a standard Army item.

The announcement by the Secretary of Health, Education, and Welfare in November 1959 that all lots of cranberries (fresh and canned) grown on the west coast were suspect of contamination with aminotriazole caused great concern in the military services. The Surgeon General advised the Office of The Quartermaster General to suspend further issue and use of these cranberries. In December 1959, The Surgeon General concurred in the requirement that the producer furnish a certificate showing the product had been inspected and certified free of contamination by a U.S. Department of Agriculture inspector.

Warnings were dispatched to all army area surgeons to alert personnel owning a certain type of trailer heater that a large volume of carbon monoxide gas was found to be escaping into living quarters instead of being exhausted outside and that this was a definite health hazard

Fitzsimons General Hospital reported the deaths of several guinea pigs after they had consumed lettuce leaf trimmings. Results of studies indicated that there were excess amounts of insecticides in certain stocks of lettuce. The Food and Drug Administration recommended that a report be made immediately to its Washington office concerning any stocks of lettuce found to contain excess amounts of insecticides.

Increased emphasis was placed on the importance of training vector control details at the company level in all major commands as a result of The Surgeon General's concern about the inadequacy of this trait in some commands. Sanitary reports from these commands indicate that this type of training has been intensified.

The chief of the Environmental Health Branch of the Prevention Medicine Division made a trip overseas in connection with the study of heat stress in desert operations.

Entomology.-Increased resistance of numerous species of insects to insecticides in many areas of the world has developed into one more important problems in arthropodborne disease prevention. During the year, USAEHL prepared and distributed a worldwide list medically important insect-resistant species of arthropods. A bibliography


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of  57 references was included. A similar list published by the Armed Forces Pest Control Board classifies resistant species in three categories or types of resistance as follows:

            Type I ..........Resistant to DDT (DDD-methoxychlor)

            Type II..........Resistant to dieldrin (BHC-chlordane)

            Type III.........Resistant to organic phosphates (malathion, Diazinon)

A protocol for the large-scale field testing of 1 percent malathion dust was developed and sent to the surgeon of the Eighth U.S. Army for use during fiscal year 1961 in tests on personnel in Korea to evaluate further the usefulness of this material. It is an item needed by the armed services during emergencies to control body lice in areas where resistance to DDT and lindane is encountered.

A cold-fogging machine was standardized during the year for use by preventive medicine companies and by engineer insect and rodent control personnel.

Recommendations were made to OTSG planning officers that a "basic load" of insecticide be included in the supplies for preventive medicine companies which accompany STRAC (U.S. Strategic Army Corps) forces on emergency missions. Also recommended was a plan for resupply of these units with necessary insecticides and rodenticides for accomplishment of their stated mission during emergencies.

The Orlando Laboratory initiated a project in central Florida to test the "sterile male release technique" in mosquito control. Thousands of males of the malaria vector species, Anopheles quadrimaculatus, were produced in laboratories, sterilized by gamma radiation, and then released on a tract of land in the lower part of Lake Okeechobee. Tentative impressions, obtained during the months subsequent to releases, suggest a resulting reduction in population of that species; the tests, however, must be continued through the summer and fall of 1960 to complete the study.

Descriptions, requirements, and justifications were initiated for the development of a "family" of lighter weight and more efficient items of equipment for use in control of arthropod vectors of disease. These data are being processed through appropriate research and development channels.

Detailed studies were instigated to determine the effectiveness of aerial insecticide spray programs on Army and Air Force installations that are to be carried out jointly by personnel of the Army and Air Force. These studies will include prespray and postspray entomological surveys as well as studies of insecticide resistance during the season.

Sanitary engineering.-A conference of 25 sanitary engineers was conducted at WRAIR, 30 November-5 December 1959, at which time a


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critical review was made of the Army sanitary engineering program. The committee reports from this conference were the basis for a series of staff studies on various portions of the program. A syllabus of the conference was being prepared for publication by the Historical Unit, U.S. Army Medical Service.

The Chief Chemical Officer and the Chief of Engineers consulted the OTSG regarding the contamination of ground water at the Rocky Mountain Arsenal, Denver, Colo., resulting from past industrial-waste disposal practices. Conferences on the subject were held with health agencies. Review of the entire problem and appropriate surveys were initiated by USAEHL.

The Surgeon General approved the request of the Chief Chemical Officer to install a deep injection well for disposal of industrial wastes from Newport Chemical Plant, Ind. The project was coordinated with the Indiana State Health Department, a site survey was conducted, and construction plans were reviewed. Arrangements were made with Chemical Corps for USAEHL to conduct studies concerning the trem ability of the wastes from this plant when operation commences.

At the request of the Surgeon, Eighth U.S. Army, the Chief Sanitary Engineer visited that command and provided assistance on its water supply program.

Sanitary engineering advice was given to the Chief of Engineers and to the U.S. Army Medical Research and Development Command at a conference concerning problems encountered at the Army installation on Greenland Ice Cap. A major result of this consultation was the instigation of a research project on waste-disposal methods to be used at Camp Century, the subsurface camp on the icecap.

Work continued on the evaluation of small sewage-treatment plants serving Nike sites.

In response to a request from the Chief of Engineers, an evaluation was made and approval given for the use of hydrofluosilicic acid in the the fluoridation of Army water supplies.

A liaison officer was provided to the Engineer Research and Development Laboratories during their field testing of prototype demineralizers developed for the purpose of removing radioactive substances and salinity from water.

Approval was granted for the institution of fluoridation of water at Fort Jay, N.Y.; Fort Rucker, Ala.; Fort Jackson, S.C.; Two Rock Ranch Station, Calif.; and Fort Richardson, Alaska. I

At the request of the fifth Engineers Tripartite Conference, activity was was reinstituted to develop a tripartite drinking water standard. Of particular interest to the requesting agencies are acceptable combat limits for chemical, biological, and radiological agents.


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Major staff studies were made on area sanitary engineering services and medical facilities planning. The former received general staff acceptance while the latter was still under study at the end of the year.

Army Health Nursing

The Army health nurse is the public health nurse of the military community. She is a member of the preventive medicine team, along with the preventive medicine officer, the sanitary engineer, and the entomologist, and she works closely with other AMEDS personnel in the hospital and outpatient services.

Visits to 17 Army installations in CONUS by the Chief Health Nurse, OTSG, indicated that there still was a lack both of written policies concerning the role of the health nurse in the prevention and control of communicable disease and of continuity in the existing health nursing programs as a result of changes in personnel.

During the fiscal year, The Surgeon General approved the recommendation that a consultant in health nursing be appointed, and action was being taken to process the appointment.

A request that a study be conducted concerning the health nursing needs and the utilization of health nurses was submitted to the U.S. Army Medical Research and Development Command.

The need for minimum health standards for day care centers on military posts was discussed with DCSPER, who plans to initiate action to establish the responsibility for the operation of these centers and then to request The Surgeon General to provide professional and technical guidance in establishing and maintaining minimum health standards.

Current health educational films and professional films relating to health nursing have been previewed and recommendations made regarding the addition of some of these films to the Central Film and Equipment Exchanges. Additional copies of frequently used films have been added to the film exchanges. The supply of health educational films is now grossly inadequate to meet requirements. New health educational literature has been reviewed and recommendations made regarding its use at local installations.

A new exhibit on health nursing was displayed at the annual convention of the American Public Health Association convention in Atlantic City. This exhibit will be displayed at other national nursing meetings. Production on the film "The Army Health Nurse," which is to be primarily for recruiting and orientation purposes, began in June 1960 at Fort Dix, with the Chief Health Nurse as technical advisor.

A short course in Army health nursing and outpatient nursing was held at WRAIR, in March 1960, with 18 health nurses attending.


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Other participants included outpatient nurses on active duty with the Army, Navy, Air Force, and Veterans' Administration, and Reserve public health nurses. The content of the course centered on health teaching in clinics and in the home. The Chief Health Nurse was consultant to the director of the course and presented papers on "Philosophy of Outpatient Care and Nursing Implications" and "Nursing Trends in Military Clinic Services."

Nutrition

The Surgeon General continued his active interest and participation in the field of nutrition through representation at the meetings of the Interdepartmental Committee on Nutrition for National Defense, the Master Menu Board bimonthly meetings, and the 28th Food Research and Development Coordination Meeting.

Civil Public Health

The Civil Affairs Functional Manual on Public Health was published during the year and will be used at the Civil Affairs School, Fort Gordon, Ga.

One nurse attended the advanced course and two nurses attended the basic course in civil affairs at Fort Gordon in fiscal year 1960. It is expected that three spaces for this training will be allotted in fiscal year 1961 and that they will be filled by two Army health nurses and one veterinary officer.

The proposal delineating AMEDS support of refugees in any future foreign theaters of war has received favorable comment to date. It is currently under discussion in the Office of the Chief of Engineers. Further discussion is expected to resolve the portion of the paper dealing with medical facilities.

World Health Data

The Preventive Medicine Division, OTSG, provided support and guidance to the Department of Health Data, WRAIR, in the publication of unclassified information on health practices and disease conditions on a worldwide basis. Special attention was devoted during the year to the tropical and subtropical regions.

The Department of Health Data prepared and distributed reports in fiscal year 1960 on Laos (28 August 1959), Cambodia (15 October 1959), the Republic of Panama and the Canal Zone (November 1959), Cuba (15 December 1959), Liberia (January 1960), Ecuador (27 January 1960), Haiti and the Dominican Republic (March 1960), and the Colony and Protectorate of Kenya (March 1960).


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The publications are prepared primarily for the use of officers of the Army Medical Service and are based on the latest information available.

Preventive Medicine Personnel and Training

Personnel in the Preventive Medicine Division participated in instruction at the various military schools, such as the U. S. Military Academy, the Walter Reed Army Institute of Research, and the Army Medical Service School.

The second Advanced Military Preventive Medicine Course at WRAIR was completed in October 1959. This 3-month course is designed to supplement civilian institution training and is usually given after completion of military public health training and before beginning the military portion of preventive medicine residency training.

Based upon the requisition of the military command in Taiwan, a mobile preventive medicine team, made up of a preventive medicine officer, a sanitary engineer, and an entomologist, was formed and spent a 90-day temporary-duty period instructing selected Chinese Nationalist officer personnel.

Preventive medicine officers.-Close liaison with the Personnel and Training Division, OTSG, was maintained throughout the year for the coordination of assignments and career planning of officers in the field of preventive medicine. Two military posts (Fort Dix, N.J., and Fort Ord, Calif.) are participating in the preventive medicine residency training program. It is anticipated that such program will be established at Fort Bragg.

As of 31 May 1960, the Army Medical Service had 78 preventive medicine officers on duty-31 in oversea areas and 47 in CONUS. Of these, 49 are Regular Army officers and 13 are career reservists. The other 16 are young physicians serving the 2-year obligatory military term. Of the 62 Regular Army and career preventive medicine officers, 32 are board certified.

The outlook appeared brighter for the procurement of potential preventive medicine officers. Applications for training in the 3-year preventive medicine residency program were numerous. In addition, nine applications were approved for 1960 in the preventive medicine clinical clerkship training program, as compared to three during 1959.

In connection with efforts to provide advanced training in communicable disease control to selected AMEDS personnel, two preventive medicine officers were participants in the fellowship in tropical medicine at the Calcutta School of Tropical Medicine; the first participated from October through December 1959, and the second during May and June 1960. In addition, one officer participated in the


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Louisiana State University fellowship in tropical medicine and parasitology in Central America. A bilateral agreement was reached between the ICA (International Cooperation Administration) and the Department of the Army for the assignment of a medical officer to an ICA field team in Cambodia. Participation in this assignment was not possible during the fiscal year.

A preventive medicine officer space was established in the Military District of Washington, U.S. Army, and an officer was assigned.

The occupational medicine residency training program at USAEHL was approved by the American Medical Association.

Entomologists-Several entomologists were lost through retirement and resignation recently and a sufficient number had not been obtained by direct appointment, as of 30 June 1960, to meet the needs. Requirements totaled 46, while 41 were on duty. Three career officers received postgraduate training in civilian universities and five attended short courses in entomology. One officer, who had previously received the master of public health degree at a civilian university, attended the 3-month Advanced Military Preventive Medicine Course at WRAIR.

A 2-week course in Military Entomology, under the joint sponsorship of the three military services, was held 2-15 August 1959, at the U. S. Naval Medical School, Bethesda, Md. This course is designed particularly to provide advanced training for active and inactive Reserve officers and civilian entomologists of the military services.

Sanitary engineers.-The shortage of sanitary engineers that has prevailed since the Korean War was partially alleviated during year as the result of an intensive recruiting program. The yearend strength was 72, as contrasted to 54 at the end of the preceding year. It now appears that the full strength of 85 will be reached early in fiscal year 1961. Enrollment of sanitary engineers in training courses during the year included 19 in MSC Officers Basic Course, 2 in the AMEDS Officers Advanced Course, and 9 in the Preventive Medicine Officers Course, all at the Army Medical Service School; 1 in the Command and General Staff College Course; 1 in the civilian postgraduate long-term course; 14 at the Robert A. Taft Sanitary Engineering Center, Cincinnati; and 25 at the Sanitary Engineering Postgraduate Short Course and 2 in the Advanced Preventive Medicine Course, both at WRAIR.

The career progression plan for sanitary engineers was revised in accordance with the recommendations at the conference of sanitary engineers at WRAIR. This provides a means for guiding the career monitorship of sanitary engineers and should aid in their utilization.


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A brochure was published during the year as an aid in the recruiting of sanitary engineers.

Army health nurses.-At the end of the fiscal year, there were 39 Army health nursing programs in the United States, including Hawaii and Alaska, and 20 in oversea areas (Germany, France, Italy, Eritrea, Korea, Okinawa, and Japan). Two new programs were initiated in Alaska. Of the 85 health nurses on duty at the end of the year, 73 had a primary MOS 3431 (Army health nurse) and 3 a secondary MOS 3431. All authorized spaces were filled with the assignment of nine additional health nurses during the year. Two of these were experienced public health nurses who received their commissions in the Army Nurse Corps this year. Two nurses completed their master's degree in public health at civilian universities, three completed the Advanced Military Preventive Medicine Course at WRAIR, and one completed the Advanced Military Nursing Course at the Army Medical Service School. The OTSG Professional Education and Training Committee approved the applications of two Army health nurses to enter civilian universities in the fall of 1960 for training in public health leading to the master's degree. Three nurses attended the course at the Civil Affairs School at Fort Gordon. One attended a course in Industrial Nursing at New York University and the Chief Health Nurse completed the Occupational Medicine Course at USAEHL.

Every effort is being made to assign nurses with limited experience or no experience in public health nursing to work under the direction of qualified supervisors. Six training spaces for the purpose of providing practical experience under proper supervision have been requested. Efforts to recruit fully qualified and experienced public health nurses into the Army Nurse Corps have been intensified and a request was submitted for a new health nursing brochure to aid in this program.

Publications

Arrangements were made for the purchase and distribution of the ninth edition of "Control of Communicable Diseases in Man," published by the American Public Health Association, 1960. Major commands were requested to distribute a copy to each MC officer, sanitary engineer, health nurse, and entomologist.

The following Department of the Army publications in the field of preventive medicine were issued during fiscal year 1960:

AR 40-409, Army Health Nursing Records, 31 December 1959.

AR 40-554, Prevention and Control of Communicable Disease of Man-Venereal Diseases, 13 May 1960.


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AR 40-562, Immunization Requirements and Procedures, 28 March 1960.

Changes 3 to TB MED 81, Cold Injury, 4 February 1960.

TB MED 114, Immunization, 22 December 1959.

TB MED 124, Plague, 13 May 1960.

TB MED 164, Malaria, 30 June 1959.

TB MED 212, Viral Infections of the Central Nervous System, 30 June 1959.

Changes 1 to TB MED 223, Respiratory Protective Devices, 4 September 1959.

TB MED 230, Treatment and Management of Venereal Disease, 11 December 1959.

TB MED 259, Treatment and Prevention of Streptococcal Disease and Its Sequelae, 13 May 1960.

DA Circular 40-3, Biennial Conference of Preventive Medicine and Laboratory Officers, 23 March 1960.

DA Circular 40-4, Influenza Immunization 1960-61, 8 April 1960.

DA Circular 40-6, Prevention of Heat Injury, 18 April 1960.

DA Circular 40-8, Animal and Plant Quarantine Regulations, Australia, 16 May 1960.

DA Circular 40-40, Poliomyelitis Immunization, 19 August 1959.

DA Circular 40-41, Special Immunization Requirements in USARPAC, 11 September 1959.

DA Circular 40-43, Adenovirus Immunization of Recruits, 5 October 1959.

DA Circular 40-47, Prevention of Cold Injuries, 31 December 1959.

DA Circular 385-2, Safety Precautions to be Observed in Handling Calcium Hypochloride, 28 March 1960.

TM 8-272, Manual for Army Health Nurses, November 1959.

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