DIAGNOSIS and TREATMENT of PNEUMOCOCCUS PNEUMONIA Prepared by the ADVISORY COMMITTEE ON PNEUMONIA CONTROL of the IOWA STATE DEPARTMENT OF HEALTH DIAGNOSIS and TREATMENT of PNEUMOCOCCUS PNEUMONIA Prepared by the ADVISORY COMMITTEE ON PNEUMONIA CONTROL IOWA. STATE DEPARTMENT OF HEALTH of the IOWA STATE DEPARTMENT OF HEALTH ADVISORY COMMITTEE ON PNEUMONIA CONTROL Fred M. Smith, M.D., Iowa City, Professor Theory and Practice of Medicine, University of Iowa, Chairman Carl F. Jordan, M.D., Des Moines, Sec’y Dennis H. Kelly, M.D., Des Moines Herbert W. Rathe, M.D., Waverly Albert A. Schultz, M.D., Fort Dodge Benj. F. Wolverton, M.D., Cedar Rapids FOREWORD Pneumococcus pneumonia caused 1,300 deaths in Iowa during- each year of the five-year period 1934- 1938. It is readily appreciated that among the acute infectious diseases, pneumonia occupies foremost place as a cause of illness and death. Contributions by various investigators during past decades have added greatly to our knowledge of the pneumococcus. Recent developments in the fields of chemotherapy and serotherapy have focussed attention upon pneumococcus pneumonia as a definitely control- lable disease. Pneumococci have been classified into thirty different types, with emphasis on the importance of accurate type determination as an essential part of the diagnosis of pneumonia. This booklet entitled “Diagnosis and Treatment of Pneumococcus Pneumonia” has been prepared by the Iowa State Department of Health’s Advisory Commit- tee on Pneumonia Control. The following pages will serve in a useful way to render physicians of Iowa familiar with the various details of management of pneumococcus pneumonia; the booklet also considers the functions of the Iowa State Department of Health in relation to control and preventive measures. Widespread application of present knowledge is des- tined in the immediate future to bring about a signifi- cant reduction in mortality caused by the pneumococ- cus. Walter L. Bierring, M.D., Commissioner of Health CONTENTS Pages Foreword 3 Diagnosis 5-7 History 5 Laboratory Studies 6 Sputum Typing 7 Treatment General Care 7-9 Use of Oxygen 9 Serotherapy 10-12 Technique of 10 Administration of 10 Dosage 11 Prevention of Reactions 12 Sulfapyridine 13-17 Treatment of Reactions 12 Mode of Action 13 Absorption, Excretion 14 Clinical Application 15 Combined Treatment 18 Toxic Manifestations 16 Pneumonia in Childhood 18-19 State Department of Health Interrelationships 20-27 Pneumonia Deaths, Cases in Iowa 20 The Attending Physician 22 The Typing Station 23 Distribution of Serum 24 The Pharmacist-Distributor 25 Educational Measures 26 List of Typing Stations 27-34 List of Pharmacist-Distributors 35 DIAGNOSIS AND TREATMENT OF PNEUMOCOCCUS PNEUMONIA Recent developments in the treatment of pneumococcus pneu- monia promise a decided reduction in the mortality from this disease. In order to attain this objective, however, it is im- portant that the diagnosis he established and proper treatment instituted as early as possible. DIAGNOSIS History, Symptomatology, Physical Findings Characteristic physical signs often do not appear until pneu- monia is well developed. Thus, the history is of the utmost importance in establishing an early diagnosis. In the typical case the onset is sudden with chill, sharp rise in temperature, pain in the side, hacking cough and the raising of blood-tinged sputum. Pneumonia in many instances follows an upper res- piratory infection, but even under these circumstances the beginning is generally marked by the more or less sudden occurrence of the above symptoms. There are certain cases in which the onset is gradual and in which the more typical symp- toms may be entirely absent. Cyanosis of the lips and increase in the respiratory rate are highly significant. Blood-tinged sputum is one of the convincing evidences of pneumonia. Inspection may reveal limitation in the movement of the in- volved side. This and the pain frequently direct attention to the portion of the lung concerned. In the early stage it is well to bear in mind that except for slight dullness, results from palpa- tion and percussion may be negative. Auscultation commonly discloses suppression of the breathing sounds or the presence of fine crepitant rales at the end of inspiration or after coughing. The above discussion pertains particularly to lobar pneu- monia. In general the diagnosis of atypical bronchopneu- 5 monia is more difficult because the clinical picture is commonly obscured by the various predisposing factors. Furthermore, the onset is more often of an insidious character. The possibility of this type of pneumonia, however, should always be suspected in the presence of an increase in an already existing fever, eleva- tion of the respiratory rate, and the appearance of fine crepitant rales in the lungs. Laboratory Studies The onset of pneumonia is ordinarily followed by a sharp rise in the leukocyte count with relative increase in the polymorpho- nuclear cells, particularly of the nonsegmented forms. Counts of 18,000 to 25,000 are common and in occasional instances, especially in children, they may reach 40,OCX) to 60,000. Thus, the extent of the leukocytosis is of considerable importance from the standpoint of diagnosis and also has a bearing on the prog- nosis. It is generally recognized that the death rate is much higher in patients with poor leukocytic response. The X-ray not infrequently discloses pneumonia before it is evident from physical signs. If there is a question regarding the diagnosis, films of the chest should be made whenever pos- sible. The portable unit also provides a valuable aid in follow- ing the course of the disease. Typing of the Sputum The etiologic diagnosis is essential in order that the patient may receive the benefit of specific therapy at the earliest pos- sible moment. In this connection it should be remembered that the pneumococcus is the causative agent in 40 to 50 percent of the cases of a typical or broncho pneumonia and in 90 to 95 percent of the cases of lobar pneumonia. The earlier the diag- nosis and administration of adequate therapy, the lower is go- ing to be the mortality rate. Typing likewise should be done prior to the institution of chemotherapy for there is evidence that sulfapyridine may interfere with the subsequent carrying out of this procedure. Moreover, it has not been determined 6 what method of treatment is most effective and until this ques- tion is answered, routine typing is recommended. Samples for typing should be obtained from sputum that has been coughed up from the lungs. Secretions from the upper respiratory passages are of doubtful value. In children and the aged it may be difficult to obtain sputum. Under these circum- stances it is often possible to obtain sputum on the end of a swab after having made the patient gag. Smears may be made di- rectly from the swab or the latter may be dropped into a culture tube. The mouse inoculation test is of special value as an aid in pneumococcus type determination. The sputum should be collected in a clean wide-mouthed bot- tle and, if possible, typed within an hour. It should be kept cool enroute to the typing station in order to avoid autolysis. Every physician should acquaint himself with the local facilities for typing specimens at any hour of the day or night. He should also know of the pharmacist-distributor who has therapeutic serum available in case of emergency. For further information relative to typing stations and pharmacist-distributors, the read- er is referred to Appendix A and Appendix B, pages 28-35. A blood culture should be taken as soon as pneumonia is sus- pected or the diagnosis established, and should be repeated during the course of illness. This is essential because the presence of bacteremia calls for a doubling of the amount of the type specific serum administered. Moreover, the blood cul- ture serves as a check on the typing of sputum. Further at- tention will be called to this matter in the discussion of serum treatment. GENERAL CARE Pneumonia is one of the most serious of all infectious dis- eases. While type specific serum or sulfapyridine when given early and in sufficient amounts may abort the disease in 24 to 72 hours, best results are insured if these are supplemented by all other available means of conserving the patient. Hospital- ization is always preferable. However, if the patient is to be transported to a hospital, this should be done as soon as pneu- 7 monia is suspected or the diagnosis made, and not postponed un- til the disease is well established. In deciding this question, the conditions in the home and other circumstances must necessa- rily be taken into consideration. Careful, detailed attention to the general care is one of the first essentials in treatment. Competent nursing is of the ut- most importance and in the more severe forms of the disease may be the determining factor in the outcome. The patient must be kept quiet, made as comfortable as possible and if ap- prehensive, assured. Relaxation and adequate sleep are indispensable to the wel- fare of the individual. In order to ensure these, it is ordinarily necessary to administer a sedative. Frequently bromides, pheno- barbital or chloral hydrate produce the desired result. A fluid intake of at least 3,000 cubic centimeters during 24 hours, is recommended; this may be given for the most part in the form of water and fruit juices. If it is not possible to give this amount of fluid by mouth, it'should be supplemented by the intravenous administration of 5 percent glucose in salt solution. The diet should be simple, consisting of milk, gruels, pureed vegetables, soft boiled or poached eggs, toast, soda crackers, jellies, custard, jello, ice cream, etc. It is best that the bowels be regulated by simple measures, preferably mineral oil and, if necessary, warm water enemas. In the presence of pain from pleurisy and for the control of an harassing cough, codeine or morphine are frequently necessary. Morphine, in small doses, is of value in afford- ing relief from pain. Care must be exercised in avoiding sup- pression of the respiratory center. Frequent check as to the condition of the abdomen should be a routine practice in following a case of pneumonia. Ab- dominal distension because of the elevation of the diaphragm aggravates dyspnea, increases cyanosis, and thus adds greatly to the patient’s discomfort. Distension is not infrequently a troublesome feature in the more toxic cases, but may be 8 avoided to a large extent by maintaining the fluid intake at a high level, and by the exercise of proper care regarding the diet and regulation of the bowels. If these measures and the insertion of a rectal tube fail, it may he advisable to employ turpentine stupes, the hypodermic injection of pituitrin in doses of 0.5 to 1 c.c., or prostigmin, 1 c.c. of a 1-2000 solution. Digitalis is seldom indicated in the treatment of pneumonia, except in the presence of an already damaged heart or auricular fibrillation. There is ordinarily sufficient time to administer the drug in ample amounts. In a majority of fatal cases, death is due either to respiratory failure or peripheral circulatory failure and not to cardiac failure. The presence of circulatory failure is indicated by rapid and thready pulse, profuse per- spiration, low blood pressure and other manifestations of shock. Under these circumstances the intravenous administration of glucose in salt solution or transfusion is indicated. The use of epinephrine in doses of 0.5 to 1 c.c. (1-1.000 sol.) at in- tervals of 20 minutes for six doses or until there is improve- ment in blood pressure and pulse, has been recommended. Caf- feine may be employed instead of epinephrine or alternated with it. USE OF OXYGEN Oxygen therapy is one of the basic treatments of pneumonia. Cyanosis and to a large extent dyspnea are due to anox- emia. When oxygen is given in adequate amounts, there is generally obvious improvement in the condition. This is man- ifested by lessening of cyanosis and reduction in the respiratory and cardiac rates. Moreover, the patient is made more com- fortable, feels relaxed and frequently is able to sleep. With careful supervision of administration, oxygen may be given in adequate amounts by nasal catheter, in combination with a high pressure oxygen supply and reducing valve. The catheter should be of small size with four to six small holes near the end, inserted and introduced to a level of a half inch below tbe nasopharynx. The application of a simple lubricant is advisable to reduce irritation. The catheter should be removed 9 at 8 hour intervals, thoroughly cleaned, and re-lubricated. Ad- ministration of oxygen at the rate of four to six liters per minute is usually sufficient. TREATMENT OF PNEUMOCOCCIC PNEUMONIAS WITH TYPE SPECIFIC SERUM The efficacy of serum therapy depends upon early diagnosis, accuracy of typing, and whether or not bacteremia exists. Technique of Administration The patient should be questioned carefully for possible al- lergic manifestations such as hay fever and asthma and concerning previous administration of horse serum. If there is a positive history, together with a positive eye test, it is not ad- visable to use any serum, unless it be rabbit serum, since this is least likely to cause reactions. Test for sensitivity regardless of history. The technique of sensitivity tests is the same for horse serum and rabbit serum. 1. Eye test. This is performed by introducing one drop of a 1 :10 dilution of serum in the outer canthus of the eye. If the subject is sensitive, conjunctival irritation ordinarily occurs within 20 minutes. A positive reaction is usually interpreted as indicating a higher degree of sensitivity than the skin test. 2. Skin test. Inject 0.1 c.c. of a 1:100 dilution of serum intradermally. A positive reaction is indicated by the development of an erythematous flare or wheal within 20 minutes. If there is no response, it is usually safe to proceed with the initial dose of therapeutic serum. With each of these tests there should always be on hand a syringe containing 0.5 c.c. to 1.0 c.c. of 1:1,000 solution of epine- phrine ready for immediate use. Administration of Serum The intravenous route is the method of choice and should be used if at all possible. In young children and in obese individ- 10 uals, it is sometimes necessary to give the serum intramuscu- larly ; under the latter circumstances the dosage should be doubled. Therapeutic serum, especially the rabbit variety, may be in- troduced directly into the vein, provided that the serum is warmed slowly to body temperature. (Water used to warm serum should be tepid, not so hot but that fingers can be kept immersed with comfort.) No more blood than necessary should be drawn into the syringe, because of the possibility of thrombus formation. Dosage When serum is introduced directly into the vein the initial dose should be divided as follows: 1. Inject 2 c.c. (about 20,000 units) very slowly, at the rate of 2 to 3 minutes per c.c. 2. If there is no reaction after one and one-half hours, give the balance of the estimated dosage. When serum is used early and in combination with sulfapyridine, 50,000 units may be adequate for type I and the higher types of pneu- monia. It should be remembered that type IT and type III cases usu- ally require twice the amount of serum used for type I. Under the following circumstances the dosage for the aver- age adult patient should be doubled: 1. When the treatment is started after the third dav. 2. When the patient is pregnant or in the first week of puer- perium. 3. When the patient is over 40 years of age. 4. When more than one lobe is involved. 5. When the patient is an alcoholic. 6. When bacteremia is present. A favorable response is indicated by 1. Subsidence of fever. 2. Reduction in pulse and respiratory rates. 3. Marked subjective improvement. 11 In children the initial dose is 2,500 units if the age is one year or under and 5,000 units for those over one year of age. If the response to serum therapy is not favorable within twenty-four hours, retype the sputum, check for bacteremia, and look for possible development of empyema. Prevention of Serum Reactions 1. The administration of aspirin, grains X to XX before each dose of serum may prevent thermal reactions. 2. Inject the serum slowly. 3. While the serum is being administered, the patient should be carefully watched for a reaction. If there is definite increase in the heart rate or drop in the blood pressure, give epinephrine (5-10 minims 1:1,000 solution) subcu- taneously. 4. Reject any serum which shows a precipitate or which is even slightly cloudy. Treatment of Serum Reactions 1. Thermal reactions appear in 30 to 90 minutes after the serum injection and are preceded by a chill. a. Warm the patient with hot water bottles, blankets and hot drinks. b. Give aspirin, grains V-XV. c. If hyperpyrexia develops, lower the temperature by sponging, ice caps, and cooling enemas. d. Do not give epinephrine. 2. Anaphylactic reactions usually occur immediately and are characterized by apprehension, cyanosis, dyspnea, tightness in the chest, backache, and rapid weak pulse. Anaphylactic reactions are best combatted by the ad- ministration of epinephrine 5-10 minims (1:1,000 sol.) subcutaneously or 1 to 2 minims intravenously. 3. Serum sickness appears in from five to fifteen days after injection of the serum and is characterized by fever, urti- caria, joint and muscular pain and enlarged glands. Any 12 rise in temperature after it has been normal for several days may be due to serum sickness. This is treated by epinephrine in doses of 15 minims (1:1,000 sol.) subcutaneously every three hours or by ephedrine, grains 1/6 to 3/8 by mouth every three or four hours. The latter drug is frequently effective in children. TREATMENT OF PNEUMOCOCCAL PNEUMONIAS WITH SULFAPYRIDINE Reports thus far published furnish convincing evidence that sulfapyridine is a valuable agent in the treatment of pneumo- coccal infections in general, and pneumococcal pneumonias in particular. It cannot be too strongly emphasized, however, that the use of sulfapyridine in no way justifies the abandon- ment of any of the well established measures for the treatment of pneumonia; namely, specific antiserum, oxygen, and good nursing and general care. On the contrary, the introduction of this drug creates new problems, and, if anything, increases the need for good clinical judgment and close observation of patients. It will be a grave mistake if any physician attempts to reduce the treatment of pneumonia to a routine administration of sulfapyridine alone. Each case must be considered indi- vidually and every measure used which will contribute to the patient’s recovery. Mode of Action of Sulfapyridine The mode of action of sulfapyridine is essentially, if not solely, that of bacteriostasis, or inhibition of growth of suscep- tible organisms. It does not neutralize the toxic carbohydrate substance derived from the pneumococcus capsules, nor does it aid phagocytosis. The devolopment of specific antibodies in the patient’s hlood, if such occurs, is independent of the action of sulfapyridine, and their presence in adequate amount is essential to the patient’s recovery. All types and strains of pneumococci are not equally inhibited in their growth by sulfapyridine. In some instances pneumo- 13 cocci become resistant to the action of the drug (sulfapyridine- fast). Absorption, Concentration in the Body, and Excretion Sulfapyridine is absorbed rapidly, but irregularly, when given by mouth. It is not absorbed when given by rectum. The so- dium derivative of the drug has been used intravenously; it is now available for general use. The concentration of sulfa- pyridine in the blood after any given dosage varies widely in different individuals and in the same individual at different times. Following the dosage commonly used, the blood concen- tration of free sulfapyridine may vary from a trace to 18 mg. percent. The effective concentration is thought to be in the range of about 4-6 mg. percent. In the blood a portion of the drug becomes conjugated, that is, it combines with the acetyl group and becomes acetyl-sulfapyridine, which is inactive against the pneumococcus. If acetylation is marked in a given case, it may be difficult to obtain an effective concentration of free sul- fapyridine in the blood. The drug diffuses readily through the other bodily fluids, in- cluding exudates and transudates. It passes into the cerebro- spinal fluid and pleural exudates in approximately one-half the concentration of that present in the blood. Both free sulfapyridine and acetylsulfapyridine are excreted in the urine. Acetylsulfapyridine has a very low solubility, which fact tends to make it precipitate out in the urinary tract as needle-like crystals which may form calculi in the kidneys, ureters, or bladder. This tendency accounts for the hematuria, with or without attacks of renal colic, which has occurred in some patients. The precipitation of crystals has been so extensive as to produce renal insufficiency. Since acetylsulfa- pyridine is more soluble in alkaline solutions than in acid, main- taining an alkaline urine would seem indicated on theoretical grounds. Patients who have diminished kidney function (eld- derly individuals and younger patients with nephritis) excrete sulfapyridine slowly and may, therefore, develop undesirably high concentration in the blood. 14 Clinical Application of Sulfapyridine to the Treatment of Pneumonia It is recognized that the procedure to be recommended here may be difficult to carry out in all its features, under certain conditions. Nevertheless, it is urged that it he followed as com- pletely as possible. The pressure of time, bad roads, and the economic status of patients may at times necessitate the omis- sion of important laboratory procedures. However, it should be pointed out that typing stations are now well distributed over the state (see Appendix A, pages 28-34) ; that inexpensive blood culture outfits are available; that bacteriological diagnosis may help save the patient’s life and may actually reduce the total cost to the patient. When a clinical diagnosis of pneumonia is made, the follow ing procedure is recommended : 1. Bacteriological diagnosis. a. Take sputum specimen for typing. b. Take blood culture. 2. Sulfapyridine (should be started without waiting for re- sults of typing or blood culture). a. Before starting treatment with drug, make hemoglobin determination, red and white blood cell count, differen- tial white cell count and urine examination. b. Make daily blood and urine examinations during sulfa- pyridine administration for evidence of hemolytic ane- mia, neutropenia and hematuria. c. If available, make blood estimation for presence of free sulfapyridine after first 12-18 hours, then every 1 or 2 days, depending on the response. The initial dose for an adult is 2.0 gm. (30.8 grains, 4 tablets), followed by 1.0 gm. (15.4 grains, 2 tablets) every 4 hours, day and night until temperature has been normal for 48 hours; then 1.0 gm. (2 tablets) every 6 hours until resolution is well under way; then, 0.5 gm. (1 tablet) 4 times daily until patient is ready to leave his bed. In most instances, a total of 25 gm. of the 15 drug will be sufficient. For cases in which treatment is started early in the disease, as little as 15 gm. may suffice. Sulfapyridine is available in tablets of 0.5 gm. (7.7 grains) and capsules of 0.25 gm. (3.8 grains). It is quite unsoluble but in some cases it is desirable to crush the tablets and give the drug mixed with water, milk, or fruit juice; or, it may be given in applesauce or in honey. More than half the patients receiving sulfapyridine are nau- seated by the drug, and about one-third vomit more or less se- verely. Usually, the drug need not be discontinued because of the nausea and vomiting because satisfactory sulfapyridine levels in the blood may be attained in spite of vomiting shortly after in- gestion of the drug. The vomiting does not parallel the blood concentration, and often subsides after several days. It is prob- ably of central origin, rather than due to gastric irritation by the drug. If severe, the drug may be omitted for one or two doses. Patients on sulfapyridine treatment should receive an ade- quate fluid intake, a total of about 3,500 c.c’s. daily, by all routes. There seems to be no reason for withholding any other drug during sulfapyridine administration that is indicated by the pa- tient’s condition, with the exception of saline cathartics. Toxic Manifestations of Sulfapyridine Sulfapyridine produces many of the toxic manifestations that may occur in the course of sulfanilamide therapy, but not so frequently. On the other hand, sulfapyridine causes more nau- sea and vomiting than sulfanilamide, and is also responsible, by the excretion of acetylsulfapyridine in the urine, for hema- turia and the formation of renal calculi. Any patient, who has once shown a toxic reaction either to sulfanilamide or sulfapy- ridine, may have a more severe reaction if one or the other of these drugs is given a second time. 1. Central nervous system effects a. Nausea and vomiting b. Mild depression c. Toxic excitement d. Encephalitis syndrome 16 2. Drug rashes a. Resemble measles eruption b. Stop the drug c. Keep patient out of sunlight 3. Drug fever (uncommon) a. Rule out complications before diagnosing: empyema, otitis media, sinusitis, pericarditis, menin- gitis. b. Discontinue drug if certain fever is due to it. 4. Cyanosis a. Less common than with sulfanilamide b. Does not require discontinuance of drug unless respira- tion is embarrassed. 5. Renal irritation a. Avoid by adequate fluid intake and maintaining alkaline urine. b. Indicated by gross or microscopic hematuria or renal colic. c. Watch urine for brownish, spearhead-shaped crystals of acetylsulfapyridine. 6. Effects on the blood a. Neutropenia (decrease in neutrophiles) i. Stop drug ii. Give pentnucleotide, liver extract, blood transfusion. b. Acute hemolytic anemia. i. Indicated by pallor, jaundice, falling red blood cell count. ii. Stop drug. hi. Treat by blood transfusion. 17 COMBINED TREATMENT WITH SULFAPYRIDINE AND SERUM Recent reports and experience indicate that the combined use of drug and serum is more effective than when either of these agents is used alone. Combined sulfapyridine and serum treatment is especially indicated under the following conditions when: 1. Adequate response to sulfapyridine has not occurred after 12 to 24 hours. 2. Blood culture is positive. 3. The patient is pregnant or in the first week of the puer- perium. 4. The patient is over forty. 5. Two or more lobes are involved. 6. There is relapse or spread of the infection after early re- sponse to the drug. The above conditions are given with the assumption that neither the drug nor serum are contraindicated on other grounds. PNEUMONIA IN CHILDHOOD The treatment of pneumonia in infants and children necessi- tates the same fundamental procedures as in the treatment of adults: 1. Obtain sputum for typing as soon as the diagnosis is made. 2. Obtain a blood culture if possible. 3. The administration of sulfapyridine after sputum is sent for typing. The recommended dose is 0.2 grams per kilo- gram of body weight (approximately 1 grains per pound weight). a. Infants: to 15 grains (grams 0.5 to 1.0) Stat. and 73/2 grains (grams 0.5) every 4 hours until symptoms abate. b. Children under 12 years: from 15 to 30 grains (grams 1.0 to 2.0) Stat. and 15 grains (grams 1.0) every 4 hours until symptoms abate. 18 c. Children over 12 years: from .30 to 60 grains (grams 2.0 to 4.0) Stat. and 15 grains (grams 1.0) every 4 hours until symptoms abate. The administration of sulfapyridine for a period of 24 to 48 hours is usually sufficient and reduces the danger of toxic effects. Daily blood counts and urinalyses are as necessary in children as in adults for the toxic effects of the drug may occur at any age. Nausea and vomiting are common but may be lessened by giving the drug in milk, honey or applesauce. 4. The administration of type specific antiserum in children may be deferred for 24 hours and, if sulfapyridine is not effective, the intravenous injection of 5,000 to 30,000 units of antiserum should be employed. If the serum is given in- tramuscularly, twice the recommended dose should be given. In fulminating cases both serotherapy and chemo- therapy should be employed at once. The same precautions used in the serum treatment of adults should be exercised in children. 5. The tendency in pneumonia in children is to overtreat the patient. The child should be left alone as much as possible and be permitted to rest. 6. Oxygen is equally as valuable in children as in adults. The indications for the use of oxygen and the technique of ad- ministration are the same in both age groups. 7. The prevention of dehydration and of acidosis by an ade- quate intake of liquids and of glucose is of even greater im- portance in children than in adults. Milk is usually poorly tolerated and if distension is present, it should positively be prohibited. The parenteral administration of fluids is one of the most effective therapeutic measures available to com- bat toxemia. 19 FUNCTIONS OF THE STATE DEPART- MENT OF HEALTH The Iowa State Department of Health keeps the state records of deaths from pneumonia and of reported cases of pneumo- coccus pneumonia; (2) the department participates in measures for early diagnosis of pneumonia and supplies diagnostic anti- pneumococcic serum to all typing stations without cost; (3) furnishes type specific curative serum for the underprivileged patient; (4) tabulates pneumonia case reports and death rec- ords; (5) encourages complete reporting; (6) investigates pneu- monia outbreaks and cases; (7) furthers health education; (8) cooperates in various measures with the Advisory Committee on Pneumonia Control, attending physicians, pneumonia typing stations, pharmacist-distributors, local health organizations and with other interested individuals and agencies. A. Pneumonia Deaths and Cases in Iowa. 1. Total pneumonia mortality. The accompanying table (Table I) indicates the num- ber of deaths attributed to lobar pneumonia, broncho- pneumonia and unspecified pneumonia in Iowa during the five-year period 1934-1938. The figures, released by the Division of Vital Statistics of the State Department of Health, are based on death certificates completed by Iowa physicians during the period mentioned. The Table fol- lows : TABLE I Lobar Broncho- Pneumonia Year Pneumonia Pneumonia Unspecified 1934 1020 924 21 1935 1078 835 16 1936 1170 909 21 1937 962 769 14 1938 761 739 24 Total Deaths .. 4991 4176 96 Average Annual Deaths (1934-1938) . 998 835 19 Pneumonia Deaths in Iowa—1934-1938 During 1939 (first six months), 499 deaths were at- 20 tributed to lobar pneumonia, 466 to bronchopneumonia and 22 deaths to pneumonia (unspecified). 2. Mortality from pneumococcus pneumonia. It is evident from Table I that during the period 1934- 1938, lobar pneumonia caused approximately 1,000 deaths a year. Estimating 90 percent of such deaths as due to the pneumococcus, fatalities from pneumococcic lobar pneumonia in Iowa during the period mentioned, num- bered 900 per year. Table I shows that fatalities from bronchopneumonia in Iowa averaged about 800 for each year of the five-year period 1934-1938. Estimating that 50 percent of these deaths are caused by the pneumococcus, such deaths num- bered 400 per year for the period under consideration. Total deaths in Iowa from pneumococcus pneumonia are conservatively estimated to have numbered 1,300 each year for the five-year period 1934-1938. 3. Morbidity caused by pneumococcus pneumonia. For every death from pneumococcic pneumonia it is believed that five persons sufifer an attack of the disease. Each year on this basis, 6,500 Iowa persons sufifer an at- tack of one or another of the 30 types of pneumococcus pneumonia. That official notification of cases of pneumococcus pneumonia has been woefully inadequate in past years in Iowa is indicated by figures in the following table: Reporting of Pneumonia in Iowa No. of Year Cases 1934 232 1935 278 1936 202 1937 542 1938 588 1939 (1st 11 mos.) 1159 TABLE II A gratifying increase in reported cases of pneumo- coccic pneumonia occurred during 1939. Credit for the 21 more complete reporting of cases is attributable largely to the cooperative arrangement between the State Depart- ment of Health and typing stations in hospital and other laboratories distributed throughout the state. The following Table (Table III) contains figures showing the relative frequency of occurrence of the var- ious types of pneumococcus as reported from typing sta- tions to the State Department of Health during the first quarter (January, February and March) of 1939: Pneumococcus Type Incidence in Iowa TABLE III Type of P neumococcus Number Percent I 160 31.19 II 82 15.98 Ill 71 13.84 IV 23 4.48 V 9 1.75 VI 8 1.56 VII 44 8.58 VIII 19 3.70 IX to XXXII . ., 97 18.94 Total 513 100.02 B. The Attending Physician. The State Department of Health is vitally dependent up- on the interest and cooperation of the attending physician in relation to the following measures: 1. Reporting of pneumonia cases. Whenever the type of pneumococcus pneumonia is determined by the usual laboratory procedure, a report card is mailed from the typing station to the State De- partment of Health; when this is done, it is unnecessary for the physician to fill out a separate report card. 2. Clinical case report. After the card reporting a case of pneumococcus pneu- monia has been received, the department forwards a let- ter and pneumonia case record form to the attending 22 physician or hospital, so that more detailed information may be obtained relative to the case. 3. Patient’s economic status. The attending physician should determine whether in his judgment the patient, family or relatives are regarded as underprivileged to the extent of inability to pay the cost of an adequate amount of curative serum. 4. Cooperation with district and county health services. Attending physicians and typing stations in counties organized as a health district or county-health unit, are requested to avail themselves of the services of their dis- trict and county health officers in connection with the re- porting and investigation of pneumonia cases. 5. Special report to State Department of Health. Physicians desiring to communicate with the State Department of Health, may do so by telegram or by tele- phoning “4-9111, Extension 137”. After 5 p. m. on week days, on Saturday afternoon or Sunday, Des Moines tele- phone numbers are “7-1417” and “4-6332”. C. The Pneumonia Typing Station. The State Department of Health cooperates with hospital and other laboratories that serve as typing centers and are equipped to examine sputum and other specimens for deter- mination of the type of pneumococcus pneumonia. 1. List of typing stations. Pneumonia typing stations in Iowa, arranged according to county are listed in Appendix A, pages 28-34. 2. Diagnostic antipneumococcic serum. The department, promptly on request and without cost, furnishes and forwards diagnostic serum to typing sta- tions. 3. Report cards and report forms. Individual report cards and monthly report forms are distributed to typing centers from the State Department 23 of Health. The supply of these cards and forms is re- plenished promptly on request. a. Report of the case is forwarded from the typing laboratory to the State Department of Health when- ever sputum, blood culture or other specimen from the patient shows presence of the pneumococcus. The report card should be mailed the same day that laboratory findings prove positive. The card, car- rying the physician’s name and address, the patient’s name, type of pneumococcus, and the signature of the laboratory worker, constitutes official report of a case of pneumococcus pneumonia. b. A summary of laboratory findings is forwarded monthly from the typing center to the State Depart- ment of Health. It is requested that the monthly report be com- pleted and mailed as soon as possible after the first of each succeeding month. 4. Blood culture bottles. Blood culture outfits are forwarded on request of the State Department of Health, for use in special cases. It is expected that hospital laboratories will when possible, supply their own blood culture material. 5. Mouse inoculation. Information regarding the mouse inoculation test is obtainable from the department’s State Hygienic Lab- oratory. 6. Pneumococcus killed culture material. The department through its State Hygienic Labora- tory, forwards pneumococcus killed culture material on request, for use in the technique of pneumococcus typing. D. Distribution of Curative Serum. The State Department of Health in cooperation with designated pharmacist-distributors, supplies curative se- rum without cost, subject to the following conditions: 24 1. That the attending physician or hospital administrator determine whether or not the economic status of the pa- tient and of relatives renders necessary the furnishing of serum, in adequate amount and without cost, by the State Department of Health. 2. That the case of pneumonia be specified as to type, after accurate determination by the Neufeld method. 3. That the case be reported by card, from a typing sta- tion, district or county health office. 4. That type specific serum be secured from a designated pharmacist-distributor. (See list, Appendix B) E. Sulfapyridine. The State Department of Health will furnish sulfapyri- dine for the underprivileged or indigent patient without cost: 1. When county supervisors, relief or other agencies re- fuse to provide this kind of medical care. 2. When the case of pneumococcus pneumonia has been reported and specified as to type, after accurate de- termination by the Neufeld method. 3. Provided that distribution of the drug is limited to pharmacist-distributors as listed in Appendix B, page 35. F. The Pharmacist-Distributor In order that type specific antipneumococcic serum for the underprivileged patient may be supplied with the least pos- sible delay, the serum should be obtainable from a pharma- cist-distributor in or near the locality in which the pneumonia case occurs. It is expected that the pharmacist will keep in stock at least 100,000 units of the first eight types of pneu- monia serum and of some of the more common higher types, especially XIV, XVIII and XIX. 1. List of Pharmacist-Distributors. Pharmacist-distributors who cooperate with the de- 25 partment in supplying serum for the underprivileged pa- tient, are listed in Appendix B, page 35. 2. Advance notice of serum transaction. The pharmacist, on the day that the serum is supplied, is requested to fill out a “Notice of Serum Transaction” (supplied from the State Department of Health) and mail the same to State Department of Health, Des Moines, Iowa. 3. Financial statement in triplicate. The pharmacist, after supplying pneuomnia serum to a physician and after mailing the advance “Notice oi Serum Transaction”, is requested to make out an invoice in triplicate, one copy to be forwarded to Walter L. Bier- ring, M.D., Commissioner, State Department of Health, Des Moines, Iowa; one copy to be mailed to the biological company and the third copy to be kept on file by the pharmacist. The invoice should include all of the fol- lowing items: Amount of Serum (number of units) Type of serum (I-XXXH) Name and address of patient Name and address of physician Cost price of serum Name of biological company 4. Should serum in adequate amount and of desired type be unobtainable locally, such serum will need to be for- warded as promptly as possible from the State Depart- ment of Health and directly to the attending physician or hospital. G. Educational Measures. Control and preventive measures against pneumonia to be effective, must be a matter of common knowledge to the phy- sician and to the public. 26 1. Medical Meetings, Films, Medical Literature. It is desirable that medical societies cooperate with the Speakers Bureau, the Advisory Committee on Pneu- monia Control and the State Department of Health, in arranging special meetings from time to time for the study of pneumococcus pneumonia. 2. Pneumococcus study course. Special pneumococcus study courses have been spon- sored by the State Department of Health and conducted at the department’s State Hygienic Laboratory, for lab- oratory technicians and physicians who give time to lab- oratory work. 3. Lav Education. With the aid of the press and the radio, through the preparation and distribution of literature and use of ap- propriate films, accurate information regarding pneumo- nia can be carried to people in rural as well as urban communities. 4. Continued investigation of pneumonia. Further advances in our knowledge of clinical, labor- atory and epidemiologic aspects of the pneumonias, will result from (1) analysis of case reports; (2) study of death records; (3) investigation of cases, carriers, epi- demics, and from (4) special studies of the pneumococcus and of the associated types of pneumonia. 27 Name of Hospital or County City or Town Laboratory Physician or Person in Charge Allamakee Lansing Office John W. Thornton, M,D. Allamakee Waukon Rominger & Jeffries Roy R. Jeffries, M.D. Appanoose Centerville St. Joseph’s Mercy Chas. F. Brummitt, M.D. Sister Mary Natalie* Appanoose Centerville Office, Health Dist. No. 2 Frank J. Condon, M.D., Director* E. G. Zimmerer, M.D., Acting Dir.* Benton .Vinton Virginia Gay T. L. Chadbourne, M.D.* Black Hawk... .Cedar Falls Sartori Memorial Leaf el Norton* Black Hawk Waterloo Clinical Laboratories J. L. Kestel, M.D. Black Hawk... .Waterloo Presbyterian W. H. Acker, M.D. Black Hawk... .Waterloo St. Francis J. L. Kestel, M.D. Sister Mary Valeria* Black Hawk... .Waterloo Allen Memorial Lorraine Lindquist* Mildred Patterson* Boone Boone Boone County Bessie M. Bryan* Boone Boone Clinic Laboratory E. M. Myers, M.D. Lorraine Burke* Bremer Waverly St. Joseph’s Mercy Herbert W. Rathe, M.D. Virginia Peacock* Buchanan Independence.. .Peoples’ C. W. Tidball, M.D.* N. L. Hersey, M.D. F. F. Agnew, M.D. A. B. Shelitto, M.D. Buchanan Independence.. .State R. A. Stewart, M.D., Supt. Calhoun Lake City McVey Memorial F. W. Hobart, M.D. Calhoun Rockwell City.. Office .Drs. Stevenson & Grinley Carroll Carroll St. Anthony W. M. Shirley, M.D. Sister M. Gregory Cass Atlantic Atlantic Incorp W. S. Greenleaf, M.D. Lilyan C. Zindell* Cedar Mechanicsville, .Office E. H. Littig, M.D.* Appendix A PNEUMONIA TYPING STATIONS IN IOWA Cerro Gordo... .Mason City Park L. R. Woodward, M.D. Bernice Benish* Cerro Gordo... Mason City St. Joseph’s Mercy H. W. Morgan, M.D. Margaret Krepsky* Cherokee .Cherokee State. Chas. F. Oberman, M.D., Supt. Cherokee Cherokee Sioux Valley Elizabeth F. Beisecker* Chickasaw New Hampton. .St. Joseph’s H. Haumeder, M.D. Clarke Osceola Harken H. Irwin Kelsall, M.D. Clarke Osceola Osceola H. E. Stroy, M.D. Estella Moran* Clinton Clinton Jane Lamb Memorial Wray J. Tomlinson, M.D. Clinton Clinton St. Joseph’s Mercy Sister M. Elaine; Miss Ernst* Crawford Denison Denison P. J. Brannon, M.D. Dallas Woodward School for Feeble Minded Chas. E. Irwin, M.D., Supt. Dallas .Perry Kings Daughters K. W. Diddy, M.D. Mrs. P. N. Refsdal* Dallas Dexter Office . .Chapler & Osborn Clinic C. R. Osborn, M.D.* Decatur ..Leon Decatur County M. W. Rogers, M.D. Eva Greene* Delaware Manchester Manchester Marie Mawe* Delaware Manchester.... Office, Health Dist. No. 3 C. L. Putnam, M.D., Director* D. M. Harris, M.D., Ass’t Director* Delaware Manchester.... Office Paul Stephen, M.D. Des Moines Burlington Protestant E. J. Wehman, M.D. Miss H. B. Hastings* Des Moines Burlington Mercy.. Geo. B. Crow, M.D. Sister Mary Francella* Des Moines Burlington Security Laboratories J. B. Wahl* Des Moines Burlington St. Francis E. J. Voigt, M.D. Des Moines Burlington D. M. Co. Health Unit E. C. Sage, M.D.C.P.H., Director Dickinson Lake Park Office W. E. Bullock, M.D.* Dubuque Dubuque Clinical Laboratories Lorraine Wilhelm* Dubuque Dubuque St. Joseph Mercy H. A. Stribley, M.D. Sister Mary Vivian Name of Hospital or County City or Town Laboratory Physician or Person in Charge Dubuque Dubuque Finley F. P. McNamara, M.D. Anne Schwartz* Emmet Estherville Coleman J. M. Wolden, Supt.* Emmet Estherville Office M. T. Morton, M.D.* Fayette Oelwein Mercy Sister Mary Edward* Fayette West Union... .West Union Community Mrs. David Madsen, Supt. Fayette Oelwein Office H. Risk, M.D. Fayette Oelwein Office R. J. Galvin, M.D. Franklin Hampton Lutheran W. L. Randall, M.D. Miss p Bsbcock^ Floyd Charles City... Cedar Valley J. B. Miner, M.D. Vernon Moore Greene Jefferson Greene County G. W. Franklin, M.D. Ethel Anderson Guthrie Guthrie Center. Office C. I. Thomas, M.D. Hamilton Webster City.. .Hamilton Co. Public Eppie Klooster* Hardin Eldora Eldora D. M. Nyquist, M.D. Orville Peterson, Supt. Hardin Iowa Falls Ellsworth Community F. N. Cole, M.D. Miss A, Peterson* Henry Mt. Pleasant.. .Henry Co. Memorial W. A. Sternberg, M.D. Dorothy Menefee* Henry Mt. Pleasant.,. State L. P. Ristine, M.D., Supt. Carol Martin* Howard Cresco St. Joseph Mercy C. R. Rominger, M.D. Howard- Mitchell Riceville Office Thomas G. Walker, M.D. Jackson Maquoketa City Memorial Arthur Graff Jackson Maquoketa Office .Earl V. Andrew, M.D. Mrs. E. V. Andrew* Jasper Newton Mary Frances Skiff Mem Julius S. Weingart, M.D. Jefferson Fairfield Jefferson County Cora Marie Murray, Supt. Phyllis C. Baker* Appendix A—Continued Johnson Iowa City Mercy Hospital .Sister Mary Philomena* Johnson Iowa City State Hygienic Laboratory.... M. E. Barnes, M.D., Director* I. H. Borts, M.D., Assoc. Dir.* Johnson Iowa City University Hospitals R. E. Neff, Administrator Vivian Floerschinger* Jones Anamosa Mercy Sister Mary Ignatius* Jones Monticello John McDonald Ruth E. Johnson, R.N., Supt. Miss D. N. Flynn Lee Keokuk St. Joseph’s Sister M. Evangelista, M.T. Clara Blakely* Lee Keokuk Graham R. L. Feightner, M.D. Lee Fort Madison.. Iowa State Prison Lab. Johannes Andersen* Roland Blackburn* Lee Fort Madison.. A. T. and S. F E. L. Durrill, M.D. Lee Fort Madison.. .Sacred Heart Sister Luciana* Linn Cedar Rapids.. .Mercy F. W. Mulsow, M.D. Sister M. Annunciata* Lorraine Bardsley* Linn Cedar Rapids...St. Luke’s Methodist F. W. Mulsow, M.D.; Esther Lorenc* Josephine Emery*; Ruth Beitel* Linn Cedar Rapids.. .Security Laboratories M. A. Chehak, Ph.C. Jean Wise* Lucas Chariton Yocom A. L. Yocom, M. D.; Dr. K. E. Lister Madison Winterset Winterset Drs. C. B. Hickenlooper & R. L. Wicks Lois Hooper* Mahaska Oskaloosa Mahaska County Miss A. Black* Mahaska Oskaloosa Mercy Willhelm Voigt, M.D. Mahaska Oskaloosa Office E. M. Williams, M.D.* Marshall State Center... Office A. D. Woods, M.D.* Marshall Marshalltown.. Evangelical Deaconess Alma Brandt* Marshall Marshalltown.. St. Thomas Mercy J. J. Noonan, M.D. Mills Glenwood State Harold B. Dye, M.D., Supt. John H. Kuitert, M.D.* Mitchell—See Howard Co. Monroe Albia Miners’ H. J. Richter, M.D. Name of Hospital or County City or Town Laboratory Physician or Person in Charge Montgomery... Red Oak Murphy Memorial H. C. Bastrom, M.D. Mildred Gilbert* Montgomery... .Villisca Office J. Clark Cooper, M.D. Nora Wood* Muscatine Muscatine Bellevue J. L. Klein, M.D. Ida A. Koehler* Muscatine Muscatine Benjamin Hershey Mem L. E. Howe, M.D. Ova Leggins* O’Brien Hartley Hand W. C. Hand, M.D. O’Brien Sheldon Good Samaritan X. E. Hogel, M.D. Osceola Sibley Osceola F. P. Winkler, M.D. Catherine Deegan* Page Clarinda State R. D. Smith, M.D., Supt. Wayne Cox* Page Shenandoah... .Hand E. j. Gottsch, M.D. Ernestine Lambert* Plymouth Le Mars Office, Health Dist. No. 1 H. H. Ennis, M.D., Director* Plymouth Le Mars Sacred Heart Sister Ritamary* Pocahontas Laurens Office J. H. Hovenden, M.D. Polk Des Moines.... Broadlawns General D. W. Goughian, M.D. Bertine Hooper* Polk Des Moines.... City Municipal Lab .H. E. Ransom, M.D. Nell Fishel, B.S.* Polk Des Moines Glomset Laboratory Anna T. A. Glomset, B.A., M.S. Polk Des Moines.... Lutheran Julius Weingart, M.D. M. D. Vuagnieux, B.S. Irene Carlson* Polk Des Moines.... Methodist James E. Kahler, M.D. Mrs. R. C. Rickabaugh* Polk Des Moines Mercy Julius Weingart, M.D. Sister Mary Joseph* Polk Des Moines Office, Polk Co. Health Unit... .E. N. Hesbacher, M.D., Director Appendix A—Continued Polk Des Moines.. . . la. State Dept, of Health Carl F. Jordan, M.D., C.P.H.* Mrs. Mae Chader* Polk Des Moines Army Station A. E. Montgomery, M.D. Polk Des Moines.... Veterans Admin. Facility E. J. Butzke, M.D. H. D. Smith* Pottawattamie. .Council Bluffs. .Council Bluffs Clinic A. A. Johnson, M.D. Marguerite Morehouse* Pottawattamie. .Council Bluffs. .Jennie Edmundson Mem Mary L. Tinley, M.D. Roberta Nelson* Pottawattamie. .Council Bluffs. .Mercy A. S. Rubnitz, M.D. Sister Mary Antoinette* Poweshiek Grinnell Community S. D. Porter, M.D.* Doris Butts* Poweshiek Grinnell St. Francis C. W. Howell, M.D. Ouita B. Thompson* Ringgold Mt. Ayr Office C. L. Seaman, M.D. Sac Sac City Sac City L. B. Amick, M.D. Margaret B. Maystadt* Scott Davenport St. Lukes F. H. Lamb, M.D. Mrs. Clara Kerrigan* Shelby Harlan Offices Carl Bisgard, M.D. J. P. McGowan, M.D.* A. L. Nielson, M.D. • C. D. Winder, M.D. Sioux Orange City... .deBey John G. deBey, M.D. Roschia A. Gilmore* Sioux Hawarden Hawarden Community Dorothy Schaefer Sioux Hull Office Herman J. Kooiker, M.D.* Story Ames College Hospital J. G. Grant, M.D. Amanda Ganschow* Story Ames Office G. E. McFarland, M.D. Story Nevada Iowa Sanatorium A. E. Gilbert, M.D. Herman Staff* Tama Toledo Sac and Fox Sanatorium Ira Nelson, M.D., Supt. Jos. E. Strelak, Jr.* Tama Toledo State Juvenile Home Knight E. Fee, M.D. County City or Town Laboratory Physician or Person in Charge Taylor Bedford Office G. W. Rimel, M.D.* Union Creston Community A. Fred Watts, M.D. H. G. Beatty, M.D.* Matilda Lanahan* Wapello Ottumwa Ottumwa Lillian M. Corey, Supt. Wapello Ottumwa St. Joseph F. A. Hecker, M.D. Warren Indianola Office Drs. Shaw & Trueblood Mrs. Iva Belden* Warren Indianola Office Drs. Hooper & Fullgrabe Inez Lukenbill* Washington... .Washington... .County C. A. Boice, M.D. Blanche Robertson* Washington.., .Washington... .Office, Co. Health Unit D. C. Barrett, M.D., Director* Webster Fort Dodge.... Lutheran A. Langehand, Supt. Herman N. Dulaney, B.A. Webster Fort Dodge.... St. Joseph’s Mercy R. S. McMillan, M.D. Mary Stageman* Webster Fort Dodge... .Office Health Dist. No. 4 F. J. Austin, M.D., Director* Winnebago Forest City.... Irish. C. W. Thomas, M.D. Winnebago Lake Mills Office N. T. Johnson, M.D.* Winneshiek Decorah Decorah Lester E. Larson, M.D.; Nancy Nitz* Woodbury Sioux City Lutheran A. C. Starry, M.D. Genevieve Nesby* Alfred Carlson* Woodbury Sioux City Methodist A, C. Starry, M.D. Woodbury Sioux City St. Joseph A. C. Starry, M.D. Woodbury Sioux City St. Vincent’s E. H. Boyer, M.D.* Woodbury Sioux City City Hall E, E. Peebles* Wright Belmond Belmond S. P. Leinbach, M.D.* * Attended one of the Pneumococcus Study Courses held at the Department’s State Hygienic Laboratory, Iowa City, during December, 1938 and November, 1939. Appendix A—Continued Name of Hospital or tPHARMACIST-DISTRIBUTORS OF PNEUMONIA SERUM IN IOWA Appendix B County Town Pharmacist Appanoose Centerville St. Joseph Hospital Black Hawk Waterloo Miller Drug Co. Boone Boone Wilson Drug Co. Bremer Waverly CaPhenin Drug Co. Carroll Carroll St. Anthony Hospital Cerro Gordo Mason City Prescription Shop Cherokee Cherokee McWilliams Drug Store Chickasaw New Hampton... .McGrane Prescription Shop Clay Spencer Bjornstadt Drug Co. Clinton Clinton Milo J. John Co. Des Moines Burlington Sutter Drug Co. Dubuque Dubuque Holscher Drug Co. Floyd Charles City May Drug Co. Hardin Iowa Falls Aborn Drug Johnson Iowa City Rose Pharmacy Lee Keokuk Bergman Drug Co. Linn Cedar Rapids Security Laboratories Mahaska Oskaloosa Green and Bentley Marshall Marshalltown H. S. Mayer Page Shenandoah Geo. Jay Drug Co. Montgomery Red Oak Artz Drug Co. Polk Des Moines Dennv Brann Sipes Prescription Shop Iowa State Dept, of Health Pottawattamie.... Council Bluffs Taffe Drug Co. Poweshiek Grinnell Large’s Pharmacy Scott Davenport Schlegel Drug Co. Swan Drug Co. Union Creston Newcomb Drug Co. Wapello Ottumwa Hoffman Drug Co. Washington Washington McDaniel Drug Webster Fort Dodge Iowa Medical Supply Co. Winneshiek Decorah Darling Drug Co. Woodbury Sioux City Toller Drug Co. tNote; Above is a list of the pharmacist distributors who carry an adequate stock of therapeutic antipneumococcic serum for the underprivileged patient, in accordance with the plan of the Iowa State Department of Health. The above list is subject to revision.