COCCACE^E AND THEIR PARASITIC RELATIONSHIPS 263 



at the present time. Veritable epidemics of streptococcus in- 

 fection in the surgical and obstetrical wards of hospitals made 

 this one of the most dreaded of diseases. Even to-day the 

 virulent streptococcus is held in great respect by many surgeons, 

 and cases of erysipelas and other recognizable active streptococcus 

 infections are commonly excluded from surgical wards. 



Erysipelas is an acute febrile disease characterized by a local 

 redness and edema of the skin which tends to spread to contigu- 

 ous areas. In the lymph spaces beneath the epithelium there is a 

 collection of leukocytes and serum, and the streptococci are also 

 found here, especially at the periphery of the reddened area. 

 In follicular tonsilitis and many cases of pseudo-membranous 

 angina as well as in the pharyngitis of scarlet fever, streptococci 

 occur in large numbers, and doubtless bear a causal relation to 

 at least a part of the pathological process. In true diphtheria, 

 streptococci seem to play rather frequently the role of important 

 secondary invaders. From the pharynx the streptococcus 

 may gain access to the middle ear and the rnastoid cells, to the 

 meninges, to the trachea, bronchi and lungs, setting up purulent 

 inflammations in any of these locations. It is an important 

 secondary invader in pulmonary tuberculosis. The streptococcus 

 seems also to cause enteritis, particularly in infants. In the 

 puerperium, streptococci are practically always present in the lochia. 

 In spite of many attempts to differentiate between virulent 

 and non-virulent types in this situation, it is still impossible to 

 distinguish them. Probably local conditions in the uterus as 

 well as the general condition of the pateint have much to do in 

 determining her resistance to infection of the uterine wall with 

 these normal streptococci. Undoubtedly the frightful epidemics 

 of puerperal fever in some hospitals previous to 1875 was due to 

 the transference of virulent organisms from patient to patient 

 by the attending physicians and nurses. This was first suggested 

 by Holmes (1843) an d more definitely proven by Semmelweiss 

 (1861), but their ideas received little credence until the last 

 quarter of the nineteenth century. Streptococcus bacteremia 



