OriginalArticles. liberal view taken of the matter by General Wood, the Acting Surgeon-General, and the War Depart- A COMPARATIVE STUDY OF TSUTSUGAMUSHI ment, we were ordered; and this report is based DISEASE AND SPOTTED OR TICK on the observations on tsutsugamushi disease FEVER OF MONTANA. made on that trip and the observations made by one of us in 1904 and 1905 on the BY P. M. ASHBURN, M.D., (Ashburn) Captain and Assistant Surgeon, U. S. A., cases of spotted fever occurring in those years in AND the Bitter Root Valley in Montana. CHARLES F. CRAIG, M.D., The that we were to to deter- First Lieutenant and Assistant Surgeon, U. S. A., specific point try Constituting the United States Army Board for the Study of Tropical mine, and which we think we have determined, Diseases as They occur in the Philippine Islands. was the question of the identity or nonidentity of I. Synonymy. II. Introduction. III. History of the two diseases and most emphasis will be laid on both Diseases. IV. Etiology. V. Symptoms, Tsutsu- that in this Spotted Fever. VI. Blood Examinations. point report. gamushi, both so re- VII. Mortality. VIII. Immunity Conferred by At- However, diseases, being closely as are to tack. IX. Susceptibility of Animals. X. Prog- stricted to locality, necessarily unknown nosis. XI. Pathological Anatomy. XII. Diagnosis. the very great majority of medical men, and a XIII. Prophylaxis. XIV. Treatment. XV. Case brief description of each will therefore be given Histories of Tsutsugamushi Disease. XVI. Con- and an effort made to run the par- clusion as to the Nonidf.ntity of the Two Dis- descriptions so eases. XVII. Does Flood Fever Occur in the Philip- allel, that the resemblances and differences may pine Islands? be brought out more strikingly. The descrip- I. SYNONYMY. tions to be given are based on personal observa- and Tsutsugamushi Disease : Japanese River Fever. tions of some 22 cases of spotted fever Flood Fever. Island Fever. Kedani Disease. 7 cases of tsutsugamushi disease, as w^ell as on the Akamushi Disease. Shimamushi Disease. Yo- writings of other men who have studied one dis- chubio. Shashitsu. ease or the other more carefully than we could or Mushi is a Japanese word meaning bug, and the did. compounds ending with it all relate to the etiology Both diseases are still subjects of earnest and of the disease. Tsutsugamushi is the term em- careful investigation by expert workers and it is ployed by most Japanese people and professional therefore unnecessary and would be futile, in a men as it has the derived from paper of this kind, to attempt the thorough con- and, prestige will ancient and specific usage, it will be employed in sideration of them which they deserve and this paper. receive later. Montana: Mountain Spotted Fever of Rocky HISTORY OF THE TWO DISEASES. Fever. Tick Fever. Pyroplasmosis Hominis III. (Wilson and Chowning). Tick Fever of the Rocky According to Tanaka the name tsutsugamushi Mountains. Rocky Mountain Spotted Fever. has been known since the earliest historical times, As so-called fever has been described in while the name shashitsu occurs in old Chinese spotted a A various parts of the Rocky Mountain region and writings of more than thousand years ago. from one such indicates that at as it has not been determined that the same dis- quotation writing that time the disease was as a distinct ease in all those parts, the term Spotted or recognized prevails and was ascribed to the bite of a mite Tick Fever of Montana will be used in this paper, affection to that in which occurred in summer time in certain dis- the disease referred being occurring rains. western in the Bitter Root tricts that had been flooded by the spring Montana, particularly statement made in Missoula and Ravalli counties. The bite was described and the Valley, that after three days high fever developed and a II. INTRODUCTION. pustule appeared at the site of the injury. It was For years kedani or tsutsugamushi also recognized that only certain regions were in- many past in disease has been an annual subject of the most fected and that the disease only appeared per- active and painstaking investigation on the part sons entering them. of Japanese physicians and the Japanese govern- The disease was brought to the attention of the ment. Western world by Palm, in 1878 and Balz, in 1879, One of the leading investigators of late years is and since that time it has been the subject of Dr. M. Miyajima, of the Institute for Researches much painstaking wrork by Japanese medical men of Infectious Diseases, of Tokyo. Dr. Miyajima and of numerous articles in Japanese and some in had read of the work of Wilson and Chowning, foreign journals. Numerous micro-organisms, have Anderson, Stiles and others, on the study of including cocci, bacilli and protozoa, been " " " " cause the several spotted or tick fever in Montana, and he described as the of disease, and had found so many points of similarity in the two investigators are working at the present time, diseases that he thought it quite possible that each with what he thinks the causative factor. these workers has they were the same. Consequently, when he It cannot be said that any of came to Manila as a representative of his govern- yet established his claim. ment to the Philippine Islands Medical Associa- Three hypotheses at present divide the workers tion and we met, he was desirous that we should and rule the work of investigation: visit at the season and determine, if 1. That the disease is due to a bacterium, a Japan proper Institute for possible, whether or not such be the case. Thanks belief favored by the workers of the to the representations of Dr. Miyajima and the Infectious Diseases. The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UNIVERSITY COLLEGE LONDON on June 26, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. 2. That it is a protozoal infection. Professor phatic glands becoming enlarged and painful and Ogata is the leading exponent of this idea. an attack of fever succeeding. 3. Tanaka thinks the disease due to a toxin It is the experience of practically all who have contained in the body of the red mite. carefully studied the disease, and they are numer- Spotted fever of Montana has been recognized ous, that every case of it is preceded by the mite for only a few years, twenty-five at the most, while bite and in the great majority of cases the bite is the literature relating to it has practically all been located by an examination of the region drained made since 1902. At that time Wilson and by the lymphatic glands which first became Chowning published their first account of it and enlarged and tender. So far as could be learned their ideas as to its cause and method of trans- in Japan, Bälz's contention that such is not the mission, in a preliminary report to the Montana case has not received support, and later investiga- State Board of Health, which appeared in the tors agree that the bite of the mite is the sole Journal of the American Medical Association. It means of infection. The mite in question is the is true that Major Wood, in 1896, and Maxey, in larval form of a trombidium, species unknown. 1899, had reported a similar, or the same, disease The larva bears a great resemblance to that of in Idaho, but the form occurring there presents Leptus autumnalis. It is so small as to be almost such points of difference, particularly in regard to invisible to the naked eye, bright red or orange in mortality, that it is not considered in this paper. in color, and is found on land that has been sub- Since the work of Wilson and Chowning in 1902, merged by flood. Here it is best collected by the disease has each year been the subject of tying a monkey out over night or by catching the careful investigation and report and the prospects field mice (Arvícola hatanedzumi, Sasaki) occur- now are that its etiology will soon be well under- ring in such regions. The mites collect in groups stood. on or about the eyelids of the monkey, while they The total number of cases occurring each year are always found attached in large numbers to the is small and that, considered in connection with inner surfaces of the ears of the mice. Mites the further facts that the disease occurs in such a resembling these in size and color occur in many limited and relatively isolated region and that it parts of Japan but they do not attack persons. has been known for so short a time, makes it The akamushi of other than infected regions do remarkable that the present knowledge con- not transmit disease. Several supposed causative cerning it should be as great as it is. organisms have been described for this disease, the latest and probably the one calculated to IV. ETIOLOGY. excite most interest being Ogata's plasmodium. Tsutsugamushi disease occurs along certain None of these alleged discoveries has been con- limited parts of the banks of a few rivers on the firmed, and, judging from what we heard and west coast of the main island of Nippon, being what blood examinations we could make in Japan, limited to Echigo and Akita provinces. The it appears that Ogata's plasmodium does not distribution of the infected areas is irregular and, exist.