The plague has not confined itself to the large cities of India, but has spread all over that country. It has extended into the northwestern provinces, has crossed the frontier, and passed into Baluchistan and Afghanistan. In many of the interior cities it has proved quite as fatal, in proportion to the population, as at Bombay and Calcutta. At Poonah the mortality has during some weeks been as high as eighty per cent of the cases, and four hundred deaths a week have been reported. At Sholapore, in the Punjab, far to the northwest of Bombay, the disease has prevailed in epidemic form.
With the plague widely diffused over the Indian empire, what measures have been taken to prevent its spread to other parts of the world? There are two routes by means of which the disease may pass from India to Europe. One of these is by ship through the Red Sea, the Suez Canal, and the Mediterranean; the other is overland from the northwestern provinces of India through Afghanistan into southeastern Europe. In fact, there are three overland routes from northwestern India into Europe. One of these leads from Lahore, the capital of the Punjab, through Afghanistan into the Transcaspian Province of Russia. The Transcaspian Railway extends from Samarkand, a place of about thirty-five thousand inhabitants, through the desert to the Caspian Sea at Ouzoun Ada. The latter place is connected by steamer with Baku and the Russian railroad system. The second overland route starts from the northwestern provinces, or Afghanistan, or Baluchistan, passes through Persia, extending on up between the Caspian and Black Seas, and crosses the Caucasus Mountains in the neighborhood of Tiflis. Both of these routes are quite extensively traveled and pass through cities of considerable commercial importance. Samarkand has extensive manufactures of cotton and silk, and carries on considerable trade by means of the Transcaspian Railway with European Russia. The second route passes through Teheran, the capital of Persia, with a population of about two hundred and twenty-five thousand. This route is also largely employed by commercial travelers, especially from Russia. The third overland route passes through Persia and Turkey in Asia up to Constantinople. This route can not be called a commercial highway, but it is used to a considerable extent, especially by pilgrims, and since at no point do travelers along this route come in contact with European guards against the plague, it is most likely that the pest will find its way into Constantinople by this avenue, if at all. The first two overland routes are guarded by Russian medical inspectors. Russia has not been slow to protect itself against the introduction of this epidemic. In December, 1896, the following lines of action were determined upon, and have apparently since that time been carried out quite thoroughly: First, Russian medical men were sent to the larger cities of Persia, such as Teheran and Meshed, for the purpose of watching the approach of the plague. All Russian consular officers in Persia were requested to inform these medical men of every rumor of the epidemic. Second, points of embarkation on the Persian shore of the Caspian Sea have been watched, in order to detect suspicious cases that might pass to Russia along this route. Third, observation stations have been established along the frontiers of the Transcaspian Province. Inspection officers stationed at these places have been notified to close the frontier, with the exception of certain points where inspection stations have been established. Fourth, inspectors have also been placed to guard the region of Tiflis against the introduction of the plague from both Persia and Turkey. For the reasons above mentioned, it seems to me probable that if the plague reaches Europe, it will likely do so by way of Turkey in Asia, across the Bosporus into Constantinople. The large number of pilgrims passing along this route, with the Turk's well-known fatalistic belief, render it quite probable that infection gathered anywhere along the route may be carried into Europe. Since several places in Hedjaz, along the eastern shore of the Red Sea, have already become infected with the plague, it is by no means improbable that the disease may find its way into the Balkan Peninsula. There are also several centers of infection along the shores of the Persian Gulf. It will be seen from these statements that Mohammedan pilgrims are exposed to the infection. Indeed, already the disease has been detected among these pilgrims on steamships in the Red Sea.
Certain international measures for the restriction of the plague were formulated at the Sanitary Convention of Venice in 1897. Nearly all civilized nations sent representatives to this conference, and certain general rules were adopted. Recognizing the fact that Mohammedan pilgrims from infected districts in India, coming to Mecca and other places along the eastern shore of the Red Sea, would mingle with those of like faith from Turkey and northern Africa, special rules concerning pilgrims were adopted at this conference. It should be understood, however, that these rules are likely to prove efficient safeguards only among those pilgrims who travel by sea. In the first place, the conference made certain regulations concerning the construction and sanitary arrangements of pilgrim ships. The upper deck must be kept clear for these people, and on the main covered deck every pilgrim has to have at least sixteen square feet of surface. Every one embarking on a pilgrim vessel must pass a medical inspection. No sick person or one suspected of having an infectious disease is allowed to go on board. The number which the vessel is allowed to carry is determined beforehand, and the names of all passengers and their home residences are recorded. The ship must supply wholesome water and make provision for food, proper in quality and sufficient in quantity. Every vessel carrying pilgrims must have on board a medical officer and a disinfecting stove. Details are given concerning the sanitary regulations during the voyage. All pilgrims are landed on the island of Camaran, in the Red Sea, before being allowed to disembark on the last stage of their journey. The period of detention from healthy ships at this place extends through only three days. If no disease appears during this time, the pilgrims are allowed to embark again, and go directly to Jeddah. If disease appears either before or after landing at Camaran, the pilgrims are detained at least ten days from the date of the last case. Arriving at Jeddah, they are no longer under international sanitary regulations, and any control exercised over them at that time must be administered by Turkish authorities. Just here, in my opinion, lies the greatest danger so far as pilgrims are concerned. It is true that the conference made certain recommendations and formulated certain rules concerning the return of those pilgrims going to the north or into Egypt, but the fact must not be overlooked that these restrictions are applicable only to those who go by sea. No restrictions are placed upon Mohammedan pilgrims returning from Mecca to India. India is already so generally infected that such restrictions have been deemed unnecessary.
The following is a general statement of the rules applicable to vessels coming to European ports from India through the Suez Canal: All vessels that have been ten days or longer at sea after departure from an infected port are allowed to pass through the canal without question and without precaution. Suspected vessels or those which have been at sea less than ten days since departure from an infected port, and which are provided with a medical officer and a properly equipped disinfecting plant, are allowed to pass through the canal in quarantine. This means that while passing through the canal there shall be no communication between those on board the vessel and those on the land. Other suspected vessels are compelled to proceed to the Wells of Moses for disinfection. Here the passengers and crew are disembarked, isolated for twenty-four hours, and their effects disinfected. At the same time the contents of the ship undergo disinfection. If the plague be found on board, all passengers, as well as the crew, are detained for a period not exceeding ten days. All clothing, the cargo, and the ship itself are disinfected. When a vessel passes through the Suez Canal in quarantine, notice of that fact is telegraphed to the country to which the vessel is going, and it is not allowed to land elsewhere.
Should the plague appear in any European country, the following rules were formulated to prevent its spread: (1) Whenever a case of the plague appears in any country the sanitary authorities of that country must give immediate notice to all other countries represented in the conference. This notice may pass through diplomatic or consular agencies, or it may be sent directly by telegraph. After this the sanitary authorities of the country in which the plague has appeared shall inform other countries at least once a week concerning the progress of the disease and the measures resorted to to prevent its spread.
(2) When an infected person enters a country by rail or other conveyance overland, disinfection of his person and personal effects is made obligatory. Land quarantine is condemned, and it is recommended that modern disinfection be practiced in its stead. Each country, however, may reserve the right to close its frontier against any other country in which the disease exists. It is recommended that medical inspection along the frontier be established in connection with custom-house examinations, in order to prevent unnecessary delay in travel. Passenger trains and postal cars are not to be detained at any frontier, but if a car be found to contain a real or a suspected case of the plague, this car shall be detached from the train at the frontier or at the nearest station thereto and its contents disinfected.
(3) Travelers coming from infected countries may be, at the discretion of the sanitary authorities, detained under observation for a period not exceeding eight days. Individual governments are allowed to take any special measures that may be deemed wise against the importation of the disease by means of gypsies, vagrants, and immigrants.
In formulating the above-mentioned rules to prevent the importation of the plague into Europe the members of the Venice Congress seem to have been thoroughly convinced that the longest period of incubation possible in this disease is ten days. It seems to have been assumed that if a vessel had been for ten days or longer at sea after departure from an infected port, and no cases of the plague had developed up to that time, there could be no danger of this vessel carrying the infection. It appears to me that a safer course would have been to require inspection of all persons and things going on board a vessel leaving an infected port, and the thorough disinfection of certain things, at least, on such vessels arriving at uninfected ports. The disinfection of a ship and its cargo by means of steam is not at present a very costly procedure.
Since the plague, if it reaches America at all, must come to us by sea, it may be of special interest to inquire concerning outbreaks of this disease on board ship. In making this inquiry we will confine ourselves to such cases as have occurred within the past two years. In March, 1897 (I have been unable to ascertain the exact date), the transport Dilwara left Bombay, bound for Southampton, with a regiment of English soldiers, together with their wives and children. On March 18th, while the vessel was in the Red Sea, a child died of the plague and was buried at sea. On arriving at Suez the persons who had been in immediate contact with the child were transferred to the Wells of Moses and properly disinfected. After this had been done, the vessel was allowed to pass through the Suez Canal in quarantine. No fresh case occurred, and the vessel arrived at Southampton April 6th. Here all articles which might possibly contain infection were disinfected, the passengers were allowed to go to their homes, and the troops were placed in barracks. No other cases resulted.
On July 6, 1897, one of the crew of the Carthage, of the Peninsular and Oriental Company's line, was attacked with the plague. The ship was then in the Arabian Sea. Two days later the sick man, with two other members of the crew detailed to attend him, was landed at Aden. Six days later a second member of the crew was attacked with slight symptoms of the plague. This fact was reported when the vessel passed Malta. The Carthage had intended to stop at Marseilles, but, on account of the plague on board, continued its course to England. Both of these patients were isolated by being placed in a large boat hung at a height at the side of the vessel so as to avoid communication with others on the ship. When the vessel arrived at Plymouth the passengers were allowed to depart to their respective homes. The only precaution that was taken consisted in ascertaining the destination of each person, and informing the health authorities of the places to which these people were going. The Carthage had on board a steam disinfector, and everything that had been exposed to the infection was thoroughly disinfected. On arrival at the port of London the second patient was isolated until he recovered. No cases developed in England.