Transcript
of the Court of Enquiry held "...to inquire into the origin, outbreak, and existence
of any infection or other disease or bodily ailment on board the ship called the
Scimitar."
To his Excellency the
Right Honourable Sir James Fergusson, Baronet, a member of Her Majestys Most
Honourable Privy Council, Governor and Commander-in-Chief in and over Her Majestys
Colony of New Zealand and its Dependencies, and Vice Admiral of the same.
We the undersigned Commissioners
appointed by your Excellency on the eleventh day of March A.D 1874 to inquire into the
origin, outbreak, and existence of any infections or other disease or bodily ailment on
board the ship Scimitar, during her voyage from Plymouth in England to Port
Chalmers in the Colony of New Zealand, and into the state of health of the passengers,
immigrants and other persons at the time of their embarkation on board the said ship at
Plymouth aforesaid. or immediately prior thereto, and also as to the mode and time of the
medical examination of such passengers, immigrants and other persons before or after such
embarkation as aforesaid, and into all the facts and circumstances attending the death of
all or any such passengers, immigrants, and other persons as aforesaid on board the ship
during her said voyage; and into the compliance or non-compliance by all and every person
and persons liable and chargeable in that behalf with the laws relating to or affecting
passenger ships, in so far as the same affects the said ship Scimitar and
generally seek the provision made for the medical and other treatment and the actual
medical or other of the immigrants on board said ship during the said voyage proceeded to
examine such witnesses on oath as could best speak concerning the subjects under
investigation, and having taken the evidence of twelve witnesses and also personally
inspected the said ship respectfully submit to your Excellency our opinion and conclusion
resulting from the said inquiry of the several matters and things thereon set forth as
follows.
1. The Scimitar is a fine new ship of 1225 Tons
burden being particularly lofty between decks (eight feet six inches high) and altogether
well adapted for Immigration service. The vessel sailed from London to Plymouth where four
hundred and thirty immigrants were taken on board from the depot on the twenty-second day
of December 1873. The vessel finally left for New Zealand on the twenty-fourth day of
December 1873, and arrived at Port Chalmers on the fifth day of March 1874 after an
unusually quick passage of seventy-one days.
- The Surgeon, Captain, and other officers appear to
have been specially attentive in the discharge of their respective duties.
- The supply of water was good and abundant, the
ordinary medical stores satisfactory, the medical comforts liberal and the usual food
plentiful.
- On the fourth day after sailing (December 28) a
child named Brown was observed covered with Scarlatina and removed to the Hospital. While
under treatment an attack of measles supervened and the child died on the eighth day
(Jany. 5th). The period of incubation of measles being usually fourteen days
the child must have been sickening of the measles before embarking.
- Both measles and Scarlatina developed rapidly
especially among the children and altogether there were fifty cases of Scarlatina and one
hundred cases of measles. The latter ceased about a month before landing but the
Scarlatina continued during the whole voyage. There were twenty-six deaths in all with one
exception, a girl of seventeen all children. Fourteen of the deaths were from measles,
nine from Scarlatina, two from dentition and diarrhoea and one from bronchitus. This last
child died on the fourteenth day of the voyage, having been ill since embarkation. In
addition to the cases referred to there was one hundred and twenty severe cases of
diarrhoea, twelve of Erysipelas, Carbuncle Whitlow and boils, thirty of Bronchitus;
numerous Stomatitis, Quinsy and Ulcerated sore throat.
- The number of cases prevented the possibility of
isolating the infected in the Hospital, and the major number were treated in their bunks,
every precaution being taken by disinfectants and otherwise to prevent the disease
spreading.
- The seeds of both Scarlatina and measles must have
been in a state of vitality amongst some of the immigrants while in the depot before
embarkation, and there is no reason to believe that the origin of these diseases is at all
to be attributed to the ship or the arrangements on board.
- After embarkation and before sailing a family
named Smith were sent ashore with strong symptoms of Scarlatina. A few hours before
sailing a child named Wolfrey was found covered with Scarlatina rash and the whole family
immediately sent ashore. This family came from Jersey and there is reason to believe that
several members of that family were only convalescent from Scarlet fever before entering
the depot.
- The infection of Scarlatina had also been imported
into the depot by a family named Tanner from Ireland. Just a few days after entering the
depot a girl named Tanner became ill of Scarlatina and it appears that a young girl on
board the steamer in which they came from Cork to Plymouth was suffering under that
disease. Some of the Tanner party were rejected from the ship Carnatic and
others of them from the Mongol both of which vessels sailed before the
Scimitar on account of fever symptons.
- The depot at Plymouth is said to be damp; the
bedding in many cases being damp. The situation is not a healthy one. The accommodation in
the way of fireplaces was too limited, and the front of the stoves usually occupied babies
clothes drying. The depot at the time was overcrowded. The weather was very rainy and the
immigrants going out and in got wet. Colds and Catarrh were prevalent in consequence and
during the voyage the imperfect ventilation on board, was also productive of colds and
sore throats. The preserved milk issued did not agree with the children, and the navy
biscuit provided for them was not suitable food. The large number of persons on board, the
imperfect ventilation and the unsuitable dietary for children, tended to aggravate the
epidemic and other forms of diseases in existence and latent at the time of embarkation.
- These facts exhaust the full head of the inquiry,
namely, the origin, outbreak and existence of any infectious diseases or other
disease or bodily ailment on board the said ship during the voyage, and tend us to
the opinion that the infectious diseases had their origin from cases imported into the
depot before the sailing of the Scimitar, from Jersey and Ireland, that once
being developed on board they rapidly spread owing to inability to ensure isolation and
that the other diseases were partially caused by the wet weather at starting and the
crowding and dampness at the depot, and partly by the usual limitations and discomforts of
a between decks voyage, in this instance accompanied by defective ventilation. We desire
to add that in our opinion everything was done by the Surgeon, Captain and Officers which
was in their power to arrest or mitigate the disease on board.
- In reference to the second head of the inquiry
namely, the state of the health of the immigrants at the time of embarkation or
immediately prior thereto, it is proved that on the whole the health of the immigrants was
good, with of course, the exceptions above referred to. The time of sailing was the depth
of winter and this must be considered as productive of bronchial and chest affectations.
There was no infectious fever within the depot at the time of embarkation so far as known,
the rejected cases having been sent outside. It appears that the parents of the child
Wolfrey who were subsequently sent ashore, had while in the depot been consulting a
Chemist in Plymouth, a fact they had carefully concealed, from fear of being left behind.
While the health of the immigrants generally was good at the time of embarkation it is
equally clear that epidemic disease was latent if not in active existence in the depot. In
the case of the child Wolfrey there is every reason to believe that she was infected on
arrival there. The other younger members of that family being only convalescent from
Scarlet fever, and that stage being a very infectious one, and it being unlikely that the
infected clothes they had worn during illness were destroyed or left behind, these
children must have been so many centres of infection likely to spread the disease. There
is no evidence to show how measles were introduced into the depot but there is no doubt
that disease was latent among the children in the depot before embarkation. The
precautions at the depot against the spread of disease were not efficient. There were no
sheets on the beds and blankets which had been previously in use, were issued to the
Scimitar immigrants. Assuming this to be the practice it is manifest that persons sleeping
in used blankets are very liable to take any infectious disease the previous occupants may
have had upon them.
- The mode and time of the medical examination of
the immigrants forms the next point of the inquiry. Intending immigrants appear to have
been examined by a surgeon at the towns where they resided before being accepted. When
accepted they proceeded to the depot where they were at once taken in without further
investigation. This preliminary medical examination does not appear in some instances to
have been searching enough. The witness Francis Newson had been an inmate of the Brompton
Hospital for consumptive patients, where he was told his chest was affected. The examining
medical officer at Woolwich had never examined his chest at all. The examiner of the
Wolfreys at Jersey ought to have made a special report concerning the children who
had been infected with Scarlet fever. In every instance before a free immigrant is
accepted there should be a special examination as if the person had been making a proposal
for life assurance or joining the army as a recruit. There is reason to believe some
immigrants leave England for New Zealand to gain health. Attention should also be paid by
the examiner to the personal appearance of the intending immigrant. Three Irish girls were
deficient in clothing, and one of them so filthy in her habits that her bed and bed
clothes had to be thrown overboard. No person inspected to see that each had the
prescribed quantity of clothing. The dirty condition of the girl referred to should have
been noticed by the Surgeon who examined her. A number of the immigrants were five and six
days in the depot without any medical examination. The medical examination at the time of
embarkation seemed to have been as efficient as the hurried inspection at the time of
sailing usually is. There not being time at sailing for a careful examination of several
hundred persons, greater care should be exercised on the occasion of previous
examinations, first before acceptance and second at or immediately after entering the
depot. The medical examination during the voyage appears to have been satisfactory, and
the Surgeon appears to have discharged a heavy weight of duty in a creditable manner.
- The facts and circumstances attending the deaths
have already been alluded to. Seven of the children who died were infants under a year
old, some of whom must have succumbed to the hardships of the voyage in any circumstances.
The want of milk and proper farinaceous food must have had a prejudicial effect on them
and the other young children. Sixteen children were under five years of age; two seven
years; and one girl of seventeen. It is a satisfactory result that with so many adults on
board, there was not one death among them.
- The laws concerning the inspection of the ship and
passengers appear to have been complied with. When the ship was in dock at London the
stores were inspected by the Surgeon accompanied by an Imperial Immigration Officer, and
the despatching officer of the New Zealand Shipping Company. Dr Eccles, the Imperial
Government Commissioner, latterly inspected the immigrants at the depot. This does not
appear to have been a very minute inspection. George Grigg stated Dr Eccles
examination of myself and family occupied about five minutes. This was a week after
his admittance. This witness stated that Wolfreys child was ill all the time. This
seems to have escaped the notice of the medical inspector. Dr Hosking, the
Scimitar Surgeon made a more careful examination at the depot afterwards, the
immigrants being made partly to strip and show their vaccination marks and their chests.
After embarkation their was an inspection by Dr Eccles, Mr Smith and Captain Smail, R.N.
The Surgeon states the medical examination was very careful, the immigrants
were passed one by one, the tongue examined, and in any doubtful case the throat and the
skin of the chest. The witness characterised this as a slight general examination. On the
assumption that he was a healthy subject himself and easily passed this does not conflict
with the Surgeons testimony. It is doubtful whether the children were very carefully
examined. To do this properly more time was necessary than was given, and the parents
being afraid of losing their passage concealed any incipient illness. In the case of the
Wolfrey's Scarlatina was detected and the family sent ashore. From what the Surgeon
saw at the general inspection he was not satisfied and had doubts of the propriety of
sending away so many infected people, and expressed his opinion to Dr Eccles that they
should if practicable have been detained ashore for isolation and treatment until the
epidemic had passed. Dr Eccles and Mr Smith deemed this impracticable and urged that the
mortality afloat would be no worse than if they remained ashore. We do not concur in this
opinion and believe that the fact of a number of persons being crowded together on board
was unfavourable to the proper treatment of any epidemic disease, besides the danger to
the colony afterwards by the introduction of disease. We are of the opinion that the
circumstances then existing should have induced a more stringent and careful examination,
and that all suspected cases should have been detained for treatment on shore.
- The provision made for the medical and other
treatment on board was satisfactory, with the exception of ventilation, the supply of
means for baths, and the food for children. The medical stores were ample. The Hospital
was on the main deck and in ordinary circumstances the accommodation would have been
sufficient. The best was done for the treatment of patients in their berths, and the sick
and convalescent, were provided with fresh meat all the voyage. The energies of the
Surgeon must have been severely taxed, but his treatment appears to have been attentive
and skilful, and considering the number of cases of all kinds he had to deal with very
successful.
- The foregoing details completely exhaust the
points of this inquiry, and reference is made generally to the evidence of witnesses
examined. The following recommendations as applicable in addition to the arrangements
which existed on board the Scimitar, which were generally satisfactory, are
respectfully submitted for consideration, viz.
- A better mode of ventilation on board so as to
prevent the mischievous affects of top draughts, as well as the sickening influences below
when the hatches are closed. Metal tubes might be employed opening to the wind, and
leading to the lower deck, similar tubes turning the reverse way being used to draw off
the vitiated air. The remarks of the Surgeon of the Scimitar on this point
deserve attention.
- A supply of soft bread to be issued for women and
children, and for the latter an abundant supply of farinaceous food, as well as a cow put
on board to supply them with fresh milk.
- The children should be messed together by
themselves under the supervision of their parents under a special dietary scale suitable
for them.
- Abundant means for baths should be supplied to
ensure cleanliness and health.
- The Surgeon as acting for the Government should
have an independent authority in many particulars where not interfering with the
discipline or navigation of the ship. This should be especially in the matter of the water
supply and baths and anything affecting the health or cleanliness of the immigrants. The
school should be under the control of the Surgeon. Circumstances may arise to render the
assembling of the children together expedient.
- An ample supply of sawdust and sand for the better
cleaning of the lower deck should be on board.
- An exhaustive series of medical questions, as
thorough as in a case of life assurance, should be prepared to be put to intending
immigrants, to be filled up by the examiner and forwarded for consideration of the Agent
Generals department. In addition there should be a minute and careful personal examination
before acceptance.
- An experienced medical officer should be attached
to the Agent Generals department who should make a personal inspection of the immigrants
at London or at the depot. At or immediately after entry at the depot a careful
examination should take place. The habits as well as the health of the immigrants should
be considered and untidy persons rejected.
- The bedding at the depot should be washed after
use and the mattrasses (sic) and the apartments should be lime washed on each occasion
after use, and otherwise cleanliness observed. The smell of guano noticed should be
overcome. In winter better fireplaces should be used. Childrens clothes should be dried in
the Laundry or drying room. The site of the depot is not suitable and it would be better
were a site found near a Railway Station a few miles out of town, where several
inexpensive small wooden houses could be erected adapted for the purpose required.
We annex hereto the evidence of
the several witnesses examined.
All of which we respectfully
submit to your Excellency's consideration.
(Signed )
John Bathgate, A.Chetham Strode
Thos Morland Hocken.