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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 Majesty’s Most Honourable Privy Council, Governor and Commander-in-Chief in and over Her Majesty’s 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.

  1. The Surgeon, Captain, and other officers appear to have been specially attentive in the discharge of their respective duties.
  2. The supply of water was good and abundant, the ordinary medical stores satisfactory, the medical comforts liberal and the usual food plentiful.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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 Wolfrey’s 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.
  13. 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.
  14. 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 Wolfrey’s 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.
  15. 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.
  16. 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.
  1. 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.
  2. 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.
  3. The children should be messed together by themselves under the supervision of their parents under a special dietary scale suitable for them.
  4. Abundant means for baths should be supplied to ensure cleanliness and health.
  5. 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.
  6. An ample supply of sawdust and sand for the better cleaning of the lower deck should be on board.
  7. 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.
  8. 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.
  9. 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.