REPORT OF THE COMMISSIONERS APPOINTED TO INQUIRE INTO CERTAIN MATTERS CONNECTED WITH THE SHIP "ENGLAND," AND CORRESPONDENCE WITH THE AGENT-GENERAL THEREON.

Appendix to the Journals of the House of Representatives, 1872 Session I, G-03

a.—No. 3.

REPORT OF THE COMMISSIONERS APPOINTED TO INQUIRE INTO CERTAIN MATTERS CONNECTED WITH THE SHIP "ENGLAND," AND CORRESPONDENCE WITH THE AGENT-GENERAL THEREON.

PRESENTED TO BOTH HOUSES OF THE GENERAL ASSEMBLY, BY COMMAND OF HIS EXCELLENCY.

WELLINGTON.

1872.

SCHEDULE.

fo. Date. From To Subject. 1 1872. May 10 Commissioners His Excellency the Governor Agent-General Report, with Evidence and Documents attached. 2 March 16 Hon. W. Gisborne... Informing him of the arrival of the "England" with small-pox, &c., and calling for his report as to her despatch from London. Telegram informing him of arrival of " England " with small-pox. (See enclosure to No. 7.) A Commission of Inquiry has been issued by His Excellency the Governor. Forwarding a copy. Directing measures to be taken to remedy defective arrangements pointed out by Commissioners. Requesting His Excellency to call attention of Secretary of State to certain portions of Commissioners' Report. Acknowledging receipt of telegram. Acknowledging receipt of telegram, and affording explanations. March 17 Hon. W. Gisborne... Agent-General 3 April 17 Hon. W. Gisborne... Agent-General i, 5 May 13 June 5 Hon. J. D. Ormond Hon. W. Reeves ... Agent-General Agent-General 6 June 5 Hon. W. Reeves ... His Excellency the Governor 7 8 May 2 May 2 Agent-General Agent-General Hon. W. Gisborne... Hon. W. Gisborne...

G.—No. 3.

REPORT OF THE COMMISSIONERS APPOINTED TO INQUIRE INTO CERTAIN MATTERS CONNECTED WITH THE IMMIGRANTS BY THE SHIP " ENGLAND."

May it please your Excellency,—■ We, the Commissioners appointed to inquire into and report upon all the facts concerning the outbreak and existence of small-pox and of any other infectious or other disease on board the ship " England," during the voyage of that ship from England to Wellington, and particularly into the compliance or non-compliance by all and every the persons and person liable or chargeable in that behalf with the law relating to or affecting passenger ships in so far as the same affects the said ship "England," and into the fitness of the said ship for the conveyance of immigrants, and the provision made for the medical and other treatment of such immigrants, and into the actual medical or other treatment of persons infected with small-pox, or infected with any infectious disease, or ill with any other disease or bodily ailment whatsoever, having proceeded to make the inquiry intrusted to us, and having taken evidence thereon, after careful deliberation have agreed to the following Report. It will be convenient to class the observations we have to make under the following heads :— I. Compliance with the Passengers Act, as affecting the ship " England." 11. Outbreak and Existence of Disease on Board. 111. Treatment of the Immigrants. (a.) Their treatment generally. (b.) The provision made for their medical treatment, and their actual medical treatment. IV. Conclusion arrived at. Upon the evidence taken we propose making comments as we proceed; but before entering on these specific matters, a short statement of the purpose of the voyage can most appropriately be given here. The "England," a vessel of 860 tons register, was engaged by the New Zealand Government to bring out immigrants to this Colony, the engagement of the ship having been entered into with Messrs. Shaw, Saville, and Co. of London who had chartered her from the owner (Captain Harrington) as a general ship. The immigrants were 102 in number, reckoning as 81 adult persons, so that the "England" was a "passenger ship" within the meaning of the Passengers Acts. She also had cabin passengers, and carried a general cargo. The vessel left Gravesend on the Bth December last, and arrived in Wellington on the 9th March, after a passage of ninety-two days. On the voyage there were sixteen deaths from various causes, and two births. The whole of the evidence taken is attached hereto, by way of appendix, together with copies of such of the documents produced as seemed to us material to the inquiry. I.—Compliance with the Passengers Act, as affecting the Ship " England." It will be seen that this involves the fitness of the ship for the conveyance of emigrants, which may be disposed of at once by saying that the "England," both in capacity and seaworthiness, was fully adequate to the conveyance of the people she brought with her, and that if she had not been loaded with cargo between decks she could easily have carried a larger number. On this voyage the ship was commanded by Captain Harrington, who is also owner, and who appears

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to have had considerable experience in the conveyance of emigrants to different colonies. A duly qualified surgeon was on board, and an interpreter for the foreign emigrants had been provided, as required by law. Early in December the vessel was cleaned and painted, and surveyed by the Government Surveyors, while lying in the East India Docks, and then the spaces were measured off for the bunks, and these, with the other fittings and requisites, were erected by the charterers, Messrs. Shaw, Saville, and Co. The spaces allowed for the bunks, as well as the passage room and the spaces devoted to the hospitals in the 'tween decks, were sufficient to comply with the Act. About the 4th December the emigrants began to arrive, but as the fittings were not completed and the cargo not taken in, they were subjected to inconvenience and hardships, to which reference will be made more particularly hereafter. _ The completion of the fittings appears to have been delayed till close upon the period of sailing; and as the formal inspection of these required by the Act did not take place till the afternoon of the day preceding the sailing of the ship, it seems clear that scant time was afforded to permit of defects bein^ rectified. In proof of this we may refer to the evidence given by Captain Harrington, where he complained to the charterers of the defective construction of the sky-light to cover the main hatch, and which was insufficient for the purpose it was required to serve, viz., to afford light and ventilation to the deck below, and at the same time be open in all weathers. This was also pointed out to Mr. Morrison, but it was not remedied. The sky-light actually used is said to have been of so flimsy a character that it was dangerous to the ship to carry it (see Daniel's evidence, Appendix, page 11). The absence of a properly constructed sky-light had an injurious effect upon the ventilation; and as the'ship had cargo between decks, stowed between the single men's compartment forward and the space allotted to the married people, it was not easy to maintain efficient ventilation, because in bad weather this sky-light had to be closed, and consequently a thorough current of air could not be maintained. Upon this defect being discovered, the captain did what could be done to improve the ventilation, by keeping a large wind-sail down the main hatch, but this could not be always there, for the reasons mentioned before. The effect of this defective ventilation in a space crowded with people, many of them young children, and where a great deal of sickness prevailed] requires no further comment. During the voyage it was also found that the bunks were boarded un so as to obstruct the ventilation, and the steps taken to remedy the evil will be found in the evidence of the carpenter (Daniel). The after hospital was situated on the port side of the ship, in the midst of the people, and was badly ventilated and lighted. The only means of lighting was from a scuttle in the ship's side—a small aperture under the most favourable circumstances, but at times, when the ship was on one tack, wholly ineffectual for the purpose; while the hospital was rendered still more useless for its original purpose by being closely boarded up, so as to prevent the free circulation of the air. The 24th section of "The Passengers Act, 1855," is specific as to the nature of the hospital accommodation to be provided, and although the space allowed was in accordance with the law, we think greater judgment should have been exercised in the position chosen. A properly secured deck-house would seem to be the most advantageous for such a purpose. Proceeding with the other requirements of the Act, we have been unable to get any evidence as to the inspection of the stores and water supplied for the use of the passengers. The third officer of the ship (Cullen), whose evidence will be found at page 14 of the Appendix, received the stores at the ship's side, in dock, as they were delivered by the carrier, but he is positive in stating that no inspection of them took place then nor at any time afterwards; so that if any inspection was made, it must have been made before the stores reached the dock. The captain, in one part of his evidence, states that the stores were inspected, but he afterwards explains that by this he meant that Shaw, Saville, and Co. told'him they had got them passed. It is however right to add here, that there does not appear to have been any well-founded complaint made as to the quality or quantity of the provisions supplied.

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According to the evidence of the surgeon (Mr. Leigh), the medical inspection of the emigrants, which is an important provision of the statute, is stated to have been "loosely conducted," inasmuch as there was confusion among the passengers assembled on the deck, and it is not clear that all who were called answered to their names. We cannot say, with any certainty, whether any person was not inspected. The interpreter (Swenson) is positive that all were inspected; yet there is evidence given of some of the crew having been sent below to get up any stragglers, and although they did turn a man out of his bunk, the evidence does not establish whether or not he found his way to the inspection. It would be quite likely, from the confusion prevailing on board just prior to the departure of a ship, that some persons might have escaped notice. Other witnesses besides the surgeon speak as to the apparently imperfect nature of the inspection. The reason why we were anxious to get full information on this point, will be evident when that part of the Report is reached which speaks of tho origin of the epidemic. With regard to the inspection of medical comforts, medicine, &c, which is required under the same section of the Act that provides for the inspection of the passengers, there is an absence of direct testimony; but as there is evidence that they were supplied in accordance with the law, and as no complaint has been made with respect to the quality of the medical comforts, we may assume that they were duly passed by the proper authority. The surgeon, indeed, states in his evidence that Dr. Eeathersfon came to his cabin and looked at his instruments, but he is not aware that there was a regular inspection as required by the Act; while at the same time he states that he preferred a request for splints for use on board, which was not complied with. Of medicines there seems to have been an ample supply. There is another point of some importance, as evidencing the hurry with which the ship was got ready for sea, and which for a time endangered the safety of the ship and passengers. We allude to the defective stowage, referred to in the evidence of the captain and the carpenter. About a week after leaving, and when passing the Bay of Biscay, the ship was found to roll and labour so much that a part of the cargo had to be shifted, and efforts made to trim the ship. The cargo was stowed by stevedores employed by the charterers ; the captain, under the charter party, has the general direction of the stowage. This is clearly one of the evils resulting from the divided responsibility of the captain and the charterers ; but, at the same time, the persons intrusted with the final inspection of the vessel should have taken especial pains to see that the cargo was properly stowed, so as not to endanger life. Eortunately fine weather was experienced all down the Channel and across the Bay of Biscay. Had it been otherwise, there might have been a greater penalty paid for negligence in this respect. Proceeding further in the inquiry, we find that the captain did not fill up the passenger list in the manner required by the 16th section of the Act; and the absence of this list, and this non-compliance in the matter of recording deaths and births occurring on board, becomes of importance, because, as we shall hereafter have occasion to show, the official log of the ship, which would have been valuable as a check on these matters, has also been insufficiently kept. But further, one of the most important requirements of the Act respecting the fitness of the vessel, which would have afforded evidence of the due compliance with the provisions before alluded to, does not appear to have been observed; —we allude to the clearance to be obtained by the master of the ship, under the 11th section of the Act. That section provides, in effect, that no ship fitted as a passenger ship shall clear out or proceed to sea until the master shall have obtained, from the Emigration Officer at the port of clearance, a certificate that all the requirements of the Act have been complied with, and that the ship is seaworthy, in safe trim, and in all respects fit for her intended voyage; and he is further required to enter into a bond, as provided by the 63rd section. The captain states that he neither obtained the certificate nor entered into the bond, and says that Messrs. Shaw, Saville, and Co. will have it. The captain may have been mistaken asj^o the execution of the bond, inasmuch as, just before closing

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our labours, we learned that the required bond is in the possession of the Customs authorities here. Erom this fact it may, perhaps, be inferred that the clearance also has been obtained in due form; and although the captain refers to his charterparty, by which Messrs. Shaw, Saville, and Co. obtained the entire control of the vessel, and which he seems to consider relieved him from the responsibility of attending to the requirements of the Act, the Commissioners do not assent to this, and think that the captain is to blame in not having satisfied himself of the fact whether a clearance had been obtained or not. We need scarcely point out that the terms of the charter-party will not release the master of the vessel from the liability to which he is subjected by law ; but a reference to the charter-party discloses the fact that it contains a clause to the following effect:—That the responsibility of the charterers as regards the cargo, passengers, and Passengers Act, shall cease on the completion of the loading. Independently of this, however, it is clear that the requirements of the statute have not been fully complied with in so far as the captain is concerned. It may be that the clearance has been obtained and is in the hands of the charterers, as alleged; but it is very unsatisfactory to the Colony not to be in a position, in a case of this kind, at once to cast the onus on those persons who are chargeable with neglect of the law in the particulars to which we have referred. Before quitting this subject, we also take occasion to refer to the official log, and to the evidence of the captain as to the mode in which this was kept. Many of the entries made are not properly signed by the master, and in no cases are entries of the deaths signed by him; while sometimes the surgeon entered them, sometimes the chief officer, and, as a consequence, mistakes have been made in names of the persons reported to have died. There are two especial instances of this among the records of death—in the case of the person named in the log "Maria Olson," but whose real name was "Bertha Maria Olsdatter;" and again in the case of the man whose name is entered as " Peter Nielsen," but whose real name was " Neils Peter Larsen." Peter Neilsen is a different man, and is still alive. It must be admitted in extenuation that the captain was, at the time of these entries being made, fully occupied with the duties of the ship, and that, with a crew reduced by sickness, and with the anxiety which must have affected him during the alarming spread of disease on board, there is some excuse for the absence of his personal attention to this matter. Taken, however, in conjunction with the want of the proper passenger list, we feel somewhat doubtful of the value of the log as a correct record of the deaths which occurred on board. ll.—Outbreak and Existence of Disease on Board. Very shortly after leaving London, disease appears to have broken out amongst the children. The date is fixed about the 21st December by the captain, that being the occasion when his attention was called to the fact by one of the female passengers ; but there is a difference in the evidence given on this point. One of the Scotch immigrants (George McDonald, Appendix, page 6) says that measles had appeared amongst the foreigners at Gravesend, but his authority for this is his having overheard them before the ship left speaking of " measly " and " kinkhaust," the former being the Norsk for measles, and the latter a term well-known in Scotland to designate hooping-cough. There is other testimony, however, as to the existence of hooping-cough, which, with catarrhal complaints, would appear to have been in existence on board at leaving. On the 28th December, a child (Carl Neilson) died after having had measles, and thereafter measles, followed by diarrhoea, seems to have spread rapidly among the children; and although the disease gained ground,, there do not seem to have been any effectual steps taken to arrest its progress. The surgeon states that he urged isolation by the use of the hospital; but the captain represented that a removal of the stores to the hospital from under the main hatch was required to put the ship in safe trim. The space subsequently vacated by this removal being left free for better ventilation, the surgeon acquiesced in the change, and asserts his belief that it was to the advantage of his patients. Erom the description given of the hospital, however, its position and small size, it was palpably inadequate for the purposes of effectual isolation during such an epidemic.

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A reference to the extracts from the official log between the 12th and 21st January shows that in that period no less than five children died, the causes of death being stated to be " morbilli, diarrhoea, and exhaustion." The firstdeath among the adults was that of a married woman, the wife of Christopher Ericksen, whose name appears in the official log as " Maria Olson," but whose real name was " Bertha Maria Olsdatter." She fell ill about the 20th December, and an eruption, with glossy pimples, appeared on the 26th. The character which this eruption assumed is described in a distinct manner by several witnesses, and, notwithstanding that it is not so described by the surgeon, there is no doubt that it was the pustular eruption which is characteristic of small-pox. The evidence of the medical witness (Dr. Johnston) is conclusive on this point. The description of the disease, stated to have been written at the time by the surgeon in. his journal, discloses its fearful nature; and the pitiable appearance of this woman towards the close of her illness, will be found described in the evidence of several other witnesses. The case appears to have been treated as one of " malignant measles " by the surgeon, and she eventually died on the 2nd January, 1872. It appears that no steps were taken to isolate this woman, or to remove the people who slept near her, but she was moved from one bunk to another close under the main hatch, so as to secure the benefit of better air when the hatchway could be kept open. She had a child at the breast, which died on the 14th January, having presented the same appearance as the mother, but in a modified degree. The woman above mentioned had been nursed in her illness by a single woman named Mina Bergersdatter, who took ill almost immediately afterwards. In her case the eruption appeared in the same form, and the pitted character of the pustule which is peculiar to small-pox is distinctly testified to. She eventually died on the Ist Pebruary. The immediate cause of death is stated to have been a chest complaint, accelerated by getting suddenly into a colder latitude. The third fatal case among the adults was that of Neils Peter Larsen, whose name is recorded in the official log as Peter Neilson. He fell ill on the 14th Pebruary. The evidence given by several witnesses identifies his appearance, with respect to the character of the eruption, with that of the woman Maria Olson. He died on the 3rd March. In all these cases, the symptoms described, and the opinions we have received from competent medical authority, lead us to the conclusion that although there are slight differences in the description of the appearance of the eruption, they suffered from the same disease, and there seems to be no reasonable doubt that that disease was small-pox. Several other adult cases followed, both among the passengers and the ship's officers and crew, but none of them were fatal. Indeed, at one period of the voyage there was not a part of the ship in which disease did not exist; and considering the way in which the people were cooped up with an infectious disease right in their midst and no effectual isolation, it seems difficult to imagine how a greater mortality did not occur. One of the worst of the non-fatal cases appears to have been that of a ship's apprentice named Spring, whose evidence will be found at page 12 of Appendix. Spring was examined before us, and in appearance is so pitted as to leave no doubt, even in the mind of a non-professional person, that he suffered from small-pox. Direct testimony, however, as to the nature of Spring's case will be found in the evidence attached. During the progress of the disease on board, the only attempt at isolation was the removal of the single women to the long-boat, which was housed over for them after Mina became ill. Reference has already been made to the unfitness of the hospital for the purpose intended; but it seems to us that it might have been possible to make some arrangement, even between decks, which would have had the effect of limiting the spread of the infection, as, from the history of the cases, it appears to have required direct contact for its propagation. Thus the two fatal cases among the adults occurred between decks, and the woman Mina became infected by attending on Maria Olson, and was allowed to carry infection among the single women in the saloon. In not preventing this, we think the surgeon was to blame; because, even supposing that his opinion of the disease was that it was only measles, yet he admits its malignant character, and it would there--2

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fore be almost certain to communicate itself to the other young women. Nor, as far as we can ascertain, did the surgeon warn, the people that the disease was of an infectious nature; while the appearance of the woman Olson at her death must have been such as to startle even the most apathetic into taking some precaution against possible infection. Erom the several witnesses examined we have endeavoured to extract what their own ideas of the disease were, with a view to test the treatment adopted and the steps taken to arrest its progress. We find that many, both of the passengers and crew, entertained the idea that the disease of which the adults died was small-pox. The foreigners thought these cases were small-pox, and several witnesses, McDonald, Spring, and Gulden, speak directly as to their having told the surgeon so; but he appears uniformly to have considered the cases as measles of a malignant kind. The surgeon himself admits that some of these persons did tell him it was small-pox; but none of the witnesses can say whether they told the captain so, and this is borne out by one of the cabin passengers (Mr. Baclknd), who states that he never heard that it was supposed to be small-pox, although the nature of the disease was frequently discussed. The captain states that he relied on the doctor's opinion as to the nature of the disease, and distinctly avers that the idea of small-pox never suggested itself to him. Notwithstanding this assertion, after witnessing the appearance of the lad Spring, and having heard a description of the symptoms in several other cases, and of the appearance of the convalescents, it seems difficult to believe that a person of ordinary observation could have any doubt as to the nature of the disease. Allusion was made by several witnesses to a disease they called " foreign measles," and it is said the surgeon so called several of the cases, but he does not allude to it in his evidence, his journal, or his report as such. We have had evidence that there is a disease known in the north of Eurojoe as " Rothelm," a co-existent form of measles and scarlatina. Dr. Johnston however states in his evidence that the symptoms of the disease on board the " England " do not bear the characters of "Rothelm." We have been at a loss to trace the origin of the disease with any degree of certainty. It is clear that it must have been brought on board, either in the person of some of the passengers, or in clothing. We direct attention to the evidence of several witnesses who speak distinctly as to the appearance of a Danish emigrant —a man named Claus Petersen Maii—who was observed to have scabs on his face within a few days after the voyage commenced. Some of the witnesses noticed him at periods varying from two to four days after leaving, and it is certain that very early in the voyage these scabs were observed by several persons, and were commented on. He himself says in his evidence (page 23, Appendix), that he passed the inspection at Gravesend, having then nothing the matter with him; that when about seven days at sea, scabs appeared on his face containing matter, and that he showed them to the surgeon, who said they were caused by foul blood. No remedy appears to have been given, and the surgeon states that he does not remember to have seen him, nor is any entry of his name or of any treatment to be found in the surgeon's journal. It is of course impossible for us to say from what disease the man suffered, although we are strongly disposed to believe, from the description given by himself and others, that he had a mild attack of small-pox. In any case these facts remain : that he had an eruption on his face containing matter, and similar in appearance to those observed in other cases on board; that on either side of the bunk where this man slept, there occurred the two first and only fatal cases of small-pox 'tween decks. 111. —Treatment of the Emigrants. (a.) Their Treatment generally. Under this first head we have to remark that, as far as regards the treatment of the emigrants from the time they left their own country prior to their arrival in London, there is nothing to show that they were badly cared for in any particular. Evidence will be found, both from Norwegians and Danes, to the

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effect that they slept betvf een decks on their voyage to England, and had plenty of food. The weather was cold and stormy, but it must be remembered that a passage across the North Sea in the month of December is pretty sure to be attended with bad weather. Reference has already been made to the arrival of the emigrants in London before the ship was in a state fit for their reception; and in the evidence of the captain, the surgeon, and others, ample proof will be found that they were put on board before the vessel was fitted to receive them, and that, by reason of the loading of cargo being carried on at night, all between decks were exposed to the inclemency of the weather, while the absence of many conveniences necessary on deck subjected them to great discomfort. One of the witnesses (Cullen) speaks of their having to sleep in the dock-sheds, but this is expressly denied by the captain and other witnesses ; and we think Cullen must have been mistaken in the evidence he gave on this point. Very shortly after leaving, difficulty appears to have been encountered by the surgeon in carrying out the sanitary arrangements, and the captain, observing this, relieved him from this portion of his duty. We think these arrangements were better carried out under the captain's more experienced direction, and that a more ready obedience w Tould be given to his authority. We have already stated that the provisions supplied to the immigrants were according to the legal scale, and that there were no well-founded complaints; but the medical comforts do not appear to have been by any means sufficient to provide against the contingencies of sickness. As a matter of fact they were soon exhausted, and it is only just to Captain Harrington to say that he was most generous in ministering to the wants of all classes of the passengers during the voyage. He personally inspected the culinary arrangements, and from his own stores supplied what was requisite in the way of increased medical comforts. The list of medical comforts supplied by the charterers will be found in the Appendix (marked E), and it seems manifest that the quantities are very small for the number of persons on board, especially with so large a proportion of children. (b.) The Provision made for their Medical Treatment, and the Actual Medical Treatment. This part of the duty assigned to us gave us great difficulty in dealing with it so as to elucidate satisfactory conclusions. We may first refer to the appointment of the surgeon, who was selected by the charterers, and engaged under the agreement marked Hin the Appendix. It seems that he was not appointed till close upon the elate fixed for the departure of the ship, and that in a conversation which the captain had with the manager of the charterers, the latter made a remark which appeared to convey a doubt as to his mental capacity. It is true, the captain states that he did not, from his after experience, consider this remark justified ; but the terms of the conversation alluded to leaves an impression on our minds as to Messrs. Shaw, Saville, and Go's, knowledge of an unfitness in the surgeon for the post to which he was appointed. On the other hand, however, the surgeon, although a young man, has held responsible offices connected with the practice of his profession, in particular the position of House Physician to the North Staffordshire Infirmary, and during the period of his study he took four silver medals in different subjects at the class examinations of Charing Cross Hospital. He admits, however, that he was compelled to relinquish his employment in England from ill health, and that he undertook the voyage for the purpose of re-establishing it, and that he suffers from epileptic fits. After being a fortnight at sea, he became irregular in attendance on the people; and although this was caused by his sea-sickness, yet when he did again attend, and found sickness among the children, there seems to have been a lack of energy in grappling with the difficulty. In the captain's evidence, and in that of other witnesses, it will be found that one special feature which rendered the surgeon unable to discharge his duty was that he laboured under a defective memory, and that he seemed to forget the treatment which had been adopted on a previous day, and even mistook the character of the disease and sex of the patient. In his medical journal, which was produced to us, there is evidence of this confusion shown by the entries.

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Although we have been unable to obtain clear evidence of any specific act of neglect on the part of the surgeon, yet there is proof that very early in the voyage he lost the confidence of "the majority of the immigrants, and that, as disease increased in intensity and the deaths became frequent, this feeling deepened, till it took the shape of a formal protest on the 15th January, in which the passengers declined to have his further services. There is a conflict of evidence between the captain's version of this protest and the surgeon's, and which has a bearing on the duties of the latter from the time of the interview alluded to. The surgeon states that he then told the captain that if his services were dispensed with by these people he would cease his duties, and that when he handed over the key of the medicine chest he handed over his duties as ship's surgeon. The captain, on the other hand, states expressly that he told the surgeon that he was not released from his duty, and that he would compel him to attend the people. It appears to us that the subsequent facts are in favour of this statement, as we find that the surgeon did attend the people after this period during the illness of the captain, and thereafter during the rest of the voyage, whenever he was called upon; while, in addition, the entries in the log book and the journal kept by the surgeon show that he still continued his duties, and certain letters which passed between the parties on the voyage (X and L in the Appendix) seem further to bear out this view. As already observed, no specific charge of actual negligence has been established against the surgeon, nor can we trace any wilful refusal on his part to attend a case reported to him. At the same time it is evident that he was annoyed at the steps taken by the persons who refused his services, and this refusal appears to have irritated him to a degree which, in his state of health and with the responsibilities incident to his duties, rendered him often incapable of performing them in a proper manner. As frequently occurs in inquiries of this nature, there is discrepancy in the evidence given in many particulars, and we experienced great difficulty in getting at the real facts, as there seemed to be an unwillingness on the part of many of the witnesses to speak otherwise than in general terms; yet enough has been stated to show us that the medical attendance was not of that kind which should have prevailed in a ship tainted with any kind of disease, infectious or otherwise, and we are forced to the conclusion that the surgeon's duties were not efficiently performed. What effect might have been produced by more skilful and diligent attendance we cannot say, but it is clear that all was not done by him that might have been to alleviate the sufferings of the sick. In concluding this part of our Report, it is our duty to say that the concurrent testimony of the witnesses proves that the captain's active exertions in the treatment of the sick, and his unwearied efforts to lessen the sufferings of the emigrants, are worthy of the highest praise, and were gratefully appreciated by those on board. IV.—Conclusion arrived at. Having noticed all that seems to us of importance in the evidence, it only remains that we should state first our opinion on the whole matter, and secondly some general conclusions which may be of use hereafter in improving the arrangements for the introduction of immigrants. / I.— (a.) We think that the emigrants should not have been put on board before the ship was ready to receive them, as they were thereby unnecessarily exposed to suffering and inconvenience; and that, as they arrived on the date fixed for their reception on board, arrangements should have been made by the charterers for their lodgment on shore till the ship was ready. (b.) That the evidence discloses a method of procedure with regard to the fulfilment of the requirements of the Passengers Act which is most unsatisfactory, some of the inspections by the Imperial authorities being apparently mere matters of form. (c.) —1. That small-pox existed on board the "England," and that it originated among the Danish emigrants, and to that disease the three fatal cases among the adults are to be attributed.

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2. That measles existed throughout the voyage, and though not directly fatal as far as we can learn, yet that many of the children seem to have died from its after-effects. 3. That the existence of small-pox was known to several persons on board soon after its outbreak; and that its peculiar characteristics were so clearly developed, that we fail to understand how the surgeon and captain could have remained in ignorance of its true nature. (d.) That the surgeon appointed did not properly discharge his duty to those under his charge, but that there is some excuse to be found for him in his ill-health and its effects upon his temper, of which defect those who employed him in London appear to have been cognizant. (c.) That excepting the neglect of the captain to satisfy himself that the provisions of the Passengers Act had been complied with, there is nothing that occurred during the voyage which leads us to the conclusion that he has not done his duty. We also think that his interference with the surgeon was warranted by the circumstances, and was for the benefit of all persons on board the ship. 11.— ( a .) That in future the Government should insist that the persons with whom they contract should be directly responsible for all noncompliance with the law relating to passenger ships, and that evidence that the requirements of the Act have been complied with should be producible at the port of arrival in the Colony. (b.) That in all future shipments it would be desirable that some person appointed by the Agent-General should exercise a general supervision over the arrangements made for the carriage of the passengers and as to the due compliance with the law, before the day for the formal inspection arrives. (c.) That the appointment of the surgeon should be subject to the approval of some competent authority on behalf of the Government, and that he should be made personally acquainted with the emigrants for some days previous to embarkation. (d.) That an inspection of all the emigrants should be made ashore, prior to that required at the port of clearance. (c.) That cargo should not be carried 'tween decks, and that a ship chartered for the carriage of emigrants should carry no other class of passengers, so that efficient discipline may be maintained. (/.) That emigrants of different nationalties should be conveyed in separate ships, if possible, inasmuch as where this is not the case, great difficulty will always be experienced in maintaining the necessary discipline and control. (g.) That in order to accomplish these objects, it is desirable that the emigration should be conducted in as large shipments as the circumstances of the Colony will permit, and that the employment of ships carrying a small number of immigrants should be avoided. James Hector. Walter S. Reid. A. Eollett Halcombe. Wellington, 10th May, 1872.

G.—No. 3.

APPENDIX.

EVIDENCE TAKEN ON INQUIRY; WITH COPIES EOR EXTRACTS FROM THE PRINCIPAL DOCUMENTS REFERRED TO.

"Wednesday, 17th Apeii, 1872. Geoege Heney. Haeeisgtox, being duly sworn, saith as follows :— I have made two voyages in the ship " England "to this port, as commander. On my arrival in England last voyage I remained seven weeks, and then returned to New Zealand. Time occupied in discharging cargo was three weeks. I commenced to re-load outward cargo about 20th November, fifth week after arrival, so that the ship was empty for a fortnight, one week of which she was in dry'dock. Ship was thoroughly repaired, scraped, varnished, and painted throughout before commencing to take ia cargo. The bilge of the ship was found in good order. Nothing unusual in the state of the ship, in my opinion, at this time. On the last week of November I commenced taking in cargo, but the bulk of the cargo did not come in until 2nd December, or within seven days of sailing. Loading is done by a stevedore, under directions from me. Shaw, Saville, and Co. are charterers of my vessel, and chartered the whole ship, having full power to put any sort of merchandise and any number of'passengers they liked on board. The number of passengers was received by me about the end of November, in order to give time to the charterers' carpenters to provide berths. I was aware I was to have emigrants when I was chartered, and took steps to have the ship surveyed, and it was surveyed while in dry dock. Subsequently, about the end of November, after the number of emigrants had been communicated by the agents, the passenger accommodation was measured off by the Government Surveyors, and inspected by them after they were built—that is, the berths and hospital, and all other accommodation. Emigrants arrived on board on Monday, 4th December; the ship sailed on the following Thursday. Soon after I was chartered, I was informed that I must be ready to receive emigrants on 4th December.^ My ship, so far as under my control, was ready on the 4th, but I should have wished it to have been in a more advanced state on that date; I mean with respect to the receipt of cargo and putting up of the fittings, which were behind hand. On this date, fully half the cargo had not been received ; the principal fittings were put uo- but not completed ; the joiners were not out of the ship when we left the Dock on Thursday, nor was the ventilation completed. 1 employed men at my own expense to put the fittings in order, and paid their passage from Gravesend" where the fittings were inspected. The official inspection was made about 3 o'clock, on Thursday afternoon, at Gravesend. The name of the surveyor is Captain Westbrook ; he was one of the surveyors who had inspected the ship in dock. Government Medical Officer accompanied the Surveyor, as also Dr. Eeatherston, whom I however did not see. The inspection took place in my absence, while I was clearing ship in London, at the request of the charterers. The provisions and water were examined and sampled on the clock quay, before bringing on board. I was not present, but my chief mate was. I first saw the emigrants on Monday before we sailed, on board my ship; they lived on board between decks from that time. Cold north-cast winds, frost, and snow, prevailed during this time. I thought the emigrants miserable in appearance, which I attributed to their having recently come off a sea voyage. The emigrants were not well clothed, but did not look sickly, but just as if they had come off a hard voyage. They hud full permission to go about, and I met them on different occasions outside the Docks. The above remarks only apply to the foreign emigrants. The inspecting medical officer informed me that his inspection was satisfactory, and did not inform me of any sickness on board, but recommended me to bo careful on account of'the large number of children on board. The spaces were ample, according to the Passenger Act. The ship was in good sea-going order on leaving Gravesend, and there was nothing to incommode the passengers during the first part of the voyage. I believe, to the best of my recollection, the first case of sickness, excepting coughs and colds, was a case of measles, one of the foreigners' children; one of the Scotch women was the party who informed me of this (Mrs. McDonald). I saw the child, and there was a slight eruption, appearing to me as if it were measles ; the child was about twelve months old, and had only a slight attack, and recovered in a few days. [The official log of ship "England," marked A, produced,"and identified by Captain Harrington] This log has been kept by the chief officer of the ship, but signed from time to time by me—that is, all entries requiring my signature. The list of the crew contained in the log is correct" and the name of the surgeon who signs the articles is also correct. It is the duty of the surgeon to report to me any casesof sickness occurring on board ; no report was made by him to me of the case of sickness already mentioned. Ido not think the parents had reported the illness of their child to the doctor. The surgeon seemed to be out of health, on account of sea-sickness as I suppose, for over a fortnight. Two or three days after we left, I went down between decks and found the place was not kept properly clean by the emigrants, who should have done so under direction of the doctor. I represented to the doctor that the place was not kept clean, and he said they refused to do it. lat once took steps to have the 'tween decks cleaned, and I informed the doctor that I and my chief officer would afterwards attend to all sanitary arrangements during the voyage, and that he should only attend to the medical wants of the emigrants, as I considered he was inexperienced. The doctor agreed to be thus relieved. I consider the doctor was thus relieved from any attendance as to sanitary arrangements. I. consider 4

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14

REPORT OE COMMISSIONERS UPON MATTERS

that experienced doctors take great care during the first fortnight of the voyage, and that they arrange their duties according to experience. There is generally a fear of measles in outward-going ships. There was no reason for my relieving the doctor, except his inexperience of his duties, and his sickness. Complaints were made to me by the passengers, about a fortnight after we left, on. account of the negligence of the doctor; this complaint was made verbally to me by the interpreter on behalf of the foreign emigrants. The Scotch emigrants complained to me direct. I spoke to the doctor, and accompanied him on his visits, and I found a good many sick suffering from bronchitis and dysentery. I had not previously been aware of sickness, with the exception of colds. The doctor was aware of the sickness on board. I frequently accompanied the doctor after this, and I considered he did not understand how to treat them, having forgotten apparently the medicine or treatment of the previous day, and forgot those people he had treated, and did not even know their sexes on several occasions. I found the doctor was subject to epileptic fits; he told me so himself. Three weeks after we left, the Scotch passengers complained of the doctor, that their children were sick, and that the doctor refused to attend to them ; they also spoke disparagingly of the doctor, as to his capabilities. The first death occurred on the 28th, after complaints were made as to the doctor. Carl Neilson, the. child who died on this date, was supposed to be suffering from sea-sickness, and the parents therefore did not call upon the doctor. The neglect on the part of the people could not have occurred were they property inspected by the doctor. The child died from diarrhoea. I pointed out to the doctor that the disease of measles was spreading, and used every endeavour to prevent its spread. This was before the first case of death. I urged upon the doctor the necessity of his paying better attention to the people on account of the spread of the disease, but he did not do so, and did not seem to share my anxiety. I found the passengers after the death occurred obey my orders as to cleanliness strictly. Maria Olson was in a berth near the ship's side, but after her falling sick I removed her under the main hatch. I had previously removed the stores from the main hatch into the hospital, tho hospital being on the lower deck, and not properly ventilated. I think the rough sketch of the ship (marked B) now shown to me, is a correct one, and shows the position of the hospital. The ventilation I never thought sufficient, and therefore increased it by opening the whole of the main hatch ; a very small portion, about two feet square, in one corner, having been passed as sufficient by the Inspector in London, against my objections urged at the time. Ido not consider she would have been so safe in the hospital as in the place where I removed her. I took all precautions to prevent the spread of the disease on my own account, without consulting the doctor, and the doctor acquiesced. On Monday, 15th January, the passengers came aft (the whole of the emigrants), and wished to see me, and made complaint to me of the conduct of the doctor, as they and their children were suffering, and he refused to attend on them, and also stated that they would not have his services again, and mentioned several instances of neglect. I called the doctor, and the cabin passengers were present on the occasion. I explained to the emigrants that Dr. Leigh was a qualified surgeon, and, being appointed surgeon of the ship, they would run a great risk by declining his services, and I could not attend to them. They declared if left in his hands the half of them would die, and they would be thankful for anything I could do for them. I wanted them to put their complaints in writing. The documents marked C and D, and Dl, are those received by me at that time. Document marked E, I received after my arrival in Wellington, but it was made at the time and reduced to writing after arrival in Wellington. After this I attended on the sick myself, and obtained the assistance of one of the cabin passengers, Mr. Badland. Erom time to time I requested the doctor to make up medicines from the chest. I had the key and also supplied medicines myself. I had to insist on the doctor assisting me with the medicines. I did not consider the doctor relieved from his duties by the action taken by the passengers. I appointed my cabin cook to prepare food for the sick, and after my taking charge of them they had no food cooked at the emigrants' galley. The medical comforts, under the extraordinary consumption, although on the proper scale, were done before we were half-way on the voyage. The medical comforts were under my control, and all requisitions for them were at once complied with. I supplied my own private stores to the sick, and set them apart entirely for their use. On no occasion were the emigrants in want of an ample supply of necessaries during the whole voyage. AYe gave tip nearly all our cabin extras for their use, and I attended twice every day at the galley to see as to their food. During the latter part of the voyage, about the 10th of February, I was ill for about ten days, and had no personal knowledge of what was taking place amongst the immigrants ; but I believe the doctor attended during my illness to his duties, and saw to the emigrants. There was much sickness at that time affecting the crew as well as emigrants, principally the infectious disease, also dysentery and diarrhoea among the children. After my recovery I visited the lower deck and found two of the emigrants very ill, and feared they were dying. I asked the interpreter what had been done for them during my illness, and he informed me the doctor had only given one of them a gargle, and this was all he had done, I went on deck and spoke rather hotly to the doctor, and told him it was cruel on his part to undertake to look after them and not to do it. One of these men died within a few days afterwards. I did all I could for them. It is the man who died on March 3rd I refer to. On my recovery I again took charge of the emigrants. After the 15th January I entirely attended on the sick with the exception of the period of my illness, and all the duties of the doctor consisted only of making up such medicines as I required. During this period the doctor attended only on my crew, not on the passengers. He used, I believe, to visit the lower deck when he liked, but lam not aware of his having attended any of the emigrants, except Wellington and his wife. Mrs. Burness broke her arm during the voyage ; it was at the time I was ill, but I was able to be about in the cabin, and came out purposely on this account, and provided the doctor with splints, there being none among the medical stores. The doctor set her arm. I was informed that the arm had afterwards been rebroken and reset by the doctor. I went and saw the woman eight days after the accident, and inspected the arm. I found it swollen and not united. I reset the arm, and informed the doctor that I had done so. When I reset the arm I was assisted by the carpenter. [The witness described the mode in which he reset the arm, by placing the palm of his hand fiat on the table with the arm to the side, showing the manner by which the forearm was strapped down to a board, the hand being pronate.]

G.—No. 3,

CONNECTED WITH THE SHIP "ENGLAND."

15

I found it in that position, attached between two splints confined by three bandages, the upper ones being slack. The bandages were all below the elbow-joint. It was at the request of Mrs. Burness I attended her. I consider that the surgeon has been out of health during the whole voyage, but, in addition, has at certain times shown an amount of irritability which quite unfitted him for his situation, and he admitted to me that he was subject to such irritability. I made myself acquainted with ail tho cases of sickness on board. I have seen measles but never small-pox, only its effects. Maria Olson was the first case I observed, as also McDonald's child; the child had it very slightly. In the case of Maria Olson eruption appeared on her face, and her head was very much swollen ; she was ill about fifteen days before she died. The eruption was, before her death, still there, her arms and fingers much swollen, her eyes running with water, and she appeared to have died from choking in the throat. The features were so much swollen as to be undistinguishablo. The eruption was in distinct spots, the skin showing white between them. A man named Nielson, subsequent to the death of Maria Olson, was attacked with similar symptoms, but got well. He was suffering from headache ;no eruption. Gave him opening medicine. Three or four days after saw spots on his face. The spots were raised and red. His face was not swollen. A little running at the eyes. The spots came to a head in eight to ten days, and dried away. He was marked with the disease. Mrs. Olson's child was the next case ; it had exactly the same complaint as the mother; it was six months old, and died in eight or ten days. The child died in the midst of the disease. Mina was thenext case. She was in the cabin along with 'the single girls, in the forepart of the saloon next my cabin. I removed her companions to the long-boat which I housed over for their use, and they remained therefor three weeks, until after her death. I did this, as I was impressed with the belief that the disease was infectious. I observed the progress of the eruption in her case, and thinking it measles, expected it would turn on the fourth day, and afterwards remarking that it must have been the same disease Maria Olson had. It was about the tenth day I noticed the change. By change I mean when the eruption began to dry up. We gave her wine ; the eruption dried up, and she appeared to'be getting well, when she was attacked with chest complaint, and I attribute this to the change of weather, owing to the ship changing her course southward, but she had been suffering from chest complaint before she embarked. My niece's case (Miss Tee) was of the same character. She was taken ill on 3rd February, the day after Mina was buried. The eruption appeared on or about the fourth day, and came to a head in about ten or twelve days. Her head was very much swollen, as were also her hands ; a little water in the eyes, but not so much as in some of the other cases. After that time she gradually got well, and her appetite returned. In my own case, I first had a violent headache and giddiness which lasted for a week, and lightheadedness, followed by weakness, from which I have gradually recovered, with the exception of a spasmodic cough. Miss Tee had been vaccinated, but there is no mark left. Spring's case was similar, the symptoms being of the same order, except that he slept heavily for about forty-eight hours at the commencement of his attack. He recovered, and is marked very much as if from small-pox. In no case on board did I see any confluent pocks ; they were always separate. Spring, told me that he had used soap and hot water in order to remove the scab before it was ready, to which I attribute his being marked. I should think he was laid up about three weeks. The two men whom I saw below, Neilsen and Larsen, had the same disease of the same character. Eour or five of the crew, three of whom were in the same berth as Spring, had the same disease, but of a milder form ; they had small pointed spots with white heads ; they were confined to bed about fourteen days ; they also had all the symptoms of the other cases, such as headache and lassitude. It commenced inmost of the cases, both severe and mild, as if it was a cold. Two of the Norwegian girls, after leaving the longboat, had the same small eruption, which lasted a few days and cleared away without leaving any spots. The first time I ever suspected that it was anything but measles of a malignant form, as stated by the doctor, was after arriving at the quarantine ground. I had never read or looked up as to small-pox in my medical books, because I was satisfied with the doctor's opinion. About a day before we arrived, Dr. Leigh asked me for one of my books, and mentioned that he was now reading up in order to determine what sort of disease we had on board. In my treatment of the cases I always referred to them in my books, supposing them to be measles. I could not reconcile the symptoms with those of measles, but it never occurred to me that it was small-pox. I treated some of the cases homoeopathically, as I have been a homceopathist for the last seventeen years, but I also treated other cases otherwise, when required to do so by the parties. I believe from what I have since learned, and the idea being suggested to my mind, that the cases of Spring, Neilsen, Larsen, Olson, and the child of Olson, approached small-pox more than anything else. In the case of Miss Tee, lam doubtful as to whether it was small-pox or otherwise. During the whole voyage any of the emigrants or passengers could have the doctor's services, as he was always ready, and I would not have objected. The interpreter was one of my crew, and signed the articles. He was appointed by Shaw Saville and Co., as interpreter under the Passengers Act. I was satisfied with his conduct during the voyage. He not only performed his duties as interpreter, but was chief nurse on the lower deck, and his conduct was extremely satisfactory to me in all ways. I produce list of medical comforts, marked E ; also charter party, marked G. The captain's copy, called the Master's Passenger List, required by 16th section of Passengers Act, is in the hands of Messrs. Turnbull. The charter party is only a copy; the original is not in my possession, having been left in England. I cannot produce my certificate of clearance, as I did not get one ; but it is most likely the charterers, Shaw, Saville, and Company, have it. I have often shipped passengers under Passenger Act, but have never received such certificate. I entered into no bond as required by tho 63rd section, nor was I asked to do so —nor have I entered into such bonds on previous occasions. Till within three days of the embarkation of the emigrants, Shaw, Saville, and Co. told me there was a difficulty in getting a doctor. "When they did engage a doctor, in reply to my inquiry as to what kind of man he was, I was told by Mr. Sutherland, the manager of their passenger department, that the person engaged "was all right, but that he had a 'tile' off." These are his exact words. I

Examination continued, 18th April.

Further examination on 25th April.

G.—No. 3.

REPORT OE COMMISSIONERS UPON MATTERS

16

remonstrated, and said that I had great difficulty with the doctor found for me by Shaw Saville and Co. last voyage. Mr. Sutherland replied, " Oh, he (meaning Dr. Leigh) is all right; he's got his papers —that's enough for us." From my subsequent acquaintance and knowledge of Dr. Leigh, I do not think that Mr. Sutherland was warranted in making the remark he did containing the inuendo against Dr. Leigh's sanity. I only mention the subject in order to show the loose way in which these engagements are made. I know theprovisions of the existing Passengers' Acts, and have carried thousand of immigrants to various Colonies, more especially to Sydney and Melbourne. In this voyage, the way in which I was chartered by Messrs. Shaw, Saville, and Co., in my opinion, prevents the provisions of these Acts being given effect to as far as lam concerned. The system is defective, because the charterers undertake work for which I am responsible, but over which, by the terms of my charter-party (produced, marked G), I have no control, as by that document I authorize Shaw, Saville, and Co. on my behalf, to sign any tender for carrying immigrants, while the Act leaves the responsibility of complying with its provisions on the master. That is my interpretation of the charter-party referred to. 1 consider that this defective system has led to mischievous results on the occasion of my last voyage. To this cause I impute the defective ventilation of the ship, defective fittings, especially the water-closets, and the imperfect hospital arrangements. In all previous cases where I have carried immigrants other than with Shaw, Saville, and Co., I have had the hospital in a deck-house or poop, where we could isolate the cases. In all these instance, had the arrangements for this last voyage been under my control, I would have made better provision. Before the loading of the " England " was completed, I repeatedly remarked on the defective arrangements referred to, to the charterers or their managers or clerks. With respect to the ship's stores, I had no opportunity of seeing the stores shipped for the immigrants, nor had I a voice in the matter. I am not aware whether they were inspected under the Passenger Acts by the Government Inspector or other officials. If they were, neither I nor my officers were cognizant of it. In my previous evidence, my statement that the provisions and water for the immigrants had been examined, referred to the fact that one of the firm of Shaw Saville and Co. informed me that they had passed the stores. On the Friday before the Sunday on which the immigrants were expected to arrive, I applied to Mr. Sutherland (Shaw, Saville, and Co.'s manager) to have lodgings taken for them ; and they refused on account of the cost, which he told me would be £13 a clay, adding that I must do the best I could. He told me he had consulted the firm, and they refused to accede to it. The immigrants arrived on Monday, at which time the ship was quite unprepared to receive them, and they had no other place to go but the ship. I am not aware that the emigrants had to sleep in the dock-shed. I was on board all Monday night taking in cargo, pushing on the taking in of the cargo until 3 o'clock on Tuesday morning. I know that the emigrants passed the night on board, although they could not sleep much on account of the noise made in getting in cargo. It was very cold, snowing and freezing. I had some sails hung up to try and keep the draughts off the women and children, who were lying exposed to the weather, the hatches being open, and the snow drifting on to the bunks near the hatches in the squalls. In consequence of this, I waited on Messrs. Shaw, Saville, and Co. the following morning, and represented very forcibly the sufferings of these people ; I said I would not serve live stock so. I saw Mr. Temple, one of the partner's, and he told me to do what I could for the people, and they would bear the expense. I got stoves and charcoal, and tried to dry the lower decks up, as I had heard much coughing, among the children especially. All Tuesday night I was taking in car g 0 —the hatches were open and the weather still bad —very cold. The hatches were not open by my order; the order for working at night was given by Shaw Saville and Co. In my previous evidence, in referring to the loading being under my direction, I only mean the disposition of the particular packages — not the time at which the loading was carried on. That is the meaning of the clause in the charter party referring to the employment of the stevedore. During the period between the arrival of the immigrants, and the departure of the ship, great confusion prevailed on board on account of the taking in the cargo, so that food could not be regularly supplied to the emigrants, and they had no water-closets for a portion of this period. Shaw, Saville, and Co. sent a man down to cook their food, and he did the best he could under the circumstances. I have never on any other occasion taken emigrants on board till the cargo was wholly taken on board, the lower decks cleared and dried, and every thing in order, so that they can at once take up their berths and form into messes. On this occasion this could not be done till they arrived at Gravesend. Ido not consider that the dietary scale provided by the charterers for my late voyage was sufficient, especially as it affects the women and the children. I produce a copy of this dietary seale —there being no flour prescribed in that scale for making bread, and only 4 oz. of butter being allowed for an adult, and 2 oz. for children under twelve years of age. I did not adhere to this dietary scale, but altered it as I thought fit. The people did not suffer in consequence of this defective dietary scale, as I always remedied it when complaints were made to me, and supplemented it from my own private stores. The list of medical comforts (marked F), I consider quite insufficient for the number of people I had on board, over 100. I consider it a mere form in compliance with the Act. lam not aware whether there was any inspection by a medical officer of these medical comforts before the ship left. This might have been done without my knowing it, but I have never known it to be omitted on previous occasions when I have carried immigrants. I have not obtained a clearance of the ship under the 11th section of "The Passengers Act, 1855." I believe Shaw, Saville, and Co. have it. I have no doubt they have it. The certificate of the medical officer (if there is one) as to the inspection of the medical comforts, &c, will be included in the certificate of clearance. I signed two lists of passengers at Shaw, Saville, and Co.'s office, to enable them to clear at the Customs, but I cannot say whether these were lists of passengers as required by the Passenger Acts. I brought out a list of passengers, which I have handed to Messrs. Turnbull, my agents here. In that list there are no entries of deaths which occurred on board. I trusted to the official log, where they are recorded, and from which I could make out a list of deaths after arrival. The chief mate kept that log ; all the entries there were made by him (except certain entries of deaths made by the doctor), and signed by me when necessary. There was a marriage took place on board the evening of the day before we arrived, about 9 o'clock in the evening, and the log was handed over to the Health

CONNECTED WITH THE SHIP "ENGLAND."

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G—No. 3,

Officers before an entry could be made of the circumstance. I know the provisions of the Merchant Shipping Acts respecting entry of any illness of the crew in the official log. These should have been entered by the mate, whose duly it was to do it. The reason why these entries were not more closely looked after by me was, that I had my hands full in consequence of the unusual amount of sickness, and the anxiety consequent thereon, and I was unable for the greater part of the voyage to keep up my own private journal. When I was laid up, the chief mate had a double duty to perform. The entries made have not all been signed by me ; they ought to have been, but, for the reasons given above, I did not attend to the entries made in the log. I left it entirely to the mate. I was looking after the active duty of the ship—attending to the sick, and navigating the ship. Soon after leaving the longitude of the "Capo, nearly half the crew were disabled by sickness, and I had to put the emigrants into watches. At that time the nearest place to make for was Wellington, our destination, and I did not consider the sickness of the passengers at an earlier period so important as to cause me to deviate from my voyage. We were in the longitude of the Cape about the beginning of February. At the time when I was ill myself, I gave general directions to the chief officer what to do in case of my death, which were to keep the ship before the wind, and make for Wellington. Owing to the sickness of crew and immigrants, I could sometimes only muster five or six hands in a watch —I mean of the immigrants ; and I have been reduced to two seamen in a watch, besides the man at the wheel. I have had to carry sail at a great risk during some portion of the time when I was down south, because I had not hands to take it in. The dietary scale to which I have referred as having been, furnished to me on this voyage, is in every respect inferior to tho dietary scales issued for emigrants to Yietoria and New South Wales—l mean both as to quantity and quality. The difference in the cost of maintenance is £2 to £2 10s. more per head than the cost of those which I brought out in the "England." The cost of the latter per head, including fittings, medical comforts, and provisions, I estimate at £6—l mean for each statute adult. The sum of £1,600, mentioned in my charter party as paid to me by the charterers, represents about four-sevenths of the net receipts for freight and passage money received by the charterers. In the eases of the Colonies of Victoria and New South Wales, there are no middlemen. The agents for these Colonies charter the emigrant ships, and obtain the ships by public tender, so that the Agent of the Colony deals directly with the owners of the ship. I consider that this course obviates many of the difficulties in giving practical effect to the Passengers Act which 1 have experienced this last voyage. Emigrants to Victoria and New South Wales are always received into depots, either at Birkenhead for Liverpool ships, or Southampton or Plymouth for Loudon ships, where they are kept at least a week in the depots. These depots are specially fitted for the reception of emigrants, there being a master and matron specially appointed to take "charge of them. They are medically inspected there before embarkation ; the inspection is a thorough one ; the doctor who is to go out with them resides with them for two or three days before departure, and they are then finally inspected on board before leaving. This last inspection "is made by the Imperial Emigration authorities, and is a mere formal one, to which I attach no importance. The surgeons employed are continuously engaged, and are termed " Surgeon-Superintendents." They are paid by the number that they land alive, and receive an increase of Is. per soul (including children) for each voyage they have made. They commence at 14s. a soul, and rise to 215., and they also receive sixty guineas for their return passage to England; and they are only employed again on the production of satisfactory certificates from the Immigration authorities at the port of discharge as to the manner in which the Immigrants were landed. The payment is called a " gratuity," so that the payment is completely in the discretion of the Immigration authorities. I speak from my own personal knowledge as to the mode adopted in conveying immigrants to the Colonies referred to, and as to the mode of their treatment and the medical provision made for them. I know several medical men who are regularly employed in this duty, who have made several voyages, and are now employed in it; I mean extending over"a period of several years. I have been told by some of them that they make as much as £600 or £700 a year, and I. do not consider they are at all over paid ; they are very attentive, incessant in discharging their duty. Under the system adopted by the Colonies referred to, the mortality in emigrant ships has been reduced to a merely nominal rate. I have never known the mortality to exceed 1 to 2 per cent., and have known it as low as -} per cent. I have carried to Victoria 450 souls with one death, and the like number on another occasion with three; and these were carried under the system I have referred to. I have never known the mortality at all equal to what it was this last voyage, we having lost nearly 20 per cent, by deaths. Ido not think such a mortality could have occurred under the system I refer to, as disease would have made itself known before departure by means of the more perfect arrangements for medical inspection. The ships employed by the Colonies of Victoria and New South Wales are exclusively devoted to immigrants. Cabin "passengers and second-class or intermediate passengers are not carried. By having only one class of passengers, facilities are given for preserving discipline which cannot exist in a mixed passenger ship. I do not think there should be cargo carried between decks, because it impedes the ventilation, and to obviate this the emigrants should be taken in greater numbers in one ship. In the " England " this last voyage, the passengers were shut up as if in wells, and there could be no thorough current of air, the cargo intervening. In all cases the dead weight in the lower hold of emigrant ships should be limited. It was the neglect of this which led to the rolling of the "England," and endangered the safety of the ship and people. James Badland, being sworn, saith as follows; — I was cabin passenger on board the " England," and joined the ship on Thursday, 7th December, at the Docks. I had every opportunity throughout the voyage of seeing what transpired, so far as a cabin passenger could do. I have to explain that I objected to the accommodation on board ship, on account 5

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REPORT OE COMMISSIONERS UPON MATTERS

of a part of the saloon being occupied by emigrants. I perceived a great amount of confusion on board and did not consider the ship in a fit state to receive emigrants. All I have had to complain of was put to rights shortly after the vessel, sailed. I did not consider the foreign emigrants in a good state of health, especially the children, —as if they had not received proper nourishment. They are greatly improved now. On 28th December, by reference to my diary, I first became aware of sickness, at the time of a child, dying, when I found measles on board. I never during the voyage heard it supposed to be small-pox, nor till the Board of Health came alongside. Never heard the captain consult the doctor as to the disease. It was a common subject of discussion on board, in which I joined, as to the nature of the disease, on account of its very serious symptoms. I have no doubt, if it had been known to be smallpox, much greater precautions would have been taken by the captain and others. In assisting the captain in attending the sick, I for some weeks, from about the middle of January, had frequent Opportunity of knowing the state of the 'tween decks. As regards dryness and cleanness, I believed the ship in a good state, but the emigrants themselves very dirty—a very unpleasant smell, so bad that I do not wish to meet the same again—it often reached the poop-cabin, and was so bad that I was obliged to go on deck. Ido not know what the smell came from, and it continued during the whole voyage, more or less. The light of the 'tween decks I consider quite sufficient. The ventilation was as sufficient as possible —as circumstances permitted of; my visit was after the opening of the main hatch by the captain. I observed the place called the hospital; it was never used to my knowledge, and quite unfit for such a purpose, on account of being deficient in light and ventilation, through being surrounded by cargo. I recognize rough sketch marked B as a correct plan of 'tween decks, where emigrants were lodged. I was present when the emigrants had a conversation with the captain as to the conduct of the doctor; there were three or four spokesmen, among whom were Brand, McDonald, Burness, and the interpreter Swanson for the foreign emigrants. They said they would not allow the doctor to come 'tween decks any more, on account of his neglect of them generally. They made specific charges, but I clo not remember what they were. I considered the surgeon neglectful of his duties, but attributed this to his ill health and mental incapacity at the time. I have frequently seen him in epileptic fits, and they leave him weak and enervated. I have never observed the doctor otherwise than perfectly sober, and my opinion is that any neglect on his part, was owing to his state of health. The conduct of the captain and officers I consider to have been very good, and they did everything they possibly could under the circumstances to alleviate them. I believe from some communication of the foreign emigrants themselves, that the disease was a common one in their own country. The children were, I should fancy, (some of them,) scorbutic and subject to boils. The spread of the disease created a great amount of alarm. I have heard what Captain Harrington has said as to the symptoms of the disease, and I concur in his description in every respect of its various forms, but would be inclined to describe the pustules, in the mild cases that came under my immediate notice, as being larger and containing more fluid matter than what I inferred from Captain Harrington's description.

Thtjesday, 18th April, 1872. Geoege McDonald, being sworn, saith as follows : — I with my wife and child were passengers by the ship " England," and joined at the East India Docks. I was a steerage passenger. I was accompanied on the voyage by my brother-in-law Burness, wife and four children. They came from Aberdeen ; I met them in London. I arrived in London four days before the vessel sailed. There had been no sickness in that part of Edinburgh where I resided previous to my leaving. Went on board, but had to leave during the first night on account of cold through the main hatch being open. Mr. Burness's family and mine were in perfect health when we went on board. We remained on shore until the vessel sailed. I am not aware of any sickness where we lodged in London. When we rejoined tho ship before sailing, she was in better order. Self, wife, and child had one bunk allotted to us, which we occupied until my wife was confined, when the bunk above, until then occupied by John Wellington and wife, was removed, and they were put into another bunk which_ had, until then, been filled with our provisions. Plan of the ship laid before me, marked " B," correctly shows the accommodation between decks, and arrangements. Position of hospital is correct. I first saw the foreign emigrants on the Monday before ship sailed ; they appeared very dirty; there was hooping cough among them. About two or three days after we sailed, I saw one of the foreign emigrants with his face covered with scab. I do not know his name, but he occupied one of the bunks immediately on the port side of the main hatch. He used to lie in his bunk, from which I judged he was sick. These scabs were the subject of remark among others. I remember the storekeeper remarking them. I remember the vessel being inspected at Gravesend. I was called with the other passengers on deck. We walked past several persons on deck, but they asked me no questions. I understood at the time the persons I refer to were the Government Inspectors. I heard them ask the Burnesses and several others if they were well. I also saw the same gentlemen below examining tho deck. At the time, it was generally remarked in my hearing that there was a man below who was not inspected with us. It was said he was tried to be put up for inspection by the sailors. The 'tween decks was generally very damp throughout the voyage. There was a bad smell which might have been from the passengers. Tuesdays and Fridays were the scrubbing days; this was seen to by the first mate. Deck was scraped and swept every morning so far as I recollect. The slops were always removed morning and evening, and more frequently when children were sick. I overheard, when at Gravesend, from the Scandinavians that there was "measley " and " kinkhost " on board. I feel sure they w rere talking about these complaints, but did not know if measles were actually on board, but was certain as to hooping-cough, as we could hear it. I saw Dr. Leigh, who is now present, on board before the ship sailed. I do not recollect his visiting the passengers. Ido not remember seeing him 'tween decks before inspection took place at

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Gravesend. I cannot say if he was present at the inspection. During the first part of the voyage we were always about the deck; it was fine weather at this time. The doctor used to come down in the morning ;he came as far as the top bunk, and called upon them to got up. He came to the top bunk of each division. I mean the bunk nearest midships as the top bunk. His inspection did not take many minutes generally. I have seen him go round with the interpreter and also without him. I never saw the doctor personally inspect each bunk during first part of voyage. I was much engaged in nursing my brother-in-law's children and my own, and was constantly 'tween decks. The children began to get sick within a fortnight after we sailed. We called in the doctor in the case of my own child, when it fell sick ;he thought it was teething on examination, and lanced his gums. I thought he was not attentive to my sick child. An eruption was out on the child's face when he lanced the gums ; it afterwards proved to be measles. The doctor stated it was measles. The doctor directed the treatment of the child, but wo did not follow his directions ; he gave us medicine, but the child did not get it all. My wife and I had not confidence in the doctor. My reason, or one of my reasons for want of confidence in the doctor was, that one of the foreign children had a pimply rash, and my child had a rash and no pimples, and he called them both measles. I have seen the child in question within a few feet of me; the rash consisted of raised pimples, containing matter ; the face was covered with this rash. It was a young child, and afterwards died, but not from that disease. So far as I know, it might have been from the effects of it. My child got over the worst of the measles in three days, but afterwards had diarrhoea and then hooping-cough, so that it was ill more or less during the voyage. It was in splendid health when it came on board. Ido not recollect of the doctor seeing it when it had diarrhoea, but did when it had hooping-cough, for which he said he could do nothing. The doctor did not attend my w 7ife during her confinement. She was taken ill on the 6th February. I had previously on the 15th January, written the letter marked D, declining to have the doctor's services. I was aware that the doctor knew of my having done so, because he asked me to withdraw it, as otherwise he would not attend me or my family. Three or four days after her confinement he came to see her. She was then delirious, and with an eruption out on her face ; her features were disfigured, and head swollen ; eruption was also more or less on her body. The doctor was attentive at that time, and until she recovered, and I had no fault to find with him; the treatment was chiefly nourishing. He ordered her eyes to be washed, and gave her a gargle. She also got nourishing food, which I got from the captain. My baby died a week afterwards ; I think it was a premature birth. Ido not think the doctor ever saw the baby. I saw all the sickness that was 'tween decks. I saw no measles before the case of my own child, but there might have been. After that I saw at least one of Burness's children and Ralph Douglas with the same kind of measles as my child had. My child was vaccinated when he was six months old. My wife had been vaccinated ; the marks are quite plain on her arm. Two or three days after my wife was attacked, Mrs. Wellington was attacked with a similar complaint, but milder, —that is to say, that her features were not so much distorted, and the spots were as large, but fewer ; they had matter in them. The doctor attended her. She was confined to her bunk for upwards of a week, but was better before my wife. I did not think it was measles that my wife or Mrs. Wellington had from the first. I considered the disease my wife had was the same as the foreign child had ; the pimples were of the same kind. The doctor told me it was foreign measles. I have seen small-pox (several cases). I thought this was small-pox, and stated so to the doctor at the time ; he said that it was just measles getting into a severe form, from one case to the other. Mrs. Burness said to me it was smallpox, and also John McAulay, who had seen small-pox and measles. I mentioned to the captain that I did not think it was measles ; the captain told me that he did not think it was measles either, and that he did not know what it was. Cannot say that small-pox was ever mentioned by me to the captain. There was no person put into hospital 'tween decks during the voyage ; stores were kept there. I did not think it a fit place for an hospital, it being right in the centre of the people. It was not a place I should like to lie in if I was sick. The hospital was fitted up with two bunks. The most of the voyage the hospital was used as a store-room for serving out stores ; it was not full of stores, and they could have been removed at a moment's notice. The medicine chest belonging to the doctor was kept there during the early part of the voyage, so that he had therefore to go there to serve out medicines. I remember Mrs. Burness's arm being set by the doctor on the first occasion; I helped to hold her down. This was some time between the 10th and 14th Februarj^. Mrs. Burness lost four children on the voyage ; a girl aged seven or eight, who died the last; she wasted away. She had had hooping-cough and afterwards diarrhoea. Second, a boy five or six years ; had had measles and afterwards diarrhoea, and gradually wasted away. The third, a boy about four years, did not have measles ;he got a cold the first night, when we had to search for lodgings. I heard the mother of the child call the doctor's attention to the child, whose name was Alexander Tom; he said there was nothing the matter with the child, and ordered it to be put back in its bunk ; within forty-eight hours afterwards the child was dead. No particular symptoms except that it wore away. During the forty-eight hours before its death the parents gave the child wine, which they got from the captain. I saw them pouring it down its throat with a spoon. We also put a mustard poultice to its chest and back. We were not directed to do this by the doctor. The fourth child, a baby seven months old, was never very strong, in my opinion; it was wasted away, and died from exhaustion; it had hooping-cough. The second boy, James Burness, had been a day or two confined to bed when his mother met with her accident, so that he was left along with his sister in his father's charge ; he could not, of course, attend to them as well as a mother could, but he was very attentive to them ; he nursed them in every way, and got food for them from the captain. I had every opportunity of seeing these children, and saw no ill-treatment, but quite the reverse. I heard a rumour to the contrary ; a sailor named Knowles told me of it; he had no opportunity of knowing how the children were treated, and I told him at the time it was a lie. The doctor attended James Burness before he died, from day to day ; he examined him closely, as closely as I did myself. He said it was diarrhoea. The day the child died he made remarks in my hearing, that if the child had been under his care from the time we wrote the letter to the captain on the 15th January, it would not have been in that way. The child was then dead, and he did not know of it; he had seen the child on the previous day. All the Burnesses' children had been vaccinated. During the time I lived on shore, from Monday until Wednesday evening, Mr. Morrison, the Agent for Hawke's Bay,

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20

paid my expenses. The man who had scabs on his face when we went on board recovered. My wife is now slightly pock-marked, as the result of her illness. On the occasion of the visit of Dr. Leigh, forty-eight hours before the death of Alex. Burness, in 8" the captain's presence, the doctor asked Mrs. Burness what she was crying for ; he said " the child, has nothing the matter with it—put the kid into the bunk;" the captain reproved the doctor. Mrs. Burness's infant was at once put in charge of a nurse, by the captain's order, on the occasion of Mrs. Burness breaking her arm. I was asked by Dr. Leigh to allow him to lance my child's gums, and I refused, because the teeth were already through ; he asked me again next morning, and, representing that the child might take fits, I allowed him to do it; the rash had then been out two days on the child. He did not come every day during the first part of the sickness while the eruption was coming out. Additional reasons besides the one stated for my not having confidence in the doctor were, on account of his treatment of Burness's children and my own wife. One day my wife asked him for some castor oil, and he told her there was none on board ship ; this was in the early part of the voyage. I never called on the doctor to attend me or my family during the voyage. Ciiaeles Batt, being sworn, saith as follows: — lam chief officer of the " England." I have a mate's certificate. This is my second voyage in the ship. I rejoined the ship about three days before she left on this voyage. She had about half her cargo in ; the emigrants were on board. I remember an inspection being made of the ship in the East India Docks; inspection was made from time to time while she was being fitted up. I remember Inspectors suggesting alteration in the ventilation of that part of the poop allotted to single girls. I remember an inspection of the ship at Gravesend. I took part in the inspection, in the absence of the captain. Dr. Featherston was one of the inspectors and two others. Cannot say one. was a medical man. They came on board about 3 o'clock. I refer to the ship's log for this and other dates. I have kept this log during the voyage in my own handwriting; the entries are made daily. The survey occupied two hours ; they first inspected the galley, then the fittings for the emigrants 'tween decks, both fore and aft; they suggested no alterations. They then examined the boats, then the passengers. They called each family separately on the poop ; none of them was found to be sick at that time. They had a list, and I saw them mark them off as they were called; no one was omitted from the examination, to my knowledge. If any of the sailors had been sent to get up any one from below I would have known of it. I know Erick'sen, one of the foreign emigrants. I. must have seen him at the beginning of the voyage, but do not recollect anything as to his appearance at that time. He was ill. I believe I saw a rash on him after we got to sea. There may have been a rash on him at the time of inspection, but I did not notice it then. I was very frequently between decks ; the emigrants kept their quarters very dirty at first; this was due to sea-sickness, I believe. I had charge of the sanitary arrangements; the 'tween decks was cleaned every morning — scraping, dry-scrubbing, and washing as often as weather permitted. Chloride of lime was used for disinfecting whenever it was required; it was used three or four times a day after we had disease; this was all done by direction of the master. The same arrangements were carried out in the forward department. Bough sketch of ship produced to me, marked B, is correct. On 27th December two or three cases of measles were reported to me. Made no difference in our arrangements except in the freer use of disinfectants. If small-pox had been reported to me, it would have made a difference in our arrangements. Did not think it anything unusual until I saw one or two deaths. Never saw measles or small-pox before. There was an unpleasant smell 'tween decks, but cannot say where it came from ; did all we could to prevent it. It was not bilge water, it was a close smell. I think there was plenty of ventilation, the main hatch being off so soon as weather permitted. Consider there was sufficient light. The hospital was occupied with stores ;it was a serving-out room. The sick were not put in the hospital; Ido not know the reason why. It would be the doctor's duty to order the sick into hospital. The official log, marked A, I identify as the ship's log. It has been in my charge during the voyage. Events are entered in it as they occur. I remember the married woman that died first. She occupied midship bunk on port side by main hatch. She was the wife of Ericksen, before referred to. After she was taken ill, one of the bunks was taken down, so as to allow her to have more room. I understood she died of measles; I had this from the doctor. I thought it was different from what the children had, but that it was measles of a more virulent form. She was buried at once, her bedding was hove overboard, and the place thoroughly cleaned. Ido not see that, had we known it was small-pox, anything further could have been done in the way of cleaning and disinfecting; but some steps might have been taken to separate the sick from those who were well. At a subsequent date, something was done in separating the girls, who were put in the long-boat. This was done because it was believed the disease was spreading. I never heard it referred to as small-pox by the interpreter or any one else. The first I heard of it being small-pox was after we got into port. It spread among the cabin passengers, and also among the men in the forecabin. It appeared forward about the Bth of February. The sailmaker and the storekeeper were the only ones that had to do with the people who died after: they were both 'ill. Cannot say if the sailmaker had the same complaint; he had no eruption. Parkinson was tho first to have it among the men forward, about a week or ten days before the others. I know no special cause whereby he got the infection. Do not remember any complaints being made to me about the doctor by the passengers ; they would have been made to the master. I remember the complaint made against the doctor, of which I made an entry in the official log marked A. I made my rounds generally about 9 o'clock. The doctor made no stated rounds so far as I know. The existence of sickness was well known to all on board. I speak about the time of the death of Maria Olson. I made one previous voyage with passengers to this port. I think that on this voyage the emigrants had enough space, also'sufficient ventilation, and no overcrowding. On the occasion of the previous voyage, we had more passengers, but fewer children. The fittings and general arrangements were the same. There was no sickness. We had Scandinavians on board. The only death was a case of water on the head. On that voyage, we used the same means for cleaning and disinfecting the ship as on this voyage. We had finer weather this last voyage, which was the shorter passage by twelve or fifteen days. '

By request of Captain Harrinj ton.

At Dr. Leigh's request.

By Commissioners.

CONNECTED WITH THE SHIP "ENGLAND."

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G.—No. 3

Feiday, 19th Apeil, 1872. John Swenson", being sworn, saith as follows; — I came out as a seaman on board the " England." I was engaged by the captain as interpreter, about two days before the ship sailed. I applied to no one but the captain for the situation. I was to receive £5 for interpreting besides seamau's pay. I have not been paid the interpreter's fee yet. I signed articles as a seaman but did not do seaman's work. I was working on board ship before emigrants came. It was not until we came to Gravesend I had much to do with the emigrants. I interpreted at the inspection at Gravesend. Every one was called. There was only one person that asked me anything. He asked me if they were all satisfied—meaning the emigrants. I think it was a doctor who addressed me. Ido not know if Dr. Leigh was present. I did not know him by sight at this time. I knew a man Ericksen; did not know him until his wife became sick. I believe Ericksen was inspected with the rest. I went down below, and visited every bunk, and feel sure no one was left below at the time of inspection; the chief mate was on board,^ and it was he told me to go below. I feel sure the captain was on board when the sailors were examined ; that was shortly after the emigrants were examined. I saw no eruption on Ericksen's face, either then or at any other time. Claus Petersen I remember; he was a married man. I recognize rough sketch B as correct, and point to the position of Petersen's bunk; it was the first midship bunk on the port side of the main hatch. Ericksen's bunk was next to it on the port side. Ido not remember his being inspected, but I did not know the people then. I never observed Petersen until I came to attend Ericksen's sick wife. I did not observe any eruption on his face at that time, or during the voyage. I observed no scabs on any of the faces of the grown-up foreigners, till Ericksen's wife fell sick. I never told any one before Ericksen's wife became sick that there were scabs on any of the foreigners. Dr. Bulmer asked me since I came here if I saw such, and I told him I did not. He asked me if I had seen scab on Petersen's face, and I told him no. There were children sick before Maria Olson fell sick. There was measles among the emigrants before that time. They asked me to speak to the doctor about it; I did so; this was before Maria Olson fell sick. My duty was mess constable for the single women diving the voyage; I also interpreted between the storekeeper and the married foreigners. There was no one else on board who knew their language so as to speak it except myself. I was not the only one who could speak the language. The Swedes, the Danes, and the Norwegians can all converse, the language being very similar. I did all the interpreting. When any of them were sick and wanted the doctor they came to me. I always told the doctor when they wished to see him, so long as he attended them. 1 think that it was "just after Maria Olson died, that they said they did not want his services. I remember Olson falling sick ; I was told of it by her husband. I went to see her. He asked me to tell the doctor to come and see her; the doctor was between decks at the time, and went to see her at once. There were no spots on her person at that time. This was the first time Ericksen asked me to go for the doctor. The doctor told me to tell them that there was not much the matter. Ido not remember if Ericksen ever asked me to go for the doctor again. I heard no complaint of the doctor until Peter Larsen's child fell sick; the child's name was Anthon Busk. This is a different child from Kirsten Larsen ; it was also ill, and died. This child, Kirsten Larsen, was the child of Niels Larsen who died. Peter Neilsen was a different man, and is still alive. When Larsen's child fell sick, the people (the whole of them) told me that they did not want the doctor's services, because there was so long between his visits, and when he did come his visits were very short and hurried. The doctor never went round without me that I know of; the doctor was sick. I think the first day after we left Gravesend he was down, but not after that for eight days, and then for about a month he used to go round about twice a day. He used sometimes to go first to the medicine chest, and then go right round to every bunk ;he did this twice a day at first going off. At the time of Maria Olson falling sick, or shortly" after, he did not visit so regularly as at first. He carried a little book with him. I asked for him what was the matter, and he wrote down in his book ; he used to examine the people ; he did that twice a day to those who were sick. I remember asking the doctor to come at the request of Niels Peter Larsen to see his child Kirsten Larsen ;it was in the forenoon. I think the doctor had.been down that morning. I went to the doctor at once. He said his time to visit the sick was 10 o'clock. I saw the child ; it was spitting blood, and blood coming from its nose. I told this to the doctor, and showed him the matter it had been spitting up. I think he saw the child in the evening, but lam not sure. It was before dinner I spoke to the doctor. At this time I thought the doctor did not visit regularly ; there was sometimes two days, and on only one occasion, three days elapsed between his visits. During these three days no one asked me to go for the doctor ; this was five or six days before Anthon Busk aied 21st January. The doctor sent for me at a quarter to twelve at night. I got up to go round with him ; the captain told me to go back to bed, which I did. I think the complaint was made on the following'day, at the request of the people, for the first time by me. They all went aft in a body to the captain. I wrote the letter produced, marked D. The following is the translation : — " 15th January, 1872.—We all Danish and Norwegians, 'tween-deck passengers in the ship " England " on a voyage from London to "Wellington, have because of the doctor's carelessness against the sick, given up his services; and as we find the captain a good and kind man, we wish him to attend us for the rest of the passage in a medical capacity. —J. P. Petersen, E. T. Larsen, P. Nielsen, K. Ericksen, J. Christianssen, 0. Boesen, H. Larsen, M. Hallberg, Peter Larsen, N. P. Nielsen, O.Monsen, Claus, P. Maii." , . I wrote the letter at the request of the people, and saw them sign it; 1 believe the above is a correct translation. At the time I refer to there was much sickness; I consider they were neglected, especially the children, at that time, by the doctor. I think the complaint was justified. The captain visited 'tween decks, I think, daily. He had not been attending them medically, that I know of, up to that time. I used to go round sometimes with him ;he used to ask how the people were. Ido not remember the captain directing me to make any inquiries as to the doctor from the emigrants. The doctor had been irregular in his attendance for about a fortnight. Maria Olson was sick for about a week or ten days. I remember her being sick distinctly ; I saw her every day, on the occasion of my taking her her food,—l took her no medicine. The next time the doctor saw Maria Olson, after the first 6

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time I called him in, she was in fever ; I think about two days had elapsed. It was after that the eruption came out. I remember the doctor first seeing the eruption ;he said she had the measles. I told the people he said it was measles, and they said they did not believe it; they after her death, but not until a few days before we arrived in Wellington, told me it was something between small-pox and measles. I never told the doctor it was a foreign kind of measles. Ido not remember to have seen any disease of the kind before. I have seen small-pox, but I do not remember it; but so far as Ido remember, it was the same. The doctor gave her something to wash her eyes with ; there was also cold-water cloths put on her head ; they were on her forehead and over her head. The woman who attended her was Mina Bergersdatter; these cloths were kept on from two to three days. It was the two last days before her death these cloths were on. From the first of her sickness until within three days of her death, I consider she was neglected by the doctor. On Maria Olson the eruption was big pimples, some as big as a threepenny-piece, some of them were long and joined one into the other; they were raised, yellow in colour, and with matter in them. At first they were shining; then there was a hole formed in the middle ; then they dried up and the scabs fell off. Ido not remember their being red. Her face was swollen, and the skin came off underneath her eyes, there were patches of bare flesh about an inch across. At the time the cold-water cloths were put on, her face was in the condition I have described ; the doctor saw her face and ordered these cloths. The doctor saw her twice a day during these last two days. On the afternoon before she died, he ordered a hot-water cloth to be applied to her side ; it was because she had stitches in her side. I did not understand it was infectious. The doctor warned me not to come to her breath. He also told me to warn Mina not to come over her breath ; Mina was at the time living in the young women's department, and was back and forward every day from the young women's compartment to 'tween decks. She was not warned by me, nor was I told to warn her against this. I was not warned against going amongst the others. I went all over the ship at this time. My duty took me to the single women's department also to single men's department. I slept in the forecastle. The bunk, and about where Maria Olson lay, was disinfected with carbolic acid and powder; the captain or the mate told me to do this. The doctor did not tell me ; I believe the captain had charge of the cleaning. I have seen the doctor touch her ; he looked at her throat and held her mouth open. I think he always went up stairs immediately after. Ido not remember the doctor ever asking about the disinfecting. Maria Olson had a child ;it was with her until a few days of her illness, when Mina took it from her. The eruption was out before the child was taken from her ; the child was suckling. The child afterwards died of the same complaint as the mother ; I saw it before its death, the eruption was of rather smaller spots, with yellow heads. I think it was early in January. I was called out in the night as soon as Olson was dead. Mina was there, and some other foreigners. She was sewn up in the morning, and buried before breakfast. About three days before her death a board was knocked out, and she was moved nearer the main hatch. About that time the main hatch was altered, and the ventilation improved. I have been in the hospital helping to serve out stores ; helping William Cullen, third mate, who was storekeeper. The hospital was a bunk's length alongside the ship, and about one and a half as broad, with a portscuttle in the side that could be opened ; there were two bunks in it. At first, when we came from London, there was bedding in it. That bedding was put down underneath the cabin. The hospital was full of stores. Fresh stores were brought and put in as these wore served out from time to time. It would have been necessary to move these stores, as the bunks were full of stores, if people had to be put into it. At first when we started, stores were served from near the main hatch, where there was a storeroom ; they were served through the bulk-head; this space was afterwards filled with salt, it came from below. I heard at the time this was done to trim the ship. The captain told me so. The space thus filled up was bigger than the hospital. I remember Mina falling sick. I saw her everyday at that time; she was then in the single women's compartment. She complained of weakness and headache. She told me she was going to get the same sickness as Maria Olson. An eruption came out on her very bad, I do not know how many days after, exactly the same as Maria Olson's, the pimples running together ; they dried up about five or six clays after the hole in the centre appeared. The doctor saw her at the commencement of the sickness. I do not know if he saw her when the eruption was out; she got medicine from the captain. She got medicine from the doctor which made her vomit all day, and she told me she would rather die than allow him to attend her. I told the captain what she told me. She died after most of the scabs were dried up and had fallen off. She died in the middle of the day, and was buried same evening. The body laid on the main hatch from about 2 o'clock till it was buried. There were four men stood beside the body at the funeral within a foot of it, but not for long ; the sailmaker, the carpenter, and two others whom Ido not remember. Ido not remember Spring was one of them. It was not many days after that that Spring fell sick. It was after the eruption was out on Mina that the other young women were sent to live in the long-boat. Five of them used to sleep in the boat. There was two of them took it in turns to stay up with Mina all night Three of them fell sick with a disease—something of the same kind, but not so bad. There were pimples with white instead of yellow matter, and not so many ; one here and one there all over. They dried away and scales fell off. They were not very sick. The doctor did not attend them. Ido not know if he saw the eruption. The girls never asked to see the doctor. The captain gave them medicine. I remember Niels Peter Larsen having died ten or twelve days before we had arrived here. Ido not know how long he was sick. I was told of his sickness by his wife, Karen Nilsen. The doctor came down and asked mo if any one was sick, and I showed him Larsen. The captain was sick at that time. Larsen had only been sick one or two days before the doctor saw him. The doctor told Jens Peter Petersen, who was waiting on Larsen, to wash his face with lukewarm water; the eruption was not out at _ this time. The doctor was down mostly twice every day after this, and I interpreted for him up till within five or six days of Larsen's death. Ho had the same yellow spots as Maria Olson, but not so big: some of the spots ran together. I remember distinctly the doctor looking closely at these spots. He never said to me what they were. Some of the foreigners said they were much like small-pox, and told so to Dr. Leigh. I did not see the doctor call upon him for four or five days before he died. I was not asked by Larsen's wife to call the doctor in. After two days had elapsed without the doctor calling, at his wife's desire I asked the captain to come, and he continued to come twice a day until

G—No. 3.

CONNECTED WITH THD SHIP "ENGLAND."

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the man died There was cold-water bandages put upon bis head, both before and after the eruption, by the doctor's direction. I saw Peter Larsen the night before he died; the eruption was not then dried up • his features were much disfigured. Only Jans Peter Petersen, besides me and his wife, went near him • the people kept away as much as they could. He was not moved from his bunk all the time until he died. I attended and gave food to all the sick people, such as arrowroot, cornflower, wine brandy, beef tea, and chicken broth, &c. ; they were always given to me by the captain s steward. The captain always told me to give them as much as they could eat, and was always very kind and attentive to their wants in that respect. Except in bad weather, it was dry 'tween decks and kept clean ; there was smell of disinfectants, but no other bad smell. There was a very heavy musty putrid smell from the sick people • not like any smell I can remember before. The ventilation was sufficient. In fine weather the main hatch was open, and there was one large windsail. I will produce those certificates of vaccination that I can get from the emigrants. I have also Mina's certificate. In Norway and Sweden everybody is obliged to be vaccinated. I do not know as to the Danish law. lam vaccinated myse f and "I know that every person in Norway and Sweden must be vaccinated, otherwise they would l-i -fi A With reference to the putting of salt instead of stores near the main hatch, the change in arrange- ; ment gave more ventilation. j Johk Daniel, being sworn, saith as follows:— Tarn carpenter on board the ship " England," and signed the articles. I was on board ship the whole time she was in London. I was at work all the time. I saw the stevedore s work done, but had nothing to do with it. I had nothing to do with loading the ship. The ballast was removed, the bottom thoroughly cleaned, and the ballast was relaid. It was the same stone ballast as before. Tho stone ballast was removed, and she was ballasted with cargo-railway iron. The first chance after we were outside we had to shift the cargo because she rolled and pitched badly; this was owing to the great amount of dead weight in the bottom. It was little more than a week after we were out; we were then clear of the Channel. We took salt up from below and placed it midships, underneath the deck The obiect of doing this was to make the ship seaworthy, and we found the benefit oi it directly I recognize the plan produced to me—rough sketch of ship, marked B-to be as nearly correct as I can fudge of; there was a berth or two more than shown, or rather, the berths occupied more space. The salt was right down aft, as far down on the keel as we could get at and was taken from there and brought up as near the deck as possible, some of it being kept aft under the saloon; the rest was taken forward and put before the spare sails right up as near the deck as possible; the space was previously occupied by stores. The light stores were put into the hospital, which by this time we found was no good for an hospital; the wet goods (casks) were put down the fore-hatch lam speaking of the ship's stores. I do not think the hospital was a right place; it was 6 feet long by 8 feet wide, and about 7 feet 6 high 'tween decks. It was partitioned off by five-eighth boards ; these wore all that was between the sleeping bunks outside and the hospital. I remember the inspection of the ship at Gravesend. Ido not remember the hospital being inspected. I here was two bunks in the hospital; the only ventilation was a space between the bulkhead and the upper deck, and one port-hole, which would open only in good weather, and when the vessel was on certain tacks. The captain sent for me one mght-this was during the first hot weather-this was after Maria Olson s death j we took down a number of boards which separated the bunks, so as to allow the air to pass freely this was after the shifting of the salt; and after the opening of the mam hatch a large windsail, which was made out of a royal, was let down, and within a day or two it was found the air did not circulate • this was the reason the boards were taken down, for the purpose of the air circulating right round This applies to all the bunks. In the hospital bulkhead we had to cut round holes at the same time, and this secured proper circulation, but only while we could keep the main hatch open We had not a booby hatch over the main hatch; that was what the captain wanted before we left London. The booby hatch over the companion the captain had put on at London before we sailed ; this was done by me at the captain's desire; this was at the after hatch. The main hatch was not arranged as the captain wished it. He told Mr. Morrison the agent of the Government, and the Inspectors and Shaw.Saville, and Co.'s contractor, that he wished it arranged so that it might be open m all weathers and admit of the ventilation 'tween decks ; the plan he proposed was agreed to. As we went down to Gravesend, a skylight with only 6-inch combing was fixed over■the hatch, raised on four stanchions and inch boards, so as to give it a combing of about 2 feet 6 inches ; it covered one-eighth of the area of the hatch, but the stanchions were inside this measurement; it was neither wind nor water tight. This was not a bit like the plan suggested by the captain. If a sea had struck it, it would have been carried away, and dangerous to the safety of the ship. The captains plan was to have carried a skylight, built of 3-inch planking, which would well stand a sea, to have taken it right athwart so that it would cover a quarter of the area of the hatch, and would have been all built in the clear, and open in all weathers. The spare sails occupied about 6 feet wide on the starboard side between where the salt had been moved to and the bulkhead in contact with the berths tween decks ; they remained there throughout the voyage; they were put there, I think, when we shifted the salt; there were emigrants' boxes there-they were shifted forward. The stores were cleared out of the mainhatch. Before they were cleared out they were not in the way of the small skylight in the mam-hatch. By clearing out the stores there was room made to let air down by the forepart of the hatch as well, but this could only be used in fine weather; the windsail was also let down in this part. This change m arrangement of cargo gave more space than the area of the hospital, which was filled up by changing the stores from under the main-hatch into it. I consider that the change was advantageous to the emigrants. I was down where the emigrants were frequently every day . I know Dr. Leigh, who is now present. The first particular notice I took of the emigrants was in the case of the woman Olson. I was called in to shift the boards of her bunk, to get her out nearer the air ; she was moved from one bunk to the next one nearer the mam hatch which was opened at that time • there was a good light where she lay. I saw her husband then. Ido not know his name, but

By Captain Harrington's desire.

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REPORT OE COMMISSIONERS UPON MATTERS

I am sure he was her husband ; he was a tall fine-looking man afterwards, but looked very sick then ; we used to think he was as likely to die as his wife. We noticed him sick from a few days after we started. Ido not know if he was sick when he came on board ; I observed no marks on his face, but I never was very close to him ; I would not say that he had not. A single man, Douglas, was sick about that time with measles ; he lived forward in the forecabin ; it was about the same time Olson fell sick I saw him ; he had red spots in his face; there was no matter in them ; he was well again in a few days. There was another man there who also looked very sick ;he was a foreigner. Ido not know his name ; he had a wife and three children, one of whom died. I do not remember seeing this man early on the voyage. I saw Maria Olson several times after moving the bulk-head, which was only a few days before she died ; she was very ill by that time, her face disfigured, and an eruption on her. Never saw any person like that before. It w ras quite different from what Douglas had. The doctor was there when we shifted her. I saw the doctor examine her throat; he said she had ulcerated throat; the spots were on her face at that time. The doctor said it was foreign measles. I have had smallpox when I was young ; cannot say if I have been vaccinated ; I do not think that the marks have grown out. The sailmaker had headache ; we both had it at same time ; this was the latter part of the voyage. At that time Spring was sick forward ; I saw him frequently. His case was like Maria Olson's, but he had a cold besides, before the eruption came out. The storekeeper, Cullen, was also sick ; he had an eruption ; I saw it throughout the whole time. He was attended by the doctor. The eruption on the storekeeper came out in sharper points than on the others, and not a quarter so large ; they had white heads, but were not flat; there was no watery stuff about his skin. It differed in this respect from Maria Olson's. In her case there was a great deal of water on the face and surface of the body ; it had to be wiped up constantly; it looked more like from the heat of the bod}-. I do not think it came from the pimples, because the pimples seemed to be white; they were much the same, but the surface of her skin was drier when I first saw her. I knew Mina, who nursed Maria Olson; she was laid up about ten days after Maria Olson died. I saw her frequently from that time up till her death ; as far as I can judge, the eruption was much similar to Maria Olson's. Maria Olson's baby had also the same eruption. Another foreigner, who died about a week before we came in, had the same eruption. Ido not remember any other cases so bad —that is, so much all over the face. I heard the remark passed that it was not like measles. I did not know what it was, but that it was not the same disease Douglas had; it was quite different. The first time I heard it was similar to small-pox, was when the doctor's report was read by Dr. Johnston, from the Health Officer's boat. The second night before we came in the doctor called me and asked me if I heard what the captain called the disease, as he said he had to make out his final report to-morrow, and he must give it a name. I replied he had better go and ask the women below; I refer to the women generally. Next day the doctor went down, and afterwards came on to the poop, where I was working, and told the captain that they said it was a disease with a foreign name, which he explained to the captain was cow-pox. The doctor asked the captain, in my hearing, for his homoeopathic medicine book, which he received, and took away with him for some time ; and in giving it back said to the captain that the days did not agree with smallpox. lam sure he used the word small-pox. McCarthy, who was one of the men who was sick, told me, after he was better, he fancied it was small-pox ; that was not long before we reached Wellington. I heard the captain remonstrate with Mr. Bligh's foreman (Mr. Bligh was the contractor for Messrs. Shaw Saville and Co., for fitting up the ship) in regard to the skylight. The booby-hatch over the fore-cabin was insufficient; we had to make it good and water-tight during the voyage. If the sea had struck it, it would have been dangerous to the ship. The fore-hatch was done at the time of the inspection at Gravesend, the skylight over the main-hatch was being finished; the day before we left the dock, the bunks were up 'tween decks but not finished, the emigrants being then on board three days; the poop fittings were being put up that day, and the single girls slept in them that night. The fittings were all of planed clean wood, and dry. As we went down to Gravesend, there was a hole cut in the poop to ventilate the poopcabins. There were four water-closets on deck, but I think they could have been better arranged; they were of the same description as I have generally seen for emigrants. These closets were not ready for several days after the emigrants came on board; I think they were not finished until the day before we started; this exposed the emigrants to more inconvenience than would have been the case if they had been ready. I know Captain Scott, managing man for Shaw Saville and Co.; he was on board at Gravesend at the time of inspection, and he was also frequently on board when she was in dock. Captain Scott gave all orders to the joiners and carpenters. I have heard Captain Harrington continually find fault with Shaw and Saville's foreman at the work being behind-hand, and the water-closets unfinished. On the Saturday night before the emigrants came on the following Monday, there was very little cargo in. I recollect that after all the emigrants were on board on Monday night, the stevedores were working all that night, and the hatches were open. Weather was very cold and foggy, also snow. The emigrants got no food on Monday on board ship. Ido not think the emigrants' galley was up on Monday, nor do I think the ship's galley was up on Monday. Ido not think it was until Tuesday evening the emigrants got any food on board. I was busy, and do not know whether they got food elsewhere or not; I only know there was no food on board the ship for them. The hatches were also open on Tuesday and Wednesday nights. The loading was not finished until after the ship was hauled away from the quay. The hatches being open would have occasioned much suffering 'tween decks during these three nights and days. I remember seeing charcoal stoves sent down 'tween decks for the use of the passengers during this time, and saw them used. The loading of the ship was under direction of Captain Scott. The hatchways were kept open by Captain Scott's orders. William Geoege Speing, being sworn, saith: — lam an apprentice on board the ship "England," and came out last voyage. I joined the ship about the 23rd of November, and remained with her all the time. I saw the emigrants when they arrived on board. They all looked pretty healthy. I did not remark any of them sick. I was never

By request of Captain Harrington.

CONNECTED WITH THE SHIP "ENGLAND."

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'tween decks more than two or three times during the passage. I was present at the inspection at Gravesend. Our names were called out, and we walked past the Inspectors. Ido not know who they were. I, the storekeeper Cullen, Dr. Leigh, and Swenson, went down below 'tween decks on this occasion. This was by direction of the first or second mate, in order to see if all the emigrants were on deck. There was a man lying in his bunk. I recognize the rough sketch of the ship marked B, and point to the bunk where the sick man was. It was the lower bunk midships, nearest the hatch on the port side. Cullen made the remark he thought the man had been drinking. Dr. Leigh asked Swenson the interpreter to ask him to put his tongue out, and then said he had been drinking. I was close to him and saw no scabs on his face. I did not report this, as I did not consider it my place to do so. When I left he was out of his bunk putting his clothes on. At this time all the rest were on deck being inspected. Ido not know if he was inspected. I could see the man quite plainly after he got out of his bunk. Had there been scabs on his face I could easily have seen them. I never saw any of the foreign emigrants with their faces marked during the early part of the voyage. I caught the disease early in February. I thought there was sickness coming on me some days before I went to Captain Harrington. I remember the occasion of the funeral of Mina. It was five days after she was buried I went to Captain Harrington, and was laid up in my bunk. I felt weak, and pains in my head. I slept in the deckhouse on the starboard side. After that, I slept for three days and three nights, and do not remember anything until Friday, when Dr. Leigh called in, said itwas measles, and afterwards Captain Harrington came in and said measles were breaking out on me. It was on the Saturday evening, forty-eight hours after Mina's funeral, I felt the. first symptoms, cold shivering. Ido not remember seeing the doctor until Friday. He asked me nothing about shivering, nor about any early symptoms. For a fortnight after that Friday I do not remember anything, so that it was after that time I wanted a glass in order to look at my face. It was all in little pimples joined together. The doctor used to come two or three times a day. He used to look at me and say I was getting on. That was at the time there was yellow matter. I was then very ill, but felt getting better. My throat, my gums, and tongue seemed to be all in the same state as my face. About twenty-eight days from the Friday the eruption was pretty well dried up and gone, and I was able to go about deck a little. This was eleven days before we got to Wellington, i know Mrs. Hall. When I was better, the second day I was out on deck, or nine or ten days before we arrived in port, I had a conversation with Mrs Hall, who told me I had caught the disease on the night of Mina's funeral. She called it small-pox, and I all along considered it small-pox. I told Dr. Leigh so when I came to my senses after the fortnight I had been delirious. I heard Cullen and McArthur, a seaman on board, also tell Dr. Leigh it was small-pox. He said it was nothing but foreign measles ; this was in presence of all of us. He looked at each, of us, all three being ill, to see if we had been vaccinated. The other two had the same kind of eruption, but it was slight in comparison to mine. The three of us lived together. He could not see any marks on my arm, but he could on the others. I was vaccinated when I was young, but it did not take. I have heard my mother say so. During the inspection at Gravesend my arm was not looked at, nor did I see any other person's arm inspected. The first medicine I had was sent by the captain; all the rest was sent by the doctor, so far as I know. My eyes were washed every three or four hours. There were no cold-water cloths put on to my head or face that I know of. The cabin was kept as light as usual; it was light enough to read in. It was so kept during the whole time I was getting better. Cullen and McArthur occupied the same cabin with me during my illness. McArthur had been in the forecastle, and was sent in as soon as he became sick. There were two men who had slept there before sent out when I became sick ; their names were Shearwood and De Freize. I never told the captain it was small-pox, nor heard the word small-pox mentioned in his hearing. Before I joined the ship I lived in Barking. There were several persons I knew died of small-pox there before I left. I lived in a country place, fully a mile from where any case of small-pox had occurred. My face was not marked before this illness. I cannot say when I first knew Dr. Leigh was the ship's doctor, but I knew he was such when we arrived at Gravesend on December 7th. Some time after dinner the inspection took place at Gravesend. After the fortnight during which time I was delirious, I and my sick messmates received all necessary comforts from the captain. Feedeeick Shearwood, being sworn, saith: — I shipped on board the " England "as sailmaker. I saw mostly all the bad cases of sickness on board. I recollect Spring's case. I have seen small-pox in China. I saw eight cases there. I was in the same ship with them. It was said to be small-pox by the Chinese doctor. Tho eruption differed from Spring's; their pimples had dark heads, and Spring's were white. It did not scatter over the faces of the Chinamen ; in the case of Spring the pimples did not run together, but, in drying up, the matter from the pimples ran together and formed one scab. I stayed in the same cabin, and left it when he became sick—l believe by the captain's orders. I heard then it was measles that was the matter with him. I heard Spring say it was small-pox during his illness. I heard for the first time it was small-pox from any other person when we came into harbour; it surprised me very much, as I did not think it was small-pox. I did not think it was small-pox from what 1 had seen in China ; by that I mean, it was not like what I had seen on the Chinamen. I had charge of the spare sails ; they were stowed in the starboard side under the main hatch; they were before the main hatch when we sailed. Early on the voyage they were shifted further aft, on the same side, under the main hatch. I helped to stow them. Moved stores out from the place where they were put, and salt was put in the place where they were taken from; I mean that they were placed to the starboard side of the main hatch. There was plenty of space left in the main hatch. I superintended all the funerals, and assisted the carpenter. I used plenty of disinfectants on each occasion—by plenty, I mean I put it all over the bodies and the places where they died. The bodies were buried as soon as possible after death on each occasion. I was always made aware when they died. The bedding and clothing of persons who died was always sown up with the body, by the captain's order. The main hatch was always ventilated by a wind-sail when weather permitted. 7

By request of Dr. Leigh. By request of Captain Harrington.

By request of Captain Harrington.

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REPORT OE COMMISSIONERS UPON MATTERS

Monday, 22nd April, 1872. William Cullen, being sworn, saith: — I came out in the " England "as third mate. I joined about a fortnight before we sailed. I was on board at Gravesend, and remember an inspection being made there. Dr. Featherston was there ; I did not know the others. I was inspected—merely asked what duties I had to perform. I was examined with the rest of the crew. I cannot say if this was before or after the emigrants were examined. I saw the emigrants examined; the examination consisted of asking names and casual inspection; there was no medical examination. The Inspectors went below ; they went all over the ship, I understand. I did not observe if Dr. Featherston went between decks. I knew Dr. Featherston in New Zealand. I knew Dr. Leigh at that time ;he introduced himself to me as doctor of the ship before we reached Gravesend. I did not observe Dr. Leigh with the Inspectors, but he might have been. I was storekeeper ; by that I mean I had charge of the stores and serving them out. I received charge of them in the Docks. I stowed them. The stores were not inspected after being in my charge by any person at London or Gravesend. I do not think it possible they could have been inspected without my knowing it. I received them at the ship's side, and checked them as they came on board. I received them, or they were received under my inspection, from the carrier, aud I signed for everything I received. I did not see them inspected on the wharf; they could not have been inspected from the time they left the carrier's hands until they were stowed on board. The stores I refer to were both emigrants' and ship's stores. The list of stores and medical comforts, marked F, now shown to me, I believe to be correct. Watering the ship was part of my duty; it was done in the East India Docks ; we took the water out of the lighters, and pumped it directly into tanks on board; there were ship's tanks and emigrants' tanks; they were all filled with the same water. I filled them. I had the tanks from that time under my charge during the passage. I think the tanks must have been inspected, as one of them was injured and replaced, and I do not think this would have been done unless they had been inspected. I was told how many passengers we were to have, and that we would require 150 days' water ; the amount of water taken on board was as much as I considered to be sufficient. I think the water was inspected at Gravesend, but cannot be positive. The stores were all in good order when received, in so far that the packages were all sound. I am not aware of their being sampled until they were served out. I remember going 'tween decks on the occasion of the inspection for the purpose of putting things in order. I think all the emigrants were on deck at the inspection. Dr. Leigh was down at this time getting them on deck, and Swenson was along with him. I had conversation with them, but I do not recollect any particular man remaining behind. I remember, on another occasion, after we left Gravesend, that a man we called Claus Petersen Maii, gave us some difficulty in getting him out of his bunk on deck with the rest; it was either the first or second morning after leaving Gravesend ; we were trying to got him on deck for the purpose of going through the routine of cleaning laid down by the captain. Dr. Leigh and Swenson were with me at the time. The doctor was going his rounds. Swenson was interpreting for him, and I was called to assist; he then came out of his bunk and went on deck ;he was partly dressed. He might have been drunk or sick—all I know was that there was a great difficulty in rousing him. I saw him closely ; there was plenty of light. I recognize the sketch marked Bto be correct, and I point to the berth occupied by this party ; it was the lower tier middle bunk on the port side main hatch. I observed bis face was full of pimples and blotches, and very inflamed ; there was yellow matter on his cheeks and forehead ; they were not very thick, but they were all over his face ; this was the first time I had remarked this man. At the time of the inspection, it was possible that this man might have lain in his bunk and avoided inspection without my knowing it, but I do not think it possible he could have done so without some party knowing it. I cannot say whether he was inspected or not. None of the foreigners went ashore at Gravesend. Ido not think any could have come aboard there without my hearing of it. I think this man must have been aboard on the occasion of the inspection. I think the doctor and Swenson could not but have seen the man's face as distinctly as I did; in fact I remarked to Swenson that he must have a frightful cold, or something more than common the matter with his face. I do not remember what Swenson replied particularly. I saw all the subsequent cases of sickness on board until I was sick myself. It was like the eruption on the face of Jargen Neilsen. I remember Maria Olson's face (Ericksen's wife) when she was ill. Some of the pimples on this man's face were similar, but not nearly so bad. She occupied the adjoining bunk on the port side. I was ill myself afterwards ; I saw my face in a glass ; the chief difference between my face and Claus's face was, that mine was swollen and inflamed, and the pimples were much thicker. I never took any particular notice of Claus's face after the time I first refer to. I never mentioned Claus's face being bad till towards the end of the voyage, when I mentioned it to my messmates. One occasion I can vouch for; there were present then McDonald, Swenson, Spring, and Shearwood; this was after Spring and myself were sick. We said it was small-pox ; that was my opinion. I knew it from descriptions I had heard of it. I never saw small-pox. As early as Maria Olson's death, or next day, I thought it was small-pox, and had mentioned it on board. It was the general subject of conversation, and all of us who had it—by whom I mean my messmates whom I have mentioned, and who had measles before—considered it small-pox. I told the doctor I thought it was small-pox when I was sick myself; this was in the latter end of January. He told me it was not small-pox. Although the majority thought it was small-pox, there were some of them did not. McArthur said some of the worst cases were like cases of small-pox he had seen in the hospital. Ido not know what the captain's opinion was. He often talked to me about it. In conversation I have used the word small-pox to him, and told him I thought the disease on board was small-pox ; this was when I was sick. He said the doctor said it was not. I said I had never seen measles like it, and he said he had not either; this was the third day after the pimples came out on me. Mrs. Harrington told me she always thought it was measles in a great many of the cases. I never spoke to Finch as to what Mrs. Harrington thought of the nature of the disease. I have told the second mate, also the first mate, Mr. Batt, that I thought it was small-pox ; Ido not know what their opinion was. I served the stores at first in the square of the main hatch; it was about ten feet in the square clear ; the height being about five feet, part of the

G—No. 3

space between decks being occupied by a ground tier of stores, so that I had not the full height; there was a partition, which I locked. It rose midway between the hatch fore and aft, so that I had half the area of the hatch as a storeroom. For the better ventilation of the ship when we got into warm weather, the hatch was altered, and I then served stores from the hospital. It had previously been used for holding disinfectants and the medicine chest. The partition was then taken down and the whole square of the hatch thrown into the emigrants' department, and arranged so as to promote ventilation. The medicine chest from that time was kept under the main hatch, so that any one serving medicines must go there. I heard no complaints of the quality of the food, but did of the quantity from some of the emigrants (just a few) of all sorts—English, Danes, and Norwegians. I always served the rations in excess of the regulations, by the captain's orders—that is, of things they wanted ; but some things they did not want. Their chief complaint was, that they did not get enough butter and flour. There was a list or dietary scale hung up in the storeroom, and all over the ship 'tween decks ;it was in the English and Danish languages, so that it could be read by all on board. I do not consider that they had any cause of complaint. I was 'tween decks every morning at 6 and 9 o'clock, serving out stores, and then at 6 o'clock at night. I did observe when the doctor came below ; the above were my stated times, but I was also 'tween decks off and on all day. For the first two or three days after we left, the doctor came down twice a day; then he was sick for a good time, during which he did not come down; there were great complaints made before he came down again. The complaints were that they were not visited properly. During the time I refer to, the sick people received medicine from the captain. He was down two or three times a day seeing them. When the doctor next came down, the wife of Ericksen (Maria Olson) was sick. His attendance then was not very regular, and complaints were made to me on several days that they would not have him at all to attend on them. I can mention McDonald and Burness. I said to them that the captain's treatment was different to the doctor's. I explained to them that the captain believed in homoeopathy, but that they had better consider before they refused the doctor's services. They were then complaining about the treatment of their children, and that they did not get enough medical comforts. I never saw the doctor handle any person roughly, but I thought he talked roughly to the children. I can specify one case in particular. Jens Petersen's child was sick one night; it had a swollen navel, which the doctor put back, put a button on it, and a bandage ; they complained to me at the time through the interpreter. Ido not think the doctor knew that the people complained at this time. I witnessed the operation. I considered it rough treatment; had it been a child of mine, I would not have allowed him to do it. I went to ask the doctor's advice shortly after leaving London. I had a bad head ; I told him my symptoms; he said he was bad too, in an uncivil tone, and gave me no medicine. When I was subsequently ill, I was attended by the doctor, who was very attentive ; he visited me twice a day during the whole time ; he gave me medicines; he gave me lotion for the eyes, gargle for the throat, and he attended on me in a very satisfactory way. The time the doctor was sick at the commencement of the voyage, he was part of the time confined to his cabin. This was at the time the captain was attending to the sick, and before any complaints were made. During the rest of the voyage he appeared to be well enough to go about the ship. I have on many occasions seen him on the poop reading; on the same day he did not visit the sick ; this was about the middle of January ; at this time the captain was in charge of the sick ; the doctor did not then go down at all. I remember the complaints being made to the captain by the whole of the passengers. I was present on the occasion; this complaint was against the doctor; the complaint was to the effect that he was inattentive, that they did not know what he gave them medicine for, and that it did them no good. Before that I did not remark the doctor going about the ship on any day he did not go below 'tween decks; but after that I did. It was the general habit of the doctor to speak roughly to the sick people. I cannot specify any individual case. I wish to correct the statement I made above. The case of rough handling of Jens Petersen's child, which I have described, was exceptional, and the only case of rough handling I saw. I do not remember going round 'tween decks at the time of inspection to see if any person was left below, nor do I remember going round with Spring. The medicine chest was moved four times from the hospital to the main hatch and back ; it was never moved to any other part of the ship until we got into quarantine. I remember clearing out the hospital at the request of the captain, in order to make room for a female who was expecting to lie in ; the medicine chest was removed on that occasion. The hospital was not required on that occasion, and I moved into it with my stores again. This was after the death of Mrs. Ericksen, early in January; it was before the complaint I mentioned as being made by all the passengers to the captain. The doctor did not come down regularly at the commencement of the voyage 'tween decks for as long as the first week ; it was certainly not a fortnight; it was only till we got bad weather. I saw the doctor during that time in the saloon ;he told me he was sick. I had business in the lazarette, and had to go through the saloon ;he looked ill—sea-sick, as I imagine. I never saw Dr. Leigh the worse for liquor, except perhaps on the occasion when he was excited at Gravesend. I think I once mentioned to Captain Harrington the eruption on Claus Petersen's face ; this was towards the end of the voyage. I saw Dr. Leigh on the evening of the inspection at Gravesend, in the saloon. I saw him fall down off the pig-sty forward, and he was carried aft. He was either tipsy or excited. The ship was not prepared, as I would call it, to go to sea, until after we sailed. The emigrants' accommodation was not ready when they arrived, and I know they slept a night in the sheds in the East India Docks ; I mean all the emigrants ; the sheds were open sheds ; the weather was frightfully cold. The ship's galley was up before they arrived. Shaw, Saville, and Co. sent a cook, who was on board before they arrived ; they got dinner the same day they arrived. The stores that the cook prepared for them were independent of the ship's stores. Ido not know who supplied them. The children had hooping-cough when we started—both foreign and Scotch. I observed the hooping-cough as soon as they came on board. Permission, I believe, was got from the Dock Company for the emigrants to sleep in the sheds, as no person is otherwise allowed to remain inside the gates during night. Ido not believe they had any bedding in the sheds. In discussing the origin of the disease among the crew, Swenson, I, the sailmaker, carpenter, and

By requeit of Dr. Leigh.

By request of Captain Harrington.

By Commissioners.

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REPORT OE COMMISSIONERS UPON MATTERS

others whom I cannot specify, agreed it was small-pox, and that it originated with Claus Petersen. I mentioned this to the doctor, and he said he believed the disease began with McDonald's child.

Tuesday, 23rd April, 1872. [Mr. Christian Julius Toxward was sworn as Interpreter.] Cheistoph.ee Eeicksen, duly sworn, saith as follows: — I come from Neas, a place in Norway; this is from twelve to thirteen English miles from Christiania. 1 have got friends out here who arrived last year. Four more of the emigrants come from the same place that I do ; their names are Ole Olson, Ole Amundsen, Gumierius Christiansen, Hans Larsen. I did not know Claus Petersen until I came on board the ship ;he is a Dane. We left Christiania on Wednesday, and arrived in London on the following Monday. Travelled 'tween decks on board steamer, and had plenty of food. We arrived in London at 9 o'clock in the morning ; there were six families of us, or might be seven. A person who could not speak our language met us, and conveyed us on board the ship " England." There was an agent on board the ship when we arrived who could speak our language. I first saw Swenson when the ship was about to leave ; the agent^ on the same day we arrived, showed us the bunks we were to occupy. I slept on board the ship this night, and every night afterwards. We got food the same day we arrived. We were not hungry, and we had not to wait for it; it was cooked on board the ship. All the other emigrants on board were treated in the same manner as we were ; I saw no difference. None of the emigrants after I arrived slept in a shed on the wharf; they all slept on board ship. There were emigrants from Hamburgh there, who came before I was there ; Ido not know how long. I heard of no complaint of any kind during the passage to London from Christiania. Claus Petersen occupied the bunk next to me. I made Claus Petersen's acquaintance directly I came on board ship. He'was not quite well, for he kept in his bunk for about a week after coming on board ; he did come on deck sometimes, and I saw him myself there ; I spoke to him there. At that time ho had some marks on his face ; these spots were a little red ; they were on his face when I first saw him ; the spots disappeared but again reappeared. He has not got these spots now. There was matter in these spots, but no matter ran from them; there were no scabs. I was a married man; my wife died on board ship. My wife's name was Bertha Maria Olsdatter. It was about six days before Christmas my wife fell sick. We had a child six months old; it also died from the same complaint as the mother. My wife, when she fell sick, first complained of her breast, then her throat, then her head; her skin broke out in little pimples ; she was ill for about a fortnight; the pimples showed themselves about the end of her illness. I saw them when they first broke out; they were white and glossy; when they got larger, a large red ring formed round them ; they were pointed at first, and then sunk down in the centre after a little while. They looked about the same as those I had seen on Claus Petersen's face ; this was at the beginning, by which I mean when they first appeared. I have seen small-pox at home in my own country. I thought at the beginning of my wife's illness, that it was nothing of any importance, but before her death I thought her illness was small-pox. I told this to Ole Bosen, and Johan Jespersen ; they thought it was small-pox too. I mentioned to Swenson the interpreter that I thought it was small-pox, also before my wife died. Swenson said the doctor said it was measles. I have seen measles in my own country ; I did not see measles on board ship. I did not see anything on board ship like the measles I have seen in my own country. There was a time during my wife's sickness, before the eruption became larger, that I thought it was measles. My wife was nursed in her sickness by Mina Bergersdatter. The doctor came and attended my wife at the latter end of her illness; he did not visit her at the commencement of her illness. I wished to have the doctor, and asked Swenson to request the doctor to come down to my wife. For three days after that he did not come. I did not see the doctor during these three days. The third day after the doctor was requested to attend my wife he did come, and he said that it was sea-sickness my wife had; there was then no spots or marks of any kind visible. Three days elapsed between his first and second visit. On his second visit the eruption was out; she was suckling her baby; the baby was taken from her the day after the doctor had been there the second time. From that time he attended her regularly twice a day, until she died ; that was about five days. He was there the evening before she died. I think the doctor should have looked better after my wife at the time she took ill. I thought this, because the doctor did not come when called. I believe Swenson gave my message to the doctor. Swenson brought the doctor on the first occasion. My wife was well attended to, and got everything she needed. Swenson brought her all the things. The captain came down frequently to see that everything was right, but I do not remember as to the captain's seeing my wife during her illness. When she was removed from her bunk, it was done in the doctor's presence. Ido not think the doctor assisted to remove her. It was the carpenter and Mina who principally assisted in moving her. The doctor gave her medicine, applied cold water to her face and a folded up piece of wet cloth to her forehead; also bathed her eyes with lukewarm water. I have been vaccinated. I had no disease similar to my wife during the voyage, nor had I ever. My wife had been vaccinated twenty years before. She had the same marks on her arm that I have. My child was not vaccinated. It is the law in Norway that all children must be vaccinated. The marks which I now show on my left arm are not so strong or distinct as those which were on my wife's arm. She was blonde, had blue eyes, and a delicate skin. Before I asked Swenson to call the doctor, I asked him what was the reason the doctor did not come to see us. This was three days before I first asked Swenson to call the doctor to see us. Six days elapsed between the time I first spoke to Swenson about the doctor's duty to attend before he did attend upon us, but only three days after the time I sent for him. The doctor did not see my wife until she was sick six days. I did not see the doctor 'tween decks during these six days. He might have been down without my seeing him. My child was removed from the mother by order of the doctor. I thought so because the doctor was there with Swenson. The child was taken to the cabin, and it was taken care of and nursed by

By request of Swenson, Interpreter.

By request of Dr. Leigh. By request of Captain Harrington.

CONNECTED WITH THE SHIP "ENGLAND."

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Mina Bergersdatter—this was before the mother died. The doctor gave medicine to the baby. I saw my child the day it died ; the child was awake, but quiet. I saw it the day previous to its death ; it was sleeping then. I did not see it the third day before it died. Kaeen Neilsen, duly sworn saith as follows : — lam the widow of Neils Peter Larsen. I came with my husband, who is now dead, from Oesterpy, which is thirty-two miles from Copenhagen. Wo went from Copenhagen to -Kiel by steamboat; from thence to Hamburgh by rail; and from thence to London by steamer. All the Danes came that way at the same time as myself. It was cold and snowing during the voyage from Copenhagen to Kiel. We were under deck. We were comfortable from Hamburgh to London ;we were 'tween decks. We had to pay for our own food from Copenhagen to London. We had sufficient to eat. About noon we arrived in London. There were two agents who went with us from Copenhagen to London, and who took us on board the " England " immediately we arrived. The Norwegians arrived on the evening of the same day. Wo all slept in the ship the first night. All the Norwegians and Danes were on board the ship that night. None of them ever slept on shore that night, or any night before the ship sailed. I knew Claus Petersen Maii. I first saw him in Copenhagen. Ho took ill after he came on board the ship "England," —after ho had been there a few days. I cannot say if it was before the ship left the dock or after we went to sea. Our bunks were in the opposite corners of the 'tween decks. He had an eruption on his face. My husband was ill for about three weeks, and died on the 3rd March ;he also had an eruption on his face; the eruption on Claus Petersen Maii was similar to that on my husband at the beginning of his illness, I spoke to Swenson about getting the doctor to attend my husband. Ido not know whether he told the doctor ; but the doctor did not attend him until two days afterwards ; the eruption was not out when the doctor saw him first. At first the doctor came regularly. For the last two days before he died, the doctor was not there. [This witness's evidence was not taken further, as she was seized with a fit, and her examination was not continued.] Thomas Sandeeson Bulmee, being duly sworn, saith: — lam a qualified medical practitioner. I have been employed as medical officer for the Quarantine Station at Somes Island. My services were engaged on the 10th of March, and lat once entered on my duties by going on board the ship "England," which was then anchored off Somes Island; this was on the evening of the same day. On the following day I visited every part of the ship, and mustered all who were able to be about on the poop, and also visited the sick. I found the following persons sick with small-pox: —Spring, Neils Neilsen. Hans Larsen, Cullen, Mrs. McDonald, Finch, Captain Harrington, and Mrs. Harrington. In addition to the above, I was, about forty-eight hours subsequently, informed of the case of Miss Tee, by the pilot (Holmes), and saw her, and saw that her case was also small-pox. McDonald's child, fifteen months old, had measles. In addition to the above there were cases of debility, diarrhoea, and hooping-cough, of which I did not take particular note, as they were not connected with my special duty. None of the small-pox cases were in the acute stage ; Spring, Miss Tee, and Hans Larsen, had scabs still on their faces ; they were beginning to fall off. Spring and Miss Tee were the least advanced towards recovery. In addition to the above, I would add Neils Neilsen ; and these were all declared by me to be infected. This was on 11th March. It was not until Sunday, the 17th, I was able to separate the infected from the other. During the interval I remained on board ship, and on that date I myself went into quarantine with the infected. There has been no fresh outbreak of an infectious disease since the time I went on board. I examined every person, with the view of seeing if they had been vaccinated, with the exception of Mr. Leigh. I reported the result in general terms to the Board of Health. I also ascertained that several persons on board were freshly pock-marked, and specify two cases in particular—Spring and Miss Tee's. I was positive as to the nature of the disease in the case of Spring and Miss Tee, and that it was small-pox. I think these two cases were the most malignant I had ever seen ; that is, that it had been confluent small-pox. I have had special experience of small-pox. In 1854 I attended cases of small-pox in Detroit Hospital during an epidemic. In 1864, at Chicago, also, when there was an epidemic of small-pox, during which I had private practice ; and attended cases of small-pox in the hospital. From 1865 to 1867, in Montreal, I was connected with small-pox wards in the hospital there, and treated cases. In 1869 I was in private practice in London, and saw small-pox cases in hospital and private practice. I attended the Mile-end Eoad Branch of the Small-pox Hospital. I have been on board emigrant ships as medical officer. I made a special examination of the accommodation for the emigrants on board the "England." I did so the second day I went on board, and subsequently. Tho rough sketch marked B is a generally correct plan of the accommodation, except that the water tank should be shown running right across the main hatch, so that you could not get up the main hatch without climbing up on top of the water tank. I found the 'tween decks in fair order —as a ship would be after a sea voyage. There was an unusual smell, which I called the " small-pox smell." There is such a smell recognized amongst medical men, which is a sure indication of the presence of the disease. With respect to the fittings, I think they were put up in the usual manner. The ventilation was insufficient. I think it was not as sufficient as might have been effected at that time to improve the ventilation. I should have cut a hole through the deck and fixed a funnel or an updraught pipe, i saw what I refer to had been done to ventilate the single girls' place. I have no special knowledge of shipbuilding, but I think it could be done. I saw the hospitals provided on board. I did not consider they were properly placed, or sufficient in the case of a ship with an epidemic on board, although they would answer for a ship with the ordinary amount of sickness. Cullen, Neils Neilsen, and Hans Larsen, all showed the marks of small-pox. On the 12th or 13th of March, I forwarded my report on the subject of vaccination. I think it was on Tuesday I examined the men for the vaccination marks. It was about half-past Bon Sunday evening I got on board the England. Ido not remember the captain reporting the case of the death of a child 8

I By request of i Captain HarringI ton.

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REPORT OE COMMISSIONERS UPON MATTERS

30

on that evening; he might have done so. Ido not think I saw Miss Tee on Monday. lam not aware of her being out of her cabin; she was hardly able to walk when I did see her some days afterwards. The captain did not introduce me to Miss Tee, until I heard of her being on board from the pilot. I cannot say if Mr. Badland was present when I was introduced to Miss Tee. When I examined the hands when I went on board, Spring was not in my opinion able to do duty, nor was Cullen. Finch was fit for duty. Captain Harrington was well, except that he suffered from spasms, which I consider to be the after-effects of his sickness. Neils Neilsen and Hans Larsen were still getting physic. Mrs. Harrington then appeared quite well. I could not separate the infected from the disinfected, as there was not room to do so on board ship, and I expected every day to be removed with the infected to the island. This could not have been done until the 17th, on account of the want of buildings. I knew of no other reason. I informed the captain he had small-pox on board on the Monday morning. He led me to understand he was taken by surprise to find that there was small-pox on board. I found no small-pox marks on Captain or Mrs. Harrington at the time of my inspection, or at any other time. All the infected and disinfected that were landed, were landed by my orders on Somes Island. I refer to the landing made on the 16th. I sent Miss Tee's name to the Board of Health as one of the parties who would require to be landed. On 13th March I made this report. I made no special report as regards the kind of accommodation required for Miss Tee on the island, as I did not consider it my duty. I had the vessel fumigated and disinfected before I left her. I remained after the emigrants had left the vessel, fumigated her, and reported so to the Board. I refumigated again within a week or a little more from the time of the first fumigation ; the second fumigation was on the 28th and 29th. I was aware of Miss Tee being aboard on this occasion, but not with my consent. I only fumigated in order to destroy the smell. I did not consider it was an official fumigation, as I considered I had no authority from the Board. I considered the second fumigation the official one. I saw the medical chest, which I considered had been roughly used; bottles broken, and medicine spilt. I found three or four tubes of vaccinating matter on board, almost empty. Some medicines I asked from Dr. Leigh were not there; Dr. Leigh said they had been destroyed—l can mention nitrate of silver for one; but there was ample medicine for treating all the patients in any stage of their disease. I saw no surgical instruments, not even a lancet; such things are generally put in a medicine chest. I could not vaccinate until I received a lancet from the Board.

By Commis sioners.

Wednesday, 24th Apeil, 1872. John Thomas Leigh, being duly sworn, saith as follows; —- I came out on board the ship " England," as surgeon in charge. I am registered as a surgeon under tho English Medical Act. I produce my certificate, dated 30th August, 1870. I studied at Charing Cross Hospital, London, for three years. Previous to this I had two years' apprenticeship. lam now twenty-seven years old. I acquired the following diplomas: —Licentiate Society of Apothecaries, London, 1869, and Licentiate Eoyal College of Surgeons, Edinburgh, 1870, as mentioned in certificate which I produce. I also acquired a diploma of Licentiate in Midwifery in College of Surgeons in Edinburgh, dated 22nd July, 1870, all of which I produce. I was Surgeon's Assistant in the Charing Cross Hospital for six months. I was Prosector for the same for three months. I was Assistant in Dentistry in the same hospital for three months. I took the first prize in class examination for Practical Chemistry in 1868, and for Pathology, Anatomy, and Forensic Medicine in 1869. I produce the silver medals which I won on these occasions ; also special certificates of merit on the following subjects : —Botany, Materia Medica, Surgery, and Practice of Medicine, which I produce. After passing, I held an appointment as Medical Officer in connection with the St. Ives Union for about twelve months. I produce a certificate from the Board of Guardians, that I " performed the duties to their entire satisfaction." It is a certified extract from their minutes, dated 22nd February, 1871. I was then Eesident Physician to the North Staffordshire Hospital for six months. I resigned that appointment in consequence of my ill health, and with the view of taking a voyage to improve it. I produce an extract (certified) from the minutes of the General Committee of the North Staffordshire Infirmary, expressing their satisfaction " at the zeal, skill, and assiduity, which he has shown in the discharge of his duties ; and to testify to his high moral character." I obtained the appointment on board the " England "in reply to an advertisement. It was through Messrs. Moore and Co. I made my agreement, which I produce (marked H), and which is signed by Shaw, Saville, and Co. As an additional inducement to what appears in the agreement, I was informed that I would receive from the New Zealand Government a gratuity for the emigrants on board. I joined the ship on December 4th, some time in the afternoon. I slept on shore that night, but after that continued on board throughout the voyage. Captain Harrington showed me my cabin. I saw the emigrants when I arrived on board, and made a cursory inspection of them. I did not make any written entry in my journal. I have kept a journal throughout the voyage, which I produce (marked I). It contains notes of every case that came under my observation ; in fact, all the medical notes I made. The entries were written on the same date under which they appear, or within twenty-four hours, and while the occurrences were under my notice. I took notes on a tablet, from which I made these entries. I did not particularly inspect the emigrants as to their health until the inspection at Gravesend, on Thursday, 7th December; but prior to that I had observed that there was great discomfort for the emigrants on board ship from Monday up till Thursday. They told me (some of the Scotch single girls) they were hungry, because they could not get their food at the proper times; especially the foreigners looked cold and miserable; coughs were very prevalent amongst them. The inspection I made at Gravesend was part of the official inspection. I assisted Dr. Featherston, as I thought it my duty to do so. There were two or three gentlemen officially present on the occasion ; one of them, I believe, was a medical man, from the questions he put to the emigrants. These gentlemen arrived on board about noon, and were occupied about the ship until about 3 o'clock, when all the emigrants were called aft to the poop, where I stood beside Dr. Featherston ; he held a list of the emigrants, and the clerk held another list. I was not

CONNECTED WITH THE SHIP "ENGLAND."

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introduced to Dr. Featherston as surgeon of the ship, and lam not aware if he knew me. The clerk called out the names of the emigrants from the list. The rough sketch B, produced, I recognize to be correct as a plan of the ship. The emigrants passed forward in answer to their names. I considered at the time that the examination was not sufficient to ascertain the state of health of the emigrants ; they merely walked past, some of them slipped past, and were called back again, which created confusion. All the names that were called were not answered to. One of the Inspectors told some one (I believe it was the chief officer) to go below and see if any person was left below. During this search the emigrants were all called back on the poop, and detained there. I did not assist in the search. Several persons were brought from below on this occasion. Alter that the calling of the list was taken up where it left off; it was°not recommenced from the beginning. I consider this inspection afforded me a fair opportunity of ascertaining the state of health of the emigrants in a general way. I thought their health was, on the average, fair. I am sure I did not see all the emigrants on that occasion, nor did the Inspector see them all. I was with the Inspectors all the time during the inspection of the emigrants. I thought the inspection loosely conducted ; I mean that they were not all inspected, and that those who were inspected were not sufficiently inspected. Had any eruptive disease in the eruptive stage come under my notice, I would have seen it —that is, were the eruption on the face. I saw no eruption on any of the emigrants' faces. That was the only occasion on which the emigrants were mustered for inspection during the voyage. I commenced my duty of visiting rounds the day we left. I used to get Swenson, the interpreter, to go with me ; he sometimes did accompany, and sometimes did not. I then usually first visited the married people 'tween decks, directly after breakfast. I went to each bunk ; the people were generally up then, and I must necessarily have seen them all, except they went into their bunks with the view of hiding from me. They did this sometimes, especially one foreigner, They desired to avoid the daily work of scraping and scrubbing, which I organized the first or second day after we sailed. After 'tween decks I visited the forecabin, then the forecastle, then the single girls, who were in the saloon cabin. The routine I followed was the same I had been accustomed to in the North Staffordshire Infirmary. I expected to find that all cleaning up had been done, and that the emigrants were washed, and had breakfasted; if not, I waited to see this done. I found great difficulty in carrying out these plans. I specify the case of McDonald, who on the second or third day used improper language to me, which circumstance I reported to the Captain. I also specify the case of the foreigner who had been shirking in his bunk, and whom I compelled to get up and do his share of the work. I dare say I spoke sharply to him ; they could see by my manner what I meant. I reported generally to the captain that I had great difficulty to get the people to^ attend to their cleanliness, and I considered at the time that he did not properly support me. In fact he interfered with my plans. I can specify one occasion when he prevented my using the water pails for the purpose of cleaning the 'tween decks. The supply of scrapers was very short for the emigrants, so that much delay was caused. On mentioning these and the other matters before referred to to tho captain, he told mo that I did not understand the treatment of emigrants, and told me he would relieve me of that portion of my duty. I objected; this was on the third or fourth day after we leit. He insisted on taking this portion of my duty on himself; consequently I was obliged to give way. The duty I refer to is the superintendence of tho sanitary arrangements of the ship generally. The medicine chest and drug stores were placed under my care. The medical comforts were not placed under my care. I was refused surgical appliances before the ship sailed. I can specify splints which I asked for from one of the officials inspecting, which were refused on account of expense. These articles were not included in the list referred to in my agreement. The surgical instruments which I had to provide myself were inspected in my presence by Dr. Featherston, and pronounced by him to be correct. I am not aware of any inspection being made of the medical stores and comforts, except the inspection above referred to. I considered that I should have the medical comforts under my control, because that is the law. I never had control of the medical comforts during the voyage. I did not complain of not having control of the medical comforts, but I experienced the want of them on account of my attendance to the sick. I can specify one occasion. I asked for a bottle of beer for Mrs. Wellington, when I only got one half of what I considered necessary to administer to her. I experienced difficulty during one part of the voyage, about the end of February, in obtaining medical comforts. I was refused the quantities and quality I asked for. The captain also at that time took umbrage at my wishing to see the administration of the medical comforts, but I saw it done. The medical comforts were distributed throughout the voyage by the captain, both with and without my recommendation. The reason alleged by the captain was, that he thought me incompetent on account of ill health. After the captain had relieved me of the sanitary portion of my duties, I continued my daily inspection for a fortnight. I went down generally twice a day during that period ; there was slight sickness, colds and influenza, also hooping-cough. The only entry in my journal during the first fortnight referred to a seaman; the first entry regarding the emigrants was on 22nd December, when I detected measles on board for the first time. I reported this to the captain. I never observed any eruption on the face of any of the foreign emigrants prior to 22nd December. I had full opportunity of seeing them. A man might have been on board the ship, and in his bunk up to that date without my knowing of it, as the place was dark, and curtains were round the bunks ; but I should think it very improbable such could be the case. When I reported measles to the captain, I told him it would go right through the ship, and he said he thought my fears exaggerated ; and I told him it was a very serious thing to have on board. I advised isolation, and suggested they should be put in the hospital._ The cases I refer to were three children, one of McDonald's and two of Burness's. This necessity for isolation was the subject of conversation between me and the captain for several days. The captain urged the hospital would be required as a depot for stores, in order to trim the ship. The vessel was rolling very much at that time. The hospital was not at that time occupied by stores. The stores were put into the hospital when the weather was quieter. I understood from the captain that the stores must be moved for the safety of the ship ; that the captain told me the lives of the whole must be taken into consideration before those of the few. I concurred in this idea. At the time the stores were removed, the ventilation was improved through the measures taken by the captain; the movement

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REPORT OE COMMISSIONERS UPON MATTERS

of the stores enabled this to be done. I think all subsequent efforts at isolation would have been ineffectual; the hospital was quite insufficient, and an improper place, and would not have, in all probability, done anything to stop the spread of the disease. It was badly placed, dark, badly ventilated, and not sufficiently isolated from the passengers. Directly the disease made its appearance, on the 23rd December, the captain improved the ventilation, and disinfectants were freely used, After a fortnight had elapsed, I fell sick; it was after I had reported the measles. I was not unable to perform my duties, but not with the same regularity as before ; but I went round every day. During this period, from 22nd December till 13th January, I never was unable to attend my duty. I was never called upon during this time to attend on any of the emigrants or any one on board, and did not do so. The eruptive disease began next to spread amongst the foreigners, principally children. I satisfied myself that it spread from the first three cases above referred to. I first saw the case ofMaria Olson — she was the wife of Ericksen —on 26th December. I learned from her she had been ill (through the interpreter, Swenson) for a week previously. I had.been making my rounds regularly during that week, and had received no complaint from her. I continued to attend her without intermission until her death —I believe twice a day when she was at her worst. The description I have written of her complaint was written by me on the first page of my journal, on 31st December, and Ist and 2nd January. I thought her case an attack of malignant measles; the symptoms on which I founded my diagnosis were the following: —Lachrymation, bronchial affection, general catarrh, feverishness, and constipation ; at the first time I saw her she was suffering from these symptoms, which were aggravated by her suckling an infant. On the evening of the same day I believe I noticed the rash. I did not know what it was ; I told the captain so. On the following morning it showed itself to be measles; it had acquired the character of measles. The temperature at this time was very high, and the symptoms aggravated rapidly; her face puffed up ; the rash did not consist of distinct vesicles, nor did I observe any pustules at any period of the disease. I observed pus at the last stage of the disease, from sloughs in the skin, the epidermis being in a gangrenous condition. The entry in my book in connection with the case of Spring was commenced on Bth February, and continued daily. I saw Spring after his illness had commenced; there was no rash when I first saw him; the rash came out on him on the following day. I saw the whole progress of the rash ; it was similar to the eruption I have described in the case of Maria Olson, when at its climax. In its first stage it was similar, and when at its height it was very much like Maria Olson's before she died. I have never seen a case of smallpox since the first year I have been a medical student. I have seen hundreds of cases of measles. I have seen measles approaching the character of Maria Olson and Spring's, but not nearly so bad; they were similar in character, though not so severe. I diagnosced these cases myself; I have no other authority to refer to in support of my opinion that they were measles. I thought at the time, just previous to Maria Olson's death that it was in some respects like a case of small-pox. I do not recollect any person suggesting to me it was small-pox. At that time and on different times I conversed with the captain as to the nature of the disease. I cannot say if I alluded to small-pox. Spring told mo he thought his complaint was small-pox. I told him I did not think it was. I told the captain that I thought Spring's disease was a malignant form of measles, but I also said I had doubts as to the nature of the disease. This was the first time I expressed my doubts as to the nature of the disease. It was the subject of general conversation throughout the ship, which I have heard myself, as to its being small-pox or measles. On 13th January I was taken ill with inflamation of the ear; this continued for two or three days, during which time I was unable to attend to my duty ; but on the evening of the 14th, although ill at the time, I attended to one serious case, which I heard of accidentally. Mr. Badland and the captain during this time had been attending to my cases. I wished to administer an enema to two foreign children. Being denied the assistance of the interpreter, I could not explain my wishes to the parents, who refused to allow me to carry out my treatment. On the following day a complaint was made against me for negligence by the emigrants, and Captain Harrington took all the power out of my hands as ship's doctor. The conversation occurred in the saloon. Ido not recollect who wa.s present. Captain Harrington told me I was not well, which was true ;he also said I did not understand the treatment of emigrants, and that he would take charge of the sick, and any person who was ill was to be referred to him; and he asked me for the key of the medicine chest, which I gave up, under protest. I considered I was relieved from my duty, and the captain told me so. There is an entry in the official log on 15th January, the date I refer to, to the following effect: — " Long. 34° W., Lat. 16° S. Monday, January 15th, 1872.—The emigrants complained against the doctor, en masse, for non-attendance, saying that they will not be attended by him." I made a protest, which appears in the log, on the same day. I still deny there was any foundation for such a charge. I was present when the charge was made by the emigrants. I consider the charge a general one; but I know of one special charge made at this time. Brand wanted medicine, and I refused him. I did so because I did not think he needed it. I heard no other charge made ; about twenty of the emigrants were present when the complaint was made. Swenson interpreted for the foreigners, McDonald spoke for the others. I do not consider the entry in the official log expresses what took place, as only a portion of the emigrants came, and what they said was, " That they would prefer the captain to attend on them instead of me, as I had neglected them." For a month subsequent to this date Captain Harrington did my duty, until he himself fell sick, when I immediately resumed my duty. During this interval, there was a great amount of sickness and many deaths occurred on board; but Ido not know this from my own personal knowledge. I recognize the official log marked A, produced, to which I had access during the voyage. . I certified the entries of deaths in it. I entered the deaths previous to the time I was relieved duty, and after I had resumed my duty. During the interval in which I was relieved of my duty, I merely signed the entries. Although the captain had relieved me of my duty, I consider he could not relieve me of this particular duty. I accept the responsibility of the correctness of the log referred to so far as the entries I have si<med. During the whole voyage I was cognizant of all who were seriously ill and were likely to die, including the time I was suspended. I have no other list of the deaths that occurred during the voyage except the official log. After resuming my duty, I attended to the sick during the voyage with the exception of one case, that of the man whose name is entered in the log as Peter Neilsen. He was the husband

CONNECTED WITH THE SHIP "ENGLAND."

33

G.—No. 3.

of Karen Neilsen, who was examined yesterday. I attended this man up till within two days of his death, and then ceased to attend him at his wife's request, as conveyed to me by the interpreter. He was.comatose when I left him, and died in this state. I had then no hope of his recovery. I did not consider that I was the surgeon of the ship at that time. I believed it was measles he died of. His symptoms were similar to what I have described in the cases of Spring and Maria Olson, but differed in becoming of an erysipelatous character towards the termination of the case. I saw no pustules. I saw pustules in Spring's case. I consider that a pustular eruption would have a different character from one in which there was no pustules. I mean that Spring's case advanced to a pustular stage, but that Maria Olson or Nils Peter Larsen did not advance to that stage before they died. The reference I have made in the official log (on 25th February) to the inhuman and gross neglect of the father of James Burness refers to his not having followed my directions. This child was in a filthy state, covered with vermin ; and his father refused to wash him as I instructed, and otherwise neglected him so as, in my opinion, to accelerate his death. In Mrs. Burness's case, she fractured her fore arm, and I set it, in what^ I considered to be a proper manner. It went on very well until the 23rd, when Captain Harrington took charge of it, and I found it had been reset in an improper manner. The woman told me this was done by Captain Harrington, assisted by the carpenter. I had nothing further to do with the case. _ I reset the arm on one occasion before the captain took it over, restoring the position of the bones, which had become shifted. lam subject to epilepsy. I have had two attacks on the voyage. The first was during or after the period I had been suspended. The second was on the day before the Health Officer came on board. These fits prostrated me for about a day. The drugs I have to take exercise no effect in preventing me from performing my duty. I have taken a grain of opium at intervals of one or two days several times together, never in excess of that quantity. lam at times irritable, in consequence of my ill health. I informed the captain I had undertaken the voyage for the'express purpose of benefiting my health ; this was a day or two after we left home. The report marked Jis the official report made to the Health Officers by me on the arrival of the ship. At the time I made this report, I believed the epidemic on board was a malignant form of measles. I do not allude in my report to the disagreement I had with the captain, nor to the fact that I had been suspended from duty during the voyage. My report was written the night previous, and, although unwell, I could have seen the Health Officers and delivered it, but I was not called. The captain was not aware of the contents of my report. I consider my report sufficiently indicated the contagious nature of the disease to warrant the Health Officers placing the ship in quarantine. My report was handed to the Health Officers on the second day the vessel was in port. The only reason it'was not given on the occasion of the first visit was, that I was not called. The reason I did not allude to my having been suspended from duty during part of the voyage was, that the captain and I were again friends. I still believe that the epidemic on board has not been small-pox. I believe Spring has not suffered from small-pox. Subsequent to the arrival of the ship in port, Captain Harrington placed me under arrest. It was on Monday, the 11th March, 1872. My friendly intercourse with Captain Harrington was interrupted on that morning. I was on the poop, and he came and told me to go down below to my cabin. I had that morning breakfasted with the captain ; there were no words between us at the breakfast table. lam aware of no reason for Captain Harrington's change. He used force on the occasion of my arrest. In applying the routine of the Staffordshire Hospital to the ship, I mean that I applied it to the sick and the general cleanliness on board. I did not know that the buckets refused to me by the captain were fire-buckets. I have seen the same buckets taken down and used; Ido not know for what purpose ; the emigrants had buckets of their own, which were different from these. I never made an application for medical comforts to the captain which was not complied with in some way or other. I was aware that the surgical appliances on board were insufficient, and complained of this to one of the Inspectors. Captain Harrington was present when this was mentioned. Ale was one of the things I ordered for which the captain substituted something else. I believe and now know that ale is not in the list of medical comforts, marked F. I account for the missing leaves in my medical journal from the circumstance that my oil lamp was spilt over it, and destroyed the parts removed; there were no entries on the leaves I removed, with the exception of some I recopied at the time of the accident to the book. I have been engaged for two or three hours together writing in my journal, after the passengers have gone to bed. Ido not think the captain did his best towards the wellfare of the sick under his charge. I consider his interference with my practice was prejudicial in the case of Mrs. Burness; also, in superseding me, as he is not a qualified medical practitioner, he did not do his duty towards the welfare of those under his charge. I think he did his best towards preventing the spread of the disease. I asked Mr. Badland on 13th January to attend the sick for me as we were on friendly terms. Ido not recollect informing the captain that I was ill; I presumed he knew I was ill. On 15th January, when the complaint was made by the passengers to the captain against me, the captain pointed out to them that they ran a certain risk by declining my services, but that he would attend them, and would compel me to attend them if I was required. I said I would refuse to do so if they signed the papers declining my services. I subsequently dispensed medicine to the emigrants at the captain's command. Burness was one of the complainants on 15th January. The captain charged me with neglecting Peter Nielsen, and told me he would charge me with manslaughter for neglect of this man. I' ridiculed this, because the charge was unfounded. Swenson never complained to the captain in my presence as to my treatment of Peter Nielsen. After I had set Mrs. Burness's arm and attended it for three or four days, I asked Burness to withdraw his letter of complaint, and he refused. I attended his child James after that until his death. I know Mrs. Burness's arm was taken charge of by the captain from the following circumstances. I wrote a note to the captain marked X, and received the reply marked L ; the letter Kis a true copy of that sent by me to the captain. He had the original. Captain Harrington treated me with kindness during the voyage, knowing I was in ill health. I did not consult Captain Harrington before preparing my report, nor did I inform him of the terms of my report. I have repeatedly heard the captain say we would have to go into quarantine on our arrival; this was for several weeks before we arrived. I have no positive recollection of the captain telling me to discontinue sitting at his table on the evening Dr. Bulmer arrived on board. There was a complaint or a reiteration of the complaint made by the emigrants to Dr. Bulmer in my presence. The emigrants y

By request of Captain Harrington-

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REPORT OE COMMISSIONERS UPON MATTERS

came aft, in order to confirm to Dr. Bulmer the letters they had written and signed regarding me. Captain Harrington put questions to them through the interpreter. The single man referred to in my report to tho Board of Health as being at that time suffering from malignant measles, was named Hilton. He had it very lightly, and was only in bed a couple of days. When I made my report the case was in a state of desquamation, and the man was going about. I thought he would be fit to mix with the public in a week. Miss Tee fell sick on sth February. Her case was also malignant measles, and was in the desquamating stage at the time I wrote my report. As compared with Hilton's case, Miss Tee's case was equally infectious at the time of our arrival. She was going about on deck then. I did not mention Miss Tee's case in my report, because she was not under my care ; the captain attended her himself. I think I was not bound to report Miss Tee's case. I did not make the omission intentionally. I had no communication with the captain respecting Miss Tee, excepting friendly inquiries after her health. I frequently offered my services to attend her, which were declined. My official report to the Health Officer was intended to set forth the actual state of health on board the ship, excepting no persons. Alexander Johnston, being duly sworn, saith as follows :—- lam a legally qualified medical practitioner. lam Provincial Surgeon and a member of the Board of Health. I have been in practice twenty-one years. I have been through epidemics of small-pox; one at Guy's Hospital, London, and the other in Gloucestershire. The first of these occurred about twenty years ago. I have seen cases of small-pox since that —on the occasion of the " Kaikora " being placed in quarantine in Wellington about four years ago. I have seen measles constantly up to the present date. It is endemic here ; but it is not so malignant as I have seen it at home. There is a hybrid form of disease called " rothhelm," which is a co-existent form of scarlatina and measles. I have never seen this disease, but am aware of its characteristics. It has only been distinguished within the last six years, as far as I know. I have only noticed it in medical journals within that period. I have seen the person named Spring, who came out in the ship " England " her last voyage. I have also seen Miss Tee, who came out in the same ship. They were convalescent when I saw them. I consider they had been suffering from small-pox. The eruption was in the desquamating stage, and I have no doubt that the disease was small-pox. I have never seen such scabs or markings in the face as were apparent in these cases from measles. The pockmarks or pittings occur after no other disease but small-pox. I have seen a few markings after chicken-pox ; but during convalescence, the markings can easily be distinguished from small-pox. From what I know of the disease called " rothhelm," Ido not consider that the cases above referred to could have been that disease. Small-pox is a pustular disease. A pustule can be distinguished from a rash, so as to be easily recognized and described by a non-professional observer. I was present at the examination of Dr. Leigh on the 24th April before this Commission,and heard him detail the symptoms of the case of Mariaolson,an emigrant by the "England." I would have no hesitation in describing the disease from which she suffered to be small-pox. Although no pustules are mentioned, the other characters are sufficient to form an opinion. There is no other character absent in the description of this case except that pustules are wanting. Still I believe that pustules must have been there ; and if a non-professional observer stated that pustules were there, then I think he must have been right. The period of incubation of small-pox before the eruption comes out is fifteen days. It is never shorter than that. I have never experienced it lasting for twenty-two days, nor have I ever read of its doing so. If I saw a case of small-pox with the eruption appearing after being twenty-two days at sea, I should say there must have been a previous case on board; but the infection could be carried for a much longer period in clothing that had not been fumigated. On Sunday, the 10th March, I went down to Somes Island, where the " England " was lying, and then for the first time learnt there was small-pox on board. On the previous day I went to meet the ship in the Harbour-master's boat, and got within easy speaking distance. Captain Halliday asked Captain Harrington if they were all well on board, and he replied they had had a great deal of sickness, but that they were all convalescent at that time, except an infant; that they had been suffering from measles, and had had sixteen deaths. I asked for the doctor, and the captain said he was not well. I went on the following day. I went to the ship to get a report from the doctor, and told the captain I would come for that purpose. When I got to the ship I saw two or three people at the side. I was within about twenty feet of the side. These people looked bloated and puffy in the face, as if they had had some severe illness. The doctor then came forward and brought a short report. He said, We have had the measles very badly, but I have made a condensed report; which he handed to me (now produced, marked J). As soon as I read the report, I judged that the people on board had had small-pox. It was from the symptoms mentioned on the second page of that report that I judged the disease to be small-pox. I announced my opinion to the captain, and read the extract referred to. The captain expressed great surprise, seemed rather excited, and challenged the doctor (who was present) to produce any entry in his books where he had called it anything else but measles. In my opinion, when people are walking about on a ship pitted with pockmarks, as were some of those on board the " England " that I have seen, as Spring was for instance, the most casual observation must have recognized it as small-pox. I have no reason to believe that Captain Harrington reported the disease on board to be measles when he knew it to be small-pox, excepting the opinion I have given before. On the Sunday Captain Halliday made me acquainted with the fact that Miss Tee was on board, and that she was very ill. Captain Harrington brought a man to the ship's side who was badly marked with small-pox. He said that whatever the disease is, this has been a very bad case. He meant the man he brought to the ship's side. The captain informed me on the Sunday, that the doctor had been off duty a great deal on account of ill health, and that he had no complaint to make against him. In cases of small-pox the period of incubation, according to my experience, is twelve days. The rigors have no constant period of occurrence, nor any constant intensity. The pustule in variola confiuens always pits—by which I mean, that it always carries a central depression. It becomes confluent after that stage.

By Commissioners.

By request of Captain Harrington.

By request of Dr. Leigh.

CONNECTED WITH THE SHIP "ENGLAND."

35

G.—No. 3.

EVIDENCE TAKEN AT MASTERTON BEFORE A. EOLLETT HALCOMBE, COMMISSIONER. John Swenson was duly sworn as Interpreter. Claus Petersen Maii, being sworn, said: — lam a German. I come from North Schleswig. I left for New Zealand about the 18th November last. I went from my home to Copenhagen, where I stayed at a seamen's boarding-house. From Copenhagen, I went to Kiel in a steamer, between decks, with all the Danish emigrants; at Kiel we went straight from the steamer to the train, which carried us to Hamburgh. At Hamburgh we had a meal, but did not sleep there. We went on board a steamer for London. We came to the Dock, and were landed with our things. A man met us there with a horse and cart, and we walked by the cart which was loaded with our baggage, and in about half an hour reached the ship " England." I slept on board the ship the same night, and continued to do so till she sailed. Ido not know the date of the " England's " sailing, but it was either three or four days after we arrived in London. The day we started from London we got to Gravesend. At the time I started for New Zealand from Schleswig, I was living, and had been for six years, in a house alone with my family. Neither I nor any one of my family had been sick for years, nor am I aware that there had been any sickness in my neighbourhood, for some time before I left. I did not know of any small-pox in the village I came from, except one case, that of a fellow-countryman who came from France after the war between France and Germany was over. This man was ill about three weeks, and was up and walking about nearly a month before I came away. This was not a bad case, and though I knew the man personally, I was not with him at all. About seven days after I came on board the " England," some spots came out on my face ; they were about the size of a threepenny-piece, and high, much in shape like a big pea, and white in colour ; they itched very much ; there was matter in them, which I squeezed out. Dr. Leigh saw them, and said they were the effect of foul blood. The people on board told me I had small-pox, and that was the reason I went to the doctor. By people, I mean my fellow-countrymen; but I cannot remember which of them said so, though I distinctly remember the fact. I asked the doctor, Dr. Leigh, if it was small-pox, but he said it was not. Ido not remember how long they lasted; some w rent away, and others came. I think it was about twelve days before they all disappeared. These spots were only on my face and head, not on any other part of my body, and I felt no illness while they were upon me, but two or three days before the pimples came out I had a slight cold and cough. I remember the inspection at Gravesend. I went with the rest of the immigrants upon the poop, and passed close by the gentlemen who inspected us. The gentlemen stood close by the ladder which goes down from the poop to the main deck. The interpreter who came with us from Copenhagen stood beside the Inspector ; but I was not spoken to. I have been vaccinated, but not since I was a little child. The marks are clear on my arm. Friday, 3rd May, 1872. John Knowles, being duly sworn, saith as follows ; — I am the Under Secretary for the Public Works Department, and as such have possession of certain correspondence from the Agent-General with reference to the immigrants who came out by the "England." I produce a list of these. For Wellington there were 87 souls, equal to 69 adults ; and for Hawke's Bay 15 souls, equal to 12 adults. The total number of immigrants who appear on this list is therefore 102 souls, making 81 adults. I give this information from a list enclosed in a letter signed by the Agent-General in London (Dr. Featherston). The official number of the list is P.W. 72—305. I am well acquainted with Dr. Featherston's handwriting, and I know the signature to the letter accompanying the lists to be his. I also produce a copy of the instructions given to Captain Harrington, dated sth December, 1871 (marked N) ; copy of the instructions to the surgeon, dated 7th December, 1871 (marked O) ; copy of instructions to the matron, Mrs. Hall (marked P) ; and the like to the mess-constable (marked Q). The two latter without date. Tho lists of the immigrants above referred to are certified to by Captain Harrington and by Messrs. Shaw, Saville, and Co. I produce a letter from Dr. Featherston, dated 12th December, 1871, in which he advises the shipment of the immigrants, which letter concludes with the following remarks : — " When the ship was inspected at Gravesend on the 7th instant, by Her Majesty's Emigration Officers, I was present, and satisfied myself as to the general comfort and well-being of the emigrants." This letter is signed by Dr. Featherston. (Letter produced and marked E.) Geoege Henry Harrington, being recalled on this date, says:— I received the letter of instructions addressed to me, and a copy of which is now produced (marked N.) ; as also the instructions given to the matron and mess-constable, copies of which, marked O and Q respectively, are now produced to me. These are correct copies. I did not receive the surgeon's instructions, nor did he ever show them to me. John Thomas Leigh recalled. I received the letter of instructions, a copy of which (marked E) is now produced and read to me. The journal (marked I), formerly produced by me, is the journal referred to in Dr. Featherston's letter. I have, I believe, got the list of passengers there referred to, unless I have torn it up. I cannot say whether it was in the journal or not. I did not show the captain my instructions, nor have any conversation with him about it. I now produce the list of passengers, marked S.

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Monday, 6th May, 1872. James Hackwoeth, Collector of Customs at the Port of Wellington, states :— I have received the bond produced marked T, and it is sent to me by the Customs authorities in London. This is the bond required to be given under the provisions of " The Passengers Act, 1855 • " and from the fact that this bond has been so given, and that the ship has been duly cleared by the Customs authorities in London, I should infer that the certificate of clearance of the Emigration Officer had been obtained.

A. Extract from the Official Log of the ship " England " from London to Wellington.

Thursday, December 28,1871, at 4.30 a.m. At sea, Lat. 27° 29' N. Long. 23° 23' W. Carl Neilsen, the son of Neils Neilsen and Bergitte Hans Detter, departed this hie, aged three years (steerage passengers). 28th December, 1871.—Carl Nilsen setat. three, died this day of diarrhoea, exhaustion.—John T. Leigh, Surgeon' &e.; G. H. Harrington, Commander. ' Betty Maria Olson, astat. twenty-eight, died this day of morbilli; ill eight days (steerage passenger).—2nd January, 1872.—John T. Leigh, Surgeon in charge. Eriday, January 12, 1872. Saturday, January 13. North Atlantic. Lat. 9° 39' N. Long. 27° 16' W. Lat. 6° 40' N. Long. 27° 16' W. Lat. 8° 20' S. Long. 34° 0' W. Lat. 11° 0' S. Long. 34° 0' W. Alexander Tom Burness, setat; four years, died this day of morbilli, bronchitis fourteen days.—3rd January, 1872.—John T. Leigh, Surgeon in charge. Kirsten Larsen, setat. two years, died this day of infantile diarrhoea; ill five days — 12th January 1872.—John T. Leigh, Surgeon in charge. Dinah Christopherson, astat. six months, died this day of morbilli, seven days - infantile diarrhoea, six days.—13th January, 1872.—John T. Leigh, Surgeon in charge. Karen Olsen, died this day of infantile diarrhoea, aged two years.—18th January 1872. —John T. Leigh, Surgeon in charge. Olave Olsen, died this day, aged two years six months, of infantile diarrhoea.— John T. Leigh, Surgeon in charge. The emigrants complain against the doctor (era masse) for non-attendance, saying that they will not be attended by him. Thursday, January 18, 1872. Eriday, January 19, 1872. Monday, January 15, 1872. Lat. 23° 58' S. Long. 32° 5' W. Lat. 26° 40' S. Long. 31° 49' W. Lat. 16° 00' S. Long. 34° 00' W. Sunday, January 21, 1872. Wednesday, January 31. Thursday, February 1, 1872. Friday, February 2, 1872. Thursday, February 8, 1872. Lat. 30° 20' S. Long. 31° 22' W. Lat. 44° 24' S. Long. 2° 53' W. Lat. 45° 6' S. Long. 0° 20' W. Lat. 45° 49' S. Long. 4° 44' W. Lat. 48° 40' S. Long. 35° 28'E. I deny the accuracy of this statement made against me, and am fully prepared to answer any and every charge brought against me during this voyage from London to Wellington.—John T. Leigh, M.R.C.S., Lie. Apoth. Soc. Lond., and Licentiate in Midwifery, Registered. February 15,1872. Lat. 50° 15' S. Long. 75° 00' E. Lat. 50° 11' S. Long. 75° 10' E. Lat. 50° 8' S. Long. 126° 17' E. Anthon Busk, died this day of infantile diarrhoea, aged one year ten months.— John T. Leigh, Surgeon in charge. Carl Hanson, died this day of infantile diarrhoea, aged two years.-—John T. Leigh Surgeon in charge. ' Karen Olsen, wife of Ole Olsen, gave birth to a male infant.—John T. Leigh, Surgeon in charge. Maria Bergersdatter died this day, of measles, aged thirty years.—John T. T JO igh Surgeon in charge. . ' Jessie McDonald, wife of George McDonald, gave birth to a male child.—John T Leigh, Surgeon in charge. Jane Burness this day sustained a comminuted fracture of radius and ulna lower third right.—14th February, 1872.—John T. Leigh, Surgeon in charge. George McDonald Burness died this day, tetat. seven months; bronchitis and exhaustion.—John T. Leigh, Surgeon in charge. George McDonald, setat. six days, died this clay of inanition from birth.—John T Leigh, Surgeon in charge. James Burness, setat. five years, died this day of morbilli, followed by infantile diarrhoea, and accelerated by inhuman and gross neglect of its father (mother being disabled by an accident).—John T. Leigh, Surgeon in charge. 28th February, 1872.—Jane Ann Burness, setat. seven years, died this day of infantile diarrhoea and exhaustion.—John T. Leigh, Surgeon in charge 3rd March, 1872.—Peter Nielsen, setat. forty-three years, died this day of morbilli eighteen days.—John T. Leigh, Surgeon in charge. 7th March, 1872—Lauris Hansen, setat. six years, died this day of infantile diarrhoea.—John T. Leigh, Surgeon in charge. February 15,1872. February 25,1872.

B ROUGH SKETCH OF PART OF SHIP "ENGLAND."

C.2 r v B ERTH P? Berth w ; Berth w.c Surgeon DERTH Berth Berth Berth OERTH Berth 4— Berth ia Berth Cargo 0 Cargo )h b ( Berths .✓ i-X-^c^ "ojwtaJ s I u --. '^Berth Berth A Tank H*TCf Table Table Tank Main Hatch Tank Cargo H BERTHS ; o.™ Berth CQ I Berth Berth (5 i Berth Berth Berth Girls Passage Girls Berth Berth Berth ~e Qz refe: !ENCE. From C to G shows Saloon. Erom G 1 to G 3 shows between decks. A—Saloon. B—Fore. 0—Aft. D—Water Closet. E—Captain's Cabin. E—Passage. GGGGGG —-Representing between decks. X—Hatch for Married Couples. Main Hatch. H—Hatchway for Men. -6=- Port Holes (7-inch Scuttle). Hospital, in aft part; breadth, 8 feet; length outside, 6 feet; height, 7 feet 6 inches. Hospital, in fore part; breadth, 8 feet; length outside, 6 feet 2 inches; height, 7 feet 6 inches. Aft part of Ship ; length, 46 feet; breadth, 32 feet, —for 70 adults ; without Hospital for 2 adults. Fore part of Ship; length, 11 feet 6 inches ; breadth, 32 feet, —for 16 adults ; without Hospital for 2 adults. [564

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c. Captain Harrington,— On board Ship " England," 15th January, 1872. We the undersigned steerage passengers on board the ship " England," from London to New Zealand, having witnessed the carelessness and inhumanity shown by the ship's doctor to those who required his aid, —we have determined, after mature deliberation, to have nothing whatever to do with him, leaving ourselves with the greatest confidence to your care for the remainder of the passage. Ealph Douglas. Geoege Hilton. J. W. Brand. John MacAulay.

D. Den 15 Januar, 1872. Wi samtlige Danskeog Norske folk (Mellemdekkspaoseserere) paa Skibet "England" pasereisen fra London till Wellington have ifolge af Dokkterens ligegyldihedog daarlige behanling imod vaure syge, opsagd hamalt tillid og tiltroseude, og efter som oi har fundet Captenen enkgellig og goatgorende man saa underkaster vi oss hoad Captenen for den. ovrige Delen af vaar reise finder godt passinde for dem som er eller muligen kune blive syge dete have vi alle under skrifort. F. P. Petersen. H. Larsen. E. J. Larsen. M. Hallberg. K. Ericksen. Peter Larsen. J. Christianssen. N. P. Nielsen. P. Nielsen. O. Monsen. 0. Boesen. Claus P. Maii.

[Translation of above, as given by John Swenson.] " 15th January, 1872. "We all Danish and Norwegians, 'tween-deck passengers in the ship ' England' on a voyage from London to Wellington, have, because of the doctor's carelessness against the sick, given up his services ; and as we find the captain a good and kind man, we wish him to attend us for the rest of the passage in a medical capacity."—[Here follow the signatures.]

Dl. 15th January, 1872. We tho undersigned, two married families, passengers in the ship " England," under the command of Captain Geo. Harrington, bound for Wellington, New Zealand, —we declare our intention to dispense with the services of the doctor or medical attendant, and place ourselves under the care of the captain of the ship, to find the best means he may think necessary, should we fall sick or be disabled. George McDonald. James Burness.

E. Captain Haerington,— Ship " England," Wellington, 15th March, 1872. Dear Sir, —I beg leave to state to you the charge I brought against the ship doctor or surgeon of gross neglect of his duty towards my son Alex. Burness, aged four years and four months, who died at sea. Tour obedient Servant, James Burness.

F. Medical Comports for 80 Second Cabin and Steerage Passengers.

Articles. Scale per 100. Quantities. Packages. Remarks. Carolina Rice W. India Arrowroot Barley 28 lbs. 28 lbs. 20 lbs. 20 lbs. 10 lbs. 22 lbs. 22 lbs 16 lbs. 16 lbs. 8 lbs. 1 bag 1 tin 1 bag 1 tin 1 tin In case Sundries. Sago rapioca Meat Soup Hutton Broth ?ort Wine Stout 3randy Vinegar ... lime Juice I In case Sundries. 50 tins 40 tins With Soup and Bouilli. 2 dozen 12 dozen 2 gallons 5 gallons 1 dozen 9 dozen 1 gallon 4 gallons 1 case 2 casks 1 bottle 1 bottle With Soup and Bouilli. In case Sundries. ililk 6 dozen pints 28 lbs. ( 22 tins liquid milk (_ 9 tins Swiss Milk 22 lbs. tlarine Soap Sugar

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G. London, 24th October, 1871. Memorandum of Chaetee entered into between G. H. Harrington, Esq., for self and other Owners of the ship or vessel called " England," AI, 860 tons N.N.M., whereof he is Master, now in London, and Shaw, Saville, and Co., Brokers and Charterers. The said owners undertake that the said ship being tight, staunch, and strong, and every way fitted for the voyage, and the ship, with her cabin and between decks cleaned, painted, and fit for the inspection of passengers, to the satisfaction of the charterers, shall forthwith be made ready, and proceed to such dock in London as the charterers may require, and shall there and in the river receive and take on board all such goods, passengers, &c, as may be required by the charterers, and thereupon, and on being despatched, shall forthwith, and with all due speed, proceed to one Port Wellington (as required by the charterers), in New Zealand, and there shall deliver the said cargo from alongside at the wharf, as per bills of lading. The whole ship, including poop and deck houses, is to be at the disposal of the charterers, for the conveyance of goods, passengers, specie, acids, gunpowder, and such other goods and cattle, excepting the room requisite for the crew and stores (they having the use of her raft ports, if any, and liberty to remove stanchions if required). Any cargo that, according to law, is not allowed to be stowed below, is to be carried on deck, as well as any other deck freight (provided sufficient space is left for navigating the vessel), the master being guaranteed against the dangers and accidents of the sea. The master to sign bills of lading in the usual customary manner, and at any rate of freight without prejudice to this agreement, for which purpose he is to attend daily at the charterers' office if required. The stevedore recommended by the charterers to be employed at the risk and expense of the ship, and under the direction of the master, to take in and stow the cargo —the charterers not being responsible for improper stowage. Should it be necessary to ship ballast, the same is to be provided by the owners. The room reserved for ship's tackle, apparel, provisions, water, &c, is not to exceed seven tons of /orty cubic feet for every hundred tons of the ship's register N.N.M. ; and if any excess above this is shipped, freight thereon is to be charged at current rates, and deducted from the first payment under this agreement. The ship to take Government stores, troops, and passengers, should they offer; and the owners hereby authorize the said Shaw, Saville, and Co. to sign, on their behalf, any tender for the same. The owners also undertake that the ship shall in every respect pass for the conveyance of passengers and troops, according to the Government survey. The master is to issue or cause to be issued to the several classes of passengers their provisions and other stores, according to the scales of victualling, provided for the purpose ; and also to such passengers as the law allows, and as shall be willing to purchase the same, the wines, spirits, and beer put on board by the owners, and receive from the said passengers the price thereof, at the rates fixed by the charterers. The master to keep, or cause to be kept, an accurate daily account of such issues, and to land and deliver to the agents of the charterers all surplus stores, fittings, water tanks, &c, and account to them for the same as aforesaid, according to the forms to be furnished him by the charterers. The cabin furniture, necessary linen and ware for the cabin table, as now on board, a sufficient staff of stewards, cooking, cooking apparatus for the passengers generally, to pass the survey of the Emigration Commissioners, and proper accommodation for the live stock and poultry, are to be provided by the said owners ; and the ship is to be manned, properly ventilated, and found in all manner of rigging, sails, boats, and appurtenances whatsoever by the said owners, according to the requirements of the Emigration Officer at this port. The cargo is to be brought to and taken from alongside free of expense and risk to the ship ; and the passengers to be landed, with their baggage, by the ship, according to the Passengers Act. The vessel to be subject to the usual and ordinary Custom House and printing and advertising charges, not exceeding £10, of a vessel loading on the berth for owner's benefit, and to be consigned to the agents of the charterers at the port of discharge, paying the usual commission of 5 per cent, on the amount of freight paid in the Colony under this charter party. On the completion of loading, all responsibility of the charterers shall cease, as regards cargo, passengers, and Passengers Act, the charterers having the right to insure the passage money against the liabilities of the Act at owners' expense. In consideration whereof Shaw, Saville, and Co. agree to pay for the use and hire of the said ship the sum of £1,600 pounds, in manner following—two-thirds by bills at three months after the final sailing of the ship, or in cash equal thereto, at charterers' option, and the balance in the Colony on the due landing of passengers and cargo there. Surgeon, provisions, water casks, and. joiner's fittings to be provided for the passengers by the charterers, and all other necessaries as required for ships despatched by Her Majesty's Emigration Commissioners, to be found by the owners. Thirty running days, Sundays and holidays excepted, are to be allowed the said charterers for sending cargo alongside, reckoning from the arrival of the vessel at the loading berth with a completely clear hold, masts and rigging aloft and in order, purchase rigged for taking in cargo, and the ship in every respect ready to load as above named. The owners further engage that the ship shall be ready to leave the docks at the expiration of the said laying days, or sooner, if required by the charterers. If the ship be not ready, either on the owners' or charterers' part, as above named, then demurrage to be paid by the party in default at the rate of five pounds per day (Sundays and holidays excepted) ; but three clear days are to be allowed the charterers free of demurrage, for proper completion of stowage, the embarkation of passengers, and despatch of the vessel. In the event of the navigation of the river or docks being suspended from frost, the lay days are not to be reckoned during such period; and in the event of hostilities breaking out between England and a Maritime Power, charterers to have the right to cancel this charter party.

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The ship on her return to the United Kingdom, to be consigned to Shaw Saville and Co., or their agents, the owners paying the usual commission. Penalty for non-performance of this agreement, amount of freight. (Signed) G. H. Haretngton. G. H. H. Witness—(Signed) G. W. Jones. 24th October, 1871. (Signed) Shaw, Saville, and Co. (Signed) Shaw, Saville, and Co. Witness—(Signed) John Greenway. H. Suegeon's Agreement, Ship "England." Moore and Co., Agents for appointing Surgeons to Ships to all parts of the World, No. 14 A, St. Mary Axe, London, E.C., 2nd December, 1871. It is this day mutually agreed between Mr. John T. Leigh, Eegistered Member of the College of Surgeons, and Messrs. Shaw Saville and Co., the ship "England," as follows: —Mr. Leigh agrees to perform the duties of Surgeon on board the above-named ship, during the voyage from London to New Zealand out, only attending any person in the ship who may require medical assistance. To provide all surgical instruments required by the Government Medical Officer. To sign the Government Emigration Book. To sign ship's Articles when and where required, and to deposit with Messrs. Shaw Saville and Co. his diploma and testimonials, which are to be returned to him by the Captain on the vessel sailing. In consideration of which Messrs. Shaw Saville and Co. agree to provide for Mr. Lei°h a chief cabin passage, with mess at the captain's table as an officer of the ship, and pay as follows, namely: —The sum of twenty pounds, ten pounds of which are to be advanced. Shaw, Saville, and Co., Witness—F. Moore. Per N. E. Sutherland.

J. Medical Eeport of the Ship " England," during the Voyage from London to Wellington, New Zealand. This ship left Gravesend on the morning of Bth December, 1871, laden with 103 emigrants, composed of English, Scotch, Dutch, Danish, and Norwegians. The married people with their families were placed in the midships between the decks ; they numbered altogether seventy-seven ; the single men, eight in number, were placed between decks, in a separate compartment of the fore part of the ship ; and the single women, who numbered fifteen, together with three children, were assigned a portion of the ship underneath the poop, alongside the saloon cabin. The majority of the emigrants had been exposed to great hardships and very severe weather immediately preceding their shipment on board this vessel. This, I believe, greatly contributed to the severity of the epidemic and other illness from which we have suffered. At the inspection which took place at Gravesend by Dr. Featherston, previous to our departure, no serious illness was observed amongst any on board the ship, although it was noticed that the general physique of the married people was under rather than above the healthy robust standard. During the first fourteen days, a great number of the emigrants suffered from influenza and catarrhal symptoms, as well as from sea-sickness. On 23rd December, 1871, being fifteen days out, measles first made its appearance in a child amongst the married people. The disease quickly spread, and as we neared the Line it increased in virulence, and assumed an unusually malignant character. When the epidemic attained its maximum of severity which it did, about 15th February, the symptoms of the disease very closely resembled those of variola confluens. In the worst cases the eruption became confluent, and in some of those who recovered it was followed by a troublesome erysipelas of the head and neck. The symptoms of this epidemic were those of incubation, eruption, and sequela). The incubative stage lasted nine days; the eruptive six days, and the decline of the rash and subsequent desquamation from ten to fifteen days, according to the severity of the disease. The sequelae were principally infantile diarrhoea, dysentery, laryngismus, stridulus, and bronchial affections. We have in all had sixteen deaths, being six from morbilli, eight from infantile diarrhoea, one from bronchitis, and one from inanition from birth. There have also been two births during the voyage. At the present time we have only two cases of the disease on board, one being a single man, and the other one of Ole Olsen's children. All the others are either well or convalescent. The sick list has been unusually heavy all through the voyage. The following is a list of some of the diseases that came under treatment:—Gonorrhoea, Ascaris Lambricoides, A scarides, Fecal Abscesses, Erysipelas, Cephalalgia, Catarrhs, and accidents, one of which was a fracture of the forearm. We have had on the whole remarkable fine weather, and been favoured with fair winds. The provisions and water have both been abundant and excellent. John T. Leigh, M.E.C.S., L.A.C., and L.M. Eegistered, Bth March, 1872. and Surgeon in Charge.

K. Mr. J. T. Leigh, Surgeon, to Captain Harrington. Deae Sir, — I am sorry you would not listen to me last night, for I hoped that by a little amicable discussion we might have been able to arrange our temporary estrangement, and even now I am

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willing that there should be a friendly feeling between us, and with this object I have ventured to write this to you. I think, upon reflection, you will see that you have put yourself in a false position by taking Mrs. Burness's case out of my hands, and undertaking the treatment of it yourself, conjointly with your ship's carpenter. I also believe, and feel it my duty to tell you, that you are not aware of the very probable result which will happen to that woman's arm, if left to your care and that of the carpenter. The evil I refer to is what is termed amongst surgeons anchylosis, or a false union of the bones ; and if this occurs, the woman will permanently suffer from this defect, which means, in other words, that she will lose two very important functions of the limb, namely, those of supination and pronation. An injury of such a kind will permanently disable her ; and after it has occurred, which it will have done by about the time of our arrival in Wellington, it will then be too late to remedy the mischief. If you and your carpenter persist in treating the case, and Mrs. Burness is willing that you should do so—well, I have done with it, and wash my hands of the affair. But I must also tell you, that if you do so, and not allow me to do my duty, by again taking charge of it, I shall then feel that I am but doing right in telling Burness and his wife of the probable result they may expect, and to whom they may be thankful for the injury, As it is, I believe that you have postponed the recovery of the woman (by breaking down the provisional callus thrown out, and disturbing the arrangement of the tissues), if not anything more serious. I send this with a most earnest desire to re-establish our former friendship and mutual respect one for another. In case you do not deign to reply to my overture, I would inform you that I shall keep a copy of this letter. I am, &c, J. T. Leigh.

L. Captain Haeeington to Mr. J. T. Leigh, Surgeon. Deae Sib,— _ " England," 24th Feb. I am somewhat surprised to receive this communication from you, asking to be allowed to " settle our difference." In the first place, allow me to tell you that I do not quarrel either with subordinates or equals. With reference to my taking charge of the people, you must be aware that they requested me to do so, in consequence of the neglect and maltreatment which they received at your hands ; and the case of Mrs. Burness was undertaken by me on the same alleged grounds, she having requested my assistance, in consequence of your having reset her arm three times during the first ten days after the accident, and having neglected to bind it up properly, in addition to which she informed me that you had told her that you did not care if she lost her arm so as you got ashore. Tou must be quite aware that I shall not tolerate such conduct to my passengers. If any of them allow you to treat them professionally, I must insist that your language shall be decorous, otherwise, if applied to, I shall consider it my duty to interfere, and, if I think desirable, to suspend you entirely from your duty. And I remain, Sir, Tours truly, J. T. Leigh, Esq. G. H. Hareington.

N. Dr. Featherston to Captain Harrington. 7, Westminster Chambers, Victoria Street, Sir, — Westminster, S.W., sth December, 1871. As the captain of the ship " England," for Wellington, New Zealand, I beg to recommend to your care the Government emigrants on board, and in reference thereto I have to request your attention to the following observations. The number of single women being so small, no duly trained matron has been appointed in this instance ; but I have selected one of their number, Mrs. Hall, to act in that capacity under your authority and direction. Tou will observe from the instructions addressed to her, enclosed herewith, that you have authority to remove her, should you see fit to do so, and appoint some one else to the office, in which case all right is forfeited to the gratuity of £3 payable by the Government of New Zealand for the faithful performance of her duties. I also enclose instructions for the mess-constable for the single women, whom you are requested to select from the married men, and who is likewise placed under your authority. Should he neglect his duties, you are authorized to remove him from his office, and appoint some one else—the removal, of course, making void all claim to the gratuity of £3. Wishing you a prosperous voyage, I have, &o, I. E. Featherston, Captain Harrington, Ship " England," London. Agent-General.

0. Dr. Featherston to Mr. Leigh. 7, Westminster Chambers, Victoria Street, Sir, — Westminster, S.W., 7th December, 1871. As surgeon of the ship " England," the care of the Government emigrants is confided to you. It will be your duty, apart from the medical charge of them, to maintain discipline and good order,

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also to promote a good feeling among the various nationalities. In this duty you will be cordially supported by Captain Harrington, whose well-known experience will be of great service to you. Any rules which he and you adopt for their comfort and well-being will have to bo strictly enforced. Mrs. Hall, one of the emigrants, is to undertake the duties of matron, upon the recommendation of Captain Harrington ; but in case of her neglecting the same, you will observe, from the instructions framed for her general guidance, that she can be removed. A mess-constable is also to be appointed for the single women, so that there shall be no occasion whatever for any girl proceeding to the galley or the fore part of the ship. The emigrants have been instructed to look to you as their guide, adviser, and protector throughout the voyage. A list of the Government emigrants is furnished in the accompanying " Medical Journal." Wishing you a prosperous voyage, I have, &c, I. E. Featherston, To Surgeon, Ship " England." Agent-General.

CORRESPONDENCE. No. 2. Memorandum for the Agent-General, London. (No. 37-72.) The ship "England," having on board Scandinavian and other emigrants for Wellington and Hawke's Bay, arrived in Port Nicholson on the 9th instant. From the documents accompanying the enclosed narrative* of the proceedings and occurrences with respect to this vessel, you will learn that serious contagious diseases —small-pox and malignant measles—broke out amongst the emigrants soon after leaving London; that sixteen deaths occurred during the voyage, and that since her arrival one death has taken place, and several passengers are still under medical treatment. In consequence of the vessel being in quarantine, the narrative enclosed is necessarily defective ; and while I do not wish in any way to prejudge the case, yet it is apparent that great inattention has been shown to the patients during the whole voyage. The circumstances will form the subject, here, probably of judicial, or at all events of official, investigation ; but I wish, meanwhile, to impress upon your notice several points of grave importance, into which I wish you to institute, as far as you can, a searching inquiry, and in respect of which, for the future, to take the most stringent precautions to guard against their possible recurrence. 1. In your letter of the 16th November, you do not mention the names of " the highly respectable firm" in Hamburg with whom you have contracted for the shipment of foreign emigrants from that port, nor do you mention the names of the firm in Copenhagen who are to select the Danes, nor of that in Gothenburg who are to select the Swedes; but I notice with much surprise that Mr. Horniman has been permitted to select the Danes by the " England," notwithstanding that, in his previous shipment of Scandinavians, there was, as reported in my letter to Mr. Morrison, of 13th May last, much that was highly objectionable and destructive of confidence, in addition to the selection of improper characters. Tou will notice that, in Mr. Leigh's report on the Bth March, it is stated that "the majority of the emigrants had been exposed to great hardships and very severe weather immediately preceding their shipment on board the ' England,' " and that " this greatly contributed to the severity of the epidemic and other illness from which they have suffered." I understand that this refers to the emigrants having been conveyed from the Continent to London, in the month of December, on the deck of the steamer ; and Dr. Bulmer also, in his report of the 14th instant, states " the Scandinavian passengers declare that they were treated like so many brutes in their passage from Copenhagen to London." I am not able at present to form any opinion as to whether a course so detrimental to health and injurious to emigration, was pursued with your knowledge; but lam glad to notice that in your letter of the 16th November, you expressly state that " between-deck passages " were to be provided for all the Scandinavian emigrants. Should Mr. Horniman (who is, I presume, the agent in Copenhagen) have neglected to carry out your intention in this respect, you will at once inflict such penalty as your agreement may empower you to impose. As disease broke out about a week after sailing, I regret that I have not been informed of the precautions you have directed to be taken for the approval and medical examination of the emigrants * As the circumstances detailed in the narrative are included in the evidence appended to the Report of the Commission, this Enclosure is omitted. 11

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EEPOET OE COMMISSIONEES UPON MATTEES

selected and shipped from the Continent by the contracting firms. Until I receive such information, I am not able to ascertain whether these contracting firms have neglected any of the precautions they were instructed to take; but it should at the same time be stated what provision was made for the accommodation of the emigrants during the period between their arrival in London and their embarkation for New Zealand. To the first of these two points I have already called your attention fully, in my memorandum No. 28-72,* of the 19th February last. 2. It appears to me that all emigrants, before they embark for New Zealand, should satisfy a competent medical officer, appointed by yourself, that they have been vaccinated, and failing to do so they should be at once vaccinated by him. I need scarcely impress upon you the absolute necessity of preventing any emigrants who may be found to have been suffering from an infectious disorder embarking on board ship before he shall be pronounced, after medical examination, perfectly cured. 3. The selection of proper medical officers for emigrant ships is a matter of vital importance. Not only is it necessary that he should bo professionally qualified and in good health, but he should also possess at least an ordinary amount of firmness and tact; and I think that he ought not, therefore, to be approved by you until you have been satisfied, in writing, as to his medical fitness, character, and antecedents. Even then, however, I think it would be advisable to obtain the recommendation of some recognized responsible official body in London, —such, for instance, as that which is connected with the Colonial Land and Emigration Commission. I addressed you on the subject of gratuities to medical officers in my memorandum No. 18,f of 16th February, but I now suggest for your consideration whether, in view of a considerable Government emigration, it would be practicable for the Government to obtain, and keep in their employ, a staff of surgeons, accustomed to the duties of emigrant ships, rather than be dependent on casual applicants. I understand the Colonial Land and Emigration Commission have long adopted some such system with very beneficial results. 4. Due care in the approval of ships and ships' officers is also essential; and although lam not prepared to say that in this case there have been any faults in these respects, I think a full report on this subject should likewise be transmitted. I shall be obliged by your forwarding to me as soon as possible a detailed report of the investigations which you may institute into the matters referred to herein, and also a complete narrative of the proceedings taken in respect to these particular emigrants, from their selection in their own country to their departure from England; and, should there be anything of great importance affecting the subject, which you think should be known here without delay, you will use your discretion in telegraphing it. Tou will be good enough to bear in mind that the information called for in reference to the emigrants by the " England " is information which it is desirable should be supplied more or less fully on the departure of every emigrant ship, and you are requested to supply it accordingly. W. Gisborne. Public Works Office, Wellington, New Zealand, 16th March, 1872.

No. 3. Memorandum for the Agent-General, London. (No. 47-72.) With reference to my memorandum No. 37-72, of 16th March, 1872, in which I reported the arrival of the ship " England," with Norwegian and other immigrants, and her being placed in quarantine in consequence of small-pox having broken out on board during the voyage, I have now to inform you that, in consequence of' all further absence of mortality, a portion of the passengers were admitted to pratique on the Ist April, and the remainder on the 16th instant. Tou will learn from the enclosed copy of a Commission issued by His Excellency the Governor, that an investigation is now taking place, the result of which I hope to forward by the Suez mail. Public Works Office, Wellington, 17th April, 1872. W. Gisboene.

No. 4. Memoeandum for the Agent- Geneeal, London. (No. 56-72.) My memorandum of the 17th April, No. 47-72, will have informed you of the issue of a Commission to investigate into the various matters connected with the ship " England;" and I now forward copy of the Eeport which that Commission has presented to His Excellency, together with the evidence on which the Eeport is founded. J As this Eeport (although dated the 10th instant) has only been sent in to-day, I am not by this mail able to draw your attention to several details connected with immigration which it suggests, but I will do so by the first opportunity. Meanwhile, however, I cannot too earnestly request that you will give the Eeport and evidence your prompt attention, with a view to the immediate remedy of the defects which those documents disclose. Public Works Office, Wellington, New Zealand, 13th May, 1872. J. D. Ormond. * Printed in Correspondence with Agent General. J See No. 1 of this Paper, t Printed in Correspondence with Agent-General.

CONNECTED WITH THE SHIP "ENGLAND."

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G.—No. 3.

No. 5. Memorandum for the Agent-General, London. (No. 64-72.) Having taken into consideration the Eeport of the Commission appointed to investigate the circumstances connected with the recent voyage of the ship " England," the Government desire to draw your attention to the defective arrangements which the evidence shows to have existed on board that ship, and to suggest the means which it is desirable to adopt in order to prevent their recurrence. 1. In consequence of the ship not having completed her loading at the date fixed for receiving the emigrants in London, they were subjected to great hardship during the first two days. Instead of being provided with shore accommodation, they were huddled together on board, exposed to unusually inclement weather, and irregularly supplied with food. . 2. His Excellency has been requested to call, the attention, of the Imperial Commissioners to the laxity displayed in the Government inspection of the ship and ship's stores. It is certain that the ventilation of the " England," when inspected at Gravesend, must have been deficient, and the mortality would probably have been still more serious had not Captain Harrington taken extraordinary steps to improve it. The evidence states that no inspection of the provisions and stores took place, an omission which, fortunately, in this case did not result injuriously, as all turned out to be of excellent quality. The attention of the Imperial Commissioners will also be called to the very formal nature of the inspection of the passengers at Gravesend. It is uncertain that the whole of them were inspected, and it is open to question whether, if that inspection had been more exact, the man in whom small-pox first appeared would have been allowed to proceed on his voyage. 3. Probably the sickness would have been greatly reduced had the surgeon not been in ill-health. It is otherwise difficult to understand how a duly qualified surgeon of the ability which the evidence shows Dr. Leigh to have at one time possessed, should have been unable to distinguish between measles and small-pox, and should have taken no steps for isolating the sick, or even been aware of its necessity. 4. The bad stowage of the cargo, or, rather, the loading with too much dead weight, which lead to the excessive rolling of the ship, and endangered its safety and that of the people. _ The following are the means for preventing a recurrence of these defects, which the Government desire to bring under your notice : — (1.) Tho Government have learnt from the London newspapers that there has been for some months an unusual number of cases of small-pox in London, and especially in the East End of it; and that it will therefore, for the present at least, be incurring a great risk if the ordinary lodging-houses are resorted to, should any of this season's ships be unprepared to receive the emigrants on their arrival. But the locality of the Docks is considered an undesirable lodging-place under any circumstances, not only on account of the danger of infection, but because of the moral risk incurred by the emigrants, many of whom will be young women from the country, under no efficient control. (2.) These twofold reasons long since induced the Imperial Commissioners to select Plymouth as the port of departure, and tho Victorian Agency also adopted it. The Government are desirous that the same course should, if possible, be pursued by yourself; and now that Victoria has temporarily suspended emigration, it is not anticipated that you will find much difficulty in making arrangements for the use of the well-appointed depot established,at that port. Its use will enable you to carry out a system of individual inspection by the ship's surgeon, as presently pointed out. I would take this opportunity of remarking that the statement of the surgeon placed in charge of the emigrants at the Quarantine Station, relative to the sufferings of the emigrants during the passage from the Continent to London, to which I called your attention in a previous memorandum, turns out to have been wholly incorrect. Tou will recollect that he reported to the Board of Health that " the Scandinavian passengers declared that they were treated like so many brutes, on their passage from Copenhagen to London ;" but the evidence happily establishes the fact that the betweendeck passage you had arranged to provide them with was duly provided, and that Dr. Bulmer's report was entirely without foundation. (3.) I have already, in my memorandum of the 16th March, No. 37, directed you as to the mode to be adopted in the appointment of surgeons ; and when that course is pursued by you, it will scarcely be possible that the evils which have resulted from the ignorance and want of attention displayed by Dr. Leigh can be repeated. Under the most favourable circumstances the medical inspection by the Imperial officers must necessarily be more or less cursory, and it will be requisite, therefore, that the surgeon should join the emigrants at the Plymouth depot several days before the date of embarkation, and closely inspect and watch them there. The Government are anxious to avoid burdening you with details ; suffice it to say that the plan pursued in the Plymouth depot, by the Imperial and Victorian Governments, is that which you are instructed to carry out, both at that port and the Clyde. (4.) The stowage of the ship, the fittings, hospitals, ventilation, and examination of stores, require that you should have in your employ an efficient " ships husband," who will supervise the whole of the details connected with ship-board, from the day the ship is placed on the berth to that of her departure. By no other means can you secure the faithful carrying out of the duties devolving both on yourself and the charterers. It is impossible that you can give personal attention to such matters, and it is only fitting that, in requiring you to bear the great responsibility and anxiety which the conduct of the large emigration now flowing to New Zealand imposes, every means should be placed at your disposal to enable you to conduct it advantageously to all concerned. The whole of the suggestions made by the Commission are more or less important, and I shall be obliged by your giving them your best attention, with a view to practical effect, so far as circumstances will allow. Public Works Office, Wellington, sth June, 1872. W. Eeeves.

EEPOET OE COMMISSIONERS ON SHIP "ENGLAND."

G.—No. 3,

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No. 6. Memorandum for His Excellency. Ministers have the honor to transmit herewith to His Excellency, three copies of the Eeport presented by the Commission appointed to inquire into certain matters connected with the recent voyage of the ship " England," with emigrants from London to New Zealand, and respectfully request that His Excellency will forward the Eeport to Her Majesty's Secretary of State for the Colonies and will at the same time call Lord Kimberley's special attention to section of the said Eeport headed Compliance with the Passengers Act, as affecting the ship ' England.' " Public Works Office, Wellington, New Zealand, sth June, 1862.

No. 7. Dr. Featherston to the Hon. W. Gisborne. g IH _ 7, Westminster Chambers, Victoria Street, London, 2nd May, 1872._ I have the honor to acknowledge the receipt, on the 26th instant, of the telegram of which a copy is herewith enclosed. The Hon. the Colonial Secretary, Wellington, I E.'Featherston. New Zealand.

Enclosure 1 in No. 7. (Telegram). „ Wellington 17th March 1872 General and Native affairs continue satisfactory. Ship "England quarantine. Seventeen deaths small-pox measles. Surgeon incompetent. Scandinavians complain of deck passage and bad treatment Copenhagen London. Horneman must not be employed. Investigate and report telly re surgeon s appointment and emigrants' complaints. Take stringent steps for proper examination of emigrants, and for their proper accommodation and treatment. Vaccinated emigrants alone should come. Letter by mail.

No. 8. Dr. Featherston to the Hon. W. Gisboene. glß _ 7 "Westminster Chambers, Victoria Street, Westminster, 2nd May, 1872. I have received, with very deep regret, the intelligence, conveyed in your telegram of the 17th March, of the sad condition in which the ship "England" arrived at Wellington, more especially as no batch of emigrants has been despatched under apparently more favourable circumstances _ The ship had been employed in the service, and was a favourite one on account both of its being well adapted for the conveyance of emigrants, and also for the high character of its commander, Captain Harrington, who was, on this occasion, accompanied by his wife and other members of his !"' olFar from being crowded, the emigrants—only in number equal to eighty-one adults—had, I believe, more than the usual space; but there was undoubtedly a somewhat undue proportion of y°UDf hey were' inspected by the Medical Health Officer, Dr. Humphries, after previous inspection by the surgeon of the ship, and all appeared to be in good health. . All had I understand, produced certificates of having been vaccinated. In Germany and Scandinavia, vaccination has for many years been compulsory. It is rather curious that not only was there the usual quantity of vaccine lymph put on board, but an extra quantity was supplied at the special request of the Surgeon Superintendent. The surgeon (though appointed by Messrs. Shaw, Saville, and Co.) had the necessary diplomas, and, moreover, several medals, which induced Dr. Humphries to make the remark that he was more * sunpry oTp'rovisions, water, &c, was duly examined and passed by the Emigration Officer. The ventilation seemed exceedingly good. lam afraid that it is one of those casualties which will occasionally occur in spite of every possible precaution. The following facts ought to be borne in mind:— . 1. That small-pox has for the last two years been raging m almost all the towns both m England and on the Continent. 2 That the period of incubation of the disease is about fourteen days. 3. That vaccination does not afford absolute immunity from an attack of the disease. I shall make the inquiries suggested in your telegram, and report further. I have, Ac, I. E. Featherston, The Hon. the Colonial Secretary. A gent-General.