51

D.—2.

2. I desire, however, to inform you that I do not entirely concur in the censure tho Commissioners express on tho conduct of the surgeon, Mr. W. J. Davison, and that I do not think there is anything in that conduct to prevent you giving him charge of another ship, which I understand he is desirous of obtaining. He displayed great zeai, patience, and ability in charge of the quarantine station at Dunedin. I have, Ac, The Agent-General for New Zealand, London. Julius Vogel.

Enclosure 1 in No. 49. Repoet of Royal Commission upon " Mongol." May it Please Toue Excellency,— Wellington, 22nd April, 1874. We the Commissioners appointed to inquire into and report upon the origin and existence of infectious and other disease on board the steamship " Mongol," during a voyage from Plymouth to Port Chalmers, having proceeded to make the inquiry entrusted to us, and having taken evidence thereon, after careful consideration have agreed to the following report: — 1. Wo have been unable to take the evidence of the surgeon-superintendent of the " Mongol," as he has been detained in quarantine at Port Chalmers since arrival. This will account for the delay in sending in our report. We have, however, been supplied with a copy of the report on the voyage, made by him, w-hich has been of material assistance in enabling us to arrive at a conclusion. 2. The " Mongol " was fitted up in Loudon, and there surveyed, and passed by Mr. E. A. Smith, R.N., on behalf of the Agent-General, and by Captain Forster, Emigration Commissioner. She then proceeded to Plymouth, to embark the emigrants, arriving on the night of the 20th December, 1873. The surgeon-superintendent appointed in London was here dismissed for drunkenness, and Dr. Davison, who came out in charge of the emigrants, appointed in his place. 3. The emigrants for the " Mongol " had been collecting at a depot for about ten days prior to the arrival of the vessel. This depot is kept up by the Imperial authorities, and is available for emigrants to all the British Colonies. There is no evidence to show who had medical charge of it. 4. The evidence clearly shows that, during the time the immigrants were at this depot, there were several cases of scarlet fever and measles in it. Two cases of the former and one of the latter were removed therefrom. It is also clearly proved that the depot was over-crowded and badly ventilated. 5. There was no infectious disease among the crew during tho passage from London to Plymouth, or among the crew or first-class passengers throughout the voyage to New Zealand. 6. The emigrants embarked at daybreak on Monday, the 22nd December, and were inspected that afternoon by the health officer of the port and the surgeon-superintendent of the "Mongol;" and two families were sent ashore, a child in one being at the time ill with scarlet fever, and the children in the other only lately recovered from it. 7. The vessel sailed on the 23rd December with 313 immigrants, consisting of 188 adults and 125 children, making in all 215 statute adults. 8. On the 24th December a case of measles appeared among the single women, and was removed to the hospital; and on the 25th two cases of scarlet fever, also among them, were removed there. The latter cases occurred in a family already attacked on shore. On the 26th a child in the after part of the ship, where a few married people were placed, was also attacked with scarlet fever, she being likewise removed to the hospital. The disease did not spread further in these compartments in consequence of the precautions then taken. Scarlet fever did not appear again until the 21st January, when a child in the married people's compartment forward was attacked. This case was not removed to the hospital, but was treated in the compartment. From that date till the end of the voyage—the 13th February^ —fresh cases continually arose. These cases were allowed to remain in the compartment together with the children unattacked. 9. The total number of deaths during the voyage was 16. Of these, 3 were due to bronchitis, 4to measles, and sto scarlet fever; Ito ulcer, 1 to inanition, Ito sunstroke, and Ito diarrhoea. 10. The total number of cases occurring on board of the three first-mentioned diseases, were bronchitis, 8 ; measles, 67 ; and scarlet fever, 21. 11. It appears in evidence that the married people's compartment forward was kept in a filthy state. The atmosphere in this compartment was most pernicious, in consequence of the discharges from the patients and the odour from the disease generally. The surgeon-superintendent did not propose or apply for any temporary accommodation on deck, with a view to purifying the compartment. The bed used by one of the most virulent cases was allowed to remain after the child died, and was used for the remainder of the voyage without being disinfected. The passengers complained of the damp state of the bunks and of the compartment generally, which was caused by the leaking of the upper deck, and the carrying of water through the hatchway. 12. Throughout the voyage half of the three quarts of fresh water required by the Passenger Act to be delivered to each adult, was withheld from them by order of the captain. On the 10th February there was absolutely no fresh water on board, until a supply was obtained from the condenser, about noon. 13. For the first eight days after starting, children under four years of age were deprived altogether of their rations, and the reason given was that these rations could not be got at. The only food these children had during this period, was what their parents could spare from their own rations. 14. When twenty-six days out, the supply of eggs and preserved eggs was exhausted, and w-hen twenty-eight days out, the arrowroot, sago, and milk which ought to have been served out as ordinary rations for children under four years fell short. From that time forward, the surgeon-superintendent could only issue these articles as medical comforts for the sick. 15. The conclusions to be drawn from the above facts are— (1.) That infectious disease was known by all the authorities to exist at the depot while the emigrants w-ere there.