52
D.—2
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That the medical officer in charge of the depot—if there were such an officer, which is not clearly proved —neglected his duty in not taking proper means to separate the healthy from the sick, and in permitting persons infected with, if not actually suffering from, infectious disease, to be embarked for a voyage of uncertain length. That if there were no medical officer to take charge of a depot in which there were between 600 and 700 souls, crowded together for about ten days, the authorities by whom the depot was used showed great indifference to the well-being of the people so situated. That the authorities on shore were to blame for embarking the emigrants in such a condition, and tho surgeon-superintendent accepted a grave responsibility when he took charge of them, especially as he was aware of the unusual proportion of children to adults. We cannot understand how the surgeon-superintendent, with a knowledge of the fact that the emigrants were infected with measles and scarlet fever, could think it his duty to leave port until proper steps had been taken to stop the epidemic, and until convenient hospital accommodation had been provided on board. We agree with the surgeonsuperintendent in his strictures upon the want of hospital accommodation and medical care in the depot, and also upon the manner in which emigrants are selected and inspected ; but his remarks on these subjects only cause us the more surprise that he should have been willing to sail, evidently with a knowledge that he had such an infected cargo. He says, " There cannot be a reasonable doubt that if these people had been detained on shore, and placed in well-ventilated quarters, the sick being removed from them the moment the disease presented itself, the epidemic would have been much lessened in extent and severity." That there was no regular inspection of the emigrants until they were on board tho ship, otherwise the cases sent from the ship would have been previously found out. That the surgeon-superintendent was aware of the necessity for isolation on board, as is proved by tho precautionary measures at first taken by him; but he did not continue to use the same precautions after the 10th January. The cases first treated, and which were removed to the hospital, all did well, and the compartments whence they came were, during the remainder of the voyage, comparatively healthy ; thus showing the success that followed these prudent measures. The epidemic having been arrested and driven out from the single women's compartment, and from tho married people's compartment abaft the engine-room, suddenly, on the 21st January, reappeared, with great virulence, in the married people's compartment forward; but we do not find, in the surgeon-superintendent's report, that in these cases any such active and efficient steps were taken to separate the healthy children from the sick. After recording distinctly all the early cases, and giving a very satisfactory report of them, and the precautions taken to prevent the spreading of the infection, his report of the really serious outbreak of the disease is contained in the following words : —" On 21st January, a child forward was most virulently attacked with malignant sore throat, and from this date onwards, scarlet fever of a severe type continued prevalent there." Now, as these cases in the married people's compartment forward were not removed and entirely separated from the healthy, and as the same sanatory precautions were not taken as in the earlier outbreak, we consider that the surgeon-superintendent was guilty of neglect, and we cannot accept the want of hospitals as any excuse. A steamer of the capacity of the " Mongol," carrying only 313 emigrants, must have sufficient deck space to enable the captain and surgeon to improvise hospitals sufficient to accomodate even the large number of children on board. We are the more surprised at the apparent want of precaution taken during the second epidemic, starting on the 21st January, as tho surgeon-superintendent, in his report, so satisfactorily shows how successful had been his strict treatment during the early part of the voyage. It appears, from his report, that the surgeon-superintendent regretted that the strict separation of the two parts of the vessel was not maintained during the whole voyage : at the same time he took no steps to separate the sick from the healthy in tho infected compartments situated forward. His report mentions as a curious fact, that the number of deaths in the small families was out of proportion to the number of deaths in the large families. This, possibly, will be explained by the elder children in the large families having had the disease during some previous epidemic in the neighbourhood of their homes. That a proper supply of provisions and medical comforts for the emigrants was either not put on board, or, if shipped, the former were so badly stowed as to render a most important part of them —that for the young children—useless during a great part of the voyage ; while the latter must have been so carelessly issued as to exhaust the stock of the principal articles before half the contemplated voyage was completed. If the Despatching Officer's report is to be credited, they were " excellent in quality and sufficient in quantity," and yet the surgeon-superintendent appears to have felt severely the want of proper food for the children, and also the poor allowance of medical comforts. We do not however see, in the surgeon-superintendent's report, that any mention is made about the short supply of water—quite as necessary as any medical comforts. He could not have been ignorant of this abuse of tho emigrants, and yet he does not place on record that he ever remonstrated on their behalf, or threatened the captain that he would take proceedings against him on arrival in New Zealand. That the conduct of tho captain, in systematically depriving the emigrants of their legal allowance of fresh water, is deserving of the severest censure. A proper supply of water being essential to the health of the children, the deprivation of it most probably increased the virulence of the epidemic, and the mortality ensuing therefrom. We consider, also, that great recklessness was displayed by the captain in allowing the supply of water on
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