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THE PARLIAMENT OF THE COMMONWEALTH.

HOUSE OF REPRESENTATIVES.

R E P O R T

OF THE

APPOINTED TO INQUIRE INTO AND REPORT UPON THE

ARRANGEMENTS MADE FOR THE

TRANSPORT OF TROOPS RETURNING FROM

SERVICE IN SOUTH AFRICA

IN THE

S.S. *DRAYTON GRANGE; *

AND

TO INQUIRE INTO AND REPORT UPON THE CIRCUMSTANCES

UNDER WHICH TROOPER HAROLD BURKITT, 2n d AUSTRALIAN

COMMONWEALTH HORSE, WHO WAS IN A SERIOUS CONDITION OF HEALTH, WAS NOT LANDED AT ADELAIDE FROM THE

8.8. *N O RF O LK *

Presented by Command of His Excellency the Acting Governor-General, and ordered by the House to be printed, 9th October, 1902.

[Cost of Paper. *Preparation, not given ; 1,150 copies; approximate cost of printing and publishing, £33.]

Printed and Published for the G o v e r nme nt of the C o mmo nw e a l t h of A ust r a l ia by R o ut . S. B r a in , Government Printer for the State of Victoria.

A 46 *F. 10681.

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REPORT.

To His Excellency the Right Honorable H a l l a m, Ba r o n Ten n y so n , Knight Commander of the Most Distinguished Order of Saint Michael and Saint George , Acting Governor-General and Com≠ mander-in-Chief in and over His Majesty's Commonwealth of Australia.

M a y it pl ea se Yo u r Ex c el l en c y *

We, the undersigned Commissioners, appointed by Letters Patent dated 12tli day of August, 1902, * to inquire into and report upon the arrange≠

ments made for the transport of troops returning from South Africa in the s.s. Drayton Grange, the reasons why the sick were not landed at Albany, and the circumstances under which Trooper Harold Burkitt, 2nd Australian Commonwealth Horse, was not landed at Adelaide from the s.s. Norfolk, though in a serious condition of health, * have the honour to lay before Your Excellency the following: *

That on appointment we proceeded with all speed to Sydney in the State of New South Wales, and there inspected the s.s. Drayton Grange, and had measure≠ ments taken and plans prepared of the vessel and of the structures and fittings specially provided for the accommodation of the troops.

We have since held 24 meetings *eight in Sydney, and sixteen in Melbourne, and have taken the evidence of 67 witnesses. These comprised the Principal Naval Transport Officer, an Assistant Transport Officer, the Fleet Carpenter, the Victualling Store Officer, and the Storehouse-man stationed at Garden Island; the Officer Commanding the Troops carried by the s.s. Drayton Grange, the Medical Officers of the Troops, fifteen other commissioned officers, the Captain and Officers of the ship, including the Chief Steward ; four officers from the Victorian Public Health Department, the Naval Architect attached to the New South Wales Navi≠ gation Department, the Health Officer stationed at Watson *s Bay, Port Jackson, a representative of the owners of the vessel, SO non-commissioned officers and men, and one stowaway. In addition, sworn declarations were obtained in connexion with the Drayton Grange from the Commandant of West Australia; the Disembarkation Officer at Albany; the Principal Medical Officer of Western

Australia; and from the Quarantine Officer for the Port of Albany. In connexion with the Norfolk, sworn declarations were obtained from the Acting Commandant South Australian Forces; the Officer Commanding Troops on the ship ; one of the Medical Officers with the troops ; the Acting Principal Medical Officer for the port of Adelaide; the Acting Disembarkation Officer at Adelaide; and from the Health Officer of the port of Adelaide. Evidence was taken in this manner

with a view to avoiding the expense which would have been incurred had these officers been called upon to give personal attendance. The officer commanding the New South Wales unit was, on account of ill-health, unable to attend, and his evidence,

also, was obtained in the form of a sworn declaration. All who were considered to be in a position to supply information of value on the subjects of inquiry were summoned by us, and in order that full opportunity for furnishing evidence might be afforded, advertisements were published in the Sydney and Melbourne press inviting any non-commissioned officers or men who were desirous of giving evidence to do so.

In addition to inspecting the Drayton Grange, visits were made to Garden Island, Sydney, for the purpose of inspecting the hammocks, blankets, medicine chests, and beer, returned from the ship ; to the s.s. Britannic and H.M.S. Katoomba, at Sydney, for the purpose of inspecting the sleeping accommodation provided for

the men, and to the Quarantine Station, Nepean, Victoria, with a view to obtaining further evidence from Dr. Couper Johnston,

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As regards the matters referred for inquiry, we have the honour to submit to Your Excellency the following Report : *

S.S. DRAYTON GRANGE.

It is unfortunate that our appointment was not sufficiently early to enable us to inspect the Drayton Grange with the troops on board, and all fittings and appointments in position. Before our arrival in Sydney the troops had disembarked, and certain structures and fittings such as the hospitals, the tables, and the hammock beams had been removed or dismantled; consequently, some of the information necessary for our guidance, and for the guidance of the surveyors and draughtsmen who prepared the plans, which would have been most readily and accurately obtained by observation, had to be gathered from indication and description. ' j

Idle plans attached to this report have been prepared to set out, as nearly as possible under the circumstances alluded to in the preceding paragraph, the main features of the Drayton Grange; also her accommodation as on leaving Durban, and as altered on the voyage.

I. *THE VESSEL.

The s.s. Drayton Grange is a British vessel, 6,591 tons gross, 4,245 tons net register; having twin screws; four masts; seven water-tight bulkheads and triple expansion engines ; built of steel in December, 1901, to * Lloyd *s * 100 Al Class under special survey. Length, 450 *5 feet; breadth, 55 "2 feet; depth to main deck, 30 6 feet; depth to moulded deck, 33 *5 feet. She has Board of Trade certificate for passengers, which expires in December, 1902.

We find that the Drayton Grange is structurally a suitable vessel for the transport of troops in large numbers.

II. *CHARTER.

The steam-ship was chartered by the Principal Transport Officer, Cape Town, for the conveyance of about fifteen hundred (1,500) *or more, if accommodation could be provided *return troopers to two ports in Australia on the following conditions : *

After the steamer had been brought into dock to a berth provided by the Transport authorities to land a small quantity of meat on board for Cape Town, ten days were to be allowed for embarking the troops *ship being ready *after which demurrage at the rate of fourpence per gross register ton to be paid; passage money to be payable at Cape Town on the number of men embarked at the following rates, viz.: Thirteen guineas for each private and Thirty guineas for each officer; ship to be fitted up at owner *s expense in accordance with the Admiralty Transport Regulations for Troops *that is, with boats, equipment, and necessary fittings to the satisfaction of the Principal Transport Officer; the troops to be fed as ordinary third-class passengers on a liberal scale *as agreed. The Transport Department to find all hammocks and bedding for the men. Officers to be berthed and fed as first-class saloon passengers. All dues, pilotage, tugs, &c., to be on account of and paid by owners of Drayton Grange.

In accordance with this Charter, the vessel was fitted up at Cape Town, under the authority and approval of the Admiralty Transport authorities, received from them permission to carry up to 41 officers and 2,002 non-commissioned officers and men, and proceeded to Durbail to. embark the troops.

III. *EMBARKATION.

The troops were embarked at Durban on the 10th and 11th July, 1902, and at 3.40 p.m. on the latter date, the ship unmoored, left the wharf, and anchored in the stream, starting on her voyage about four and a half hours later.

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Much confusion seems to have existed on board. This was apparently due to the absence of order in embarkation, to the men not being well in

hand, to no effective means being taken to prevent unauthorized persons boarding; to sudden compression into close quarters of so large a number of officers and men of different corps, and to the presence of details without officers. The leaving of port so soon after the completion of embarkation was, seemingly, on the instruction of the Imperial Embarkation Staff Officer, also on the decision *influenced by weather conditions *of the Master of the ship, and was against the protest of the Officer Commanding Troops. On page 206, of Part II. of Wolseley *s Soldiers * Pocket Book, the following appears: * *Under ordinary circumstances, if the voyage is to be a long one, it is advisable that the ship

should not leave until the day following the embarkation. * Had this suggestion been followed, before putting out into a rough sea, it should have evolved order, tested the numbers and the accommodation, provided time for all needful repre≠ sentations to the embarkation authorities, and allowed a fuller compliance than was attempted with the King *s Regulations for troops embarking.

No copy of the Regulations for His Majesty *s Transport Service was furnished to the Master of the ship, nor was one in the possession of the Officer Commanding Troops. The embarkation list records that 42 Officers and 1,941 other ranks, as specified in Appendix A, were booked for the vessel, but the Officer Commanding

Troops reports the actual embarkation to be 41 Officers and 1,918 other ranks, showing short embarkation of one Officer and 23 other ranks. The evidence proves beyond doubt that, in addition, others, most of whom possessed or borrowed uniforms, joined the ship, whether with or without direction of the

Embarkation Staff Officer does not appear. What the number in excess was it is impossible to say, witnesses varying greatly in their estimates, and no serious effort to discover it having been made by the Officer Commanding or the Master of the ship during the voyage. While a considerable number of

unrecorded embarkations certainly did take place, against this there were the short embarkations already mentioned. There is not sufficient evidence to prove that more than the 41 officers and 2,002 other ranks, authorized as the full complement of the vessel, went on board.

The loose methods that rendered unrecorded embarkations possible are to be deprecated.

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IV. *VOYAGE.

The vessel left Durban on the 11th July, 1902, at about 8 p.m.; arrived at Albany on the 30th July, at about 7.40 a.m., and there landed 3 Officers and 106 other ranks of the West Australian Forces in good health, and two other ranks, sick ; and 1 Officer and 197 other ranks of other State Forces, under Captain F. A. Dove, D.S.O., who to their credit, volunteered to remain till taken on by another vessel, in order to make room on board for the sick. She left Albany on the 1st August at 8.45 a.m. for Melbourne, reached Port Phillip Heads on 6tli August at 3.45 p.m., and landed 11 officers and 762 other ranks in good health and 66 other ranks sick. After fumigation the vessel left Melbourne

on the 8th August at 3 p.m. and arrived at Sydney on the 10th August at 7 p.m., landing there 26 officers and 756 other ranks in good health, and 29 other ranks sick. These figures do not include the unrecorded landings of those not on the official embarkation list.

The weather on the voyage, especially between South Africa and the Australian coast, was generally cold and boisterous, and frequently wet. Either a rough sea or a rolling swell was usually experienced, and the effect on the move≠ ment of the vessel was increased by her light draught, averaging less than 17 feet.

On sixteen of the nineteen days, between Durban and Albany, the ship *s log records either *heavy rolling, * *pitching, * *heavy swell, * *strong gale, * * high following sea, * or *dangerous sea. * The vessel *s steaming rate was about 1 ()i- knots per hour. Between Durban

and Albany she went as far south as 39∞ 55'. A more northerly route, though slightly longer, would probably have been less inclement, and consequently more conducive to the health and comfort of the troops.

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Quarters.

V. *ACCOMMODATION AND PROVISION FOR TROOPS.

The messing and sleeping quarters were on the upper and lower troop decks. The upper troop deck (immediately under the open top deck) was not divided by bulkheads, but the lower troop deck was so divided into three compartments. Particulars are given in the following table, prepared from information supplied, after inspection, by the Chief Shipwright Surveyor and Naval Architect to the Department of Navigation, New South Wales : *

Messing and Sleeping Quarters.

Cubic Space.

Superficial Floor Area.

Height.

Hinged Cattle

Hinged Portlights (Side Scuttles), t

Fixed iron Ventilators.!

Scupper Holes.

Upper Troop Deck ...

ft.

128,278

ft.

14,729 ft. in

7 11 10 56 4 24

Lower * * No. 2 ... 22,850 2,933 8 0 9 4 2

q ?> *∑ n u ∑∑∑ 29,308 3,688 9 0 14 4 2

>> n >> & ∑∑∑21,368 2,476 8 10 10 4 2 .

Totals ...201,804 23,826

* Each 5ft. Gin. to 6 feet high and 4 feet wide. The upper portion or the whole of each could be open, t Ten inches in diameter. % From about I 3∑ to 2 feet in diameter.

Messing on the troop decks was provided for by side and centre tables and forms, and sleeping entirely by hammocks suspended from hooks fixed in wooden beams. Almost all the tables were 12 feet long and 2ft. Sin. broad. Fourteen men were supposed to mess at each table, but more were allotted to some when the extension of the hospitals increased the pressure. The hammocks were slung above and across the tables, and had a stretch of 9ft. 9in., with a width of 16 inches between the hooks, and blocking-down to 6ft. 6in. from the floor was carried out, as pre≠ scribed by the Transport Regulations.

There was one hatchway in each lower compartment, and there were four in the upper troop deck. These hatchways measured from about 23 feet by 16 feet to 28 feet by 16ft. Tin., and through them were carried the companion stairs to the open deck.

The commissioned officers were quartered on the open top deck (immediately above the upper troop deck) in a deck-house, the roof of which formed the saloon or promenade deck. This promenade deck was set apart for their use till 26th July, when the larger portion of it was given up to the rank and file. The latter had the use for exercise of all other portions of the open top deck not occupied by buildings. Some of the men erected shelters on the roof's of these buildings, and used them as sleeping quarters during the voyage.

The Merchant Shipping Act of 1894 does not apply to transports, but if the accommodation on the Drayton Grange is compared with the requirements of that Act for emigrant ships, it is found that the space on her open iron deck and the cubic area in her troop decks is sufficient for more than 2,000 men, but that the superficial area of the troop deck floors is deficient, and would only accommodate fourteen to fifteen hundred. It has to be remembered, however, that in emigrant ships fixed bunks are provided.

The space allotted for messing, sleeping, and exercising is up to Admiralty transport requirements. But there was departure from Admiralty custom in the fixing of mess tables and slinging of hammocks amidships, with con≠ sequent occupation of room which would have furnished proper convenience for stowage of hammocks and kits. The hammock bins provided were too large to allow of the separation that is desirable of the hammocks of the different messes.

The uncertainty of each man receiving back his own hammock and blankets if deposited in the large and, in some cases, remote bin ; and also the desire to keep about his quarters baggage that ought to have been put in the baggage room, in the apparently well-grounded belief that otherwise he would lose it, resulted in the improper lumbering of the quarters by bedding and personal effects, and conse≠ quent difficulty in maintaining order and cleanliness. Such lumbering should not

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have been permitted by the Officer Commanding Troops, and an improvement of the hammock-stowing and baggage-room arrangements, which would have effectively secured to each man his own belongings, would have removed any excuse for it.

The open iron deck, while giving the required measurement, was so broken up by permanent and temporary structures as to be less useful than its area would indicate. Its usefulness was also minimized by its being unsheathed iron, chilling to the feet in the cold weather experienced, and yielding but a poor foothold in the almost continuous rolling of the vessel.

The relinquishing by the officers to the men of a large portion of the much smaller, but proportionately more useful, wooden promenade deck is to be com≠ mended. In view of the improvement in the men *s health which is said to have followed, and of the pressing need for additional deck space, even early in the voyage, it is to be regretted that the concession was not sooner made.

Though the hold of the ship beneath the troop quarters was generally unob≠ jectionable, one compartment is shown to have held decaying vegetables, from which a very bad smell entered a portion of the troop decks when the hatch was open. After complaint, and some delay, the vegetables were thrown overboard, and

the smell much lessened, though not entirely got rid of.

The two iron troop decks were sheathed with a wooden floor, the boards of Wood which were only 1 inch thick and about 2 to 3 inches above the iron, but the iron ?heathins of open deck was not sheathed. Article No. 72, Part 3, of Regulations for *ó. M. Transport Service, says * * Owners will have to sheathe, as required, iron decks with good deck planks not less than 2 inches thick, as neither men nor horses will ever be carried upon or under unsheathed iron decks. * No explanation is forthcoming as to why this very emphatic regulation was not obeyed.

Though it is necessary in the interests of health to sheathe the iron decks in the men *s sleeping and messing quarters, the sheathing itself, as constructed in the Drayton Grange, is apt to produce insanitary conditions in those parts. It was much thinner than deck planking, of a more absorbent wood, and not caulked, though tongued and grooved. It was, therefore, less water-tight and dirt-resisting than a wooden deck. It was not fitted so closely as to exclude water at the hatch coamings, ventilators, &c., and it had an open streak at the scupper ways to allow water to flow off it. In such circumstances, unless extreme care is exercised, the sheathing will become impregnated with dirt and grease, will remain long damp after wetting (especially when an excessive quantity of water is used in washing decks, as was frequently the case in the Drayton Grange), water will find its way and objectionable matter lodge underneath it, and noxious exhalations consequently arise in the quarters of the troops. Though greater precautions were taken by some of the units than by others, the evidence indicates that these evils were present and that no such care was exercised throughout the Drayton Grange as would pre≠ vent them. Evidence has been given of neglect in the removal of refuse from the troop decks, and of objectionable matter being found under the sheathing.

There are statements that some of the scupper-ways of the sheathed decks were used as urinals. To some extent this is substantiated, though the bad practice seems to have been limited, and to have been stopped by the men

themselves who objected to the misbehaviour of a few of their number.

The condition of all the decks was made worse by the general expectoration. The nature of the sickness on board, and the great prevalance of severe colds and coughs, induced extensive expectoration. Sputum on the decks and on the walls must have conveyed infection and increased ill-health. Some attempt to reduce

the nuisance and the danger ought to have been made by the distribution through≠ out the ship of spittoons, in the shape of boxes or tins containing disinfectant, and by insistence on their use. This was especially necessary in the troop decks, for there the men suffering from coughs were practically compelled, especially in the night, to expectorate on the floor on which they and others slept. Spittoons are frequently provided on troopships, and it is laid down in the Regulations for His

Majesty *s Transport Service (Appendix No. XII.,) Part 2, page 80, that the owners shall supply round wooden spittoons, 12 inches in diameter and 6 inches deep, at the rate of four for each 100 men.

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Ventilation. With port lights and cattle doors open, with ventilators and windsails draw≠ ing, the air supply was ample, at least in the upper troop deck. In some positions it was found too much, port lights and doors being closed and windsails tied up by those in their immediate neighbourhood, to the detriment of those further removed. Occasionally, though, owing to the light trim of the vessel, apparently for no long period, certain of the port lights (usually those in the lower decks) and of the doors were closed by the ship *s officers to exclude water. When that happened, or when many of them had been closed by the troopers themselves, or when ventilators and windsails refused to draw, owing to a following wind, the atmosphere was bad, not≠ withstanding the air movement through the hatchways. This is necessarily the case on crowded vessels under such conditions, if there is no forced draught. When the ventilation was defective the vitiating exhalations from so many human beings * some with none too cleanly clothes or persons *and from the defective and insani≠ tary deck sheathing, added to the ill odours from hospitals and sick persons in the troop decks, must have been extremely offensive and very deleterious.

Notwithstanding the great seriousness with which the Medical Officer in charge regarded the state of the atmosphere, he did not see that full advantage was taken of all available means of improving it. Attempts should have been made, but were not, to obtain from time to time a thorough air-flushing of the troop decks. Nor was any effort made to test the possibility of forced ventilation.

Latrines and The latrines contained in all 63 seats. The regulation number of seats for Urmais. the troops recorded as on board would be 39. Though sufficient by regulation, the

provision appears to have proved unequal to the need, and at times use was made of places not intended for the purpose, with uncleanly and undesirable results. The urinals were sufficient by regulation, and fairly so for requirements.

Both latrines and urinals had structural defects; some, for instance, having only a door of entrance to each row, without a door of exit at the other end, con≠ trary to the Regulation for H.M. Transport Service relating to the fitting of hired " ships, p. 8, section 15, which lays down that there shall be doors on the fore and

after ends. The troughs appear to have allowed at least some of their fluid contents to reach the iron deck, where, with the water from the wash-places and baths, it swished about with the roll of the vessel, till gradually run off by the scuppers. Wash-places Of wash-places there were five, containing 65 basins in all, or more than aªd bathe, required by regulation. Of baths, there was one for the hospital, in addition to nine

shower-baths for general use. The shower-baths were badly placed in narrow com≠ partments beside the urinals, which compartments were apt to be used as a urinal by men who could not find room in the proper place. This use made many reluctant to frequent the .shower-baths. There are complaints that the salt water for these baths

was seldom available, and that is stated to be a reason they were not in much demand. On the other hand, it is deposed that some men used them regularly. The fact seems to be that, owing to the low temperature, the exposed situation of the baths, their

iron floor, the severe colds from which nearly all on board suffered, and to the other reason already mentioned, there was unwillingness to use them, and even the more cleanly preferred the less trying, if less frequent, opportunity of a wash with fresh water, from a bucket, in a sheltered spot. The Medical Officer in charge has stated that, in view of the weather and the almost universal colds, he was rather

glad that the men were not bathing daily, because he was afraid if they did further colds would result. He knew that * men were dirty, but that would not be so

dangerous as their catching cold. * There were structural defectª which allowed some of the water from the wash-places, and the whole of the water from the shower-baths, to reach the iron deck. With a solid side rail only 2 to 3 inches higher than the deck, there should have been no difficulty in so constructing these buildings that the whole of the water, including any that fell on the floors, would have been carried over the side of the ship. As it was, outflow from them was rolled to and fro on the deck in a thin stream till worked off by the scuppers, reducing the usefulness of the deck affected and wetting the feet of those who had to be on it.

For any faults in the construction and arrangement of the wash-places and baths, as well as of the latrines and urinals, the Imperial Officers in South Africa

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who passed the work must be considered responsible, but the bad effects might have been relieved, if not entirely removed, by alterations and improvements which could have been made on the voyage. There were fifteen boats, of these six were in davits and nine on deck. They Boats, rafts, would accommodate 685 men. There were in addition eight rafts to accommodate 220, a total provision for 905, or considerably less than half of those on board. Though the boat room provided was so much below what would be necessary to accommodate the whole of those on the vessel, it appears to have been up to the Regulations of the Board of Trade for Emigrants' Steamers. The life-belts were sufficient for requirements.

The evidence shows that, if not a rule, it has been at least usual for troops clothing and returning to Australia to be supplied with a kit of sea clothing. The Officer Blankets∑ Commanding Troops reports application by himself for this in Newcastle without success, and a renewal of the application in Durban without fulfilment, apparently owing to hasty departure, except as to the caps, which he discovered at the end of the voyage to have been sent on board without his knowledge. The kits, if

issued, would have promoted the warmth and comfort of the men, and have relieved the necessity which some were under of wearing the dirty and possibly infected or infested clothing of a campaign. A full supply of blankets *two to each niqn *was provided for the voyage ;

but there seems no doubt that at least some of these were vermin-infested when distributed on board, and much discomfort resulted in consequence. Hammocks of Royal Navy pattern were provided to the number of 2,250, Hammocks, with hooks to swing a sufficiency for all the men. Though the regulation distance

separated the hooks, the hammocks were considered too close for any comfort if all occupied, and a number are stated to have been placed so near the sides, or to obstructions, as to be unserviceable. Owing to these objections and to the unwillingness of many to adopt the hammocks, a large number of men slept on the troop decks and tables. The sleeping on decks, described as damp and dirty, is

declared by the medical officer in charge to have been most deleterious to health. It also prevented free movement through the lines, interfered with visits of inspec≠ tion, and hindered ready access to the stairways leading to the open deck. It cannot be doubted that a more general use of the hammocks was desirable, but no strong effort was made to secure it.

The approval of the food is remarkably unanimous. It is described1 as Food and excellent in quality, unstinted in quantity, and generally well prepared. Some water∑ evidence was given of gross carelessness, in bags of flour and salt being laid on decks wet with water *possibly polluted *and of meat being placed on dirty decks. This was done by the crew of the ship, and ought not to have been permitted; but those witnesses who saw it failed to lodge the official complaints which should have prevented a repetition.

The water was good and issued in sufficient quantity for drinking and washing purposes.

VI. *MEDICAL SERVICES.

Three medical officers were detailed for duty with the transport. The Medical Imperial authorities at the base omitted to appoint the Medical Officer in charge 0fficers∑ of troops, therefore the appointment lay with the Officer Commanding Troops, and was not made by him until after the vessel had sailed. There was, consequently, no organisation of the medical service before departure. Under ordinary conditions the medical staff on board the Drayton Grange was ample, but with the epidemics which occurred only a careful apportionment of the work could have satisfactorily met the heavy demands on the Medical Officers. The Medical Officer in charge did not utilize the services of the other Medical

Officers to the best advantage. Lack of concord apparently existed, and a want of acquaintance was displayed with the Army Medical Service Regulations. Notwithstanding an arrangement early in the voyage for rotation of work, the

Medical Officer in charge subsequently retained the hospital duty in his own hands, the other Medical Officers being on duty only on alternate days as Orderly Medical Officers of the Day, and attending sick parades. An arrangement which allowed the junior officers time off, and kept the senior to continuous and absorbing

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Hospital Attendants.

Hospital accommoda≠ tion.

Medical Stores-and Equipment.

Sick Parades.

hospital work, was a reversal of the proper order, and precluded the Medical Officer in charge from thoroughly performing his most important functions *the inspection, observation, and control of all things relating to the health of those on board.

Ten of all ranks of the Commonwealth Army Medical Corps, Field Hospital Unit, were on board. These men were afterwards detailed for duty at the Fort Franklyn Hospital with patients landed from the Drayton Grange, and proved themselves a highly trained, well disciplined, and efficient unit. They were assisted in the hospitals on board by some of the 35 men of the Bearer Company

who returned by the vessel. Under ordinary circumstances the attendants enumerated were more than sufficient, but in the circumstances of this voyage a larger number of trained attendants would have been a great advantage. One room erected partly over the Nos. 4 and 5 hatchways, and partly

over the open upper deck, containing 40 standing bunks, was the only space allotted for hospital purposes on leaving Durban. This represented only two-thirds of the 3 per cent, minimum required by Admiralty Transport Regulations. A number of unhung swing cots, some 80 in all, or double the supply required by Regula≠ tions, were also jmt on board.

No isolation hospital for infectious disease was provided. The original hospital accommodation rapidly hlled, and five additional hos≠ pitals were fitted up on the voyage. (See Appendix B.) These extensions had to be placed where possible, and, for lack of suitable, unsuitable places were accepted. Some space was necessarily wrested from the scant quarters of the healthy, aggravating the crowding of the latter, as each sick man took the room of about three healthy ones. When this crowding process reached its limits, men needing hospital treatment had to be left to take their chances, and spread infection, in the troop decks.

No record is available as to the nature, quantities, or condition of medicines supplied at Durban. There is evidence that in place of a medicine chest a pair of Field Medical Panniers, Nos. 1 and 2, 1898 pattern, were sent. The contents of these panniers in no way represent the contents of the medicine chest which is the usual equipment of transports. Requisitions for further supplies to provide for the

1,200 men, then known to be embarking, were made at Durban by Dr. Gillies, who acted as requisitioner before the arrival on board of Dr. Shields. Though he reports difficulty in obtaining compliance with his requests, no refusal was given, and what was deemed a sufficiency for the 1,200 was eventually obtained from the Imperial Medical Officers. Any shortage *and the Medical Officers of the troops differ as to the extent of this *was due to no requisition being made by the Medical Officers on board, and no supply being provided by the Imperial Medical Officers ashore for 700 troops embarked after the fulfilment of previous requisitions. The uncertainty * not removed till after departure *as to which Medical Officer was in charge, may account for the short requisitioning, but the Medical Officers named must be held responsible for leaving port without satisfying themselves that there was a sufficiency of medical stores on board for all embarked. .

If a rather short supply of clinical thermometers is excepted, a sufficient quantity and variety of surgical and medical instruments, appliances, and dressings, in good order and condition, were provided ; and the same may be said of the *

medical comforts supplied by the ship. No disinfecting apparatus was placed on board. No complaint is made of the quantity, quality, or preparation of the food for hospital use.

Sick Parades were held twice daily, at 9 a.m. and 4 p.m., on the starboard side of the open deck, in a space extending from the General Hospital to near the counter. The sick, numbering on some days from 140 to 150, had to wait their turn for examination, exposer! to wind and weather, standing on the cold iron of the open deck, and sometimes getting their feet wet with the water from

the wash-places and urinals which passed from side to side with the roll of the vessel. This waiting frequently extended to two hours, and must have had injurious and possibly serious effects. Notwithstanding admitted difficulties, better arrangements should and could have been made by the Medical Officer in charge. ∑

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VII. *SICKNESS AND MORTALITY. The total number of patients treated in hospital between departure from Durban on 11th July and arrival at Sydney on 10th August (both days included), numbered 234, of whom 154 were suffering from measles, 39 from influenza, 23 from chest affections, 4 from dysentery, 4 from tonsillitis, 1 from enteric fever. The prescriptions for patients who attended at the sick parades between 11th July (departure from Durban) and 7th August (at Melbourne) both days included, numbered over 2,200, the illnesses treated at those parades being, to a large extent, inflammatory conditions of the respiratory organs.

The number of cases of illness of all kinds, as also that of measles, admitted daily to hospital *and, similarly, the number of prescriptions issued to men attend≠ ing the sick parades *increased to a maximum on 25th and 26th July, after which the numbers fell as rapidly as they had previously increased.

There is clear evidence that the infection of measles and of influenza was conveyed on board in the persons of men incubating those diseases at the time of embarkation, one or more new cases of both diseases having been recognised on the day after sailing ; and, as regards measles, almost daily afterwards ; while two men suffering from measles were put ashore on the very day the vessel left the wharf at Durban.

These diseases were aggravated in their effects, while others were both induced and aggravated, by exposure to cold and wet on the open deck, by the close atmosphere of the troop decks, and by other insanitary conditions, the existence of which is in evidence.

There have been 17 deaths to date, as set out in Appendix C; and some of the sick are still suffering and in hospital. In the case of Darcy Smith, whose name appears in the death list, sugges≠ tion of hospital neglect has been made, owing to his death not being discovered till some hours after it occurred. The evidence of patients who were in the same hospital at the time, and of the attendant who first recognised that he had died, show no lack of attention by the Doctor or by the Orderly in charge. The

Orderly seems to have gone round the patients regularly during his night watch, and to have visited Darcy Smith, but the latter passed away so quietly as to appear to be sleeping.

VIII. *DISCIPLINE AND ROUTINE. The evidence shows that no rigid discipline was attempted, and that the routine, laid down in the King *s Regulations, 1901, was only carried out to a limited extent. With irregular troops, the majority of whom had but a few months * service and little training, returning for discharge at the conclusion of a war, some of them time-expired, and nearly all about to revert to civilian life; with a crowded ship, sickness prevalent, and most unfavorable weather conditions, a too rigid discipline or routine might very naturally be thought undesirable.

But with all allowance for the circumstances, there appears to have been undue laxity permitted by the Officer Commanding Troops, especially in respect to the discipline and routine necessary to secure the prevention or removal of insani≠ tary conditions, to preserve health, and to promote comfort.

The Officer Commanding Troops speaks favorably of the readiness to obey his orders exhibited by both officers and men. Yet there is clear evidence, sup≠ ported by our own observation, of unnecessary dirt and untidiness. The men, on the testimony of their officers, seem to have generally sub≠

mitted with due subordination to the limited discipline and routine required of them. Two exceptions are mentioned *the one where some resistance was offered to ship *s officers placing more tables in already crowded quarters to make room elsewhere for hospital extension; and the other where some of the men of the Army Medical Corps and Bearer Company objected to give up their quarters for hospital purposes, on the ground that those they were asked to move to were already overcrowded, and were in such a locality as to interfere with the sleep

necessary in the day time for those attending all night on the sick. The Officer Commanding Troops says he knows nothing of the first-named case. It may be presumed, therefore, and it has been so stated in evidence, that what took place was not considered insubordination, or it would have been re≠ ported. As regards the second case, the Officer Commanding Troops does not

*™ . 10681, . C

11

12

charge insubordination. He explains that it was not an order of his that was disobeyed, but a suggestion rejected. But it appears as an order in the Brigade Order Book on 27th July, and it is as an order that the Staff Officer states in evi≠ dence he conveyed it to the men concerned. At the same time, it has to be re≠ corded that most of these men worked ungrudgingly for long hours in the hospitals, consequently any removal to quarters where they could not sleep when off duty would have been undesirable.

While the troops are not charged with insubordination, there is evidence of disorderly or disrespectful conduct on several occasions. The majority were well behaved, but a minority, taking advantage of the difficulty of their identification in the crowd sometimes offended. ∑

Disorder was induced by drunkenness amongst some of the men. Beer, said to be strong and heady, was served to the extent of one pint daily to each man desiring it, at a cost of Id. per pint. It is said that men obtained more than the regulation quantity by taking the allowances of non-drinking comrades, but the drunkenness appears to have been mostly due to spirits, which could be illicitly purchased from the ship *s stewards. There is evidence that the Officer Commanding Troops and the Master of the Ship endeavoured to stop this traffic, and that a reward was offered for the conviction of those carrying it on. As the supply must have come either from the ship *s stores or from a considerable illicit stock, it seems surprising that the issue from the former source could not have been prevented, or the latter source

discovered.

IX. *CROWDING.

According to Admiralty Transport requirements the vessel would not be over≠ crowded by the 41 officers and 2,002 men she had authority to carry. Considering all the circumstances, however, it must be found that she was crowded to a degree not advisable. Her passengers were returning troops, not troops being rushed to the front at all hazards; they were irregulars *the greater number with very short training, accustomed to ample space and air, and not fitted by experience or tuition to make the best of very limited quarters. They came from camps where infectious disease had been prevalent in their ranks, and, although apparently healthy when shipped, were almost certain to be accompanied by infection. The voyage is not a short one, it is in cold and stormy latitudes, and no port of relief is available between South Africa and Australia.

Economy can scarcely have been a reason for the heavy embarkation, as the men were paid for at a rate per head which would probably have been accepted by other vessels for any not shipped by the Drayton Grange. The charter guaranteed but 1,500 men, and had only that number been embarked, it would have been a reasonable complement in the case of partially- trained, irregular troops, and some of the unfortunate circumstances of the journey

would have been avoided. Without the introduction of disease, and with finer and milder weather, the voyage might have concluded without loss of life in spite of the number on board ; on the other hand, with the smaller number suggested the accompaniment of infection would probably have meant much sickness and, possibly, some mortality. There must always be discomfort and risk in the transportation of large bodies of men, but these should be minimized as far as circumstances admit. It cannot be said that all was done in that direction that might have been.

The difficulty of the task of the Imperial Embarkation Officers is recognised, and evidence has been received of the care and consideration generally extended by them to returning Australian troops. In this case, however, the conditions of the voyage could have been immensely improved by the shipment of only 1,500 men, while the cost of the return of the whole would probably have been but little, if at all, affected. With the lesser number there would have been room for the isolation of infectious cases, for the needed extension of hospital accommodation, for the sick parades, and for the better quartering and exercising of the healthy. The atmosphere of the troop decks would have been less vitiated, and consequently less inducive of infection from the illness that was introduced, and the sanitary provision would have been equal to demands.

131

The Officer Commanding Troops did not avail himself of a means of relieving crowding in the troop decks provided by the King *s Regulations * the division of the troops into three watches. By that arrangement, each third would have had four hours on deck and eight hours below in every twelve, and only two-thirds be below at the one time, thus reducing the impurity of the air and increasing the comfort in the troops * sleeping quarters. The Officer Commanding Troops states that he had sound reason for the non-adoption of watches in the

sickness and colds prevalent among the men, and the probable ill-effect of exposure at night on an iron deck, enclosed by only an open rail, in such weather as was experienced on the voyage.

X. *NON-LANDING OF SICK AT ALBANY. The wisdom of the recommendation of the Medical Officer in Charge, which obtained the indorsement of the Officer Commanding Troops, to land the sick at Albany is supported by the evidence. There can be little doubt the landing would have been beneficial to the sick, and, as little, that lives might have been saved by it.

On reaching the port the Officer Commanding Troops requested permission to land the sick. The evidence proves that the authorities at Albany were from the first adverse to receiving the sick. It is explained that this was owing to the lack of medical and nursing attendants, to the difficulty, and danger to the invalids, in landing, and to the conviction that the safer plan was to disembark healthy troops, and so improve the position on board for the sick.

The shore authorities appear neither to have attached due importance to the opinions of those who were more intimate with the conditions on the ship and the state of the patients, nor to have appreciated the fact that a hospital staff could have been constituted by the landing of a doctor and some attendants, to be reinforced by nurses when obtainable. The Officer Commanding Troops states that he suggested supplying a doctor and attendants from the vessel. This is contrary to the evidence given by the Quarantine Officer of Albany. But in any case it should have been patent that the landing of 60 severe cases would have relieved the attendants who nursed them on board and a Medical Officer of the troops, for shore duty.

As is shown by the telegram of the 30th July from the Honorable Walter Kingsmill, Colonial Secretary of West Australia, to the Quarantine Officer, Albany, reading * Please allow Lieutenant Hurst use Quarantine Station for invalided troopers from Drayton Grange; kindly acknowledge, * he readily assented to the reception of the sick. In view of that assent, the possibility of

landing attendants and a doctor from the ship, and the nursing assistance that would be forthcoming from Perth, without taking into account the generous tendering of aid by some of the ladies of Albany, which is mentioned in evidence, there seems no good reason why the landing should not have been approved and satisfactorily accomplished.

There is direct conflict of testimony regarding the communicating of the contents of the Colonial Secretary *s telegram to the Officer Commanding Troops on the vessel. The Officer in question says they were not communicated by the Disembarkation Officer at Albany, who interviewed him after receipt of the message, while the latter declares they were. Appearances support the recollec≠ tion of the Officer Commanding Troops. The Colonial Secretary *s telegram was dispatched from Perth late on the 30th July. The Quarantine Officer to whom it was addressed declares he at once telephoned the contents to the Disembarkation

Officer. The latter admits the receipt of the information; he was on board the Drayton Grange on the morning of the 31st July, took ashore an appeal from the Officer Commanding Troops to the Government Resident to facilitate landing of sick, and brought back an unfavorable verbal answer. It seems impossible that

the Officer Commanding Troops could have made that appeal or accepted the unfavorable reply if he had known that the Government Resident *s superior * the Colonial Secretary *had already given an unconditional assent. The state of the weather is mentioned as a further bar to disembarkation,

but the first day was fine, and though it rained on the second, the Officer

Commanding Troops says he would have detained the vessel till the weather

13

14

cleared, rather than not land the sick. Without some assurance of ultimate permission there would be no justification in detention, for if landing were not to be secured at Albany, the sooner the voyage was resumed, and a port reached where the sick could be disembarked, the better.

No absolute refusal to permit landing is in evidence, but the telegram of the West Australian Commandant from Perth, inspired by communications from Albany, intimating a preference for the landing of healthy troops, and the continued disapproval of the Albany authorities, were accounted a refusal; and, if the assent of tlie Colonial Secretary to the landing was not communicated to the Officer Commanding Troops, as seems probable, might reasonably be regarded as such.

It would have assisted the inquiry if the Officer Commanding Troops had conducted his communications after the first objection entirely in writing. For his own protection in so serious a matter he should have done so. Judging by the improvement in the health of many of the invalids that followed the landing at Port Phillip, it may be presumed that similar good effect, and possibly saving of life, might have resulted from landing the sick at Albany. It is consequently to be regretted that they were not disembarked. The non≠ disembarkation cannot be due to the Officer Commanding Troops, who asked, urged, and even pleaded *to save loss of life * (telegram to Commandant at Perth) for permission to land, but must be attributed to the responsible authorities ashore.

XI. *GENERAL CONCLUSIONS.

The initial trouble was the introduction to the ship of infectious disease. It was magnified by crowding and by deficient hospital accommodation. The deficient hospital accommodation necessitated the taking, for the sick, the space of the healthy, to some extent increasing the crowding of the latter. The presence in the troop decks of ill-constructed hospitals, and of sick men who should have been in hospital had room been available, extended the infection to others, many of whom were pre-disposed to sickness by the tainted atmosphere and unwholesome state of their quarters. The paucity of hospital shelter, even after extension, and its make-shift character, together with exposure to the inclemency of the weather at sick parades, and at other times, on a cold and wet iron deck, tended to trans≠ form simple into dangerous illness.

All was not done by those on board that might have been to remedy defects or to modify their consequences ; on the contrary, things were allowed which intensified the difficulties. The captain and officers of the ship are to be commended, as they appear to have readily responded to all requests from those in charge of the troops.

The officers of the combatant forces serving under the Officer Commanding are declared by him to have carried out orders, and to have performed their duties to his satisfaction, and there are no complaints lodged against them by the men. The Officer Commanding Troops, while possessed of the desire to do the best in a trying position, seems to have decided that * the best * was to accept things as they were, rather than make strenuous efforts to improve them *to endure rather than to overcome. As an officer of long standing in the Imperial and Colonial forces, he cannot be excused on the ground of inexperience.

The Medical Officer in charge never sufficiently took charge. He did not spare himself, but while he was overwrought in the hospitals, the other medical officers, though willing to take up additional work, were not fully occupied. By this faulty division of labour he withdrew himself from the keen general oversight which was his duty, and failed to give that attention to remedial measures which should have removed or mitigated some of the unwholesome conditions of which he so strongly complains. As the youngest medical officer on board, with the shortest term of active service, he appears to have felt some diffidence in exercising full authority. Considering the number and description of troops on board, and the.grave questions liable to arise, it would have been better if a medical officer of larger experience, well versed in the organization and duties of the medical services, had been placed in charge, and the appointment been made by the Imperial Authorities in South Africa prior to sailing.

15

IBS

Many of the men, though by no means all, contributed to the troubles, from which they and others suffered, by their own acts, habits, and negligence. Very few took effective steps, by representations to their officers, to have matters altered for the 1 fetter even where alteration was manifestly possible; and the majority seem to have frequently submitted to discomfort and worse, when a little arrangement or exertion on their part would have provided relief. It apparently was too generally accepted by many that, being homeward bound, active service over, and disbandment imminent, discipline was scarcely necessary, and any active and thorough performance of even the routine required in the interest of health ought not to be expected.

We find that the responsibility for what, under the circumstances of the troops and the nature of the voyage, was undue crowding of the vessel, for the insufficiency of hospital accommodation, and for the defects in the deck sheathing, rests with the Imperial Embarkation authorities in South Africa; for the nondanding of the sick with the authorities in West Australia; and for the failure to improve, and the unnecessary aggravation of, the undesirable conditions in the vessel, on the Officer Commanding Troops and the Medical Officer in Charge.

S.S. *NORFOLK. *

XII. *NON-LANDING OF TROOPER BURKITT AT ADELAIDE.

We find that Trooper Harold Burkitt should have been landed at Adelaide. That the refusal to permit his landing, entailing an operation at sea under unfavorable conditions, was an unnecessary risking of life, though fortunately unaccompanied by fatal consequences. The reason given for the refusal is that the Acting Principal Medical Officer and the Health Officer, who examined him, did not believe he was in any immediate danger. It is explained that the fact of Burkitt not being in hospital when seen, but dressed and amongst his comrades ready to go ashore, did not indicate a serious condition. The opinions formed by the Acting Principal Medical Officer and the Health Officer of the Port were opposed to those of the Two Medical Officers of the troops, who had better opportunity of judging correctly, and the accuracy of whose diagnosis, and reasonableness of whose insistence on landing Burkitt, were subsequently demon≠ strated. The landing of one man with the Adelaide sick was so simple a matter that refusal under the circumstances cannot be justified, especially as the Acting Principal Medical Officer, who is solely responsible, admits that he was under no orders which precluded his obtaining authority for landing the man.

A. McLEAN, President, (l .s.) g . Mc G r eg o r , (l .s.)

DUGALD THOMSON, (l .s.)

W. D. WILLIAMS, Colonel, (l .s.) D. ASTLEY GRESSWELL, J.P., M.A., M.D. (Oxon.) (l .s.)

16

APPENDIX A.

S.S. * DRAYTON GRANGE. *

E mba r k a t io n List .

Corps. Officers. Other Ranks. Total. Officer Commanding.

Australian Commonwealth Horse * 1st Battalion ... ...12 417 429 Lieut.-Col. J. H. A. Lee.

3rd Battalion ... ...11 482 493 Lieut.-Col. R. Wallace.

4th Battalion ... ... 4 82 86 Lieut.-Col. G. J. Johnston.

5th Battalion ... ... 5 5

6th Battalion ... ... 7 372 379 Lieut.-Col. G. G. H. Irving.

7th Battalion ... 37 37

8th Battalion ... 2 2

Australian Medical Corps ... 45 45

3rd N.S.W. Imperial Bushmen ... 6 330 336 Lieut.-Col. the Hon. Rupert Carring-

5th Queensland Imperial Bushmen 1 1

ton.

Scottish Horse ... ... 1 144 145 Capt. Long Innes.

Doyle *s Scouts ... ... 19 19

Discharged Irregulars ... ... 6 6

Totals ... ... 42 1,941 1,983

STAFF

Officer Commanding Troops * L ieu t .-Co l . J. S. LYSTER.

' Staff Officer * C a pt . F. A. DOVE, D.S.O.

Medical Officer in Charge * C a pt . D. A. SHIELDS, A.M.C.

" Chaplain * R ev d . G. S. OAKES.

Non-iommissioned Officers * St a f f Ser g t .-Ma jo r BLACK, 3r d A.C.H. St a f f Q.M.-Ser g t . FOLEY, 1st A.C.H.

APPENDIX B.

HOSPITAL ACCOMMODATION.

Location of Hospital.

Approximate Dimensions of Hospitals. No. of Standing Remarks.

Length. Breadth. Height.

Bunks and

1. On upper iron deck, aft ...

Feet. 40

Feet. 20

Feet. 10 40 Provided at Durban

*2. On upper troop deck ... ... 24 12 7 11 Added on voyage

*3. Smoking room on promenade deck 18 9 9 18 Added on voyage

*4. Orderly room on promenade deck 18 6 8 15 Added on voyage

*5. On upper troop deck, aft ... 35 *ä2 7 20 Added on voyage

6. On lower troop deck, aft ... 48 Added on voyage

- Total No. of cots ... 152

* These were abandoned owing to unsuitability, as other positions were obtained;

7

APPENDIX C.

125

17

DEATHS.

3 1 i=

Name. Bank. Battalion and Corps. Nature of Disease. Date of Death. Died at *

1902.

1768 liar land, T. ... Farrier ...3rd Batt. A.C.H. ... Measles, broncho pneumonia, and heart failure

2nd August At sea, between Al≠ bany and Mel≠

bourne

"2065 Gundy, C. ...Trooper ... rr rr * * rr

1439 Smith, JD. ... // ... rr * ,r rr H

107 MacGregor, R. ... " ∑∑∑ 6th Batt. A.C.H. ... Acute dysentery,

and heart failure 3rd August "

2026 Hodgman, V. L. ... " ∑∑∑ 3rd Batt. A.C.H. ... Measles, broncho pneumonia, and heart failure 5th August

1871 Thompson, B. ... * ... rr rr ...Pneumonia ... 7 th AugustMelbourne Hospital

50 Green, J. ... rr ... 1st Batt. A.C.H. ... Broncho, pneumonia 9th August Portsea, Victoria

911 Humphries, A. ... rr ... rr rr ... * rr I t

137 Dudley, p. ... Farrier ... 6th Batt. A.C.H. ... Dysentery ...llth AugustMelbourne Hospital

1509 iSherringham, H, Trooper ... 3rd Batt. A.C.H. ... Pneumonia ... 12 th August Portsea, Victoria 148 Barton. E. P. ... * ... 7th Batt. A.C.H. ... Broncho pneumonia 14 th August rr

222 Croome, W. ... rr 1st Batt. A.C.H. ... rr 15th August rr

125 McAndrew, A. ... n ... " " ∑%†âˆ‘ Measles and pneu≠ monia 19th August Melbourne Hospital

151 McFarlane, W. ... * 3rd N.S.W. I. Bush. Broncho pneumonia 20th August Portsea, Victoria 1747 Tarrant, E. W. ... " %†%†%† 3rd Batt. A.C.H. ... Measles and pneu≠

monia

27 th AugustSydney, N.S.W.

1418 Ryan, J . IS. ... Qrmr.-Srgt. rr rr ... Blood poisoning... 6th Sept. rr

Parker, * ... Trooper ... Scottish Horse ... Cerebral spinal

meningitis

1st October Ballarat

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