The following is a summary of the principal facts:
Hugh Mann and James D. Kennedy were partners in a contract on the
Crow's Nest Pass Railway at "Mann's Camp", about 80 miles west
from Seventh Siding, which at that time was the end of the track.
On the 3rd of January, 1898, Hugh Mann engaged the deceased
Charles P. McDonald and E. McC. Fraser to work on this contract
at $1.75 per day. Charles P. McDonald worked from noon of the
3rd to the night of the 14th January, 1898.
He was allowed for his work:
| |
10 1/2 days at $1.75 .....
Less charges store .....
Board .....
Medical dues .....
Mail .....
Leaving a balance due him of .....
|
$18.40
0.15
12.15
0.50
0.25
------
$13.05
$ 5.35
|
E. McC. Fraser worked on the 3rd of January, 1/2 day, 4th
January, 1/2 day, full time on the 5th and 6th, 1/2 day on the
7th, full time on the 8th, the 9th was Sunday, no time on the
10th, full time on the 11th, 12th, 13th, 14th and 15th, no time
on the 16th and 17th, and on the 18th, 1/2 a day, on the 19th a
full day.
His account stands thus:
| |
11 days at $1.75 .....
Board 17 days .....
Medical dues .....
Mail .....
Leaving a balance due him of .....
|
$19.25
12.15
0.50
0.25
------
$12.90
$ 6.35
|
| |
Probably Lee's Lake in Crowsnest Pass
area, Alberta, with W.H. Metzler seated on a horse - 18 Nov 1884 T.G.N. Anderton - Glenbow Museum call number
NA-2252-4.
|
At this time there were about sixty men in the camp in two
bunk-houses twenty-four by forty feet, wall seven feet, and two
windows thirty by thirty-six inches nailed up, and a door three
and a half by five feet. Each bunk-house was furnished with two
rows of bunks one above the other, on each side, each bunk six by
seven, leaving a passage way of about twelve feet. The lower
bunk one foot off the ground and the upper bunk five feet from
the ground, and leaving from one and one-half to two feet between
the upper bunk and the roof. The roof was composed of cedar logs
cut out trough shape, and covered with dirt. There was no
ventilation provided until after the death of McDonald and
Fraser. In describing this camp on the day after Fraser and
McDonald left, Louis Fontain, who had been engaged at Crow's Nest
Lake on the day Fraser and McDonald passed down, says:
"I reached the camp in the afternoon, and left next morning
because there was a good many sick, and it was not a healthy
place, and I left next morning."
Q. How many sick?
A. "There appeared to me to be like a hospital,
that is the short and long of it. I thought I could not stay in
that camp because I thought there was too many sick. I am a healthy
man and I want to stay there."
The beds consisted of poles with some brush on top of the poles,
and each man had to furnish his own blankets. The two bunk houses
were intended to accommodate sixty men each. There were twenty in
the house where Fraser and McDonald slept. There was only at this
time about one half of the full complement of men at the camp.
| |
Grading and timber gang in Crowsnest
Pass, British Columbia - 21 May 1898 Steele and Company - Glenbow Museum call number
NA-919-34.
|
The 15th of January is an important day in this investigation. On
this day McDonald for the first time remained in camp unable to
work. Dr. Gordon had on that morning called. He was on his way
to Mission hospital with a number of patients, one of whom he took
for Mann's Camp. While there he was told that there were a
couple of men who complained of sore throat. He left a cough
mixture and went on. There were a number sick in camp at this
time, but from the evidence it is clear that McDonald is referred
to as one of those who complained of sore throat; it is equally
clear that Fraser was not complaining at this time, as on the 15th
he worked all day.
Hugh Mann returned from Banff either on the evening of 15th or on
the 16th. Kennedy though frequently at the camp spent the
principal part of his time at another camp further west.
The cough mixture which was left by Dr. Gordon was spilt by the
carelessness of one of the men.
| |
Crowsnest construction workers with
picks and horses with fresnos - 1897 Photographer unknown - Glenbow Museum call number
NA-3903-82.
|
McDonald did not again go to work. Gallagher, Mann's walking
boss, had knowledge of this, but took no action with reference to
the matter. He seemed to regard it as a kindness to permit him to
remain in camp without further attention. McDonald grew worse.
For at least two days before they left camp he was not able to
take food, at least very little if any, and on the evening of the
19th, McDonald especially was in very bad condition, and had as
yet received no attention, except from the camp boy who offered
him food from time to time.
Dr. Gordon, in whose district the men were, was still west, and
did not again reach Mann's Camp until the evening of the 23rd, the
date at which they (McDonald and Fraser) arrived at Seventh
Siding. The western limit of Dr. Roy's district came to within a
few miles of Mann's Camp. His headquarters was at this time at
Crow's Nest Lake, distant from Mann's Camp about 30 or 35 miles by
the Tote Road. Dr. Gordon was at the Mission hospital on the
17th, 18th and 19th of January, and on the 20th at Cranbrook, both
places being distant from Mann's Camp about 70 or 75 miles. He
reached Wardner on the 20th.
On the morning of the 20th, Gallagher, Mann's walking boss, drew
the attention of Mr. Kennedy to the condition of the men. That
was the first that he, at all events, had knowledge of their
condition. He examined their throats and from such an
examination was at least suspicious that they had diphtheria,
(and McDonald expressing a desire to be sent to the hospital)
after consulting with Mann, decided that they should be sent.
Fraser requested that he might accompany his chum, and this was
agreed to. Mann says that he had decided independently of
Kennedy to have them sent to the hospital. No attempt had been
made to send for a doctor or to isolate the men, or to give them
any special attention, other than that I have mentioned by the
cook, if that may be called attention.
| |
Rock cut on Crowsnest Pass railway,
British Columbia - 23 May 1898 Steele and Company - Glenbow Museum call number
ND-9-36.
|
Mann's team had already gone east, but there was then at Mann's
Camp a team belonging to McAnnany, and Mann engaged this team to
carry them until his own team was overtaken. They were placed in
an open sleigh without a box, rigged as a freight sleigh, with
poles upon either side and three cross poles, and split cedar for
the bottom. Upon this they placed a quantity of hay with blankets
over the hay. At about half-past one or two o'clock in the
afternoon of Thursday, the 20th of January, the men lay down side
by side upon the sleigh, and, being covered with two or three
pairs of blankets, commenced their long and fatal journey. Fraser
had given his overcoat to McDonald, and had taken McDonald's
overcoat, which was not large enough to button. It was a bright
afternoon and not excessively cold. It was impossible to
ascertain the exact temperature in the mountains, but at Pincher
Creek it ranged from 24 above zero at 7 a.m., to 10 above zero at
9 a.m., the maximum being 34 above zero, with a westerly wind at
8 or 9 miles an hour. They stopped at headquarters and were told
by Charlesworth to go back to the quarantine hospital which they
had passed 1 1/2 miles east of Mann's Camp, but the driver,
following his original instructions, went on. Mann having
proceeded on horseback in advance overtook and detained his team
near Michel until the sick men arrived, and the men were then
transferred to Mann's freight sleigh (which was similar to the
other) drawn by four heavy horses and necessarily slow, and
proceeded on their journey, arriving at the Loop about 7 o'clock
in the evening.
| |
Loop in railway tracks, now known as
McGillivray Loop - 7 Jun 1899 Steele and Company - Glenbow Museum call number
ND-9-8.
|
They stopped all night at a place kept by
John Bidgood, otherwise called "Jack the Ripper". Mann did not
remain to see that the men were properly cared for, but was
overtaken the next day at Crow's Nest lake. The men were offered
food but were not able to eat, and were given, as appears by the
evidence of one witness, brandy and water to drink, apparently as
much as they would take. It appears from the evidence of Mr.
Bricker, a merchant of Crow's Nest Lake, and who was taking a
chance ride from Coal Creek, and accompanied the men from Mann's
Camp to Crow's Nest Lake, that the place where the men slept was
the ordinary bunk-house, occupied by a number of other men,
freighters and others who had stopped there over night. The
place was so little desirable that he slept in another building
recently erected.
| |
West of Crowsnest Lake at the
summit of Crowsnest Pass the railway makes an abrupt swing to the south to follow the south fork of Michel
Creek for about two miles ( 3.25 km ) to ease the gradient down the western slope of the mountains. The tracks
then turn sharply back north and run along the west side of the valley before resuming their westerly direction
towards Michel. ( See the map above. )
By swinging the right-of-way up Michel Creek, the railway engineers were able to have the tracks
descend 200 feet ( 61 metres ) in elevation. The loops and the CPR station were named for Donald McGillivray,
an engineer and contractor who worked on this section of line and on many other projects in British Columbia -
Robert D. Turner.
( See a recent photo of CEFX 105 West crossing the bridge over Michel Creek on
18 May 2006 at McGillivray. )
|
No attention was given the men beyond what I
have mentioned, and it is certain that during the night one of
them was out doors. In the morning there seemed to be some
difficulty in being able to arouse the men. They were in a
deplorable condition. The driver and Mr. Bricker having got
their breakfast, and the men, being unable to take food, were
helped into the sleigh and continued their journey. The men did
not speak, they lay upon their backs with their mouths open. They
left Bidgood's between 7 and 8 o'clock in the morning. They stood
a few minutes at Bull's Head, and Campbell told the driver to go
on to Crow's Nest Lake, a distance of 5 miles from Bull's Head.
At Crow's Nest Lake they were taken into Mrs. Taylor's
boarding-house. "McDonald's face looked swollen; never spoke;
both of them always had their mouths full open all the time they
were driving. They did not seem able to keep it closed." Mrs.
Taylor was very indignant that the men in this condition should be
brought to her place on account of her other boarders and her
family, and sent for Mann, and also sent word to Corporal Hilliam
of the mounted police, whose quarters were near. Mrs. Taylor
arranged beds and made them as comfortable as possible while they
remained there. They seemed to sleep. Mrs. Taylor felt worried
about their condition, and did not think one in particular could
live very long. Mann's explanation to Mrs. Taylor was that they
had been sent past Bull's Head by mistake. At this time the
condition of the men may perhaps be best described in Mrs.
Taylor's own language: "A kind of greenish yellow mucous was
flowing from his mouth and nostrils. His clothes were spotted
with the discharge." Another witness says: "He was lying with
his back towards me on a cot just inside the door. I walked
around in front of him to get a view of his face. He was lying
with his face quite close to the front of the bed, so that his
mouth projected in front of the bed. He evidently had been placed
in that position. There was a peculiar matter running from his
mouth. I can scarcely describe it. It was several colours. When
I saw him it was hanging from his mouth clear to the floor without
a break. It was running into a cuspidor on the floor. His face
was terribly swollen, and his tongue was swollen and protruded
from his mouth, which was wide open." The person here referred to
was undoubtedly McDonald.
This point, Crows's Nest Lake, was Dr. Roy's headquarters. He had
gone west and no attempt was made to recall him at this time. The
driver, Wadddy, who had driven the men thus far, went on to Macleod,
and Mann engaged the witness, Fontain, and directed him to take the men
back to Bull's Head, giving him a note to Campbell. The men were
replaced upon the sleigh and started to return to Bull's Head, a
distance of about 5 miles. Mann made no further provision for the men
and this was the last he saw of them. He left for Macleod that
afternoon. It would appear that all, or the greater part of the hay
which had before been under them had been fed to the horses. They
returned by the lake. There was a high wind, and the driver, Fontain,
found it impossible to keep them covered with the blankets. There were
two blankets and a quilt under the men and probably two or three pairs
over them. The driver says "I drove across the lake. It was about
three miles long. Then of course the wind blew very hard. Very hard
winds blow on that lake. It was impossible for me to keep the blankets
on the sick men on the rig. The wind blew them off of them every time.
It was cold enough that day so that I could hardly stand the cold
myself. The men never squealed. I never heard them say nothing from
the time I left with them until I got into Bull's Head." The note to
Mr. Campbell, who was agent and storekeeper of the Canadian Pacific
Railway at Bull's Head, was as follows:
| |
Crow's Nest Lake, 21st January, 1898.
Mr. C. Campbell, - The bearer has two very sick men that should be sent
down to the hospital. Kindly have them looked after. Kindly hire a
man to look after them and I well settle with you.
Yours, &c.,
HUGH MANN.
|
Campbell received the letter and wrote to the keeper of a restaurant as follows:
| |
Mr. Sangren, - Will you please keep these two sick men until tomorrow.
I will pay you. Take good care of them.
Yours truly,
J.C. Campbell
Bull's Head, 21st January, 1898.
|
Mr. Campbell took no further trouble with the men.
Q. Now, Mr. Campbell, just tell me yourself what provision there was for the comfort
or attendance of the men who were ill at that time on that part of the
route?
A. "I do not know of any."
| |
Summit, Crowsnest Pass, Alberta -
1900 Photographer unknown - Glenbow Museum call number NA-1314-17.
|
Mr. Campbell says that he understood it to be his duty to lend
assistance in cases of this kind. Corporal Hilliam forbade Mr.
Campbell from allowing the men to proceed further. The sick men had
passed Dr. Roy on his way west, the doctor being at this time within
20 miles at most of Bull's Head, but his exact whereabouts was not
known. He had been passed by the men on their way down, and if inquiry
had been made might have been found. The men arrived at about two or
half past two o'clock in the afternoon of the 21st, and remained at
Sangren's all night. Oscar Stenstrom, who was cook for Sangren,
describes their condition while at Bull's Head: "I went into the
restaurant. I saw the two men sitting there. They appeared very sick
and matter was flowing out through their mouth. I understood that
Charles Flodin, being the cook, cooked them some beef broth and tried
to give them all possible assistance, but they could only take liquid
beef tea, and finally between six and seven on the evening of the 22nd
the ambulance wagon called. When Mann's driver arrived at the
restaurant with the patients he was asked whether these men had any
contagious disease, but he answered that they only had sore legs, which
was accounted for by their staggering when they walked in from the
sleigh. On the strength of that statement, and Mr. Campbell's note,
they were received. Under other circumstances they would not have been
allowed, it being a public restaurant, having between 50 and 60 people
at each meal. They tried to get a doctor, but there was none to be
had. Finally, after having been kept there for 26 hours, the ambulance
arrived. The driver said his horses were played out, so he could not
start with them before morning. The owners of the restaurant insisted
on his taking them away from their place, as they at that time were
satisfied that the men were infected with contagious disease. After
some parleying the men were taken out in the ambulance about seven
o'clock in the evening".
It will be seen that the men remained at Bull's Head 26 hours, and I
do not hesitate to say that within half that time medical attendance
could and should have been obtained, and that the duty to obtain it
devolved upon Hugh Mann and Campbell, the company's agent.
| |
Horses and asses are tethered in front
of the Summit Hotel at Crowsnest Pass, Alberta - 1900 Photographer unknown - Glenbow Museum call number
NA-1171-13.
|
Corporal Hilliam, whose conduct throughout I desire to commend, having
received a message from Mrs. Taylor in regard to the men, went to Mr.
Campbell and told him: "That he had no business to send them there
to a public restaurant, but should have erected a tent away from his
camp and left a man in charge of the two sick men, as I believe the
men were suffering from some very serious disease according to the
information of Mrs. Taylor. He pooh-poohed the idea altogether that it
was diphtheria, and said it was nonsense. He (Campbell) then wanted
to have a four horse team hitched up and the men sent at once to the
end of the iron. I would not allow him to do so until I had been over
to see what condition these men were in. I then went over to the house
where these men were lying and saw the two men. One of the men, whom I
was told was Fraser, was so helpless that he could not move at all,
hands, legs, or anything else. He was lying on the broad of his back.
His face and neck were very much swollen and the spittle that he had
been trying to spit from his mouth was all over his own face and
clothes. He could just mutter, so that by getting very close to him
you could understand what he was saying. He asked me not to allow him
to be moved from that place, as he had enough driving about in the
cold, and he would rather die where he was. McDonald, who did not
appear so sick as Fraser although he could scarcely move at all, asked
me not to take any notice of what Fraser said, but if possible to have
them sent down to the hospital that day. I looked around the place and
went outside and called the proprietor out. He told me nothing had
been done for them since they had been in his charge, excepting what he
had given them himself, which was something to drink, and that he would
like to have the men sent away from his house. I told Johnston that he
would have to keep the men there and attend to them himself until the
doctor came, whom I had already sent for, and he was to allow nobody in
or out of the restaurant. I went back to Mr. Campbell and told him.
Of course I could not say what was the matter with the men, but they
certainly were not in any condition to be moved, and that they were to
stay in this restaurant until the arrival of a doctor, who would then
give this own directions and he could work on them as he liked. I sent
west for Dr. Roy that morning."
That is on the morning of Saturday the
22nd. Notwithstanding this warning, and the fact that the doctor had
been sent for by Corporal Hilliam that morning, the men were sent east
at Mr. Campbell's instance. It seems that John Davis (alias Williams)
the ambulance driver, had reached Bull's Head on Saturday evening, and
although he complained that his horses were nearly played out, he was
told by Campbell that he must return that night. He asked to be
permitted to wait until morning, and describes his interview with
Campbell as follows:
Q. What did you say to him?
A. "He asked me how my horses could
stand it to go right back again. I told him they were pretty nearly
played out. Then he says you have to go right back tonight with
these sick men. Well, I says, my horses are pretty nearly played
out, Mr. Campbell, what is the matter with the men? They have got
the quinsy, he says. Well, I says, cannot you wait until morning,
and he says no, pull them out tonight for fear they would die."
Q. Did he say that?
A. "Yes."
Q. What else?
A. "Well, I says, there's no use pulling them out of
here if they're going to die."
Q. What did he say to that?
A. "Well, he says, my orders to you is
to pull them out tonight. Eat your supper and go right back."
Williams was reluctant to remove the men without the order of Dr.
Roy, because he says, "I always took my orders from Roy, with papers to
admit them to the hospital." Campbell told him that by the time he
got his men loaded Dr. Roy would be there, and after the men were in
the ambulance the driver called at Campbell's and asked, "Have you got
the letter from Dr. Roy for these people," and Campbell said, "No
Williams, go ahead, he is not here." The ambulance in which the men
were placed plied between Bull's Head and Seventh Siding, a
distance of about 40 miles. It was a Democrat wagon covered with a
kind of canvass or oil cloth, with springs in the bottom and a
mattress over that, and with a flap to close it in behind. There was
no stove or other means of heating the ambulance. There was one pillow
given by Mrs. Taylor, and apparently three pairs of blankets, two of
which were provided by Mr. Campbell. The men were placed in the
ambulance covered with the blankets, and at about 7 o'clock on the
evening of Saturday, the 22nd of January, proceeded on their journey.
They went that night as far as Willoughby's about 16 or 17 miles from
Bull's Head. No stimulants or nourishment of any kind was given them
upon the road. Williams endeavoured to obtain permission for the men
to remain at Allison's, which is about six or seven miles east of
Bull's Head, and again at McGillivray's about four and a half miles
still further east, but was refused at both places, which were crowded
with freighters and other men. Mr. Willoughby helped the men into the
house, and offered them some milk and tea and a little gruel, but they
were not able to swallow. The room where they slept was kept warm, and
though not a place suitable for sick men, doubtless Mr. Willoughby did
the best he could for them. Another witness, Mr. Parr, says that he
saw them lying upon the floor. In the morning they were again offered
some tea, but they wanted water, with which they gargled their throat,
and from it flowed froth and scum "like corruption". They were again
placed in the ambulance and at half past seven or eight o'clock on the
morning on the 23rd January, started for 7th Siding, distant about 25
miles. They reached Will Eddy's at noon, and asked if they could take
a cup of soup, but they shook their heads. They were then brought out
some tea. They could not drink the tea, but wanted water, which was
brought them. They could not drink, but gargled their throats with the
water, and again flowed out froth and scum, "white and green-like
corruption". The driver here remained about twenty minutes for dinner,
the men remaining in the wagon outside. He then drove on to 7th
Siding, reaching there, as he says, "about half past 4, between 4 and 5
in the afternoon." The driver then saw Reuben Steeves, Canadian
Pacific Railway operator and agent at 7th Siding, and said: "I have
got two men here very sick, I think they have got diphtheria." Steeves
replied: "Bring them up to Joe Wark's car, the Jumbo, and see him up
there." (The "Jumbo" was the boarding and sleeping car for Canadian
Pacific Railway men at 7th Siding.) The driver saw Wark, and said to
him: "I have two sick men here, Joe, and Steeves sent them up to the
Jumbo." Wark replied: "What is the matter with them?" and the driver
said: "I don't know what is the matter with them, it might be
diphtheria, or something like that." Wark then said: "If its
diphtheria you won't put them in my car." The driver went back and
told Steeves that Wark would not have them in his car among his men
with diphtheria, and Steeves said: "You tell Joe Wark to take these
men in or I'll report you." The driver went back and told Joe Wark
what Steeves had said, "put them in this car down here" (indicating
with his head the box car standing on the siding along with the flat
cars), so the driver took them down to the car and ordered out the
three or four men that were in the car. The ambulance was backed up
to the box car, the side door slid back, and the men crawled out into
the car, and the driver says that he put their blankets and a bottle of
water in the car, and shut the door and went off to the hotel and did
not see them again. The day was cold and had been growing colder
towards evening. At 7 o'clock in the morning it was 13 degrees above
zero, at 9 p.m. it was 5 degrees below zero, and fell to 8 degrees
below zero during the night, with a wind from the north-east blowing
nine miles an hour, as appeared from the report kept at the Hudson Bay
Post at Pincher Creek, four miles distant. The condition of the car at
the time the sick men were placed in it is described by William
McAllister. He and other freighters were occupying a tent near by.
The night being cold they thought they would make themselves more
comfortable in the car, which was an ordinary box car without windows
and with the usual sliding door. At one side there were a number of
bunks in the car, but no mattresses, bedding or other furnishings.
There was a small tin camping stove broken in at the top and unfit to
be used as a coal or wood stove, as it smoked. The smoke pipe went out
through the side of the car. The freighters had endeavoured to start
a fire of hay and coal before the ambulance drove up. The witness is
asked:
Q. Was there a fire there?
A. "A kind of a fire."
Q. When you went to the car?
A. "Yes."
Q. What do you mean by that?
A. "A poor fire - smoking."
Q. What did you do?
A. "We got some more coal and put it into the
stove, and it hadn't started well before we had to get out."
He goes on to say that they used hay mixed with the coal. That the
stove smoked so badly they had to leave the door open to let the smoke
out, that had they not opened the door they would have been blinded
with smoke, that the car was very cold at the time they left it; that
when the ambulance was backed up to the car door the driver used foul
language to the sick men and ordered them out. They crawled out on
their hands and knees. He says that the driver put in their blankets,
but denies that he put in any water. The stove was still smoking at
the time this witness left, and he says the car was not fit to receive
the men. The witness further says that he was ordered out of this car
personally by Mr. Steeves. Steeves, the Canadian Pacific Railway agent
says: Williams came to him and said he had two sick men, "and I sent
him to the Jumbo car, where I generally send the rest of them that come
down from the west", and generally confirms what the driver says in
regard to the men being put in the box car. Steeves then went back to
his office. He then saw Kidd, afterwards Dechene and then Hogan, and
asked them to look after the men. There is a great discrepancy in the
evidence as to the hour when these men were engaged and when they
actually went on duty. One would infer from Steeves' evidence that it
was shortly after the ambulance drove up that he spoke to Kidd and
afterwards to the other men. The order in which they were engaged and
went to the car is of great importance in reaching a conclusion upon
this point. The evidence shows that Kidd was first engaged, then
Dechene and last of all Hogan. Later in the evidence Steeves says that
he procured Hogan's service later on, after he had sent for the doctor.
Now, the doctor was not sent for until 8 o'clock, which corresponds
with the time that Kidd says he first went to the car; and if Hogan and
Dechene went there afterwards it must have been 8 o'clock before anyone
gave the men any attention whatever. Hogan and Dechene, however, both
say that they were at the car shortly after 6 o'clock. This may
possibly be true as to Dechene, but cannot, I think, be true as to
Hogan, because he at all events was not seen by Steeves until after
Kidd was spoken to. It is very possible that Dechene may have been to
the car and then left, if prior to the first visit by Kidd. There is
an uncertainty here that I was unable to clear up. One thing is,
however certain, I think, the car was in darkness, there was absolutely
no fire in the stove, and the temperature was five degrees below zero,
with a wind blowing 9 miles an hour. The deplorable condition of the
men at this time is described by the witness Kidd, of whose
truthfulness I entertain no doubt. He was in the employ of the
Canadian Pacific Railway at the time he gave his evidence, but gave it
in such a manner as to command my entire confidence. Steeves is asked:
Q. Why did you get as many as three men to look after these sick
men?
A. "Well, after I got Kidd I knew his duties would not allow him
to look after the men properly, as he would have to look after his
engine, and the same with Hogan. He had his duties outside to
perform, and he could drop in and out as required, and I got this
third man who would remain with them."
Turning now to the evidence of Kidd, he was at 7th Siding when the
sick men arrived. He was engine watchman. His hours were from 7 p.m.
to 5.30 a.m., and his duty was to watch the engine, clean the fire, get
the engine ready for starting and call the crew in the morning. On the
night in question he went on duty at five minutes after 7 o'clock;
filled the boiler full of water which took about 20 minutes; cleaned
the fire which took another 20 minutes; then took off his overalls and
went to the Jumbo car to get his lunch for midnight. This was
somewhere within a few minutes of 8 o'clock. He got his lunch and
started back again. It was now about 8 o'clock; he then says: "I
started back towards the engine, and on my way back I went on the
south side of the side track for to get Hogan's lunch, because I had
been taking his lunch other nights to keep it warm for him. While I
was passing some cars I heard some person crying inside. I opened the
door for to see what was going on. I wanted to know who was in there,
somebody said: "I am sick." He says, "my mate is sick too, I would
like to get some person for to get a fire." I got in the car and he
said it was a shame that they were left there alone in the dark
without a fire and without any person to look after them. He wanted to
know if there was a doctor around. I told him no, that I would try to
get one as soon as possible. He then wanted water. By this time I had
a fire started, and I went and fetched him some water."
Q. Was there any fire or remains of a fire in the stove?
A. "No, sir, not when I found it."
Q. Was the stove warm?
A. "No, sir."
Q. Was it cold so that there was no indication of fire having been
there?
A. "Yes, sir, there was no indication of fire whatever."
The witness then took some pieces of boards and broke them up and got
some pieces of shavings and lighted the fire. He says coal was there
but he did not use it because it was not a coal stove, and he did not
think it would burn. He describes the position and condition of the
men when he went into the car. The car was not lighted. The witness
had a lantern with him. Fraser was lying on his left side beside the
stove on the floor. He had some hay under him and some behind him, but
no blankets about him. McDonald was on the top bunk, lying on his
right side, partly covered up with an overcoat. The witness asked him
if he had any blankets and he said, yes; asked where they were, he said
he didn't know. Kidd then left them and started for the operator's
car. He met Hogan upon the road and told him he had found two sick men
in the box car. Hogan asked where they were and then went down to the
operator's car with Kidd. Kidd then went into the operator's car and
reported to the operator that there were two sick men in the car on the
siding; he said, I asked him what we could do for them. He said he
didn't know. I then asked him if there was a doctor around or could we
get one, he said he would try to get one from Macleod if possible. He
says, will you go back and keep on the fire until we can get a doctor.
I told him I could not very well do it, because I must not leave the
engine alone for long at a time. I said that I would go back and see
that the fire was all right. I took Hogan back to the car with me, and
he took hold of Fraser and lifted him up on the bunk, because the stove
was pretty hot, and we were afraid he would get burnt or burn his
clothes. Fraser was not strong enough to get up himself. He then
left Hogan there and went back to his engine, then went into the
caboose and told the engineer and conductor that he had found two sick
men in a car, and was told that if he thought it was safe to be around
them, to look after them. It was now about 9 o'clock. Kidd then left
the caboose and went down to the car where the men were. He saw that
the fire was burning all right and spoke to Hogan.
Q. What did you say to him?
A. "I told him we ought to try and hunt
some blankets or something to make them a bed, and he said he did
not know what to do about blankets, and I suggested to go to the
operator's, so we both went down to the operator's car and told him
that we had to have some blankets or something."
Q. Told Steeves?
A. "Yes, sir. He said he did not know what to do
until he had seen Mr. Ryan. I told him I would have to go and look
after the rest of my work then, and to get some person else to stay
with them. He asked me if I would go up to Wark, the gang boss, and
ask him to put a man down there with them."
Kidd then found Wark who promised to see that it was done. He then
went down to the car again and found Hogan, and a Frenchman, evidently
"Dechene", in the car. He asked the Frenchman if he was the man Wark
sent to look after them, and he said "yes". Kidd then went down to the
operator's car and asked him if there was a doctor coming. Steeve said
there was no train going out from Macleod that night, but that they
would send to Pincher Creek for a doctor. Kidd then went back to his
engine, and a few minutes afterwards Hogan came down and said: "Come
up to the car with me, I am afraid one of them fellows is going to
die." Kidd could not leave the engine just then. He told Hogan if he
would wait just about five minutes he would go up with him. Hogan said
he would warm himself until Kidd was ready to go. When Kidd got back
to the car Fraser was on the floor. It was now about ten o'clock.
Kidd asked him where he came from and what his name was. He said his
name was E. McC. Fraser, that his mate was up in the bunk and his name
was Charles P. McDonald; that they came from Nova Scotia, near New
Glasgow; that they had been working near the loop, when they got sick
and they were sent down there. They were trying to get to the hospital
at Macleod. McDonald was so weak that the witness could not understand
what he was trying to say, "but I made out that he wanted a drink of
water, and I gave him some water. I sent Dechene for it." This is
important as it indicates the time when Dechene went for the water, of
which he speaks afterwards. There was nothing there to bring it in,
and he got a pail from the engine and gave McDonald a drink. He seemed
to swallow some but not much. It was very hard for him to swallow.
He then gave Fraser a drink. Fraser got down on the floor off the bunk
and lay down close to the stove and was talking to the Frenchman. It
was now nearly 11 o'clock. Kidd then had to go back to his engine, and
remained there until the operator called him. Before leaving the car
he and Hogan had prepared some wood by cutting up a couple of boxes.
Dr. Mead having arrived from Pincher Creek between 10 and 11 o'clock,
the operator asked Kidd if he would go down with the doctor and show
him the car where the sick men were. The doctor asked Kidd if he had
any kind of a light to take with him, Kidd replied he had a train
light, it was not a very bright light, but it was the best he could do.
He then took the doctor up to the car where the men were. The
Frenchman also had a lantern. Kidd went back to the caboose and got
another lantern, the conductor's lantern, and returned to the car.
The doctor said if that was the best they could do he would try and
make out with it.
Before referring to the doctor's evidence it will be convenient here
to refer to the evidence of Hogan and Dechene. Hogan says that the
first he knew the men had arrived was at six o'clock in the evening.
His foreman, Wark, told him "there was two sick men up there, and to
have a look after them. He told me to assist the Frenchman by the name
of Dechene in looking after them. He told me to attend to them good."
Hogan then went from Wark's office to the agent's office, and the agent
told him to attend to the men, so he went down to the car and McDonald
and Fraser were sitting up in their bunks. They were not separate
bunks. Fraser asked for a drink. Hogan describes what he did as
follows: "I told him I would get him a drink. He said he would like
some snow to eat, so I went out and got him a dish of snow on a pie
plate, and by the time I had brought the snow in Dechene had brought in
a dipper of water from the Jumbo car. I did not know he was on. We
gave McDonald a drink. He drank pretty near all the water. We did not
give him all he wanted to drink. He was pretty dry. Fraser drank the
balance of the water."
Q. How much was there for Fraser?
A. "About a quart of water was
brought up; I should judge there would be about one quarter of it
left - one quarter of a quart."
Q. What did you do next, or what is the next thing you know about it?
A. "Well I was in and out of there all night."
Q. What was done after they got a drink of water?
A. "Nothing."
Q. Did you get anything further for them except the snow and Dechene
the water?
A. "No, that is all they wanted. I asked them if they
wanted anything else, and they did not seem to want anything except
water and snow."
Hogan went to lunch, he says, about 11 o'clock.
Q. Did either of them leave the car that night after they went in?
A. "Well, Fraser told me that while I was down at lunch that he went
out and got a little snow, and came in again. I did not think he
could open the car door, it was very hard to open."
Q. Had they anything to drink from the time they got the water in
the first instance about a quarter after six until twenty minutes to
eleven?
A. "Nothing except the snow."
Q. Did you or anybody else get more water up to twenty minutes to
eleven?
A. "No, snow is the principal thing they wanted."
Q. Do you want me to understand that although McDonald took a drink
of three-quarters of a quart, you say he did not want anything more
until eleven o'clock?
A. "They got all they wanted there."
Q. Just answer my question. Did he not want a drink again until
near 11 o'clock?
A. "He did not ask for any."
Q. Did you get any or did anyone else?
A. "Dechene got water."
Q. That was near 11 o'clock?
A. "Yes."
Q. But between those times?
A. "They were eating snow."
Q. Did they have any water?
A. "No."
Q. During all the time that you were there what did they have
besides the water on two occasions and snow?
A. "Nothing except the
medicine that Dr. Mead gave them."
Q. Up to the time that Dr. Mead came did they have anything?
A. "They did not have anything."
Q. And you say they did not ask for anything?
A. "That is all they
asked me for - snow and water; snow principally."
Q. Did you take any soup over, or did anybody tell you to, or take
any tea over with milk in it?
A. "No."
Q. Was anything offered to them or any attempt made to induce them
to eat or to drink?
A. "No, sir."
Q. Anything that you know of?
A. "No."
Q. Do you call that treating them good?
A. "Well, I asked them if
they wanted anything."
The Frenchman, Narcisse Dechene, was at 7th
Siding when McDonald and Fraser were brought down. He says the men
came in about 4 o'clock. That Wark called for him, and he and Wark
together went to the car a little after 6 o'clock; that he went in
the car. He found one of the men right across the door, about 2 1/2
feet from the door, and the other one was in front of the stove.
They were pretty cold, because they were shaking. Dechene said,
"What is the matter with you?" and one of them replied, "We are cold
and want water." One asked for water and one for snow. The car was
pretty tough; it was not fit for a sick man. There was no window in
it, and no lamp in it. It was a dirty car. There was a little fire
when Dechene went there, but it was choked with smoke. It would
have been better if there was none. It was a tin stove and broken
on top; he could not keep it from smoking. He says the car was
pretty cold when he went there. He went to get some water. While
he was away to get the water Fraser went down himself and got some
snow. He got off the car himself and got in himself. He was not
so strong after. It seemed as if it hurt him a little to go down,
and the snow was for his chum McDonald.
Q. Well, when you brought the water what did you do?
A. "I gave it to Fraser."
Q. How did he drink?
A. "By gosh, he take it with both hands, and I
had to take it away from him. I was afraid he was going to choke, he
grabbed it that way with both hands. His chum was near cry alongside
of him to get the water."
Q. And he took the water up to his mouth in his hand?
A. "Yes."
Q. And you say his chum, McDonald, was crying for the water?
A. "Yes, pretty near cry. He was say for God's sake give me some water."
Q. How much water did you have?
A. "I had a dish full. I thought it
was no use to give him some more at the time, and I says I could get
some more."
Q. How much did you have?
A. "About a pint."
Q. Did McDonald drink any?
A. "No. He tried to take some but it
pass all over the outside of his mouth. With snow he get along
better. He says he didn't get any snow or any water on the road."
Q. Then did you build a fire before you went for the water a second
time?
A. "Yes, I built a good fire."
Q. What did you get?
A. "I had coal with me."
Q. Where did you get the coal?
A. "I went back to the Jumbo car for
it. The first time I had nothing, I went with Wark."
He says the fire burnt well enough as long as the wood was on it, but
it smoked very badly. He had to open the doors some time, opened it
about six inches, to let the smoke out. He says: "We were not sick
men and we were hardly able to stand it ourselves."
Q. Well, when did you go for the water?
A. "I went straight back as
soon as I built the fire. I says, now I am going to get you some
more water. I didn't like to give them too much, but they asked so
much for it, and, by gosh, I says I will go for more. They says
they don't get any on the road at all."
Q. Did they drink any more?
A. "That was the time Mr. McDonald tried
to drink. The first time I could not take it from Fraser. He drink
the whole of it."
Wark stayed a half an hour at the car. He seemed to know Fraser.
Fraser had worked for him on a railway near Winnipeg. Then Fraser
cried and said to Wark, "We are going to die here." and Wark said we
will leave old Joe here with you, and he will give you everything you
want, and Wark turned to Dechene and said: "Joe, what do you think of
these two men now? Are they going to die or live? And I says they
will die by two in the morning, the both of them."
Q. Why did you say that?
A. "Because they were too far gone. They
were too low. They were too cold. I knew it was not possible to live
then."
Q. What did Wark say to that?
A. "Well, he said we will do the best
we can anyway."
Q. How long did Wark remain there after that?
A. "He went away after that."
He came once afterwards. Dechene thinks it was about 9 o'clock. He
is not sure as to the time as he had no watch. The next person that
Dechene saw was Hogan. He says that this was nearly two hours after he
had been at the car. It would seem from this that Dechene may have
been at the car before Kidd went there; if so he was away long enough
for the fire to go out and the car to become cold. Dechene being asked
if the car could be kept comfortable with that stove, answers: "No,
sir. There was no man in the world could."
Q. Did it smoke all through the evening more or less?
A. "Sometimes
they didn't smoke very much, sometimes they smoke enough to choke
anybody, and we had to open the door. Sometimes we could not leave
it open because it was too cold; too cold for any sick man. The
sick men complained of the cold."
Later on in his evidence Dechene says that he thinks Hogan went there
ahead of him. If this be true, then I think it is tolerably certain
that Kidd was in fact the first man at the car. That would be about
eight o'clock.
Dr. Mead resided at Pincher Creek, four or five miles distant. The
roads were bad, the night was cold, and the roads were filled with the
drifting snow, so much so that it was difficult to follow them. Dr.
Mead received the message about nine o'clock at night, and reached the
siding about ten. It was then that he was shown to the car by Kidd,
as mentioned. When he got into the car the smoke was so thick that
he had to leave the door open. It was some minutes before he "could
see or breathe." They were trying to burn soft coal and hay in a
common box stove. Fraser was lying on the floor, close to the stove,
trying to get warm - coiled around the stove. McDonald was lying up
against the farther end of the bunk. The doctor examined McDonald and
found him at the point of death. He was suffering from pneumonia. His
pulse could scarcely be counted. His temperature was about 104. He
was too weak to speak. Fraser was not quite so weak. He tried to
speak to the doctor. The doctor put his ear close to his mouth and
heard him say, "something ease pain." He was suffering from pneumonia
and his temperature about the same. They both had diphtheria. The
doctor did not, however, know it at the time, as owing to the poor
light he could not examine them properly. The doctor asked for
stimulants, or milk or eggs. He was told that the cook's car was shut,
and they could not get in until the cook came in the morning. He gave
Fraser an 1/8 of a grain of morphia as a stimulant in the absence of
anything else to ease pain. After receiving the stimulant Fraser sat
on the side of the bunk and wanted to know if he could not sue the
company for the brutal treatment of himself and his chum. The doctor
went back to the agent's car and told the agent Steeves that if they
died before morning he should certainly hold and inquest. Steeves then
wired down to Mr. Haney and Haney wired back, "spare no expense. Send
special messenger to Creek for whatever the doctor orders." A
messenger was then, with some difficulty, procured to go back to
Pincher Creek for brandy and eggs and milk. About five minutes after
the doctor returned to the agent's car, after sending the men for the
necessaries. A man came to the car and said McDonald was dead and
Fraser was sinking rapidly. This was about midnight. The temperature
had fallen from 5 to 8 degrees below zero. The doctor, returning to
the car, found that what the man said was true. Fraser was dying.
The necessaries had come, but too late, and between one and two o'clock
in the morning the end came, Fraser died.
From the time the men were taken sick until their death they had no
chance for their life. At no time, in no place, did they receive that
reasonable care and attention, having regard to their condition and the
nature of the case, that they were entitled to. All the doctors are
unanimous that their journey to 7th Siding, and the lack of proper
treatment on the road and when they arrived, accelerated, if it did not
cause, their death. Why was the doctor not sent for? Why were they
sent out without a doctor's certificate, or at all? Why was not a
doctor summoned at Bull's Head, and why were they sent forward without
the doctor's order? Why the utter lack of proper care and treatment
when they arrived at 7th Siding? They had paid for medical service at
a rate fixed by the company. Why, in their utmost need, had they not
received it?
Before proceeding with a consideration of these matters it may be here
stated that on the following day Dr. Mead, as coroner, ordered a post
mortem examination, and took steps to hold an inquest. The post mortem
was conducted by Dr. Harwood and Dr. Kennedy, and their report, and
their evidence taken before me show beyond doubt that the men both died
from diphtheria, complicated by pneumonia resulting from that disease
and their exposure. The inquest was not completed. A copy of the
evidence as far as taken will be found as Exhibit 8. The proceedings
were stopped by an order nisi dated the 4th day of February, 1898, for
a writ of prohibition, which order was made absolute on the 24th of
March, 1898, by Judge Rouleau, and on the 28th March 1898, the writ of
prohibition was issued and served on Dr. Mead on the 30th March, 1898.
All the proceedings in connection with the writ of prohibition will be
found as Exhibit 15 in the papers 1 to 9 inclusive, No. 6 of which is a
certified copy of the judgment of Judge Rouleau. The application was
made on behalf of Michael J. Haney, manager of construction.
In answer to the question how it came about that Fraser and McDonald
were exposed to the hardships and suffering which they endured from the
time they were taken sick until they died, it will be necessary to
examine the conditions existing, including the medical system then in
operation upon the line. The distance from Lethbridge to Cranbrook is
205 miles. At the time the road commenced there was a hospital at
Lethbridge and one at Macleod, 37 miles west. It was decided to use
these as base hospitals and send the patients to these hospitals for
treatment. The instructions given to the medical staff were as
follows:
1. Medical officers are expected to make regularly one trip a week
over their division, and to make other trips when called upon to do so.
2. All serious cases and other cases requiring the constant care of
the medical officer are to be moved into the hospital assigned to
the division. Notice must be forwarded to this office at once of
such removals, together with nature of the disease. Notice must
also be forwarded when such cases are discharged from the hospital.
3. In case of infectious diseases arising, prompt measures must be
taken at once to isolate such cases, and notice of same must be
forwarded to this office.
4. Medical officers will keep this office advised as to wants,
etc., in medical supplies.
5. Prompt attention to all cases is imperatively demanded.
F.H. Mewburn, Assistant Surgeon
There was no provision made for temporary hospitals at this time, nor
was there any provision for isolating patients with contagious disease
other than the direction contained in clause 3 of the above
instructions. No tents or other equipment for that purpose were
furnished either to the medical staff upon the line, or to the
contractors, nor were the contractors instructed in that matter. Dr.
Mewburn, chief of the medical staff, who had a large private practice
at Lethbridge, had his headquarters there and attended to
correspondence and had charge of the hospital. The hospital occupied
him about three hours a day; the correspondence was principally
attended to in the evening. The rest of his time was largely devoted
to his private practice. His assistant in the early part of
construction attended to patients along the line within ten miles of
Macleod. Dr. Kennedy took charge from that point and attended patients
to within short distance of Pincher Creek, and at the time in question
to, and including 7th Siding. Dr. Roy's division extended from 7th
Siding to headquarters, and he had under him at this time, according to
the company's return (Exhibit 52), between 900 and 1,000 men. His
division covered about 65 or 70 miles. Dr. Gordon's division at this
time extended from the west end of Dr. Roy's to Cranbrook, a distance
of about 75 miles, although there were comparatively few men west of
Wardner. His headquarters was at the Mission, nine miles north of
Cranbrook, and about 25 miles north-west of Wardner. Upon his part of
the line there were at the time in question about six or seven hundred
men. Under the system then in force "all serious cases and other cases
requiring the constant care of the medical officer" from Dr. Roy's
district were to be sent to Macleod, and all such cases with Dr.
Gordon's district to the Mission hospital. The Mission hospital
proper had not at this time been built. It consisted then of a small
log building capable of accommodating 12 or 15 patients. It was
arranged that the company should pay to the different hospitals $1 per
day for each patient for their board, attendance, &c. It may be here
said that all patients who reached any of these hospitals seems to have
been well cared for.
In the language of Mr. McCaul, "Nobody suggested that the cases should
be treated at the camps where they broke out; that is not a common
sense view; the only two suggested were temporary and base hospitals."
What then was to be done with "the serious cases and other cases
requiring the constant care of the medical officer that could not be
moved to the base hospital?" No provision for this contingency was
made.
Dr. Roy had found the necessities of the case such that he had detained
patients at a restaurant kept by Mrs. Taylor at Crow's Nest Lake until
he thought it safe to send them forward. In March when the number of
men in and about the Loop and at Coal Creek were likely to be
increased, the company erected temporary hospitals, one at the Loop and
the other at Coal Creek, about 30 miles distant. Mann's Camp was
between the two, and had these hospitals been in existence at the time
in question there can scarcely be a doubt that what befell Fraser and
McDonald would have been avoided. A great deal of evidence was taken
as to the necessity of temporary hospitals upon the line, and the
overwhelming weight of evidence is that they were necessary to be used
in connection with base hospitals and without which it was impossible
that the sick men upon the line could be properly cared for. This
necessity seems to have forced itself upon the company and the medical
staff at a later stage, and resulted, as I have said, in the building
of the two hospitals one at the Loop and the other at Coal Creek, but
too late to be available for the present emergency. The great weight
of medical evidence seems to establish that temporary hospitals should
have been placed within twenty-five, or at most, 40 miles apart, having
regard to the nature of the work and the number of men employed: and
the provision could and should have been made for isolating patients
suffering from any contagious disease within a few hundred yards of the
temporary hospital, so that the doctor having his headquarters at the
temporary hospital could give patients of that kind, attention, and
contractors would know where to send them. These hospitals should have
been furnished with a nurse, cook and medicines. Nothing of this kind,
at the time in question, was provided. It is doubtful, even with
temporary hospitals, whether the doctors in charge of the divisions
west of 7th Siding could have efficiently attended to the extent of
line within their district; but it is plain that without temporary
hospitals it was an impossibility. Had Dr. Mewburn, the chief of the
medical staff been less occupied at Lethbridge with his private practice
and so been able to give more time to inspection of the work upon the
line and its requirements, the necessities of the case must have
occurred to his mind at an earlier stage. The evidence of Mr.
Shaughnessy, Mr. Haney, and Dr. Mewburn is that the want of these
provisions was not due to a lack of funds, because, although it is
clear that the fifty cents per month charged to each man upon the line
was not sufficient to defray the expense of the medical staff, that, it
is declared, by the above witnesses was not the reason why a different
system and method was not adopted. Whatever the cause, the deplorable
fact remains, that the system of utilizing the three base hospitals
without providing the necessary field, or temporary hospital elsewhere
on the line was continued until some months after the death of McDonald
and Fraser. That these base hospitals were not sufficient to meet the
requirements without being supplemented by temporary hospitals is
manifest from another consideration. Early in the fall it was found
that the hospital at Macleod was not nearly sufficient to receive the
number of patients sent down, and thereupon two or three box cars were
supplied with bunks and turned into a temporary hospital, at that
point, under the charge of Dr. Kennedy, who says that some 500
patients, nearly all of whom were sent down from the line to the west,
were there received and treated; and Dr. Roy's evidence is clear that
he utilized Mrs. Taylor's restaurant from time to time, because he
would not assume the responsibility of sending the patients through.
Dr. Harwood, in the fall of 1897, for the same reason found it
necessary from time to time to detain patients at Pincher Creek in
rooms provided on his own responsibility until they were able to go
through. He had resigned in November, 1897, from ill-health caused by
over-work. No doctor was located at Pincher Creek to succeed him, and
this temporary provision there for treating patients was discontinued.
It will be borne in mind that Mann's Camp was within Dr. Gordon's
division, distant from his mission hospital 65 or 70 miles. On the
15th of January Dr. Gordon had gone west with patients, calling at
Mann's Camp and taking one from there. Although requested to do so,
and informed that there were two sick men complaining of sore throat,
he did not visit them, saying, as one of the witnesses states, that he
could not spend all his time at one camp; and by another, he would see
them on his way back. Dr. Gordon denies this, and says he thought he
examined all the patients requiring his attention in Mann's Camp. But
he certainly did not see McDonald, and Fraser, on this day, was at
work.
Mann returned to his camp from the east on the 15th or 16th, the day
after McDonald had fallen sick. So far as the evidence shows, it does
not appear that McDonald's illness was brought specially to his
attention until the day before or the morning that they left. He says
that two days before his attention was drawn to a sick man in camp, and
at first he thought that McDonald was the man, but afterwards he
ascertained that it was another man that was sick and not McDonald.
McDonald was therefore sick in camp from the 15th to the 20th without
medical aid or other attendance in the way of nursing. For at least
two days before he left he took very little if any food, and on the
morning he left was certainly not in a condition to start upon such
a journey.
Kennedy, the partner of Mann, was at the camp on the morning he left,
and seems to have had a suspicion that the disease from which McDonald
was suffering was diphtheria, and he and Mann appear to have been
anxious that the men should be sent out of camp. It does not seem to
have occurred to them, or if it did, they did not act upon it, to
isolate the patients or to send for a doctor. The excuse given is that
the doctor had gone west and it would likely take some days to reach
him, and they took upon themselves the responsibility, without a
doctor's order or certificate, to send the men forward.
The history of the journey has been traced. At Bull's Head the men
were in a deplorable condition. They remained there sufficiently long
to have procured Dr. Roy's attendance if prompt action had been taken.
Corporal Hilliam, of the Mounted Police, finding that a doctor had not
been summoned, on the morning after their arrival sent for Dr. Roy, but
he did not arrive until the men had left, and Mr. Campbell, the agent of
the company there, took upon himself without a doctor's certificate to
order the man in charge of the ambulance to take the men forward,
although Corporal Hilliam had forbidden him to do so. They arrived at
Pincher Creek between four and five in the afternoon. The company's
agent, although informed of their arrival, placed them in a box car
wholly unfit for their reception, and did not see to it that they had
proper attendance even there, nor did he cause the doctor to be sent
for until 8 o'clock in the evening, although only 4 miles distant, and
where they died.
It has been urged before me that the patients ought never to have been
sent forward, and in this view I concur; but having been sent they
should have received very different treatment upon the road, and having
reached Bull's Head they ought not to have been permitted to go
further, and the doctor should have been summoned. Having, however,
been sent on at the instance of the company's officer then in charge,
they should have been properly cared for on the way and on their
arrival at 7th Siding. This duty, in my judgment, fell upon the
company and their officers stationed at that point. It is true that
cases of contagious diseases were not expected there, but sick persons
were constantly being sent down, and provision should have been made,
such as that suggested by Dr. Mewburn, in December, for the reception
of patients. This request of Dr. Mewburn to provide a car properly
heated and supplied with bunks for the reception of patients sent down
to the end of the track not having been complied with, it was the
plain duty of the company's officer at that point to exercise all
diligence in making the men comfortable and supplying medical aid.
It has also been urged before me that as there was an isolation
hospital within a mile and a half of Mann's Camp the men should have
been taken there. Doubtless this would have been done had a doctor
been summoned, but it must also be remembered that Dr. Mewburn himself
says that the contractor would not have been justified in taking the
men to a diphtheria isolation hospital except upon the authority of a
doctor, lest a patient not suffering from that disease might have been
placed in imminent peril, and no provision was made for contagious
diseases except as they arose.
In the present case, while it appears that Kennedy, Mann's partner,
was suspicious that the men were suffering from that disease, Mann
denies that he had any suspicion of that fact, and also denies that he
had any knowledge that there were patients suffering from diphtheria
isolated near his camp. If it were intended that contractors should
send patients suffering from any contagious disease to the quarantine
hospital near Mann's Camp they should have been notified and so
instructed. But the fact is, that this quarantine hospital was
established to receive the cases of diphtheria from Card's Camp, and
was not intended or especially provided for the reception of any other
patients, although afterwards it was so utilized, and might have been
used in the present case had Dr. Gordon been summoned.
It is said that the system of base hospitals was preferable to that of
temporary hospitals. In my view it is not a question of alternative
systems. The base hospitals should have been supplemented by temporary
hospitals supplied with tent and stove for isolating any case of
contagious disease that might arise.
The conclusion at which I have arrived is that the medical system as
carried out on the line, at least down to the time Fraser and McDonald
died, was inadequate to the reasonable requirements of the case; and
that chiefly arose from the lack of temporary hospitals, and from the
fact that the doctors in charge had too many miles to cover within
their respective districts. I am further of opinion that the
circumstances being as they were, the men ought not to have been
removed from the camp, but that a doctor should have been summoned,
either Dr. Gordon, or if it were thought he was too far west, Dr. Roy.
That the accommodation provided for their removal was insufficient,
and the lack of stimulants and nourishment and other proper care and
treatment was inhuman and without excuse. That their detention for 26
hours at Bull's Head afforded ample time to have there procured a
doctor, and their dangerous condition while there was so manifest that
I can find upon the evidence before me no excuse for this neglect, nor
for their having been sent forward, neither can I find excuse or
palliation for the inhumanity with which they were treated when they
arrived at 7th Siding.
It has also been urged before me, and some evidence was given to the
effect that the system adopted upon this road was better than that
employed in the construction of other lines and the men better served.
It may be so, and if so it but emphasizes the following suggestions
which I beg to offer:
1. The number of men working upon the road who became ill and were
treated by the medical staff is, I think, abnormally large. With a
particularly healthy climate and sufficiently good food, how does it
happen that there should be in the neighbourhood of 1,500 men requiring
treatment in a total aggregate of 2,000 to 4,000, and all within the
space of less than a year? This, it is plain, is not attributable in
any way to the medical staff, and the reason for it must be sought
elsewhere; and I venture to think we have not far to look for at least
a partial cause. In what I am about to say I do not desire to draw any
invidious distinction between the different camps upon the line, or the
accommodation provided in each camp, but I refer to the result rather
with the object of making some suggestions for the future. There must
have been an utter disregard of the simplest laws of health somewhere,
and I think it may be found in the lack of sanitary conditions in the
camp. How is it possible that sickness could be avoided where fifty or
sixty men occupy a bunkhouse 24 x 40 feet with seven feet ceiling, and
no ventilation provided? Is it any wonder that some of the camps were
described as hospitals, and that sometimes twenty men at a time would
be unfit for work, meantime paying their board and losing their time?
The suggestion I venture to offer in this regard is, that in large
public works of this nature there should be some form of health
inspection, and probably the case could be met by appointing the
government engineer upon the works and the chief medical officer a
board of health to enforce reasonable sanitary regulations. This upon
the part of the government would not incur additional expense, and with
trifling increase of cost to the contractors would, I am satisfied,
enormously decrease the number of sick, and in the end be a great
saving to the contractors themselves.
2. I beg further to suggest that in large public works of this nature,
at a distance from cities or where hospital accommodation cannot be
had, provision should be made for field hospitals within such distance
of each other, having regard to the location and the number of men
employed, so that patients might be cared for without endangering their
lives, until they could with safety be sent to base hospitals, and that
contractors should be directed to provide or be supplied with a tent
and stove for the purpose, where in case of emergency a patient
suffering from contagious disease might be isolated at once and so not
endanger the rest of the men in the camp.
The Canadian Pacific Railway afforded every facility for the
investigation, and promptly complied with all requests for the
production of papers and documents bearing upon the matter. I desire
also to acknowledge the assistance received from the able counsel who
attended on their behalf, and on behalf of Mr. Hugh Mann and Dr. Mead.
I have the honour to transmit herewith the evidence taken under this
commission and the plans, papers, and exhibits therein referred to.
R.C. CLUTE,
Commissioner.
Dated the 17th day of January, 1899.
