You may have seen this rather long report which has been published in the past only to ignore it due to its apparent length. Don't make that mistake again.
The original Crowsnest Pass Agreement, signed in 1897, required Canadian Pacific Railway to provide lower freight rates on its lines for grain and produce in exchange for land and construction concessions given when the railway was built through the Crowsnest Pass. During this period CPR used contractor's to carry out the work required. Two of these contractor's workers died under adverse circumstances causing the federal government of the day to form a commission to investigate the circumstances of their deaths. As an historical document the commissioner's report vividly portrays some grim conditions and general attitudes prevalent in the local populace during this period.
Take the time to read this report, you will be moved by the plight of McDonald and Fraser.


Sessional Papers Volume 14

Fourth session of the eighth parliament

of the

Dominion of Canada

Session 1899


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Escort with paymaster for railway construction workers in Crowsnest Pass, Alberta - 1897 Photographer unknown - Glenbow Museum call number NC-46-2.
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 .....
$ 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 .....
$ 6.35

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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.

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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.

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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.

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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.

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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.,

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."

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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.

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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.

Dated the 17th day of January, 1899.

Associated Links

Crowsnest Pass
Crowsnest Pass Railway Route, The
Glenbow Museum
Crowsnest Museum
Frank Slide Interpretive Centre
Bellevue Underground Mine Tour
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