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stances I have mentioned to you, that the condition of the ward exercised an influence which made the results inside so different to those obtained outside?—lt is possible that it did. 140. Is it reasonable to suppose that it did ?—lt is not reasonable to suppose so until you have sifted all the chances of infection. I have eliminated the instruments and the operator ; but you have not yet asked me if there were other possible chances. 141^ What other chances are there ? —What was the condition of the woman herself? 142. You performed the post-mortem on Mrs. S did you not ?—I did. 143. Did you find anything in her condition to lead you to suppose that there was a preexisting source of danger from septic poisoning ?—lf it pre-existed it must have been very recently before operation. It was not of long standing, certainly. At all events, there was no evidence to show that there was. If there was any pre-existing cause it was quite masked by the inflammation which caused death. 144. There was nothing of a chronic character ? —No. 145. The Chairman.] There were no symptoms of there having been chronic trouble ?—There was no evidence of it. 146. If there had been, wrould you have seen it ?—-Yes, because the examination was very carefully conducted. 147. You do not say that there was chronic disease of the womb ?—No. 148. Mr. Solomon.'] If there had been there would have been thickening of the walls of the uterus, would there not ?—lf there had been thickening the evidence would have existed. 149. Was there any such evidence?—No; there was only evidence of recent acute inflammation. 150. Was there any evidence exhibited by the post-mortem to show that the woman had in herself before the operation any danger of contracting septic poisoning ?—Do you mean from the operation itself? 151. Yes?— There was none. 152. Now, we have eliminated the operator, the, instruments, and the woman herself: what else do you want?—l want to eliminate also the condition of the atmosphere. 153. The Chairman'] Do you mean to eliminate the state of the atmosphere ?—I want to eliminate the chance of infection, subsequent to the operation. [Chart handed to witness.] Was there any subsequent examination by anybody ? Who changed the dressings ? Mr. Solomon : Dr. Batchelor dressed the wound himself from beginning to end. Witness : Then, I can eliminate the chance of subsequent infection, and, having excluded these various sources, it only remains to consider the conditions of the atmosphere in the wards previous to operation. From the evidence which has been given, I should say that that was in a septic condition. W 7ere any examinations made in. the ward prior to operation ? Mr. Solomon : Dr. Batchelor has already told us that he made very careful examinations. 154. The Chairman.] You suppose septic influences to have existed in the ward ?—The patient was operated on at 4 o'clock, and it seems that she had septic symptoms at 4 o'clock next day. I should like to know the history of the case. 155. Mr. Solomon.] She was operated on on the loch, and her temperature was up to 101° on the 16th? —That would be a sufficient indication of itself of septic trouble. Subsequent to that had any interference with the woman taken place ? Mr. Solomon : No. Witness : I gather that the temperature was 101° when the first examination was made. The septic symptoms do not seem to have occurred till a few days—about four—after operation ; and then began the condition of affairs which caused death, which was peritonitis. The post-mortem in this case revealed the fact that the infection had travelled up the uterus along the fallopian tubes and then into the peritoneum. Of course, it may have taken a long time to do that. We found some pus in the tubes. 156. Mr. Solomon.] Did the post-mortem reveal to you that the fallopian tubes had been previously diseased ?—lt did not. They had a normal appearance, with the exception that they contained some pus. 157. Now we have got all that you asked for—the operator operating with perfect success on patients outside, using the same instruments as he used inside; that the condition of the ward in the Hospital was unsatisfactory ; and that the woman herself had no predisposition to septic poisoning: what conclusions do you come to? — That she had subsequent infection of the wound. 158. Arising from what ?—Having eliminated the operator and the instruments, and if there was no pre-existing diseased condition of the part, it must have been from some local germs existing in the neighbourhood of the parts operated on. 159. If she had been lying in No. 7 ward for some days, and had been examined during that time, was there anything surprising in germs being found in her ?—Under healthy circumstances a vagina contains no pathogenic germs unless air has been introduced—that is to say, that no septic trouble can occur unless a wound exists. In a case like this, we can eliminate almost every source of infection except the condition of the vagina at the time, apart from disease, and we must come to the conclusion that there were pathogenic germs in the vagina at the time, introduced, presumably, when examination was made in the wards prior to operation, and that these obtained access to the wound during operation. 160. Suppose that the patient had been lying for some days in No. 7 ward under the circumstances that I have already mentioned, is it at all surprising that there should be germs in the air of the ward ? —Theoretically it is not at all surprising. 161. Would it be surprising if they were not, there?— Yes, it would be surprising if they were not there.

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