in a recent paper by George (Archiv. f. Ohrenheilkunde 80, 1). As the result of much micro-pathological work, Goerke claims that there is a marked tendency for labyrinthine infections to become self-limited; that in many of the cases of meningitis where the infection is supposed to have spread by way of the labyrinth, the disease really followed some other path; that the canals are so fine that they get so choked with bone-dust and splinters during the operation that no efficient drainage is afforded unless the whole labyrinth is destroyed; and finally that by breaking up new membranes which have walled off exudate in the labyrinth and internal auditory meatus from the brain, the operation on the labyrinth may well precipitate a fatal result, as instanced by a case from Brieger's clinic. In a certain number of cases opening the labyrinth may certainly be a life-saving procedure, but not in anything like the proportion which the teachings of Politzer's pupils would lead one to expect. This conclusion is one in which the writer heartily concurs. In reviewing a tolerably active practice of more than twenty years he can recall but one case in which it seems at all likely that a labyrinthine operation might have saved the patient.

GIFFORD (Omaha).

Can the Colon" Tube Be Passed Into the Colon?

If you ask the average doctor, "Can the 'colon' tube be passed into the descending colon?" he will, in most instances, assert that it can. This is in accord with most teachings on this question. Dr. H. W. Soper, of St. Louis, in a recent issue of the Journal of the A. M. A. (August 7, 1909, page 426), gives an interesting account of the literature on this moot point, together with the results of some very convincing investigations carried on by him. In Germany, Nothnagel, Naunyn, Boas and others maintained that the soft tube always coiled up in the ampulla or dilated part of the rectum and could not be made to pass through the sigmoid. It was Wachmuth's early work in 1862 that laid the foundation for the general belief that the long tube could be passed high up into the colon. Cadge and G. Simon were the first to deny this, basing their opinions on experiments on the cadaver. Von Aldor is one of those who have

persistently declared that it is possible to pass rubber tubes 9 mm. in diameter and 80 cm. long into the descending colon.

Soper has carried on a series of experiments on the living subject during the past eighteen months, attempting to pass long, soft rubber, blunt-end tubes with side openings into the rectum, with the patient on the side in some instances and in the knee-chest position in others. Sixty cases were examined, in some a mixture of oil and bismuth, in others of bismuth and water, being allowed to flow through the tube simultaneously with its introduction. In others merely the well-oiled tube was used. The position of the tube was verified by means of a specially-constructed fluoroscopic apparatus. The results of these investigations were that it is not possible to introduce a soft rubber tube higher than six or seven inches in the rectum without it bending or coiling on itself. Only in the very rare instances of abnormal development of the sigmoid, i. e., cases of dilatation and hypertrophy of the lower segment of the colon, is it possible for a tube to go higher under these conditions. Soper says that his skiagraphs showed the tube invariably coiled up in the rectum. The X-ray pictures also showed that the mixture of bismuth and oil filled up the ascending, descending and transverse colon, even though the tube carrying it reached no further up than the rectal ampulla.

The lesons to be learned from this exceedingly valuable contribution are, first, there is no use trying to pass a tube, no matter what position you place the patient in and no matter what kind of a tube you use, further than the rectal ampulla. The second is, that with a short rectal tube, six inches in length, you can carry all sorts of enemata introduced for the purpose of causing fecal evacuations, using the fountain syringe or funnel and long tube in the usual way. You can cleanse the entire colon by using a large-caliber (one-half-inch) short tube, connected with a large funnel elevated three or four feet above the patient, pouring in the solution until he feels a sense of distension or desire to evacuate, then lowering the funnel until the outflow has ceased, repeating the maneuver in much the same way that you practice gastric lavage. The third point is that when you desire to make an enema remain in the bowel, as for the administration of saline solution, nutrients, etc., the fruitless attempt to pass a "colon" tube high up-only resulting in its coiling upon itself— makes for an irritability of the bowel and an expulsion of the fluid. Therefore, even for such cases, use the short tube.-Medical Brief.

The Medico-Legal Aspects of the Roentgen Rays from the Standpoint of the Surgeon.

*By R. D. MASON, M. D, Omaha, Neb.

It is now nearly fifteen years since the so-called X-rays were discovered by Rontgen of Germany. The world was startled by the announcement that a new force had been found which enabled one to see certain organs and parts of the body that in the past had been beyond the reach of human vision. This was one of the most wonderful discoveries ever made and was the means of placing surgery on a higher plain than it had ever before reached.

As is usually the case when a new method of treatment has been announced, which seems to hold out great promise of being better than those already known, it was seized upon by the profession as a cure-all and more was expected of it than the facts justified. Not only were the uses to which it could be put unknown, neither were the dangers which lurked within it seen or realized, and several martyrs to the cause of science gave up their lives in an effort to bring to light the truths hidden in this mysterious unseen agent which was so powerful, not only for good, but for evil. The profession reveres the memory of these men and acknowledges a lasting debt of gratitude to all those who laid down their lives for the love of their profession and the good of humanity.

Not only was the medical profession at a loss as to the exact status in which to place it, but the courts were equally bewildered. Here was a new witness to be reckoned with; one never before heard of, with no precedents to guide and no one who knew whether the shadowy, ghost-like image could be relied upon or whether it was some trick of the imagination.

It has taken time to straighten out these things, but now both the medical and legal professions know that the Rontgen ray, as one means of arriving at a correct diagnosis and recording what it reveals so that it may be shown to a jury, has established itself on a firm foundation, and all courts recognize it as being competent evidence when properly supported by the testimony of one expert in radiography. "The picture alone is not evidence at all, but when presented as an aid to, or a part of the oral testimony of him who produced it or knows of its production, it at once becomes valuable evidence."

*Read before the Nebraska State Medical Association, Omaha, May 4-6, 1909.

"We must remember, then, that a document, purporting to be a man, picture, radiograph, or diagram, is, for evidential purposes, simply nothing except so far as it has a human being's credit to support it. It is mere waste paper, a testimonial nonentity. It speaks to us no more than a stock or stone. It can of itself tell us no more of the existence of the thing portrayed upon it than can a tree or an ox. We must somehow put a testimonial human being behind it (as it were) before it can be treated as having any testimonial standing in court. It is somebody's testimony, or it is nothing. It is immaterial whose hand prepared the thing, provided it is presented to the tribunal by a competent witness as a representation of his knowledge.

*

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The objection that a photograph or radiograph may be so made as to misrepresent the object is generally directed against its testimonial soundness, but it is of no validity. It is true that a photograph, or radiograph, can be deliberately so taken as to convey the most false impression of the object. But so can any witness lie in his words. A photograph can falsify just as much and no more than the human being who takes it or certifies it.

The fallacy of the argument occurs in assuming that the photograph can come in testimonially without a compentent person's oath to support it. If a qualified observer is found to say, "This photograph represents the fact as I saw it," there is no more reason to exclude it than if he had said, "The following words represent the fact as I saw it," which is always in effect the tenor of a witness' oath. If no witness has thus attached his credit to the photograph then it should not come in at all any more than an anonymous letter should be received as testimony."

So far as I am able to learn, the courts have made no ruling as to whether or not a surgeon can be held liable for failure. to use the Rontgen rays in cases of fracture, dislocations, foreign bodies, etc., followed by bad results. The law clearly says that physicians and surgeons, when called upon to treat a case, are supposed to be possessed of the reasonable and ordinary qualifications of their profession. The question that then arises is what constitutes reasonable and ordinary care, skill and diligence. It is generally construed to be the care, skill and diligence possessed by the majority of the members of the same profession among whom he may practice. "The law does not expect a physician or other professional person engaged in the practice of the medical science who practices in a sparsely set

tled district, such as a village or small town, to exercise the same care and skill as would be expected of one residing in a large city where the opportunity of keeping fully alive to the latest methods and appliances are greater. Such persons are only bound to exercise the avearge degree of skill possessed by the profession in such places generally. A patient who had been improperly treated, as a result of the neglect of the medical attendant to employ the most modern method of practice, could very properly bring charges of neglect against the attendant, who, however honest in his methods of treatment, would be liable if his patient suffered injury to his person."

"The use of the X-ray is so universally commended in the modern works on surgery and medicine that the surgeon who fails to apply them in doubtful cases may justly be accused of negligent practice.

or

Liability for bad results may be due to either active passive acts on the part of the attendant. That is, he may have done things that he should not have done and that are contrary to the usual custom of the profession in which he resides, or he may leave undone things that he should have done, which would have greatly assisted him in his diagnosis or treatment. While the law may not require a medical man to make use of modern scientific instruments of precision such as the X-ray, the microscope, etc., yet it is the general consensus of opinion that he should do so, when he is practicing in a community where these things are readily attainable. It (malpractice) is active when a certain course of treatment is adopted and followed which is not sustained by authority. It is passive when those things in the treatment are omitted which should have been done, in order to obtain a result approximating perfectness."

It might be argued from this that every physician would be required to have all the latest improved equipment, including many delicate and expensive instruments, but this would not necessarily follow, as he would only be expected to make use of these things in difficult or doubtful cases, and if it could be shown that he requested the patient to be allowed to call to his assistance other members of the profession who are expert along certain lines and the request was refused because of expense or otherwise, the surgeon's duty has been performed and his liability ceases."

If a patient, by refusing to adopt the remedies or comply with the directions of the physician, frustrates or defeats the endeavor of the physician, or if he aggravates the case by his misconduct, he cannot charge to the physician the consequences