Opinion by
Mr. Justice Bell,
Plaintiff appeals from a judgment of nonsuit which was entered in her suit against defendant, a physician who was certified as specially qualified by the Board of Gastroenterology. In considering the entry or appeal from a nonsuit, the evidence and all reasonable inferences therefrom must be considered in the light most favorable to the plaintiff and a judgment should be entered only in a clear case. It is likewise horn-book law that a plaintiff must prove by a fair preponderance of the evidence that defendant was negligent and that his negligence was the proximate cause of the injury. Moreover, as we shall see, in malpractice cases we have pinpointed how a doctor’s negligence must be proved.
President Judge Carroll well summarized the facts: “The testimony of the plaintiff and her witnesses established that she entered the Kensington Hospital in Philadelphia on August 16, 1955, with a diagnosis of possible duodenal ulcer. Under the direction of the defendant various tests and X-rays were administered after which the diagnosis was modified to antral gastritis (inflammation of the stomach in the antral area). Accordingly, on August 23rd, in order to verify this diagnosis, the defendant performed a gastroscopic examination. This procedure consisted of the insertion of a semi-flexible tube approximately three feet in length and three-eighths of an inch in diameter with a soft rubber tip into the esophagus, the tube containing a light and lens periscope arrangement whereby a visual examination of the stomach could be made. [The path of the esophagus is not straight but is curved at the point of penetration.]
[102]*102“Doctor Bralow testified on cross-examination that he twice attempted to pass the gastroscope into the plaintiff’s stomach but was unsuccessful because of the resistance encountered. He attributed this resistance to persistent cardiospasm
“Plaintiff did not offer expert testimony in support of her case. Accordingly, under the authority of the Supreme Court’s holding in the case of Robinson v. Wirts, 387 Pa. 291 (1956), an involuntary nonsuit was entered. In the Robinson case, the facts were almost identical to those of the instant case in that the defendant physician had perforated the plaintiff’s esophagus by performing a gastroscopic examination necessitating the same surgical procedures employed here.”
To these findings we add that plaintiff produced no evidence that there was any improper or unskillful or negligent act, or any proof of lack of surgical skill, or any evidence of negligence by the doctor — plaintiff proved nothing except the happening of the injury and [103]*103that it resulted from the insertion of the gastroscope. The use of a gastroscope is an intricate surgical procedure employed only at the hands of doctors having specialized training and qualifications. The passage of the gastroscope through the labyrinth of the esophagus and stomach involves care and skill but the success of such passage is dependent not only upon such care and skill but also upon the condition of the wall of the esophagus and stomach and other internal physiological factors. The record shows that Dr. Bralow, in the process of inserting this gastroscope into the patient’s esophagus and stomach to determine the correctness of his diagnosis of gastritis, encountered some “resistance” at a point where the esophagus curves. He encountered this “resistance”, nothing more and nothing less. There is not a scintilla of evidence that Dr. Bralow did anything to overcome this “resistance”.
The instant case is ruled directly and unquestionably by Robinson v. Wirts, supra, where this Court speaking by Chief Justice Stern affirmed the entry of an involuntary nonsuit and said (pages 294, 296) : “Plaintiff contends that the jury should have been allowed to infer negligence on his part from the mere fact of the happening of the occurrence and that there was applicable the so-called exclusive control doctrine, . . .
“Unfortunately for plaintiff the law is definitely to the contrary. Three very recent cases on the subject are Bierstein v. Whitman, 360 Pa. 537, 62 A. 2d 843; Scacchi, Admr. v. Montgomery, 365 Pa. 377, 75 A. 2d 535; and Powell v. Risser, 375 Pa. 60, 99 A. 2d 454. They merely follow a long train of authorities in this Commonwealth to the same effect, holding that no presumption or inference of negligence arises merely because the medical care or surgical operation terminated in an unfortunate result which might have occurred even though proper care and skill had been exercised, [104]*104and where the common knowledge or experience of laymen is not sufficient to warrant their passing of judgment. In such cases the doctrine of res ipsa loquitur or of exclusive control may not be invoked, and expert testimony in support of the plaintiff’s claim is an indispensable requisite to establish a right of action. . . .
“ ‘The plaintiff had the burden of proving Dr. Montgomery’s negligence and in a case such as this it could be proved only by expert testimony to establish negligence in the operation or a procedure which was not in accord with standard medical practice or negligence in his treatment of the patient after the operation:’ [citing authorities]. ...
“It is thus abundantly clear that since, in all such malpractice cases involving an appraisal of the propriety and skill of a doctor or surgeon in his professional treatment of a patient, a lay jury would presumably lack the necessary knowledge and experience to render a just and proper decision, they must be guided by the testimony of witnesses having special or expert qualifications. The only exception to this otherwise invariable rule is in cases where the matter under investigation is so simple, and the lack of skill or want of care so obvious, as to be within the range of the ordinary experience and comprehension of even nonprofessional persons, as, for example, where a gauze pad is left in the body of a patient following an operation (Davis v. Kerr, 239 Pa. 351, 86 A. 1007), or where a dentist, in working on a tooth, uses a tool with a small rotating emery disc at the end and allows it to slip and to remain revolving in the patient’s mouth, grinding and tearing her tongue (Dux v. Shaver, 105 Pa. Superior Ct. 344, 161 A. 481). So, likewise, there might be imagined a case where a surgeon engaged in removing a tumor from a patient’s scalp would let his knife slip and cut off his patient’s ear, or where he undertook to stitch a wound on his patient’s cheek and [105]*105by an awkward move would thrust his needle into the patient’s eye.
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Opinion by
Mr. Justice Bell,
Plaintiff appeals from a judgment of nonsuit which was entered in her suit against defendant, a physician who was certified as specially qualified by the Board of Gastroenterology. In considering the entry or appeal from a nonsuit, the evidence and all reasonable inferences therefrom must be considered in the light most favorable to the plaintiff and a judgment should be entered only in a clear case. It is likewise horn-book law that a plaintiff must prove by a fair preponderance of the evidence that defendant was negligent and that his negligence was the proximate cause of the injury. Moreover, as we shall see, in malpractice cases we have pinpointed how a doctor’s negligence must be proved.
President Judge Carroll well summarized the facts: “The testimony of the plaintiff and her witnesses established that she entered the Kensington Hospital in Philadelphia on August 16, 1955, with a diagnosis of possible duodenal ulcer. Under the direction of the defendant various tests and X-rays were administered after which the diagnosis was modified to antral gastritis (inflammation of the stomach in the antral area). Accordingly, on August 23rd, in order to verify this diagnosis, the defendant performed a gastroscopic examination. This procedure consisted of the insertion of a semi-flexible tube approximately three feet in length and three-eighths of an inch in diameter with a soft rubber tip into the esophagus, the tube containing a light and lens periscope arrangement whereby a visual examination of the stomach could be made. [The path of the esophagus is not straight but is curved at the point of penetration.]
[102]*102“Doctor Bralow testified on cross-examination that he twice attempted to pass the gastroscope into the plaintiff’s stomach but was unsuccessful because of the resistance encountered. He attributed this resistance to persistent cardiospasm
“Plaintiff did not offer expert testimony in support of her case. Accordingly, under the authority of the Supreme Court’s holding in the case of Robinson v. Wirts, 387 Pa. 291 (1956), an involuntary nonsuit was entered. In the Robinson case, the facts were almost identical to those of the instant case in that the defendant physician had perforated the plaintiff’s esophagus by performing a gastroscopic examination necessitating the same surgical procedures employed here.”
To these findings we add that plaintiff produced no evidence that there was any improper or unskillful or negligent act, or any proof of lack of surgical skill, or any evidence of negligence by the doctor — plaintiff proved nothing except the happening of the injury and [103]*103that it resulted from the insertion of the gastroscope. The use of a gastroscope is an intricate surgical procedure employed only at the hands of doctors having specialized training and qualifications. The passage of the gastroscope through the labyrinth of the esophagus and stomach involves care and skill but the success of such passage is dependent not only upon such care and skill but also upon the condition of the wall of the esophagus and stomach and other internal physiological factors. The record shows that Dr. Bralow, in the process of inserting this gastroscope into the patient’s esophagus and stomach to determine the correctness of his diagnosis of gastritis, encountered some “resistance” at a point where the esophagus curves. He encountered this “resistance”, nothing more and nothing less. There is not a scintilla of evidence that Dr. Bralow did anything to overcome this “resistance”.
The instant case is ruled directly and unquestionably by Robinson v. Wirts, supra, where this Court speaking by Chief Justice Stern affirmed the entry of an involuntary nonsuit and said (pages 294, 296) : “Plaintiff contends that the jury should have been allowed to infer negligence on his part from the mere fact of the happening of the occurrence and that there was applicable the so-called exclusive control doctrine, . . .
“Unfortunately for plaintiff the law is definitely to the contrary. Three very recent cases on the subject are Bierstein v. Whitman, 360 Pa. 537, 62 A. 2d 843; Scacchi, Admr. v. Montgomery, 365 Pa. 377, 75 A. 2d 535; and Powell v. Risser, 375 Pa. 60, 99 A. 2d 454. They merely follow a long train of authorities in this Commonwealth to the same effect, holding that no presumption or inference of negligence arises merely because the medical care or surgical operation terminated in an unfortunate result which might have occurred even though proper care and skill had been exercised, [104]*104and where the common knowledge or experience of laymen is not sufficient to warrant their passing of judgment. In such cases the doctrine of res ipsa loquitur or of exclusive control may not be invoked, and expert testimony in support of the plaintiff’s claim is an indispensable requisite to establish a right of action. . . .
“ ‘The plaintiff had the burden of proving Dr. Montgomery’s negligence and in a case such as this it could be proved only by expert testimony to establish negligence in the operation or a procedure which was not in accord with standard medical practice or negligence in his treatment of the patient after the operation:’ [citing authorities]. ...
“It is thus abundantly clear that since, in all such malpractice cases involving an appraisal of the propriety and skill of a doctor or surgeon in his professional treatment of a patient, a lay jury would presumably lack the necessary knowledge and experience to render a just and proper decision, they must be guided by the testimony of witnesses having special or expert qualifications. The only exception to this otherwise invariable rule is in cases where the matter under investigation is so simple, and the lack of skill or want of care so obvious, as to be within the range of the ordinary experience and comprehension of even nonprofessional persons, as, for example, where a gauze pad is left in the body of a patient following an operation (Davis v. Kerr, 239 Pa. 351, 86 A. 1007), or where a dentist, in working on a tooth, uses a tool with a small rotating emery disc at the end and allows it to slip and to remain revolving in the patient’s mouth, grinding and tearing her tongue (Dux v. Shaver, 105 Pa. Superior Ct. 344, 161 A. 481). So, likewise, there might be imagined a case where a surgeon engaged in removing a tumor from a patient’s scalp would let his knife slip and cut off his patient’s ear, or where he undertook to stitch a wound on his patient’s cheek and [105]*105by an awkward move would thrust his needle into the patient’s eye. It would be a matter of common knowledge and observation that such things do not ordinarily attend the service of one exercising ordinary skill and experience in the work of surgery became they involve ulterior or extraneous acts or omissions the judgment of which would not require scientific opinion. But such is not the present case.”
Appellant contends (1) the doctrine of res ipsa loquitur applies, (2) the doctrine of exclusive control applies, (3) the evidence was sufficient to prove negligence, and (4) for some other reason which is obscure, a surgeon has the burden of proving that he exercised due care and skill and followed the established practice if the operation is unsuccessful. Each of these contentions has been heretofore rejected by this Court and is devoid of merit.
We have quoted at great length from Robinson v. Wirts, supra, (a) because the evidence of supposed negligence was stronger for the plaintiff in that case than in the instant case, and (b) because it so well answers and specifically refutes all of the contentions made by this appellant.
In Robinson v. Wirts, supra, when the doctor encountered “resistance” he did something to overcome the “resistance”, i.e., he applied “gentle pressure and insufflation”. In the instant case there is, we repeat, not a scintilla of evidence that Dr. Bralow did anything to overcome the “resistance” which was caused by persistent cardiospasm. Furthermore it is clear as crystal that this internal and exceptionally difficult examination by gastroscope is not a matter of common knowledge or common observation by laymen, nor does it involve extraneous acts the judgment of which would not require scientific opinion.
Judgment of nonsuit affirmed.
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