Court Opinion

ID: 9553753
Source: CourtListenerOpinion
Date Created: 2023-08-07 19:34:31.899776+00
Date Added: 2024-06-11T15:32:12.425598
License: Public Domain

Hunter, J.
(dissenting) — As stated by the majority, in order to sustain a judgment against a physician or surgeon, the following must be shown, (1) the standard of medical practice in the community; (2) that the physician or surgeon failed to follow the methods prescribed by such standard; (3) that the negligence on the part of the physician or surgeon by reason of his departure from the recognized standard of practice was the cause of the disability. The foregoing elements must be established by medical testimony unless they are so apparent that a layman would have no difficulty in their recognition.
The majority conclude that there was no medical evidence to establish these elements, as asserted by the respondent, as applied to the instant case, and that no exception to the rule can be here applied. I disagree.
A challenge to the sufficiency of the evidence, as stated by the majority, admits the truth of the opposing party’s evidence and all inferences that reasonably can be drawn therefrom; and requires that the evidence be interpreted most strongly against the moving party and in the light most favorable to the party against whom the motion was made. Traverso v. Pupo, 51 Wn. (2d) 149, 316 P. (2d) 462.
Applying these rules, the answer to the proper determination of the case lies in the record which will be examined as it applies to the proof of the above elements essential for the respondent to prevail.
*20Evidence of standards of medical care existing in Vancouver at the time of the asserted violation appears in the record. Dr. L. L. Nunn (who will be referred to as the appellant) admitted in paragraph VII of his answer as follows:
“Defendants deny each and every allegation of Paragraph VII of plaintiffs’ complaint, save and except that they admit that under the standards of care required of physicians and surgeons in Vancouver, Washington, it was and is the duty of a physician performing a surgical operation for the removal of a femoral hernia to avoid injuring the femoral nerve and to avoid sewing it into the incision resulting from such operation.”
The appellant testified as follows:
“Q. ... I notice in your answer, doctor, Paragraph 7, the answer you swore to in this case, you say this: ‘Admit that under the standards of care required of physicians and surgeons in Vancouver, Washington, it was and is the duty of a physician performing a surgical operation for the removal of a femoral hernia to avoid injuring the femoral nerve and to avoid sewing it into the incision resulting from such operation.’ Now, my question is, why does the standard of practice place that duty upon the surgeon? A. Well, simply because he wants to avoid any injury to structures which he shouldn’t injure. Q. Is it fair, doctor, to say that when you perform surgery to repair a femoral hernia in a female that you know that if you sever the femoral nerve or one of its branches, and you have mentioned certain branches, or sew it into the tissues adjacent to it, by that I mean the femoral nerve, into the tissues adjacent to the area, or damage it or the branches of it which you have mentioned, that your patient will in all probability suffer some undesirable results such as paralysis, anesthesia, paresthesia, or inflammation of the nerve or the branch affected, is that fair? A. Fair enough.”
The foregoing evidence establishes an accepted standard by which the appellant was required to abide in the performing of the herniorrhaphy upon the respondent Vera Richison. Evidence of the violation of the above standards in the performance of the herniorrhaphy by the appellant appears in the record as follows:
*21Dr. H. Frewing testified:
“Q. Now your post-operative diagnosis of scarring left groin, extensive, tell us what you found that led you to make that portion of your post-operative diagnosis? . . . A. As I dissected below the skin and towards the deeper structures in this operative area, I found that there was more than the usual scar formation in this region below Poupart’s ligament. As we go through tissue in this area, we are accustomed to find a good deal of fatty tissue. There are many additional fibres of lymph channels and lymph nodes, and it is unusual to see firm attachment of the skin to these deeper structures. That was the first note I made that there was more than the usual scar formation below Poupart’s ligament in the region and here I would like to interject a correction for the typographical work, perhaps it was my dictating and perhaps was the stenographer’s fault, but in any event, the word ‘vasa ovalis’ is used. The —that should be ‘fossa ovalis.’ f-o-s-s-a. Q. I think I developed that before. A. Yes, however, the fossa ovalis is an anatomical area overlying the femoral artery and vein just below Poupart’s ligament, and I use the term here to indicate the area where I found more than usual scarring below Poupart’s ligament. I extended that remark in my report, extending along the nerves and vessels. That means as I went deeper in my dissection in this operative area, I found that this scarring extended down around the vessels and nerves. Q. And how far down — what was the depth to which you did go in this dissection, measuring from the skin downward? A. I would estimate perhaps one and a half inches. It was to a layer deep to behind the vessels. Q. Then after you exposed the femoral nerve and, I assume, when you are using that term here, well, I won’t assume anything. I’ll ask you. When you use the term femoral nerve in this exhibit, Number 11, to what did you refer? A. I refer to the femoral nerve trunk and its principal branches in that area. Q. And did you visualize the femoral nerve as you have thus defined it to us? A. Yes, sir. Q. What did you find? A. I found there was no evidence of possible scarring or involvment of the nerve except for one branch which seemed to be adherent under Poupart’s ligament. I am hard put to describe accurately to you what Poupart’s ligament looks like. It’s a thick layer of — oh, not quite tendon. It’s fascia-like tissue, maybe that doesn’t mean any more. It’s a firm, gristly type of material that goes across the groin here (indicating). Behind that I *22found one branch of nerve which was different from the others. Q. Now where with reference to the lower border of Poupart’s ligament, did you find this condition that you described? A. My, — excuse me, as I refresh myself. I note that I released this nerve from the posterior border of Poupart’s ligament, because the change in terms there, that’s why I asked you to explain, sir. Q. Well, if this is the ligament, sir, I shouldn’t use anything that big, and I know it’s not this big, true, but posterior means the back? A. That’s right, sir. Q. And what I’m talking about, elevation, I’m describing lower border as being part part nearest the feet, the upper border being the upper part nearest the head. Now where on the back side or posteriorly, where with reference to the lower border did you find this situation? A. I would say I found it in that area where normally one would expect to find the femoral nerve, which is towards the side laterally from the femoral artery and at a point approximately halfway from the anterior-superior spine to the lower attachment of the symphysis of the Poupart’s ligament.” (Italics mine.)
Dr. Frewing further testified:
“Q. What did you observe as to what — as to the manner of adherence of this nerve to the ligament? A. I have no detailed note as to the exact manner of attachment. I would assume from my record that it was attached in ordinary fibrous scar tissue such as I had been contending with throughout the remainder of the exploration of this area. Q. How close was the nerve to the ligament itself? A. I have noted that I released it from the posterior border of Poupart’s ligament. That would mean that it was immediately adjacent to the ligament. Q. For what distance, and it was surrounded, as I understand it, with scar tissue? A. That would be a reasonable feeling. Q. You released it in what method? What did you do to release it? A. We use instruments in our operation, I would think. Now, I do not have note as to the particular instrument I used at this time, but I would be using scissors or hemostats or thumb forceps or even sometimes a scalpel, a knife. Q. And do I understand that you cut scar tissue in some manner or other to release the nerve? A. Yes, sir. Q. And what length of the nerve was there imbedded in the scar tissue? A. I have to rely on memory there. I would say perhaps one-quarter inch. Q. Now, you took specimens of this tissue and caused them to be sent to the laboratory for evaluation *23and diagnosis, didn’t you? A. I took three specimens from this operation and sent them to the pathological laboratory. Q. Now, after you had released this nerve, during this surgery, did you make some test of the nerve? A. Yes, sir. Q. Describe what you did and — A. As I explored this area, I ran into various strands which it was impossible with the naked eye to identify positively. They could have been lymph channels; they could have been vessels, either veins or arteries; they could have been fibrous tissue or they could have been nerve. In the case of this particular object which I had, I did what I had done on some of the other fragments or strands I had in front of me, I pinched it lightly with the hemostat or a forcep — that is an instrument we use in surgery to grasp small objects or vessels, to control bleeding, and we acquire a certain facility of pinching gently with it. When I pinched this nerve, there was a contraction of one of the muscles in the front of the thigh. Q. That indicated that you then and there — A. That I was dealing with a nerve, sir. Q. You were dealing with a motor nerve, sir, weren’t you? A. Yes, sir. Q. And that motor nerve goes to a muscle and not to the skin surface, doesn’t it? A. Not necessarily, sir, that segment which I was stimulating was going to a nerve — going to a muscle, but I had no assurance in this area that I didn’t have a mixed nerve which would have parts going to the skin and to the muscle. Q. Fine, very good, sir. Mixed nerves, then, carry both motor and sensation fibres, don’t they? A. Yes, sir. Q. So that an injury to a mixed nerve may produce sensation of pain and may also impair muscle function? A. Yes, sir. Q. Now I assume that you have — we’ll put it this way. When you came to sewing up, suturing, I believe you doctors call it, the wound that you had to make for this operation, what type of needle did you use, what shape is the needle? A. That depends, Mr. Kennett, on the area in which we are working, down deep we use a curved needle, what we call a half curve, semi-circular type needle. Q. Like this, Doctor, (indicating) ? A. That order; perhaps not quite so much curve, but a curving needle. Q. So that if you put a curved needle, it has the suture material attached to it, doesn’t it? A. Yes, sir. Q. Cotton, silk, whatever the surgeon has elected to use? A. That is right. Q. If you go through a ligament with that curved needle, the purpose of the curve is so that the business end — A. Sharp end. Q. — will go through and then you turn it and then it comes back out and you make the suture fast? A, *24That is right. We grasp the needle when it comes out and pick it up with our instrument. Q. And then tie your knot? A. Tie the knot. Q. So that if there was this nerve lying right down close and adjacent to the structure to which you put your curved needle, it would be quite simple matter to pick that nerve up and sew it in there, wouldn’t it? A. With your assumptions, yes.” (Italics mine.)
The findings of Dr. Frewing appear in the hospital record (exhibit No. 11) as follows:
“Findings: There was more than usual scar formation in the low Poupart’s ligament in the region of the vasa ovalis and extending along the nerves and vessels. There is no evidence of herniation. The external oblique fascia was tightly closed and there was no evident defect, neuroma or other pathology underlying the external oblique. The vein and the artery were both soft, of normal consistency and readily compressed. There was no evidence of unusual communication or extravasation. The artery in particular, had considerable scarring around. The femoral nerve and its branches was exposed, the ligaments and then through the femoral ring into the retroperitoneal area. There was no evidence of possible scarring or involvement of the nerve except for one branch, which was apparently in part, superficial cutaneous of the thigh and in part, motor to the upper portion of the sartorius muscle. When this branch was released from the posterior border of Poupart’s ligament, there was some thickening. Compression of the nerve, distal to the thickening caused contraction of the upper portion of the sartorius. However, compression of the same nerve above the thickened area, did not cause contraction of the muscle. This area of nerve was excised and sent to the pathologist for study. In addition, two other specimens, comprising scar, left node or foreign body from just below Poupart’s ligament were sent to the pathologist.” (Italics mine.)
The findings of the pathologist which appear in exhibit No. 11 are, in part, as follows:
“Specimen C, labelled small nerve and scar or suture, identifies a small nerve with surrounding collagenous connective tissue; there are also large portions of suture material with surrounding foreign body giant cells.
“Diagnosis: Segments of ligament and collagenous connective tissue with small nerve and with suture material and foreign body reaction.”
*25Referring to the tests given by Dr. Frewing on the nerve adherent to Poupart’s ligament, Dr. Davis testified on direct examination, as follows:
“Q. Well, would the test evidence some injury or damage of some kind to the nerve? A. To the branch, yes.”
Dr. Davis further testified:
“Q. You are speaking now about the type of work that you as a neuro surgeon does knowingly with respect to a nerve? A. Yes, sir. Q. Do you make a practice of sewing the nerve ends into the soft tissues and to the scar? A. No, sir.”
Dr. Frewing testified in reference to the result of the pinching test of the nerve:
“Q. Have you any explanation of why you had that result? A. I felt that this was part of the scarring process that was in this area (indicating) and this particular nerve was bound down a little more firmly than some others.”
On cross-examination, the following question and answer appears:
“Q. Did you — you did not mean that there was a branch nerve there that you would not ordinarily find in another person? A. I was not surprised to find this branch. There is ordinarily a branch [interruption]”
If the jury could infer from the above evidence that a branch of the femoral nerve was sewn into the soft tissue at the time the appellant was suturing the incision, the standard of care required in the Vancouver area in the performance of such an operation would have been violated irrespective of the absence of a statement by a medical witness that it had been violated. The testimony is clear that a branch of the femoral nerve was adherent to the underside of Poupart’s ligament. It was encased in scar tissue, and suturing material was present; it was surrounded with foreign body giant cells which is nature’s way of protection from the invasion of a foreign body; the branch of the femoral nerve is not normally attached to Poupart’s ligament; the injured branch was not a mere small cutaneous or surface sensory nerve; it was one and one-half inches beneath *26the surface of the skin and beneath Poupart’s ligament; it was where a surgeon could have and should have, with the exercise of reasonable care, observed and discovered it as did Dr. Frewing in his exploratory operation. The evidence is of such clarity that any layman could conclude that this branch of the femoral nerve, where it was found attached to Poupart’s ligament, was there by virtue of its having been sewed into the soft tissue when the appellant doctor sutured the incision. The “chain of circumstances” rule as set forth in Crouch v. Wyckoff, 6 Wn. (2d) 273,107 P. (2d) 339, cited by the majority applies. This constituted negligence for which the appellant was liable if any harm resulted to the respondent therefrom.
The testimony is clear that the respondent was in reasonably good health before her operation which was performed by the appellant; that immediately after the operation, upon coming out of the anesthetic, she was in extreme pain at the site of the incision and she has, almost continuously, endured pain ever since; that she was operated on for hernia on June 21, 1952. The record discloses substantial testimony that she thereafter suffered from a condition known as reflex dystrophy or causalgia, and that this condition was a result of the hernia operation.
Dr. Davis testified:
“Q. And I note on her medical chart that on the occasion of this hospitalization the admitting diagnosis was causalgia post traumatic, left leg. Do you find that? A. Yes, sir. Q. That was your diagnosis, pre-operative diagnosis? A. Yes, sir. Q. And the final diagnosis was the same? A. Yes, sir. Q. And what did this diagnosis mean, Doctor? A. Merely that she had a causalgia or causalgia-like syndrome.
“Q. Well, in any event, it was your opinion that her causalgia-like symptoms were a result of a trauma to her left leg? A. Depends on what you mean by ‘trauma.’ Q. What did you mean by it — that is what I am trying to get at, Doctor — when you wrote it in on the medical chart? A. Apparently this woman had developed an irritative type or irritative symptoms following an operative procedure. Q. Referring to the hernia operation? A. Yes, sir. Further than that I do not know.”
*27Dr. F. Boersma, the respondent’s physician who saw her fairly continuously within about six weeks after the hernia operation, diagnosed her condition as reflex dystrophy. This diagnosis by Dr. Boersma appears on the hospital records of eleven different exhibits, reflecting eleven different occasions when she was in the hospital under his care. The diagnosis of Dr. Kenneth E. Livingston, staff physician, appears in the hospital record (exhibit No. 41) as causalgiapost traumatic left leg.
Dr. Boersma testified as follows:
“A. Then on the 30th, September the 30th [1952], have a telephone conversation; she was very miserable. She did come to the office that day to take the films that had been taken the day before and deliver them to Dr. Selling. We had taken AP and lateral films of the pelvis and of the lumbosacral spine. I have a notation here of a tremendous emotional ailment, believe that may have an organic basis following surgical procedMre so closely.
“Q. Is the jury to understand that as of now your diagnosis of reflex sympathetic dystrophy still holds good? A. Yes, it does.” (Italics mine.)
Dr. Edward Kloos, who made a neurological examination of the respondent, testified as follows:
“Q. Did you come to any conclusion or form any opinion from your examination and the history which she related to you and the information that you had as to whether or not Mrs. Richison was suffering from a condition known as sympathetic reflex dystrophy? A. That is a loose term, yes, I think she probably was. It depends on one’s interpretation of that.”
The remaining link in the chain to be considered to determine the question of liability to be placed upon the appellant as a result of the operation is a showing that the respondent’s condition of causalgia or reflex dystrophy was proximately caused by the appellant’s negligence in injuring the branch of the femoral nerve in the performance of the herniorrhaphy. On this issue the following testimony by the appellant appears in the record:
“Q. Well, then, see if we can shorten it. It is a medical fact, is it not, that a patient may suffer reflex sympathetic *28dystrophy when that patient has not suffered trauma to a major peripheral nerve trunk? A. Yes. Q. Which means that a patient who suffers trauma to a branch of a major peripheral nerve may suffer from reflex sympathetic dystrophy? A. May? Q. Yes, do you agree? A. That is right.”
Dr. J. Bonica testified:
“Q. If it occurs to a patient, that is if causalgia follows to that patient, why it’s some pretty real, isn’t it? A. Yes, if it’s due to an injury, of course. Q. Does the pain of causalgia occur often immediately after the injury? A. Yes. Q. I want to ask you, Doctor, to* give me the characteristic symptoms of causalgia, and I am looking at Page 950 of your book, if that will speed it up any. A. Well, I would have to remind myself. It’s a pretty classical picture. Severe, almost always severe, burning pain, that is the characteristics, associated with hyperalgesia, hyperesthesia, vasamotor disturbances and subsequent trophic changes of a marked degree. Q. All right. I want to ask you, in addition to that, if another symptom is erratic alteration of the disposition and emotional state of the individual? A. Yes. Q. And I want to ask you if, in addition to that, if sudomotor disturbances is not another symptom? A. Yes. Q. And I want to ask you with reference to the pain which is symptomatic, if the following, using your language again, is still your present opinion: ‘Pain, which is usually continuous, severe, poorly localized, irradiating and burning in quality and easily exacerbated by peripheral and central (emotional) stimulation — .’ A. Yes. Q. In early cases of causalgia, is it your present opinion as follows: ‘In the early and/or milder cases the pain is limited within the territory of the injured nerve, but in severe and/or prolonged cases the pain, while most intense in the autonomous zone of the affected nerve, has a characteristic, diffuse, irradiating, poorly localized distribution well beyond the confines of the nerve.’ A. Yes. Q. I want to ask you if with causalgia the pain from a partial lesion to a nerve— A. I would like to insert ‘major nerve’ in there, please. Q. Let me rephrase the question. Dealing with causalgia, if pain from a partial lesion to a nerve is not promptly relieved, may it spread to the entire extremity and to other parts of the body? A. I would still like to qualify by saying ‘major nerve,’ yes. Q. I thought under your definition of causalgia it had to be that, so I— A. Yes. Q. I am following your answer is ‘Yes?’ A. Yes.” (Italics mine.)
*29Dr. Kloos testified further as follows:
“Q. Now I note in your report, and I am reading from Page 2 of it, you say that on examination it appeared the skin of the entire left leg was extremely hypersensitive to even the very slightest touch. I assume that is a truthful statement? A. To the best of my knowledge, it is. Q. Well, you were examining her. You could tell whether she was sensitive or not, couldn’t you. A. Yes. Q. And that was, she was extremely hypersensitive to the very slightest touch, right? A. Yes. Q. And that extended well up into the flank and the left lower quadrant of the abdomen, didn’t it? A. Yes. Q. And that would be the site of the original hernia operation and Dr. Frewing’s corrective operation, wouldn’t it? A. And above. Q. Now from all of your investigation, referring again to your report, the second paragraph and the second sentence thereof, you learned that following her hernia surgery she had immediate severe burning lancinating pain in the entire left lower extremity, didn’t you? A. Yes.” (Italics mine.)
Dr. Davis testified further as a result of his examination of Mrs. Richison:
“A. There was a healed scar over the groin. She was quite tender around this. Actually it was rather difficult to examine her because of her very wide spread tenderness. There was a — let me put it this way: In testing her sensation there was what we would term a hyperesthesia. In other words, she was more sensitive to stimulation such as pin prick or touch over a wide area in her leg, perhaps a little more sore over the inner surface of the thigh. The leg was slightly colder on the left than on the right and it was, it was a little different in color in that it tended to have a slightly mottled, purplish color change which was more apparent perhaps in the foot than the upper leg.
“Q. After examining the patient did you come to a tentative diagnosis, Doctor? A. Yes. I thought this was a causalgic-like syndrome. I could come to nothing more definite than that. Sometimes with an irritative lesion these people get involvement of their sympathetic nervous system, and she seemed to show some of the evidences of sympathetic irritation. Q. Is that, medically speaking, a reflex sympathetic dystrophy? A. Yes, sir.
“Q. Doctor, what opinion did you reach on this first occasion concerning the cause of this causalgic-like pain? A. She apparently had an irritative scar. At least her main *30tenderness was there. And I thought it was perhaps on the basis of an irritative scar. Q. An irritative nerve phenomena? A. Certainly the nerves were involved, yes. Q. What nerves, Doctor, in your opinion? I mean I know you didn’t operate on her leg— A. She had findings which involved the whole leg. In other words, she had both femoral and sciatic involvement, a very diffuse thing. Her major hyperesthesia and tenderness appeared to be in the saphenous division of the femoral. Q. Is the saphenous nerve a separate or of a separate origin from the cord or is it a lower branch of the femoral? A. It is a branch of the femoral.
“Q. Now, I am going to ask you again if it was then your opinion on July 20th, 1954, that this woman, Mrs. Richison, has an irritative nerve phenomena associated with involvement of branches of the femoral nerve at the time of her initial surgery? A. Yes, there may have been some involvement of small sensory branches.
“Q. I have some old charts, maybe, instead of new ones. That is what I was trying to enlighten myself on. All right. Now, a while ago you used the term ‘causalgic.’ Would you explain the meaning of that word? A. The term itself is — I believe it comes from the Greek and it means a burning pain. It was, I think, first used probably by Weir Mitchell in his description of causalgias that occurred during the Civil War, and he described a burning type of pain due to an irritative disturbance in which there was a great deal of sympathetic nerve activity with sometimes increased sweating, sometimes decreased, change in temperature, color, skin, so on. Q. And the irritative process involves what structures of the body? A. Usually in order to get a causalgia there is some involvement of nerve fibers.
“Q. . . . Will any trauma to the nerve which interferes with its continuity, although not completely so, be a possible cause of causalgia? A. Yes. Ordinarily causalgias develop in injuries where the nerve continuity is not completely disrupted. It may occur with very minor injuries.” (Italics mine.)
A letter to Dr. Boersma from Dr. Davis stated as follows:
“On examination, she shows marked tenderness over the left inguinal region and a hyperesthesia which seems to be primarily in the saphenous nerve distribution. She is very tender over the scar. The leg is somewhat discolored and tends to be a little purplish and there is some edema around the ankle. The leg particularly below the knee is somewhat colder than the right.
*31“As I mentioned to you over the phone, I think this woman has an irritative nerve phenomenon associated with involvement of branches of the femoral nerve at the time of her initial surgery. She is developing many of the findings of a causalgia or at least a reflex sympathetic dystrophy. . . . ” (Italics mine.)
Dr. Bonica testified further:
“A. Yes, that is. Q. I mis-spoke myself, I take it. I will ask it again. Is it still your present opinion that in the overwhelming majority of cases of causalgia the nerve lesion is incomplete? A. Yes.
“Q. I said, if a nerve was sewed, sutured— A. Oh, yes. Q. (continuing) — to a ligament so that it adhered to the ligament and scar tissue formed around it, that would be an incomplete lesion, would it not? A. Of the nerve? Q. Yes. A. Yes.”
From the above medical testimony, it would appear that the facts are so obvious that a layman could conclude that causalgia is caused by nerve damage; that the pain was in the area of an injured branch of the femoral nerve, near the nerve trunk; that the result of such a nerve injury would probably cause harmful results to the sympathetic nervous system and produce causalgia; that the respondent suffered with causalgia as a result of the operation. The chain of circumstances or facts, as testified to by medical witnesses, would justify the jury as laymen to infer that the condition with which the respondent suffered following the operation was proximately caused by appellant’s violation of the standards of medical practice in Vancouver, in damaging a branch of the femoral nerve by negligently sewing it into the soft tissue; that any absence of direct testimony as to such conclusion is not essential in this case; that the rule of the “chain of circumstances” again here applies. Crouch v. Wyckoff, supra, cited in the majority opinion. Also, see Marlowe v. Patrick, 181 Wash. 647, 44 P. (2d) 776.
The remaining assignments of error made by the appellant to the proceedings in the trial court were not reached by the majority. However, an examination of the record *32discloses it does not support the contentions raised by these assignments.
The trial court should be affirmed.
Finley and Foster, JJ. (dissenting) — We dissent. The evidence was sufficient to take the case to the jury.
January 13, 1960. Petition for rehearing denied.