Court Opinion

ID: 9714766
Source: CourtListenerOpinion
Date Created: 2023-08-26 05:45:07.262141+00
Date Added: 2024-06-11T18:23:28.401321
License: Public Domain

PRESIDING JUSTICE LEWIS delivered the opinion of the court: The plaintiff, Arnold Schuchman, Jr., brought suit against the defendant, W.R. Stackable, M.D., for damages alleged to have been caused by the defendant’s surgical treatment of him after an injury. Following a jury trial, judgment was entered in favor of the defendant, and this appeal followed. Plaintiff presents 14 issues for review. He contends that the trial court erred in failing to grant a judgment n.o.v. or a new trial “with regard to the defendant’s inexperience and consequent damage to the plaintiff,” he raises several issues concerning the trial court’s giving of or refusal to give numerous jury instructions, and he presents a number of issues related to evidentiary and other matters. We turn first to plaintiff’s contention concerning the trial court’s failure to grant his motion for judgment n.o.v. or a new trial. At trial the evidence showed that on August 17, 1984, while working as a logger, the plaintiff was injured when the upper part of a tree fell a distance of approximately 60 feet, striking his shoulder and the back of his neck. As a result, the plaintiff suffered a “burst” fracture of his second lumbar vertebra, which splintered or burst into several pieces with some of its fragments being retropulsed into his' spinal canal, obliterating it in part and exerting pressure upon the contents of the canal. Immediately after injury, the plaintiff was referred to the care of the defendant, a board-certified orthopedic surgeon, at St. Mary’s Hospital in Centralia, Illinois. On August 31, 1984, defendant performed lumbar laminectomy upon him, intending to insert Harrington rods and to perform spinal fusion during the procedure in order to stabilize plaintiff’s back but finding, according to defendant, that he could not continue the operation long enough to do so because of excessive bleeding. On September 6, 1984, while the defendant was out of town, one of the doctors caring for him in defendant’s absence, namely, Dr. R. Chandra, since deceased, had him transferred to Barnes Hospital in St. Louis, Missouri, where on September 8, 1984, Dr. William Strecker inserted Harrington rods and performed posterior spinal fusion. Later, on September 18, 1984, Dr. Strecker removed a retropulsed fragment from the spinal canal and performed an anterior fusion. In January of 1986 Dr. Strecker removed the Harrington rods, which provided stability to the spine until the fusion was solid. The plaintiff, who now walks using forearm crutches, has been unable to return to his occupation as a logger or to any work involving physical labor. The plaintiff called as his expert witness Dr. Robert Tatkow, a board-certified orthopedic surgeon, who testified that he was of the opinion that the form of treatment employed by the defendant did not meet any of the minimum standards usually used by orthopedic surgeons in the community, stating that “¡wjhat was done in this case was to further destabilize an unstable spine by removing the last vestige of possible stability, in other words, removing the bone in the back of the spine, the third column posterior column. This was the last vestige of stability that Mr. Schuchman had left so that by removal of this he totally destabilized the spine, caused the spine to shift one and a half centimeters, approximately, half an inch with further damage to the nerves.” He said that “destabilization of the spine” meant that “it allows the remaining bony elements to abnormally move on each other and thereupon can damage the nerve structures within the spine.” The witness testified that “[w]e do not do laminectomies in the presence of this type of injury, and I don’t think anybody has in many, many years. The literature goes back at least fifteen years or more don’t do laminectomies on this type of an injury. It makes people worse. Harrington instruments, of course, are the gold standard of treatment but not combined with laminectomies.” Concerning the defendant’s intention to undertake the placement of Harrington rods in the plaintiff, when the defendant had never performed such a procedure, the witness expressed the following opinion: “This is such a very demanding procedure with so many ramifications in the use of the instrumentation that it would be absolutely impossible for an individual who had not even seen a procedure in many years to go ahead and attempt to do one on such a complex patient as Mr. Schuchman was.” The witness indicated that he had reviewed the plaintiff’s records made upon his arrival at Barnes Hospital from St. Mary’s Hospital and expressed his opinion with regard to plaintiff’s neurological status upon arrival at Barnes Hospital as follows: “I reviewed the emergency room records, the treating physician’s records, and the resident’s records right after he was transferred to Barnes’ [sic] Hospital. These records all demonstrate a marked neurological deterioration by the time he was transferred to Barnes’ [sic] Hospital compared to his initial status after the injury and before he was operated on at St. Mary’s Hospital.” He indicated that at that time “[h]is quadraceps [sic] were not functioning at all. They were zero, paralyzed.” The witness testified further that X rays taken on September 5, 1984, following surgery by defendant on August 31, 1984, demonstrated “a very marked change in the alignment of the vertebral bodies. The entire upper part of his spine from the first lumbar vertebra, up the entire spine has shifted backwards on the second lumbar vertebra approximately one and a half centimeters, a half inch, more or less. This is the major change that is noted in this film.” The witness described the significance of such a shift in the vertebral bodies at the level of L1-L2: “That is a tremendous change because it infers that the nerve structures within the spinal canal at that level must be stretched one and a half centimeters in the spine, is a tremendous difference. And, in order for the spine to shift, it must stretch nerves within the spinal canal. One can’t happen "without the other.” He stated that by performing laminectomy upon the plaintiff the defendant further destabilized plaintiff’s spine and caused the upper part of his spine to shift about a half an inch onto the lower part, thereby "definitely causpng] nerve damage in this man as was substantiated by the records that I reviewed from Barnes’ [sic] Hospital.” The witness expressed the further opinion that the delay between the time of injury and the time of surgery by defendant was “very inordinate,” stating that “[t]here’s a much higher success rate if it’s done earlier,” that is, within “the first few days” following injury. He indicated that the form of treatment that he believed should have been used was the insertion of Harrington rods shortly after the injury occurred without performing laminectomy; in about “40 or 50 per cent of cases,” he said, the rods “reduce the fragment or get it out of the spinal canal” without the need to remove the fragment later surgically as was done here. The procedure the witness advocated must be performed before any healing occurs: “If you do it after a week or ten days, after healing has started, the chances of getting that fragment out of the canal rapidly become much smaller or impossible without doing another staged operation.” He said that “[t]he delay in the operative procedure then demanded that a second stage would have to be performed in order to get that piece of bone out of his spinal canal because if you try to do something to somebody’s back after two weeks the bones become sticky and you can’t move them around as well as if you did it fresh.” As to whether defendant’s treatment of plaintiff contributed to “the neurological residuals” exhibited by plaintiff, the witness expressed this opinion: “It’s difficult to answer with any definite certainty as to, as to how much neurological deficit Mr. Schuchman would have at this time if he was treated properly in the beginning. We do know that there was neurological damage as a result of the surgery that was performed and the destabilization of the spine, therefore, I have to assume within a reasonable degree of certainty that the surgery that was performed contributed to the neurological deficit that Mr. Schuchman now has.” He indicated that plaintiff’s neurological impairment had increased as a result of defendant’s treatment and that, “therefore, his residual impairment is probably greater.” As to whether plaintiff had experienced increased hospitalization and pain as a result of defendant’s conduct, the witness testified: “Hospitalization was grossly prolonged at St. Mary’s Hospital by the two-week delay between the admission and the surgery performed and because of the gross neurological deficit present by the time he was transferred to Barnes’ [sic] the period of his rehabilitation time at Jewish Hospital [in St. Louis where he was transferred from Barnes Hospital] and thereafter was, also, prolonged. I don’t know exactly how many days or weeks but the more severely injured an individual is the longer his hospitalization stay is when treatment is delayed.” Asked on direct examination “the typical length of a hospitalization for a patient who has suffered injuries similar to those Arnold Schuchman demonstrated on August 17th, 1984, who were given appropriate care” the witness answered, “The last four of these that I did this year, the people went home in a month or less.” On cross-examination the following colloquy occurred between counsel for defendant and the witness: “Q. It was your impression that he had made a nice measure of improvement with findings as those described even before you had an opportunity to do your own examination. Is that right, sir? A. I thought he had made a very nice recovery, yes. Q. And that would represent a good outcome for a man who had had injuries as serious as those suffered by Mr. Schuchman on August 17,1984, correct? A. Yes. Q. In fact, probably as good a result as any board certified orthopedic specialist could expect from a patient with such a difficult problem caused by that tree falling accident? Is that right, sir? A. No, sir. Q. Wouldn’t you say that is probably true? A. I’ll say that considering the neurological deficit and the problems that the man had at the time he was transferred to Barnes’ [sic] Hospital, yes, he has made an excellent recovery. But, I would not characterize this as an excellent recovery in view of the much less neurological deficit that he had at his initial evaluation at St. Mary’s Hospital before the destabilizing procedure was performed.” He indicated that he would not expect a man injured as the plaintiff had been on August 17, 1984, ever to return to work as a logger or to return to work involving significant manual labor regardless of the quality of medical care and treatment he had received. With regard to the duration of plaintiff’s hospitalization, the witness testified, “I can state with a reasonable degree of medical certainty that the hospital stay would surely be less than six months; and this man was hospitalized altogether including his rehabilitation time at Jewish Hospital for approximately six months.” He indicated that in medical centers “today” the procedure for treating a patient injured as was plaintiff is usually performed in two stages or operations. The removal of the Harrington rods would constitute a third operation. The witness testified that he had not reviewed any of plaintiff’s medical bills, that he knew nothing about plaintiff’s medical bills, and that he could not express an opinion as to the amount or extent of medical bills incurred by plaintiff which were produced by defendant’s alleged negligence as distinguished from those caused by the falling of the tree top upon him. On redirect, when asked “why if Arnold Schuchman had had the appropriate treatment been given [sic] did Arnold Schuchman need to have a two-stage procedure?” the witness responded, “I can only quote statistics. I cannot say in any one specific case. Statistically, thirty or forty percent of people with this type of a burst fracture can be adequately treated with just one operation. The remainder the usually [sic] that [defense counsel] questioned me about, being more than fifty percent would require a second stage anterior approach, but to take any one individual, I cannot state within a certainty.” The defendant called as an expert witness Dr. Akbarnia, whose first name is omitted from the record. This witness, a board-certified orthopedic surgeon, testified that surgery should have been performed on a man injured as was the plaintiff “at least in the first three to four weeks.” Asked, “There has been some testimony that it should be done in the first two or three days. What is your opinion on that subject?” the witness responded as follows: “Well, scientifically, there is no evidence that early surgery would alter the final outcome neurologically and there has been no proof in that. The only time that you are advised that that should be done early is when the neurological status is severely deteriorated and at that time it has to be done on a [sic] emergency basis.” The plaintiff’s condition was not, he indicated, one requiring surgery on an emergency basis. He testified that the nature and extent of permanent nerve damage in a case such as the plaintiff’s “depends on the degree and severity of the injury that he sustained at the initial impact.” Given the degree and severity of the injury the plaintiff sustained initially on August 17,1984, the witness “suspectjed] some degree of permanent residual impairment” as a prognosis. The witness discussed the alternatives in choice of a surgical technique available to the defendant, saying, “Basically, the two main techniques that you can approach is from the back or from the front, or, you can have both together.” The defendant, he said, approached “[f]rom the back.” The witness expressed the opinion that the posterior approach taken by the defendant “was appropriate.” He testified concerning defendant’s stopping the operation while the plaintiff’s back was unstable prior to insertion of the Harrington rods and performing spinal fusion by means of a bone graft: “My understanding from the operating report was there was considerable amount of bleeding and especially towards the end of the procedure. That is what my understanding is. And, I would imagine that the source of that blood loss probably was a, from small veins that are under the dura because the dura was torn, plus a general oozing that was described in the operating report and based on the records was not, you know, Doctor Stackable was not able to control that bleeding.” He testified as follows with regard to the bleeding that occurs during fusion: “Well, if he wanted to proceed with a fusion and instrumentation as he wrote in his operating report that that was his intention he had to take some bone from the pelvis, from the iliac bone, side of the pelvis. That means opening another area of the body here and then carve some bones from the ilium, which is the source of bone graft, and then, again, carve the area of the spine that has to be fused and that is the only way you can put bone graft in that heals. When you carve the bone then you have more bleeding, obviously, and those bleedings usually cannot be controlled.” The bleeding cannot be controlled, he said, because it is from the bone and, unlike bleeding from the soft tissue and muscles, it cannot be clamped. He added that it is harder to control that kind of bleeding “[bjecause the bleeding is from all small areas. You can’t deal with thousands of them, you know. It’s like the middle of a bone, you have seen like a sponge, so, from each of those holes you have bleeding, all opened blood. So that is why we usually do the fusion part at the end of the operation where the patient is, another part of the operation is done and we just do the carving and do the bone and close it, so it wouldn’t last for some time. And, that part usually bleeds.” The witness indicated that, on the basis of the materials he had reviewed, he would “probably” have terminated the operation as the defendant had; the witness concluded it would have been appropriate “to close rather than proceed” on the basis of “[e]xcessive bleeding.” Under such circumstances the spine remains unstable, he said, a condition to be managed “by not allowing the patient to bear weight and load, so, they should be in a supine, laying down position.” He testified that “[u]sually, as long as a patient is log-rolled and kept in bedrest, there’s no danger of increasing damage to the spine.” The witness said that “[w]hen you stand you put the stress on the spine and that is the psysiological [sic] load and that allows more compression of the spine; but, when a patient is lying down, that compression force is not there, so, you don’t tend to see displacement.” It is undisputed that the plaintiff had been kept at bedrest on a Stryker frame following surgery by defendant until the time of his transfer to Barnes Hospital. The witness discussed the alignment of the plaintiff’s spine, as shown on X ray, testifying that “there was some minimal displacement in comparing the X rays, original X rays and the X rays prior to the second operation.” The minimal displacement he described amounted to nine millimeters, according to his measurements, or approximately one-fourth of an inch. Asked the neurological significance of the one-fourth of an inch of displacement, he answered, “I really don’t think that alignment change affects the ultimate outcome.” He expressed the view that the displacement did not have a longstanding effect neurologically. The area of concern to the witness was the area of compression of the nerves inside the spinal canal where the retro-pulsed bone fragments were located, which had revealed no change following surgery by the defendant or, apparently, in X rays taken at Barnes Hospital after his transfer there. He testified that, in comparing the findings recorded at the initial examination of the plaintiff with the findings of Dr. Tatkow when he examined plaintiff on April 1, 1988, he thought that the plaintiff had made “a very good recovery.” He expressed the opinion that defendant’s care and treatment had not caused or contributed to plaintiff’s injuries, stating, “[I]t didn’t cause any additional injury, any more than he had.” On cross-examination the witness testified that deterioration of neurological function following back surgery for a fractured spine “is unusual, but it occurs” in around 3% to 5% of cases in which the patient is neurologically involved prior to surgery. He stated that after surgery on August 31, 1984, plaintiff’s condition deteriorated temporarily but that “the final outcome is determined at the time of injury”: “Again, I have to differentiate between the outcome, permanent outcome or temporary deterioration. When we talked before all my testimony was for the permanent injury. It is very unusual to have a permanent injury after mentioning three to five percent, but after surgery temporary deterioration can happen and that is due to an edema or as the result of surgery. But, the final outcome, I think, is what is considered. So, that is what I’m referring to.” He said further that if patients “sustain or they get some temporary neurological problem after the surgery, then, it takes that much to return it. Sometimes it takes maybe more, two or three months to return.” He testified that he had indicated in the past that laminectomy is not indicated for treatment of burst fractures, had co-authored papers indicating that laminectomy will not fully decompress neural tissue, and had written papers indicating that as an isolated procedure laminectomy may lead to greater instability with increased deformity of the spine. He indicated that the laminectomy “was a part of” the instability of plaintiff’s spine following surgery by defendant but that his spine “was already unstable when he went to surgery,” He testified that laminectomy aggravated the “potential instability” of plaintiff’s spine. When asked whether he agreed that “offset” or displacement of the spine “could cause neurological injury to a patient,” he answered: “No, I don’t agree, and the reason is that as I mentioned before this offset can be seen in the X ray. You’re right, it was written in the radiologist report and I, also, measured it. But, this might indicate the rotation of these two blocks together but actual neurological damage or any possible neurological damage is [sic] usually takes place with those fragments in the canal. Those really in conjunction and in the proximity to the nerve canal and offset themselves there’s no indication for me to say this would cause neurological deficit. That is the reason why I’m stating my opinion.” Asked, “There were many possible causes for Arnold Schuchman’s injuries, correct?” the witness answered, “No. I only know of one cause and that is the tree that fell and initial injury.”' When asked whether he would agree that the accepted standard of care in 1984 “was to remove those impinging fragments in the spinal cord by the early application of Harrington rods and fusion,” he indicated that such treatment need not have been “early” if the patient had begun to improve .neurologically and had reached a “plateau” in improvement. The testimony of the defendant shows that following injury and before surgery on August 31, 1984, the plaintiff had regained some sensation in his lower limbs. The witness suggested that in the event the patient has begun to improve neurologically but has reached a plateau, the fragments could be removed as “late as even a year” following injury. The witness testified that it is now known that Harrington rods do not reduce, that is to say, remove, bone fragments impinging on the spinal canal: “In 1977, we thought that way but now we don’t think that those instruments would do that.” In response to questioning concerning the recommended treatment for a burst fracture of the L2 vertebra, he responded in part: “I think, I cannot come here and stand here and say all the burst fractures have to be treated this way and I know if I was in that situation it is something else. You are just coming in and saying Harrington and anterior fusion is the only method, which is not correct for me to say. Some can be treated posteriorly with Harrington and some with anterior.” Concerning the defendant’s intention to insert Harrington rods into the plaintiff although he had never performed the procedure or assisted with one, the witness testified: “It depends on the confidence of the orthopedic surgeon. If he feels that he can do it, then, it’s acceptable. There are many new procedures that are done for the first time and are done through the seminars and continued medical education, so, I think, it is very helpful to assist and to see one, observe one, you know, but I can’t tell whether one is confident in doing it.” The evidence deposition of Dr. William Strecker, a board-certified orthopedic surgeon who treated plaintiff at Barnes Hospital, was read to the jury on behalf of the defendant. This witness testified that in his opinion “the treatment that Doctor Stackable rendered did not contribute to a neurological deficit in this gentleman” and “none of his residual functional deficit was secondary to any operative procedure.” He stated that when he removed the retropulsed fragment of bone from plaintiff’s spinal canal, the fragment appeared to be in the same location in which it had been immediately after injury on August 17, 1984, as revealed by CT scan. On cross-examination he said that the use of laminectomy in the case of a burst fracture in which an anterior fragment was retropulsed “forward” had been abandoned by the “[m]id to late seventies.” The procedure of choice in such a case, he said, would have been an anterior or a posterior lateral approach to remove the retropulsed fragment. He stated further upon cross-examination that, “[according to his medical record and the deficits which he had prior to the August 31st surgery and the deficits on the physical exams after August 31st when he got to me, there was no appreciable change in those deficits in the previous medical records.” He testified that this lack of appreciable change in plaintiff’s neurological condition was the basis for his opinion that he sustained no additional neurological damage as a result of the surgery performed by defendant. With regard to any change in quadriceps functioning of the plaintiff, the witness stated: “I cannot state that there’s [sic] been a difference. When he was initially seen it states that he has I believe it was one to two plus and two to three plus which states that in the way motor function is graded that is some muscular contraction, not enough to move a joint against gravity. And when I saw him after three and a half weeks down the line being at complete bed rest I wasn’t able to get much of a quadriceps contracture. One plus is basically a flicker of contracture. So it’s a subjective grading. I can’t say that there’s been a definite neurological change in this gentleman after a three-week change of bed rest from the fact that does he have a flicker of quadriceps contracture that’s not enough to move a joint versus no appreciable quadriceps contracture because you can get atrophy of the quadriceps muscle within ten days of taking a normal subject and putting them to bed rest. So you’re looking at a subjective grading system and there’s not one examiner always doing the grading.” Dr. Strecker testified that the plaintiff had indicated that initially, upon injury, he had been paraplegic but upon arriving at the hospital in Centraba he had regained use of his right leg but had noted some residual weakness in his left leg. He said that he understood from defendant’s operative note that defendant had aborted the operation because of excessive bleeding and had subsequently undertaken hematologic investigation to determine whether plaintiff had a bleeding problem. The plaintiff was not, according to his knowledge, permitted to get up, twist, or turn after the operation by defendant by virtue of having been placed in a Stryker frame, whose purpose is to keep a patient immobile in a bed while permitting the patient to be turned over without having to move any part of his body. Although the defendant testified at length, the dispute in this case pertains not to the care that was given plaintiff but to the quality of that care. Hence, we deem it unnecessary to set forth the undisputed details about which defendant testified concerning his care and treatment of plaintiff.  A party is entitled to a judgment n.o.v. only in cases where all the evidence, when viewed in a light most favorable to the opponent, so overwhelmingly favors the movant that no contrary verdict based on the evidence could ever stand. (Pedrick v. Peoria & Eastern R.R. Co. (1967), 37 Ill. 2d 494, 229 N.E.2d 504.) Application of the Pedrick standard to medical malpractice cases requires the reviewing court to scrutinize the evidence submitted by the plaintiff in support of his case. (Mielke v. Condell Memorial Hospital (1984), 124 Ill. App. 3d 42, 463 N.E.2d 216.) We have examined the entire record and conclude that plaintiff’s motion for judgment n.o.v. was properly denied. In a medical malpractice action plaintiff bears the burden of establishing the standard of care by which the defendant physician’s conduct is to be measured and the breach of that standard which resulted in the injury. (Piano v. Davison (1987), 157 Ill. App. 3d 649, 510 N.E.2d 1066.) Where the parties offer conflicting medical testimony concerning the applicable standard of care and defendant's breach of that standard, the jury is uniquely qualified to resolve the conflict, and a judgment n.o.v. is not required. (Piano, 157 Ill. App. 3d 649, 510 N.E.2d 1066.) In the instant case, as is apparent from the facts set forth above, both parties offered conflicting expert testimony on virtually every point relating to the proper standard of care and the defendant’s alleged breach thereof. Thus, the conflicting testimony was sufficient to raise a question of fact to be decided by the jury, and the trial court properly denied plaintiff’s motion for entry of judgment n.o.v.  In ruling on a motion for granting a new trial, the trial court will weigh the evidence and set aside the verdict and order a new trial if the verdict is contrary to the manifest weight of the evidence. (Mizowek v. De Franco (1976), 64 Ill. 2d 303, 356 N.E.2d 32.) A verdict is contrary to the manifest weight of the evidence when the opposite conclusion is clearly apparent or the verdict is palpably erroneous and clearly unwarranted. (Cadral Corp. v. Solomon, Cordwell, Buenz & Associates, Inc. (1986), 147 Ill. App. 3d 466, 497 N.E.2d 1285.) In view of the conflicting expert testimony, the verdict here may not be said to be contrary to the manifest weight of the evidence, and the trial court did not abuse its discretion in denying plaintiff’s post-trial motion for a new trial.  The plaintiff contends that the trial court erred in failing to instruct the jury properly “on the issues concerning aggravation of a pre-existing injury.” Specifically he contends that the court erred in refusing to give his instruction No. 18 and erred in giving instead his instruction No. 18(a) concerning the burden of proof. Plaintiff’s instruction No. 18 reads in pertinent part as follows: “Third that the negligence of the defendant was a proximate cause of injury to the Plaintiff.” His instruction No. 18(a) reads in relevant part as follows: “Third, that the negligence of the defendant was a proximate cause of the injury to the plaintiff ***.” (Emphasis added.) The language of his instruction No. 18(a) is that of Illinois Pattern Jury Instructions, Civil, No. 21.02 (2d ed. 1971) (hereafter referred to as IPI Civil 2d). Plaintiff urges that the reference to “the injury” in instruction No. 18(a) implies that he suffered only one injury when, in fact, he says, he suffered two separate injuries to his back. He argues that the instruction was plainly misleading because it implied that he could recover only if the jury found that the defendant was responsible for “all” his injuries. He maintains that “[u]se of the term ‘the injury’ operated in effect as a grant of a directed verdict to the Defendant because Plaintiff could never prove that Defendant’s conduct was a cause of the original injury to the Plaintiff and the jury was not informed that the words ‘the injury’ could refer to any injury rather than to ‘the injury.’ ” Illinois courts have long held that the test of correctness or propriety of instructions is not what meaning the ingenuity of counsel can, at leisure, attribute to them, but how and in what sense, under the evidence before them and the circumstances of the trial, ordinary men acting as jurors will understand the instructions. (Nicholl v. Scaletta (1982), 104 Ill. App. 3d 642, 432 N.E.2d 1267; Newton v. Meissner (1979), 76 Ill. App. 3d 479, 394 N.E.2d 1241.) Under the evidence before them, the jury in the exercise of common sense could not have understood this instruction to require proof by plaintiff that defendant’s conduct caused the original injury plaintiff sustained when the tree top fell on him. Similarly, plaintiff argues that the trial court erred in refusing to give his instruction No. 16, giving instead his instruction No. 16(a). He argues that the use of the words “his injuries” in instruction No. 16(a), instead of the words “injuries to the plaintiff” in proposed instruction No. 16, “again, in effect directs a verdict for the Defendant because the Plaintiff could never show in this case that the Defendant was a cause of the tree falling on him.” We consider the contention equally unmeritorious. Plaintiff states that he tendered his instructions Nos. 19(a) and 35(a) “[i]n order to remedy the problem” raised by the trial court’s alleged error pertaining to the giving of his instructions No. 18(a) and No. 16(a), which refer, he says, to “a single undifferentiated set of injuries” to the plaintiff as opposed to the situation presented here in which only some of the injuries were attributable to the defendant. He contends that the trial court’s refusal of his proposed instructions Nos. 19(a) and 35(a) was error. However, we have determined that the trial court committed no error with regard to the giving of instructions Nos. 18(a) and 16(a); hence, there was no problem to be remedied, and no error could have occurred in the trial court’s refusal of them. The plaintiff assigns as error the trial court’s refusal to give the long form of IPI Civil 2d No. 15.01 defining proximate cause although the instant case involved “multiple causes.” The trial court gave the first sentence of this three-sentence instruction but refused to read the second and third sentences thereof. This instruction as proposed by plaintiff reads: “When I use the expression ‘proximate cause,’ I mean any cause which, in natural or probable sequence, produced the injury complained of. It need not be the only cause, nor the last or nearest cause. It is sufficient if it concurs with some other cause acting at the same time, which in combination with it, causes the injury.” The trial court refused to give the long form of the instruction because the plaintiff did not contend that, in the words of the court, “the tree limb and Doctor Stackable acted at the same time to bring about this injury.” In refusing to give the long form of IPI Civil 2d No. 15.01, the trial court gave plaintiff’s instruction No. 14(a), which is IPI Civil 2d No. 12.05, concerning the intervention of an outside agency. That instruction reads as follows: “If you decide that the defendant was negligent and that his negligence was a proximate cause of injury to the plaintiff, it is not a defense that something else may also have been a cause of the injury. However, if you decide that the sole proximate cause of injury to the plaintiff was something other than the conduct of the defendant, then your verdict should be for the defendant.” (IPI Civil 2d No. 12.05.) In determining that IPI Civil 2d No. 12.05 would be given, the trial court stated, “I’m going to give your 12.05. I don’t think you are entitled to it but in any event you have an instruction 12.05 which takes away any possible chance that the Jury misunderstand it, I think.”  The test in determining the propriety of submitted instructions is whether, taken as a whole, they are sufficiently clear so as not to mislead the jury and whether they fairly and correctly state the law. (Curry v. Summer (1985), 136 Ill. App. 3d 468, 483 N.E.2d 711.) IPI Civil 2d instruction No. 12.05 given here made it clear that there could be more than one proximate cause of injury to the plaintiff. In addition, the jury was further informed concerning proximate cause by plaintiff’s instruction No. 35(b), a non-IPI Civil 2d instruction approved in Balestri v. Terminal Freight Cooperative Association (1979), 76 Ill. 2d 451, 394 N.E.2d 391. Plaintiff’s instruction No. 35(b) reads as follows: “If you find that the defendant was negligent and that his negligence was a proximate cause of injury to and disability of the plaintiff, you should then find for the plaintiff and his right to recover damages for such injuries and disability is not barred or to be limited in any way by the fact, if you find it to be a fact, that the plaintiff’s injury and disability resulted from an aggravation of a pre-existing condition by the occurrence in question.” We think that, under the circumstances, error, if any — and we make no determination with regard to that question — was obviated by the trial court’s giving of IPI Civil 2d No. 12.05 and plaintiff’s instruction No. 35(b).  The plaintiff assigns as further error the trial court’s refusal to give his instruction No. 14, which consisted of only the first paragraph of IPI Civil 2d No. 12.05; instead, the trial court gave plaintiff’s Instruction No. 14(a), consisting of both paragraphs of No. 12.05, quoted above. The plaintiff contends that it was error for the trial court to have given the second paragraph of No. 12.05 because, he argues, “there was no evidence that the Plaintiff’s tree accident was the sole proximate cause of all injuries to the Plaintiff,” including “additional hospitalization and temporary neurological deficit.” However, as the evidence disclosed, the jury could have concluded on the basis of expert testimony that the defendant’s care and treatment caused no injury to plaintiff in addition to that sustained by the falling of the tree top upon him. A party has a right to have the jury instructed on his theory of recovery or defense if that theory is supported by facts in evidence or by reasonable inference from facts in evidence. (Smith v. Ford (1976), 43 Ill. App. 3d 407, 356 N.E.2d 1306.) In view of the evidence adduced at trial, the trial court did not err in giving the second paragraph of IPI Civil 2d No. 12.05. The plaintiff urges that the trial court erred “in refusing in evidence and barring discussion of Dr. Chandra’s hospital consultation note on the plaintiff.” As we have stated, Dr. Chandra, who died prior to trial, treated plaintiff when defendant was out of town following the surgery of August 31, 1984. The defendant last saw plaintiff on September 3, 1984. Thereafter, until plaintiff’s transfer to Barnes Hospital, Dr. Chandra assumed plaintiff’s care for defendant. Specifically, plaintiff contends that the report was admissible into evidence as substantive evidence and that the plaintiff’s expert should have been permitted to read from the report in support of his opinion. He states that the purpose of offering this document was “to show the deterioration in Plaintiff’s condition was obvious from the document itself and from Dr. Tatkow’s and Dr. Strecker’s testimony.” Plaintiff argues: “The issue of the Plaintiff’s condition following surgery was critical to disposition of the case because both Dr. Strecker and Dr. Tatkow stated that whether the condition of the Plaintiff deteriorated following Defendant’s surgery was a key determinant in ascertaining whether the Plaintiff suffered permanent deficit as a consequence of the Defendant’s surgery. * * * Specifically Dr. Strecker stated that he did not think the Plaintiff suffered any long term damage because he didn’t think the Plaintiff’s condition deteriorated following the Defendant’s surgery. *** Had Plaintiff been able to admit Dr. Chandra’s report into evidence, he would have been able to show that Dr. Strecker was mistaken in that respect and had a direct means of comparing the condition of the Plaintiff before and after surgery.” Although the plaintiff’s expert witness, Dr. Tatkow, was not permitted to read from Dr. Chandra’s report on direct examination, the witness testified that he had reviewed “the records of another surgeon by the name of Doctor ‘Chandra’ who evaluated Mr. Schuchman just before his transfer to Barnes’ [sic] Hospital in St. Louis after the surgery had been performed by Doctor Stackable.” Asked, “How were Doctor ‘Chandra’s’ [sic] notes significant in the formation of your opinion as to his neurological condition following surgery?” Dr. Tatkow answered, “It demonstrates marked deterioration in Mr. Schuchman’s neurological status and further paralysis.” Dr. Tatkow testified further, as quoted above, concerning the plaintiff’s neurological status upon his arrival at Barnes Hospital. The records of the emergency room, of the treating physician, and of the resident “right after he was transferred to Barnes’ [sic] Hospital” all demonstrated, Dr. Tatkow said, a marked neurological deterioration by the time of plaintiff’s transfer to Barnes Hospital compared with his initial status after injury and before surgery by the defendant. Dr. Tatkow indicated further that plaintiff’s quadriceps were not functioning and were paralyzed at the time of the plaintiff’s transfer to Barnes Hospital. As we have already stated, on cross-examination by plaintiff, Dr. Strecker testified that the lack of appreciable change in plaintiff’s neurological condition was the basis for his opinion that plaintiff sustained no additional neurological damage as a result of the surgery performed by defendant. As outlined above, this witness indicated that he could not state that there was a difference in plaintiff’s quadriceps functioning as graded by himself and earlier by the defendant in view of the subjective nature of such grading and the effects of bedrest upon the quadriceps muscle. The witness indicated further on cross-examination that “Doctor Stackable and I do not grade muscle function the same way.” Like Dr. Tatkow, Dr. Strecker testified that when the plaintiff arrived in St. Louis from Centraba, his quadriceps function was absent on both the right and the left. Concerning Dr. Chandra’s report, Dr. Strecker testified as follows during this colloquy between the witness and counsel: “Q. Now you also received Doctor ‘Chandra’s [sic] dictation from St. Mary’s Hospital; correct? A. That’s correct. Q. And Dr. ‘Chandra’ [sic] indicates that on September — at the time of his discharge on September 6 from St. Mary’s Hospital that Arnold Schuchman had no voluntary control of movement of either extremity, is that not correct? A. Can I see where you’re reading from there? Q. Sure. And also down here, the patient has no voluntary control of movement of either lower extremities [sic]? A. He does say that there but then he also quotes muscle grading strength at the same time. So I’m not sure what he means by that. It says that patient has no voluntary control of movement of either lower extremities [sic] but he has very weak adductors of the hips, weak flexors and abductors of the hips, patient had active ham strings but could not resist any force. I don’t know how that statement alone fits with him also saying that he’s got hip abductors, adductors and ham strings. So I look more at what he says he has functioning than no voluntary motion because he must have some voluntary motion or he couldn’t do all of these things. So I don’t know what Doctor ‘Chandra’ [sic] meant at the time.”  Generally, a reviewing court will not reverse a jury verdict because of error in the admission of evidence unless there has been a denial of real justice. (Greene v. Rogers (1986), 147 Ill. App. 3d 1009, 498 N.E.2d 867.) Not every error requires reversal; where it appears that an error did not affect the outcome in the trial court, or where the reviewing court can see from the entire record that no injury has been done, the judgment will not be disturbed. (Greene, 147 Ill. App. 3d 1009, 498 N.E.2d 867.) Here, in light of this testimony by both Dr. Tatkow and Dr. Strecker concerning Dr. Chandra’s report and deterioration of plaintiff’s condition following surgery by defendant, together with testimony by Dr. Akbarnia concerning neurological deterioration following back surgery for a fractured spine, we think that even if it were error, as urged by plaintiff, to refuse to admit the report of Dr. Chandra as substantive evidence and to refuse to allow Dr. Tatkow to read it in support of his opinion, the outcome of the case would have been no different and, thus, such error was harmless. We need not and do not make any determination as to whether, in fact, the trial court erred in its rulings in this regard. Plaintiff assigns as further error the trial court’s refusal to allow the plaintiff’s expert witness to “discuss” certain textbooks and studies in support of his opinions in this case. In partial response to the defendant’s oral motion in limine to preclude Dr. Tatkow from “reading from notes of the medical literature or otherwise summarizing the literature or testifying to the context [sic] of any treatisef,] journal or other work,” counsel for plaintiff stated, “I’m not going to specifically ask him about any studies, however, I think, he may in his answer, he may want to bring up things that he has relied upon and read from a portion of a text.” The trial court responded in part as follows: “I’m not going to allow him to read from any portion of any text. He can say he has relied, in part, on medical treatises, journals, and articles and might even be able to say what he has read, the source of it. Those would be proper to be cross examined as to those as far as that goes, but he’s not going to be able to sit there and read. That is pure, pure unadulterated hearsay, which is not subject to cross examination.” Plaintiff’s counsel asked the court, “Your Honor, you are not saying that he can’t say that there are studies that exist that are consistent with his opinion, are you, and there are studies that have shown that people who have had X injury have made such and such recovery?” The trial court answered: “I haven’t said that. I have said he cannot read, he cannot paraphrase statements out of any journals or medical treatises. You are not required to, but you can lay a foundation of basis for his opinion. Under Wilson v. Clark [(1981), 84 Ill. 2d 186, 417 N.E.2d 1322,] all the matters in which an expert could have been examined prior hereto still exist but now you can also, after qualifying an expert call him to the stand and ask him if he has an opinion. If he says yes, you can ask him what his opinion is and leave it to the cross examiner to develop the basis for it but that is taking Wilson v. Clark literally. In fact, that is almost what they said. He can state the basis for it, but I’m not going to let him get into paraphrasing journals and articles or reading from them; but he can say based upon studies.” During direct examination of Dr. Tatkow counsel asked him whether studies had been done using certain grading systems to ascertain levels of improvement in a patient with a nerve root injury. Upon objection by the defense, the trial court reiterated its ruling, stating in part: “I said that he could not paraphrase, or he could not recite word for word from any literature. He can say that studies have been made and he is acquainted with them, has read them, and he can say whether he has based any part of his opinion on those studies. But, they are not, the studies, themselves, are not necessarily disclosable. *** If he is generally basing his opinion upon some recognizable studies, he can say that. Let’s go on.” Counsel addressed no further questions to this witness pertaining to studies or articles in the medical literature. Later plaintiff made an offer of proof, including page numbers of those pages of five medical articles Dr. Tatkow would have, in counsel’s words, “[r]ead or referred to as supportive as [sic] his testimony.” At the conclusion of the offer of proof, the following exchange occurred between the trial court and plaintiff’s counsel: “[THE COURT] Well, you have made your offer of proof and I have previously indicated the reason for my ruling why I don’t think you can allow the witness to simply read from, on direct examination, read from various articles — . MS. de SAINT PHALLE: Or refer to- THE COURT: Well, now, don’t put words in my mouth. Don’t put words in my mouth. The record will reflect that the, you indicated to the Court that you wanted to use these for that purpose and my ruling previously. You are making your offer of proof now and I’ll accept them for the file but I’ll refuse them admission into evidence.”  The record shows that plaintiff made no effort on direct examination to question his expert within the limitations outlined by the trial court in its ruling. With regard to the trial court’s refusal to permit the witness to read from any articles from the medical literature, it has been held that an expert witness may not read from notes taken while reviewing literature and thereby summarize findings of studies in the medical literature (Mielke v. Condell Memorial Hospital (1984), 124 Ill. App. 3d 42, 463 N.E.2d 216). If an expert witness may not summarize the findings of articles, it follows logically that an expert witness may not read from such articles. In Mielke the trial court prohibited the plaintiff’s expert from reading from his notes although the plaintiff stated that she did not wish to have the notes admitted into evidence. The plaintiff in Mielke had made an offer of proof in which her expert stated that his notes summarized articles written by well-recognized authorities, his opinion of the standard of care was based upon the notes, and his testimony, if allowed, would parallel his notes. The reviewing court in Mielke concluded that, by summarizing the findings of the studies in the medical literature, the plaintiff there was attempting to recite the data and conclusions of the articles. Like the authors of the articles summarized by the plaintiff’s expert in Mielke, the authors of the articles in the instant case were unavailable for cross-examination, a matter of concern to that court as it is to this one. The court in Mielke considered Wilson v. Clark (1981), 84 Ill. 2d 186, 417 N.E.2d 1322, in which the court upon review prospectively allowed a nontreating expert to give his response to a hypothetical question based upon facts contained in hospital records even if the records themselves are not in evidence. The court in Mielke pointed out that, unlike the situation before it, in Wilson “the expert witness was answering a hypothetical question based upon facts contained in the plaintiff’s hospital chart” and that, therefore, those facts were “directly pertinent to that litigation” (Mielke, 124 Ill. App. 3d at 55, 463 N.E.2d at 227). By contrast, the excluded testimony of the plaintiff’s expert in Mielke, the court said, did not directly concern the plaintiff’s treatment. Similarly, the excluded testimony of Dr. Tatkow in the instant case does not directly concern this plaintiff’s treatment. Thus, the trial court did not err in refusing to permit Dr. Tatkow to read from articles from the medical literature. Furthermore, our examination of the record indicates that in light of all the evidence, even if it were error for the trial court to have prohibited the reading of these materials, such error would have been harmless at most.  The plaintiff presents three issues for review concerning damages: whether the trial court erred in excluding from evidence plaintiff’s medical bills, whether the trial court erred in refusing his instruction No. 20 pertaining to the apportionment of damages when aggravation of a preexisting condition has occurred, and whether the trial court erred in refusing plaintiff’s instruction No. 21 pertaining to certain elements of damages. It is well established that where a defendant is found not liable, alleged errors pertaining solely to the question of damages do not afford grounds for reversal. (Mackey v. Daddio (1985), 139 Ill. App. 3d 604, 487 N.E.2d 1167.) In the instant case the jurors were instructed by IPI Civil 2d No. 36.01, as defendant’s instruction No. 4, that if they decided for the defendant on the question of liability, they would have no occasion to consider the question of damages. The jury decided for the defendant on the question of liability. Hence, the trial court’s alleged errors in failing to instruct concerning certain matters pertaining to damages are not grounds for reversal. The plaintiff raises a number of other issues concerning instruction of the jury as well as evidentiary and other rulings of the trial court. We have examined each one and conclude that the contentions are either without merit or are so minor as not to constitute reversible error. Affirmed. RARICK, J., concurs.