Appellant Cassidy-Alexis-Ediger-an-infant-by-her-Guardian-as

48 Pages·2012·2.64 MB·English

File No. 34408
IN THE SUPREME COURT OF CANADA
(ON APPEAL FROM THE COURT OF APPEAL FOR BRITISH COLUMBIA)
BETWEEN:
CASSIDY ALEXIS EDIGER,
AN INFANT BY HER GUARDIAN AD LITEM, CAROLYN GRACE EDIGER
Appellant
AND:
WILLIAM G. JOHNSTON
Respondent
APPELLANT'S FACTUM
FILED BY THE APPELLANT CASSIDY ALEXIS EDIGER,
AN INFANT BY HER GUARDIAN AD LITEM, CAROLYN GRACE EDIGER
pursuant to the Rules of the Supreme Court of Canada, SOR/2002-156, Rule 42
BORDEN LADNER GERVAIS LLP BORDEN LADNER GERVAIS LLP
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Solicitors for the Appellant Ottawa Agent for the Appellant
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Vancouver, BC P.O. Box 466, Stn "D"
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Counsel for the Respondent Agent for the Respondent
Table of Contents
PART I(cid:9) OVERVIEW AND FACTS (cid:9) 1
A. Overview (cid:9) 1
B. Evidence and Findings on Standard of Care (cid:9) 3
Material Risks of Mid-forceps Procedure (cid:9) 3
(i)
(ii) Failure to Obtain Informed Consent to Mid-forceps Procedure (cid:9) 4
(iii) Standard of Care for Mid-forceps Deliveries (cid:9) 4
(iv) Dr. Johnston's Breach of the Standard of Care (cid:9) 7
C. Evidence and Findings on Factual Causation (cid:9) 9
Events Preceding Rotational Mid-forceps Procedure (cid:9) 9
(i)
(ii) Rotational Mid-forceps Procedure (cid:9) 10
(iii) Events Following Rotational Mid-forceps Procedure (cid:9) 10
(iv) Cause of Fetal Bradycardia (cid:9) 11
(v) Cassidy's Birth (cid:9) 13
(vi) No Back-up Immediately Available a But-for Cause of Injuries (cid:9) 13
(vii) Lack of Informed Consent a But for Cause of Injuries (cid:9) 14
PART II(cid:9) ISSUES (cid:9) 15
PART III(cid:9) ARGUMENT (cid:9) 16
A. Evidence Sufficient to Draw Factual Inference of Causation (cid:9) 16
(i) Legal Principles (cid:9) 16
(ii) Standard of Review (cid:9) 19
(iii) Primary Facts Supported Causal Inference on "Threshold" Issue (cid:9) 20
(iv) Primary Facts Supported Causal Inference on Better Outcome (cid:9) 27
(v) Alternatively, Power to Draw Inference Not Impaired by Causal Uncertainty
of "Threshold" Issue (cid:9) 30
B. Alternatively, Evidence Sufficient to Draw 'Legal' Inference of
Causation (cid:9) 35
(i) Mid-forceps Procedure a 'Legal' Cause of Bradycardia (cid:9) 36
(ii) No Back Up Immediately Available a 'Legal' Cause of Injuries (cid:9) 38
PART IV(cid:9) COSTS (cid:9) 39
PART V(cid:9) ORDER SOUGHT (cid:9) 40
PART VI(cid:9) TABLE OF AUTHORITIES (cid:9) 41
PART VII(cid:9) LEGISLATION AT ISSUE (cid:9) 45
PART I(cid:9) OVERVIEW AND FACTS
A.(cid:9) OVERVIEW
1. On January 23, 1998, Carolyn Ediger was admitted to Chilliwack General
Hospital to give birth to her first child, Cassidy Ediger. Dr. William Johnston, her treating
obstetrician and gynaecologist, induced labour and instructed her to return to the hospital in the
evening. When Mrs. Ediger returned, Dr. Johnston ruptured her membranes. She remained in
hospital overnight. On January 24, Dr. Johnston returned in the morning and left orders for
further induction. Mrs. Ediger's labour then progressed more quickly. By 14:30, she had been
pushing for about one and a half hours without much descent. Dr. Johnston concluded that
Cassidy had become stuck sideways in the mid-pelvic region of the birth canal in a "deep
transverse arrest". He told Mrs. Ediger that he would attempt to deliver Cassidy using forceps.
He inserted both forceps blades but eventually abandoned the procedure because he was unhappy
with the placement of the second blade. Within (at most) one to two minutes of his attempt to
perform the procedure, Cassidy's heart rate dropped precipitously. Dr. Johnston and his nursing
staff then took steps to deliver Cassidy by Caesarean section. A surgical team was eventually
assembled and Cassidy was delivered about twenty minutes after her heart rate dropped. The
lengthy period of asphyxiation caused catastrophic brain damage. Cassidy suffers from spastic
quadriplegia and cerebral palsy of a mixed type. She is not expected to live past thirty-eight
years of age.1
2. The following issues are not in dispute on this appeal:2
• Did Dr. Johnston owe Cassidy a duty of care? Yes.
• Did the duty of care include a duty to obtain Mrs. Ediger's informed consent to material
risks of personal injury to herself and to Cassidy? Yes. One of the widely-acknowledged
complications associated with a mid-forceps procedure is the risk the foetus will
experience a prolonged drop in heart rate resulting in asphyxiation and consequent brain
damage.
Reasons of the Trial Judge, paras. 2, 8, 28, 30, 33, 124.
1
Reasons of the Trial Judge, paras. 7, 10, 61, 64, 91-94, 146, 152-154, 158, 187, 210, 213-214, 219.
2
2
• Did the duty of care include a duty to take reasonable steps to guard against those risks?
Yes. Dr. Johnston was obliged to have a surgical team trained in Caesarean sections
"immediately available" before performing a mid-forceps procedure.
• Did Dr. Johnston breach the standard of care? Yes. He did not obtain Mrs. Ediger's
informed consent and he did not secure the availability of a surgical team.
• Did Cassidy suffer foreseeable, actionable damage? Yes. Cassidy suffered the very kind
of catastrophic physical injuries that Dr. Johnston owed a duty to guard against.
3. On March 24, 2009, the Honourable Madam Justice Holmes found Dr. Johnston
liable in negligence for his breaches of the standard of care. She awarded damages of
$3,667,035,3 p re- and post-judgment interest, assessable costs, and disbursements (the "Trial
Judge's Order"). Dr. Johnston appealed from liability; Cassidy cross-appealed from the damages
award. On May 30, 2011, D. Smith J.A. (Saunders and Groberman JJ.A. concurring) allowed the
defendant's appeal and dismissed the action (the "Court of Appeal's Order"). The Court of
Appeal held the plaintiff had not met the burden of proof that Dr. Johnston's mid-forceps
procedure was a cause of Cassidy's asphyxiation.4
4. The subject of this appeal concerns the standard of proof of factual causation and
the correct legal test of factual causation. Standard of care and causation are intertwined. As
Professor Philip Osborne has stated in The Law of Torts:5
It has recently been pointed out...that clarity, accuracy and certainty are
enhanced by recognizing that the application of the but for test involves a
number of discrete steps. First, the harm that is alleged to have been
caused by the defendant must be identified. Second, the specific act or acts
of negligence of the defendant must be isolated. Third, the trier of fact
must mentally adjust the facts so that the defendant's conduct satisfies the
standard of care of the reasonable person, being sure to leave all other
facts the same. Fourth, it must be asked if the plaintiff's harm would have
occurred if the defendant had been acting with reasonable care. The fifth
step is to answer the question.
Tax gross-up, management and committee fees were resolved by agreement of the parties: APPELLANT'S
3
RECORD, Vol. I, Tab 3, Trial Judge's Order, Item "1(g)".
Reasons of the Court of Appeal, para. 103.
P.H. Osborne, The Law of Torts, 4th ed. (Toronto: Irwin Law, 2011), at p. 53 [Tab 61]; D.W. Robertson, "The
5
Common Sense of Cause in Fact" (1997) 75 Tex. L. Rev. 1765, at 1769-73 [hereinafter "Cause in Fact"][Tab 63].
3
B.(cid:9) EVIDENCE AND FINDINGS ON STANDARD OF CARE
(cid:9)
(0 Material Risks of Mid-forceps Procedure
5. A mid-forceps delivery is a high-risk procedure. A rotational mid-forceps
procedure adds even greater risk and has a significant failure rate. Dr. Johnston acknowledged
the procedure is difficult, potentially dangerous, and requires advanced experience and skill.
Mrs. Ediger's labour demonstrated "clear evidence of failure to progress after maternal expulsive
efforts" and could have been anticipated to be "amongst the most difficult and challenging" of
mid-forceps deliveries.6
6. Dr. Johnston informed Mrs. Ediger of the steps involved in a mid-forceps
procedure, but not the associated risks to the baby. Those risks include skull fracture, facial
nerve entrapment, inter-cranial haemorrhage, rotational spinal cord injuries, bruising, and
transient heart rhythm changes. A mid-forceps procedure also increases the risk of umbilical
cord compression, which, in turn, is a cause of bradycardia (i.e., a slowing of the baby's baseline
heart rate that lasts more than two minutes).7
7. Prolonged bradycardia is a cause of hypoxic ischemia (i.e., a lack of blood and
oxygen flowing to the brain). After about ten minutes, a lack of blood and oxygen causes
hypoxic ischemia encephalopathy (i.e., a type of brain injury caused by a reduction in the oxygen
supply to the brain). If a baby is delivered within five minutes, it will likely be normal and
healthy. Even if the baby is only delivered within ten minutes, the prospect of a normal outcome
is still "very high" and the baby is "almost always okay". But, if prolonged bradycardia
continues for as much as fifteen to twenty minutes, the outcomes are usually fairly significant:
Reasons of the Trial Judge, paras. 26, 54, 61, 86, 148, 154. RECORD, Dr. Farquharson ,V ol. II, Tab 13,
6
Direct, p. 47, 1. 42 to p. 48, 1. 3; p. 50, 1. 31 to p. 51, 1. 27; p. 53, 11. 20-31; p. 54, 11. 4-6; Cross, p. 55, 1. 37 to p. 56,
1. 7; p. 62, 11. 15-19; p. 64, 1. 8 to p. 66, 1. 4; Dr. Shone ,V ol. II, Tab 16, Direct, p. 91, 11. 14-35; p. 94, 1. 43 to p. 95,
1. 2; Dr. Johnston ,V ol. II, Tab 18, Direct, p. 138, 11. 3-6; Cross, p. 165, I. 40 to p. 168, 1. 2; p. 169, 11. 9-23;
Dr. Liston ,V ol. III, Tab 19, Cross, p. 6, 11. 3-37; Opening ,V ol. I, Tab 11, Read-ins, p. 179, 1. 28 to p. 180, 1. 2;
Reports of Dr. Farquharson ,V ol. IV, Tab 67 (First Report), at p. 5 and (Second Report), at pp. 9-10.
7 Reasons of the Trial Judge, paras. 27, 61, 64, 146-149, 152. RECORD, Dr. Farquharson ,V ol. II, Tab 13,
Direct, p. 34, 11. 3-23; p. 38, 11. 1-44; p. 40, 11. 4-15; Cross, p. 76, 1. 43 to p. 77, 1. 4; Dr. Shone ,V ol. II, Tab 16,
p. 91, I. 36 to p. 92, 1. 33; p. 96, 1. 36 to p. 97, 1. 11; p. 102, 11. 29-33; Cross, p. 113, 1. 38 to p. 114,1. 20;
Dr. MacGregor ,V ol. II, Tab 17, Direct, p. 122, 11. 20-30. Dr. Johnston ,V ol. II, Tab 18, Direct, p. 133, 11. 1-35;
p. 154, 11. 1-14; p. 163, 11. 12-20; Cross, p. 166, 1. 27 to p. 167, 1. 6. Dr. Simpson ,V ol. III, Tab 21, Direct, p. 24,
1. 39 to p. 25, 1. 8; Cross, p. 34, 11. 22-25.
(cid:9)(cid:9)
4
"timing is very important, because the timing that creates this kind of injury is usually less than
about 20 minutes." Cassidy was delivered about twenty minutes after the onset of bradycardia.8
(ii)(cid:9) Failure to Obtain Informed Consent to Mid-forceps Procedure
8.(cid:9) Dr. Johnston did not inform Mrs. Ediger of possible alternatives to an immediate
mid-forceps delivery: (a) to perform a Caesarean section or (b) to delay the mid-forceps
procedure until a surgical team became immediately available. Dr. Johnston did not disclose the
relative risks between these two procedures. A Caesarean section does increase health risks to
the mother but it decreases risks to the baby (e.g., laceration, fractures and wet lung disease).
The trial judge found Mrs. Ediger would have accepted a risk to herself to avoid a risk to
Cassidy. Properly informed, she would have elected to proceed with a Caesarean section or to
postpone the mid-forceps procedure until an anaesthetist could provide back-up.9
(iii)(cid:9) Standard of Care for Mid-forceps Deliveries
9.(cid:9) The Society of Obstetricians and Gynaecologists of Canada ("SOGC") and the
British Columbia Reproductive Care Program ("BCRCP") published guidelines that were the
"driving force" behind the standard of care in obstetrics in 1998. The objective was to make the
practice of instrumental obstetrics as safe as possible for mother and baby. Some medical
experts opined that the standards were derived from evidence-based studies (which provided data
supporting a risk "outcome analysis") and expert medical opinion. The trial judge found the
widely-acknowledged risks of bradycardia and asphyxia "were in large part the impetus for the
professional guidelines". Those guidelines heavily influenced the standard of care. Obstetricians
were expected to pay attention to the potential need for surgical back-up during forceps
procedures with "additional considerations and caution" being emphasized during mid-forceps
8
Reasons of the Trial Judge, para. 138. Reasons of the Court of Appeal, para. 26. RECORD, Dr. Solimano,
Vol. III, Tab 20, Direct, p. 14, 11. 38-46; p. 16, 1. 17 to p. 17, 1. 25; p. 18, 11. 7-45; Dr. MacGregor ,V ol. II, Tab 17,
Direct, p. 120, 1. 39 to p. 121, 1. 11; p. 122, 11. 20-37; p. 126, 1. 28 to p. 127, 1. 31; Reports of Dr. Solimano,
Vol. IV, Tab 71, (First Report), at pp. 131-133, and (Third Report), at pp. 135-137.
Reasons of the Trial Judge, paras. 10, 146, 152, 156, 158, 166, 170-172. RECORD, Dr. Johnston ,V ol. II,
9
Tab 18, Direct, p. 134, 11. 11-37; p. 163, 1. 12 to p. 164, 1. 1; Cross, p. 195, 1. 42 to p. 196, 1. 17; Dr. Shone ,V ol. II,
Tab 16, Cross, p. 107, 11. 3-36; p. 118, 1. 7 to p. 119, 1. 7; C. Ediger ,V ol. II, Tab 12, Direct, p. 1, 11. 5-26; p. 2, 11. 7-
34; p. 3, 11. 11-37; p. 4, 1. 31 to p. 6, 1. 6; p. 6, 11. 38-42; p. 7, 11. 31-33; p. 10, 1. 8 to p. 11, 1. 10; p. 12, 11. 27-44;
Cross, p. 18, 11. 8-14; p. 21, 1. 6 to p. 22, 1. 22; p. 24, 11. 6-9; p. 25, 1. 28 to p. 31,1. 7; Re-exam, p. 33,11. 9-41;
Opening ,V ol. I, Tab 11, Read-ins, p. 184, 11. 31-46; Reports of Dr. Shone ,V ol. IV, Tab 70 (Fourth Report) at
pp. 120-121; Reports of Dr. Farquharson ,V ol. IV, Tab 67 (First Report) at p. 7 and (Second Report), at p. 10.
-5
procedures. The SOGC and the BCRCP guidelines were equally authoritative and well-founded.
Chilliwack General Hospital did not modify the guidelines for mid-forceps deliveries.1°
10. SOGC Guideline 17, "Guidelines for the Safe and Appropriate Use of Forceps in
Modern Obstetrics", confirmed that forceps procedures should have "adequate facilities and
backup available". SOGC Guideline 21, "Attendance at Labour and Delivery", elaborated on
this requirement. As a general rule, physicians and operating staff covering obstetrics, when
called, should be available in the delivery suite to perform a Caesarean section within about thirty
minutes (the "30-minute rule"). However, when obstetricians performed high-risk procedures —
mid-forceps deliveries, breech vaginal deliveries and multiple pregnancies — SOGC Guideline 21
required them to arrange for immediate availability of an anaesthetist and nursing staff trained in
the delivery of the baby by Caesarean section (the "immediate availability rule"). A physician's
clinical judgment and confidence in performing a high-risk procedure "did not remove this
precaution from the scope of those" required by the standard of care.11
11. Medical witnesses at trial divided on the standard of care contemplated by the
immediate availability rule. SOGC Guideline 21 defined "immediate availability" as "the
presence in the hospital of an anaesthetist and nursing staff trained in Caesarean sections." The
plaintiff's experts opined that mid-forceps procedures carry such a high risk — especially
rotational, mid-forceps procedures — that the standard of care contemplated by the rule was best
achieved in a "double set-up" scenario. A double set-up takes place in a "high risk" delivery
suite or operating room. The surgical team, including an anaesthetist, stands by, scrubbed and
ready for surgery, in the event the mid-forceps procedure is not successful. The baby can be
delivered by Caesarean section within two to five minutes depending on whether analgesics need
Reasons of the Trial Judge, paras. 52-54, 84, 89, 153-154. RECORD, Dr. Farquharson ,V ol. II, Tab 13,
10
Direct, p. 54, 11. 19-34; Cross, p. 61, 1. 34 to p. 62, 1. 4; Dr. Shone ,V ol. II, Tab 16, Direct, p. 101, 11. 15-31; Cross,
p. 108, 11. 33-45; Dr. Johnston ,V ol. II, Tab 18, Direct, p. 136, 11. 13-22; Cross, p. 169, 1. 39 to p. 170, 1. 8; p. 178,
1. 28 to p. 179, 1. 9; p. 179, 1. 42 to p. 182. 4; p. 184, 11. 4-24; p. 197, 1. 29 to p. 198, 1. 3; Dr. Pendleton ,V ol. III,
Tab 22, Direct, p. 42, 11. 15-30, Cross, p. 46, 11. 28-43, p. 47, 11. 17-30; p. 60, 11. 25-45; Dr. Simpson ,V ol. III,
Tab 21, Direct, p. 23, 11. 2-21; CGH Committee Minutes ,V ol. III, Tab 25, at pp. 70, 72.
I IR easons of the Trial Judge, paras. 55-58, 79, 82, 92. RECORD, Dr. Johnston ,V ol. II, Tab 18, Cross, p. 170,
1. 9 to p. 171, 1. 21; p. 187, 1. 43 to p. 188, 1. 45; Dr. Farquharson ,V ol. II, Tab 13, Cross, p. 67, 11. 1-11; p. 69, 1. 29
to p. 70, 1.4; Dr. Shone ,V ol. II, Tab 16, Direct, p. 93, 1. 29 to p. 94, 1.4; p. 98, 1. 25 to p. 99, 1. 13; p. 100,1. 25 to
p. 101, 1. 45; Cross, p. 110, 1. 45 to p. 111, 1. 9; Dr. Pendleton ,V ol. III, Tab 22, Cross, p. 44, 1. 25 to p. 45,1. 43;
Dr. Liston ,V ol. III, Tab 19, Cross, p. 7, 1. 16 to p. 8, 1. 4; p. 9, 1. 11 to p. 10, 1. 26; p. 11, 11. 4-39; Dr. Simpson;
Vol. III, Tab 21, Cross, p. 31, 1. 31 to p. 33, 1. 13; SOGC guidelines ,N os. 17 and 21, Vol. III, Tabs 26-27.
-6
to be administered and the patient needs to be positioned. The trial judge found the trend in
obstetrical practice had moved toward an increased use of the double set-up but accepted that this
safeguard had not yet crystallized into a requirement at the time of Cassidy's birth, if the
procedure was performed by a skilled obstetrician.12
12. Dr. Johnston suggested the immediate availability rule was no more burdensome
than the 30-minute rule for mid-forceps deliveries. To be immediately available meant to be
available within thirty minutes. The trial judge did not accept this submission either. The 30-
minute rule only applied generally to obstetrics. It did not displace the physician's duty "to
arrange for more immediate back-up for the identified higher-risk procedures". The trial judge
also noted that BCRCP Guideline 14, "Assisted Vaginal Birth: The Use of Forceps or Vacuum
Extractor", emphasised the availability of timely care during a "trial of forceps", even though the
guideline was of general application to procedures involving the use of forceps.13
13. The trial judge concluded that the applicable standard of care was the immediate
availability rule as expressed and reflected in SOGC Guideline 21. The rule created a more
demanding standard than the 30-minute rule. A surgical team, comprised of an anaesthetist and
nursing staff trained in Caesarean sections, should be present in the hospital. But "literal"
presence was not sufficient; the surgical team could not be "immediately available" while also
occupied with another high-risk situation. Recognition of the "particularly serious risks"
associated with a mid-forceps delivery, which led a sizeable portion of the medical community to
conclude that a double set-up constituted the standard of care, also "cast more general light on
the precautions expected of the reasonable practitioner, including a highly skilled practitioner,
such as Dr. Johnston." The immediately available surgical team should, for example, be
12 R easons of the Trial Judge, paras. 58, 61-64, 73, 76. Reasons of the Court of Appeal, para. 3. RECORD,
Dr. Farquharson ,V ol. II, Tab 13, Direct, p. 52, 11. 29-47; Cross, p. 57, 1. 23 to p. 58, 1. 26; p. 59, 11. 14-24; p. 67,
11. 1-25; p. 68, 1. 42 to p. 69, 1. 19; p. 70, 11. 8-19; Dr. Shone, Vol. II, Tab 16, Direct, p. 94, 1. 36 to p. 95, 1. 6; Cross,
p. 103, 11. 14-30; p. 110, 11. 36-44. Report of Dr. Shone ,V ol. IV, Tab 70 (Second Report), at pp. 116-117; SOGC
guidelines ,N os. 17 and 21, Vol. III, Tabs 26-27.
Reasons of the Trial Judge, paras. 80, 82, 84, 86. RECORD, Dr. Farquharson , Vol. II, Tab 13, Cross, p. 63,
13
1. 32 to p. 64, 1. 7; Dr. Shone ,C ross, p. 109, 11. 30-46; BCRCP guideline ,N o. 14, Vol. IV, Tab 73, at p 146.
-7
"assembled" and available to respond "quickly", "swift[ly]", "speed[il]y", "instantly", or
"immediately", should an emergency arise.14
(iv) Dr. Johnston's Breach of the Standard of Care
14. Dr. Johnston conceded that the immediate availability rule contemplated a double
set-up for breech and multiple pregnancy deliveries. Moreover, the standard practice at
Chilliwack General Hospital was to deliver these categories of high-risk delivery (but not mid-
forceps deliveries) using a double set-up. He claimed he had read the SOGC and BCRCP
guidelines before Cassidy's delivery, and mulled them over, thinking "gees, you know, we don't
do that in our hospital", but stated "time moves...slowly in a community hospital". His practice
respecting compliance with the guidelines was one of balancing the risks to his patient with the
risks of depleting the resources available for the remaining patients in the community. He
suggested "tradition" might explain why a double set-up was used for breech vaginal deliveries
and multiple pregnancies but not for mid-forceps deliveries.15
15. At Chilliwack General Hospital, the maternity ward, the labour and delivery
rooms, and the "high risk" operating room were located on the third floor. Physicians used this
operating room to perform Caesarean sections and sometimes forceps deliveries. The third floor
operating room was equipped to perform a Caesarean section. There was a nursing pack
containing all of the sterile instruments a surgeon required. It was left sitting on the table in the
room, and "the nurse would simply unwrap the pack and the instruments would be there." The
third floor operating room was set up with the delivery system, monitors, anaesthesia cart,
medications, equipment and airway instruments.16
16. Chilliwack General Hospital's standard back-up plan was to have a surgical team
on-call, including an anaesthetist and operating room nurses, for mid-forceps deliveries.
Dr. Charles Boldt, the anaesthetist who assisted in Cassidy's delivery by Caesarean section,
Reasons of the Trial Judge, paras. 83-86, 91-93, 152, 172.
14
RECORD, Dr. Johnston ,V ol. II, Tab 18, Direct, p. 130, 1. 32 to p. 131, 1. 25; p. 142, 11. 11-20; Cross, p. 177,
15
1. 31 to p. 179, 1. 9; p. 179, 1. 42 to p. 180, 1. 38; p. 182, 1. 5 to p. 183,1. 43; p. 189, 11. 16-40; p. 879, 11. 3-39; p. 192,
11. 31-38.
RECORD, Dr. Boldt ,V ol. II, Tab 14, Direct, p. 299,11. 1-11; p. 302,11. 21-43; Dr. Johnston ,V ol. II, Tab 18,
16
Direct, p. 131, 11. 21-31.