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What is the "Cause" of
Disability?

WILLIAM RENWICK RIDDELL, LL.D^

imtONTO,
FEIXOW. »OVAI. HISTORICAL SOCTETY, ETC.

Rcfrintcd from The New York Medkal Journal for
January 13, igj/.

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III

Reprinted from the New York Medical Journal for
January is, 1917.

WHAT IS THE "CAUSE" OF DISABILITY?
A Medici^egal Question,

By Wizxiam Renwick Riddell, LL.D., Etc.,
Toronto, Ont

In the Supreme Court of Ontario, a medicolegal
case has recently been decided which will be of in-
terest to many medical men.

Doctor Mitchell took out an accident insurance
policy in the Fidelity and Casualty Company of
New Yoric ; a few days thereafter, he was thrown
from his berth in a Pulhnan car and sprained his
wrist. The injury did not improve as expected ow-
ing to tuberculous infection ; and it appeared to be
permanent. The policy called for $150 a week for
total disability, "however long continued, if resulting
from accident directly, independently, and exclu-
sively of all other causes" ; the company held that
the accident was not the <Mily cause and refused to
pay. Doctor Mitchell sued and succeeded at the
trial. The matter came to be decided in the Ap-
pellate Division of the Supreme Court, of which I
have the honor to be a member.

I add here so much of my judgment as is not of
interest to lawyers only :

"Riddell, J. : — ^This appeal involves the interpreta-
tion of a contract of veiy common occurrence. Were
it a case of less importance, I should be content to
adopt without further comment the conclusions of
the learned trial judge, and so dismiss this appeal.

But the advance of knowledge raises and will con-
tinue to raise novel contention : and what is a com-
monplace at one time becomes a matter of great con-
troversy at another. Until very recently, the main
ground of dispute of liability here would not have
been thought of: or, if thought of, would have re-

Riddell: A Cauu of Ditability.

,; i

ceived scant consideration— but tempora mutantur it
nos mittamur in Mis. • .• » •

The plaintiff, a doctor of mediane, a specialist m
diseases of the eye, ear, noM, and throat, took out
an accident policy with the defendants, an accident
insurance company. In most accident insurance pol-
icies, the beneficiary is entiUed to payment only for
a limited time (usually on. year or less), but this
company finds its account in making its policies per-
petual, that is, for the Ufe of the patron who may
be injured. No doubt, tliis forms a strong induce-
ment to those desiring accident insurance, to prefer
ihiit company.

In the appUcation, the duties of his occupation are
described as "special work on eye, ear, nose, and
throat," and the insurance was against "bodily injury
sustained . . . through accidental means . . . and
resulting directly, independently, and exclusively of
all other causes in an immediate, continuous, and
total disability that prevents the insured from per-
forming any and every kind of duty pertaining to
his occupation."

The plaintiff was thrown from an upper berth i..
a sleeping car and thereby sprained his wrist
severely — it is not contended by the defendants that
this was not an injury within the meaning of the
policy— and, had the injury healed within a short
time, no doubt the company would have paid the
$150 per week without demur.

But the injury did not heal, it is not yet healed,
and It is doubtful whether it will ever be much im-
proved—the company find themselves charged with
an obligation to pay $150 per week for years, per-
haps until the death of the plaintiff; and hence, they
dispute liability.

Several medical men of eminence were examined
at the trial: without at all reflecting on any other,
it seems to me that the evidence of Doctor Anderson
gives the mosi satisfactory explanation. He says
that some time ago, probably some ten or fifteen
years before the accident, there had been a tuber-

Riddell: A Cautt of DtMbilily.

culous condition of part of the pleura, protably
the apex of the left lung: any existing tuberculous
mass had become encysted so as to leave no apparent
disease— the patient would be quite well, whdly un-
conscious of any trtmUe, danger, or disease; and
there would be no danger of another outbreak pro-
ceeding from the original disease.

But an accident happens, tissues are injured, a
lessened resistance to the "germs" occurs, these,
otherwise innocuous, find a ludus into which to in-
trude and in which to become active.

I can see no difference b^een this case and the
case of an injury causing a break in the skin and
thereby allowinr some of the germs which are
(practically) dways and everywhere floating
around, to enter and set up a diseased condition.
How is a "lessened resistance" of tissues, without
a breach of continuity of the skin allowing germs
which may be in the Wood to enter and set up or
continue an inflammatory cemdition, different from
a lesion of the skin allowing similar germs which
may be in the air to enter with the same result?

Until a comparatively recent day, no one knew
anything about the tubercle bacillus, and such affec-
tions as are now known (so far as such matters are
known) to be due to the invasion of a bacillus were
supposed to be due to exposure to the air. Would
any one in that state of theory— knowledge if you
will— say that the air was a contributing cause of
the disability ? And is the meaning of words to be
changed by the change of medical theory?

We must interpret this document on common
sense principles ; no one could, when obtaining acci-
dent insurance, imagine that he was guaranteeing
the company against the presence, accidental and
temporary or otherwise, of tubercle bacillus or any
other bacillus or spirillum in his system. We must
interpret the language of this contract in its ordi-
nary and popular meaning — the use of language
preceded scientific investigation.

That this disability has as a cause the accident.

^mmmmmm

RiddtU: A Cause of Disability.

cannot be disputed. In a well known Scottish case
a miner was, by reason of an accident to a pump,
compelled to stand for some time in cold water, ex-
posed to a current of cold air. This reduced his
vitality and permitted the pnexunococci which are
(practically) everywhere, to overcome the resistance
of the tissues; pneumonia set in and the man died.
The arbitrate held that the pneumonia was causei
by the occurrence; and, of the seven judges, six
agreed with him — one onlv thinking that there must
be some direct lesion. This case was approved in a
case in the House of Lords. A miner was exposed
to a cold current of air which "brought on pneu-
monia," and it was held that the death was the re-
sult of the exposure.

I do not know of any difference between the case
of a tubercle bacillus infection and that of a pneu-
mpcoccus infection — it is said you cannot have tu-
berculosis without the former or pneumonia with-
out the latter. And I can see no difference in law
I .ween an accident weakening the power of resist-
ance of the tissues and allowing the pneumococcus
to enter and an accident of another kind weakening
the power of resistance of the tissues and allowing
the tubercle bacillus to enter— the infection of either
kind could not fairly be called a cause within the
meaning of Ais policy.

It is to be noticed that in both the pneumonia
cases, the pneumococci did not enter by any external
lesion, but attacked the tissues in the same way as
the bacillus in the case now under consideration.

The case of Brintons Limited v. Turvey contains
much of value. A workman engaged in sorting
wool contracted anthrax, which caused his death.
"According to the medical evidence and theoiy," an
anthrax bacillus passed into his eye, thereby infect-
ing him with that terrible disease, and causing his
death. The County Court Judge held that the en-
try of the bacillus was an accident ; his decision was
affirmed by the Court of Appeal and the House of
Lords. Lord Halsbury gives examples of what he

RiddeU: A Cautt of DitahiHly.

'• .uld call accidents : "A workman . . . spills
some corrosive acid on his hands ; the injury caused
thereby sets t^> erysipelas- 4 definite disease: some
trifling injury by a needle sets up tetanus." No one
in the present state of medical science doubts that
erysipelas and tetanus are germ diseases like tuber-
culosis, pnetunonia, and malaria.

In ."uiswer to the argument or suggestion that the
condition of the plaintiff's bodily system was a con-
tributine cause, I asked, "Suppose the plaintiflF were
"a bleeder' — of the hemo rhagic diathesis, as the
technical ex, -ession runr -> that a trifling lesion
would produce (in the sei of being followed by)
excessive hemorrhi ,5je, lon^ continued, almost impos-
sible to check, coi'^'! it be argued that the diathesis
vas a contributir" r»use to the continued disabil-
ity ?" -.1 »ly such uv.ditions of the body are condi-
tions 01 , '^in the logical sense of the word) and not
causes.

The appeal should, in my opinion, be dismissed
with costs."

All the four judges of the highest court in the
Province agreed that, while medically the infection
was a cause of the disability, it should not be con-
sidered such in interpreting such a contract.

The case is interesting (if for no other reason)
as showing that even courts of lav/, conservative as
thej' are and must be, cannot avoid taking cog-
nizance of the adv ;nce of medical science.

Osgood Hall.