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What is the "Cause" of 
 Disability? 
 
 BY 
 
 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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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- 
 
 Copyright, 1917, by A. R. Elliott Publiibinc Comowiy. 
 
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. 
 
 il 
 
^mmmmmm 
 
 H 
 
 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. 
 
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