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of Disease and Injury Causation
AMA Guides® to the Evaluation
AMA Guides® to the Evaluation of
Disease and Injury Causation,
second edition AMA Guides® to the Evaluation of
Determining causation is a critical issue
DISEASE and INJURY
Causation
Is my condition work related or caused by another specific event? Health care providers are
often asked this question when patients seek treatment. It is incumbent on clinicians to give an
opinion based on a careful review of the individual’s clinical findings, workplace exposures, and
the literature linking (or not linking) the exposure of concern and the condition in question.
In occupational health, causation has become a crucial measure. Today, determination of

causation is the gate keeper to treatment and a key factor in determining who is financially
responsible. This second edition of AMA Guides® to the Evaluation of Disease and Injury
Causation is dedicated to updating the science, expanding the focus, and including additional
perspectives to improve the understanding of causation, which will eventually improve the
treatment outcomes for injured workers as they stay at work or return to work.
What others are saying:

“Personally, I wish this text would have been published 30 years ago in that it provides the
reader with a very educational, scientific approach to causation, which is not found
in any other publication that I am aware of …. I give it five stars.”
—William E. Blair Jr., MD
2nd
Medical Director of
Occupational Orthopaedics
Waco, Texas
EDITION
SECOND EDITION
J. Mark Melhorn, MD | James B. Talmage, MD

William E. Ackerman III, MD | Mark H. Hyman, MD
OP210313
BQ77:07/13:13-0069
Table of Contents vii
de Quervain’s Disease 262

Intersection Syndrome of the Wrist or Forearm 266
Triangular Fibrocartilage Complex Injuries or Tears 269
Painful Elbow—Lateral and Medial Epicondylitis (Tennis Elbow
or Golfer’s Elbow) 274
Median Nerve Entrapment at the Wrist (Carpal Tunnel Syndrome) 278
Ulnar Nerve Entrapment at the Wrist (Guyon’s Canal Syndrome
or UNW) 301
Ulnar Nerve Entrapment at the Elbow (Cubital Tunnel Syndrome
or UNE) 307
Radial Nerve Entrapment at the Wrist (Wartenberg’s Syndrome
or RNW) 312
Radial Nerve Entrapment at the Elbow (Radial Tunnel Syndrome
or RNE) 314
Shoulder Tendinopathy, Impingement, and Rotator Cuff Tears 318
Summary 330
Chapter 10 Lower Limb�� 357
Naomi N. Shields, MD, David A. Fetter, MD, Matthew J. Dietz, MD, and
Hany Bedair, MD
Foot and Ankle Disorders/Dysfunction 357
The Knee 362
Hip Osteoarthritis 376
Avascular Necrosis of the Femoral Head 377
Acetabular Labral Tears 378
Chapter 11 Musculoskeletal Disorders: Conditions of Uncertain Pathophysiology—

Acute and Chronic Pain��389
James B. Talmage, MD, J. Mark Melhorn, MD, William E.

Ackerman III, MD, and Robert J. Barth, PhD
Pain 389
Musculoskeletal Pain 391
Chapter 12 Causation of Common Cardiovascular Problems �� 411
Mark H. Hyman, MD, and Thomas E. Kottke, MD, MSPH

Established Cardiovascular Risk Factors 412
Novel Cardiovascular Disease Risk Factors 412
Stress, Psychosocial Factors, and Cardiovascular Risk 413
Cardiomyopathy and Heart Failure (HF) 415
FM_Causation_i-xxiv.indd 7 18/06/13 3:20 PM

viii AMA Guides® to the Evaluation of Disease and Injury Causation
Arrhythmia, Syncope, and Heart Rate Variability 416

Peripheral Arterial Disease 417
Venous Thromboembolism 417
Occupational Risk Factors for CVD 417
Assessing the Contribution of Occupational Risk Factors to CVD 418
Questions for Future Research 419
Chapter 13 Causation in Common Pulmonary Problems�� 433
Julia E. Klees MD, MPH, and Mark H. Hyman, MD

Pulmonary Risk Factors 434
Occupational Pulmonary Diseases 435
General Considerations for Asthma 436
Hypersensitivity Pneumonitis 440
Fibrotic Lung Disorders (Pneumoconiosis) 442
Chronic Obstructive Pulmonary Disease 444
Lung Cancer and Mesothelioma 445
Obstructive Sleep Apnea 446
Bronchiolitis Obliterans 447
Assessing the Contribution of Occupational Risk Factors to Pulmonary
Disease 447
Chapter 14 Neurological Disorders�� 457
Edwin H. Klimek, MD
Introduction 457
Central Nervous System 457
Stroke 459
Parkinson’s Disease and Parkinsonism 460
Multiple Sclerosis 461
Peripheral Nervous System 462
Chapter 15 Rheumatologic Diseases�� 469
David Silver, MD, Stuart L. Silverman, MD, and Mark H. Hyman, MD

Osteoarthritis 469
Rheumatoid Arthritis 471
Systemic Lupus Erythematosus 474
Fibromyalgia Syndrome 476
Osteoporosis 478

Table of Contents ix
Less Common Rheumatic Diseases 478

Capacity 479
Tolerance 479
Chapter 16 Mental Illness�� 485
Robert J. Barth, PhD, Les Kertay, PhD, and Joel S. Steinberg, MD

Introduction 485
The Necessity of Independent Evaluation 486
Step 1: Definitively Establish a Diagnosis 487
Step 2: Apply Relevant Findings from Epidemiologic Science
to the Individual Case 490
Step 3: Obtain and Assess the Evidence of Exposure 499
Step 4: Consider Other Relevant Factors 500
Step 5: Scrutinize the Validity of the Evidence 508
Chapter 17 Genitourinary �� 523
Karl T. Rew, MD
Introduction 523
Genitourinary Cancers 523
Urinary Tract Stones 524
Acute Kidney Injury 525
Chronic Kidney Disease 526
Voiding Dysfunction 526
Male Infertility 526
Sexual Dysfunction 527
Chapter 18 Gastrointestinal�� 531
Cynthia W. Ko, MD, MS, and Mark H. Hyman, MD

Introduction 531
Dyspepsia, Ulcers, and Gastritis 531
Gastroesophageal Reflux Disease 533
Irritable Bowel Syndrome 534
Inflammatory Bowel Disease 535
Hernias 537
Assessing the Contribution of Occupational Risk Factors for
Gastrointestinal Disease 537

x AMA Guides® to the Evaluation of Disease and Injury Causation
Chapter 19 Ear, Eye, Nose, and Throat�� 545
William E. Ackerman III, MD, and Scott W. F. Carle MD

Hearing Loss 545
Cataracts 550
Nose and Throat 552
Chapter 20 Selected Topics: Gender, Leukemia Related to Radiation,

and Occupational Skin Lesions (Sun Exposures)�� 561
William E. Ackerman III, MD, Laurie Massa, MS, MD, and

David Harshfield, MD
Gender and Occupational Risks (Pathology) 561
Risk Factors for Leukemia 566
Occupational Risks for Skin Disease 569
Chapter 21 Chemical Exposure Claims: A Framework for Causation

Analysis �� 577
Gideon Letz, MD, MPH, Mark H. Hyman, MD, Harold E. Hoffman, MD,
Scott Phillips, MD, and Robert B. Palmer, PhD
Three-Step Process for Analyzing Exposure Causation 578
Biological Monitoring and the Establishment of Chemical Disease 582
Case Examples 586
Summary 590
Chapter 22 Putting It All Together: Causation Analysis as Illustrated

by Examples�� 593
Roger M. Belcourt, MD, MPH, and J. Mark Melhorn, MD

Introduction 593
Example 1 594
Criteria for the Evaluation of Causation Using Epidemiologic
Evidence 598
Example 2 602
Chapter 23 Example of Causation Methodology�� 609
J. Mark Melhorn, MD, Larry K. Wilkinson, MD, and Shirley

M. Seaman, MS, PA-C
Step 1: Literature Search 610
Step 2: Quality Scoring Scale Applied 612
Step 3: Study Design Determined 612
Step 4: Final Study Impact Rating 612
Step 5: Strength of Evidence of Causation in Epidemiologic Studies 613
Summary 613

Table of Contents xi
Chapter 24 Causation: The Attorney’s Perspective�� 615
David J. DePaolo, JD, MBA, and Robert G. Rassp, JD

Introduction 615
Defining Causation 616
Causation and Fault 618
Evidence: Standards of Proof 620
Presumptions and Shift in Burden of Proof 621
Case Examples 622
Practical Application: The Medical Report 625
Summary 626
Chapter 25 Causation: A Judge’s Perspective �� 627
Bruce E. Moore, JD
Introduction 627
What Is Proof? 630
Foundation 632
Relevance and Materiality 632
Substantial and Competent Evidence 633
Probative Evidence 634
Reasonable Inferences 635
Weight 635
Consistency 635
Credibility 636
Putting It All Together 637
Case Studies 638
Summary 643
Chapter 26 Causation: The Employer’s Perspective�� 645
Wanda K. Roehl, CSP

Heinrich’s Accident Pyramid: A Method to Study Causes
of Work Injuries 646
Guidance for Workers and Employers for Preventing Injuries 648
Human/Machine Interfaces, Equipment Design, and Changing
Techniques 649
Factors Affecting Filing of Workers’ Compensation Claims 650
Cost Shifting 650
Task Rotation in the Workplace 651
When the Courts Decide Causation 651
Why State Legislatures Change Workers’ Compensation Laws 652
Accident Investigation Deficiencies and the Effect on Causation 653
Integrating the Medical and Workplace Facts and Findings 653

xii AMA Guides® to the Evaluation of Disease and Injury Causation
What Employers Need to Ask the Physician 654

Employers’ Concerns 654
Summary 654
Chapter 27 Causation: The Insurer’s (Payer’s) Perspective�� 657
David C. Deitz, MD, PhD

Background 658
Acute Injuries vs Chronic Disease 658
Exacerbation and Aggravation 659
Investigation of Causation 660
Cost Shifting and Causation 662
Summary 663
Chapter 28 Causation: The Workers’ Compensation Commission

Perspective�� 665
Destie Lee Overpeck, JD, Minerva Krohn, Merle Rabine, JD,

and Dwight T. Lovan
Causation of Industrial Injuries in California 667
Psychiatric Injuries 668
Presumptions 669
Causation, Commissioner’s (Adjudicator’s) View in Kentucky 672
Chapter 29 Causation: The Occupational Physician’s Perspective �� 679
Section 1 680
Melissa D. Tonn, MD, MBA, MPH

Occupational Physician Causation Analysis of Uninjured Limb—Case
Examples 682
Section 2 688
Douglas W. Martin, MD
Traditional Causation Assessment (Bradford-Hill Criteria) 688
Modern Use of the Bradford-Hill Criteria 689
Practical Applications 691
Chapter 30 Causation: The International Perspective�� 695
Causation: Australia Experience 696
Mark Burns, MBBS

Table of Contents xiii
Causation: Canada Experience 699
David Linklater, MD, MBA
Causation: Ireland Experience 703
Clement Leech, MD
Chapter 31 Causation Issues for Public Safety Personnel�� 717
Fabrice Czarnecki, MD, MA, MPH, Daniel G. Samo, MD, and

Mark H. Hyman, MD
Introduction 717
Firefighters 717
Law Enforcement Officers 721
Chapter 32 Effects of Whole-Body Vibration on the Spine�� 749
Jesse E. Bible, MD, MHS, Clinton J. Devin, MD, and Dan M.

Spengler, MD
Subjective Low Back Pain vs Objective Imaging Evidence 751
Does Objective Imaging Exist? 753
Conclusion 754
Chapter 33 Evaluating Causation of Favoring for the Opposite Limb �� 757
Section 1: Evaluating Causation for the Opposite Upper Limb 758
J. Mark Melhorn, MD, James B. Talmage, MD, Charles N. Brooks, MD, and
Christopher R. Brigham, MD
Example: Carpal Tunnel Syndrome 758
Causation Analysis 759
The Science 761
Shoulder 763
Elbow 766
Carpal Tunnel Syndrome 767
Summary 768
Section 2: Evaluating Causation for the Opposite Lower Limb 769
Christopher R. Brigham, MD, Charles N. Brooks, MD, and James B.

Talmage, MD
Index�� 775

Foreword
By Gunnar B. J. Andersson, MD, PhD

Professor, Rush University Medical Center
Causality explores the relationship between cause and effect. Physicians are trained to
determine the medical cause of symptoms and signs using history, clinical examina-
tion, laboratory results, and imaging tests. Usually the most likely source of a patient’s
symptoms and signs can be identified. Since treatment depends on the diagnosis and may
be expensive and sometimes invasive, it becomes important to accurately determine the
cause of the symptoms and signs. In fact, unless we think that a patient’s symptoms and
signs can be explained by a specific underlying pathology we cannot justify treatment,
which sometimes can result in complications. And on the other hand, an untreated source
of the patient’s symptoms and signs may have disastrous consequences in the future. We
require a high degree of certainty.
A different type of causation, which we may be less familiar with and often is not taught
as part of our education, is where a disease or injury is potentially caused by an external
event. This type of causation analysis is important when caring for patients with worker’s
compensation claims and other types of disability claims. In most state worker compen-
sation jurisdictions, the burden of proof concerning causation is “more likely than not,”
which is less rigorous than medical causation.
Determining injury causation is sometimes easy; take the patient who falls from a lad-
der and fractures his ankle. In other cases causation can be difficult, sometimes resulting
in different conclusions by different evaluators. Consider for example a patient with a
long history of a back problem who alleges an injury when lifting an object at work, or
a patient with carpal tunnel syndrome who alleges his or her problem was caused by fre-
quent or prolonged typing.
To cover this topic comprehensively the editors of this book have assembled a large group
of experienced medical professionals to guide us through this process. In addition, the
book provides the perspectives of attorneys, judges, employers, insurers, and commis-
sioners on this complex problem.
We have an obligation to provide a fair and comprehensive analysis of possible cause.

This is sometimes difficult, particularly when all information is not available or when we
are the treating physician and therefore in an advocacy position. The important monetary
consequences of these analyses cannot be underestimated.
For these reasons, this is an important book. It provides the basis for the thought process
that has to go into disease and injury causation analysis and clarifies some of the differ-
ences between the medical and legal requirements with respect to probability and decision
making. I warmly recommend this book not only to those involved in disability evalua-
tion, but to the medical community at large. Enjoy.
xiv

Foreword
By LuAnn Haley, JD
Administrative Law Judge for the Industrial Commission of Arizona
The issue of medical causation remains critical in disability determinations. It has become
more complex with the current widespread availability of information regarding medical
conditions and the move toward evidence-based medicine. Medical experts, no matter
how well credentialed, will find their medical opinions rejected in legal proceedings un-
less they can communicate that the opinion is supported with an adequate factual founda-
tion and backed by well-reasoned medical science. Understanding the issues addressed by
the experts in this edition regarding medical and legal causation is crucial to all involved
in assessing disability in injury claims.
Analyzing causation in disability cases is the most critical, yet difficult, issue to resolve
and requires input from both medical and legal experts. It is well accepted that legal
causation is established when there is evidence that the injury or disease arose out of the
employment, and medical causation requires showing that the accident or circumstances
of the employment caused the injury or condition. An understanding of the relationship
between work activities or exposures and a particular medical condition is essential for
medical and legal experts alike in the field of occupational injury medicine. Additionally,
the judges and administrators of these cases must provide a well-reasoned determination
of medical and legal causation as a foundation for their decisions.
The Second Edition of the AMA Guides® to the Evaluation of Disease and Injury Causa-
tion provides a comprehensive guide to understanding medical causation issues for every
evaluator. The expert’s analysis of medical causation, when supported by sound medical
evidence, is critical for a fair and just decision in every disability claim. The editors of
this text have provided an excellent resource for medical and legal professionals and it is
recommended reading for anyone asked to handle disability evaluations and injury cases.
I wish to personally thank the contributing authors for providing this informative guidance
and thank the American Medical Association for a job well done.
xv

Foreword
By R. H. Haralson III, MD, MBA

Past President, American Academy of Disability Evaluating Physicians
There is a disability epidemic in the United States. Delays in treatment are often related
to the need for determining causation, which is required to establish financial responsi-
bility. Unfortunately, huge numbers of citizens remain off work after on-the-job events,
liability injuries, or other health conditions even when sufficient data concerning cau-
sation is readily available. These delays in treatment ultimately impact treatment and
outcomes. Early treatment and early return to work remain key components to improving
outcomes. Studies continue to show that the longer a person remains off work, the less
likely he or she is to ever return to work.
The disability epidemic is closely linked to the issues of return to work and is due to nu-
merous factors: workers who are dissatisfied with their jobs and would rather not return,
or who believe that the job caused their condition; well-meaning plaintiff attorneys who
feel that their clients deserve compensation, are convinced that remaining off work will
result in a larger settlement, and do not realize that by discouraging return to work they
may be contributing to the disability; employers who believe that the job holds little risk
and who do not want a worker that is not 100%; judicial systems that may slight the sci-
ence of causation in an effort to maintain social justice; and physicians who do not under-
stand the consequences of remaining off work and find it easier to certify being off work
than to take the time to explain to patients and employers why the worker should return
despite not being 100%.
Return-to-work issues are addressed in the AMA Guides® to the Evaluation of Work
Ability and Return to Work. This Second Edition of AMA Guides® to the Evaluation of
Disease and Injury Causation improves on the First Edition methodology and provides
up-to-date references supporting the scientific evidence of causation. Drs. Melhorn,
Talmage, Ackerman, and Hyman have gathered together truly knowledgeable experts in
the field of workers’ compensation and tort. The addition of chapters from multiple van-
tage points and perspectives is a significant addition to this volume. An understanding of
this text by all involved in causation and return-to-work decisions—patients, attorneys,
judges, employers, and physicians—will go a long way toward addressing the disability
epidemic and provide future approaches to prevention by reducing proven risk factors in
the workplace.
xvi

About the Editors
J. Mark Melhorn, MD, is an occupational orthopaedic physician who specializes in the

hands and upper limbs. He received his BS from McPherson College and his MD from
the University of Kansas. Dr. Melhorn is board certified in orthopedic surgery, with added
qualifications in surgery of the hand. In addition to his practice of orthopaedics at The
Hand Center in Wichita, Kansas, Dr. Melhorn is a Clinical Associate Professor, Section
of Orthopaedics, Department of Surgery, University of Kansas School of Medicine—
Wichita. He has authored articles, chapters, and publications about his research on
workplace injuries and illnesses; return-to-work options; impairment and disability; and
prevention of musculoskeletal pain in the workplace. Dr. Melhorn is co-editor of the
AMA GuidesTM to the Evaluation of Work Ability and Return to Work, Second Edition
(2011). He has lectured extensively to physicians, employers, insurers, administrators,
and legislators on industrial musculoskeletal, upper extremity disorders, and prevention
of musculoskeletal pain (MSDs) in the workplace. He is actively involved in continuing-
education programs and committee work for the American Academy of Orthopaedic
Surgeons, American Academy of Disability Evaluating Physicians, American College of
Occupational and Environmental Medicine, American Society for Surgery of the Hand,
AMA’s Guides Newsletter, Official Disability Guidelines, and MDGuidelines by REED
group. Dr. Melhorn is past president of the Kansas Orthopedic Society and AADEP.
James B. Talmage, MD, is an orthopaedic surgeon by training who specializes in oc-

cupational medicine. He is a graduate of The Ohio State University’s undergraduate and
medical schools. His orthopedic surgery training was in the United States Army. He is
board certified in both orthopaedic surgery and emergency medicine. He is an Adjunct
Associate Professor in the Division of Occupational Medicine, Department of Family and
Community Medicine, Meharry Medical College, Nashville, TN. Dr. Talmage is a Fellow
in, and Past President of, the American Academy of Disability Evaluating Physicians.
Dr. Talmage is the associate editor of, and a frequent contributor to, the AMA’s Guides
Newsletter. He was a case contributor and a case reviewer for The Guides Casebook, Third
Edition (AMA, 2009), and an associate editor of the Second Edition of that text. He was
a contributor to Guides to the Evaluation of Permanent Impairment, Sixth Edition (AMA,
2008), and a member of the Errata Committee. He is co-editor of AMA GuidesTM to the
Evaluation of Work Ability and Return to Work, Second Edition (2011). He serves on the
ACOEM Practice Guidelines and Return to Work committees. Dr. Talmage has chaired the
Musculoskeletal Advisory Board for the Medical Disability Advisor, Third, Fourth, Fifth,
and Sixth Editions (Reed Group). He chairs the overall Medical Advisory Board for the
Medical Disability Advisor Seventh Edition. He is a peer reviewer for Archives of Physical
Medicine and Rehabilitation, The Spine Journal, and American Family Physician. He is
on the editorial advisory board for The Spine Journal. Recently he served as the temporary
medical director for the State of Tennessee Division of Workers’ Compensation. He still
teaches frequently for a number of organizations.
xvii

xviii AMA Guides® to the Evaluation of Disease and Injury Causation
William E. Ackerman III, MD, is currently the Medical Director of the Pain Medicine
Consultants Group, PA, in Little Rock and Conway, Arkansas. He is a board-certified
anesthesiologist and completed a fellowship in pain medicine. Dr. Ackerman is also board
certified in pain medicine. He has been chief of anesthesiology at two Army medical
centers and an associate professor and director of an academic pain center. He has pub-
lished over 125 scientific articles in peer-reviewed journals and presented scientific
abstracts at international and national academic meetings. Dr. Ackerman has authored
one academic textbook, along with many chapters in others. He has also published his
research on complex regional pain syndrome involving worker’s compensation cases. He
presently evaluates bodily injury cases for injury causation and performs IMEs for pain-
related cases. He has lectured at claims adjustor meetings, nurse case manager meetings,
medical schools, and various scientific meetings. He has also been an expert witness on
chronic pain causation related to motor vehicle accidents. He has served on the editorial
board of two peer-reviewed medical journals. Dr. Ackerman has been nominated for the
Southern Medical Society Medical Research Award and the Bristol-Meyers Squibb award
for distinguished achievement in pain research. He was the recipient of the Karl Koeller
research grant from the American Society of Regional Anesthesia and Pain Medicine.
Mark H. Hyman, MD, is an associate professor on the clinical faculty at the University
of California—Los Angeles (UCLA). He was born in Detroit and attended the Univer-
sity of Michigan for undergraduate studies. He pursued medical school, internship, and
residency at UCLA. His internal medicine research and interests have expanded to in-
clude headaches, smoking cessation, spinal disorders, police arrest techniques, Tuberous
Sclerosis Complex, impairment, and workers’ compensation issues. Dr. Hyman is a fellow
of the American College of Physicians and the American Academy of Disability Evaluat-
ing Physicians. He is currently President of the National Board of Directors of AADEP.
He has published research on worker’s compensation patients for sleep disorders, addic-
tions, and obesity in professional football players. He has authored many articles and is
co-editor of the AMA GuidesTM to the Evaluation of Work Ability and Return to Work,
Second Edition (2011), a contributor to Guide to the Evaluation of Functional Ability
(AMA, 2009) and Transition to the AMA Guides Sixth (2009), the author of Guides Sixth
Impairment Training Workbook: Internal Medicine (AMA, 2008), and a contributing
editor to the Guides to the Evaluation of Permanent Impairment, Sixth Edition (AMA,
2008). Dr. Hyman also served as the chair for the internal medicine section of the Medical
Disability Advisor, Fifth Edition (Reed Group, 2005), and is currently co-editor for the
Seventh Edition. He has lectured extensively for legal groups and the insurance indus-
try and at national disability meetings. Dr. Hyman has testified before the United States
Congress as a national expert on disability issues. WebMD selected Dr. Hyman for their
annual Heroes of Health award.

Acknowledgements
We would like to acknowledge all of the individuals who have been instrumental in the
publication of this book. A special thank you to the chapter contributors and peer re-
viewers; to the AMA publication staff: Nancy Baker, Michael Ryder, Janet Thron, and
Meghan Anderson; to Yolanda Davis, Copyright/Library Services Coordinator, AMA, for
her extensive article research and professionalism; and Cheri Sellers and Cam Gentry, Via
Christi Library Services for their extensive article research and professionalism.
xix

Contributors
Steven Babitsky, Esq., JD David C. Deitz, MD, PhD

SEAK, Inc. Vice-President
Falmouth, Massachusetts National Medical Director
Workers’ Compensation
Robert J. Barth, PhD Liberty Mutual Insurance
Chattanooga, Tennessee Boston, Massachusetts
Hany Bedair, MD David J. DePaolo JD, MBA

Instructor of Medicine WorkCompCentral
Massachusetts General Hospital Camarillo, California
Harvard Medical School
Boston, Massachusetts Clinton J. Devin, MD
Assistant Professor
Roger M. Belcourt, MD, MPH Department of Orthopaedics
Occupational Health Services Vanderbilt University Medical Center
Davis, California Nashville, Tennessee
Jesse E. Bible, MD, MHS Matthew J. Dietz, MD

Orthopaedic Surgery Resident Instructor of Medicine
Department of Orthopaedics Massachusetts General Hospital
Vanderbilt University Medical Center Harvard Medical School
Nashville, Tennessee Boston, Massachusetts
Christopher R. Brigham, MD Marjorie Eskay-Auerbach, MD, JD

President WellAmerica, Occupational Medicine
Brigham and Associates, Inc. SpineCare and Forensic Medicine, PLLC
Kailua, Hawaii Tucson, Arizona
Charles N. Brooks, MD David A. Fetter, MD

Bellevue, Washington Waukegan, Illinois
Mark Burns, MBBS Gary Freeman, MD, JD, MLA

Occupational Physician Houston, Texas
Sydney, Australia
Ian Blair Fries, MD
Scott W. F. Carle, MD Bone, Spine, and Hand Surgery
Lead Physician Chartered, Vero Beach, Florida
Concentra
Little Rock, Arkansas Lee S. Glass, MD, JD
Associate Medical Director
Fabrice Czarnecki, MD, MA, MPH Washington State Department of Labor &
Baltimore, Maryland Industries, Mercer Island, Washington
xx

Contributors xxi
David L. Harshfield, MD, MS Gideon Letz, MD, MPH

Little Rock, Arkansas Occupational Medicine and Toxicology
Consulting
Kurt T. Hegmann, MD, MPH San Francisco, California
Professor and Center Director
Dr. Paul S. Richards Endowed Chair in David Linklater, MD, MBA
Occupational Safety and Health Medical Manager, WCB Alberta
Rocky Mountain Center for Occupational Edmonton, Alberta, Canada
& Environmental Health
Salt Lake City, Utah Dwight T. Lovan
Commissioner, Department of Workers’
Harold Hoffman, MD Claims, Commonwealth of Kentucky
Edmonton, Alberta, Canada Frankfort, Kentucky
Les Kertay, PhD Douglas W. Martin, MD

Chief Medical Officer Medical Director
Lincoln Financial Group St. Luke’s Center for Occupational Health
Chattanooga, Tennessee Excellence
Sioux City, Iowa
Julia E. Klees MD, MPH
Associate Corporate Medical Director Laurie Massa, MS, MD
BASF Corporation Volunteer Clinician
Florham Park, New Jersey Faculty, University of Kentucky
Lexington, Kentucky
Edwin H. Klimek, MD
Neurologist Bruce E. Moore, JD
St. Catharines, Ontario, Canada Administrative Law Judge, Kansas
Department of Labor
Cynthia W. Ko, MD, MS Division of Workers’ Compensation
University of Washington Lawrence, Kansas
Seattle, Washington
Steven J. Oostema, MS
Thomas E. Kottke, MD, MSPH HealthInsight
Medical Director for Evidence-Based Salt Lake City, Utah
Health, HealthPartners
Minneapolis, Minnesota Destie Lee Overpeck, JD
Acting Administrative Director and Chief
Minerva Krohn Legal Counsel for
Counsel California Division of Workers’
Division of Workers’ Compensation Compensation
State of California Oakland, California
Alameda, California
Robert B. Palmer, PhD
Clement Leech, MD Clinical Toxicologist, Rocky Mountain
Chief Medical Advisor Poison & Drug Center
Department of Social Protection University of Colorado School of
Government of Ireland Medicine
Dublin, Ireland Denver, Colorado

xxii AMA Guides® to the Evaluation of Disease and Injury Causation
Scott Phillips, MD Stuart L. Silverman, MD

Denver, Colorado Medical Director, Cedars-Sinai Bone
Center of Excellence
Merle Rabine, JD Clinical Professor of Medicine
Workers’ Compensation Administrative and Rheumatology
Law Judge, State of California UCLA Medical Director
San Francisco, California Osteoporosis Medical Center
Beverly Hills, California
Robert G. Rassp, JD
Los Angeles, California Dan M. Spengler, MD
Professor and Former Chairman
Karl T. Rew, MD Department of Orthopaedics
Assistant Professor Vanderbilt University Medical Center
Department of Family Medicine Nashville, Tennessee
Department of Urology
University of Michigan Joel S. Steinberg, MD
Ann Arbor, Michigan Clinical Assistant Professor
Departments of Medicine and Psychiatry
Wanda K. Roehl, CSP Case Western University School of
Wichita, Kansas Medicine, Cleveland, Ohio
Daniel G. Samo, MD Matthew S. Thiese, PhD, MSPH

Northwestern Memorial Physicians’ Salt Lake City, Utah
Group
Chicago, Illinois Melissa D. Tonn, MD, MBA, MPH
Dallas, Texas
Shirley M. Seaman, MS, PA-C
The Hand Center Larry K. Wilkinson, MD
Wichita, Kansas Occupational Medicine Director of Via
Christi, Occupational & Environmental
Naomi N. Shields, MD Medicine
Clinical Professor, University of Kansas Wichita, Kansas
School of Medicine
Wichita, Kansas
David Silver, MD
Executive Vice President for
Medical and Scientific Affairs
Targeted Medical Pharma
Associate Clinical Professor of Medicine
UCLA School of Medicine
Los Angeles, California

Reviewers
Alex Ambroz, MD, MPH Robert A. Dobie, MD

Clinical Assistant Professor Clinical Professor
Marshall University University of Texas Health Science Center
Martinsburg, West Virginia San Antonio, Texas
Gunnar B. J. Andersson, MD, PhD Martin Grabois, MD

Professor and Chairman Emeritus Professor, Baylor College of Medicine
Rush University Medical Center Houston, Texas
Chicago, Illinois
Michael I. Greenberg, MD, MPH
William E. Blair, Jr, MD Professor of Emergency Medicine
Medical Director of Occupational (with Tenure)
Orthopaedics Chief of Division of Medical Toxicology
Waco, Texas Drexel University College of Medicine
Philadelphia, Pennsylvania
Robert E. Bonner, MD, MPH
Medical Director and Vice President LuAnn Haley, JD
Medical Practices Industrial Commission of Arizona
The Hartford Tucson, Arizona
Hartford, Connecticut
Morton Kasdan, MD
Sherri Brown-Keller, JD Clinical Professor of Plastic Surgery
Attorney at Law, Member-Owner- University of Louisville
Executive Committee Louisville, Kentucky
Fogle Keller Purdy, PLLC
Lexington, Kentucky Richard T. Katz, MD
St. Louis, Missouri
Ross W. Cairns
Melbourne, Victoria, Australia Gregory Krohm, PhD
Consultant
August Colenbrander, MD Wilmette, Illinois
Affiliate Senior Scientist
Smith-Kettlewell Eye Research Institute Patrick R. Luers, MD
Novato, California Spine Radiologist
Murray, Utah
Stephen L. Demeter, MD, MPH
Honolulu, Hawaii Kathryn Mueller, MD, MPH
Professor, Department of Emergency
Lorne Direnfeld, MD Medicine
Neurologist University of Colorado, Anschutz Medical
Maui Neurological Associates, Inc. Campus
Kahului, Hawaii Denver, Colorado
xxiii

xxiv AMA Guides® to the Evaluation of Disease and Injury Causation
David C. Randolph, MD, MPH Joseph P. Tansey, MD

Physician, Milford, Ohio Orthopaedic Physician
Oak Lawn, Illinois
Carrie A. Redlich, MD, MPH
Professor of Medicine, Yale David B. Torrey, JC
University School of Medicine University of Pittsburgh School of Law
Program Director, Yale Occupational Pittsburgh, Pennsylvania
and Environmental Medicine Program
New Haven, Connecticut Russell L. Travis, MD
Cardinal Hill Hospital
Marcia Scott, MD Neck and Back Clinic
Instructor in Psychiatry Lexington, Kentucky
Harvard Medical School
Cambridge, Massachusetts David Vearrier, MD
Assistant Professor of
Adam Seidner, MD, MPH Emergency Medicine
Global Medical Director Drexel University College of Medicine
Travelers Insurance Company Philadelphia, Pennsylvania
Hartford, Connecticut
Pamela A. Warren, PhD
E. Randolph Soo Hoo, MD, MPH Clinical Psychologist
Tucson, Arizona Carle Physician Group
Urbana, Illinois
Emily A. Spieler, JD
Edwin Hadley Professor of Law
Northeastern University School of Law
Boston, Massachusetts
FM_Causation_i-xxiv.indd 24 19/06/13 10:35 AM

Chapter 1
Chapter 1
Introduction
J. Mark Melhorn, MD,
William E. Ackerman III, MD,
James B. Talmage MD, and Mark H. Hyman, MD*
Purpose
Background
Costs
Fraud
Definitions
Summary
Determining causation is a critical issue in occupational health, yet its definition

remains elusive. Why? The causation concept may have a different meaning to various
parties. Essentially a cause is something that results in an effect. Causation is utilized in
theology, science, philosophy, law, statistics, medicine, psychology, etc. In philosophy,
if A causes B, then A must always be followed by B. Many theologians adhere to the
belief or hypothesis that there is an infinite, ultimate cause and that every natural event
is the effect of a supernal cause. Scientists use the scientific method, which consists of
experiments to determine causality in the physical world.
Physicians and statisticians use statistics to arrive at suggestions from observational

studies that A probably caused B. Biostatistics can never establish exact cause and effect
but gives the probability (eg, p # 0.05) that A contributed to B. For example, smoking
cigarettes may contribute to lung cancer, but cigarette smoking itself does not always
cause lung cancer because lung cancer is also linked to other environmental exposures
(risk factors). In law, it must be proven that a sufficient causal link exists that relates the
plaintiff’s disease or injury to the event in question. Jurisdictions may have different
requirements to determine causation. Psychologists attempt to determine how individuals
attribute causes to events and how this cognitive perception affects their actions. One may
infer, therefore, that the establishment of causation can be elusive in some situations.
*We thank Thomas Hales, MD, MPH, senior epidemiologist at the National Institute for Occupational
Safety and Health, Robert Taft Lab, Cincinnati, Ohio, for review and contributions to this chapter.
Ch01_Causation_001-014.indd 1 14/06/13 10:38 AM

Chapter 1 2 AMA Guides® to the Evaluation of Disease and Injury Causation
Why elusive? An Internet search on November 11, 2011, for “causation” resulted in
7,820,000 hits, which increased from 7,580,000 Web pages in 2008, while a PubMED
“all fields” search using “causation” returned 477,485 articles, compared to 388,461.
Wikipedia (http://en.wikipedia.org/wiki/Causation; accessed on June 27, 2012) defines
causation as a key component to establishing liability in both criminal and civil law;
in English law as the requirement for liability in negligence; in sociology as the belief
that events occur in predictable ways and that one event leads to another, in proximate
cause as “not too remote a consequence”; in philosophy as an event that is closest to, or
immediately responsible for causing, some observed result and is the basis of liability;
and as a key component in determination of negligence in the United States.
In occupational health, causation has become key, since determination of causation is

the gatekeeper to treatment and to determination of who is financially responsible.1
In other words, if a medical condition is determined to be “caused by or arising out of
employment” and meets the “legal threshold for causation,” the injured worker is entitled
to health care for the condition (possibly for the rest of his or her life) and possible
reimbursement for the functional loss (indemnity award for permanent impairment).
This Second Edition of AMA Guides® to the Evaluation of Disease and Injury Causation
is dedicated to updating the science, expanding the focus, and including additional
perspectives to improve the understanding of causation, which will eventually improve
the treatment outcomes for injured workers as they stay-at-work or return-to-work.
Why all the quotation marks in the above paragraphs? Because causation is often not
black and white. The science (evidence-based medicine) is often in conflict with the law
(derived from social justice) (Chapters 1 to 7). Recently, the gap between science and
law has been closing (Chapter 2, “Understanding Work-Relatedness,” and Chapter 3,
“Causal Associations and Determination of Work-Relatedness”). Furthermore, the
science of causation has increased yearly, although most of the publications remain
lower-quality hypothesis-generating epidemiologic studies, which cannot effectively
address confounders. (A confounding variable, or confounder, is an extraneous variable
in a statistical model that can correlate positively or negatively with a specific condition
or diagnosis.) The ideal hypothesis-testing prospective cohort studies are expensive and
difficult to complete. It is important to remember that a well-conducted retrospective
cohort study or case control study with stronger methodology can provide some insight,
and a poorly conducted prospective study can be misleading. Furthermore, case reports and
case series should not be viewed as epidemiological studies but more as sentinel events.
Again it is important to understand the source of the data (Chapter 4, “Methodology”).
Chapters 8 to 21 focus on causation by body location or disease type. These chapters

have been expanded to include additional authors and updated references using the
methodology outlined in Chapter 4. Despite the increase in evidence-based medicine,
conclusions can often be confusing or contradicting. Chapters 22 to 33 have been
developed to provide insight and perspective on determinations of causation.
Has science ever been wrong? The answer is yes. The information contained in
this book reflects our current best understanding of science that supports causation.
Therefore, sometimes the answer to a question concerning causation may be that the
evidence is insufficient to make a determination. Additionally, the difficulty of applying
epidemiological data to a specific individual must be understood; thus, the additional
chapters in the Second Edition to provide insight and guidance on this matter.

Introduction 3
Chapter 1
Purpose
Health care providers are often asked whether a condition is work-related or attributable
to a specific event. It is incumbent on clinicians to give an opinion based on a careful
review of three critical pieces of information:
1. Individual clinical findings.
2. Individual workplace exposures.
3. The literature linking (or not linking) the exposure of concern and the condition in
question.
This book is designed to assist health care providers, ancillary service providers,
attorneys, workers’ compensation risk managers, workers’ compensation commissions,
judges, and legislatures in using this information, in conjunction with clinical and
exposure data, to make evidence-based decisions about whether a medical condition is
work-related or attributable to a specific event or exposure.
Background
There is a large body of literature about the causal relationship between non-work-related
factors (eg, genetic, dietary, age-related, anthropomorphic, and environmental) and
disease. The evidence basis used to determine causation as it relates to these factors has
generally already been well characterized, with the strengths and limitations of available
evidence well appreciated by experts in the relevant medical specialties.
This book attempts to fill the void by examining the evidence-based literature available
to better understand the relationship between selected medical conditions and exposure to
physical and environmental factors that occur in the workplace or as a result of a specific
exposure. Specific attention is given to analyzing the weight of the evidence for the
strength of the association between these medical conditions and work factors commonly
referred to as occupational exposure. Because the relationship between exposure to
physical work factors and the development and prognosis of a particular illness, disorder,
or medical condition may be modified by preexisting conditions and biopsychosocial
factors, the literature concerning nonoccupational risk factors and biopsychosocial factors
and their impact on symptoms will also be considered. Understanding the interaction of
these associations and relating them to the cause of symptoms is critical. Because the
final determination of work relatedness is established by legal definitions, a discussion of
jurisdictional statutes is included.
The US Congress recognized that statistics on workplace injuries and diseases were
essential to an effective national program of occupational disease prevention. Therefore,
when the Occupational Safety and Health Administration (OSHA) Act was passed in
1970 (Code of Federal Regulations, Title 29, Chapter XVII, Part 1910), employers were
required to maintain records on workplace injuries and illnesses using the OSHA 200 (or
now 300) log. The act delegated responsibility to the Bureau of Labor Statistics (BLS) for
collecting statistics on occupational injuries and illnesses. To comply with the OSHA Act,
the BLS conducts an annual survey of occupational injuries and illnesses in the United
States.2 The survey compiles the OSHA 300 logs from more than 200,000 establishments

grouped by industry codes established by the BLS in the North American Industry
Classification System (http://www.bls.gov/bls/naics.htm).
Exact figures for occupational injuries and illnesses are not available. The best data for the
United States are provided by the Annual Survey of Occupational Injuries and Illnesses
by the BLS, US Department of Labor.2 To understand the data, it is important to know the
definitions for injuries and illnesses. According to OSHA, an occupational injury is any
injury such as a cut, fracture, sprain, or amputation that results from a work accident or
from a single instantaneous exposure in the work environment.3 Minor injuries are defined
as injuries requiring only first-aid treatment (eg, not involving medical treatment, loss of
consciousness, restricted work, or transfer to another job) and are not recorded in the logs.
An occupational illness is any abnormal condition or disorder, other than 1 resulting

from an occupational injury, caused by exposure to environmental factors associated with
employment. Occupational illnesses include acute and chronic illnesses or diseases that
may be caused by inhalation, absorption, ingestion, or direct contact.3 All occupational
illnesses are recordable. There are known limitations of the BLS data. The survey
estimates of occupational injuries and illnesses are based on a scientifically selected
probability sample rather than a census of the entire population. Because the data are
based on a sample survey, the injury and illness estimates probably differ from the
figures that would be obtained from all units covered by the survey. Also, the survey
measures the number of new work-related injury and illness cases that are recognized,
diagnosed, and reported during the year. Some conditions (eg, long-term latent illnesses
caused by exposure to carcinogens) are often difficult to relate to the workplace and
are not adequately recognized and reported. Thus, long-term latent illnesses are widely
acknowledged as being understated in the BLS data. In contrast, new illnesses with short
latency periods (eg, hours to days) such as contact dermatitis are easier to track than those
with longer latency periods (eg, cancer and osteoarthritis).
Although they are among the best sources for benchmarking occupational disease,
BLS data markedly underreport the extent of the problem. Why? In addition to the
unrecognized work-related conditions, both the employer and the employee have
incentives to underreport work-related injuries and illness. For the employer, this would
involve reduced workers’ compensation premiums and fewer OSHA inspections (fewer
entries on the OSHA 300 logs may limit the frequency and extent of OSHA workplace
inspections). For the employee, this would involve fear of employer retaliation,4 or
administrative obstacles,5 or lack of awareness that a condition could be work-related.
It is important to understand that the OSHA definition for work-relatedness is more

inclusive than most definitions used in scientific articles that are considering risk factors
(causation). This is because OSHA is looking for possible injury or illness patterns that
might allow for the development of additional “safety protocols” or “safety education”
guides. So, injuries and illnesses that occur at work but do not have a clear connection
to a specific work activity, condition, or substance that is peculiar to the employment
environment may be included in the OSHA data. If there is no underlying condition
for injuries (such as tripping hazards due to poor lighting, cluttered layout, poor floor
maintenance, etc), nor a workplace culture of sexual harassment, for example, an
employee may still trip for no apparent reason while walking across a level factory floor,
be sexually assaulted by a coworker, or be injured accidentally as a result of an act of
violence perpetrated by a coworker against a third party. In these and similar cases, the

Introduction 5
Chapter 1
employee’s job-related tasks or exposures did not create or contribute to the risk that such
an injury would occur. Therefore, a causal connection is established because the injury
or illness happened to take place in the workplace but was not a result of the actual work
activities the individual was performing as a part of his or her job.6
Examples of how these data are reported can be reviewed in the October 2011 update to
the BLS Workplace Injuries and Illnesses in 2009,2 which data update to October 20111
reported that, in 2010, nonfatal workplace injuries and illnesses numbered 3.5 million,
of which 3.1 million (approximately 88%) were injuries, resulting in an occurrence rate
of 3.5 cases per 100 equivalent full-time workers among private industry employers.
Compare this to the data in the first edition for 2005, when nonfatal workplace injuries
and illnesses numbered 4.2 million, of which 4.0 million (approximately 95%) were
injuries, resulting in an occurrence rate of 4.6 cases per 100 equivalent full-time workers
among private industry employers.7 This rate was a decline from the rate of 4.8 reported
for 2004.8 Incidence rates for injuries and illnesses combined declined in 2005 for most
case types, with the exception of 2.2 million cases with days away from work, transfer to
another job, or restricted duties. The rate for days away from work was 1.4 cases per 100
workers and for job transfer or restriction, 1.0 case per 100 workers.8
Statistics for nonoccupational injuries and illnesses are not as easily determined. There is
not a specific agency that tracks these injuries and illnesses. Knowing the rate at which
injuries and illnesses occur without workplace exposure is essential to determining
whether or not work activity increases the risk of the injury or illness in question. The
annual report by the National Safety Council provides some insight into these numbers.
However, care must be taken when interpreting these numbers. For example, if the rate
of arm amputation due to a chain saw in loggers (on the job) is lower than the rate of arm
amputations in homeowners, is the logger’s amputation not work-related? Determining
statistics for this group of injuries and illnesses is further complicated by the fact that the
injuries and illnesses may occur with the responsibility attributable to the person affected
or to someone else. When responsibility is attributable to another person, tort law may be
involved. A tort is a civil, not criminal, wrong or an injury against a person or property,
with the exception of breach of contract. Tort is derived from the Latin word tortus, which
was changed to tortious in English, which means twisted. Tort law is the body of the law
that permits an injured person to recover compensation from the injuring party, which may
occur when one person injures another, intentionally or by negligence. A court may award
money damages to the injured party as compensation for the injury. The requirement to
establish responsibility in tort law is a major reason that health care providers are asked to
provide an opinion concerning causation. The costs associated with torts are significant.
Several sources provide injury and cost data: the Centers for Disease Control and
Prevention (http://www.cdc.gov), the National Safety Council (http://www.nsc.org), the
National Library of Medicine at the National Institutes of Health (http://www.nlm.nih
.gov), insurance providers, and other sources on the World Wide Web. By using these
sources, several key documents were identified, as follows: The Economic Costs of
Injuries,6 Summary Health Statistics for the US Population: National Health Interview
Survey, 2002,7 and the National Safety Council’s 2007 edition of Injury Facts.9
The First Edition of the AMA Guides® to the Evaluation of Disease and Injury Causation
reported the total cost of nonoccupational injuries and illnesses (often labeled as
unintentional) in 2005 was $625.5 billion. Of this $625.5 billon, 50% was assigned to

wage and productivity losses, 18% to medical expenses, 18% to legal and administrative
costs, 10% to property damage, and 4% to uninsured costs. No data were available for
costs of punitive damages associated with unintentional injuries, when applicable.
Costs
Current cost data for workers’ compensation is provided by the 2009 National Academy
of Social Insurance report.10 Highlights include: benefits paid in the United States in
2009 were $58.3 billion, an increase of 0.4 percent from $58.1 billion in 2008; medical
payments decreased by 1.1 percent, to $28.9 billion; cash benefits to injured workers
increased by 1.9 percent to $29.4 billion; and costs to employers were $73.9 billion.
Workers’ compensation covered an estimated 124.9 million workers in 2009, a decrease
of 4.4 percent from the previous year due to the recession, which began in 2007, while
benefits paid to workers increased as a percentage of the wages of covered workers.
It has been suggested that these current figures do not include the total costs such as
productivity loss, administrative, property damages, or cost shifting. Cost shifting has
become an increasing concern, especially with the Affordable Care Act of 2012 or possible
future legislated “universal health insurance” requirements. LaDou suggests that cost
shifting is a more significant expense to the US economy than is commonly recognized.11
Using 2006 data, he reports the country’s total health care costs at over $2.3 trillion.11
LaDou suggests that workers’ compensation health care costs being shifted by employers
to Medicare/Medicaid and disability costs being shifted to the Social Security system far
exceed the total costs of all the state workers’ compensation programs. This has resulted in
most of the responsibility for compensating disabled workers now residing in the federal
government, not in the states’ workers’ compensation systems. Therefore, current federal
funding of workers’ compensation cost is at least four times that of state programs. This
concept was confirmed by a study of carpenters in 2009.12
Cost shifting is influenced by multiple factors. For example, increasing medical costs (co-
payments and higher deductibles) was positively and significantly linked to an increase in
the number of lost-time cases.13 Additionally, employer-provided health insurance did not
result in a reduction of workers’ compensation indemnity claims.14
Occupational exposures and their association with, or causation of, injuries and
illnesses are often debated because the science of causation may be limited.15 Because
a determination for association or causation is required to determine eligibility for
compensation and, therefore, financial responsibility for workers’ compensation or tort
cases, debates and disputed legal cases often ensue. The determination process is often
motivated by a desire to cost shift or to redirect the financial burden to another party.
The significance of such disputes is underscored by the reported direct health care costs
for the nation’s work force of more than $418 billion and indirect costs of more than
$837 billion. Reducing the more than $1.2 trillion workers’ compensation cost16 and
the $625.5 billion nonoccupational cost8 has become a national priority. Even though
the reported incidence of work-related injuries and illnesses is slowly decreasing, direct
and indirect costs, which include indemnity associated with the injuries and illnesses,
are increasing—especially in the illness group commonly described as musculoskeletal
disorders (such as carpal tunnel syndrome).17

Introduction 7
Chapter 1
Although described as a single system, workers’ compensation is a complex set of
judicial and legislative rules and regulations that are different for each state and territory,
with separate systems for state and federal employers; railroad employers; and long-
shore and harbor workers. The causation threshold requirement in different state workers’
compensation systems varies from “iota,” “1% contribution,” to “more probable than not”
contribution. Some states have presumptive laws that consider a particular illness to be
work-related (eg, some specific types of cancer in fire fighters) versus other states that
have laws precluding a particular illness from being considered work-related (eg, carpal
tunnel syndrome or noise-induced hearing loss). Thus the type of cases that drive the cost
of care can be different in different jurisdictions, making universal cost control solutions
difficult.
The tort law system is even more varied. Because each state establishes case precedents,
the approach from state to state can vary widely in what is considered acceptable
evidence and how the evidence is to be applied.
Fraud
Statistics for fraud (defined in the broadest sense as deception made for personal gain)
are difficult to determine. Fraud can be intentional or unintentional and can be committed
by the employee, employer, physician, insurer, and others. The estimates provided by
insurance companies are general. The insurance industry estimates that nearly a quarter
of all workers’ compensation claims filed involve some degree of fraudulent activity.18
Of the 25% suspected fraudulent claims, most involve some type of malingering in
which the claimant may extend time off even though the injury has healed sufficiently
for return to work. Malingering is an abuse of the system and is fraud, but little time is
spent investigating it because of limited resources.18 The types of workers’ compensation
claims that are usually investigated involve injuries that did not occur at work and
claimants working second jobs while collecting benefits for injuries sustained on their
primary job. These types account for about 10% of all compensation claims filed.18
Fraud can also occur when the claimant tries to mislead the physician. One study reported
that 42% of subjects were not truthful on a test of memory. The authors concluded
that exaggeration of cognitive (brain) symptoms is widespread in disability-related
evaluations.19 It would be unwise to accept self-reported memory complaints at face
value. Criteria-normalized symptom validity testing should be done to rule out symptom
exaggeration.19 A physician can also contribute to fraud when granting unnecessary
time off work or, possibly, based on a misguided sense of social justice, attributing
causation when causation does not exist.20-26 This most often occurs when an individual
has an obvious injury or illness for which treatment is available, but he/she has no
health insurance. Fraudulently classifying the condition as work-related and eligible for
workers’ compensation treatment allows the individual to be treated (and the physician to
be compensated for the treatment).
Fraud is not limited to the employee or physician. The employer can also contribute to
fraud by denying claims and by submitting false injury and illness rates to obtain lower
WC premiums. There also opportunities for fraud by the other participants in work-
related injuries.

Definitions
The remainder of this chapter contains definitions used throughout the book.
Evidence-based medicine has become the standard for determining appropriate medical
care. The most common definition was provided by Sackett et al27: Evidence-based
medicine is the conscientious, explicit, and judicious use of current best evidence
in making decisions about the care of individual patients . . . integrating individual
clinical expertise with the best available external clinical evidence from systematic
research. Unfortunately, controlled, randomized clinical studies are uncommon and
difficult to perform in the workplace. Therefore, most of the information available is
from epidemiologic studies. Although epidemiologic studies can prove or disprove an
association, they cannot prove causation.28
Epidemiology is the biomedical discipline focused on the distribution of and determinants

of disease in groups of people who happen to have some characteristics, exposures, or
diseases in common. Viewed as the study of the distribution and societal determinants of
the health status of populations, epidemiology is the basic scientific foundation of public
health.29 The goal of epidemiologic studies is to identify factors associated (positively or
negatively) with the development or recurrence of medical conditions. For this book, a
search of medical databases was used to identify epidemiologic literature that addresses
causation related to specific medical conditions, as outlined in Chapter 4, “Methodology.”
Medical conditions are injuries or illnesses that meet the standard criteria for a diagnosis
in the International Classification of Diseases, Ninth Revision.30 (The Tenth Revision is
currently scheduled for use in the United States in 2013.)
Impairment is a significant deviation, loss, or loss of use of any body structure or function
in an individual with a health condition, disorder, or disease.31 Compare this to the AMA
Guides to the Evaluation of Permanent Impairment, Fifth Edition as a loss, loss of use, or
derangement of any body part, organ system, or organ function.32
Disability is an umbrella term for activity limitations and/or participation restrictions in

an individual with a health condition, disorder, or disease.31 Compare this to the AMA
Guides, Fifth Edition defining disability as the alteration of a person’s capacity to meet
personal, social, or occupational demands or statutory or regulatory requirements because
of impairment. Disability is a relational outcome, contingent on the environmental
conditions in which activities are performed.32
Occupational exposures and physical factors at work are identifiable occupational

exposures to possible causative or aggravating agents. Examples of physical factors for
the musculoskeletal system are often described in terms of repetition, force, posture,
vibration, temperature, contact stress, and unaccustomed activities.33,34 For hearing, sound
levels are often measured in decibels; for radiation, exposure levels in millirads; and for
chemical, exposure levels in milligrams per cubic meter or parts per million.
Nonoccupational exposures include individual risk characteristics such as age, sex, hand
preference, hobbies, and comorbid medical conditions such as diabetes, body mass index,
depression.

Introduction 9
Chapter 1
Work environment is defined by OSHA in paragraph 1904.5(b)(1) as the establishment
and other locations where 1 or more employees are working or are present as a
condition of their employment.35 The work environment includes not only physical
locations but also the equipment or materials used by the employee during the course of
work.6
Aggravation occurs when a preexisting injury or illness has been permanently and
significantly changed.
For purposes of OSHA record keeping, the concept of aggravation is incorporated into
the definition of a recordable injury and illness, which occurs when an event or exposure
in the work environment results in any of the following:6
1. Death, provided that the preexisting injury or illness would likely not have resulted in
death “but for” the occupational event or exposure
2. Loss of consciousness provided that the preexisting injury or illness would likely not
have resulted in loss of consciousness “but for” the occupational event or exposure
3. One or more days away from work, days of restricted work, or days of job transfer that
otherwise would not have occurred “but for” the occupational event or exposure
4. Medical treatment in a case in which no medical treatment was needed for the injury
or illness before the workplace event or exposure or a change in medical treatment was
necessitated by the workplace event or exposure
This definition of aggravation is similar to that in the AMA Guides to Evaluation of

Permanent Impairment, Fifth Edition:
Aggravation A factor(s) (eg, physical, chemical, biological, or medical condition) that
adversely alters the course or progression of the medical impairment. Worsening of a
preexisting medical condition or impairment.32
Reflecting the increasing legal use of the AMA Guides, Sixth Edition states:
Aggravation Permanent worsening of a preexisting condition. A physical, chemical,
biological, or other factor results in an increase in symptoms, signs, and/or
impairment that never returns to baseline, or what it would have been except for the
aggravation (the level predetermined by the natural history of the antecedent injury or
illness)31
Exacerbation is a transient worsening of a prior condition by an injury or illness, with the

expectation that the situation will eventually return to baseline or preworsening level.36
Exacerbation is defined in the AMA Guides, Sixth Edition as:

Exacerbation Temporary worsening of a preexisting condition. Following a transient
increase in symptoms, signs, disability, and/or impairment, the person recovers to
his or her baseline status, or what it would have been had the exacerbation never
occurred. Given a condition whose natural history is one of progressive worsening,
following a prolonged but still temporary worsening, return to preexacerbation status
would not be expected, despite the absence of permanent residuals from the new
cause.31

Recurrence is similar to exacerbation, but it generally involves the reappearance of signs

or symptoms attributable to a prior injury or illness with minimal or no provocation and
does not necessarily occur related to work activities.36
Impairment evaluation is the acquisition, recording, assessment, and reporting of

medical evidence, using a standard method as described in the AMA Guides, to determine
permanent impairment associated with a physical condition.31 Again, for an injury to be
considered work compensable, the legal threshold for causation must be met.37
Apportionment represents a distribution or allocation of causation among multiple factors

that caused or significantly contributed to the injury or disease and resulting impairment. The
factor could be a preexisting injury, illness, or impairment.32 Apportionment is also updated
in the AMA Guides, Sixth Edition as the extent to which each of two or more probable
causes are found responsible for an effect (injury, disease, impairment, etc). Only probable
causes (at least more probable than not) are included. Hence, the first step in apportionment
is scientifically-based causation analysis. Second, one must allocate responsibility among the
probable causes and select apportionment percentages consistent with the medical literature
and facts of the case in question. Arbitrary, merely opinion-based, unscientific apportionment
estimates, which are nothing more than speculation, must be avoided. When appropriate
current impairment can also be apportioned to more than 1 cause.31
Summary
We have come full circle with the above statement, “Hence, the first step in
apportionment is scientifically-based causation analysis.”
What is a cause? Rothman38 defined a cause as “an event, condition, or characteristic that
plays an essential role in producing an occurrence of the disease.” There is causation, in
other words, only when 1 factor necessarily alters the probability of a second. Causality
is the relating of causes to the effects they produce. Most of epidemiology concerns
causality, and several types of causes can be distinguished. It must be emphasized that
epidemiologic evidence by itself is insufficient to establish causality, although it can
provide powerful circumstantial evidence (association).
What is risk? Risk is the probability that an event will occur. In epidemiology, it is most
often used to express the probability that a particular outcome will follow a particular
exposure. A risk factor is an environmental, behavioral, or biologic factor confirmed by
temporal sequence, ideally in prospective, longitudinal studies, that if present directly
increases the probability a disease will occur, and if absent or removed, reduces that
probability. Risk factors are part of the causal pathway or the causal model, where the
individual can be exposed to multiple factors.39
Precisely which factors predominate in the etiology of work-related medical conditions is

the subject of ongoing debate. Often a specific diagnosis has a multifactorial etiology, and a
single cause cannot be identified. Multiple risk factors are occupational and nonoccupational.
Furthermore, the presence of 1 risk factor does not negate other pathways with other
causal roles. Causal models are complicated by differences in personal susceptibility

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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)
The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.
NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.
MAKONDE LOCK AND KEY AT JUMBE CHAURO

This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]
MODE OF INSERTING THE KEY
With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
“We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
BRAZIER
Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT
SMOOTHING WITH MAIZE-COB
CUTTING THE EDGE

FINISHING THE BOTTOM
LAST SMOOTHING BEFORE

BURNING
FIRING THE BRUSH-PILE

LIGHTING THE FARTHER SIDE OF
THE PILE
TURNING THE RED-HOT VESSEL
NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK
DRAWING THE BARK OFF THE LOG
REMOVING THE OUTER BARK

BEATING THE BARK
WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT
MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN

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AMA Guides to the Evaluation of

Disease and Injury Causation, Second

In occupational health, causation has become a crucial measure. Today, determination of

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J. Mark Melhorn, MD | James B. Talmage, MD

de Quervain’s Disease 262

Chapter 11 Musculoskeletal Disorders: Conditions of Uncertain Pathophysiology—

James B. Talmage, MD, J. Mark Melhorn, MD, William E.

Chapter 12 Causation of Common Cardiovascular Problems �������������������������������� 411

Mark H. Hyman, MD, and Thomas E. Kottke, MD, MSPH

FM_Causation_i-xxiv.indd 7 18/06/13 3:20 PM

Arrhythmia, Syncope, and Heart Rate Variability 416

Chapter 13 Causation in Common Pulmonary Problems���������������������������������������� 433

Julia E. Klees MD, MPH, and Mark H. Hyman, MD

Chapter 14 Neurological Disorders���������������������������������������������������������������������������� 457

Chapter 15 Rheumatologic Diseases�������������������������������������������������������������������������� 469

David Silver, MD, Stuart L. Silverman, MD, and Mark H. Hyman, MD

FM_Causation_i-xxiv.indd 8 18/06/13 3:20 PM

Less Common Rheumatic Diseases 478

Robert J. Barth, PhD, Les Kertay, PhD, and Joel S. Steinberg, MD

Chapter 18 Gastrointestinal���������������������������������������������������������������������������������������� 531

Cynthia W. Ko, MD, MS, and Mark H. Hyman, MD

FM_Causation_i-xxiv.indd 9 18/06/13 3:20 PM

Chapter 19 Ear, Eye, Nose, and Throat���������������������������������������������������������������������� 545

William E. Ackerman III, MD, and Scott W. F. Carle MD

Chapter 20 Selected Topics: Gender, Leukemia Related to Radiation,

William E. Ackerman III, MD, Laurie Massa, MS, MD, and

Chapter 21 Chemical Exposure Claims: A Framework for Causation

Chapter 22 Putting It All Together: Causation Analysis as Illustrated

Roger M. Belcourt, MD, MPH, and J. Mark Melhorn, MD

Chapter 23 Example of Causation Methodology������������������������������������������������������ 609

J. Mark Melhorn, MD, Larry K. Wilkinson, MD, and Shirley

FM_Causation_i-xxiv.indd 10 18/06/13 3:20 PM

Chapter 24 Causation: The Attorney’s Perspective�������������������������������������������������� 615

David J. DePaolo, JD, MBA, and Robert G. Rassp, JD

Chapter 25 Causation: A Judge’s Perspective ���������������������������������������������������������� 627

Chapter 26 Causation: The Employer’s Perspective������������������������������������������������ 645

Wanda K. Roehl, CSP

FM_Causation_i-xxiv.indd 11 18/06/13 3:20 PM

What Employers Need to Ask the Physician 654

Chapter 27 Causation: The Insurer’s (Payer’s) Perspective������������������������������������ 657

David C. Deitz, MD, PhD

Chapter 28 Causation: The Workers’ Compensation Commission

Destie Lee Overpeck, JD, Minerva Krohn, Merle Rabine, JD,

Chapter 29 Causation: The Occupational Physician’s Perspective ������������������������ 679

Melissa D. Tonn, MD, MBA, MPH

Chapter 30 Causation: The International Perspective���������������������������������������������� 695

Causation: Australia Experience 696

Mark Burns, MBBS

FM_Causation_i-xxiv.indd 12 18/06/13 3:20 PM

Causation: Canada Experience 699

David Linklater, MD, MBA

Causation: Ireland Experience 703

Chapter 31 Causation Issues for Public Safety Personnel���������������������������������������� 717

Fabrice Czarnecki, MD, MA, MPH, Daniel G. Samo, MD, and

Chapter 32 Effects of Whole-Body Vibration on the Spine�������������������������������������� 749

Jesse E. Bible, MD, MHS, Clinton J. Devin, MD, and Dan M.

Section 1: Evaluating Causation for the Opposite Upper Limb 758

Section 2: Evaluating Causation for the Opposite Lower Limb 769

Christopher R. Brigham, MD, Charles N. Brooks, MD, and James B.

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By Gunnar B. J. Andersson, MD, PhD

We have an obligation to provide a fair and comprehensive analysis of possible cause.

Chapter 12 Causation of Common Cardiovascular Problems �� 411

Chapter 13 Causation in Common Pulmonary Problems�� 433

Chapter 14 Neurological Disorders�� 457

Chapter 15 Rheumatologic Diseases�� 469

Chapter 18 Gastrointestinal�� 531

Chapter 19 Ear, Eye, Nose, and Throat�� 545

Chapter 23 Example of Causation Methodology�� 609

Chapter 24 Causation: The Attorney’s Perspective�� 615

Chapter 25 Causation: A Judge’s Perspective �� 627

Chapter 26 Causation: The Employer’s Perspective�� 645

Chapter 27 Causation: The Insurer’s (Payer’s) Perspective�� 657

Chapter 29 Causation: The Occupational Physician’s Perspective �� 679

Chapter 30 Causation: The International Perspective�� 695

Chapter 31 Causation Issues for Public Safety Personnel�� 717

Chapter 32 Effects of Whole-Body Vibration on the Spine�� 749