1976 PLP 502 (PLC)

5. The learned counsel for the respondent, on the other hand, relied on the statement of the appellant's witness, Dr. Hasham Ansari who stated in cross‑examination that the possibility of some serious disease out of injuries received by the respondent was not ruled out. Since no reasons were given by the said doctor to come to the above conclusion, I was not satisfied with his evidence. In the interest of justice I examined a medical expert, Dr. Syed Riaz Mustafa as a Court witness. He is a surgeon in Service Hospital, Lahore and is a lecturer in Anatomy in Lahore Medical College, Lahore. His qualifications are M. B. B. S. (Pb.) M. S. (Pb.) and F. R. C. S: (Edinburgh). He made the following statement: ‑ "In my opinion the injury suffered by the respondent to his right foot and leg has nothing to do with Buerger's disease, which later resulted in the amputation of both his legs. My reasons are :‑ (i) That in the entire literature dealing with Buerger's disease there is, no mention of Trauma being a predisposing factor in the causation of Buerger's disease. (ii) That the interval between the injury and the subsequent amputations so very great that any possibility of Trauma leading to Gangrene is excluded. Further in any case there is no history of Trauma, to left lower extrimity which also required amputation subsequently:" When he was asked as to whether Buerger's disease was infectious, he gave the following answer :‑ "No, but the nature of Buergers disease is such that if it is in one leg it, may travel to the other leg and even to the upper limbs, though this is comparatively very rare." When he was asked as to what were the causes of Buerger's disease, he replied :‑ "Exact cause is not known but what is definitely known is that smoking has a very definite relationship to the causation of Buergers disease. We always advise the patients to stop smoking and it has been seen: that the progress of the disease is retarded if not completely halted by the stopping of smoking." In cross‑examination by the respondent's counsel, he stated that since all the exact causes of Buerger's disease are not known, therefore, the doctor cannot specifically state as to what was the actual cause. According to him this disease can be suffered even by non‑smokers. He was asked as to whether the Trauma from compression of artery due to crushing injury cause, throm bosis formation, he replied that it can. According to him Thrombosis of any vessels can occur by crushing injury. He stated that an embolus from thrombosed blood vessels can travel down the blood vessels. He was asked as to whether this can cause Buerger's disease, he replied:‑ "No, but when the embolus travels down from larger blood vessel and occludes smaller blood vessel, it may produce gangrene in the area of supply of blood vessel, if the collaterals are insufficient and this is known as embolic gangrene." He also stated that an arterial clot cannot travel beyond the capillary bed of the same side but the venous clot can travel to other parts of the body When he was asked as to whether a crushing injury creating a wound with the passage of time cause acute and chronic inflammation, he replied :‑ "As long as a wound is not properly healed, there is always inflammation around and in the wound Buerger's disease is not due to infectious agent." In re‑examination be stated :‑ "Gangrene can be due to an embolus It can be due to division of' blood vessel, Buerger's disease etc. Buergers disease is one specific disease entity and so also are the thrombo‑embolic phenomena. The' question as to whether gangrene if at all has to set in will depend upon the nature of the residual wound and its subsequent course.." 6, The learned counsel for the respondent contended that since the doctor cannot definitely state as to what was the cause of the disease, with, which the respondent had suffered, his opinion was not reliable.

7. The learned counsel relied on the quotations from the various medical books :‑(1) William Boyd's Text Book of Pathology. Volume II, edition 1970. On page 593 first line in column II, it is mentioned :‑ "This is in essence a thrombolic occlusion of the vessels of the legs is relatively young men with resulting gangrene of the toes and then the feet." (2) Book of Pathology by Robinson, 3rd Edition, 1968. On page 592 the fllowing is written :- "Thromboangities Oblirerans (Buerger's Disease).‑At the turn of the last century, Buergers described an apparently distinctive disease charac terised by segmental, thrombosing, acute and chronic inflammation of arteries and veins that occurred almost exclusively in men who were cigarette smokers. He attributed the disease to some infectious agent which he could not isolate but was able to transmit by transplantation of thrombus from acutely affected vessels. (3) In Cecil Loeb's Text Book of Medicine, Volume II, Edition 1971 at page 1123 the following is written :‑ "Although many agents toxic and infectious, have been suggested, no etiology has received general acceptance. Cigarettes are used moder ately or exclusively by many, but not all, patients with thromboangiitis obliterans and have been thoroughly investigated as a causative agent, since smoking aggravates the disease. An increased skin sensitivity to tobacco has been reported by some investigators but not found by others."

8. In none of these quotations it has been mentioned that physical injuries, as received by the respondent, could lead to Buerger's disease. It is correct that all the causes of Buerger's disease are not known but the doctor was definitely of the opinion that the injuries received by the respondent could not have been the direct cause of Buerger's disease, with which th respondent suffered. In view of the above, I am satisfied that Buergers disease, with which the respondent had suffered, was not directly attributable to the injuries received by him during the accident.

9. I, accordingly accept the appeal, set aside the order of the learned Commissioner and dismiss the petition of the respondent which he had filed before the learned Commissioner.