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Question. Tell the jury what the X-ray shows with reference to the left lung.

Answer. There is a diffused mottling over the central part of the chest, with the apices and bases much less marked. The fibroid tissue over the greater part of the lung, the left hilus or part next to the heart is much increased in density, and the greatest area of density is in the subelavicular region.

Mr. Couch. What is that?

Answer. Subelavicular, below the clavicle. The gr ter portion of this lung contains diffused nodules.

General LILLY. I think that has been fairly well described, but we feel it is important in the instant case. Just define as fully as you can what you mean by nodules.

Answer. The nodules that we speak of are small areas of increased density that occur usually at the bifurcation of the lymph channels, and are caused by some irritating material which is stopping the drainage from flowing toward the mid-portion of the lung, where it goes on into its other courses.

Question. Now, speaking with reference to both lungs, how prevalent or diffused are these nodules as to the whole lung area, Dr. Lambert.

Answer. They are about equal in each lung.
Question. How extensive are they now? I mean as to number, and so forth.
Answer. There is no way of estimating the number that I know of.
Question. Are there a great many?
Answer. A great many; yes, sir.

Question. Tell the jury, if you know, what effect these nodules have with reference to the breathing or the health of the individual or how they affect his lung.

Judge LEE. We object to that. The COURT. Objection overruled. Answer. It would cause a great impairment of the respiratory function of the lungs.

By General LILLY: Question. Have you had occasion to examine the X-ray made about a week before yours by Dr. Hughey, of Charleston?

Answer. I examined it today; yes, sir.

Question. Well, now, taking into consideration the X-ray about 10 months ago and the X-ray which you took, concerning which you have given evidence, give the jury your professional opinion as to what that X-ray shows in the way of disease, if anything, of Raymond Johnson.

Mr. Couch. We object.

The COURT. Well, if he can base an opinion on these X-rays alone, I suppose it would be a question for the jury as to the weight they would give it. The objection is overruled. He may answer it.

Answer. It shows rapidly advancing silicosis.
Mr. Couch. We move to strike out the answer.
The COURT. Motion overruled.

By General LILLY :
Question. Tell the jury whether or not a silicotic condition, say of the de-
gree or intensity you find in this X-ray picture, can be diagnosed from an
X-ray.

Answer. Yes, sir.

Question. Tell the jury, in your opinion, or from your observation, as to whether or not it is the best, most dependable single information in that regard.

Judge LEE. We object.
The COURT. The objection is sustained. It is a leading question.

By General LILLY : Question. What is the value, Doctor, in your opinion, of an X-ray of a silicotic lung, with reference to diagnosing its condition?

Mr. Couch. We object.

Thfe COURT. That question cures the objection to the other question, I think. The objection is overruled. You may answer.

Answer. It is probably the best means of diagnosis.

General LILLY. Now, what significance do the nodulations have, concerning which you have testified and described, with reference to indicating silicosis in the instant case?

Mr. Couch. We object.

The COURT. Read the question, please.
(The question was read by the reporter.)
General LILLY. What significance, if any-put that in.
The COURT. Go ahead and answer. Objection overruled.
Answer. Diffused nodulation appears in all cases of silicosis.

General LILLY. Have you had occasion, Doctor, to take X-ray pictures of miners or people who have worked in the coal fields here in West Virginia ?

Answer. Yes, sir.

Question. About how many chests would you say you have X-rayed of such people?

The WITNESS. Of miners? General LILLY. Yes; coal miners, I mean. Answer. I should say three or four or five hundred, something of that kind. That is a guess. I don't know.

Question. Tell the jury whether or not those X-rays, as reflected from the occupation of coal mining, have disclosed nodules.

Mr. Couch. We object.
The Court. The objection is overruled. You may answer it.

Answer. I found four cases of silicosis in mi rs, but those miners gave a history of working in the hard-coal veins in Pennsylvania. I have seen no nodules in coal miners who work in this region in West Virginia.

General LILLY. That is true, but it is hard to get these boys up here, and we are using him for all purposes now. We appreciate it is defense, Your Honor, or might be.

Question. Did you answer it, Doctor?
Answer. No. I did not see any evidence of tuberculosis.

General LILLY. We desire to ask this witness some questions that might arise more properly on rebuttal, but in view of the fact it is hard to get the doctor up here, and under the conditions, we want to ask these questions at this time.

Question. How many stages do you understand there are of silicosis, Doctor?

Answer. There are three stages agreed upon, I believe, and some of them divide the last stage into two or three.

Question. And what would you say as to stages, the common or medical designation of stages, in tuberculosis?

Mr. COUCH. We object.
The COURT. The objection is overruled.
Answer. That is also divided into three stages.

General LILLY. Now, Doctor, I wish you would in your own way explain to the jury the X-ray difference, if any, of tuberculosis in the first stage and silicosis of the first stage.

Mr. COUCH. We object.
The COURT. Objection overruled. You may answer.
The WITNESS. That is, from an X-ray examination?
General LILLY. That is what my question purported, Doctor.

Answer. Tuberculosis in the first stage, you have small, fan-shaped areas of density either in the apex, clear in the top of the lung, or what we call the first or second interspaced trunks and out to the end of them, clear out to the periphery—that is the outside of the lung. By the first and second interspaces we mean what we see on the X-ray plate between the first and second ribs. It may occur in either side of the chest. In the tubercular chest in the first stage you can see various stages of pathology; you can tell which area from the X-ray plate was first infected. The scar is more dense, with beginning small granules or particles of calcification. The next area of infection is less dense than the first, and if you have a third, that is still less dense. There is no cavitation in the first stage, and very little calcification froin hilum. In the first stage of silicosis your trouble is altogether in a different area; it is down in the central portion of the lung, and has a tendency to spread out into the chest, while the tuberculosis is in the apices and out at the other portion and spreading in. I know that they say your parabronchial type of tuberculosis begins around the bronchial, but it is my opinion and the opinion of many others that you always have your foca out at the periphery even in your parabronchial type.

Question. Now, what do you observe with reference to nodulation in the first stage of silicosis, if anything, Doctor?

Answer. There is very little nodulation, if any. If you were talking to X-ray men you possibly might agree on a nodulation. It would be mighty hard for the average physician or for a layman to see and understand.

Question. In that connection, Doctor, tell the jury whether or not the average layman, or even the average doctor, can interpret X-rays, and especially with reference to the chest?

Answer. Not unless that doctor has spent a great deal of time in the study of interpretation of X-ray chest plates. Question.

Would that apply to the average layman? Answer. Yes, sir.

Question. Now, Doctor, you have described the difference in tuberuclosis, as shown by the X-ray, in the first stage, and silicosis in the first stage. I wish you would describe the difference, if any, of those two diseases in the second stage.

Answer. What we call the second stage of tuberculosis is the beginning stage of cavitation ; small cavities appear, and as the stage goes on they have a tendency to get larger. The stage of fibrosis occurs; the increase of your hilum shadows or the drainage at the midportion of the chest occurs. At this stage you can trace your tubercular patient almost from the beginning of his attack by the different areas throughout his chest and the healed areas, because tuberculosis has a tendency to heal and to develop in the same lung at the same time. In silicosis you have a widening of the hilar shadows, beginning in the center of the chest and growing out. There is a different arrangement on the X-ray plate of the fibrosis of tuberculosis and of the silicosis case. In silicosis the fibrosis is much finer, smaller lines than in tuberculosis. In tuberculosis the fibrotic lines are pretty heavy and dense They show altogether a different picture on the plate than the silicotic lung. In the second stage of silicosis you have your stage of nodulation, where nodules form, millions of them, throughout the chest, depending upon the severity of the attack and exposure.

Question. Now, Doctor, referring to and asking the same question concerning the third stage of tuberculosis and the third stage of silicosis, please tell the jury.

Objection; overruled; exception.

Answer. In the third stage of tuberculosis you have the stage of large cavitation, large areas of fibrotic tissue, which is almost entirely more pronounced in one lung than the other. It may be entirely unilateral, but it is certainly more pronounced in one lung than in the other.

Question. That is tuberculosis?
Answer. Tuberculosis.
Question. Go ahead.

Answer. In silicosis that is a bilateral disease, both lungs are affected, and usually in the same proportion, with marked areas of nodulation which tend to coalesce and apparently grow together. The fibrosis is of a different quality, as shown on the X-ray plate, and even when it amalgamates or grows entirely together, even that density is different from the density of the tubercular plate.

Question. Doctor, please tell the jury your opinion, if you have such, as to what stage of silicosis the X-ray you took indicates present in Raymond Johnson.

Mr. COUCH. Objection.
The COURT. Objection overruled; you may answer.

The WITNESS. It indicates the beginning third stage, because of the coalescense or the grouping together of the nodules.

By General LILLY : Question. Doctor, referring to this first X-ray taken about 10 months ago, and the X-ray taken by you, and also the one Dr. Hughey took, state in your opinion how progressive his silicosis is indicated by a comparison of the first X-ray with these last X-rays, which were taken this month.

Mr. COUCH. We object.
The COURT. If you can do that, go ahead.
The WITNESS. It is certainly very rapid in its progress.

General LILLY. Tell the jury what the indications are, if there are such from this X-ray, as to how progressive this silicostic disease is in Raymond Johnson at this time.

Mr. COUCH. We object.
The Court. I thought that was asked in your preceding question.

General LILLY. I am asking him about one X-ray to the other. Now I am asking him what this X-ray indicates. I don't know, that might cover it. Read that question.

(The question was read by the reporter.)

The Court. I think I will sustain the objection. I do not see any occasion for this second question, in view of the one preceding it.

General LILLY. Doctor, you have explained, but it was with your long explanation there, with reference to the relative locations and the spread of tuberculosis and silicosis. I wish you would just confirm your answer to that one feature, as to what the differentiation is as to the location and spreading of tuberculosis and silicosis.

Mr. DILLON. He has answered that.
Mr. Couch. We object, Your Honor.

General LILLY. He has said that, but I thought it might clear it a little more to let him explain it to the jury again, Your Honor.

Mr. Couch. We object on two grounds: In the first place, it is repetition, and in the second place it is not correct direct questioning.

The COURT. It is anticipating the defense or possible defense. We waived that in view of the statement it is difficult to get these doctors back here. Now, there may be another objection to it. I think it is repetition. I thought the doctor was very clear in his explanation. The objection is sustained. General LILLY. That is all.

Cross-examination by Mr. Couch: Question. Doctor, I understood you to say a while ago that nodulation appears in all cases of silicosis. Is that correct?

Answer. Yes, sir.

Question. I also understood you to say that you took this X-ray picture of Raymond Johnson on March 16, 1933. Is that right?

Answer. Yes, sir.
Question. I am referring to film no. 2513.
Answer. Yes, sir.
General LILLY. I overlooked introducing this.
Question. Doctor, I believe that is the X-ray film you referred to?
Answer. Yes, sir.

General LILLY. We now ask to introduce this as the plaintiff's exhibit no. 16, marked “Dr. Lamber, 2513.".

Question. As I understand there is another counterpart of that?
Answer. Yes, sir.

(The X-ray film referred to was received in evidence, marked as above described.)

Mr. Couch (continuing cross-examination). Doctor, undestood you to say you specialized in radiology?

Answer. Yes, sir.

Question. I will ask you if you can tell, from the X-ray alone, whether a patient has got silicosis in the first stage?

Answer. You can't tell until after nodulation starts.
Question. Then you can't always tell whether he has got it, can you?
Answer. Not in the first stage.

Question. Can you tell, from the X-ray alone, whether or not he is a silicottc in the second stage?

Answer. Yes, sir.

Question. How can you tell a silicotic from a patient who has got miliary tuberculosis?

Answer. Very easily.
Question. Tell us, if it doesn't take too much time.
Answer. Sir?
Question. I wish you would tell us, please.

Answer. A patient with miliary tuberculosis that would be marked upon an X-ray plate in the form of nodules, the nodules would be more dense; there would be practically no fibrotic tissue accompanying them.

Question. How can you tell a second-degree silicosis from a carcinosis? How can you tell those two apart?

Answer. Very easily. Simply because your carcinosis is not so evenly distributed as your silicosis. Your formation of fibrous tissue are altogether different from your silicotic tissued bands—that is, the shadows of the X-ray plate.

Question. Do all the medical authorities you have read coincide on that, Doctor-on that belief that you have just given us?

Answer. I don't know whether they do or not, sir.
Question. I say, all that you have read. Do they coincide on that theory?
Answer. A great many of them do that I have read; yes, sir.

Question. Do you know of any of them that do not?
Answer. I don't remember of any.

Question. You talked a while ago, Doctor, about a widening of the hilar shadows in silicosis.

Answer. Yes, sir.

Question. Do you attach any significance to the widening of the hilar shadows in silicosisany particular significance?

Answer. There is no more significance except that that is the first blockage of drainage from the lung.

Question. How do you know that that thickening is not a hilar tuberculosis, or an early cancer, even?

Answer. You don't know it until nodules form that are uniform over the lung.
Question. And there is no way of knowing it, is there?
Answer. Not that I know of; no, sir.

Question. You stated a while ago that you had tuberculosis trouble generally in one luing. Is it not true that you can have tuberculosis in both lungs?

Answer. Yes, sir.
Question. Frequently you do have tuberculosis in both lungs, do you not?
Answer. Yes, sir.

Question. I believe you stated on direct examination that your knowledge of silicosis was obtained from the study of 20 cases.

Answer. No, sir.
Question. Did you not state that?
Answer. No, sir. I said I had examined and diagnosed about 30 cases.
Question. About 30 cases?
Answer. Yes, sir.

Question. How do you explain the indistinct margins of the nodules shown in your X-ray picture or film?

Answer. Simply because it is still active, and not in a latent form.

Question. You stated they were of rapid growth. Did you find such hazy margins in your previous film, or in the previous film?

Answer. No, sir.

Question. Doctor, have you found silicosis among miners in West Virginia ? I mean coal miners.

Answer. Yes, sir. I diagnosed four cases.
Question. Four cases in West Virginia ?
Answer. Yes, sir.
Question. Doctor, when did you first examine Raymond Johnson ?
Answer. The day we made the X-ray plate.
Question. That was on the 16th day of this month?
Answer. Yes, sir.
Question. Did you obtain a history of the case at that time?

Answer. No, sir; not any more than that I was told that he worked in this tunnel.

Question. Who told you?
Answer. I believe he told me, himself.
Question. Did you make a clinical examination of him at that time?
Answer. No, sir.

Question. Can you make a positive diagnosis of silicosis on an X-ray examination alone?

Answer. Yes, sir.
Question. Do you make that as a positive statement, that you can?

Answer. Yes, sir. I beg your pardon—when it is advanced to where there is nodulation, past the first stage.

Redirect examination by General LILLY: Question. Just one question. Doctor, you on cross-examination spoke of finding four people who had worked in the mines afflicted with silicosis. I mean coal miners. Were those the same four cases you referred to as having given a history of working in the anthracite coal? Answer. Yes, sir.

Cross-examination by Mr. COUCH: Question. Were these miners that you speak of working here in West Vir. ginia when you made your diagnosis?

Answer. Yes, sir.
Question. Working in the mines in West Virginia ?
Answer. Yes, sir.
(Witness stands aside.)

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