Document LgdvpbgDbokLB5VK03wovv3k5

NO. E-149519 IN THE DISTRICT COURT OF JEFFERSON COUNTY, TEXAS 172ND JUDICIAL DISTRICT CHARLES DOUGLAS YORK VS. TEXACO, INC. ET AL DEPOSITION OF ETHAN A. NATELSON, M.D January 26, 1998 Houston, Texas 2 1 RXAMINATION INDEX 2 PAGE 3 BY MR. DILLARD 6 4 BY MR. SCOTT 53 5 BY MR. CARRINGTON 56 6 BY MR. MORGAN 59 7 BY MR. DILLARD 146 8 BY MR. SCOTT 160 9 BY MR. CARRINGTON 161 10 BY MR. MORGAN : ___ 11 12 EXHIBIT INDEX 13 PAGE 14 NATELSON EXHIBIT 1 6 Curriculum Vitae of Ethan A. 15 Natelson, M.D. 16 NATELSON EXHIBIT 2 10 January 14, 1998 letter to John S. 17 Appleman from Stephen C. Dillard 18 NATELSON EXHIBIT 3 - 164 Compilation of data pertaining to 19 aplastic anemia 20 NATELSON EXHIBIT 4 167 Articles published by Dr. Natelson 21 pertaining to anemias 22 NATELSON EXHIBIT 5 170 Copy of Dr. Natelson's calendar for 23 May 1998 24 NATELSON EXHIBIT 6 172 Results of blood work done on 25 Mr. York on January 15,1998 3 1APPEARANCES 2 3 FOR PLAINTIFF: 4 Mr. Glenn W. Morgan Mr. Larry W. Thorpe 5 Reaud, Morgan & Quinn 801 Laurel Street 6 Beaumont, Texas 77701 7 8 9 FOR DEFENDANTS, MOBIL CHEMICAL COMPANY, INC., TEXACO, INC., TEXACO CHEMICAL COMPANY, TEXACO 10 REFINING AND MARKETING, INC., CHEVRON, U.S.A., INC. (including Gulf Oil Corporation), CHEVRON 11 CHEMICAL COMPANY AND UNOCAL CORPORATION: 12 Mr. Stephen C. Dillard Fulbright & Jaworski, L.L.P. 13 1301 McKinney, Suite 5151 Houston, Texas 77010-3095 14 15 16 FOR DEFENDANT VELSICOL CHEMICAL CORP.,: 17 Mr. Robert P. Scott 18 Abrams, Scott & Bickley L.L.P. 600 Travis Street; Suite 6601 19 Houston, Texas 77002-3007 20 -and 21 Ms. Bonnie J. Semilof Spriggs & Hollingsworth 22 1350 I Street, N.W. Washington, D.C. 2005-3305 23 24 25 4 1 FOR DEFENDANT DuPONT: 2 Mr. M. C. Carrington Mehaffy Weber, Keith & Gonsoulin, 3 A P.C. 2615 Calder Avenue, Suite 800 4 Beaumont, Texas 77704 5 6 FOR DEFENDANT FINA OIL & CHEMICAL COMPANY: 7 Mr. Kirk E. Martin 8 Jenkins, Grove & Martin, L.L.P. 2615 Calder, Suite 500 9 Beaumont, Texas 77704 10 11 ALSO PRESENT: 12 Mr. Charles York 13 14 15 THE VIDEOGRAPHER: 16 Mr. Devon Rochelle 17 18 19 20 21 22 23 24 25 5 1 On the 26th day of January 1998, 2 commencing at 1:19 p.m., at the offices of 3 Dr. Ethan A. Natelson, 1315 Calhoun, Suite 4 1800, Houston, Harris County, Texas, ETHAN A. 5 NATELSON, M.D., F.A.C.P., appeared before me, 6 Jack B. Moorhead, a Certified Shorthand 7 Reporter in and for the State of Texas, and 8 being by me first duly sworn, testified by his 9 videotaped deposition as hereinafter set out, 10 pursuant to Notice and the Texas Rules of 11 Civil Procedure with the following stipulation 12 by counsel: 13 It was stipulated that if the 14 original deposition has not been signed by 15 the time of trial or any hearing, an 16 unfiled/unsigned copy may be used in lieu 17 thereof. 18 19 20 21 THE VIDEOGRAPHER: Today is January 22 26, 1998. The time is 1:19 p.m. We are now 23 on the record 24 (Witness sworn.) 25 6 1 EXAMINATION 2 QUESTIONS BY MR. DILLARD: 3 Q. State your name, please, sir. 4 A. Ethan Allen Natelson. 5 Q. And what is your occupation? 6 A. I am a physician, a hematologist. 7 Q. You are a medical doctor? 8 A. Yes. 9 Q. And how long have you been a medical doctor? 10 A. Since 1966. 11 Q. Have you brought with you a current resume or 12 curriculum vitae that identifies your 13 background and your training and education 14 A. Yes, I have. 15 Q. And is this a copy of it here today? 16 A. Yes. 17 (Natelson Exhibit 1 18 marked for identification.) 19 Q. All right. Your resume has been marked as 20 Exhibit Number 1, Doctor, and I am going to 21 ask you a few questions about your 22 background. I am not going to go through the 23 entire resume in any detail. 24 But can you tell us, first of all, 25 where you attended medical school? 7 1 A. Baylor College of Medicine. 2 Q. And when did you graduate? 3 A. In 1966. 4 Q. Did you have any additional formal training 5 after you received your M.D. degree in 1966? 6 A. Yes, I did. 7 Q. And would you describe that for us, please, 8 sir, in a summary fashion? 9 A. Well, I did a residency training in the Baylor 10 affiliated hospitals, which consists of the 11 Ben Taub Hospital, Methodist Hospital, the 12 Veterans Administration Hospital, and then I 13 did a fellowship in hematology at the 14 Methodist Hospital. 15 Q. Just some formal questions. Is your license 16 to practice medicine on file with the 17 appropriate authorities in Houston, Harris 18 County? 19 A. Yes. 20 Q. You have said, now, a couple of times that you 21 specialize in a particular field of medicine 22 called hematology? 23 A. Yes. 24 Q. Can you describe for us briefly what the field 25 of hematology consists of? 8 1 A. Well, it's a broad field that covers certain 2 types of malignancies, for example, leukemias 3 and lymphomas. In the area of malignancy, it 4 covers certain inflammatory conditions, such 5 as autoimmune diseases. It also covers 6 bleeding disorders, such as hemophilia and 7 problems with bleeding from low platelet 8 counts, and it also involves the evaluation of 9 various causes of anemia. So it's a rather 10 broad-based field. 11 Q. When you say anemia, would one of the anemias 12 be called aplastic anemia? 13 A. Yes. 14 Q. Are you certified as -a specialist in any 15 particular field? 16 A. In hematology. 17 Q. And when were you certified as a specialist in 18 the field of hematology? 19 A. I will have to look to be sure. I think 20 1974. Let me see if that's right. Yes, 1974. 21 THE WITNESS: Can you hang on one 22 second while I get this telephone call? 23 MR. MORGAN: Yes. 24 THE VIDEOGRAPHER: Off the record. 25 (Off the record.) 9 1 THE VIDEOGRAPHER: Back on the 2 record at 1:24 p.m. 3 Q. Doctor, how does one become board certified in 4 a particular specialty in medicine? 5 A. Well, each specialty sets up particular 6 requirements for their board certification. 7 And those requirements may involve a period of 8 training time, it may involve a period of 9 patient experience. And they will vary from 10 specialty to specialty. And at the time I was 11 certified in hematology the requirement was 12 one to two years of training specifically in 13 hematology. 14 Q. And are you what is called a board certified 15 physician? 16 A. Yes. 17 Q. All right. Are you affiliated with any 18 hospitals, and if so which ones? 19 A. I am affiliated with St. Joseph Hospital. 20 Q. And that's where we are today, in the 21 professional building next to St. Joseph 22 Hospital? 23 A. Yes. 24 Q. Do you have any teaching responsibilities? 25 A. Yes. I am what is called the director of 10 1 medical education in St. Joseph Hospital, and 2 I'm specifically in charge of our transitional 3 internship here at the hospital. 4 Q. And can you just briefly describe for us what 5 that means? 6 A. Well, in terms of the internship I recruit -7 interview and recruit 12 transitional interns 8 that spend a year here at St. Joseph Hospital 9 and then go off into various types of 10 subspecialty training. I'm also in charge of 11 all of our teaching programs, each one, such 12 as surgery or obstetrics, as a subdirector, 13 who is intimately involved with the program. 14 But I am the person in charge of all the 15 programs. 16 Q. In your capacity as a hematologist have you 17 had occasion to examine and treat a patient, by 18 the name of Charles Douglas York? 19 A. Yes. 20 (Natelson Exhibit 2 21 marked for identification.) 22 Q. And did you, at our request and pursuant to 23 this deposition notice, bring with you today 24 your records concerning Mr. York? 25 A. Yes, I did. 11 1 Q. When did you first see Mr. York? 2 A. If I can look in the record to tell you that. 3 It would be 7-20-83. 4 Q. And what were the circumstances at that time? 5 A. Well, Mr. York came to see me for a second 6 opinion concerning his blood condition. 7 Q. All right, sir. And do you know who referred 8 him to you? 9 A. Yes. His doctor, Dr. Esslinger. 10 Q. Did you take a patient history from Mr. York? 11 A. Yes, I did. 12 Q. And do you have your notes concerning that 13 patient history? 14 A. Yes. 15 Q. Will you relate that patient. history to us 16 that you took from Mr. York? 17: A. Yes. Mr. York had been seen by. Dr. Esslinger, 18 basically because of weakness, and was found 19 to be anemic. He had undergone a bone marrow 20 examination about a month or so before I saw 21 him, and on the basis of that marrow. 22 examination it was thought that he might have 23 what's called a megaloblastic anemia, which is 24 due to a deficiency of vitamins. He had 25 received vitamins but hadn't improved. 12 1 He was then sent to Baylor College 2 of Medicine for evaluation because that's 3 where Dr. Esslinger was in the habit of 4 sending his hematologic patients at that 5 time. Mr. York had been evaluated at the 6 Methodist Hospital, and I spoke with the 7 physician who evaluated him there. And what 8 Mr. York related to me was that the conclusion 9 at Baylor was that he had a so-called pre 10 leukemic syndrome -and that he had a marrow 11 disorder for which there was no specific 12 treatment and, that they would simply like -to 13 follow that illness along to see if it, in 14 fact, did eventually enter into acute 15 leukemia. And I confirmed that by speaking to 16 one of the physicians that saw him at the 17 Methodist Hospital. 18 Mr. York indicated that he was 19 employed as a pipe fitter at that time, and I 20 specifically questioned him about drug 21 exposures, chemical exposures that might or 22 might not have had a role to play in his 23 anemia; and there were no specific things that 24 stood out in his history that were helpful. 25 Q. So you took an occupational history from him? 13 1 A. Yes. 2 Q. Was that something that you routinely did? 3 A. Yes. 4 Q. And what type of questions would you have 5 asked him in that occupational history? 6 A. Well, I would have asked him what, if any, 7 medications he had taken in the preceding 8 three or four months. I asked him had he had 9 any exposure to any unusual chemicals or 10 drugs, and had he had any exposure to 11 radiation, had he had. hepatitis, was there any 12 family history of illnesses of the blood. 13 Q. And what did he tell you in response. to that? 14 A. Well, as I best recall, there were no unusual 15 exposures that had relevance to this illness. 16 Q. Did Mr. York report to you that he had had an 17 occupational exposure to benzene? 18 A. No. 19 Q. Did the history that you took from him, was it 20 such that would have brought out that kind of 21 information? 22 A. I think so, yes. 23 Q. And if he had reported to you an occupational 24 exposure to benzene .or hydrocarbons, would you 25 have noted that in your records? 14 1 A. Yes. 2 Q. And are there any such notations in your 3 records? 4 A. Let me look and see what I said. 5 There are no such notations. 6 Q. Did you run some tests? 7 A. Well, we reviewed the slides of the bone 8 marrow that he had had done elsewhere, and 9 also we repeated his bone marrow study to see 10 if we could further clarify why he was anemic. 11 Q. Just in general terms what is a bone marrow 12 study and what's the purpose of it? 13 A. Well, all the circulating cells that we have 14 are produced in the bone' marrow, and the cells 15 that are present in the bone marrow may look 16 somewhat different than the ones that 17 circulate, but we can recognize them as the 18 precursors of those cells. And when a person 19 has a lack of circulating blood cells, it's 20 sometimes very helpful to look inside the bone 21 marrow and to look at the way the cells are 22 developing in the bone marrow. And many times 23 that will shed light on the cause for the 24 anemia. 25 Q. Where is the bone marrow located, and how do 15 1 you obtain access to the bone marrow for 2 purposes of such studies? 3 A. Well, the bone marrow is located throughout 4 many of the bones, typically centrally, such 5 that it's highly concentrated in the sternum, 6 in the ribs, and in the pelvic bones. As you 7 get further out the arms and legs, the bone 8 marrow gives out. So that when we want to study the bone marrow, we typically. put a 10 needle into the sternum, which is probably the 11 most cellular, area of the body in terms of 12 bone marrow, or into what's called the 13 posterior iliac crest, which is the back part 14 of the hip. Now, there are certain advantages 15 from doing it in the hip area, because you can 16 also do a biopsy with it. 17 Q. And what are you looking for, the number of 18 cells? 19 A. Well, we look for a number of things. We look 20 for the numbers of cells, the total 21 cellularity in the bone marrow. We look for 22 the presence of cells that shouldn't be there, 23 tumor cells. We look for the presence of 24 other things that shouldn't be there, such as 25 fibrosis or scar tissue. We look for the 16 1 presence of organisms that -- such as 2 tuberculosis, for example, or footprints of 3 organisms, such as what we call granulomas, 4 which is a reaction of the bone marrow. We 5 look at bone structure. There are really many 6 things we look at, including the morphology of 7 the cell; that is, what is the character of 8 the cell under the microscope. 9 Q. What are the basic or main cells that are 10 manufactured in the bone marrow? 11 A. Well, most of what is in the bone marrow are 12 what we call myeloid cells, or white cell 13 producing elements. We then have a large 14 number of red cell producing elements, and a 15 smaller number of what are called 16 megakaryocytes, which are the parent cells for 17 platelets. And out in the circulating blood 18 what we see are large numbers of white cells, 19 red cells and platelets. Those are the three 20 general cell types 21 Q. And what are the roles or functions of those 22 different blood cells? 23 A. Well, the red cells carry the oxygen, such 24 that if a person doesn't have enough red cells 25 we say they are anemic. And they may have 17 1 some symptoms of weakness, depending on how 2 anemic they are. 3 The platelets can control bleeding. 4 And a person who lacks platelets tends to 5 bleed easily. 6 The white cells -- and there are 7 varying number of types of white cells -- in 8 general, they fight bacterial and viral 9 infections, depending on what cell type you 10 are talking about. 11 Q. When did you do your examination of Mr. York's 12 bone marrow? 13 A. I would have to look that up to see what day: 14 that was done. Bear with me. He has had more 15 than one bone marrow. I did one on 7-20-8:3. 16 Q. And what did your bone marrow by examination 17 reveal? 18 A. Well -19 MR. MORGAN: Excuse me. Excuse me. 20 Are we -- I thought you were referring to the 21 bone marrow review he did of Methodist 22 Hospital? Are you asking for one that he 23 performed? 24 MR. DILLARD: I think that was my 25 question. 18 1 MR. MORGAN: That he performed? 2 MR. DILLARD: Correct. 3 MR. MORGAN: Okay. 4 A. Yes, I performed one on 7-20-83. And at that 5 time his hemoglobin was 7.3, with the normal 6 being about 14; his platelet count was 12,000, 7 with the normal being around 200,000; and his 8 white cell count was about 4,100, with a 9 reduced number of what we call neutrophils, 10 which are the cells that fight infection. And 11 essentially what the marrow showed were a 12 number of abnormalities: One. is that there 13 wasn't enough in the way of cellularity in, the 14 marrow, the marrow was what we call 15 hypoplastic or hypocellular: There was a 16 reduction in the total number of cells. 17 In addition, when we stained the 18 cell for iron, we saw a few of what were. 19 called ringed sideroblasts, which are an 20 abnormal accumulation of iron in the. red cells 21 themselves. And we also saw the fact that the 22 red cells look slightly abnormal in 23 morphology, the red cell precursors. Those 24 were the striking things that we saw. 25 Q. On the basis of that and your examination, did 19 1 you ultimately arrive at a diagnosis of 2 Mr. York's condition? 3 A. Well, we thought that he had aplastic anemia. 4 This was especially true when we reviewed the 5 bone marrow biopsy. 6 You see, when we do a bone marrow, 7 what happens is we remove a small amount of 8 bone marrow and put it on a slide. And that 9 we can look at right away. We also take a. 10 little biopsy, or a snip of the bone marrow, 11 that then goes to pathology and is sectioned 12 the following day. And sometimes we see more 13 accurate estimation of the total cellularity 14 from the biopsy than we do from what we call., 15 the aspirate, which is the type -- part of 16 what we look at right away. 17 And when we looked at the total 18 picture of this bone marrow, I felt that the 19 problem was more aplasia, that is lack of 20 cells, than dysplasia, which is abnormal cell 21 production. 22 Q. What is aplastic anemia? 23 A. Well, aplastic anemia is a relatively rare 24 illness in which the bone marrow becomes 25 empty. And generally there are no malignant 20 1 cells there. We just see a lack of cell 2 production of all of the cell lines. 3 And when that occurs, because of the 4 fact that blood cells live such a short time, 5 the blood count in the peripheral blood, the 6 circulating blood, drops very abruptly. 7 Q. Is it a cancer? 8 A. Well, it is not a cancer, no. We don't think 9 of aplastic anemia as a cancer. 10 Q. Or is it a leukemia? 11 A. Well, it is not exactly a leukemia. It is a 12 lack of production of cells. 13 Q. You mentioned it was a rare condition? 14 A. Yes. 15 Q. Can you give us some frame of reference, how 16 rare? 17 A. Well, the general dogma in hematology is that 18 in the United States there are about two cases 19 or so, two to three cases per million per 20 year. 21 So, for example, if you say Houston 22 has, let's say, 3 million people, we might 23 expect to see six patients a year in the city 24 of Houston with aplastic anemia. 25 Q. Does it afflict both sexes? 21 1 A. Yes. 2 Q. Does it afflict essentially all age groups? 3 A. Yes. 4 Q. I mean, children, do they get it on 5 A. It can affect children, yes. 6 Q. And young adults and adults? 7 A. Yes. It would affect all ages and both sexes. 8 Q. Is it a disease or is -- is it a disease or a 9 condition? Which is the proper term? 10 A. I would say a condition would be the better. 11 Q. Is it a condition that crosses different 12 socioeconomic lines? 13 A. Yes. 14 Q. How about countries? Are there certain 15 countries in the world where it just doesn't 16 exist for some reason? 17 A. Well, the incidence will vary. For example, 18 it's found in much higher incidence in the 19 oriental countries, such as Japan and china 20 The incidence varies from country to country. 21 But in the United States it's around two or 22 three per million per year. 23 Q. And does it afflict all races or ethnic 24 origins? 25 A. Yes, it can affect all races. 22 1 Q. And would it afflict all populations, all 2 occupations, for example? 3 A. Well, I'm not sure I understand that question 4 exactly. 5 Q. Do you know of any occupation that would, for 6 some reason, be immune from contracting this 7 condition? 8 A. No. 9 Q. From July the 20th, when you did the bone 10 marrow examination, what's the next step you 11 took in the care of Mr. York? 12 A. Well, generally,. when one has a patient with 13 aplastic anemia, there are two primary avenues 14 that you go down. And that was true in 1983 15 when I saw him -- it really is still true 16 today in 1998. And we either try to go toward 17 bone marrow transplantation, or we try to use 18 drugs to remedy the situation. 19 -So we did what's called HLA typing, 20 which is a match, to see if there was a family 21 match for the possibility of a bone marrow ., 22 transplant. Marrow transplants can be done 23 outside-of family matches; but in 1983, and 24 even today, that was a very hazardous 25 undertaking. And, in fact, he did not have a 23 1 match. so it did not look like there was a 2 good family match to do a marrow-transplant. 3 The second alternative at that time, 4 and still today, was the use of a drug called 5 ATG, or anti-thymocyte globulin, which was 6 made by the Upjohn Company, or ATGAM, 7 A-T-G-A-M, was its trade name. And that 8 particular drug had been used successfully in 9 reversing the course of aplastic anemia. 10 Q. And is that the course of treatment that you 11 followed in his case? 12 A. And that is the course we followed. We gave 13 him a course of ATGAM, which is given 14 intravenously in the hospital over several 15 days. And there are various protocols for the 16 treatment with that drug, various-dose levels 17 to give; but we gave him a particular dose 18 over about six days in the hospital. 19 Q. How does the ATG therapy work? What are- the 20 mechanics of how it works in the body? 21 A. Well, to describe what this drug is, 22 lymphocytes, or more specifically lymphocytes 23 from the thymus which sits up in the chest, 24 are injected into a horse, and the horse makes 25 antibodies or immunity against these 24 1 lymphocytes, and then you harvest the plasma 2 from the horse. And it can also be made from 3 rabbits and other animals, but this material 4 was from a horse. You harvest those 5 antibodies, and they will destroy 6 T-lymphocytes when injected into the body. 7 They hone in on these lymphocytes and damage 8 them. 9 And it's thought that in aplastic 10 anemia, one of the reasons that that illness 11 is sustained is that shifts occur in the 12 population of T-lymphocytes and in the 13 substances they produce that tend to suppress 14 the bone marrow. That is to .say,. there is 15 nothing the matter with the environment of the 16 bone marrow, but somehow the lymphocytes are 17 preventing growth. And if you whack them with 18 a hammer by giving them a large amount of 19 anti-thymocyte globulin, sometimes you cause a 20 reversal of the process and you allow the bone 21 marrow to recover. And at that time, 22 depending on the dose you used and the 23 duration, people were claiming about a 50 24 percent response rate in patients with 25 aplastic anemia. 25 1 And so, in fact, that's what we did, 2 we gave him a course of this material. 3 Q. Was that done in the hospital or as an 4 outpatient? 5 A. It was done in the hospital, because there can 6 be some fierce side effects of that drug. It 7 produces a serum sickness-like reaction, and 8 you can get sudden anaphylactic shock and 9 death; you can get a lot of edema around the 10 body; you can get high fevers; drops in blood 11 pressure. And so you want to be very cautious 12 about giving that drug. And you like to drip 13 it in slowly over several hours, and you have 14 the precaution of certain medicines, such as 15 epinephrin and steroids, in case the person 16 has an acute severe reaction. We also 17 pretreat the patients with corticosteroids to 18 try to reduce the severity of the reactions. 19 And so that all entailed coming in the 20 hospital for several days. 21 Q. Do you have your discharge summary from that 22 hospitalization? 23 A. I'm sure I do. Let's see. 24 Q. I do, if you don't. I was just going to 25 A. I think I might have. Let me just see here. 26 1 Yes, I am looking at it right now. 2 Q. All right. And what's the date on that? 3 A. The date is, date of admission, 8-2-83; date 4 of discharge, 8-9-83. 5 Q. I noted under the history there on this 6 hospital discharge that you, again, make 7 reference to the employment history of 8 Mr. York. Is that correct? A. I said history indicated patient is employed 10 as a pipe fitter. 11 Q. okay. 12 A. And I also said that the patient had not been 13 taking any medications on a regular. basis and 14 that the past medical history was. 15 unremarkable. 16 Q. I notice that it says, no etiologic factors 17 for the aplastic anemia were established. 18 Now, what does that mean? 19 A. I'm looking to see where that was that I. said 20 that. Ah, I see. Yes, no etiologic factors 21 for the aplastic anemia were established. 22 Well, generally, when we look at 23 patients who have aplastic anemia, about 7:5 24 percent of the time we don't discover any 25 etiology; and we call that idiopathic, meaning 27 1 of itself. About 10 percent of the time we 2 find a drug or a chemical that might 3 conceivably be causative, an antibiotic or an 4 anti-inflammatory drug, for example. And 5 probably 8 or 10 percent of the time we find a 6 history of hepatitis. Certain kinds of 7 hepatitis may precede aplastic anemia. 8 So what we are looking for are a 9 history of chemical or drug exposures that 10 might provide a clue as to why the aplastic 11 anemia developed, or looking for a history of 12 hepatitis. Those are the things that we 13 some of the things we are after. And, of 14 course, a history of radiation exposure, which 15 would be unusual. 16 Q. Now., did Mr. York continue under your care 17 after he was discharged in August of 1983? 18 A. Yes. Because what happens when you give a 19 person a course of anti-thymocyte globulin is 20 there typically is no immediate benefit. That 21 is to say, you don't give the. course of 22 treatment and the next week everything is 23 wonderful. It usually takes weeks or months. 24 to get the full effect of that drug. And so 25 what we did is- continued to follow him. We 28 1 placed him on male hormones, or androgens, 2 which can also stimulate the bone marrow and 3 sometimes will help to get a faster 4 improvement after ATG. And we initially had 5 treated him with corticosteroids, another type 6 of hormone. And we proceeded to follow him 7 over several months. 8 Q. Did you do another bone marrow on him? 9 A. Yes. 10 Q. And when was that? 11 A. We did one on 9-30-83.. 12 Q. Was he admitted to the hospital for that? 13 A. No. 14 Q. Done on an outpatient basis? 15 A. That would have been done on an outpatient 16 basis. 17 Q. Do you have your history and physical 18 examination records from that procedure, or 19 from that trip to the hospital? 20 A. Well, that-s. done in the office, in other 21 words; and so .I. would just have my report from 22 that. 23 Q. The reason I asked is I am looking at, in the 24 records of your office that we have 25 subpoenaed, a history and physical examination 29 1 form that's dated 9-30-83. 2 A. Yes. 3 Q. Okay.' Do you have that in your records here? 4 A. Probably so. Let me see if I can backtrack to 5 find that. 6 I have an admission 9-29-83, and a 7 discharge 9-30-83. 8 Q. All right. And, again, in the -- under the 9 category of present illness, if you would just 10 read the first couple of sentences in the 11 second paragraph. 12 A. I said, the history indicates that a diagnosis 13 of aplastic anemia was established about four 14 months ago. The patient had no apparent 15 etiology for this illness and was taking no 16 drugs at the time of the diagnosis. Attempts 17 were made to do HLA typing between the patient 18 and his sister in preparation for a marrow 19 transplant, but there was no compatibility 20 seen. The patient was then treated with a 21 combination of anti-lymphocyte globulin. 22 Following treatment with the anti-lymphocyte 23 globulin, there was, again, no significant 24 improvement, and he was placed on long-term 25 therapy with androgens, including 30 1 Deca-Durabolin and Halotestin. 2 Q. All right. And you did another bone marrow 3 examination at that time. What did that 4 reveal? 5 A. Well, that showed much more in the way of 6 cellularity. It was more cellular. In other 7 words, it looked like the cells were coming 8 back into the bone marrow. 9 Q. In response to the ATG therapy? 10 A. Yes. Generally you expect to see a 11 ,significant response in about three, three to 12 four months afterwards. The complete response 13 to this drug may not occur for a long period 14 of time, for many months. 15 Q. When did you next see him after September 30 16 of 1983? 17 A. Well, we -- after September 30? Let me see my 18 office notes. . 19 We saw him on-10-20-83. 20 Q. And what was the purpose of that visit? 21 A. Just for a continued follow-up. And what we 22 saw at that time was his platelet count had 23 started to improve a bit. 24 And then we saw him the following 25 month on 11-16-83, and at that point the 31 1 platelets were continuing to improve, but so 2 was his hemoglobin, the red blood cell count 3 was improving. 4 And we continued to see him up until 5 10-25-1984. And at that time his hemoglobin 6 had recovered to normal. It was 15.3. And 7 his platelet count at that time was 55,000, 8 which was not normal, but was a very 9 satisfactory improvement over the initial 10 values. 11 Q. Between November of '83, I think you said 12 November 16, 1983 -13 A. Yes. 14 Q. -- and October of 1984, did you have occasion 15 to see him? 16 A. Yes. Let's see. I have my office notes 17 here. 18 Tell me again those dates you are 19 talking about. 20 Q. November 16, '83 and October of '84. 21 A. Well, I -saw him in January of '84, in April of 22 '84, and then for the last time on 10-25-84. 23 Q. So you saw him three times, then, in 1984? 24 A. Yes. 25 Q. And did his condition improve or progress 32 1 throughout those visits? 2 A. Well, he showed steady improvement. In other 3 words, what happened first was he lost his 4 transfusion requirements. He had such a 5 severe anemia, he needed blood transfusions. 6 And first the anemia stabilized to the point 7 where he didn't need transfusions; and then 8 the hemoglobin, which is a reflection of the 9 red blood cell count, returned into the normal 10 range. And at that point that was the last 11 time we saw him. 12 Q. And what was that date, again? 13 A. That was 10-24-84 -- yes, 10-24-84.10-25-84. 14 Q. Was he discharged from your care at that time? 15 A: Well, I suggested at that time that he see us 16 again in about six months. 17 Q. And did he return? 18 A. No, I didn't see him. 19 Q. Was he taking any medication that you had 20 prescribed as of the time you last saw him? 21 A. No. We suggested that he stop all of his 22 medications at that point. And, 23 parenthetically, I had relayed this material 24 to Dr. Esslinger, who was continuing to follow 25 the patient. 33 1 Q. But the ATG therapy that he received was only 2 in the summer of '83? 3 A. Yes. Generally, that drug, it's a one-time 4 shot. You can try it a second time, but it 5 becomes very life threatening to give it a 6 second occasion. You can also go to different 7 species. This was horse anti-thymocyte 8 globulin; and if a person doesn't respond, you 9 can try rabbit anti-thymocyte globulin, which 10 some people feel is a little more potent. But 11 it's very, very hazardous to come back and try 12 a second course of this drug again. You can 13 get very fierce reactions. 14 Q. How would you characterize his response to the 15 ATG therapy? 16 A. Well, he had a superb response. 17 Q. Is it your understanding that he returned 'to 18 his duties as a pipe fitter? 19 A. I don't know what he did after I saw him. In 20 other words, I saw him at the last time in 21 1984, and what happened subsequently I don't 22 know. 23 Q. When you last saw him in '84, do you know if 24 he was back a-t work at that time? 25 A. I don't recall. 34 1 Q. Are you familiar with the term "secondary 2 aplastic anemia" and "idiopathic aplastic 3 anemia"? 4 A. Yes. 5 Q. What do those terms mean? 6 A. Well, as I mentioned earlier, most patient's 7 with aplastic anemia are classified as 8 idiopathic, meaning we don't identify a 9 specific etiology. Obviously, there may be 10 one; but we can't identify it. And so we 11 classify those patients as having so-called 12 idiopathic aplastic anemia. 13 In other circumstances we think we 14 know the cause. That is to say, a person may 15 have had an episode of hepatitis immediately 16 preceding the aplastic anemia, and we know 17 that there is a good relationship there and we 18 may suspect that hepatitis was the causative 19 agent. We also may obtain a history of 20 certain drugs that have been strongly 21 associated with aplastic anemia that were 22 taken, let's say, in the preceding- two, three 23 or four months prior to the illness. And, 24 again, by inferring the fact that we know 25 large number of people may have gotten 35 1 aplastic anemia from that drug, we say that 2 that's quite possible that that was the 3 etiology in the particular case you are 4 looking at. So that we use our clinical 5 judgment to assign a cause. 6 Q. What type of drugs have been associated with 7 aplastic anemia? 8 A. Well, for many years the most frequently 9 reported association was with an antibiotic 10 called chloromycetin or chloramphenicol. That 11 antibiotic is still available, but not used as 12 frequently today. And I have seen several 13 patients with aplastic anemia from 14 chloramphenicol, I think. 15 Also, the phenylbutazone, or 16 Butazolidin was reported as causing aplastic 17 anemia, and that drug was taken off the 18 market. 19 Also Gold injections, which have 20 been used for rheumatoid arthritis, have been 21 thought to cause aplastic anemia. And as I 22 say, I have seen patients who have had 23 aplastic anemia in which we thought Gold was 24 the etiology and also in which I thought 25 phenylbutazone was the etiology. 36 1 Sulfonamides is another drug of 2 sulfa antibiotics that occasionally has caused 3 aplastic anemia. And there have been isolated 4 reports on other drugs, such as Allopurinol or 5 Colchicine, which are used for gout. 6 So, actually, a large number of 7 drugs have been reported to cause aplastic 8 anemia. But over the years the ones we think 9 of immediately are chloramphenicol and 10 phenylbutazone because the bulk of the early 11 case reports dealt with those two drugs. 12 Q. And has the chemical benzene been associated 13 with aplastic anemia in some individuals? 14 A. Yes. 15 Q. Are you generally familiar with the literature 16 on benzene induced aplastic anemia? 17 A. Yes. 18 Q. In an individual who has been exposed to 19 benzene and has aplastic anemia secondary to 20 that exposure, what are the levels of benzene 21 exposure that are thought to be required in 22 order to do that? 23 A. Well, very high levels. In other words, we 24 sometimes talk about part per million years. 25 Like you talk about smokers have pack per year 37 1 smoking histories. And in the case of 2 hematologic diseases consequent to benzene, 3 many of the epidemiologicstudies suggest that 4 you need very high total concentrations, 5 greater than a hundred part per million years 6 of exposure, usually in the range of 200 part 7 per million years. 8 Q. What is a part per million year? 9 A. Well, that means that you've been exposed to 10 that many -- you have a year's worth of 11 exposure. In other words, it's like you were 12 exposed every day to 200 part per million for 13 365 days. That gave you a part per million 14 year. In other words, that gave you that many 15 part per million years. So it's a cumulative 16 exposure. 17 Q. In an individual who has very high exposure to 18 benzene and who develops aplastic anemia, do 19 you have an opinion as to the time lag or 20 latency period between that exposure and the 21 onset of the aplastic anemia? 22 A: Well, generally, we think of the hematologic 23 effects of benzene as quite similar to those 24 that we see with chemotherapy. In fact, 25 benzene was originally used as a chemotherapy 38 1 drug; and it's toxicities to the marrow are 2 very similar to what he have even today with 3 our chemotherapy drugs. And we generally 4 believe that there -- after a major exposure 5 or, let's say, the last major exposure, we 6 think the bulk of the leukemias or aplastic 7 anemias occur within a few years. And 8 generally by 10 or 11 years after the 9 exposure, you are back to baseline in terms of 10 incidents. 11 Q. Are these drugs; these medications that you 12 referred to a few moments ago, thought to be 13 significant factors in aplastic anemia today? 14 A. Yes. I must say, even though chloramphenicol 15 is still used around the world, it rarely is 16 used in the United States. And I have not 17 seen a chloramphenicol induced aplastic anemia 18 for many years. I have seen an Allopurinol 19 induced aplasia. That's probably the most 20 recent one that I saw that I thought a drug 21 was responsible. But chloramphenicol is not 22 very widely used anymore, and phenylbutazone 23 has been taken off the market, so that one 24 wouldn't expect to see that problem here in 25 this country. 39 1 Q. Have you had occasion to treat a patient with 2 benzene induced or benzene caused aplastic 3 anemia? 4 A. No, not to my knowledge. 5 Q. In the literature is benzene considered to be 6 a significant factor today in terms of causing 7 aplastic anemia? 8 A. No. It would be considered to be 9 indistinguishable from baseline. In other 10 words, most studies of aplastic anemia, 11 looking at large numbers of patients with this 12 illness, don't list any cases from benzene. 13 Q. We were taking a look at your records as we 14 were about to start the deposition a few 15 moments ago. 16 Have you had occasion to see 17 Mr. York since October 25th of 1984? 18 A. Yes. 19 Q. And when was that? 20 A. That was on January the 15th of this year. 21 Q. And what was the purpose of that? 22 A. Well, Mr. York called and said that he would 23 like me to see him as a patient and reevaluate 24 his situation. 25 Q. Did you examine him at that time? 40 1 A. 2 Q. And what did that examination consist of? 3 A. Well, I took a history of what had happened to 4 him since the last time I saw him in 1984 and 5 I examined him briefly on physical examination 6 and we did some laboratory work. 7 Q. And what did the physical examination consist 8 of? 9 A. I examined his abdomen to see if I could feel 10 if his spleen or liver were enlarged or if he 11 had any swollen lymph nodes. 12 Q. What did that reveal? 13 A. The physical exam were normal. 14 Q. And what lab work did you run? 15 A. We ran a complete blood count and a routine 16 chemistry panel. 17 Q. And do you have those results today? 18 A. Yes. 19 Q. Okay. We are going to want to get a copy of 20 those before we leave. But, if you would, 21 summarize for us the results from the 22 laboratory analysis. 23 A. Well, in terms of his blood counts, his blood 24 counts were perfectly normal. He had a 25 hemoglobin of 16.1; a platelet count of 41 1 215,000; and a white cell count of 5,500; and 2 the differential cell count, meaning the 3 distribution of white cells that he had, was 4 normal. So his -- and his blood looked normal 5 under the microscope. So essentially he had a 6 normal blood count. 7 In terms of the chemistries that we 8 obtained, these consist of a variety of 9 things, including blood sugar and calcium 10 levels and protein levels and so on. And the 11 only notable abnormality -- abnormalities 12 detected were that his cholesterol level was a 13 little bit elevated at 225, and the 14 recommended normal is up to 200; and a liver 15 function test, the SGPT, was elevated at 9.5, 16 and the upper limits of normal in this 17 laboratory are 50. 18 Q. By history, did you obtain any additional 19 information from him that you had not gathered 20 before when you had seen him 13, 14 years 21 earlier? 22 A. Yes, there were several pieces of history. He 23 indicated that in the ensuing years -- and 24 I've forgotten which year this was -- he had 25 some trouble with coronary artery disease and 42 1 required an angioplasty procedure on his 2 heart. He also indicated that he had chronic 3 bursitis with his right shoulder and had 4 required steroid injections on several 5 occasions for the shoulder. He also indicated 6 that he had chronic hepatitis, and that he had 7 had a liver biopsy -- and I believe he said 8 the most recent biopsy was about two years 9 ago -- and that he had seen a 10 gastroenterologist for the liver situation. 11 Those were the things that stand out -- oh, 12 and that he had changed occupations, and that 13 he was working in an attorney's office now. 14 Q. As far as his blood counts were concerned, you 15 said the platelet count was what, 215,000? 16 A. 215,000, yes. 17 Q. And that that is a normal platelet count? 18 A. Yes. Generally, the normal platelet count, 19 the lower limit of normal is usually given as 20 150,000, and the usual normal range is, say, 21 150,000 to about 350,000. 22 Q. Did you evaluate the appearance of the 23 platelets? 24 A. Yes. We stained a slide and I looked at it 25 under the microscope and I thought it was 43 1 within the range of normal. 2 Q. How about the size of his platelets, was there 3 anything abnormal about that? 4 A. Nothing striking on examination of the slide. 5 Q. Was there any evidence that he had aplastic 6 anemia? 7 A. Not now, no. 8 Q. To your knowledge, between the time that you 9 had last seen him in 1984 and you saw him 10 again here recently in 1998, had he had any 11 relapse or recurrence of aplastic anemia? 12 A. No. He indicated that his blood counts had 13 been fine during that period. 14 Q. I think the record will pick up what you said, 15 but there was a page right about that time. 16 A. All right. Okay. I asked him about his blood 17 counts, and he indicated that his blood counts 18 had been essentially normal. in the ensuing 19 years since I saw him. 20 Q. Are there other patients that you have had 21 occasion to follow for this long a period of 22 time that have had aplastic anemia and 23 received-the ATG therapy? 24 A. Yes. 25 Q. What kind of a track record do you have with 44 1 that? 2 A. Well, you know, it's interesting. If you look 3 at the literature on the subject, it says that 4 perhaps the response rate is 50 to 60 5 percent. I guess I may have a selected 6 population. I would say, in my experience, it 7 has been closer to about 70 or 80 percent have 8 had good responses to it. So that, obviously, 9 some people don't respond, and I suppose if I 10 treated 5,000 patients I might arrive at the 11 60 percent figure. But for the numbers that I 12 have treated with it, I have had better than a 13 50 to 60 percent response rate to it. 14 Q. And Mr. York was one who did respond? 15 A. Yes. 16 Q. For those that do respond to it 17 A. Yes. 18 Q. -- like Mr. York, have you had any of them 19 relapse 20 A. No, I have had no relapses. 21 Q. Based upon what you know about Mr. York's case 22 and the opportunity that you have had to 23 follow him over this period of time, I want to 24 ask you if you have any opinions about his 25 prognosis from the standpoint of his aplastic 45 1 anemia. 2 Is there any reason that you have, 3 based upon what you know and what you have: 4 seen, to believe that he will have a relapse 5 in the future? 6 A. Well, I don't see anything about his blood. 7 counts now that would suggest that he would 8 have a relapse. 9 Q. And in terms of reasonable medical 10 probability, what would your opinion be? 11 A. Well, if you look at the large populations of 12 people that have been treated for aplastic 13 anemia, and treated successfully, there is an 14 increased incidence of hematologic abnormality 15 over the ensuing years. 16 And, for example, I can think of in 17 my files I have one study of 500 and some odd 18 patients followed longitudinally with aplastic 19 anemia, and I believe about -- and don't hold 20 me to the exact numbers -- but about, say, 19 21 developed a peculiar condition we call PNH, 22 which is where the red cells develop abnormal 23 membranes, and they undergo breakdown very 24 easily. 25 Also, in that same group about 11 of 46 1 those patients later developed myelodysplasia; 2 and I believe in about five of those patients 3 they went on to develop acute leukemia. 4 And we generally think that in 5 people who have had aplastic anemia there is a 6 slight increased incidence over the general 7 population of further hematologic diseases, 8 such as leukemia or PNH. In other words, 9 these numbers would come to just a few 10 percent; but a few percent is much higher than 11 what we see in the general population. 12 Q. Given that it's a small percent, in terms of 13 reasonable medical probability, what's the 14 future outlook for Mr. York? 15 A. Well, I think in reasonable medical 16 probability his blood counts will remain 17 normal. is Q. You mentioned that he reported having 19 bursitis 20 A. Yes. 21 Q. -- in his right shoulder? 22 A. Yes. 23 Q. For which he was receiving injections? 24 A. Yes. 25 Q. Do you know what they were -- it was a 47 1 steroid? 2 A. He said he had had steroid -- several steroid 3 injections in his shoulder. 4 Q. And did he indicate to you when the bursitis 5 problem started? 6 A. He may have, and I don't recall exactly what 7 he said about that in terms of what he's told 8 me. 9 Q. Had he reported a bursitis problem to you at 10 any time back in '83, '84 time frame? 11 A. Well, one of the expected side effects of 12 anti-thymocyte globulin is a diffuse 13 inflammation of all of the joints. And after 14 we gave him -- gave it to him, he had that. 15 In other words, he had swelling of his knees, 16 swelling of his elbows, and he had generalized 17 inflammation of his joints back in 1983. And 18 that subsided. Generally it subsides about 19 two or three weeks after you have given the 20 drug. It seems to peak at about a week or two 21 after they leave the hospital, and then starts 22 to gradually subside. 23 Q. And did it subside in his case? 24 A. Yes. 25 Q. Do you have an opinion, again in terms of 48 1 reasonable medical probability, as to whether 2 there is any link between that ATG therapy 3 back in 1983 and the bursitis that he is 4 reporting in his right shoulder now? 5 A. I would doubt it, because this is a single 6 joint problem. And, of course, bursitis in 7 the shoulders is a very common problem. And I 8 would think that if it was, let's say, drug 9 related, I wouldn't know why it would simply 10 be in one joint and not multiple joints. I 11 think that would probably be very unusual. So 12 I would say, in my opinion, it would not be 13 related to the ATG. 14 Q. And would the passage of time be of 15 significance to you, between the week or two 16 that you said where the peak occurs, if it has 17 such effect? 18 A. Well, generally, the inflamed joints that one 19 sees after ATG are an acute phenomenon. I 20 really have not seen anybody that I have 21 followed that I have given the drug to who has 22 a chronic illness in their joints from it., So 23 I don't think of that as a toxicity from ATG. 24 Q. Now, this one -- was it one liver test that 25 was elevated? 49 1 A. Yes, of this group. Several of the tests -:hat 2 he had could be considered liver tests. We 3 measure the bilirubin and a test that's called 4 the alkaline phosphatase and the total 5 proteins and so on. And one particular one 6 was elevated, the SGPT. 7 Q. He said he last had a liver biopsy two years 8 ago? 9 A. I believe that's what he told me. 10 Q. Do you have any knowledge of what that showed? 11 A. Only what he told me about it. I don't have 12 the report. 13 Q. Is it your understanding that his hepatitis is 14 in an active phase, or is it a chronic phase, 15 or how would you describe it? 16 A. Well, he indicated to me that-he was told that 17 he has what's called chronic persistent 18 hepatitis as opposed to chronic active 19 hepatitis. In recent years, those two terms, 20 the distinction between them is somewhat 21 blurred. But based on what he told me, the 22 abnormalities in his liver were mild, and his 23 physicians did not recommend specific 24 treatment for the hepatitis. 25 Q. Did he report any history of having been 50 1 diagnosed with cirrhosis? 2 A. No. 3 Q. And are you familiar with the medical 4 literature, as far as the percentage of 5 patients who have chronic hepatitis C who 6 develop cirrhosis? 7 A. Yes. 8 Q. And what does that demonstrate? 9 A. Well, in general terms, the dogma that we use 10 today is that after an acute, episode -- or 11 after an acute episode of hepatitis with 12 hepatitis C, about 80 percent of patients 13 develop some form of a chronic phase of the 14 illness. And in probably around 20 percent of 15 those patients, cirrhosis ultimately develops 16 at an average of about 15 to 20 years out from 17 the date of the episode of hepatitis. 18 Q. Again, looking at Mr. York's situation and 19 knowing what you know about him and the 20 opportunities that you have had to see him, do 21 you have an opinion, in terms of reasonably: 22 medical probability, as to whether or not he 23 would fall in that 20 percent? 24 A. Well, as I say, I haven't seen the liver 25 biopsy. I don't really have any reports from 51 1 his gastroenterologist. I guess I would have 2 the defer to the gastroenterologist on that in 3 terms of an opinion. Although, I must say 4 from what he is telling me the liver biopsy 5 findings are very minimal at this point, and 6 that would certainly be in his favor. 7 Q. In this disease, hepatitis C, if a patient 8 does not develop cirrhosis, does the issue of 9 liver transplant arise? 10 A. No. We typically consider transplant in 11 circumstances where the patient develops 12 cirrhosis or develops liver cancer. And some 13 centers still try to transplant. livers for 14 liver cancer development, if it's a very 15 localized lesion. But, primarily, liver 16 transplants are done for symptoms of liver. 17 failure. 18 Q. All right. We talked earlier about idiopathic 19 versus secondary aplastic anemia. Do you :have 20 an opinion, in terms of reasonable medical 21 probability, as to the cause of Mr. York's 22 aplastic anemia? 23 A. Yes. 24 Q. And what is that? 25 A. I think that in looking at the entire picture, 52 1 I would feel comfortable with the diagnosis of 2 idiopathic aplastic anemia. 3 Q. And why is that? 4 A. Well, in looking at the common etiologies. In 5 other words, we have no evidence that he had 6 hepatitis preceding this illness, we didn't 7 uncover any particular drugs that were at 8 fault, we know that he had an outstanding 9 response to the anti-thymocyte globulin and 10 has persisted in remission. And that suggests 11 to me that this is an -- that his disease was 12 basically an immunologic problem. 13 In the case of chemicals, what we 14 are talking about is basic stem cell damage. 15 In other words, the aplastic anemia that you 16 see from benzene is really a form of 17 myelodysplasia. And I would not think that 18 someone who had that from benzene would get 19 better and have a sustained improvement in 20 their blood count with anti-thymocyte 21 globulin. 22 Q. Which Mr. York did? 23 A. Which Mr. York did. 24 MR. DILLARD: Thank you, sir. 25 That's all I have got right now. 53 1 While they are conferring, could I 2 look at your records? 3 THE WITNESS: Sure. 4 MR. SCOTT: Steve, are you still 5 going? 6 MR. DILLARD: Oh, no. I said I pass 7 the witness. 8 9 EXAMINATION 10 QUESTIONS BY MR. SCOTT: 11 Q. Dr. Natelson, my name is Bob Scott, and I have 12 just a couple of questions. 13 You have used a term "idiopathic," 14 and can you tell us what that means in lay 15 terms? 16 A. In lay terms, it means of itself. We use that 17 term a number of times in medicine. In other 18 words, we talk of idiopathic thrombocytopenic 19 purpura. That's a situation where the 20 platelet count goes down. And we don't know 21 specifically what set the illness off. It's 22 of itself, so to speak, and we don't have a 23 specific etiology. 24 In the case of aplastic anemia, we 25 use that same term "idiopathic," meaning that 54 1 we cannot assign a specific cause to it based 2 on our level of knowledge. 3 Q. You also discussed with Mr. Dillard the 4 platelet size, I think, which you have seen 5 from the blood counts and so -- in examination 6 of Mr. York's marrow or blood. Have you seen any 7 indication that Mr. York has either large 8 or small platelets? 9 A. Well 10 Q. Smaller than normal? 11 A. -- there is a range of normal. In other 12 words, platelets are typically about, oh, they 13 are smaller than what we -- what we see in the 14 blood as small lymphocytes. We usually use 15 the lymphocyte as a reference point. We look 16 at the diameter of the small lymphocyte and 17 then look at the diameter of the platelets and 18 see how close they correlate. And the 19 platelet is about the fifth of the size of a 20 lymphocyte. And there is a normal variation. 21 And in people, for example, who have a high 22 platelet turnover, the platelets are coming 23 out of the bone marrow too fast, they may be 24 large. And there are certain hereditary 25 syndromes in which they are too small. 55 1 And I would say from my looking at 2 his peripheral blood film, I was not impressed 3 that there was anything out of the ordinary in 4 the distribution of his platelet size. 5 Q. You also indicated that you don't think you 6 have seen a case of benzene induced or caused 7 aplastic anemia in your career; is that true? 8 A. That is correct. 9 Q. Do you have an explanation for that, given 10 that, at least as you have indicated, there 11 are reports in the literature of benzene 12 induced aplastic anemia? 13 A. Well, there are certainly reports; but many of 14 these date back in what I would call older 15 literature. Let's say before I was a 16 hematologist. And they date back to the times 17 that we had very little control on benzene 18 exposure in our factories. And with time, 19 control of benzene exposure has improved and 20 the hazards have been recognized and the 21 companies have taken steps to modify that. So 22 in many areas, we haven't seen hematologic 23 problems from benzene for a long, long time. 24 Q. All right. And you have been a hematologist 25 since 1966? 56 1 A. Well, I became a physician in 1966. I would 2 say along around 1968 I began to really become 3 exclusively interested in hematology. 4 MR. SCOTT: I think that's all I 5 have right now. 6 7 EXAMINATION 8 QUESTIONS BY MR. CARRINGTON: 9 Q. Dr. Natelson, my name is M.C. Carrington. I 10 have a couple of additional questions for :you, 11 as well. 12 Earlier I believe it was Mr. Dillard 13 asked you about Mr. York and when he returned. 14 to work. I was looking at your records. 0n 15 his January 17th, '84 visit to you, did he 16 indicate to you that he was back at work 17 full-time? 18 A. Let me just look at my note. '84. Yes, I did 19 make that note. I said, Mr. York continues to 20 do well since his recovery from severe 21 aplastic anemia and is now working on a 22 full-time basis. 23 Q. And I assume you obtained that history or 24 information from Mr. York? 25 A. Yes. 57 1 Q. Certainly, I would assume, based on that, that 2 as far as you were concerned Mr. York was fit 3 to work from your medical standpoint if he was 4 able to do the work from his standpoint? 5 A. Yes. 6 Q. And at any other time after that did you ever 7 suggest to Mr. York that he not return to 8 work? 9 A. No. 10 Q. Did you ever suggest to Mr. York he not return 11 to work as a pipe fitter? 12 A. No. 13 Q. Let me back up. You described a benzene 14 induced aplastic anemia as causing damage Ito 15 the stem cells. 16 A. Yes. 17 Q. Is that an acute type reaction, an acute 18 situation, something that occurs with some 19 degree of a rapid onset? 20 A. Well, exposure to benzene, high levels of 21 benzene, can produce an abrupt aplasia which 22 is temporary. And the patient may have a :Fall 23 in their blood count and may recover from it. 24 But then later on, a few years later, may (jet 25 another fall on their counts as their bone 58 1 marrow becomes further abnormal. So that it 2 may be an acute event, or it may be sort of a 3 subacute event, you might say, from the 4 benzene exposure. 5 Q. Does that vary depending on the amount of 6 exposure? 7 A. Oh, I think in part it depends on the amount 8 of exposure. In other words, the highest 9 exposures would give you the abrupt drop in 10 white blood cell count. And they may produce 11 damage that isn't fully evident for some few 12 years after that exposure. 13 MR. CARRINGTON: That's all the 14 questions I have. Thank you, Doctor. 15 MR. MARTIN: I have no questions. 16 MR. MORGAN: Steve, do you have 17 anything else? 18 MR. DILLARD: No, not until after 19 you question him. 20 MR. MORGAN: Why don't we take a 21 break for a little bit. 22 THE VIDEOGRAPHER: Off the record at 23 2:27 p.m. 24 (Brief recess.) 25 THE VIDEOGRAPHER: Back on the 59 1 record at 2:37 p.m. 2 3 EXAMINATION 4 QUESTIONS BY MR. MORGAN: 5 Q. Dr. Natelson, my name is Glen Morgan, and I 6 represent Mr. York and I have a few questions 7 for you. Some I thought of myself and others 8 were prompted after I got here by some of the 9 questions these other lawyers asked you. 10 will try to be as brief as I can; and if you 11 don't understand any questions I ask you, let 12 me know that so I can try to rephrase it, 13 perhaps repeat a different question so that we 14 can be on the same wavelength. Okay? 15 A. All right. 16 Q. Just to get a little more background 17 information on you. Since we-are here talking 18 about a case where Mr. York alleges exposure 19 to benzene as being a cause of the aplastic: 20 anemia, I need to ask you about your 21 experience in terms of writing articles. 22 Have you ever written an article 23 about the relationship between benzene and 24 aplastic anemia? 25 A. Not specifically. I think I did write an 60 1 article on a review of aplastic anemia on one 2 occasion for our St. Joseph Hospital Journal, 3 but not specifically in relation to benzene. 4 Q. All right. What about have you presented any 5 type of lecture or other type of presentation 6 to either a peer group or others concerning 7 benzene and the cause or relationship between 8 that chemical and aplastic anemia? 9 A. Not specifically benzene. I have talked about 10 aplastic anemia, but not specifically in 11 relation to benzene as an isolated event. 12 Q. Have you ever conducted any studies concerning 13 the exposure to benzene in resulting aplastic 14 anemia? 15 A. No. 16 Q. The relationship between benzene and aplastic 17 anemia-has -been known for many years, hasn't 18 it? 19 A. Yes. 20 Q. And benzene, I think you would agree, is 21 clearly established as a causative factor in . 22 aplastic anemia? 23 A. Yes. 24 Q. The literature -- and you mentioned earlier 25 something about the older literature -- dates 61 1 back to the late 1800s and early 1900s, 2 describing this relationship, doesn't it? 3 A. Correct. 4 Q. You were in medical school, I believe you 5 said, in the '60s? 6 A. Yes, 1962 to 166. 7 Q. And, of course, 60 or 70 years after this 8 older literature we're talking about, I assume 9 that they were still recording that 10 relationship in the medical books that you 11 were studying from? 12 A. Yes. 13 Q. Your textbooks at the time had that 14. information in it? 15 A. Yes. 16 Q. And I'm sure, again, that you learned it 17 there, and I guess you continued throughout 18 your internship, et cetera,. to .be aware of 19 that relationship? 20 A. Yes. 21 Q. Now, you mentioned something about being a 22 hematologist. Are you an immunologist? 23 A. No. 24 Q. Are you an occupational medicine specialist? 25 A. No. 62 1 Q. What is the difference between immunology and 2 hematology? 3 A. Well, immunology has to do with the study of 4 the functions of the immune system 5 specifically. And it may have to do with the 6 cytokines and materials that lymphocytes 7 make. It may have to do with the defense 8 system the body has against foreign antigens. 9 It basically has to do with your immune 10 system. 11 Q. Do you find immunologists involved in the 12 treatment of aplastic anemia? 13 A. Not commonly, no. 14 Q. And then occupational medicine specialist, how 15 does that differ from hematology? 16' A. Well, an occupational medicine specialist 17 might be seeing a variety of occupational 18 injuries, from fractures and sore backs to 19 skin rashes to blood related problems. A 20 hematologist is more specific in the area of 21 blood related problems. 22 Q. All right, sir. And I take it you are not an 23 industrial hygienist? 24 A. No. 25 Q. You don't have any training in that area? 63 1 A. No. 2 Q. Also, I assume that you are not trained in the 3 treatment of liver disorders. You mentioned 4 earlier that would be -- and you would refer 5 to or defer to a gastroenterologist for that? 6 A. Well, it depends on what you mean by trained. 7 I'm a board certified internist, general 8 internist; and in our training, liver disease 9 is a common medical problem. I personally, in 10 my training, did about 60 or 70 liver 11 biopsies. And so I consider myself somewhat 12 knowledgeable in terms of liver disease, but I 13 don't specialize in their treatment. 14 Q. Well, I guess perhaps my phraseology was a 15 little wrong. While you may have received 16 training in a lot of areas, you basically 17 specialize your practice to the practice of 18 hematology? 19 A. Yes. 20 Q. And you have done that for how many years now? 21 A. Well, since about 1969. 22 Q. All right. So for the last almost 30 years 23 you have been treating people who have blood 24 disorders, among those of which would be 25 aplastic anemia? 64 1 A. Correct. 2 Q. Now, do you know what a pipe fitter does for a 3 living? 4 A. Not entirely. 5 Q. Do you know -- have you ever been to the Mobil 6 facility in Beaumont? 7 A. No. 8 Q. Have you ever been to the Mobil chemical 9 facility in Beaumont? 10 A. No. 11 Q. Were you ever at the -- well, just let me list 12 some of these plant sites that are involved in 13 this case and see if you have ever been 14 there. I will just list them all, and if I 15 come to one you have actually been to the 16 premises, well, then stop me. 17 Either Gulf or Gulf Chemical, Texaco 18 or Texaco Chemical, or Jefferson Chemical, 19 Fina, or might be American PetroFina, 20 Velsicol, or Union 76. Any of those 21 facilities? 22 A. No. 23 Q. Have you ever requested documents from any of 24 those facilities I have just mentioned 25 concerning the benzene or the presence of 65 1 benzene or the aromatic hydrocarbons on their 2 premises? 3 A. No. 4 Q. In Mr. York's case, from the occupational 5 history standpoint, you realized he was a pipe 6 fitter. Did you request any work records from 7 him or from any of his employers to show what 8 he may have been doing for a living? 9 A. No. 10 Q. You mentioned that this was a referral from 11 Dr. Esslinger? 12 A. Yes. 13 Q. What type of relationship did you. have with 14 Dr.' Esslinger back at that time, that was in 15 the early '80s? 16 A. Well, the relationship was like this, 17 Dr. Esslinger was in the habit of referring 18 his hematology patients to Dr. Robert Heddig, 19 who died a number of years ago, who was the 20 chairman of hematology at Baylor. And as a 21 fellow in hematology, I would often see these 22 patients with Dr. Heddig. And I assume that's 23 how Dr. Esslinger knew my name, and he 24 suggested that I see this patient. But I have 25 never personally met him or had any specific 66 1 dealings with him. 2 Q. Are you aware that Dr. Esslinger was, at one 3 time, the company doctor for Mobil? 4 A. No. 5 Q. You mentioned -- you mentioned that you have 6 been practicing hematology for almost 30 7 years; and as I understand, you've been 8 testifying in cases involving benzene exposure 9 for almost 20 years; is that right? 10 A. No. I would think that that's probably not 11 true. I don't know how many years I have 12 offered testimony in -- I have given testimony 13 on a variety of subjects In the case of 14 benzene, I can't tell you when I first gave 15 testimony in benzene; but it certainly wasn't 16 20 years ago. 17 Q. Do you recall testifying that your testimony 18 in the different types of trials could date as 19 long as 20 years? 20 A. Correct. 21 Q. All right. 22 A. But those trials may be anything from 23 subdivision suits to malpractice suits. And 24 most of those from 20 years ago had nothing 25 whatsoever to do with benzene. 67 1 Q. Well, you are typically retained as an expert 2 witness approximately six to eight times per 3 year; is that correct? 4 A. That would be probably true, yes. 5 Q. And as I understand it, the majority of the 6 cases in which you are consulted, you consult 7 on behalf of the defense? 8 A. The majority, yes. 9 Q. For instance, in this case, who first 10 contacted you about giving your testimony in 11 this case? 12 A. It would be Mr. Dillard. 13 Q. Is this the first time that you have had 14 occasion to work with Mr. Dillard on a case? 15 A. No. 16 Q. On how many other occasions have you dealt 17 with Mr. Dillard? 18 A. I can't tell you exactly. I recall a case 19 that, I believe, the patient's name was Morin, 20 M-O-R-I-N; and that would be what comes to 21 mind in terms of dealing with Mr. Dillard. 22 Q. Have you ever met Mr. Dillard outside the 23 office setting? 24 A. Outside my office or his office? 25 Q. Yes. 68 1 A. Yes, I have been to his office, I believe, on 2 one occasion. 3 Q. Have you ever met him outside his office or 4 your office? 5 A. No. 6 Q. Have you ever testified in trial for 7 Mr. Dillard? 8 A. I don't believe so. 9 Q. Has Mr. Dillard referred cases to you in the 10 past to review where you have not given a 11 deposition? 12 A. Possibly. 13 Q. Well 14 A. I don't recall. In other words, I have seen 15 cases for various attorneys in which I'm never 16 asked -- I'm asked to give an opinion, but 17 never deposed and never testified at trial. 18 And I don't keep any particular record of 19 those. 20 Q. Do you know what firm Mr. Dillard is with? 21 A. Fulbright & Jaworski. 22 Q. Do you do work for other attorneys in that law 23 firm? 24 A. I don't know. I don't pay much attention 'to 25 what firm the material comes to -- comes from. 69 1 Q. Comes from. Well, you knew Mr. Dillard. 2 A. Yes. 3 Q. On how many occasions would you .s ay that you 4 have dealt with him, then? 5 A. Certainly no more than three occasions; maybe 6 not even that. 7 Q. Over what time period? 8 A. Forever. In other words, I have perhaps 9 discussed a case on the phone with him. I 10 recall this Morin case that had to do with 11 in part with hepatitis C. Certainly no more 12 than a very handful of cases. 13 Q. What about Mr. Scott, do you know Mr. Scott:? 14 A. I met Mr. Scott. 15 Q. Have you worked with Mr. Scott or anyone from 16 his law firm on other cases before this one? 17 A. Tell me what his law firm is, and I 18 MR. SCOTT: Abrams, Scott & Bickley. 19 A. I may have. I don't recall a specific case. 20 Q. All right. What about Mr. Carrington, who is 21 also here? He's with the law firm of Mehaffy, 22 Weber. They have both a Beaumont and a 23 Houston office. 24 A. I'm certain I have not worked for his law 25 firm. 70 1 Q. And what about Mr. Martin, who's here for 2 Jenkins, Grove & Martin? 3 MR. MARTIN: Close enough. 4 A. I'm not familiar with that law firm, either. 5 Q. All right. At one time you were charging $200 6 an hour to testify. Has that rate changed? 7 A. No. 8 Q. Is it the same? 9 A. It could be the same, yes. 10 Q. Is it the same in this case? 11 A. Yes. 12 Q. And you charge that amount for just reviewing 13 the records -- I mean, I'm sorry, for just 14 testifying or also for reviewing the records? 15 A. For reviewing the records. 16 Q. How much time do you think you have had in 17 this case so for, up to now? 18 MR. DILLARD: You are talking about 19 his treatment of Mr. York? 20 MR. MORGAN: No. I'm talking about 21 his expert testifying time that you've asked 22 him to do. 23 MR. DILLARD: We're hereto take his 24 deposition. 25 A. I really haven't discussed the case. In other 71 1 words, I mean, I have seen Mr. York again in 2 the office for an hour or so. The deposition 3 has been set a couple of times, and so I have 4 gotten the records ready that I had. But not 5 a large amount of time. 6 Q. Well, are you talking 10 hours, up to the 7 deposition? 8 A. Certainly less than that. 9 Q. Have you ever talked to any type of oncologist 10 or hematologist in the Beaumont area 11 concerning what knowledge they may have 12 concerning work sites in the area? 13 A. No. 14 Q. Have you done any research? .And I don't mean 15 formal research, but any inquiries, casual 16 conversation, or anything like that, with 17 medical provider, be it a doctor, hospital, 18 nurse, concerning the chemical situation as it 19 would exist in the petrochemical area of 20 Jefferson County? 21 A. No. 22 MR. DILLARD: Objection, vague. 23 Q. The money that you charge, I take it, goes to 24 you directly, and in your pocket, as opposed 25 to some research facility? 72 1 A. Correct. 2 Q. You are not employed by St. Joseph's Hospital? 3 A. Yes, I am. 4 Q. Your salary is paid by them? 5 A. Well, yes and no. Part of my salary is. I'm 6 what's called a contract employee, and they 7 pay me a salary for being the director of 8 medical education. 9 Q. All right. But in terms of your work 10 responsibilities throughout the day and the 11 patients you see, those are your patients, not 12 the hospital patients? 13 A. Correct. 14 Q. Have you requested from Mr. Dillard any type 15 of exposure information that he may have 16 concerning Mr. York and his work years? 17 A. No. 18 Q. Did Mr. Dillard offer to send you any 19 information along those lines? 20 A. No. 21 Q. Have you seen Mr. York's deposition testimony? 22 A. I don't believe so. 23 Q. Would you find it beneficial to have all of 24 the information that exists concerning 25 Mr. York's work life, his exposure history to 73 1 benzene, et cetera, in order to make an 2 opinion about the cause of his condition? 3 MR. SCOTT: Objection to the form of 4 the question. It assumes such exists. 5 A. Well, I think that -- in his particular case, 6 I think we have the long follow-up now. And I 7 think I'm satisfied with the original 8 information I got. And seeing what the years 9 have allowed to happen, I feel confident that 10 this problem is not one that's consequent to 11 benzene. 12 Q. So it's your testimony, then, that you do not 13 need any exposure to benzene evidence that may 14 exist as, in your opinion, is it not relevant? 15 A. To this particular case, yes. 16 Q. And that's because of the response to the 17 treatment that he received, the -- you call it 18 the ATGAM? 19 A. ATGAM or ATG, anti-thymocyte globulin. 20 Q. And had it not been for that response, or had 21 his response been due to something else, then 22 we would look back to the benzene, then, as 23 the potential cause, wouldn't we? 24 A. No, not entirely. Because his bone marrow 25 findings were not typical of benzene aplastic 74 1 anemia. 2 Q. Okay. I will get into all that, but in terms 3 of the causes that you mentioned earlier, you 4 mentioned hepatitis, you mentioned drugs, ,and 5 you mentioned chemicals, correct? 6 A. Yes. 7 Q. Now, if it's -- we know of no history of 8 hepatitis that preexisted the diagnosis of 9 aplastic anemia, correct? 10 A. Correct. 11 Q. And we know of no drugs that were used that 12 preexisted the aplastic anemia diagnosis that 13 would have caused aplastic anemia, correct'? 14 A: Correct. 15 Q. And, by the way, the drugs, if -- you know 16 that's an immediate response, isn't it? 17 A. Well, within a few months. In other words,, 18 weeks to months. 19 Q. Okay. As opposed to a chemical exposure, 20 which you could have exposure over time that,, 21 just as you described, a latency period could 22 exist of many years in some cases?. 23 A. Yes. 24 Q. Okay. So what I'm saying is, is if the 25 response -- if Mr. York's condition changed, 75 1 but it wasn't as a result of the ATG, then, 2 wouldn't that necessarily, in light of the 3 history of these other conditions not 4 existing, indite some chemical type of 5 exposure? 6 A. You lost me on that question. You will have 7 to repeat that one. 8 Q. Okay. So basically you think it's non-benzene 9 related because of the response to the AT GAM 10 treatment? 11 A. And the character of the bone marrow 12 diagnosis. 13 Q. Okay. Now, my question deals with -- for 14 instance, are you aware -- let me go back. 15 What's the difference between ATGAM 16 and ALG instead of ATG? 17 A. ATG -- well, the initial preparations were 18 called anti-lymphocyte globulin, meaning that 19 lymphocytes were used to inoculate the animal 20 to make the antibodies. Well, thymocytes are 21 lymphocytes. They are a specific type of 22 lymphocyte. There are more T-cells in then, 23 so that anti-thymocyte globulin is 24 anti-lymphocyte globulin, but anti-lymphocyte 25 globulin is not always anti-thymocyte 76 1 globulin. Thymocytes are a particular type of 2 lymphocyte that tend to excite a response in 3 the horse that produces a high titer anti 4 T-cell immune response. And so the 5 preparation is referred to as ATGAM, or 6 anti-thymocyte globulin. 7 Q. All right. Now, which treatment was Mr. York 8 given? 9 A. He got ATGAM, which is Upjohn's product. And 10 I guess you would have to question Upjohn as 11 to exactly how they made that product, but my 12 understanding is that that was an equine 13 was a horse anti-thymocyte globulin. 14 Q. Could you look at your records where you 15 describe the treatment for me? 16 A. Which particular record 17 Q. Earlier you read something about the 18 treatment. Perhaps it was on the discharge 19 summary. 20 A. Well, I said here, he has been treated for 21 this with blood transfusions, anti-lymphocyte 22 globulin, and androgens. Is that what you're 23 talking about? 24 Q. Well, that certainly would be one reference. 25 Does that tell us which type of treatment he 77 1 received? 2 A. No. Because, as I say, anti-thymocyte 3 globulin is anti-lymphocyte globulin. 4 Q. All right. 5 A. And anti-lymphocyte globulin is the more 6 general term. 7 Q. So it just -- it's the same thing, you are 8 saying, then? 9 A. Yeah. 10 Q. In essence? 11 A. Yes. 12 Q. Do you know who Dr. Neil Young is? 13 A. Yes. 14 Q. Who is he? 15 A. I believe he's with the NIH. He has written a 16 number of articles on aplastic anemia. 17 Q. Would you consider him to be an expert or an 18 authority in the field of benzene and aplastic 19 anemia? 20 A. Well, I don't know that anybody is a 21 particular authority in hematology. He has 22 written some articles, and I have read some of 23 his material. 24 Q. You don't consider him to be an authority in 25 the area? 78 1 A. I wouldn't consider anybody to be an authority 2 in the area. In other words, every doctor 3 learns by experience. And one doctor's 4 experience may be different from another 5 doctor's experience. And what you try to do 6 is you may gain a piece of information from 7 one article and a piece of information from 8 another and there may be errors in one article 9 or errors in another and you try to amalgamate 10 what fits from the literature with what fits 11 from your clinical practice and your knowledge 12 and your attendance at lectures and so on. 13 And that's the way you conduct your practice. 14 You don't set yourself up to follow one 15 particular knight on a horse as this is the 16 only way to do something or this is the only 17 cause of an illness. We try to look from all 18 areas of the medical literature. 19 Q. So I take it that you do not think that 20 Dr. Huang is an authority in the field, 21 either? 22 A. He's written many articles in the area. 23 Q. He's not an authority? 24 A. He's an expert, but he may not be the ultimate 25 authority in that area. 79 1 Q. And you do not consider him to be an 2 authority, do you? 3 A. He has written many articles on the subject. 4 Tell me what you believe an authority means, 5 and I will tell you if that's what that means. 6 MR. MORGAN: Well, first let me 7 object to the responsiveness of my question. 8 THE WITNESS: Okay. 9 MR. MORGAN: Your answer to my 10 question. 11 Q. Doctor, what is an authority in the field? 12 A. I don't know. You tell me. My -- I don't 13 like to use the word "authority," because it 14 gives the impression that that is the dogma, 15 that that is the only way. To me, I like to 16 use the term "expert." A person has wide 17 experience in the area, but it doesn't always 18 mean that what he or she says is correct. 19 Q. All right. So you are saying, then, that the 20 word "authority" is just a word that you do 21 not use? 22 A. I don't like the -- yes, I don't use that 23 word. 24 Q. The word you use as -25 (Brief interruption.) 80 1 Q. So as opposed to authority, you use the word 2 "expert"? 3 A. I use the word "expert." 4 Q. All right. Would you consider Dr. Young to be 5 an expert in the field? 6 A. Yes. 7 Q. He is the director of hematology for the 8 National Institute of Health, I believe; is 9 that correct? 10 A. I don't know what his titles are. 11 Q. And what about do you know Dr. Sinsenbruner? 12 A. No. 13 Q. Or of him? 14 A. No, I don't recognize the name. 15 Q. Would you agree that a chemically induced 16 aplasia can respond to ATG treatment? 17 A. Well, certain kinds of aplasia may respond to 18 ATG, at least according to Dr. Young. 19 Q. So you are aware that Dr. Young is of the 20 opinion that virus associated aplasias can 21 respond to the ATG treatments? 22 A. He is of the -- he has published some 23 abstracts I have seen in which he has treated 24 a number of patients with ATG that he -- that 25 have various forms of myelodysplasia. And he 81 1 has short-term results indicating that they 2 have an improvement in their blood counts. I 3 believe the last abstract I saw, some of these 4 patients, the maximum was about six or 700 5 days post therapy. 6 Q. When a doctor uses the term "rule out," what 7 does that mean? 8 A. To exclude. 9 Q: All right. Did you have any type of ruling 10 out to do in this case when you saw Mr. York, 11 when you first saw him? 12 A. Well, in the case of aplastic anemia you are 13 looking for common things: That is to say,, if 14 Mr. York had come in and said; I just finished 15 my bottle of chloramphenicol a few weeks ago, 16 I would say, gee, it's quite possible 17 chloramphenicol might have caused that 18 aplastic anemia. That might be a close 19 association, but he gave me no such history. 20 So ruling out in the terms of 21 aplastic anemia is difficult because there 22 isn't any one chemical test that we use to 23 assign aplastic anemia to one category or 24 another. 25 Q. Well, I understand. But what you do is by the 82 1 process, I guess, of elimination you start 2 narrowing down the potential causes, don't 3 you? 4 A. Yes. We go on the basis that common things 5 occur commonly. And we try to see if the 6 illness fits into the common pattern that we 7 identify. 8 Q. All right. Well, let's go through what you 9 would have gone through. And you have told us 10 the causes of aplastic anemia. 11 A. Yes. 12 Q. So I assume we start there. You knew when 13 Mr. York presented himself in your office that 14 he had aplastic anemia? 15 A. Correct. 16 Q. And I believe you used the term "severe 17 aplastic anemia"? 18 A. Yes. 19 Q. Now, that disease, untreated, results in 20 death, doesn't it? 21 A. Correct. 22 Q. Because the factory of our cells, the bone 23 marrow, is not producing the cells. And once 24 our cells in our body start dying off, as they 25 normally do, there is nothing to replace them 83 1 and we die, correct? 2 A. Well, we die, not specifically from -- not 3 directly from the loss of cells but the 4 diseases that that causes. In other words, if 5 you don't make any white cells, you get 6 infected and may die of infection; if you 7 don't make any platelets, you may bleed to 8 death. 9 Q. For instance -10 A. So that that's what the cause of death usually 11 is in aplastic anemia. 12 Q. For instance, a common cold could result in 13 someone who has aplastic anemia in death? 14 A. It might. 15 Q. Same thing, shaving, cut yourself -- I mean, I 16 know it has to be a severe cut -- but 17 basically bleeding to death would be -18 A. Bleeding to death usually is intracerebral 19 bleeding, such as like a massive stroke or 20 hemorrhage that might cause death. 21 Q. Okay. So we are dealing in 1983 with a 22 potentially fatal condition.. I assume you 23 advised Mr. York of that? 24 A. I don't recall the conversation, but I 25 probably did. 84 1 Q. All right. And in trying to find the cause -2 well, first of all, does the treatment depend 3 upon the cause? 4 A. Well, to a certain extent. In other words, if 5 we feel like that a person has aplastic anemia 6 from Gold, for example. That Gold is in the 7 system. We can remove it by chelating 8 agents. And some believe that chelating 9 therapy helps the recovery of Gold induced 10 aplastic anemia. And I have done that years 11 ago on a patient with that problem. 12 In the case of a drug, you try to 13 remove that drug from further use in the 14 patient's case in the hopes that the marrow 15 may spontaneously recover. 16 In the case of certain of these 17 other illnesses, such as hepatitis, we don't 18 have a specific treatment that might help. 19 Q. Okay. Let's go through now, look at the first 20 time you saw him, your notes from that first 21 visit. 22 A. All right. 23 Q. And let's be. in your office, Mr. York presents 24 himself with aplastic anemia, severe, it's 25 potentially life-threatening, and we want to 85 1 try to find the cause. I assume you asked him 2 if he had taken any of the type of drugs that 3 we mentioned? 4 A. Correct. 5 Q. And what did he tell you? 6 A. He said no. 7 Q. All right. Now, benzene is not a drug, is it? 8 A. No. 9 Q. Okay. So drugs, we are talking about aspirin, 10 prescribed medication from a doctor, things 11 like that? 12 A. Yes. 13 Q. Okay. So your inquiry as to the drugs, 14 basically, was negative? 15 A. Correct. 16 Q. The responses. were negative. 17 The other thing that was hepatitis, 18 I believe you mentioned. 19 A. Yes. 20 Q. Did Mr. York have any evidence of preexisting 21 hepatitis at that time? 22 A. He had no history suggesting the hepatitis. 23 Q. Okay. Now we are left with chemical 24 exposures. Can you tell me what the history. 25 was from the chemical exposure standpoint? 86 1 MR. DILLARD: I'm going to object to 2 the characterization "we are left with," his 3 testimony about the cause of aplastic anemia 4 being unknown in most cases, object to that. 5 MR. MORGAN: Excuse me. I thought 6 we were reserving everything except to the 7 form of the question. 8 MR. DILLARD: Well, I think it 9 misstates his testimony. 10 MR. MORGAN: Well, that's supposed 11 to be reserved. 12 MR. DILLARD: Okay. 13 Q. Go ahead. 14 A. So we are talking about his chemical history. 15 Sure, I asked him if he was exposed to any 16 chemicals in his work, and he said no. 17 Q. Well, show me in your records where it says 18 that. 19 A. I can't show you that. 20 Q. Why can't you show me that? 21 A. Well, I didn't -- I don't -- well, maybe I 22 have it written somewhere, but -- and let's 23 see. In my letters to Dr. Esslinger, let's 24 see what I said. 25 I said he had -- patient had no 87 1 apparent etiology for this illness and was 2 taking no drugs at the time of the diagnosis. 3 Q. And show me -- I think there's a reference in 4 your records somewhere about his chemical 5 exposure. 6 A. Well, I don't see that right offhand. Well, I 7 don't see that. I don't see that specific 8 statement. 9 I said -- talked about no apparent 10 etiology. If I said that, I'm not finding 11 that right off the bat. 12 Q. Well, in your office practice, do you have a 13 questionnaire that the patient fills out? 14 A. We do now, up here in this office. I was in a 15 different office in 1983, and we did not have 16 any such questionnaire. 17 Q. All right. Do you make notes when you 18 interview a patient? 19 A. Not generally during the interview. 20 Q. Afterwards do you make notes? 21 A. I dictate a note of some sort, yes. 22 Q. And you just dictate it from memory as opposed 23 to some handwritten notes or something that 24 you might make? 25 A. I usually dictate it from memory, because it's 88 1 typically -- well, usually almost exclusively 2 is on the day that I see that patient, a few 3 hours afterwards. And I rely on my memory. 4 Q. Are there some handwritten notes in your file? 5 A. There are none, that I know of. 6 Q. Okay. So, in looking through your file, do 7 you see any mention of any type of inquiry or 8 any information at all concerning his 9 occupation and exposure to chemicals? 10 A. I think I said he was employed as a pipe 11 fitter. As we have seen, I don't specifically 12 state anything about his chemical exposure. 13 Q. I know. This is 1983, we have discussed the 14 fact that you knew the relationship. I take 15 it that you did not discuss the relationship 16 between benzene and aplastic anemia with 17 Mr. York? 18 A. Well, I discussed the -- I asked him if he was 19 exposed to any chemicals, and he said no. 20 Q. Again, that's based upon your memory today, 21 some 16 -- 15 years later, correct? 22 A. Yes. 23 Q. You don't have anything in your notes, again, 24 that specifically says patient denies any 25 exposure to chemicals such as benzene, 89 1 toluene, et cetera, do you? 2 A. I don't specifically say that in my notes, 3 that's correct. 4 Q. And would you expect a 30 year old -- how old 5 was he, by the way, when he came in, 29 or 30? 6 A. Yes, 30. 7 Q. Would you expect a 29 or 30 year old pipe 8 fitter to know the relationship between 9 benzene and aplastic anemia? 10 A. No. 11 Q. Do you know whether or not a 29 or 30 year old 12 pipe fitter would know what chemicals he 13 worked around? 14 A. I couldn't say that with certainty. 15 Q. Okay. Now, I'm looking at a pathology report 16 from St. Joseph's Hospital that is dated, it 17 looks like, July 20th, 1983. Could you pull 18 that out for me? 19 A. I may or may not have that because that -- if 20 it's from the hospital, that doesn't always 21 come back to my records. I have one from 22 when? 23 Q. July 20th, 1983. 24 A. I don't know if I have a copy of that in my 25 records. All of the material from the 90 1 hospital doesn't always get back in the file. 2 I don't think I have that. 3 Q. Can I see your records for a minute? 4 A. Yeah. 5 Q. Doctor, first of all, these handwritten notes. 6 A. Uh-huh. 7 Q. I asked you earlier if you had any handwritten 8 note in your file, and you said you did not. 9 There are obviously -- there is a page of 10 handwritten notes in here. When were these 11 prepared? 12 A. Within the last several days. Those are not 13 patient's notes. They're a time line just for 14 my convenience. 15 Q. Let me show you the pathology report we had 16 from St. Luke's Hospital and ask you to read 17 the first sentence under comments. 18 A. I think you said St. Luke's Hospital. I think 19 this is from St. -- this says St. Joseph 20 Hospital. 21 Q. I meant St. Joseph, if I said St. Luke's. 22 A. It says, clinical information indicates that 23 this patient has been exposed to chemicals. 24 Q. All right. What does clinical -- what does 25 that mean? 91 1 A. It's means at the bedside or talking with the 2 patient. 3 Q. Okay. Can I see that, please? 4 And what doctor is this? 5 A. That's Dr. Helen Schwartz, who is one of the 6 pathologists here. 7 Q. All right. Now, can you show me in your 8 records where you followed up on that after 9 July? Do you have something in your records 10 where you went in after receiving this 11 information from the doctor, Dr. Schwartz, 12 over there and investigated his comments? 13 A. It's a she, and she has never seen the 14 patient. 15 Q. I'm sorry. She. Is the answer, then, to my 16 question that you did not do anything to 17 follow up on that comment? 18 A. Yes, that's correct. 19 Q. Okay. And I guess in terms of why she was 20 able to tell clinically that this was a 21 chemically induced aplastic anemia, and you 22 were not of that opinion, I guess, is 23 something we should ask her? 24 A. You would have to ask her. To my knowledge, 25 she has never seen Mr. York or spoken with 92 1 him. 2 Q. Okay. So you disagree with Dr. Schwartz and 3 her opinion, or at least her comment, about 4 the cause of this aplastic anemia, correct? 5 A. Well, I don't know how she can make the 6 comment without ever having spoken to the 7 patient or seen any of his clinical material. 8 Q. Did you talk to her? 9 A. I doubt it. 10 Q. Okay. 11 A. Normally when we do a bone marrow -- might 12 explain how come she is signing that report 13 normally when we do a bone marrow, we prepare 14 slides and we also take a biopsy. And the 15 biopsy is sent to pathology, and they process 16 the biopsy and issue us a duplicate report, 17 primarily on the biopsy. But all they see is 18 a test tube with formaldehyde in it and the 19 piece of bone material. They don't see the 20 patient. 21 MR. MORGAN: I object to that as 22 being nonresponsive. 23 Q. Doctor, often times there's a hospital chart 24 that accompanies the patient; isn't that true? 25 A. Correct. 93 1 Q. And that the pathologist or hematologist, 2 whomever is involved in the treatment, has 3 access to that chart, don't they? 4 A. Yes. 5 Q. So you don't know if she looked at the 6 chart -- so you don't know if she looked at 7 the chart and then looked at the specimen, 8 based upon everything she saw, felt like that 9 this was someone who had been exposed to 10 chemicals or not? 11 A. I don't know why she made that comment. 12 Q. Okay. Back to my question in terms of trying 13 to rule out potential causes. 14 A. Yes. 15 Q. We've got notes in your file that say no 16 drugs? 17 A. Correct. 18 Q. We've got notes in your file that say no 19 hepatitis? 20 A. Yes. 21 Q. But we don't have anything that says no 22 benzene exposure? 23 A. Correct. 24 Q. Can you explain why you write the other things 25 down that did not exist but you. didn't write 94 1 the benzene down that you say did not exist? 2 A. Well, there are many other causes of aplastic 3 anemia that are known, certain hereditary 4 abnormalities that can result in aplastic 5 anemia. I don't -- did I even say that he 6 didn't have hepatitis in the past? I think I 7 simply said there were none of the known 8 etiologies, and to me that includes all the 9 ones I knew about. So I felt no particular 10 need to enumerate each one. 11 Q. Now, you have been testifying on behalf of 12 defendants, I think, by 1983, haven't you? 13 A. By 1983? I don't know that. I really can't 14 tell you that with certainty. I know I have. 15 testified in some malpractice trials as long 16 ago as that. But I -- probably not in terms 17 of benzene related problems. 18 Q. You knew that in 19 -- in 1983 you knew that 19 there were claims being made that benzene was 20 causing aplastic anemia, among other 21 conditions, didn't you? 22 A. Correct. 23 THE VIDEOGRAPHER: Excuse me. We've 24 got about five minutes left on the tape. 25 MR. MORGAN: Why don't you go ahead 95 1 and change it. 2 THE VIDEOGRAPHER: Off the record at 3 3:22 p.m. 4 (Off the record.) 5 THE VIDEOGRAPHER: Back on the 6 record at 3:24 p.m. 7 Q. Dr. Natelson, I had asked you earlier about 8 Dr. Sinsenbruner. His full name, I just found 9 it, is Dr. Lyle Sinsenbruner. He is a 10 professor of medicine and the director of bone 11 marrow transplantation at the University of 12 Maryland School of Medicine. Do you not know 13 him? 14 A. I don't know him. 15 Q. Or know of him? 16 A. I don't know of him. 17 Q. Have you ever read any articles that he has 18 authored on the subject of benzene or aplastic 19 anemia? 20 A. I may have but -- because many times when I 21 will read an article I don't always check to 22 see who the author is, unless there is some 23 particular need to. So I may well have read 24 material he has written in the past. 25 Q. Have you ever attended an Aplastic Anemia 96 1 Foundation of America conference? 2 A. No. 3 Q. Were you even aware that there was such an 4 organization? 5 A. I was not aware that there was such an 6 organization. 7 Q. And you are certainly not -- I guess since you 8 didn't even know, you are not a member and do 9 not receive any type of newsletter from that 10 organization; is that correct? 11 A. No. 12 Q. Do you receive literature from other areas, 13 other -- concerning other diseases or 14 conditions that you treat? 15 A. I'm not sure how you mean. I subscribe to a 16 number of medical journals, if that's what you 17 have in mind. 18 Q. But nothing that seems to be specifically 19 related to something like aplastic anemia? 20 A. Well, many times we -- drug people come 21 through the office here trying to sell a 22 particular medicine for a particular illness, 23 and they will bring a variety of information 24 on that particular medication. But, 25 generally, what we use are the articles that 97 1 come from our medical literature. 2 Q. Look at your note from September 30th, 1983. 3 Do you have that? 4 A. Yes. 8-30-83? 5 Q. I wrote 9-30-83. Is that the wrong date? 6 A. I have one from 8-30-83. I don't have one for 7 9-30. 8 Q. Read the history that you had. I thought -9 A. Mr. York's skin rash has faded now completely, 10 and he seems to be over most of the adverse 11 effects from the- anti-lymphocyte globulin. 12 That's 8-3 -- 8-30-83. 13 Q. This was one when you did the second bone 14 marrow? 15 By the way, you mentioned that was 16 on an outpatient basis. 17 A. I don't remember. It could have been 18 inpatient. We usually do them on an 19 outpatient basis. He may have been in the 20 hospital for some other reason, and we did it 21 there. 22 Q. Because as you noticed earlier when you 23 testified, when you said it was outpatient, 24 when they asked you to look at the records, 25 you said it shows he was admitted 9-29 and 98 1 discharged 9-30, which would that indicate an 2 inpatient procedure, or inpatient, at least, 3 stay? 4 A. You know, it doesn't always mean that. In 5 other words, many times what will happen is we 6 will do the bone marrow in the office and then 7 decide to admit the patient to the hospital. 8 It's a lot more convenient to do it in the 9 office. Sometimes we admit the patient -- we 10 don't admit a patient to the hospital 11 specifically to do a bone marrow test, that 12 doesn't happen. But we sometimes may do it. 13 during the course of the hospitalization. 14 I'm sorry. You are asking me to 15 look at something. I have a discharge summary 16 from 9 -- well, this is 9-30-83. 17 Q. Yes, sir. Earlier you mentioned that -- as 18 you were reading through the history, I 19 thought you indicated that the history showed 20 aplastic anemia had been diagnosed 21 approximately four months earlier with no 22 etiology and there was no drugs to point to. 23 And in looking back at the record, I didn't 24 see that in the records -- I'm sorry, I'm 25 looking at your discharge summary as opposed 99 1 to the admission -- okay. 2 Look at your history and physical 3 from your report, not the discharge summary. 4 A. Let's see if I can find it. Yes, I think I 5 have that. 6 Q. All right. Now, at the very top, just so I 7 have the record straight, under present 8 illness it says, this is one of several 9 St. Joseph Hospital admissions for this 30 10 year old male who had aplastic anemia. He was 11 admitted on this occasion because of weakness 12 and nausea? 13 A. Yes. 14 Q. Okay. Now, here is where we are talking about 15 the history again. It says, the history 16 indicates that a diagnosis of aplastic anemia 17 was established about four months ago. The 18 patient had no apparent etiology for this 19 illness and was taking no drugs at the time of 20 the diagnosis. 21 Now, I assume that in light of what 22 you told us earlier that you're pointing to 23 the cause there, or trying to rule out things? 24 A. Yes. I said the patient had no apparent 25 etiology for this illness. 100 1 Q. All right. And, again, we discussed -- I 2 don't want to go back into it, but we have 3 discussed the potential causes of aplastic 4 anemia and drugs being one of them. And, 5 again, I ask you why, if your comment earlier 6 that no etiology covers everything, why you 7 say no apparent etiology and then also say was 8 taking no drugs? A. I can't tell you that. It was not necessary 10 to say that. I could have simply stopped and 11 said the patient had no apparent etiology for 12 this illness. Perhaps for some emphasis, I 13 added that last part of the sentence, 14 emphasizing the fact that there was no 15 potential drug relationship. 16 Q. And, again, the information you have -- you 17 were operating on from a chemical exposure 18 standpoint is, as we sit here today, you 19 recall-asking Mr. York if he was exposed to 20 any chemicals; and he told you no? 21 A. Correct. 22 Q. But that's based on memory, not based on your 23 record review? 24 A. That's based on my memory of the 25 conversations, yes. 101 1 Q. And I guess just to sort of help make my 2 point, how many people do you think you see a 3 day? 4 A. On days I see patients in the office, 5 sometimes I would say anywhere from 10 to 20. 6 Q. And has your practice been steady throughout 7 the years? 8 A. More or less. Probably see a few more 9 patients nowadays than I did in 1983. 10 Q. You see patients how many days a week? 11 A. In this office two days a week, Tuesdays and 12 Thursdays. 13 Q. And then you see patients at other places? 14 A. In the hospital. If I have consultations in 15 the hospital, or patients I have admitted to 16 the hospital, I see those. 17 Q. And do you see people in the hospital, how 18 many days a week? 19 A. Well, it may be every day of the week. If 20 they are my patient and I have admitted them 21 there, I make daily rounds. And depending on 22 if I'm asked to see a patient for some 23 specific reason from another physician, I 24 might see a patient. So there is no day, 25 let's say, that's protected where I don't see 102 1 patients. Let's put it that way. 2 Q. And do you have a day off during the week? 3 A. No. But we have -- I have weekends off on a 4 rotational basis with some other physicians. 5 Q. There was some talk about hepatitis C after 6 the diagnosis of aplastic anemia. 7 A. Yes. 8 Q. And in looking through your records, I think 9 that we see that there was a blood transfusion 10 given to Mr. York. 11 A. Yes. 12 Q. Is it thought that the transfusions were. 13 somehow contaminated and as a result of those 14 he contracted hepatitis C? 15 A. That's the most likely explanation, yes. 16 Q. And are you of the opinion, based upon 17 reasonable medical probabilities, that that is 18 the cause of his hepatitis C? 19 A. Yes, that's the most likely situation. 20 Q. And that treatment was something that was 21 reasonable and necessary as a result of his 22 aplastic anemia? 23 A. Yes. 24 Q. Why do you do blood transfusions in treating 25 aplastic anemia? 103 1 A. Well, he received both blood and platelets. 2 He had an extremely low platelet count, and I 3 don't recall the exact circumstances, whether 4 he was actively bleeding or whether we thought 5 he was going to actively bleed, but we 6 typically transfuse platelets when we think 7 there is a potential for a life-threatening 8 bleeding. 9 Q. All right. You also mention something about 10 the type of levels needed from an exposure 11 standpoint to benzene in order to cause 12 aplastic anemia. Do you recall the levels -13 A. Yes, yes. 14 Q. Now, I didn't think that you were someone who 15 felt qualified to talk about statistics and 16 different studies or different levels of 17 exposure. Do you feel like that you are 18 competent to get into a discussion about the 19 different levels of exposure to benzene 20 necessary to cause aplastic anemia? 21 A. Well, I have read the literature on the 22 subject; but, obviously, I am not out in the 23 field measuring benzene levels on people. 24 Q. Yes, sir. But my question is, do you feel 25 competent and qualified to testify concerning 104 1 the levels necessary to cause aplastic 2 anemia -- levels of exposure to benzene 3 necessary to cause aplastic anemia? 4 A. I feel confident in the sense that I know what 5 the literature says about the subject. 6 Q. All right. Tell me what it says about the 7 subject, what kind of levels are required. 8 And I want to know, since you are, you just 9 told me, aware of the literature, tell me what 10 the literature says about levels of exposure 11 necessary to benzene to cause aplastic anemia? 12 A. Well, Dr. Huang, whose name you have brought 13 up, has published a number of papers looking 14 at studies of petrochemical workers and trying 15 to identify what sort of exposure might result 16 in a statistical increase of hematologic 17 related illnesses. And his general conclusion 18 has been, and the numbers may vary a little 19 bit over the years, that you need to have at 20 least about 100 to 200 part per million year 21 exposures. 22 Now, you may give a person an 23 abrupt, sudden exposure of high levels of 24 benzene one time and the blood counts may go 25 down. At what that level is, I don't know 105 1 with certainty, but I would guess it would 2 have to be extremely high. 3 And I have seen patients who have 4 had an acute exposure to chemicals and dropped 5 their blood counts, but seldom do we really 6 have accurate measurements as to what that 7 exposure was. We know they got sprayed with a 8 chemical and presumably had very high levels, 9 but we don't have those actual measurements. 10 So that acutely a person can develop a big 11 drop in their blood counts. We are talking 12 these kinds of levels primarily relate to 13 looking at populations for leukemias, 14 lymphomas, and aplastic anemia. 15 Q. All right. Is that the only literature that 16 you are familiar with? 17 A. Well, there are various government 18 publications on the subject of benzene 19 exposures. And I can't sit here and quote 20 what levels they say. I have them in my 21 files. But they are high exposures. 22 Q. Any other literature that exists on the 23 subject you are familiar with? 24 A. Again, I can't quote you. I have a large file 25 on hematologic illnesses in which there are 106 1 many papers that deal with benzene exposure. 2 Q. Well, you were able to quote off the top of 3 your head Dr. Huang's numbers. 4 A. Yes. 5 Q. And you told me that the other publications 6 would be governmental publications, but you're 7 not familiar what their numbers are. And then 8 you told me there are some other reports in 9 the literature, but you are not familiar with 10 those numbers either, are you? 11 A. I can't tell you, as we sit here, whether one 12 says 75 or one says 50. I don't keep that 13 kind of information handy in my head. 14 Q. How is it you know so quickly Dr. Huang's 15 numbers? 16 A. I may have recently read an article from him. 17 I know quickly Dr. Young's numbers, too, 18 because I have recently seen his articles. 19 Certain things that may have recently come 20 across my desk, I would remember more 21 frequently than something I've seen a long 22 time ago. 23 Q. Well, what does Dr. Young, the hematological 24 director of the National Institute of Health, 25 say the numbers are? 107 1 A. Oh, in terms -- I was talking about the 2 numbers of the ATG. We were talking about 3 treatments that you brought up. 4 Q. No, sir. Dr. Huang is often times used by 5 defendants in lawsuits. Are you aware of 6 that? 7 A. Correct. Yes, I am. 8 Q. And so you and he are much aligned in cases, 9 aren't you? 10 A. We may be in certain cases. 11 Q. Have you worked on a case where Dr. Huang has 12 also appeared on behalf of a defendant in the 13 case? 14 A. I'm sure I have, yes. 15 Q. Have you talked to Dr. Huang before 16 A. No. 17 Q. -- personally? 18 A. No. 19 Q. Does Dr. Huang say anything about lower levels 20 of exposure than these numbers you have given 21 us? 22 A. I don't recall specifically his comment about 23 low level exposure. I recall his comments 24 about higher exposures. 25 Q. Of course, if we only focus on the higher 108 1 exposures, that means, if I am right, that 2 it's harder to get a disease, isn't it? 3 Wouldn't that be correct 4 A. Harder to get what? 5 Q. Well, aplastic anemia from a benzene 6 standpoint, let's say. 7 MR. SCOTT: Object to the form of 8 the question. 9 A. I don't understand what you are saying. 10 Q. Okay. Just so I will be straight and the 11 jury, and perhaps they are not confused, but 12 the higher the number it takes to -- the 13 higher number of parts per million of exposure 14 to benzene, the harder it is for an individual 15 who's exposed to benzene to get the disease of 16 aplastic anemia. Is that a true statement? 17 A. The higher they get exposed to, the less 18 likely they would have the illness? 19 Q. Yes, sir. In other words, if I'm exposed to 20 benzene every day, to 50 parts per million, 21 then under the numbers you gave us from 22 Dr. Huang, I'm not going to get aplastic 23 anemia from that, correct? 24 A. You will if you are exposed long enough. In 25 other words, it's cumulative. He's talking 109 1 about part per million years. 2 Q. All right. Explain that to me, then, how 3 that's broken down. 4 A. Well, it's the amount of exposure. In other 5 words, a part per million year is the amount 6 you are exposed to over the course of -- if 7 you were working over the course of a year. 8 Q. All right. So if I go to work one day and I'm 9 working a shutdown and working 12 hours that 10 day and I get exposed to 12 hours at 50 parts 11 per million -12 A. Okay. 13 Q. -- for that day. 14 A. For that day. 15 Q. Do I put 50 down on the column? 16 A. And if that's the only day you ever got 17 exposed during the course of .a year, it would 18 be -- you would have 50 divided by 365 days in 19 the year. 20 Q. Okay. And your interpretation of the math 21 that's involved here, is you add up your 22 exposures on a daily basis over the 365 days, 23 you divide that number by 365, and if it comes 24 up to between 100 and 200, then that's 25 something you would feel at that point you 110 1 point to the exposure of the benzene being the 2 cause of the aplastic anemia? 3 A. If you are exposed to one part per million of 4 benzene for a year, you have a one part per 5 million year exposure. And depending on what 6 you are exposed to, you may be exposed to a 7 massive level in a short period of time and 8 accumulate the same degree of risk. 9 Q. And as we sit here today you do not know what 10 Mr. York's exposure history was in terms of 11 benzene, do you? 12 A. I do not know. 13 Q. If I told you that it was in excess of 100 14 parts per million years. 15 A. Yes. 16 Q. Then would that change your opinion about the 17 cause? 18 A. No. Because we now have the results of. the 19 long-term therapy. And, again, as I said, the 20 character of the bone marrow is really unlike 21 what we would expect to see in benzene. 22 Q. If I told you that it was more than 200 parts 23 per million years, would you change your 24 opinion? 25 A. No. 111 1 Q. How many cases of aplastic anemia that -2 well, first of all, have you ever testified, 3 of all the cases you have testified in, that a 4 worker's aplastic anemia or leukemia was 5 caused by benzene exposure? 6 A. No. 7 Q. And in those cases, have other doctors been of 8 the opinion that, just like in this case, that 9 the individual's condition was, in fact, 10 caused by benzene exposure? 11 A. Yes. 12 Q. So it's just a difference of opinion, in your 13 mind? 14 A. Yes, I would have a difference of opinion. 15 Depends on the case and the circumstance. 16 Q. In terms of counting these cells, you 17 mentioned that Mr. York's numbers went up. 18 And you said, I think, that they were 19 somewhere around the 200,000 range? 20 A. The recent, most recent platelet count was 21 215,000. 22 Q. 215,000. Is there something scientific that 23 counts those for us? Do we have a computer 24 in today's world that we have some many 25 advances technologically, is there something 112 1 you put the blood in and it spits out the 2 number of 215,000? 3 A. Yes. 4 Q. What's that called? 5 A. Well, it's a cell counter of one type. Ours 6 happens to be made by Colter. There are many 7 different kinds of cell counters. 8 Q. And the cell counter by Colter that you used, 9 I take it you put the blood in and it does its 10 business and then spits out a number? 11 A. Correct. 12 Q. And it said 215,000? 13 A. Yes. 14 Q. Okay. And then what about the size of the 15 cells and the shape of the cells, is there 16 again some advanced machine or computer that 17 tells us if the cells are normal shape and 18 size? 19 A. Yes. One can use certain equipment for that, 20 or you can simply look at them under the 21 microscope. 22 Q. Well, what piece of equipment did you use to 23 determine that they were normal in size and 24 shape? 25 A. I used my microscope. 113 1 Q. Okay. So that is your subjective 2 interpretation of the way they looked? 3 A. Yes. When you look at blood under an oil lens 4 in a microscope, the -- you can actually do a 5 platelet count fairly accurately. For every 6 platelet that you see in an oil field on a 7 well made slide, that's worth 20,000. So if I 8 looked in an oil field, and I looked through 9 10 or 15, 20 different oil fields and I only 10 saw one platelet in each field, that person 11 has a platelet count around 20,000. If I saw 12 two platelets on average, that person would 13 have a platelet count around 40,000. And 14 someone who has looked at blood films for many 15 years can look at a slide and come awfully 16 close to what the machine counts in terms of a 17 platelet count. And you also have a general . 18 idea of what the range of normal might be and 19 whether something is distinctly outside the 20 normal range or within the normal range. 21 Now, obviously, the human eye is not 22 going to be as accurate as a computer in terms 23 of sizing cells. In other words, when I look 24 at a slide, I'm not going to be able to tell 25 you to the micron what the average diameter is 114 1 and a machine can do that much more 2 accurately. 3 Q. A11 right. And so in this case you just 4 looked at it yourself and did not use the 5 machine? 6 A. We -- well, we ran his counts through a 7 machine; but in terms of the platelet sizing, 8 I looked at it. 9 Q. Okay. You mentioned that Mr. York went back 10 to work. Did you advise him .at that time in 11 light of his condition about possibly being 12 exposed to benzene? 13 A. I don't recall. I would doubt it, but I don't 14 recall that. 15 Q. If someone has aplastic anemia, would it be 16 something -- would you recommend that they 17 stay away from chemicals such as benzene? 18 A. In high doses, certainly. 19 Q. Would they be more susceptible to having some 20 problems with exposure to benzene than, say, 21 someone who does not have aplastic anemia? 22 A. I don't know that we know that with certainty, 23 but you might surmise that. 24 Q. Would you -- if you had known that a pipe 25 fitter works in the petrochemical area and is 115 1 exposed to these aromatic hydrocarbons, would 2 you advise them to go back to work in that 3 type of environment? 4 A. Probably not. 5 Q. You've had cases referred to you by defense 6 attorneys or that you saw on your own where 7 you have requested work records of the 8 individual, haven't you? 9 A. Well, I have been sent work records by various 10 attorneys on patients. I don't know that I 11 have ever specifically requested a work record 12 for chemical exposures. I have requested work 13 records to look at blood counts and 14 chemistries on patients over the years. But 15 looking for drug exposures, I can't recall 16 such an instance. I may have, but I don't 17 recall it. 18 Q: How many aplastic anemia cases have you seen? 19 A. Oh, personally, probably in the range of 20. 20 Probably in the range of 20, I would say, over 21 the years. 22 Q. All right. You mentioned earlier that you had 23 about a 70 to 80 percent response rate to the 24 treatment that we mentioned, the ATGAM 25 treatment. 116 1 A. Yes. 2 Q. Which, of course, means that 20 to 30 percent 3 did not respond? 4 A. Correct. 5 Q. What happened to them? 6 A. Well, one I can think of, the most recent one 7 died of severe infection. That's one that 8 comes to mind. I can't think off the top of 9 my head what has happened to some of the 10 others. Some have had very slight responses. 11 Some have had striking responses. So when I 12 say improvement at 70 or 80 percent, that 13 includes the partial responses, as well. as the 14 complete responses. 15 That's -- the most recent case I can 16 think of died. 17 Q. And you can't remember the other ones that did 18 not respond to treatment? 19 A. I just can't recall at this point. 20 Q. Wouldn't you feel like that the doctors who 21 study this type of disease who perform these 22 different groups, these cohort studies, since 23 they see more people, they may see thousands 24 of people over their life, that those people 25 would be in a better position to tell us about 117 1 this disease and causative factors, et cetera, 2 than you and me, only having seen 20? 3 MR. SCOTT: Object to the form of 4 the question to the extent it misdefines 5 cohort studies. 6 A. I mean, I can't comment about other 7 investigators that I don't know. In other 8 words, all of this work gets published. And 9 I'm familiar with what's in the medical 10 literature about aplastic anemia and the 11 causation. And most of the recent reviews of 12 aplastic anemia provide charts as to what 13 those authors thought were the predominant 14 etiologic factors. Whether, someone who 15 collects all of that data would be in a better 16 position than someone like myself who reads 17 the data, I don't know. 18 Q. You mentioned that you would not expect -a 19 relapse, but you would not expect a relapse of 20 aplastic anemia, would you? 21 A. In Mr. York's case, at this point in time, I 22 would think it would be very unlikely-he would 23 relapse with aplastic anemia. 24 Q. Right. If he has a problem, I think you 25 mentioned, it's either going to be 118 1 myelodysplasia or some type of leukemia? 2 A. Correct. 3 Q. Again, from the same original incidence of 4 aplastic anemia? 5 A. That's simply based on what others have noted, 6 looking at large cohorts of aplastic anemia. 7 Q. How can we tell today, as we sit here, that 8 Mr. York will or will not come down with some 9 form of leukemia in the future as a result of 10 this aplastic anemia? 11 A. Well, I think if you were to have chromosome 12 studies done now on his bone marrow and they 13 were perfectly normal, I would think that 14 obviously it would be far less likely that he 15 would have later development. of leukemia than 16 if we did chromosome studies on his marrow and 17 a number of abnormalities were seen. 18 Q. I guess what you are saying is absent a 19 chromosomal study of the bone marrow, we are 20 unable to tell right now what the future holds 21 for him? 22 A. With certainty that's correct. 23 Q. And even, I guess, with the chromosomal. study 24 you still wouldn't be sure that he would not 25 come down with some form of leukemia? 119 1 A. I think it would be pretty unlikely at this 2 late date, after treatment. And, of course, 3 if he had a chromosomal defect, certain ones 4 are more hazardous than others, particularly 5 multiple defects. So that I think that kind 6 of a study would have some predictive 7 activity. 8 Q. Well, let's combine what we know his condition 9 is today with the hepatitis C that he also 10 has. 11 A. Yes. 12 Q. What is the difference between chronic 13 persistent and chronic active hepatitis? 14 A. Well, I think that that distinction used to be 15 very critical a number of years ago. And many 16 GI doctors today don't like to make that 17 distinction. What we thought was that chronic 18 active hepatitis meant there was tremendous 19 inflammation in the liver, there was an active 20 going process going on where the liver was 21 being chewed up as opposed to chronic 22 persistent hepatitis .in which there was still 23 viral activity but the liver wasn't actually 24 undergoing necrosis or cell death on a 25 vigorous basis. So the thinking was that 120 1 chronic persistent hepatitis was less vigorous 2 than chronic active hepatitis. 3 Today, most people are looking at 4 what's called viral loads. They actually 5 measure the number of viral particles in the 6 blood. And you can get some idea as to how 7 vigorous the infection is by the actual amount 8 of virus that's being synthesized. And 9 sometimes the distinction of persistent versus 10 active is not as nice as we used to think it 11 was. 12 Q. Well, then, let's just put it in terms of 13 having some problems and really needing 14 treatment for it. 15 A. Yes. 16 Q. What would the -- what type of treatment would 17 you normally give if you began to have liver 18 problems to try to stop that? 19 A. Well, in the course of hepatitis C, if a 20 person has a lot of viremia, they have a lot 21 of virus in the bloodstream, and they have a 22 bad looking liver biopsy, if there is active 23 inflammation ongoing, you can treat them with 24 interferon, or some people combine interferon 25 with another antiviral drug called Ribavirin. 121 1 And what you find is about 20 to 25 percent of 2 the time the viral levels will drop 3 dramatically in the blood, and the liver may 4 heal to a certain extent. 5 Now, unfortunately, in a number of 6 those patients, once you stop the therapy the 7 virus comes right back; but in some people the 8 virus seems to stay dormant and, obviously, 9 those people you've benefited a lot by the 10 therapy. 11 Q. What effect does interferon have on the bone 12 marrow? 13 A. Well, it depends on the dose you use. In high 14 doses it certainly can suppress the bone 15 marrow. The dose that's generally used for 16 hepatitis is typically a three day a week 17 dose. It's not what I would consider a high 18 dose. And it's not very suppressive on the 19 bone marrow. It may be a little suppressive, 20 but not much. 21 Q. You wouldn't advise any suppression of bone 22 marrow in an individual who has been diagnosed 23 with aplastic anemia, would you? 24 A. Well, I think it depends on the circumstance. 25 For example, let's take this case. If I knew, 122 1 having done a bone marrow examination on 2 Mr. York, that the bone marrow, not just the 3 peripheral blood that I have looked at, but 4 the bone marrow really looked normal and it 5 had normal chromosomes. Now, the GI doctor 6 told me, look, his blood is really full of 7 virus, do you think -- I really feel like he 8 ought to get benefit from interferon 9 treatment, I would say go treat him: Because 10 the risk of one is less than the risk of the 11 other on the progression of the liver disease. 12 Q. What you're saying there, I believe, is that 13 if you don't treat the liver, he will die from 14 that? 15 A. That's correct. 16 Q. And it's better to go ahead and try the 17 immediate cause of what may be the death, even 18 if it affects the bone marrow, and ultimately 19 he dies from that, because he's going to die 20 from one of the two anyway? 21 A. Well, I think in a person who has a normal 22 cellularity bone marrow, it's not likely that 23 the usual doses of interferon would suppress 24 that very much. And so I think it would be 25 probably safe to use it, particularly if 123 1 you've got aggressive liver disease that needs 2 treatment. 3 Q. Almost the squeakiest wheel has to get the 4 oil? 5 A. Correct. 6 Q. In talking about the future, there was a 1991 7 article from the New England Journal of 8 Medicine that talks about immunosuppression in 9 aplastic anemia, postponing the inevitable, 10 question mark. And it goes -- I take it you 11 read the New England Journal of Medicine on 12 occasion? 13 A. Yes. 14 Q. Do you subscribe to that? 15 A. No. Well, I take that back. I don't 16 personally, but the office does up here. 17 Q. And you are welcome to look at this, but in 18 looking at some of the parts that I have read 19 that I can understand, it talks about 20 long-term survival and the effects of the 21 treatment of the immunoglobulin treatment, 22 either the ATC or 23 A. Yes. 24 Q. And it says that in one study of 103 patients 25 with severe aplastic anemia who were treated 124 1 with anti-lymphocyte globulin, the risk of 2 these hematologic complications increased over 3 time, reaching 57 percent after eight years, 4 without attaining a plateau. And then it 5 says, quoting further, in a further study of 6 223 patients who survive more than two years, 7 clonal disease developed in 31, with a median 8 follow-up of four years with no plateau in the 9 risk of clonal disease was noted. Thus, 10 immunosuppressive therapy can lead to 11 improvement in hematologic status and survival 12 in the majority of patients with severe 13 aplastic anemia, but the patients are probably 14 not cured and remain at high risk for clonal 15 malignant disease. 16 Would you agree with that? 17 A. Well, they remained at much higher risk than 18 the general population. But as I -- the study 19 I quoted earlier, some 500 patients, a little 20 bigger than this study, the numbers were 21 certainly increased over the general 22 population, but they were not overwhelming 23 numbers. 24 But, yes, someone who has aplastic 25 anemia is at risk of a clonal disease, and 125 1 what they're specifically referring to is 2 myelodysplasia, acute leukemia, and PNH. 3 Q. What is the treatment for myelodysplasia? 4 A. Well, that's a very complex area. Because 5 myelodysplasia is sort of a general term. And 6 within that general term there is some 7 distinct syndromes of myelodysplasia. 8 Q. Can you tell by the type or severity of 9 aplastic anemia what type of myelodysplasia 10 that you may have? 11 A. You mean what type of myelodysplasia you may 12 eventually get. 13 Q. Yes. In other words, Mr. York, as we sit here 14 today, you've talked about he's at increased 15 risk for developing this disease. Can you 16 tell what type of myelodysplasia he may 17 develop? 18 A. No. 19 Q. All right. And you are about to tell me, I 20 believe, that the treatment for the different 21 types of myelodysplasia is also different? 22 A. Yes. That varies considerably, because in 23 some cases of myelodysplasia we see almost 24 normal looking bone marrow, but there are 25 things such as ring sideroblasts or distinct 126 1 abnormalities that we can identify in the 2 marrow, but no increase in what we call blasts 3 or leukemic cells. And' we put those people in 4 one category. 5 Then there are people who have 6 refractory anemia with an increase in their 7 blast count in the bone marrow, but not enough 8 blast to make us want to call it acute 9 leukemia. 10 Then there are people who have a 11 tremendous proliferation in white cells, and 12 we call that chronic myelomonocytic leukemia, 13 or something of that nature. And depending on 14 what -- in a way, the more blast forms you 15 have in the bone marrow, the worst the 16 long-term prognosis is. And those that have a 17 great increase in blast forms, you are more 18 liable to want to jump in with some form of 19 therapy than someone who simply has what we 20 call refractory anemia with ring sideroblasts. 21 Q. I guess what I am asking is, is the treatment 22 for the myelodysplasia conditions that you 23 discussed extensive, or is it something you 24 can just give prescription medication to and 25 have it go away? 127 1 A. Again, it depends, but the most severe 2 myelodysplastic syndromes essentially need to 3 be treated like acute leukemia. They may be 4 treated with high doses of chemotherapy, with 5 bone marrow transplants. Dr. Young has some 6 evidence in the short-term, he has used 7 anti-thymocyte globulin in some of these 8 patients with benefit. I've used it in a few 9 and have not seen any responses. But the more 10 vigorous the myelodysplasia, the more vigorous 11 the treatment. 12 Q. Again, are any of the treatments -- give me 13 some idea, I'm not familiar with treatment for 14 leukemia, for instance. 15 A. Okay. 16 Q. So is it -- again, is it very minor treatment 17 or is it -18 A. No, this would be-a major treatment. 19 Basically, in the case of leukemia, we think 20 of this as a good cell/bad cell situation. 21 And there are bad cells in the bone marrow, 22 and they need to be hit with a hammer. So you 23 give high doses of chemotherapy and you hope 24 that you can have enough surviving good cells 25 to re-populate the bone marrow. 128 1 In cases of myelodysplasia, often 2 times there really aren't enough good cells 3 lying around, and so, therefore, you have to 4 ablate the bone marrow with chemotherapy and 5 put in somebody else's bone marrow cells, 6 actually do a transplant. And in some 7 instances that will be curative, or cause 8 remission. Sometimes just treatment with the 9 chemicals as we treat acute leukemia can cause 10 a remission. In some few instances, you can 11 give what are called maturation agents; that 12 is, drugs that, for obscure reasons, tend to 13 want to make the leukemic cells turn normal. 14 And you can improve some bone marrows by low 15 doses of continuous chemotherapy by trying to 16 drive the abnormal cells into a growth mode 17 where they turn more normal. 18 In some of the lesser forms of 19 myelodysplastic syndrome, you can use male 20 hormones to stimulate the marrow, 21 erythropoietin injections to stimulate the 22 bone marrow, certain vitamins to stimulate the 23 bone marrow, and the prognosis may be much 24 more benign. 25 Q. From a cost standpoint, what's the range of 129 1 cost for the treatment in its least aggressive 2 form versus the most aggressive? Are we 3 talking about tens of thousands versus 4 hundreds of thousands? 5 A. I would say that's fair, because even least 6 aggressive treatments, simple injections of 7 erythropoietin are extremely expensive. And 8 so these days in medicine, there are very few 9 inexpensive treatments. 10 Q. Now, in terms of the other treatment 11 modalities, because you mentioned bone marrow 12 transplant, Mr. York does not have that 13 available to him, does he? 14 A. Well, he doesn't have a related bone marrow 15 transplant. These days we have a national 16 registry, and one can put your numbers into 17 the registry and expect to find a match of 18 somebody who sort of looks like you, but they 19 are really not your relative, and you can get 20 a transplant from a so-called unrelated 21 donor. But the risks of that are vast because 22 our current typing is not perfect, and they 23 may look identical but they aren't identical. 24 And so transplantation has improved since 1983 25 in a major way, and we do do more unrelated 130 1 donor transplants, but there are a lot of 2 hazards with that. 3 Q. Are you saying that one of the hazards that 4 you say is vast would be that it just would 5 reject? 6 A. Well, what tends to happen is that the bone 7 marrow will usually take, but then you reject. 8 You get what's called graft-versus-host 9 disease, and the bone marrow tries to reject 10 the body that it's in. Also, overwhelming 11 infections occur. And using mismatched or, 12 let's say, matched but unrelated donor marrow 13 has a high track record of graft-versus-host 14 disease. Let's put it that way. 15 Q. And if you have that condition result, does it 16 usually result in death? 17 A. Not always, but it's often a chronic disabling 18 illness. In the very acute forms it may 19 result in death. 20 Q. So if Mr. York were to come down with some 21 form of myelodysplasia or leukemia and it 22 required a bone marrow transplant, not only 23 does he have to worry about the surgery, of 24 course, the condition, but also in his 25 situation, whether or not he really can find a 131 1 match? 2 A. That's correct. 3 Q. Would the type of treatments be the same for 4 the acute leukemias and the PNHs that you 5 mentioned earlier? 6 A. Well, acute leukemia would require very 7 vigorous treatment. PNH is often a very 8 chronic illness that may not do you in, but 9 just may cause some chronic disability. 10 People can have PNH for many years. They 11 usually can't have acute leukemia for many 12 years. 13 Q. And, again, the cost of treating PNH or a -14 A. Well -15 Q. -- range -16 A. It's different in different patients, but I 17 would say in most patients it would not be 18 vast. It's a variable illness in terms of 19 some patients have problems with clotting 20 problems, thromboses. Others have problems 21 with poor blood production and may require 22 blood transfusions. So it's a little 23 different in different people. But as a 24 general rule, I would say that the treatment 25 of PNH is not enormously expensive, as opposed 132 1 to acute leukemia or myelodysplasia. 2 Q. So it might be fifty to a hundred thousand, 3 the course of treatment, versus the hundreds 4 of thousands we talked about, potentially, on 5 the others? 6 A. Well, it would certainly be hundreds of 7 thousands if you got into the bone marrow 8 transplant or high doses of chemotherapy 9 arena. How much it would be to treat someone 10 for PNH, it's hard to put a number on that. I 11 guess it depends how many transfusions they 12 might need, how well they respond to therapy, 13 which is often with corticosteroids and 14 androgens. There are a lot of. variables, but 15 it might not be very expensive to treat PNH. 16 Q. Again, relatively speaking? 17 A. Relatively speaking. 18 Q. You mentioned earlier that Mr. York told you 19 that he had, at least your recollection what 20 he told you was he had a shoulder that 21 bothered him with bursitis? 22 A. Correct. 23 Q. And when did you meet with Mr. York? 24 A. Oh, this would just be a few weeks ago, or 25 whatever the 15th, whenever it was. That 133 1 would be on January 15th. 2 Q. Okay. And today is the 26th? 3 A. Uh-huh. 4 Q. So 11 days ago. And your recollection was -5 do you recall which shoulder it was that 6 bothered him? 7 A. He said it was his right shoulder, and that he 8 had had repeated injections of steroids to the 9 point where the orthopedist felt like that he 10 had some atrophy of the tissue from the 11 steroids and that it wouldn't be wise to give 12 him an additional set of injections. 13 Q. Okay. You don't recall Mr. York telling you 14 that that has occurred in both shoulders? 15 A. I believe he just told me the right shoulder. 16 Q. I think the records reflect that he has had 17 injections of cortisone in both shoulders, 18 that the problems exist in the right and the 19 left shoulder. 20 A. That may be so, but I simply recall him 21 telling me about his right shoulder. 22 Q. Do you have any notes from that visit? 23 A. I'm sure I dictated a note, but it hasn't made 24 it back to the chart. And that's probably 25 because this is an old chart from my other 134 1 office, and they are probably trying to figure 2 out what chart to put that note on. 3 Q. Where is it typed? 4 A. We send it out to a typing service. 5 Q. And if it were back -- where would it be if it 6 were back in your office but not filed? 7 A. It would be -- we could probably retrieve it. 8 It's probably here somewhere. 9 Q. Okay. You mentioned something about not 10 seeing as many cases because of the control of 11 benzene. Could you tell me when the control 12 of benzene started? 13 A. I can't tell you the exact years. I know the 14 levels have gradually diminished over time; 15 that is to say, the government regulatory 16 levels that were permissible. I can't cite 17 the years that the changes occurred. 18 Q. Would you recommend any exposure to benzene, 19 regardless of the level, you, yourself? 20 A. Well, we get exposed every time we pump gas. 21 I mean, it's hard to avoid benzene. I mean, 22 it's a ubiquitous compound. But, obviously, 23 if you can avoid a high exposure you are 24 better off doing that. 25 Q. Do you know what, for instance, Mobil did? 135 1 Well, let me ask you this. 2 You knew it -- when you were in 3 medical school you knew the causation of 4 diseases from exposure to benzene, we have 5 been through that? 6 A. Yes. 7 Q. And that was general accepted knowledge in the 8 medical community at that time? 9 A. Yes. 10 Q. Have you ever advised people who worked on 11 some type of either board or some capacity 12 where you were called upon to, perhaps, advise 13 some entity medically? 14 A. About benzene? 15 Q. About anything. 16 A. Well, I sit on numerous committees at the 17 hospital. Some of that has to do with a 18 variety of things, from chemotherapy order 19 forms to a number of things. So, yeah, I'm 20 sure I have given advice on a lot of things. 21 Q. Well, let me ask you this way, then. If you 22 were employed by Mobil, for instance, and you 23 knew that because of the process involved with 24 taking crude oil from that state and making 25 different products, that part of the process 136 1 would involve benzene, and you were employed 2 by them, say, in the '60s and '70s, would you 3 make any recommendations to them concerning 4 precautions that should be taken in order to 5 allow people to work around the products that 6 may have benzene in them? 7 A. Well, I wouldn't be in a position to know 8 about the particular equipment that they have 9 or what potential vapors would be coming out 10 of that equipment. So with specific reference 11 to a particular factory, I could only advise 12 in general terms, that high doses, that 13 exposure to benzene is not good, and if they 14 could do something to avoid that, that would 15 be desirable. 16 Q. Would you advise allowing workers to wash 17 tools with benzene? 18 A. No, certainly would not. 19 Q. Would you advise allowing workers to wash 20 their hands with benzene? 21 A. No. 22 Q. If someone were going to work around either 23 benzene or a product containing benzene, what 24 type of protective devices should be used; or 25 should they just simply not be exposed to it 137 1 at all? 2 MR. SCOTT: Objection. 3 A. No. 4 MR. SCOTT: I'm sorry. Object to 5 the form of the question. You haven't defined 6 the product containing benzene. 7 A. I think that's the situation in terms of the 8 fact that if you are talking about contact 9 that might be on the hands, you are talking 10 about protective gloves or covering that you 11 might have. If it's exposure to benzene in 12 the vapors, then it's however you are going to 13 prevent that by mask devices. 14 Q. Would a simple paper respirator, paper mask, 15 stop the inhalation of benzene fumes? 16 A. No. 17 Q. Would we have to-go to a fresh air mask before 18 we would be able to prevent the inhalation of 19 those benzene fumes? 20 A. I'm not an expert on masks, so I can't tell 21 you what you'd have to have. 22 Q. From a medical standpoint, if they had -- if 23 Mobil had come to you and asked -- and I just 24 use Mobil because it's one of the plants. If 25 Mobil had come to you and said, Dr. Natelson, 138 1 we have got some products out here that 2 contain benzene, we've got drums marked 3 benzene on them, should we warn people about 4 benzene and the effects of it, what would you 5 tell them? 6 A. You've got sealed drums of benzene? 7 Q. Well, yes, sir, they are sealed; but they are 8 not unable to be opened. 9 A. Well, there should be signs on them indicating 10 that they are a toxic chemical and that access 11 should be restricted to them. 12 Q. Okay. And in what type of -- should you -- in 13 your opinion, should a person know what 14 effects may be caused by exposure to that 15 substance? 16 A. Well, I think if somebody. is working regularly 17 with a particular substance, it would be 18 helpful to let them know what they might 19 expect if they got exposed to it. In other 20 words, is it an irritant, will it make your 21 eyes run, will it make you choke, or does it 22 damage the skin; and then you could, of your 23 own, better evaluate what problems you might 24 be having. 25 Q. For instance, you may see a chemical that says 139 1 it may be caustic and cause irritation or rash 2 to the skin, that's one thing. You may decide 3 1 will go ahead and work around it, it can't 4 be that bad, as opposed to seeing something 5 that says may cause leukemia or even death? 6 A. Yeah, that would get your attention more. 7 Q. And benzene, would it -- would benzene deserve 8 a warning that involved cancer or death being 9 associated with the word "benzene"? 10 A. I think if you are talking about a vat of 11 benzene that's sealed, there should be signs 12 on it indicating that it's a major health 13 hazard. 14 Q. Doctor, you've seen other people with diseases 15 that are known to be caused by benzene from 16 the petrochemical. plants in the Beaumont, Port 17 Arthur area, haven't you? 18 A. Yes. 19 Q. And you've never asked for records from the 20 Mobil facility, or any other petrochemical 21 facility in that area, have you? 22 A. No. Sometimes they have come with records, 23 but I haven't specifically asked for records. 24 Q. You've never been provided with depositions 25 from any of the employees of the different 140 1 entities that I mentioned earlier, have you? 2 A. On certain cases I have seen depositions that 3 I have reviewed. 4 Q. Well, do you recall any depositions from the 5 Mobil facility in Beaumont concerning the 6 warnings that they give to the employees, both 7 of Mobil and the contract employees, 8 concerning working with benzene? 9 A. No. 10 Q. Have, you ever been provided with any 11 information about the level of benzene 12 exposure that the pipe fitters may receive at 13 any of the facilities that I read to you 14 earlier? 15 A. No. 16 Q. Have you been provided with any of the levels 17 of benzene exposure, regardless of the 18 occupation that may be working in the area, 19 but from any of the plants that I mentioned 20 earlier? 21 A. No. 22 Q. In terms of Mr. York himself, this was a 23 pretty stressful situation, wasn't it? 24 A. I'm sure it was, yes. 25 Q. And when you treated him, he had severe 141 1 aplastic anemia, the bone marrow transplant 2 was not something that was available to him, 3 and I believe the ATGAM treatment at that time 4 was experimental, wasn't it? 5 A. Yes, more or less I would say, yes. 6 Q. And so he was just telling me how he had to 7 sign all these forms because it was such an 8 experimental drug. And, of course, that would 9 add to the anxiety, wouldn't it, that you are 10 taking some experimental drug that we weren't 11 really sure what all would happen? 12 A. Yes. Actually, I think I probably had more 13 anxiety than he did, because I knew better 14 what the end results might be if he didn't 15 respond and so on. In terms of his situation, 16 I mean, he was a good patient, he accepted 17 what we offered, and of course then everything 18 went well. 19 Q. I hope you were being facetious that you had 20 more anxiety than he did. 21 A. I had a lot of anxiety. 22 Q. More than someone who's facing a potential 23 fatal disease? 24 A. Well, because of the fact many times -- that's 25 true all right. But the knowledge of how 142 1 fatal it is, many times a patient, they only 2 know about themselves, they haven't seen many 3 other people die of aplastic anemia. And they 4 don't really appreciate how bad an illness it 5 can be. And so I'm sure he had a lot of 6 anxiety; but I'm telling you, I did, too. 7 Q. Well -- and as we sit here today, Mr. York may 8 not appreciate someone going from aplastic 9 anemia after several years of remission into 10 some form of leukemia; but you have seen that, 11 haven't you? 12 A. Correct. 13 Q. And I guess at this point your concern for 14 Mr. York, being his physician, that that might 15 happen, might be even greater from an anxiety 16 standpoint than Mr. York may have? 17 A. Well, as I say, at this point in time, I think 18 that going into leukemia, he's certainly got a 19 higher risk than the general population; but I 20 wouldn't think it's vast at this point. 21 Q. And, of course, you have seen the effect of 22 this type of disease on spouses and family 23 members? 24 A. Yes. 25 Q. You knew Mr. York had some small children at 143 1 the time? 2 A. Yes. 3 Q. And you mentioned -- and I just used the word 4 remission -- and you mentioned that Mr. York 5 had a response to the ATG and persisted in 6 remission. Now, that, of course, is different 7 than cured? 8 A. Yes. 9 Q. Remission means there is still something there 10 but it is not -- he's not 100 percent over the 11 incident? 12 A. Well, remission is a peculiar word. In other 13 words, it means that the -- you may not be 14 able to see or identify the something else 15 that may still be .there, but there is a 16 statistical risk that something may happen in 17 the future. So remission is a -peculiar word. 18 Not really a very satisfactory word, but we 19 use, that particularly in cases of leukemia 20 and cancers and also in aplastic anemia. 21 Q. You know Dr. Gardner, do you not? 22 A. Yes, I do. 23 Q. He's a hematologist? 24 A. Yes. 25 Q. And as a hematologist, I believe you have 144 1 respect for him; is that right? 2 A. Yes. 3 Q. Is there a safe level of exposure to benzene 4 that has no risk associated with it? 5 A. Well, I think low levels of benzene we don't 6 statistically associate a risk with. In other 7 words, you are talking about a 1, 2, 3, 4 8 percent level of exposure, I don't think 9 there's significant risk for that. We can't 10 demonstrate that statistically, let's put it 11 that way. 12 Q. Well, as we sit here today, do you know 13 specifically of a safe level of exposure to 14 benzene with no risk associated to it? 15 A. No. But it's my belief that low levels are 16 not with risk. 17 Are you trying to tell me -- I can't 18 tell you whether 6.5 is worse than 5. 19 Q. Well, you are telling me on the one hand that 20 there is no safe level of exposure that has no 21 risk with it, but then you say but there are 22 some levels that are safe. That seems to be 23 inconsistent. 24 A. No. In other words, we know the high levels 25 that have been statistically shown to cause 145 1 leukemia. Now, there may be people who are 2 slightly below that high level who may still 3 be in that ballpark. In other words, we know 4 in very general terms. And the reason for 5 that is that usually the exposure data is not 6 perfect in the case of benzene. And so, you 7 know, we say, okay, I think I have said a 8 hundred part per million years, we know 9 statistically you've got to have at least that 10 to catch leukemia. Well, maybe in an 11 individual guy it's only 95, maybe only 90. 12 But certainly not two or three. So I can't 13 tell you what that number is, but low level 14 exposure we don't think causes leukemia. I 15 don't. 16 Q. Well, let me show you testimony you gave three 17 months ago -18 A. All right. 19 Q. -- on October 22nd, 1997 on page 145. 20 A. I think I'm saying the same thing today. 21 Q. Well, let me, just so the record will be clear 22 then, perhaps I was misunderstanding. 23 The question asked of you in this 24 deposition, which you gave under oath, was, as 25 we sit here today do you know specifically of 146 1 a safe exposure level to benzene with no 2 risk? And you ask, with no risk associated 3 with it? And the questioner said, yes, sir. 4 And your answer was, I would have to say no. 5 Is that still your sworn testimony 6 today? 7 A. Yeah. I don't think I said anything 8 different. 9 MR. MORGAN: Thank you. That's all 10 I have right now. I think some of these other 11 attorneys will ask you some other questions 12 and perhaps I will have some after they ask; 13 but right now that's all I have. 14 MR. DILLARD: You all want to 15 stretch for a minute. 16 THE VIDEOGRAPHER: Off the record at 17 4:27 p.m. 18 (Brief recess.) 19 THE VIDEOGRAPHER: Back on the 20 record at 4:36 p.m. 21 22 EXAMINATION 23 QUESTIONS BY MR. DILLARD: 24 Q. Dr. Natelson, I'm going to do my best to wrap 25 this up. 147 1 I wanted to ask you, looking at your 2 resume, you're, of course, board certified in 3 two different fields, both internal medicine 4 and in hematology; is that correct? 5 A. Yes. 6 Q. And as a result of your board certification in 7 internal medicine are you able to address 8 issues that involve the liver? 9 A. Yes. 10 Q. You are comfortable with that and feel that 11 you are an expert concerning liver matters? 12 A. Yes, within reason. In other words, I would 13 defer to a gastroenterologist who specializes, 14 highly specializes in liver disease; but in 15 the general sense of things, yes, I'm 16 experienced in the area of liver disease. 17 Q. All right. Now, I want to focus on 18 probabilities. 19 A. Yes. 20 Q. Reasonable medical probabilities, as opposed 21 to on the one extreme, certainty, and the 22 other extreme, possibilities. Are you with me 23 so far? 24 A. Yes. 25 Q. Okay. Focusing on reasonable medical 148 1 probability, is there any evidence that this 2 gentleman has leukemia or myelodysplasia or 3 PNH or that he's likely and reasonably 4 medically probably, probability to get those 5 diseases in the future? Is there any evidence 6 of that? 7 A. Well, you have asked two questions. One, does 8 he have them at this. time; and the answer is 9 no, there is no evidence that he has those 10 diseases at this time. 11 What is the probability that he will 12 get them? I would say if 13 Q. I'm asking is it probable? 14 A. Is it probable? It certainly is not probable 15 that he will get them. 16 Q. All right. Now, he came to you in 1983 at the 17 referral of a physician in the Beaumont area; 18 is that correct? 19 A. Yes. 20 Q. And he was a pretty sick individual at that 21 time; is that correct? 22 A. Yes. 23 Q. And you were entrusted with his care and 24 treatment, correct? 25 A. Yes. 149 1 Q. And, in fact, I think you said he had been to 2 another hematologist before he came to see 3 you? 4 A. Yes, that's correct. 5 Q. All right. So you had a patient who had been 6 to another hematologist, and for some reason 7 had left that physician's care, and he come to 8 see you, correct? 9 A. Yes. 10 Q. All right. And he entrusted his care and 11 treatment to you, correct? 12 A. Yes. 13 Q. We, either me or any of these lawyers in this 14 room, didn't send this gentleman to see you, 15 did we? 16 A. No. 17 Q. All right. None of the clients, the companies 18 that we represent, sent this gentleman to see 19 you, did they? 20 A. No. 21 Q. All right. In fact, none of us in this room 22 had ever met back at that time, had we? 23 A. Not to my knowledge. 24 Q. All right. And you did treat him? 25 A. Yes. 150 1 Q. And, frankly, you treated him with success, 2 did you not? I'm not asking you to brag and I 3 don't mean to be immodest about it; but you 4 did treat him successfully, did you not? 5 A. No. He was fortunate, and he responded well 6 to the treatment. 7 Q. All right. And then 14 years went by and he 8 came back once again 11 days ago and sought 9 out your care and treatment and opinions, 10 correct? 11 A. Yes. 12 Q.. All right. And, again, we did not send him to 13 you at that time, did we? 14 A. No. 15 Q. We didn't recommend that he come to see you, 16 did we? 17 A. No. 18 Q. And we haven't paid you for him to come over 19 and see you, correct? 20 A. No. 21 Q. All right. In fact, we have never paid you 22 for anything in connection with Mr. York, have 23 we? 24 A. That's correct. 25 Q. All right. And we are certainly willing to 151 1 pay you for the time that you have spent here 2 today, but we certainly have not had any -3 made any payments of any sort to you prior to 4 today, have we? 5 A. That's correct. 6 Q. All right. Now, looking at the patient 7 history that he gave you, I think you said 8 that there are a number of causes that are 9 known for aplastic anemia, but that far and 10 away most cases of aplastic anemia are of 11 unknown cause; is that correct? 12 A. That's correct. 13 MR. MORGAN: Objection, leading, 14 asked and answered. 15 A. Most of the causes are said to be idiopathic. 16 Most of the cases are said to be -17 MR. MORGAN: Object to the 18 responsiveness of the answer, in light of my 19 objections to the question. 20 Q. Approximately what percentage in the published 21 literature are felt to be of unknown cause? 22 A. Well, I, a few years ago, perhaps. two years 23 ago, looked at a series of papers that totaled 24 something over 700 patients from many 25 different areas of many different studies. 152 1 And in that group, I believe that the numbers 2 that were assigned to the idiopathic group was 3 either 75 or 77 percent, something in that 4 nature. 5 Q. All right. And of the other 22 to 25 percent 6 where the cause is known, there are a number 7 of possible causes, I take it? 8 MR. MORGAN: Objection, leading. 9 Q. Is that correct? 10 A. There are a number of other causes that are 11 known of aplastic anemia. 12 Q. All right. My question to you is, did you 13 list each and every possible cause of aplastic 14 anemia, and expressly in your own writing, 15 rule each and every one of those out in your 16 records, in your patient history records? 17 A. Not in the patient records, no. 18 Q. Ail right. As a routine examination and a 19 routine practice in the history and fiscal 20 that you took, did you ask Mr. York questions 21 that would have brought out information as to 22 possible causes? 23 A. Yes. 24 Q. All right. And that was your custom and 25 practice back at that time? 153 1 A. Yes. 2 Q. And is so today? 3 A. Yes. 4 Q. So that when you wrote in your records in any 5 number of places, no etiology factors were 6 identified, what did that mean? 7 A. That meant to me that this case was going to 8 fall into the idiopathic group, because there 9 was nothing that stood out, to my mind, from 10 the history and the physical and the data that 11 I had that suggested a specific cause. 12 Q'. Now, you were asked a question about this 13 pathology report of a Dr. Schwartz. And I 14 think Mr. Morgan -- that's the attorney 15 representing Mr. York here today -- I think 16 Mr. Morgan's question was something to the 17 effect of her opinion as to the cause of his 18 aplastic anemia. Is there any reference 19 whatsoever in that passage to an opinion of 20 that doctor as far as the cause of aplastic 21 anemia? 22 A. No. 23 Q. All right. Who was the physician who saw 24 Mr. York, the hematologist who saw Mr. York 25 before you had seen him? 154 1 A. That would be Dr. Larry Rice at Baylor. 2 Q. All right. I want to show you -- because they 3 have been subpoenaed in this case, I want to 4 show you the records of Dr. Larry Rice, 5 specifically his notation concerning the 6 history that he obtained from Mr. York, and 7 ask you if you would read that into the 8 records -- into the record from the report of 9 Dr. Rice? 10 A. He says pipe fitter, dash, frequently works in 11 chemical plant. Never sick from exposure. No 12 specific exposures. Some lead, no benzene. 13 Q. No benzene? 14 A. No benzene. 15 Q. All right. And that was before he came to see 16 you, correct? 17 A. Yes. 18 Q. Now, as far as the bursitis that Mr. York has 19 reported,. whether it's left shoulder or right 20 shoulder or both shoulders, in reasonable 21 medical probability would bursitis that 22 developed some years after the ATG therapy, in 23 your opinion, be related to that therapy or 24 not? 25 A. No, in my opinion it would not be related. 155 1 Q. Is that because any reaction of that sort 2 would be an acute reaction, as you said, 3 following shortly on the heels of the ATG 4 therapy? 5 MR. MORGAN: Objection, leading. 6 Q. Let me ask it again. 7 Why is that? 8 A. Well, the reason is is that we expect an acute 9 arthritic problem, or acute bursitis when we 10 give ATG. It doesn't happen in everybody, but 11 the bulk of the patients get that. It's 12 temporary, may last for a few weeks, and then 13 it's gone. And to cause a bursitis in one or 14 even two joints many years later, I'm not 15 aware that the literature suggests, and 16 certainly not in my experience has it been, 17 that that might be caused by the ATG. 18 Q. All right, sir. You were asked a number of 19 questions, again by Mr. Morgan; the attorney 20 representing Mr. York, about whether some of 21 these companies had supplied records to you. 22 I would ask you this. Mr. York was 23 in your office 11 days ago. Did he bring any 24 such records to you? 25 A. No. 156 1 Q. Incidentally, was he by himself; or did he 2 have someone with him? 3 A. No. He had an attorney with him. 4 Q. All right. Did they bring any records? 5 A. No. 6 Q. All right. And who was the attorney? 7 A. Attorneys here at the table. 8 Q. Mr. Morgan? 9 A. No, not Mr. Morgan. This gentleman. 10 Q. Mr. Thorpe? 11 A. Mr. Thorpe, yes. 12 Q. Okay. As Mr. York's treating hematologist, 13 and having seen him again recently and going 14 back to the time you saw him some 13 years ago 15 for the first time, has Mr. York ever asked of 16 you if you felt that his aplastic anemia was 17 caused by benzene exposure? 18 A. Well, not until this last visit on the 15th. 19 We discussed to a certain extent etiology of 20 aplastic anemia. 21 Q. What did he ask you? 22 A. Well, I don't remember the specific -- well, I 23 may have been specifically asked whether or 24 not I thought it was caused by benzene. But I 25 do remember discussing the reasons why I 157 1 didn't think it was caused by benzene. 2 Q. And what did you tell him? 3 A. Well, I .said there are two things. One, the 4 initial morphology of the bone marrow. Many 5 of the cases of benzene were reported in what 6 I would call the older literature, let's say 7 literature before 1960, and it really wasn't 8 into the 1960s when bone marrow biopsy was 9 popularized by Dr. Domaschk, who was a 10 well-known hematologist. And in the older 11 literature many times we saw a patient have a 12 pancytopenia; that is to say, the blood counts 13 were very low in the peripheral blood. And it 14 was assumed, based on the marrow study, that 15 this was so-called aplastic anemia. But in 16 the case of benzene it was always thought to 17 be very peculiar. People used the term 18 proliferative aplasia. And-that almost goes 19 against each other. Proliferating means 20 growing very fast. Aplasia means absent. And 21 the reason for that was because they noticed 22 there were a bunch of cells in the bone 23 marrow. It really wasn't aplastic. And I 24 think not until we got into the era of doing 25 bone marrow biopsies did- we find out that many 158 1 of those patients really had myelodysplastic 2 syndromes that caused the pancytopenia, all 3 right, but were, in fact, aplastic -- were not 4 really aplastic anemia. 5 And that actually occurred in this 6 particular case. If you will look, initially 7 the bone marrow done was a sternal bone 8 marrow. And many years ago all the bone 9 marrows were done from the sternum. But the 10 problem with doing sternal bone marrows is you 11 can't do a good bone marrow biopsy. The bone 12 is too thin. And so on the basis of that bone 13 marrow from the sternum, they thought 14 megaloblastic anemia. In other words, they 15 didn't think aplastic anemia. 16 It really wasn't until we saw a -bone 17 marrow biopsy and we could actually see the 18 total cellularity in the bone marrow that it 19 became clear that the problem was really. an 20 aplastic one, not a dysplastic one as Dr. Rice 21 originally thought, that this might be a 22 dysplastic bone marrow, but --~so I think that 23 the -- in benzene induced aplasia, most of 24 what we are talking about is really 25 myelodysplastic syndromes. And those are stem 159 1 cell defects, like acute leukemia, and often 2 eventuate into acute leukemia. Those 3 illnesses, I don't believe, are caused -- that 4 you can cause that kind of an illness to go 5 into remission with anti-thymocyte globulin, 6 although apparently you can improve the blood 7 count somewhat. 8 But I don't believe there is any 9 literature that suggests that you can take a 10 person with myelodysplasia, such as caused by 11 benzene, and make that person have a normal 12 blood count with anti-thymocyte globulin. 13 So when I look at the whole case 14 here, the initial marrow morphology showing 15 really aphasia rather than dysplasia, and then 16 I look at the response to the anti-thymocyte 17 globulin, I'd have to say that this bone 18 marrow was likely suppressed on an immune 19 basis. And we interrupted that with the 20 anti-thymocyte globulin; such that he was 21 allowed to go back in remission. And that is 22 what we think of as idiopathic aplastic 23 anemia, and I think, unlike what we think of 24 in terms of the type of dysplasia that we 25 would see from benzene or our chemotherapy 160 1 drugs. 2 MR. MORGAN: I object to the 3 responsiveness of the answer. 4 Q. Along that line, we talked to Dr. Gardner, 5 whose name was brought up a moment ago. Did 6 he ask for and did you send him the slides? 7 A. Yes, I did. He did write and ask if I would 8 send him -- and this -- I can't tell you exactly when it was. Probably three or four, 10 maybe even five years ago. He wrote and asked 11 for the slides on Mr. York, which I did send 12 them -to him, and he wrote me back a short note 13 saying he agreed with the diagnosis of 14 aplastic anemia and sent me the slides back. 15 MR. DILLARD: Thank You. That's all 16 I have got right now. 17 18 EXAMINATION 19 QUESTIONS BY MR. SCOTT: 20 Q. Dr. Natelson, I don't want-to beat a dead 21 horse, but in 1983, it was your opinion that 22 Mr. York had an idiopathic aplastic anemia; is 23 that true? 24 A. Yes. 25 MR. MORGAN: Objection, asked and 161 1 answered. 2 Q. And, of course, at that point you had no idea 3 there was any lawsuit or any of these 4 defendants were involved, true? 5 A. That's correct. 6 Q. You were a treating physician at that time? 7 A. That's correct. 8 Q. Your opinion 11 days ago in 1998 was exactly 9 the same as it was in 1983, true? 10 A. Yes. 11 MR. SCOTT: Thank you, sir. That's 12 all I have. 13 14 EXAMINATION 15 QUESTIONS BY MR. CARRINGTON: 16 Q. Mr. Natelson, when you have an office visit 17 with a patient for any particular type of 18 disease, whether it's leukemia or aplastic 19 anemia, whatever it may be, do you inquire as 20 to medications they are presently taking or 21 have recently taken? 22 A. Yes. 23 Q. And that's not always for diagnostic purposes, 24 is it? 25 A. No, because sometimes we are looking at 162 1 possible drug interactions. In other words, I 2 might prescribe a medicine that might be 3 contraindicated or modified by some medication 4 they are taking. 5 Q. So, generally, you will ask questions about 6 prescription medications they're taking for 7 purposes of future treatments that you may be 8 anticipating rendering? 9 A. Yes. 10 Q. And you generally make those notations in your 11 records? 12 A. Yes, many times. Today we have a patient form 13 that the patients fill out, and they will list 14 their current medications in there. 15 Q. Well, in 1983 you didn't have that form so-you 16 would make the notations in the record? 17 A. Generally. If I felt they were important, 18 yes. 19 Q. And I would assume-that, for instance, in this 20 case, you noted in the record, initial visit, 21 that Mr. York was not taking any prescription 22 medication. Do you make those notes so that 23 months down the road if you are thinking about 24 prescribing medication you can refer to any 25 medication they may be taking? 163 1 MR. MORGAN: Objection, leading. 2 A. Well, when you say he wasn't taking 3 prescription medicines, actually he was. He 4 had be given injections of vitamin B-12 by 5 Dr. Esslinger. He had been taking some 6 medicines for the blood condition. But in 7 general, the -- if I think it's an important 8 medication, I would make a notation. Someone 9 came in there on digitalis for a heart 10 problem, I would make a notation of that. 11 MR. CARRINGTON: That's all I have. 12 13 EXAMINATION 14 QUESTIONS BY MR. MORGAN: 15 Q. Dr. Natelson, then I take it from that last 16 exchange with Mr. Carrington that you are 17 saying that your notation of the drugs, the 18 fact he was not taking any drugs,- was really 19 for drug interaction purposes and not for 20 diagnostic purposes; is that right? 21 A. No, that would be false. 22 Q. So it was just the opposite, it was for 23 diagnosing information as opposed to just 24 treatment information? 25 A. Well, I asked -- I mean, you might use it for 164 1 two things. One doesn't prohibit the other. 2 Q. Yes, sir. 3 A. In his particular case, I 'was looking at drugs 4 that he might have been taking that could have 5 played a role in aplastic anemia. 6 Q. Right. You mention that there was studies 7 that showed 75 percent of unknown -- of 8 aplastic anemias were of unknown causes. What 9 paper was that? 10 A. I can get you -- I'm not -- that's not a 11 single paper. That's an amalgamation of about 12 10 or 12 different studies on aplastic anemia 13 where the causation was listed, and I 14 collected all that data and collated it. 15 Q. Did you do that for litigation purposes? 16 A. Yes. That was in a case called Frias case. 17 Q. All right. And you have that somewhere 18 A. Yes. 19 Q. -- here in the office? 20 A. Not up here, but in my other office, yes. 21 Q. Could you get a copy. of that to the court 22 reporter and have him attach that as Natelson 23 2 if you will, the entire packet? 24 A. Yes. 25 Q. I'm sorry, Natelson 3. 165 1 A. Okay. 2 Q. And can -- well, let me ask it this way. 3 Could the bursitis that Mr. York has in his 4 shoulders be related to viral immune complexes 5 from the hepatitis C? 6 A. From hepatitis C? Possibly, yes. 7 Q. Well, do reasonable medical probabilities say 8 that one of the side effects of the-viral 9 immune complexes that are associated with. 10 hepatitis C are known to be bursitis? 11 A. Well, it may be so; but in general, when you 12 have someone who has, let's say, something 13 floating around in the blood, like a complex 14 that's causing an arthritis or a bursitis, you 15 would say, well, why would it only attack one 16 joint, or perhaps two, as opposed to all the 17 other joints in the body. So, generally, 18 people that have a systemic cause for their 19 arthritis have it in multiple joints. 20 Q. In all joints? 21 A. No. In multiple joints. 22 Q. Well, more than one is multiple, is it not? 23 A. More than one is multiple, yes. 24 Q. Okay. You also mention that you had given a 25 presentation or perhaps prepared a paper at 166 1 St. Joseph's concerning aplastic amenia? 2 A. Yes. 3 Q. Is that listed on your curriculum? 4 A. I'm sure it is, yes. 5 Q. Could you -- which one is that? 6 A. Well, there is one, Number 52, current therapy 7 of aplastic anemia. That's in the Houston 8 Medical Journal in 1985. 9 And then there is another patient 10 another article, number 38, treatment of iron 11 overload in patients with chronic anemias. 12 And that had to do -- I believe one of the 13 patients in that article had aplastic anemia 14 and had iron overload from the frequent 15 transfusions. So both those papers would have 16 dealt, to a certain extent, on aplastic 17 anemia. 18 And then number 55 was an article 19 about bone marrow depression from 20 allopurinol. And that paper discusses 21 aplastic anemia. That looks to be it. 22 Q. You mentioned you published an article in the 23 St. Joseph's Hospital Journal? 24 A. That's correct. 25 Q. That's not listed? 167 1 A. Well, that's the same thing. In other words, 2 this journal has gone by several names. It 3 used to be the St Joseph Hospital Journal, 4 then the name was changed to Houston Medical 5 Journal. And so that's really one and the 6 same. 7 Q. Okay. 8 A. So some of these articles I have in here will 9 say St Joseph Hospital Medical Journal and 10 other ones will say Houston Medicine, but 11 that's -- Houston Medical Journal, rather, but 12 that's basically the same journal. They 13 changed its name. 14 Q. All right. Could you get a copy of numbers 15 38, 52 and 55 for me? 16 A. Sure. 17 Q. And attach that as Natelson 4? 18 A. Yes. 19 Q. Also, are those peer reviewed articles? 20 A. In the Houston Medical -- in the St. Joe 21 Medical Journal, no. Some of them are. In 22 other words, this journal underwent an 23 evolution. And when it was the Southern 24 Medical Journal, or the -- rather, the 25 St. Joseph Hospital Medical Journal it was not 168 1 peer reviewed. When it became the Houston 2 Medical Journal, it did become peer reviewed. 3 And so if it says Houston Medical Journal, it 4 was peer reviewed. If it says St. Joseph 5 Medical Journal, it was not peer reviewed. 6 They are the same journal. 7 Q. Mr. Dillard was talking to you about the fact 8 that you hadn't been paid. You remember those 9 questions? 10 A. Yes. 11 Q. You certainly expect to get paid; don't you? 12 A. I would like to, yes. 13 Q. And you expect Mr. Dillard, or at least the 14 people on that side of the table, to pay you? 15 A. Yes. 16 Q. And they have paid you on other cases? 17 A. Yes. 18 Q. When Mr. York came in 11 days ago, did you 19 tell him that you had been contacted by the 20 defense in this case or that you. had testified 21 on many occasions and seen people at the 22 request of Mr. Dillard in the past? 23 A. No. 24 Q. This case is set for trial in May of this 25 year, and we've sort of asked the court to 169 1 allow us to go toward the latter part of the 2 month. Is there any particular thing going on 3 in May that would prevent you from being in 4 trial, if you were given enough notice? 5 A. Not that I'm aware of, no. 6 Q. Okay. How much notice would you need of the 7 trial date in order to be physically present 8 in trial? 9 A. Probably a few weeks. 10 Q. A couple of weeks, three weeks? 11 A. Yeah, I think so. Because there are certain 12 meetings that my presence is required at that 13 I have on my calendar that my secretary in my 14 other office keeps. So if you were to say 15 today a particular date, I wouldn't be able to 16 tell you if that's a good day or not a good 17 day for me, or if I will be in the city. 18 Q. Well, but at least if I give you two months 19 notice, which May is four months? 20 A. Yeah, but there are a lot of days in May; and 21 I would have to look and see if I have some 22 meeting out of the city, depending on what the 23 day might be and if I could modify that. 24 Q. Okay. Do you have a calendar where that would 25 be kept? 170 1 A. My secretary in my other office, Carol Reese, 2 keeps that. 3 Q. Okay. If you would, I would appreciate a copy 4 attached to the deposition as Natelson 5 of 5 the month of May 6 A. Okay. 7 Q. -- as it currently exists,. 8 And then would you require a 9 subpoena to be present or would just someone 10 letting you know the day and time to be there? 11 A. No, I don't think it would be necessary to 12 subpoena me. I would be happy to come. 13 Q. Okay. So if either side were to call you and 14 ask you to come over at a certain date and 15 time, you would accommodate them? 16 A. I would certainly do that, yes. 17 MR. MORGAN: Thank you. That's all 18 I have. 19 MR. DILLARD: Doctor, you understand 20 that we scheduled your deposition here today, 21 and that we expect to pay you for the time 22 that you have spent here today, but that you 23 are Mr. York's treating doctor and we have not 24 retained you as an expert witness in this 25 case. You understand that, sir? 171 1 THE WITNESS: That's fine. I will 2 certainly understand that. 3 MR. DILLARD: Okay. Thank you, sir. 4 MR. SCOTT: Can we attach as Exhibit 5 6 to Dr. Natelson's deposition his 6 typewritten notes? Do you have them in your 7 file, Doctor, from this recent meeting? 8 THE WITNESS: Well, this copy is the 9 only existing one. Then I gave a copy to 10 Mr. Morgan. 11 MR. SCOTT: Glen, will you agree 12 that we can attach a copy of that as Exhibit 6 13 to this deposition? 14 MR. DILLARD: Well, let's include in 15 that the records from the 15th of January. 16 There were two pages. 17 MR. SCOTT: Oh, yeah. We don't have 18 the whole file. Those are more recent. 19 MR. DILLARD: Could we make those 20 today and 21 THE WITNESS: Oh, you are talking 22 about the 23 MR. SCOTT: Those two pages of blood 24 counts and so forth. 25 THE WITNESS: Before you leave I can 172 1 give you these. 2 (Natelson Exhibit 6 3 marked for identification.) 4 MR. SCOTT: And we'll attach those 5 collectively as Exhibit 6. And is it correct 6 that those are the only written records you 7 have got which evidence in any way your 8 meeting 11 days ago with Mr. York and his 9 lawyer, Mr. Thorpe? 10 THE WITNESS: Correct. 11 MR. SCOTT: Thank you. 12 THE VIDEOGRAPHER: Off the record at 13 5:04 p.m. 14 (Deposition concluded ) 15 16 17 18 19 20 21 22 23 24 25 JACK MOORHEAD REPORTING SERVICES, INC. PHONE: 713-956-5655 173 1 THE STATE OF TEXAS 2 3 I have read the foregoing testimony 4 given by me on January 26, 1998 in the case of 5 CHARLES DOUGLAS YORK VS. TEXACO, INC., ET AL 6 and have made all corrections deemed 7 necessary. 8 9 ETHAN A. NATELSON, M.D. 10 11 12 13 SUBSCRIBED AND SWORN to before 14 me, the undersigned authority, on the 15 day of 1998. 16 17 18 NOTARY PUBLIC IN AND FOR 19 THE STATE OF TEXAS 20 21 22 23 24 25 98-024 JACK MOORHEAD REPORTING SERVICES, INC. PHONE: 713-956-5655