A SUCCESSFUL CASE 
OF 
SPINAL RESECTION, 
BY 
ROBERT H. M. DAWBARN, M. D. 
WITH NEUROLOGICAL NOTES, 
f 
BY 
LANDON CARTER GRAY, M.D. 
M. J. ROONEY & CO., PRINTERS, 
COR. BROADWAY AND THIRTY-FIFTH STREET. 
NEW YORK. A SUCCESSFUL CASE OF SPINAL RESECTION.* 
BY ROBERT H. M. DAWBARN, M. D. 
LECTURKR IN OPERATIVE SURGERY, NEW YORK POLYCLINIC. 
It gives me great pleasure to lay before this section of 
the Academy to-night, at the request of its chairman, Dr. 
Gray, the history of so rare and interesting a case as one 
in which excision of a portion of the spinal column was per- 
formed for the relief of paraplegia due to traumatism. 
Trephining the spine, or resection by some other means, 
has been done so seldom that it can hardly be said to have 
a literature. I refer, of course, to the operations done since 
the days of antisepsis, since these alone have any statisti- 
cal value for us. Most of the recorded cases, too, have been 
for the relief of some condition other than fracture. For ex- 
ample, of Macewen’s six cases, reported some months since 
in the “ Lancet,” five were for relief of paraplegia due to a 
tumor, generally areolar in its nature, situated between 
theca and bone, and apparently starting from Pott’s disease 
as an irritating cause. It is the more necessary, therefore, 
that this case should be reported somewhat in detail. 
The history is as follows : 
Mr. Harry S., twenty-nine years of age, unmarried ; oc- 
cupation, superintendent at the new aqueduct works ; fell 
from a height of twelve to fifteen feet, on the last day of 
August, 1888, striking upon his back. He may have struck 
a wagon-wheel in his descent. He is not sure regarding 
this. Was unconscious for a time, and on awaking found 
himself completely without sensation or power of motion in 
the parts below the ribs. He was delirious for fifteen days 
thereafter, having considerable fever during this time. 
° Read before the Section in Neurology of the New York Academy of Medi- 
cine, May io, 1889. 2 
A plaster splint was applied at once by his physician, 
Dr. C. S. Collins, of Sing Sing, who first moulded toward the 
median line two broken spinous processes which had been 
deflected toward the left ; aparently these were the eleventh 
and twelfth dorsal. The latter spine, moreover, projected 
backward about two-thirds of an inch further than its fel- 
lows. This cast was left on for seven weeks. Then another 
was applied, and left on for two weeks. Thereafter the 
patient, now able to be lifted into a chair without much pain, 
wore a kind of corset, stiffened somewhat with corset- 
steels. During most of this period faradic electricity was 
used from time to time. 
Dr. Collins brought his patient to this city and put him 
in my hands on December 20th. His condition then was as 
follows : Complete paraplegia, beginning a few inches below 
the ribs. Involuntary passage of faeces ; retention of urine 
with overflow. Apparently the lesion had involved the so- 
called lumbar enlargement. The back showed a kyphotic 
twelfth dorsal spinous process, as previously mentioned, 
and that of the eleventh was deflected to the left about one 
inch and somewhat flattened down. Otherwise the column 
seemed normal, save for some tenderness on light pressure 
over the fractured bones. A sacral bed-sore was present, 
also ammoniacal cystitis. The former was subsequently 
healed, although with difficulty. The latter yielded quite 
readily to dilute carbolic and benzoic-acid irrigations, two 
or three times daily. 
I advised an immediate consultation, and Professor 
Seguin was called in, January 6th. He thought the spinal 
bones were very probably pressing on the cord ; but, there 
being no reaction of degeneration, he considered the prog- 
nosis moderately good, if no such compression actually 
existed. Advised galvanism applied daily, also massage 
and strychnine, and said that if no decided improvement was 
noted within a period of from six weeks to two months he 
would certainly advocate cutting down upon the spine to 
remove a possible compressing force. 
The largest-sized chloride-of-silver battery—fifty cells 
—being insufficient to cause contraction in some regions, 3 
notably the muscles at the back of the thigh, I procured 
another galvanic battery of the same strength, connecting 
the two. The most obdurate muscles responded to eighty 
or ninety cells, with the cathode placed upon their nodal 
points. Reaction to the current was quite prompt when 
one of sufficient strength was used. The left leg and the 
right thigh required an especially large number of cells. 
For nearly a month there was a steady though slow im- 
provement in the electric response. The muscles felt 
harder. The patient regained voluntary control of one 
muscle on each side—the sartorius—but no more. Fol- 
lowing this period of improvement was one in which for 
nearly a month the patient merely marked time, so to 
speak. In fact, it seemed that the muscles were gradually 
wasting ; and this although the most thorough applications 
of electricity and massage were daily employed. 
It was during this period that Professor Gray was called 
in consultation. After a most careful and painstaking ex- 
amination of the case he made a diagnosis which agreed 
entirely with that previously pronounced by Professor 
Seguin. 
Since the condition at this time was practically identical 
with that when Dr. Seguin saw the case, I shall refer you 
for certain details to Dr. Gray’s report. He urged immedi- 
ate interference, believing that the patient’s only hope lay 
in surgical exploration without further delay. 
Examination of Air. S., made Feb. 8, 1889, by Dr. L. C. 
Gray.—“ Facial muscles are normal, as are also all the 
cranial nerves. Optic nerves and the fundi normal. In the 
upper extremities tact, pain, muscular and temperature sen- 
sations were normally appreciated. The grasp of the right 
hand, tested by the dynamometer, was forty-four kilo- 
grammes, that of the left hand being forty. Upon the cuta- 
neous surface of the trunk no definite area of hyperaesthesia 
was detected. The tests regarding this point were so con- 
tradictory that no value could be attributed to them. The 
area of anaesthesia upward ceased at a line drawn just above 
the umbilicus. The deep reflexes were present and active. 
In the lower extremities the sensations of pain, tempera- ture, and muscular movements were absolutely and en- 
tirely abolished. There was, however, a very slight and 
imperfect appreciation of tact over the toes and the front of 
the feet. The plantar and knee-jerk reflexes were lost. 
Cremasteric reflex was present, and especially active on the 
left side. In the right leg the only muscle that reacted 
to the strongest faradaic current was the sartorius, and 
this reaction was fibrillary ; in the same muscle no con- 
traction could be obtained by galvanic currents running 
up to twenty-five and thirty milliamperes. There were no 
polar changes. The anterior tibial and peronei muscles 
reacted feebly to moderate faradaic and galvanic currents, 
without polar change. In the left leg the strongest faradaic 
and galvanic currents failed to produce any reaction in the 
thigh and buttocks. In the anterior and posterior leg 
groups there was no faradaic reaction. Thirty milliamperes 
of the galvanic current produced a feeble cathodal closing 
contraction in the anterior tibial, but only produced a slight 
flicker in the posterior tibial ; even in these there were no 
polar changes. There was no anodal or cathodal contract- 
ion.” 
During the time subsequent to Dr. Seguin’s visit I had, 
in anticipation of the probable necessity, practiced resec- 
tion of the spine in my operative-surgery course at the 
Polyclinic upon six or seven cadavera. 
It has happened that all of the few traumatic cases of 
spinal resection recorded hitherto, or at least those of which 
I have seen reports, were done at a point higher in the 
spine than the dorsi-lumbar junction. I quickly found that 
the incision heretofore recommended—a single, vertical, 
and generally central stroke—while permitting easy separ- 
ation and retraction of the muscles from the spines and 
laminae in the cervical and upper dorsal region, where,the 
muscles are comparatively thin, was not so satisfactory low 
down. The dorsal spinous processes near the lumbar ver- 
brae no longer dip sharply downward but project backward; 
and the muscle filling the spaces here between these spines 
and the transverse processes is suprisingly thick to one 
who has not removed the lower part of the cord at autop- 
sies. 
4 5 
Still, if we are to use the rongeur forceps, as is commonly 
done, gnawing away piecemeal the offending bones, the 
central incision must remain the best. If, however, we wish 
to saw through the laminae, removing them entire with 
their spinous processes, then the lateral incision, about to 
be described, is decidedly the preferable one—easier for the 
surgeon and safer for the patient, because involving less 
muscular detachment. 
In this instance I determined to make an attempt which 
I believe is new of application to the spinal bones. I refer 
to reimplanting the detached portions of the column should 
it be shown at the operation that these are not lying in 
contact with the cord. 
This idea rendered the central incision running down 
the spines still further objectionable. If the bones were by 
this usual method entirely bared of muscular attachment at 
the back, such bones, when cut away, might as a possibility! 
if kept aseptic and warm, reunite and live when replaced, 
just as the button removed when trephining the skull will 
frequently do. But, considering their size, this would be 
unlikely. And if chipped into small fragments, as advo- 
cated by Macewen in skull-trephining, the great difficulty 
of keeping such fragments absolutely quiet, even with the 
patient in a plaster jacket, will at once appear to every one. 
Upon the skull such absolute immobility can of course 
easily be secured. 
As the best means of attaining my object I determined 
upon an incision which I will call the “H” incision. This 
runs like a capital H down the back, with a vertical stroke 
on either side the spine, and a transverse stroke placed 
opposite to, above, or below the middle of the vertical, as 
may seem best. The vertical strokes are directed, as they 
are deepened, obliquely inward toward the median line of 
the body and strike the bones about the middle of the 
laminae. This obliquity permits sawing the laminae with 
Hey’s saw with much less retraction of the muscles and 
consequent laceration than otherwise. The muscles are 
separated by blunt means a sufficient distance at the bone- 
level to permit of sawing without laceration. Retractors 6 
with an especially deep and flat traction surface are of 
course indispensable. 
In sawing here one must direct the saw quite sharply 
inward. If the saw-cut is made at all parallel with the long 
axis of the spines, the canal will probably not be opened, 
but the teeth will advance into the body of the bone. This 
necessary obliquity of the saw-cut, too, prevents the reim- 
planted bone from sinking too far inward toward the cord, 
even under pressure. The saw-teeth should cut the nar- 
rowest possible groove. The laminae being severed over a 
sufficient number of vertebrae, with due care not to wound 
the theca, the next step is to make the transverse cut of the 
“ H ” between two of the spinous processes. This stroke 
is deepened obliquely upward, and of course cuts the supra- 
spinous and interspinous ligaments. 
Assuming that our transverse stroke is made low down 
in the “H,” we now have a long superior flap of spinous 
processes and their laminae covered with their undisturbed 
muscular and cutaneous investments. Their vascular sup- 
ply being so little interrupted, these bones are almost sure 
to live. This flap is now reflected, not directly upward nor 
(if the lower flap) directly downward—for the spinous pro- 
cesses coming mutually in contact will quickly prevent this 
—but obliquely upward, outward, and backward ; or down- 
ward, outward, and backward, as the case may be. And in 
this way a perfectly free view of the theca and canal is 
easily obtained. 
My intention was, in the case of my patient,, to replace 
this bony flap should no part of it be found pressing on the 
cord, and by silver-wire or silkworm-gut sutures to fasten 
the laminae at a few points to their severed bases for addi- 
tional security against motion in the fragments. 
The operation upon Mr. S. was performed on the 27th 
day of February, 1889. Dr. Gray was present, and the 
writer was assisted by Dr. F. A. Manning, Dr. H. J. Kelly, 
Dr. H. J. Brower Browning, and Dr. R. M. Cramer. To the 
careful attention of these gentlemen during the subsequent 
difficult and tedious work the ultimate success was largely 7 
due. Ether anaesthesia was used. The usual precautions 
were observed, which I need not detail here, to insure 
asepticism of the wound. 
The patient lying in the left latero-prone position, the 
“H” incision was made. The vertical arms ran eight 
inches in length from the seventh dorsal to the second 
lumbar vertebra, slightly diverging as they descended. 
The transverse arm ran between the kyphotic spinous 
process of the twelfth dorsal and the first lumbar spine, 
which point was about two inches above the lower ends of 
the first incisions. (The accompanying figure, from a pho- 
tograph, taken about two months and a half after the 
operation, will make this clearer, perhaps.) There was 
very little haemorrhage. For the smaller vessels I would 
compress with sponges in one vertical arm for a time, 
meanwhile deepening the other ; and vice versa. The saw- 
ing was made difficult because of the wide deviation of the 
eleventh spine toward the left. Of course I had to go still 
lurther to the left to saw its lamina on that side. 
Extreme caution was necessary in order to avoid injury 
to the theca under the right lamina of this same vertebra. 
1'his right eleventh lamina was found crushed down much 
below the level of its fellows. Section of the arches of the 
eleventh and twelfth being finally completed, the twelfth 
was easily raised obliquely, together with its superjacent 
flap. It was now apparent that the depressed eleventh 
lamina was firmly adherent to the theca, and could not be 
moved. This fact, and a subsequent discovery as to the 
cord, compelled me to give up my original plan. In order 
to remove the depressed bone it became necessary to use 
the rongeur ; and so firm was the thecal adhesion to the 
bone that, to separate it safely, it became necessary to saw 
and elevate the posterior arch of the tenth dorsal as well, 
thus stripping the adherent theca away partly from above 
and partly from below. The view of the cord now given 
caused any idea of reposition of the bones to be abandoned. 
About a finger’s length of the cord (covered with its dura- 
mater, of course), was in sight. This formed a distinct 
knuckle, making an angle of perhaps 150, its apex pointing 8 
backward and lying immediately below the depressed arch. 
Evidently there had been a fracture of at least the twelfth 
dorsal, which had in part been thrown backward. The lam- 
inae and spine of this, the kyphotic vertebra, remained un- 
broken. The cord, then, was compressed between two 
abnormal bony points—one in front, one behind—or at 
least these points lay firmly in contact with the theca- 
And opposite the tenth and eleventh spines, while not 
compressed, it lay so closely in apposition with the arches 
that I thought it would be unwise to attempt to save these, as 
the width of the saw-cut would cause them to fall slightly 
nearer still to the cord. 
The posterior arches of the tenth, eleventh, and twelfth 
were therefore dissected clean away from their muscular 
investment, with as little laceration of the latter as possible. 
The first lumbar arch proved normal, and consequently no 
lower flap in the “H” was made. The theca did not pul- 
sate at all, and seemed adherent to the cord. Just below 
the eleventh lamina was evidence of an old transverse 
rupture of this sheath which had reunited, but with slightly 
overlapping edges. No break in the cord could be appre- 
ciated by the sight or the finger, and a curved probe passed 
at intervals gently beneath the theca could not find any 
bony point on the anterior wall pressing it—save the one 
named, which was not acute. 
The writer would much have liked to open the dura 
mater and examine the state of the cord by actual sight, 
and would certainly have done so if the patient’s condition 
had justified a further prolongation of the operation. But 
the pulse was failing, and, as anaesthesia had lasted more 
than three hours already, it was considered wisest not to 
explore further. Accordingly, the wound was closed with 
sutures of retention and of coaptation—both of catgut—and 
drained at the middle of the transverse arm of the “H.” 
An ample and smooth iodoform- and bichloride-gauze was 
applied, then thick layers of cotton wadding about the 
body, and over all a stout plaster jacket going from the 
armpits to the trochanters. The patient reacted well. 
Unfortunately, the temperature of the hot bottles placed 9 
about him was not carefully noted, although the attendants 
were cautioned ; and several small sloughs on his thighs 
and feet resulted. These have since healed, as have two 
very large ones on his soles caused by heat injudiciously 
used a few weeks previously. 
For some days after the operation he suffered from great 
pain in the wound, only being able to lie on his face with 
any comfort at all. Although the temperature did not rise 
above ioo°+ at any time, I made a trap-door in the splint 
the third day, and investigated. The wound was perfectly 
aseptic and well drained. Removal of the slight pressure 
upon it gave considerable relief. Briefly, the wound jhealed 10 
by primary union save at the point of drainage, and this 
closed quickly upon removal of the tube. The pain ceased 
with the healing of the wound. 
It is now ten weeks since the operation, and it will be 
interesting, perhaps, to give a summary of the changes in 
the patient’s state at the present time. These may be 
epitomized by saying that he is none the worse in any 
respect for his operation, but, on the contrary, is in many 
ways somewhat improved, so that he expresses himself as 
very glad that it was performed. 
The following points may be particularly noted : 
Motion remains lost, save that the sartorii are under 
control and stronger than at any time since the fracture. 
Reflexes—testicle, knee, and ankle—absent as before, 
but pricking the limbs causes free contractions and of other 
groups in addition to those irritated. 
Muscular sense considerably improved. 
Common sensation not much better in limbs. But 
patient can now feel a catheter the whole length of the 
urethra, can tell when the bladder is full or even nearly 
full, and can throw quite a vigorous stream. Before the 
operation the bladder showed no evidence of muscular 
power. This improvement has dated only from the past 
week. 
Within three weeks after the operation rectal sensation 
and motion became strikingly better. While he still cannot 
retain faeces, unless rather hard, he can now feel intestinal 
distension, and the finger introduced is grasped. Formerly, 
the rectum was completely paralyzed regarding both sen- 
sation and motion. 
The improvement from which he derives the greatest 
comfort is present ability to move in any direction without 
pain. Until the operation any free motion of the head 
caused pain at the seat of fracture, and this region was 
quite sensitive to pressure. Now tenderness no longer 
exists here ; simply normal sensation. 
Before the operation his muscles responded only to 
strong galvanic currents in the paralyzed area, and very 
poorly to faradaism. Now his muscles respond to electri- 11 
city more easily and vigorously than ever before. Perhaps 
one-third fewer galvanic cells are needed now; but where 
formerly he hardly reacted at all to faradaism, now he does 
so much more easily, much more vigorously, than to gal- 
vanism. This I believe is favorable. 
His erections, although the penis has but little sensi- 
bility, are more frequent than formerly. 
A striking improvement is in the temperature of his legs. 
They were often bluish, and frequently felt cold, but within 
a few hours after operation they became warm, and are 
now almost always so. The toes are no longer in a state 
of flexion, with the exception of the left great toe, the 
extensor of which is the only muscle that cannot be made 
to respond to electricity. 
From the time of fracture the toe-nails of the left foot 
ceased to grow, although those of the right foot had to be 
cut several times between September ist and the date of 
the operation Since the resection the left toe-nails have 
grown vigorously, having required cutting more than once. 
Dating from the injury the left leg ceased to sweat, 
although the right one did so whenever the patient was in 
a sufficiently heated atmosphere. Since the operation, 
however, both lower extremities have perspired freely and 
frequently—more than would naturally be expected, in 
fact. 
V 
As to the probable final outcome of this most interesting 
case the gentlemen of this Section will all be able to speak 
with greater authority than myself, and I shall hope to 
profit by their expression of opinion. 
A few words now upon some general considerations. 
There are so few recorded cases in which the operation 
under discussion has been done for traumatic paraplegia 
that each case almost stands alone in its own part of the 
spine, and there is very little with which to compare it, 
either in technique or result. 
It is, of course, absurd to expect a brilliant outcome in 
these fracture cases—a result which, however, experience 
has shown to be abundantly possible where tumor is the 12 
cause of the paraplegia. In most cases of spinal fracture, 
with resulting paralysis below, the original injury to the 
cord has been so severe, the laceration of the cord by the 
broken bones so great, that even where pressure can be 
demonstrated and it is removed by surgical means at once, 
this relief only makes an ultimate recovery possible ; it does 
not at all make it probable. 
Still, when it is demonstrated that the cord can safely 
be exposed, that in a case of traumatic paraplegia the oper- 
ation for relief of bony pressure becomes by care and asep- 
sis even approximately as safe as one for a traumatic hemi- 
plegia from depressed bone in the skull, then the surgeon 
will not be considered free from responsibility who witholds 
his hand. 
Each new case, whether successful or otherwise, should 
be recorded at once, to stand as a guide-post or a warning 
on our path in these recent domains of surgery. 
It seems to the writer that we may now advance the 
following statement as a rule of practice : 
Whenever, following traumatism, even a slight abrupt 
irregularity of the spinal column is observed to coexist 
with paraplegia from this level, a cutting operation is indi- 
cated to determine whether the paralysis is not, by bony 
pressure, made incapable of spontaneous relief. 
This operation should be deferred no longer than re- 
covery from the original shock of the injury demands. If 
needed at all, it is needed early ; and we make a mistake 
if, as in my case, we wait until electricity and time have 
alike proved futile before attempting what I may call ex- 
ploratory resection. It will be the easier by far to the sur- 
geon at this early stage, and the safer for the patient, at 
least when the obvious displacement is due to a broken 
posterior arch, as then comparatively little bony section 
would be needed, the fragments not having become con- 
solidated by bony union in their false position. 
Possibly it might be best to do this, too, even in cases 
(almost always cervical) in which a simple dislocation is 
present. Here we have the widest difference of opinion 
among able men. Most surgeons advocate attempts at reduction by pressure, with or without accompanying ex- 
tension of the spinal column. Others, who have had one 
or more patients die suddenly during such manipulations, 
say “ Hands off.” May it not be true that in dislocation 
with paraplegia the removal of one or more arches would, 
by relieving the cord, be our safest and therefore wisest 
expedient ? When attempted, the “ H ” incision would 
seem best, permitting as it does the several laminae to re- 
unite, in those cases where no pressure is discovered. 
Nothing is more hopeless in medicine than paraplegia 
from bony pressure. If this condition were even deemed a 
strong possibility, operation seems to the writer indicated. 
This is really in the line of conservatism, since that is wise 
conservatism which, by whatever means, best conserves or 
prolongs the patient’s life. 
If in cases of this kind, although not curing the mangled 
cord, we shall relieve to a notable extent the patient’s suf- 
ferings, making his life more endurable and prolonging it, 
our treatment is more than justified. 
13 
It is now February 1st,1890,nearly a year since the date of 
operation which I have described. It may interest those 
who have followed the history of this case to know how the 
patient now is. Accordingly I publish below a letter 
recently received from him, which tells its own tale. 
While I strongly doubt if he ever recovers fully his lost 
powers, and do not take so hopeful a view of the future as 
he seems to do, yet it must be evident to us all what a con- 
trast is herein shown. On the one hand, a pain-racked, 
bed-ridden paraplegic, steadily failing in all repects. On 
the other, the same man capable of being up and about, 
going driving, free from pain, and getting some enjoyment 
out of an existence indefinitely prolonged. 
Sing Sing, N. Y., P. O. Box 402, 
December 14th, 1889. 
Dr. Dawbarn, 
My Dear Doctor.—You ask me for a report upon my 
present state of health. In giving this, let me go back a little. 14 
February 27, 1889, the operation was performed by you, 
after much kindly work, interest and attention, for which I 
am also deeply indebted to Dr. Gray. After recovering 
from the ether, I found I could move my head without the 
sharp pains I had experienced before the operation. In a 
week’s time I felt like another person, as far as the pain 
from the fractured bone pressing on the spinal cord was 
concerned. My appetite improved, and I became stronger in 
everyway. After a little the battery was again applied. Before 
the operation, where I could stand one hundred cells, now 
I could barely stand forty cells. We, now if you remember, 
tried the faradic battery, and found we could get a better 
and more vigorous response to the muscles that would only 
respond to the galvanic battery before the operation, and 
some muscles that would not respond at all responded now 
quite vigorously. Under the daily application of the battery 
and massage treatment I improved in every way, the feeling 
gradually began to creep down, my bowels became stronger, 
so that in a short time I could tell when I wanted to have a 
passage, also when my bladder was full. My legs now 
picked up in flesh, and muscles became harder and more 
prominent, and at present time, December 14, 1889, are as 
large as ever they were and of a good healthy color. 
Before the operation they had wasted away to nothing but 
skin and bones. 
I soon began to get control of the inside muscles of my 
legs, also to get stronger through the hips; and when I 
drew a long breath, I could draw my stomach in, some- 
thing I had been unable to do before. I continued to gain, 
so that in ten weeks from date of operation I could sit up 
eight and ten hours a day without the least pain. June 23, 
1889, I came up in the country again, when I commenced 
to ride out every pleasant day in a phaeton, driving for 
myself. At the present time I can ride twenty to twenty- 
five miles without becoming fatigued, sometimes being in 
the phaeton six and eight hours. Now, when lying on 
either side, I can voluntarily lift one leg over the other, viz., 
if on left side, I lift the right leg over the left; vice versa; 
also, when lying on my back, can draw my right leg up so 15 
that my knee is four inches clear of the bed. Have been 
stood upon my feet, and find I can bear most of my weight 
on my legs without my knees bending. The feeling on 
back part of my body is down to the second lumbar, on 
front part about six or seven inches below the hip-joint. 
When applying the battery, can feel the cords in any part 
of my legs contract; also know when the bone is being 
squeezed. My toe-nails on both feet grow as vigorously as 
a well person’s. I have no bed-sores any more, and my 
water is clear. Blood circulates fairly well. And I sincerely 
believe it is only a matter of time before I shall walk again ; 
which I never would have done had not the operation been 
performed, but would have been numbered with the dead. 
Sincerely yours, etc., 
Harold Sarles. 
To Robert H. M. Dawbarn, M. D. 
P. S.—If you care to publish this report with my name 
and address do so, and I should be glad to answer any in- 
quiries.