After the operation the patient progressed favorably for some time. He had no rises of temperature, and received no medication other than 10 grain doses of bromide of potash three times a day.

The wound healed, and the patient was up and about the ward, with no cerebral symptoms. On the 20th (eight days after the operation), he became sleepless and restless at night, and was given 30 grain doses of sulphonal with but little benefit. Was then given morphine gr. 4 with bromide of potash; this gave him sleep for some time, but soon lost its effect. The patient now became noisy and irritable. On the 26th it became necessary to use hypodermics of hyoscyamin, which appeared to be the only thing which would quiet him. He had to be constantly watched by a special nurse, and was much worse at night. After a few days it became difficult to induce him to swallow anything, and on the 30th he was nourished per recHe gradually grew weaker, and died on the 4th of December. His temperature remained nearly normal throughout, sometimes reaching 99%. He had no paralysis, no convulsions, but was wildly

tum.

delirious.

AUTOPSY.

Dec. 5th, made by house staff.

Body.-Fairly nourished, rigor mortis present. Head.-Wound in left temporal region, healed. A portion of the left temporal bone was absent, being removed at a previous operation. There was a fracture extending from the squamo-parietal suture downward, across the opening left by the operator, along the petrous portion into the middle lacerated foramen. The scalp and the dura were firmly adherent over the opening, and the dura was adherent to the brain on the inner side opposite the wound. There was a small abscess about one inch by one inch in the gray matter in immediate contact with the wound, this abscess extended through the gray matter into the white matter, and was filled with brain detritus and pus. The pia mater over the convexity was somewhat thickened and there was some exudation serum under the pia.

Thorax.-Left pleural cavity obliterated by adhesions. heart normal.

Lungs and

Abdomen. -All organs normal except the kidneys. The right kidney contained a cyst in the upper end, size of a hickory-nut; appears normal otherwise.

The autopsy being made in my absence, I was very much disappointed in not securing more accurate notes on the exact locality of this abscess. It is remarkable that the man did not show any pressure symptoms, his speech was not interfered with, he had no chill, and no marked rise of temperature to indicate the formation of an abscess. I am at a loss to determine the exact way in which he died.

W. A. S., 44, English, shipping-clerk; admitted by ambulance Nov. 26.

Suffering from an extensive compound depressed fracture of the skull, crescentic in form, about three inches in length by one inch in width at its broadest point. The fracture was located in the left parietal region extending downward and backward almost to the occipital protuberance. Patient comatose. Dr. Valentine operated upon him very soon after his arrival. The wound was enlarged, the fragments elevated without the use of the trephine. The depressed portion was in two pieces; on removing the second portion, which was loose from the pericranium, a profuse hæmorrhage took place, which was controlled by packing with sponge. Strict antisepsis was observed; the wound was closed with silk, and a few strands of catgut were left as drains. The wound was dressed every second day, and healed kindly. The patient's general condition was not good, he was quite weak, and took but little nourishment the first ten days; after this he began to improve.

Dec. 9th. Half the stitches removed. Scalp sunk into the opening in the skull slightly.

11th. Remaining stitches removed. cept a small point left for drainage.

Wound entirely healed, ex

13th. Only a small stain on the gauze dressing.

On the third day after the operation, the patient regained consciousness, and although somewhat dull at first, remained rational throughout. Dec. 14. Patient sat up in a chair for a while, walked about the room, and felt well except a slight pain in the right side of the head, which had bothered him more or less since the accident.

Progressed favorably and was discharged, cured, on the 23d.

THE DWELLINGS OF THE LABORING CLASSES IN THEIR RELATION TO INFANT MORTALITY.

BY ALFRED T. WHITE, BROOKLYN.

Read before the American Public Health Association at its Brooklyn Meeting, 1889.

The poorly-constructed and badly-arranged houses, which too frequently have to form the homes of the working classes, have been long. recognized as among the prominent causes of excessive mortality, and especially of infant mortality, in many large cities here and abroad. Although the worst conditions of this sort exist to-day in this country in only a few of the larger cities, symptoms of them begin to appear in many smaller places. It must be remembered that scarcely fifty

years ago there, had not been a regular tenement house built in New York City. Another fifty years may as radically change the conditions of scores of other cities, if their inhabitants and their officials are not wise in time. These conditions of life affect not only the health, but the minds and morals of the people who are obliged to accept them, and are a source of danger outside of the walls of such buildings as well as inside of them.

Much has been accomplished already in New York, in Brooklyn and in other cities in the way of controlling the plans of new buildings and the alteration of old buildings, and this has no doubt contributed among other causes to reduce the average death-rates of such cities. But to find the most conspicuous illustration of what can be done in this direction to improve health and lengthen life, we must cross the ocean and take a look at London. In that enormous and still rapidlygrowing metropolis, sewerage arrangements have long been most difficult, and the water supply would here be reckoned very scanty indeed. But time and money have been freely expended in investigating conditions and possibilities, and when it was found where money was needed to be spent, it has been expended in heroic measure, and as one result, step by step, the death-rate has been reduced to figures which even twenty years ago would have been deemed impossible of attainment. To compare the 18.50 death-rate of London in 1888 with the 26.18 of New York, the 23.23 of Boston, the 22.72 of Brooklyn or even the 20.72 of Philadelphia, is to suggest to all these cities that there is abundant room for them and for others to advance the conditions which assist to maintain health and lengthen life. And yet at no time has London caught up with its best possibilities and much less have our American cities approached theirs.

It was about the time when the first tenement house was built in New York (1838) that in London a few people began to struggle with the problem of the better housing of the poor. Since then many individuals and societies have invested millions of pounds sterling in erecting buildings intended to furnish the best accommodations within the rent-paying power of the working classes. Among these efforts, it seems to me, the first place unquestionably belongs, equally by its plans, its management, its magnitude and its results, to the Improved Industrial Dwellings Company, of which Sir Sydney H. Waterlow is chairman. This company has now invested over one million pounds sterling and has, or soon will have, accommodations for 5,300 families in its London buildings. Their plans afford an abundance of direct light and air to every room in the buildings, and furnish all necessary sanitary conveniences separately to every tenant. Their buildings are moreover distinguished by the exterior staircase, usually sunk into the

front of the building, though sometimes in the rear, and open to the air, so that there is no common interior shaft, staircase or hall, and no interior communication whatever from floor to floor.

Almost all of these dwellings are let to families with children, and the percentage of children to total population must be higher within these buildings than in the metropolis at large. Because of this and of the greater birth-rate we should expect a higher death-rate in these buildings than the average of London, but the official returns of the Registrar-General prove the contrary. I quote years for which I have

Note that while the death-rate of all London has steadily diminished, these improved dwellings keep their distance in advance all the time.

Attracted by these figures, I wrote Mr. James Moore, the secretary of the company, asking for some details regarding infant mortality, and quote from his reply.

"I have had the returns of births and deaths for last year abstracted, with the following results:

"No. of deaths under 1 year, 88; or 4 per 1,000 of population.

from 1 to 5 years, 49; or 2.2 per 1,000 of population.

"This is for the year to the 30th of June last, during which our total death-rate was only 11.2 per 1,000, the birth-rate being 35 per 1,000."

The buidings erected in London by the Peabody Trust Fund are built on models more closely like old style houses, but with abundant light and air. Their tenants, about 20,000 in number, average somewhat less in weekly earnings than those of the I. I. D. Co. In the buildings erected by the trustees of this fund, the average annual deathrate in recent years is 0.96 per 1,coo below that of all London. This would be considered a very large percentage in the saving of life, were is not contrasted with the saving of 6.3 per 1,000 in the buildings of the I. I. D. Co. I cannot but regard the greater saving of these latter as due to the superior plans of construction, and especially to the outside staircase system. In the reports of the Peabody Fund some interbirths to infant deaths are given, which I quote.

esting ratios of infant

An average annual saving of 13.77 in the ratio of infant deaths to births.

Reckoned per 1,000 of population of all ages, the death-rate of infants under one year shows a slight excess over the same ratio in all London, in all these buildings, but reckoned per 1,000 of infants living it is decidedly lower than the outside average. The unusual proportion of young children in improved dwellings is, of course, balanced by a lower adult proportion. Hence, while we find an infant death-rate nominally a trifle above that of all London, we find a death-rate for those above one year old scarcely one-half of the average for the whole metropolis. It is unfortunate that we cannot compare the deaths under one year, under five years, and above five years, with the number of living of same ages. Such a comparison would, in my judgment, show that of the lives saved annually to the occupants of these improved dwellings, half, or more than half, were saved under five years of age.

Those interested to see buildings constructed as closely to these best London models as differences of climate, building materials and tenants' wants allow, can find them here in Brooklyn in the Tower Buildings at the corner of Hicks and Baltic streets, where accommodations for 1,000 to 1,100 people have been in use since 1878, or can see similar buildings in course of erection at the foot of Joralemon Street. The tenants of the Hicks Street buildings are usually perfectly willing to show their apartments to visitors, if the hour be convenient.

A record of deaths in these Brooklyn buildings has been kept by the agent, but it is quite possible that deaths occur without his being advised or hearing of them, and a population of 1,060 is moreover too small to furnish reliable averages. It was my intention to make a close comparison of the ratio of children dying to children living, in these blocks and in all the neighboring blocks of old style tenement houses; but it has been practically impossible to obtain figures of the population of these other houses, as there has been no census here since 1880, and those returns are seemingly inaccessible in Washington, and the Health officers here felt themselves powerless to secure the information desired.

In the city of Brooklyn at large, the annual deaths of children under five appear to average 9 to 10 in the hundred of those living within same