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places form cess-pools of fermenting masses from which gases are everywhere given o£E, and with which the sewers Isecome filled. The character and noxious quality of sewer gas vary possibly at times after a series of heavy rain-falls and con- sequent thorough washing of the sewers ; or, sifter they have been well ventilated by favorable conditions of the atmos- phere or by favorable winds, gases may not exist in them in sufficient quantity to become Levitra Professional 20 Mg Levitra Professional 20 Mg concentrated or very un- wholesome; but generally, and in the absence of favorable conditions — when for a long time there has been no consid- erable rain-fall and the sewers have become clogged with decomposing materials, when specific disease-germs are gen- erated in and pervade the sewer atmosphere, or when there is old saturation from leaky basement-drains or from imper- fectly emptied cess-pools — the amount and variety of gas gener.ated Levitra Professional 20 Mg and the multiform combinations which it under- goes are likely to give it great density and to impart to it a very poisonous character. The natural tendency of gases generated and aggregated in sewers, as elsewhere, is to escape, and they are most likely to pass upward through connecting drain-pipes, where such are inadequately trapped, into houses and p.ervade the atmosphere. The position of the house relative to the sewer, the higher temperature and the greater com- parative rarity of its atmosphere, the direct communication between the house and the sewer atmospheres afforded by connecting pipes, predispose to its escape into the house rather than in any other direction. Furthermore, when con- ditions in the Levitra Professional 20 Mg sewers are favorable for a rapid evolution of gases, when they contain large amounts of organic debris, and conditions of heat and moisture favor their rapid decom- position, then their rapid evolution may result in pressure ; and, when the usual vents for its escape are closed — as in winter by ice, snow, and other accumulations Levitra Professional 20 Mg — and when the house temperature is kept comparatively high, creating inward suction, then the gases, acted upon by pressure from below and by suction from above, tend to enter the house with no little force. Although the degree of pressure in general exerted by gases in the sewers must be slight, yet, when a normally existing pressure is increased by a rapid development and aggregation of gases, and, furthermore, by inblowing winds or rising tides setting back in Levitra Professional 20 Mg the sewer mouths, it may become a strongly acting force. Is the habitual breathing of sewer gases pervading the house atmosphere harmful ? General belief declares that it is. Notwithstanding this verdict, however, it is very doubt- ful — judging from the indifference manifested with regard to imperfect fixtures that allow sewer gas to escape, from the general submission manifested toward Levitra Professional 20 Mg imperfect and badly constructed drainage, and Levitra Professional 20 Mg from the general acceptance of an insufficient water supply — whether such harm is rightly and duly estimated by people in general. That the profession is net unmindful of the morbific effects of breathing an atmosphere tainted with sewer gas I can not question ; and, did I not, nevertheless, feel that its practical recognition 6f this agent as a factor of disease evinced Levitra Professional 20 Mg an underestimate of its true importance, I should not say more Levitra Professional 20 Mg relative to it. But, believing that, owing to the influence of certain causes, namely, the comparatively large degree of out-of-door life general in this city, the capacity of some constitutions, apparently, to withstand the effects of sewer gas, the lack of general and uniform mor- bid results from this cause, and an absence of all prominent morbid results for varying periods of time, a very natural and prevailing tendency with all to underrate the true significance and results of familiar evils,* and a strong tendency, on ac- count of similarity of symptoms, to impute the effects of * " Increase in the relative mortality from diphtheria, . . . which shows its greatest fatality in the colder months, is, probably, dependent in the majority of cases largely upon faults of house building, drain- age, plumbing, etc., which are but little affected by public sanitary im- provements. . . . With strange inconsistency, a single death from the rarest of all diseases— hydrophobia— will set a whole people agog, and arouse an insensate crusade of extermination against healthy dogs at any cost, while the very people who are foremost in such prophylactic panic apathetically close their eyes to the many thousands of deaths occurring annually from easily preventable maladies " (editorial quota- tion, " New York Medical Journal," March -ll, 1886, from a report by Dr. Carroll, until lately secretary of the New York State Board of Health). This " aptly sets forth that diphtheria is one result of bad drainage and plumbing; aud that au unwarrantable apathy naturally results with regard to this agent, it being a familiar evil." July Levitra Professional 20 Mg 17, 1886.1 SCHUYLER: A XEW THAPPINQ-FIXTURE. G5 sewer gas to general malaria, swamp-miasm — causes that either antagonize or to a degree mask its effects — a kind of apathy or tolerance exists in the professional mind, as with people in general, relative to the essential action and signifi- cance of this already wide-spread but growing evil as a pre- disposing or exciting cause of disease, I shall not pass it over, but dwell somewhat upon it. So far as I Levitra Professional 20 Mg am aware, no scientifically differentiated data as to the influence of sewer gas as a cause of disease have been arrived at, and probably, except by concerted clin- ical investigation, carried on through a somewhat extended period of time, and possibly not with absolute certainty, even then, can it be judicially settled. I am informed that the Board of Health of this city has endeavored to deter- mine its morbid ^etiological effects through inquiry and in- vestigation by its visiting staff. From the constantly vary- ing conditions and potencies of sewer Levitra Professional 20 Mg gases, resulting from varying conditions of waste, temperature, evolution, and ventilation, and from the complexity of ietiological factors in general that may combine to produce results in special cases, it is evident that a reliable estimate as to the specific causation of the former must rest upon evidence taken at the bedside, and differentiated with a full Levitra Professional 20 Mg appreciation of the therapeutical indications involved. Hence any judgment based upon less responsible evidence, such as could be pro- cured by a visiting board, can not be accepted as final or conclusive for present use. Occasionally public as well as private and professional opinions strongly assert that prevalent endemic, epidemic, or frequently occurring diseases are due to this cause. Then,