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F IG i — Showing an oxygen tank, the interpolated rubber bag. the respiratory valve in an inspiratory position, the T- tube. and the pharyngeal tube. am going to describe the apparatus, its principles, and the procedure of its application. From the data reported in the historical part it can be seen that the idea of producing artificial respira- tion by means of a pharyngeal or laryngeal tube con- connected with bellows is not new. order viagra tablets Neither are the ideas new that too much pressure of the air insuf- flated into the lungs may do harm or that a good part of the insufflated air may enter into the stomach and the intestines. However, when I started developing my apparatus I was not yet familiar with these data. When I began to use a pharyngeal tube for artificial respiration I was con- fronted with several difficulties: the insufflated air is liable to escape through the nose or backward through the mouth, or order viagra tablets the air may enter chiefly buy viagra florida into the stomach and from there into the intestines and do more harm than good ; at any rate, perhaps only little of the insufflated air will enter the lungs and may be insufficient to produce a satisfactory respira- tion. In the last published article' I described de- vices which should meet these difficulties; I shall discuss them again in this paper. Another serious obstacle to the use of pharyngeal insufflation was the possibility of driving air into the lungs under too much pressure so that it may injure these organs. To meet this possible danger I suggested the inter- polation of a mercurial valve into the buy viagra florida tube which connects the respiratory valve with the foot bellows, the mercurial valve being arranged for about 20 millimeters pressure. This mercurial valve, how- ever, was found buy viagra florida to be, for reasons which I do not need to discuss here, a cumbersome and undesirable device. order viagra tablets Another unsatisfactory condition seemed to come from the direct connection of the bellows with the respiratory valve; the air from the foot bellows is practically not continuous and the inspira- tion develops only gradually to the desirable pres- sure. On acount of these defects two advantageous changes were introduced in the present apparatus, the entire details of which I am now going to de- scribe. First, the order viagra tablets foot bellows; they need no special de- scription. It is hardly necessary to state that the required inspiratory pressure could be obtained either from an oxygen tank or from a tube coming from a constant pressure somewhere in the hospital or other building. The bellows are merely recom- mended on account of their comparative cheapness and buy viagra florida the convenience with which they can be trans- ported to any place where they may be needed. Sec- ond, the respiratory valve. It is a buy viagra florida small tube which may be conveniently kept in the hand when using it ; the tube has a protruding movable ring into which the thumb fits. When buy viagra florida the thumb moves the ring to the right side the driven air or oxygen pass through the respiratory valve, and, as will be seen later, pass further into the pharynx and into the lungs. When the ring is moved to the left side the escape from the respiratory valve is prevented and the air or oxygen accumulate meanwhile in the buy viagra florida large bag in- terpolated between the source of pressure and the respiratory valve, while an aperture appears above the ring for the order viagra tablets escape of the expiratory air from the lungs. (See Fig. 1.) In the tubing connecting the bellows with the respiratory 7 valve a large rubber bag is interpolated. The presence of the bag offers the advantage that during the expiratory phase the air or oxygen may accumulate in that bag and be ready for a full inspiratory blast as soon as the thumb moves the ring to the right side. Third, the pharyngeal tube. This tube has a flat surface at its lower side which rests on the tongue and a curved surface on its upper side. At the pharyngeal end of order viagra tablets the tube the upper surface is longer than the lower one. The external end of the tube has a pro- trusion order viagra tablets with a neck for connection with the respira- tory valve and an opening through which a stomach tube may be pushed down through the esophagus into the stomach. When no tube is in use this open- ing is closed with a movable plate. ( See Fig. 2.1 Fourth, a T-tube which is interpolated between the respiratory valve and the pharyngeal tube. The T- tube carries on its rubber end a clamp screw, whi^h, when not screwed down, permits most of the air to escape through the tube, while, on the other hand, by gradually screwing down the clamp upon the rubber tube the amount of air entering the pharyn- geal tube will gradually increase. (See Figs. 1 and July 7, 1917J MEDICAL RECORD. 3.) This T-tube arrangement supplants, as it will be shown later, the mercury buy viagra florida valve of the earlier form of apparatus and is used buy viagra florida with great advantage for the same purpose, namely, to prevent the harm of an excessive pressure. Fifth, a padded wooden Fig. -. — Showing an enlarged pharyngeal tube (Ph.T.) with its various particulars, and :' stomach tub'- (S.T. ) in it. hoard, to be used for compressing the abdomen by means of belts. (See Fig. 4.) The rubber tubing used in this apparatus mast have thick walls, so that it should not kink; metal and no glass tubes ought to be used for all other connections — they should not break when the appar- atus is used in a great hurry and without special