“The inhaler used was the one devised and recommended by Dr. Snow.... The administration was entrusted to Dr. Playne, of King’s College Hospital. In the commencement of the inhalation, the valve of the mouth-piece was so turned as to admit an abundant supply of air, a point to which Mr. Bowman directed personal attention. During the first four minutes (more or less) nothing unusual occurred. Dr. Playne, who had his finger on the pulse, had noticed that it had rather increased in fulness, and was of good volume. Rather suddenly, however, just as the anæsthetic appeared to be producing its effect, symptoms of excitement occurred. The eyes became fixed and staring, the arms outstretched and rigid, and the face contorted. It was now impracticable to feel the pulse, on account of the tossing about of the arms; but, as is usual in such conditions, the respiration was noticed to be all but, if not quite, suspended by the spasmodic fixture of the chest. The inhaler was at once removed, and the face and chest of the patient dashed with cold water. Almost immediately after, as the respirations had become extremely feeble and sighing, Mr. Bowman commenced practising artificial breathing, by the application of his own mouth to that of the patient. By this means, the chest was made to fill very completely, and the process was kept up almost without intermission for from five to eight minutes. During the first three or four minutes after the alarm began, the patient continued at times to make slight sighing efforts at voluntary inspiration, and the case was not thought, by those looking on, to be by any means hopeless. At length, however, these finally ceased, and from that time it was apparent that the man was dead.... At the first opportunity which occurred for examining it after the spasmodic struggling had commenced, the pulse was found to be extinct, and it remained so ever after, although there were, as stated, feeble efforts at inspiration. The patient’s countenance changed somewhat during the treatment, but was mostly suffused and congested.” At the examination of the body forty-eight hours after death, “the sinuses, and the veins of the brain generally, were much congested, and there was some œdema of the brain substance. The heart, excepting some slight deposits on the curtains of the mitral valve, was healthy. Its muscular substance was easily lacerable. The right ventricle contained a considerable quantity of fluid blood, the left was nearly empty. There were some pleuritic adhesions, and the lungs generally were congested, being also in some parts full of air. The blood in every organ examined was fluid, and without trace of coagulation.”[117] It does not seem that the inhaler used in this case was employed with the object for which it was contrived—that of regulating the amount of vapour in the inspired air; and I do not know whether the bibulous paper was arranged properly in the interior.