On May 11th, 1854, a patient died suddenly in St. George’s Hospital as she was beginning to inhale chloroform. She was a pale and delicate looking woman, aged thirty-seven, from whose left breast Mr. Cæsar Hawkins was about to remove a mammary glandular tumour. “On entering the operating theatre she appeared nervous. Having been placed on the table on her back, in a half reclining position, the administration of chloroform was commenced. Dr. Snow’s inhaler was used. The quantity of chloroform placed in the receiver was a little more than a drachm; and the valve for the admission of air was left wide open. Apparently, from excitement, she did not inhale well, but drew her breath by deep catches, and irregularly. Mr. Potter, noticing this, spoke to her, begging her to compose herself, and try to breathe more quietly. The valve was then slightly turned on, in order that she might inhale but a very small quantity of chloroform. The same spasmodic efforts at inspiration still continued; very shortly afterwards, at most not more than a minute and a half from the commencement of the inhalation, Mr. Potter noticed her breathing to suddenly cease, and that she had become deathly pale. The inhaler was at once removed. On placing the finger on the wrist, no pulse could be found. Endeavours to arouse her by dashing the face and chest with water were immediately adopted; but, proving ineffectual, artificial respiration was commenced within a minute of the first symptoms. During the interval, two sighing attempts at inspiration had been observed; but there had been no pulse whatever; the mouth lay a little open, and the countenance was still extremely pale.”[130] Other attempts at resuscitation were made without effect. “At the post-mortem examination, on the following day, no very noticeable lesions of the viscera were discovered. There was congestion of the whole venous system, and the blood, in every organ, was of a deep purple colour, and quite fluid. The brain substance itself was perhaps a little more vascular than usual, and the veins of its meninges were loaded with blood. The heart was small and fat, the right ventricle being especially loaded with adipose material, and its muscular layer much thinned. Under the microscope there was found to be slight, yet decided, fatty degeneration of the muscular structure. Both chambers, but more particularly the right, were distended with blood in which no coagula could be found. The posterior lobes of the lungs were somewhat congested, but not more than the position in which the corpse had lain might account for. There was no disease of the abdominal viscera.”[131]