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The End of Love
 The End of Love
A Sociology of Negative Relations

EVA ILLOUZ
 Oxford University Press is a department of the University of Oxford. It furthers the
University’s objective of excellence in research, scholarship, and education by publishing
worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and
certain other countries.
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America.
© Warum Liebe endet: Eine Soziologie negativer Beziehungen by Eva Illouz © Suhrkamp
Verlag Berlin, 2018 All rights reserved by and controlled through Suhrkamp Verlag Berlin.
English Translation © Oxford University Press 2019
All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted, in any form or by any means, without the prior permission in writing
of Oxford University Press, or as expressly permitted by law, by license, or under terms
agreed with the appropriate reproduction rights organization. Inquiries concerning
reproduction outside the scope of the above should be sent to the Rights Department,
Oxford University Press, at the address above.
You must not circulate this work in any other form and you must impose this same condition
on any acquirer.
Library of Congress Cataloging-in-Publication Data
Names: Illouz, Eva, 1961– author.
Title: The End of Love : a sociology of negative relations / Eva Illouz.
Description: New York : Oxford University Press, [2019] | Includes bibliographical
references.
Identifiers: LCCN 2019003399 | ISBN 9780190914639 (hardcover) | ebook ISBN
9780190914707
Subjects: LCSH: Interpersonal relations—Psychological aspects. | Man-woman
relationships—Psychological aspects. | Love—Social aspects. | Social media. |
Interpersonal relations and culture.
Classification: LCC HM1106 .I425 2019 | DDC 306.7—dc23 LC record available at
https://lccn.loc.gov/2019003399

1 3 5 7 9 8 6 4 2
Printed by Sheridan Books, Inc., United States of America
 To my sons, Netanel, Immanuel, and Amitai
To my mother, Alice,
To my brothers and sister, Michael, Marc, and Nathalie
with whom the suffix “un” never applies.
 Contents

1. Unloving: Introduction to a Sociology of Negative Choice

Love as Freedom
The Malaise with a Critique of Freedom
Choice
Negative Choice

2. Pre-Modern Courtship, Social Certainty, and the Rise of

Negative Relationships
Courtship as a Sociological Structure
Pre-modern Regulation of Sexuality
Courtship as a Pre-modern Mode of Emotional Decision-
Making
Certainty as a Sociological Structure
Normative Certainty
Existential Certainty
Ontological Certainty
Evaluative Certainty
Procedural Certainty
Emotional Certainty
Sexual Freedom as Consumer Freedom
How Sexuality Became Free
Consumption as the Unconscious of Sexuality
Sexuality as Morality, Liberation as Power
A New Social and Sexual Grammar
3. Confusing Sex
Casual Sexuality and Its Elusive Effects
Casualness and Uncertainty
Uncertain Frames
The Uncertain Territorial Geography of Relationships
Sexuality as a Source of Certainty
Uncertainty and Negative Sociality

4. Scopic Capitalism and the Rise of Ontological Uncertainty

The Value of the Body
Producing Symbolic and Economic Value
Evaluation
The Encounter as an Evaluative Interview
Consumer Evaluation
Sexual Devaluation
Beauty as Obsolescence
Devaluation through Parceling
Devaluation through Refinement of Taste
Shifting the Reference Point of Evaluation
The Confused Status of the Subject

5. A Freedom with Many Limits

Consent to What?
Muddled Wills
Volatility as an Emotional Condition
Exiting without a Voice
Trust and Uncertainty

6. Divorce as a Negative Relationship

The End of Love
Divorce and Women’s Position in the Emotional Field
 The Narrative Structure of Departing
Sexuality: The Great Separation
Consumer Objects: From Transitional to Exiting Objects
Autonomy and Attachment: The Difficult Couple
Emotional Ontologies and Non-Binding Emotional Contracts
Emotional Competence and Women’s Position in the Relational
Process

Conclusion: Negative Relations and the Butterfly Politics of

Sex

Acknowledgments
Endnotes
Bibliography
Index
I am just a chronicler, I want my work to be about what it means to be a person
living now.
—Marc Quinn1

Comprendre qu’être subversif, c’est passer de lindividuel au collectif.

—Abd Al Malik, “Césaire (Brazzaville via Oujda)”2

I don’t ask people about socialism, I ask about love, jealousy, childhood, old age.
[…] This is the only way to chase the catastrophe into the framework of the
mundane and attempt to tell a story.
—Svetlana Alexievitch, Secondhand-Time3
The End of Love
 1
Unloving
Introduction to a Sociology of Negative Choice

[T]o see what is in front of one’s nose needs a constant

struggle.
—George Orwell, “In Front of Your Nose”1

Western culture has endlessly represented the ways in which love

miraculously erupts in people’s lives, the mythical moment in which
one knows someone is destined to us; the feverish waiting for a
phone call or an email, the thrill that runs our spine at the mere
thought of him or her. To be in love is to become an adept of Plato, to
see through a person an Idea, perfect and complete.2 Endless
novels, poems, or movies teach us the art of becoming Plato’s
disciples, loving the perfection manifested by the beloved. Yet, a
culture that has so much to say about love is far more silent on the
no-less-mysterious moment when we avoid falling in love, where we
fall out of love, when the one who kept us awake at night now leaves
us indifferent, when we hurry away from those who excited us a few
months or even a few hours ago. This silence is all the more
puzzling as the number of relationships that dissolve soon after their
beginning or at some point down along their emotional line is
staggering. Perhaps our culture does not know how to represent or
think about this because we live in and through stories and dramas,
and “unloving” is not a plot with a clear structure. More often than not
it does not start with an inaugural moment, a revelation. On the
contrary, some relationships fade or evaporate before or soon after
they properly started, while others end with slow and
incomprehensible death.3 And yet, “unloving” means a great deal
from a sociological perspective as it is about the unmaking of social
bonds, which, since Émile Durkheim’s seminal Suicide,4 we have to
understand as perhaps the central topic of sociological inquiry. But in
networked modernity, anomie—the breakdown of social relationships
and social solidarity—does not primarily take the form of alienation
or loneliness. On the contrary, the unmaking of bonds that are close
and intimate (in potentiality or in reality) seems to be deeply
connected to the increase of social networks, real or virtual, to
technology, and to a formidable economic machinery of advice-
giving or help-giving. Psychologists of all persuasions—as well as
talk-show hosts, pornography and sex toy industries, the self-help
industry, shopping and consumer venues—all of these cater to the
perpetual process of making and unmaking social bonds. If sociology
has traditionally framed anomie as the result of isolation and the lack
of proper membership to community or religion,5 it now must account
for a more elusive property of social bonds in hyperconnective
modernity: their volatility despite and through intense social
networks, technology, and consumption. This book inquires into the
cultural and social conditions that explain what has become an
ordinary feature of sexual and romantic relations: leaving them.
“Unloving” is the privileged terrain to understand how the intersection
between capitalism, sexuality, gender relations, and technology
generates a new form of (non) sociality.
*
Psychologists have been entrusted with the task of repairing,
shaping, and guiding our sexual and romantic life. While they have
been, on the whole, remarkably successful in convincing us that their
verbal and emotional techniques can help us live better lives, they
have produced little or no understanding of what plagues our
romantic lives collectively. Surely the myriad stories heard in the
privacy of psychological consultation have a recurring structure and
common themes that transcend the particularity of their tellers. It is
not even difficult to guess the recurring theme and structure of the
complaints voiced in those settings: “Why do I have difficulties
forming or maintaining intimate, loving relationships?” “Is this
relationship good or bad for me?” “Should I stay in this marriage?”
What is common to the questions endlessly reverberated throughout
continual all-invasive therapeutic advice in the form of counseling,
workshops, or self-help books used to guide our life is a deep,
nagging uncertainty about emotional life, a difficulty to interpret our
own and others’ feelings, knowing how and what to compromise
about, and a difficulty in knowing what we owe others and what they
owe us. As psychotherapist Leslie Bell put it: “[I]n interviews and in
my psychotherapy practice with young women, I have found them to
be more confused than ever about not only how to get what they
want, but what they want.”6 Such confusion, common inside and
outside the office of psychologists, is often taken to be the result of
the ambivalence of the human psyche, the effect of a delayed entry
into adulthood, or of a psychological confusion produced by
conflicting cultural messages about femininity. Yet, as I show in this
book, emotional uncertainty in the realm of love, romance, and sex is
the direct sociological effect of the ways in which the consumer
market, therapeutic industry, and the technology of the Internet have
been assembled and embedded by the ideology of individual choice
that has become the main cultural frame organizing personal
freedom. The type of uncertainty that plagues contemporary
relationships is a sociological phenomenon: it did not always exist, or
at least not to this extent; it was not as widespread, at least not to
this extent; it did not have the content it has today for men and
women; and it certainly did not command the systematic attention of
experts and knowledge systems of all persuasions. The puzzles,
difficulties, and elusiveness that are the characteristics of many
relationships and the source of psychological gloss are nothing but
an expression of what we may call a generalized “uncertainty” in
relations. That so many modern lives display the same uncertainty
does not point to the universality of a conflicted unconscious but
rather to the globalization of the conditions of life.
 This book is another installment in a two-decades-long study on
the ways in which capitalism and the culture of modernity have
transformed our emotional and romantic life. If there is a single tenet
that my work on emotions has advocated for the last twenty years it
is that the analysis of the disorganization of private, intimate life
cannot come from psychology alone. Sociology has an immense
contribution to make in its insistence that psychological experiences
—needs, compulsions, inner conflicts, desires, or anxiety—play and
replay the dramas of collective life, and that our subjective
experience reflects and prolongs social structures, are, in fact,
concrete, embodied, lived structures. A non-psychological analysis
of the inner life is all the more urgent because the capitalist market
and consumer culture compel actors to make their interiority into the
only plane of existence that feels real, with autonomy, freedom, and
pleasure in all its forms as guidelines for such interiority.7 While we
may experience our retreat to individuality, emotionality, and
interiority as sites of self-empowerment, we are in fact ironically
implementing and performing the very premises of an economic and
capitalist subjectivity, which fragments the social world and makes its
objectivity unreal. This is why a sociological critique of sexuality and
emotions is crucial to a critique of capitalism itself.
I bring my inquiry into emotional life, capitalism, and modernity to
a preliminary conclusion by engaging more forcefully with the
question that has been put on the table of liberal philosophy since
the nineteenth century: does freedom jeopardize the possibility of
forming meaningful and binding bonds, more specifically romantic
bonds? In its general form, this question has been insistently asked
for the last two hundred years, in the context of the demise of
community and the rise of market relations,8 but has been less
frequently raised in the emotional realm, and this despite the fact
that emotional freedom has entirely redefined the nature of
subjectivity and inter-subjectivity and is no less central to modernity
than other forms of freedom. Nor is it less fraught with ambiguities
and aporias.
 Love as Freedom

Love—the quintessentially fusional emotion—paradoxically contains

a fragment of the vast and complex history of autonomy and
freedom, a history that has been told mostly in political terms. To
take one example, the genre of the romantic comedy—which
emerged with the Greek Menander, continued with the Romans (the
plays of Plautus or Terence), and flourished in the Renaissance—
expressed the claim to freedom by young people against parents,
tutors, and old men. While in India or China love was told in stories
shaped by religious values, was part and parcel of the life of gods,
and did not as such oppose social authority, in Western (and to a
relative but lesser extent Eastern) Europe and in the United States,
love progressively detached itself from the religious cosmology and
was cultivated by aristocratic elites in search of a life-style.9 As a
result, love, previously destined to God,10 was the main vector for
the formation of emotional individualism,11 directing emotions to a
person whose interiority is perceived as independent from social
institutions. Love slowly affirmed itself against rules of endogamy,
against patriarchal or church authority, and against community
control. An eighteenth-century bestseller like Julie ou la Nouvelle
Héloïse (1761) raised the question of the individual’s right to his or
her sentiments, and thus the right to choose the object of his or her
love and to marry according to one’s will. Interiority, freedom,
emotions, and choice formed a single matrix, which would
revolutionize matrimonial practices and the place of marriage. Will, in
this new cultural and emotional order, was no longer defined as the
capacity to regulate one’s desires (as in Christian religiosity), but
precisely as the opposite capacity to act according to their injunction,
and to choose an object that corresponded to individual emotions as
emanating from one’s will. In that respect, in the personal realm
romantic love and emotions became the ground for moral claims to
freedom and autonomy, as powerful as these would be in the public
and male realm of politics, with the exception that this revolution did
not have its public demonstrations, Parliament bills, and physical
struggles. It was led by novelists, proto feminists, philosophers, and
thinkers on sexuality as well as by ordinary men and women. The
claim to emotional autonomy contained in love was a powerful agent
of social change, altering in fundamental ways the process of pairing
up, the vocation of marriage, and the authority of traditional social
agencies.12 And thus, while seemingly private and emotional,
romantic love in fact contained a proto political aspiration. The right
to choose one’s object of love became slowly the right to make
individuals’ feelings be their own source of authority,13 itself an
important part of the history of autonomy. The history of love in the
West is thus not just a minor theme in the large-scale fresco of the
history of modernity but was in fact a principal vector recasting the
relationship of individuals to marriage and kinship, with dramatic
consequences for the relationship that marriage had hitherto
entertained with the economic sphere. Bestowing moral authority to
love and sentiments changed marriage, and in changing marriage it
changed patterns of reproduction and sexuality, of economic
accumulation and exchange.14
What we call emotional and personal freedom is a multiform
phenomenon that emerged with the consolidation of a private
sphere, far away from the long arm of the community and the
Church, and slowly became protected by the state and by privacy
laws; it fed into the cultural upheavals spearheaded by artistic elites
and later by media industries; and finally, it helped formulate
women’s rights to dispose of their bodies (a woman’s body had not
belonged to her but more properly to her guardians). Emotional
autonomy thus contains claims about the freedom of the interiority of
the subject as well as (later) claims to sexual-bodily freedom even if
both types of freedoms have different cultural histories: emotional
freedom is grounded in the history of freedom of conscience and in
the history of privacy, while sexual freedom evolved from the history
of women’s struggle for emancipation and from new legal
conceptions of the body. Women indeed did not properly own their
bodies until recently (they could not, for example, refuse the sexual
act to their husband). Sexual and emotional freedom became closely
intertwined, the two becoming handmaidens of each other under the
broad category of libertarian self-ownership: “The libertarian principle
of self-ownership says that each person enjoys, over herself and her
powers, full and exclusive rights of control and use, and therefore
owes no service or product to anyone else that she has not
contracted to supply.”15 More concretely, the libertarian principle of
self-ownership includes freedom to have and own one’s feelings and
the freedom to own and control one’s body that would later entail the
freedom to choose one’s sexual partners and to enter and exit
relationships at will. In short, self-ownership includes the conduct of
one’s emotional and sexual life from within the space of one’s
interiority, without hindrance from the external world, thus letting
emotions, desires, or subjectively defined goals determine one’s
choices and experiences. Emotional freedom is a particular form of
self-ownership in which emotions guide and justify the freedom to
have physical contact and sexual relations with a person of one’s
emotional choosing. This form of emotional and bodily self-
ownership marks the shift to what I suggest calling “emotional
modernity.” Emotional modernity was in the making from the
eighteenth century onward, but became fully realized after the 1960s
in the cultural legitimation of sexual choice based on purely
subjective emotional and hedonic grounds and has observed yet a
new development with the advent of Internet sexual and romantic
apps.
Anthony Giddens was one of the first sociologists to make explicit
the nature of emotional modernity, viewing intimacy as the ultimate
expression of individuals’ freedom, of his or her progressive
unmooring from older frames of religion, tradition, and from marriage
as a framework for economic survival.16 For Giddens, individuals
have the resources to shape from within themselves the capacity to
be autonomous and intimate at once. The price to be paid for this,
according to him, is a state of “ontological insecurity,” a permanent
anxiety. But on the whole his much discussed concept of “pure
relationship” was a descriptive and normative endorsement of
modernity, since it suggested that intimacy enacted the core values
of the modern liberal subject as being aware of her and his rights,
able to implement these rights, most notably in the capacity to enter
and exit close relationships at will through an implicit contract. For
Giddens the subject entering the pure relationship is free,
knowledgeable about his or her needs, and able to negotiate with
another on such needs. The pure relationship was the liberal social
contract writ large. In a resonant vein, for Axel Honneth (and Hegel
before him), freedom comes to its realization through a relationship
to another.17 Freedom is thus the normative ground for love and the
family, with the family becoming the very expression of freedom
realized in a caring unit. Thus, both Giddens and Honneth
complexify the traditional model of liberalism in which the self views
the other as an obstacle to one’s freedom: for both thinkers the free
self comes to its full realization through love and intimate
relationships.
But as this book is set to show, this model of freedom raises new
questions. Intimacy is no longer—if it ever was—a process of two
fully aware subjects entering a contract the terms of which they both
know and agree on. Rather, the very possibility of drawing a
contract, of knowing its terms, of knowing and agreeing on the
procedures to enforce it has become distressingly elusive. For a
contract to be entered into, there must be an agreement on its terms;
it presupposes a clearly defined will, aware of what it wants; it entails
a procedure to enter into an agreement, and a penalty in case one of
the two signatories defaults. Finally, by definition, a contract includes
clauses against surprises. These conditions for contract-based
relationships are hardly present in contemporary relationships.
The institutionalization of sexual freedom via consumer culture
and technology has had an opposite effect: it has made the
substance, frame, and goal of sexual and emotional contracts
fundamentally uncertain, up for grabs, incessantly contested, making
the metaphor of contract highly inadequate to grasp what I call the
negative structure of contemporary relationships—the fact that
actors do not know how to define, evaluate, or conduct the
relationship they enter into according to predictable and stable social
scripts. Sexual and emotional freedom have made the very
possibility of defining the terms of a relationship into an open-ended
question and a problem, at once psychological and sociological. Not
contractual logic but a generalized, chronic and structural uncertainty
now presides over the formation of sexual or romantic relations.
While we have commonly assumed that sexual and emotional
freedoms mirror each other, that they sustain and reflect each other,
this book casts a doubt on this assumption and begs to suggest that
emotional and sexual freedom follow different institutional and
sociological paths. Sexual freedom is nowadays a realm of
interaction where “things run smoothly”: actors dispose of a large
abundance of technological resources and cultural scripts and
images to guide their behavior, to find pleasure in an interaction, and
to define the boundaries of the interaction. Emotions, however, have
become the plane of social experience that “poses a problem,” a
realm where confusion, uncertainty, and even chaos reign.
In tackling sexual freedom through the question of the emotional
experiences it generates or does not generate, this study hopes to
skirt altogether the conservative lament on sexual freedom and the
libertarian view that freedom trumps all other values. Instead, it will
engage critically with the meaning of emotional and sexual freedom
by exploring empirically its impact on social relationships. Whether
endorsed or condemned, freedom has an institutional structure,
which in turn transforms self-understandings and social relations.
This impact must be examined by suspending a priori assumptions
about the merits of monogamy, virginity, the nuclear family, of
multiple orgasms, and group or casual sex.

The Malaise with a Critique of Freedom

Such inquiry is bound to generate unease or resistance from a

number of intellectual quarters. The first comes from sexual
libertarians for whom to criticize (sexual) freedom is tantamount to
being in a “reactionary phase of hysterical moralism and prudery”—
to quote Camille Paglia’s stern condemnation.18 However, this
position is itself equivalent to the claim that a critique of economic
freedom and deregulation is a return to a hysterical desire to build
kolkhozes. The critique of freedom has been the prerogative of
conservatives as much as of emancipatory scholars and nothing
about it calls for a return to moral prudery, shaming, and double
standard. The critical examination of the current state of emotional
and sexual freedom is in fact a return to the core questions of
classical sociology: What is the fault line between freedom and
anomie?19 When does freedom end and amoral chaos start? In that
sense, my inquiry about the social and emotional impact of sexual
freedom here marks a return to the core of Durkheim’s questions on
social order and anomie: I interrogate how the intrusion of capitalism
in the private sphere has transformed and disrupted core normative
principles of that sphere.
A second objection can come from various academic disciplines
such as cultural studies, queer studies, and gender studies that have
traditionally been preoccupied with disenfranchisement, thus
implicitly or explicitly making freedom the supreme value orienting
their scholarship. As Axel Honneth correctly claims: for moderns,
freedom trumps most or all values, including equality and justice.20
All in their different styles, libertarian feminists and gay activists
(especially the pro-porn activists and scholars), literary scholars and
philosophers, have viewed freedom as the most vulnerable of all
goods and have thus been reluctant to focus on its pathologies,
except when it takes the form of the tired critique of neo-liberalism or
when it refers to “narcissism” or “utilitarian hedonism” fostered by the
consumer market. To this reluctance one may offer two different
types of responses. The first has been very well formulated by
Wendy Brown: “Historically, semiotically, and culturally protean, as
well as politically elusive, freedom has shown itself to be easily
appropriated in liberal regimes for the most cynical and un-
emancipatory political ends.”21 If that is the case, then freedom is a
social arrangement we should always be eager both to preserve and
to question. The second response to the objection follows from the
first and is methodological. Relying on David Bloor’s principle of
symmetry—examining different phenomena in a symmetrical way
without presuming to know who is good or bad, victor or loser—we
may suggest that freedom should be examined critically in a
symmetrical way in both the economic and the interpersonal
realms.22 If we, critical scholars, analyze the corrosive effects of
freedom in the realm of economic action, there is no reason not to
inquire about these effects in the personal, emotional, and sexual
realms. The neo-con celebration of markets and political freedom
and the seemingly progressive celebration of sexual freedom should
be equally scrutinized not in the name of neutrality as Richard
Posner demands in his study of Sex and Reason,23 but in the name
of a more encompassing view of the effects of freedom.24 The
principle of symmetry is relevant in yet another respect: critiques of
the current sexualization of culture come from several cultural
quarters—from movements for a-sexuality that reject the centrality of
sexuality in definitions of healthy selves; from feminists and
psychologists worried about the effects of the sexualization of
culture; and finally from Christian majorities and (mostly Muslim)
religious minorities living in Europe and in the United States. All
these critiques are uneasy about the intensity of the sexualization of
culture. Feminist scholars are the only ones who have paid attention
to this unease, and anthropologists like Leila Abu-Lughod and Saba
Mahmood have criticized Eurocentric models of sexual emancipation
from the standpoint of the subjectivity of Muslim women,25 inviting us
to imagine other forms of sexual and emotional subjectivities. The
critical examination of sexuality in this book does not stem from a
puritan impulse to control or regulate it (I do not have such program
in mind), but rather from a desire to historicize and contextualize our
beliefs about sexuality and love, and to understand what in the
cultural and political ideals of sexual modernity may have been
hijacked or distorted by economic and technological forces that
conflict with emotional ideals and norms held as essential for love. If
this work is traversed by an implicit norm, it is that love (in all its
forms) remains the most meaningful way to form social relationships.
 A final possible objection to my query has to do with the looming
presence of the work of Michel Foucault in the human and social
sciences. His Discipline and Punish,26 has been widely influential,
spreading the suspicion that democratic freedom was a ploy to mask
the processes of surveillance and disciplining entailed by new forms
of knowledge and control of human beings. Sociologists devoted
their attention to surveillance and viewed, à la Foucault, freedom as
a liberal illusion, undergirded by a powerful system of discipline and
control. In that sense, freedom as such was a less interesting object
of study than the illusion of subjectivity that freedom creates. Yet, at
the end of his life, in his Cours at the Collège de France, Foucault
increasingly paid attention to the relationship between freedom and
governmentality, that is, to the ways in which the idea of freedom in
the market had redefined, in his words, a field of action.27 My book
subscribes to the late work of Foucault from the standpoint of a
cultural sociology of emotions.28 It views freedom as indeed a
restructuring of a field of action, as the most powerful and
widespread cultural frame organizing the sense of morality,
conception of education and relationships, the fundaments of our
law, visions and practices of gender, and, more broadly, the basic
definition of selfhood of modern people. For a sociologist of culture,
freedom is not a moral and political ideal upheld by courts, but
represents an enduring, deep, and widespread cultural frame
organizing modern people’s self-definition and relationship to others.
As a value relentlessly harbored by individuals and institutions, it
orients a myriad of cultural practices, the most salient of which is
perhaps that of sexual subjectivity defined as “a person’s experience
of herself as a sexual being, who feels entitled to sexual pleasure
and sexual safety, who makes active sexual choices, and who has
an identity as a sexual being.”29 Where Foucault debunked sexuality
as a modern practice of self-emancipation ironically perpetuating the
Christian cultural obsession with sex, I focus on another question:
how does sexual freedom, expressed in consumer and technological
practices, reshape the perception and practice of romantic relations,
at their beginning, in their formation, and during shared domestic
life?
The question of freedom has become even more pressing as the
public philosophy and legal organization of liberal polities has
privileged one specific type of liberty, namely negative liberty—
defined as the freedom of actors to do what they please without
hindrance from the external world, as long as they do not hurt others
or obstruct their freedom. Such freedom is guaranteed by law and
cultivated by many institutions supposed to guarantee one’s rights
and privacy and that contain little or no normative content. It is the
“emptiness” of negative freedom that has created a space (the space
of “non-hindrance”) that could be easily colonized by the values of
the capitalist market, consumer culture, and technology, which have
become the most powerful institutional and cultural arenas of
modern societies. As Karl Marx remarked long ago, freedom
contains the risk of letting inequalities flourish unhindered. Catharine
MacKinnon drives this point aptly: “[T]o privilege freedom before
equality, freedom before justice, will only further liberate the power of
the powerful.”30 Freedom then cannot trump equality, because
inequality vitiates the possibility of being free. If heterosexuality
organizes and naturalizes inequality between the sexes, we can
expect freedom to meet, confront, or naturalize such inequality. Only
rarely does freedom trump inequality in heterosexual relationships.
What Isaiah Berlin called “negative freedom” has let the language
and the practices of the consumer market reshape the vocabulary
and grammar of subjectivity. The same language of interests,
utilitarianism, instant satisfaction, ego-centered action, accumulation,
variety, and diversity of experiences now pervades romantic and
sexual bonds and thus demands from us a sobering inquiry into the
meaning and impact of freedom, without, however, ever putting into
question the moral progress that the struggles of feminist and
LGBTQ movements represent. To endorse the historical
accomplishments of these movements and to continue their struggle
should not prevent us from examining the ways in which the moral
ideal of freedom has been deployed historically and empirically in
market forms, which also appeal to freedom.31 In fact, understanding
how ideas and values, once institutionalized, have a trajectory that is
not always the one intended by their proponents will help reclaim the
initial ideal of freedom, which was the impulse behind these
movements. Thus if neoliberalism has notoriously entailed a demise
of normativity in economic transactions (transforming public
institutions into profit-making organizations and turning self-interest
into the natural epistemology of the actor), there is no reason not to
ask whether sexual freedom does not have similar effects on
intimate relationships, that is, whether they do not mark a demise of
normativity in naturalizing self-centered pleasure and instituting
sexual competition and sexual accumulation, thereby letting
relationships go unregulated by moral and ethical codes. In other
words, has sexual freedom become the neoliberal philosophy of the
private sphere,32 a discourse and practice that melts away the
normativity of relations, naturalizes the consumer ethic and
technology as a new form of emotional self-organization, and makes
the normative and moral core of intersubjectivity less intelligible?
While freedom itself has been a powerful normative claim to oppose
the institution of forced or loveless marriages, to assert the right for
divorce, to conduct one’s sexual and emotional life according to
one’s inclinations, to grant equality to all sexual minorities, we may
wonder if today that same freedom has not unmoored sexual
relations from the moral language in which it was initially steeped (for
example by disposing of the language of obligation and reciprocity in
which all or at least most social interactions had been traditionally
organized). In the same way that contemporary monopolistic
capitalism contradicts the spirit of free exchange that was at the
center of early conceptions of the market and commerce, a sexual
subjectivity tightly organized by consumer and technological culture
conflicts with the vision of emancipated sexuality, which was at the
heart of the sexual revolution, because such sexuality ends up
reproducing, compulsively, the very schemes of thought and action
that make technology and economy the invisible movers and
shapers of our social bonds.
 Heterosexuality is a more privileged terrain from which to study
this question than homosexuality for a number of reasons. In its
present form, heterosexuality is based on gender differences, which
more often than not function as gender inequalities; heterosexuality
in turn organizes these inequalities in an emotional system that
places the burden of success or failure in relationships on people’s
psyche, mostly women’s. Freedom makes emotional inequalities go
undetected and unaddressed. Men and women, but mostly women,
turn to their psyche in order to manage the symbolic violence and
wounds contained in such emotional inequalities: “Why is he
distant?” “Am I acting too needy?” “What should I do to catch him?”
“What mistakes did I do to let him go?” All these questions, asked for
women and by women, point to the fact that heterosexual women
feel culturally largely responsible for the emotional success and
management of relationships. In contrast, homosexuality does not
translate gender into difference and difference into inequality, nor is it
based on the gender division between biological and economic labor
that has characterized the heterosexual family. In that sense, the
study of the effect of freedom on heterosexuality is sociologically
more urgent: because it interacts with the still-pervasive and
powerful structure of gender inequality, sexual freedom makes
heterosexuality ridden with contradictions and crisis.33 Moreover,
because heterosexuality was closely regulated and codified by the
social system of courtship supposed to lead to marriage, the shift to
emotional and sexual freedom enables us to grasp in a crisper way
the impact of freedom on sexual practices and the contradiction such
freedom may have created with the institution of marriage (or
partnership) that remains at the heart of heterosexuality. In contrast,
homosexuality was, until recently, a clandestine and oppositional
social form. For that reason, it was ab origine defined as a practice
of freedom, conflicting and opposing the domestic institution of
marriage, which used and alienated women and ascribed men to
patriarchal roles. This book then is an ethnography of contemporary
heterosexuality (although I occasionally interviewed homosexuals as
well), which, as a social institution, has been under the push-and-pull
of forces at once emancipatory and reactionary, modern and
traditional, subjective and reflective of the capitalist, consumerist,
and technological forces of our society.
My approach to emotional and sexual freedom contrasts with
various forms of libertarianism for which pleasure constitutes a final
telos of experience and for which the astounding expansion of
sexuality in all walks of consumer culture is the welcome sign that—
in Camille Paglia’s trenchant words—popular culture (and its sexual
content) is “an eruption of the never-defeated paganism of the
West.”34 For sexual libertarians, sexuality mediated by consumer
market frees sexual desire, energy, and creativity, and calls on
feminism (and presumably other social movements) to open
themselves up to “art and sex in all their dark, unconsoling
mysteries.”35 Such a view is seductive but it rests on the naive
assumption that the market forces that drive popular culture in fact
channel and coincide with primary creative energy, rather than, for
example, spread the economic interests of large corporations
seeking to encourage a subjectivity based on the quick satisfaction
of needs. I can see no convincing reason to assume that the
energies tapped into by the market are more naturally “pagan” than
they are, for example, reactionary, conformist, or confused. As a
prominent queer theorist put it, Margaret Thatcher and Ronald
Reagan, who advocated family values, actually enabled the greatest
sexual revolution in their neoliberal policies, which deregulated
markets.36 “Individual freedom cannot stop at the market; if you have
an absolute freedom to buy and sell, there seems to be no logic in
blocking your sexual partners, your sexual lifestyle, your identity or
your fantasies.”37

Choice

Rather than being the expression of raw pagan energy freed by

amoral popular cultures, contemporary sexuality is the vector for a
number of social forces, which undermine the values that animated
the struggle for sexual emancipation. Sexuality has become the site
of psychological human techniques, of technology and the consumer
market, which have in common the fact that they both provide a
grammar of freedom that organizes and translates desire and
interpersonal relations into a sheer matter of individual choice.
Choice—sexual, consumer, or emotional—is the chief trope under
which the self and the will in liberal polities are organized. To have a
modern or late-modern self is to exercise choice and to increase the
subjective experience of choice.
Choice is the trope of selfhood linking freedom to the economic
and emotional realms; it is the main modality of subjectivity in the
consumer and sexual realms. Choice contains two separate ideas:
one refers to the supply of goods, namely that something exists
objectively in large supply (as in “this supermarket supplies a large
choice of fresh organic vegetables”), while the second touches on a
property of subjectivity, as when an individual faced with possibilities
makes a decision also called choice (as in “she made the right
choice”). Choice then expresses both a certain organization of the
world, which presents itself as an assorted set of possibilities
encountered by the subject in a direct, unmediated way, and an
organization of the will into wants, emotions, and desires. A choosing
will is a specific kind of deliberative will, facing a world that seems to
be structured like a market, that is, as a set of abundant possibilities,
which the subject must seize and choose in order to satisfy and
maximize his or her well-being, pleasure, or profit. From the
standpoint of a sociology of culture, choice represents the best way
to understand how the formidable structure of the market translates
into cognitive and emotional properties of action. The specific will
entailed by a culture of choice has considerably changed under the
impact of technology and consumer culture, compelling us to ask
sociological questions about the relationship between the economy
of desire and traditional social structures.
This book explores then the following line of argument: Under the
aegis of sexual freedom, heterosexual relationships have taken the
form of a market—the direct encounter of emotional and sexual
supply with emotional and sexual demand.38 Both—supply and
demand—are heavily mediated by objects and spaces of
consumption and by technology (chapter 2). Sexual encounters
organized as a market are experienced both as choice and
uncertainty. By letting individuals negotiate themselves the
conditions of their encounter with only very few regulations or
prohibitions, this market-form creates a widespread and pervasive
cognitive and emotional uncertainty (chapter 3). The concept of the
“market” is not here simply an economic metaphor, but is the social
form taken by sexual encounters that are driven by Internet
technology and consumer culture. When people meet on an open
market, they meet each other directly with no or little human
mediators; they do it through technologies that aim at increasing the
efficiency of the search for a mate; they do it using scripts of
exchange, time efficiency, hedonic calculus, and a comparative
mindset, all characteristic of advanced capitalist exchange. A market
is open-ended in the sense that it is a social form governed by
supply and demand, themselves structured by social networks and
social positions of actors. Sexual exchange located on a market
leaves women in an ambivalent position: at once empowered and
demeaned through their sexuality (see chapter 4), an ambivalence
that points to the ways in which consumer capitalism works through
empowerment. The nexus of sexual freedom-consumer culture-
technology and a still-powerful male domination in the sexual arena
undermines the possibility of entering and forming what had been
the main social form assumed by the market and marriage, namely
the contract (chapter 5). Leaving relationships, being unable or
unwilling to enter a relationship, moving from one relationship to
another—what I put under the broad term of unloving—are part and
parcel of this new market-form taken by sexual relationships. These
difficulties and uncertainties carry over to the very institution of
marriage (chapter 6). Unloving is the signpost of a new form of
subjectivity in which choice is exercised both positively (wanting,
desiring something), and negatively (defining oneself by the
repeated avoidance or rejection of relationships, being too confused
or ambivalent to desire, wanting to accumulate so many experiences
that choice loses its emotional and cognitive relevance, leaving and
undoing relationships serially as a way to assert the self and its
autonomy). Unloving then is at once a form of subjectivity—who we
are and how we behave—and a social process that reflects the
profound impact of capitalism on social relationships. As sociologists
Wolfgang Streeck and Jens Beckert have convincingly argued,
capitalism transforms social action, and one may add, social
sentiments.39
*
In War and Peace, the hero, Pierre Bezukhov meets Prince Andrew,
who inquires about him. “Well, have you at last decided on anything?
Are you going to be a guardsman or a diplomat?” asks Prince
Andrew after a momentary silence.40 Choice, in his formulation, is an
alternative between two clear options, known to the person who
must make a choice and to the outside observer. It is an act that has
unmistakable boundaries: to choose one option is necessarily to
exclude the other. Moreover, Prince Andrew’s question assumes
what many economists and psychologists have claimed, namely that
choice is a matter of personal preference and of information. For
Pierre to choose his profession, he simply needs to exercise the
(universal) capacity to know and hierarchize his own preferences, to
figure out if he prefers the art of war or the art of diplomacy, two neat
and clearly differentiated options. Since the end of the nineteenth
century, sociologists have taken issue with this view of human
action, arguing that human beings are creatures of habit and
normative compliance rather than of deliberate decision. As James
Duesenberry quipped: “Economics is all about how people make
choices; sociology is all about how they don’t have any choices to
make.”41 Yet, sociologists may have missed what economists and
psychologists unknowingly grasped: that capitalism has transformed
many arenas of social life into markets, and social action into a
reflexive choice and decision-making, and that choice has become a
new and crucial social form, through which and in which modern
subjectivity understands and realizes itself in most or all aspects of
their life.42 It would not be an exaggeration to claim that the modern
subject grows into adulthood by exercising her capacity to engage in
the deliberate act of choosing a large variety of objects: her sartorial
or musical tastes, her college degree and profession, her number of
sexual partners, the sex of her sexual partners, her own sex itself,
her close and distant friends are all “chosen,” the result of reflexively
monitored acts of deliberate decision. Worried that endorsing the
idea of choice would be a naive and voluntarist endorsement of
rational action, sociologists dismissed and missed altogether the fact
that choice had become not only an aspect of subjectivity but a way
to institutionalize action as well. Instead, sociologists persisted in
viewing choice as a pillar of the ideology of capitalism, as the false
epistemological premise of economics, as the flagship of liberalism,
as a biographical illusion produced by the psychological sciences, or
as the principal cultural structure of consumer desire. The
perspective offered here is different: while sociology has
accumulated an indisputable amount of data showing that
constraints of class and gender operate and structure choice from
within, it remains that whether illusory or not, choice is a fundamental
mode for modern subjects to relate to their social environment and to
their own self. Choice structures modes of social intelligibility. For
example, the “mature and healthy self” is one that develops the
capacity to make emotionally mature and authentic choices; to flee
compulsive, addictive behaviors; and to transform them into a freely
chosen, informed, self-conscious emotionality. Feminism presented
itself as a politics of choice: In her official site, Stephenie Meyer, the
author of the worldwide bestseller series Twilight, puts it succinctly,
“[T]he foundation of feminism is this: being able to choose. The core
of anti-feminism is, conversely, telling a woman she can’t do
something solely because she’s a woman—taking any choice away
from her specifically because of her gender.”43 “Pro-choice” is even
the nickname of one the most important strands of the feminist
movement. Consumer culture—arguably the fulcrum of modern
identity—is based almost axiomatically on the incessant practice of
comparison and choice. Even if choices are in practice limited and
determined, it remains that a good chunk of modern lives are
experienced and stylized as the result of subjective choice, a fact
that changes in a significant way how people shape and experience
their own subjectivity. Choice then is a major cultural story of modern
people. If choice has become the main vector of subjectivity in the
various institutions of marriage, work, consumption, or politics—how
people enter and feel as members of these institutions—it must
become a category worthy of sociological inquiry in itself, a form of
action in its own right, shot through by cultural frames, the most
prominent of which are “freedom” and “autonomy.” Institutionalized
freedom produces a quasi-endless set of possibilities in the realm of
consumption, ideas, tastes, and relationships, and compels the self
to perform and enact its self-definition through myriad acts of choice
that have different and definite cognitive and emotional styles (e.g.,
choosing a mate or choosing a career now entail different cognitive
strategies). Thus choice is not only a widespread ideology as Renata
Salecl has showed us so well,44 but a real concrete effect of the
institutionalization of autonomy in most social institutions (the school,
the market, the law, consumer market) and in political movements
(feminism, gay rights, transgender rights). Choice is a practical
relation one has to oneself where one aims to live according to one’s
“true” and “ideal” self by transcending and overcoming the
determinism of class, age, or gender (by getting a college degree, by
undergoing cosmetic surgery, by changing one’s sexual assignation).
Under the influence of economic thought, we have been mostly
interested in positive acts of choice—what is called “decision-
making”—but we have let slip from our attention a far more
significant aspect of choice, namely negative choice, the rejection,
avoidance, or withdrawal from commitments, entanglements, and
relationships in the name of freedom and self-realization. The
intellectual (and cultural) situation was apparently different at the
beginning of the twentieth century when famous thinkers like
Sigmund Freud and Émile Durkheim had inquired about “negative
relations,” Freud under the heading of the death instinct and
Durkheim under that of anomie. In 1920, in an essay known as
“Beyond the Pleasure Principle,” Freud confronted the compulsion to
repeat and rehearse distressing experiences, a repetition that could
lead to the self-destruction of the subject, to his or her impossibility
to fully enter or maintain relationships. Earlier, in 1897, Durkheim
had published the founding text of sociology, Suicide,45 which may
be viewed as an inquiry into negative relations, a sociality in reverse,
that is, into the undoing of social membership. Both Freud and
Durkheim have seized at once two conflicting principles, sociality
and anti-sociality, as coextensive and contiguous. I continue in their
footsteps without, however, viewing anti-sociality in essentialist
terms. Instead, I explore negative sociality as an expression of
contemporary ideologies of freedom, of technologies of choice, and
of advanced consumer capitalism, in fact as part and parcel of the
symbolic imaginary deployed by capitalism. In neo-liberal sexual
subjectivity, negative sociability is not experienced as a negative
mental state (made of fear, or thoughts of death or isolation), but
rather as what Günther Anders called “self-assertive freedom,” a
freedom in which the self affirms itself by negating or ignoring
others.46 Self-assertive freedom is perhaps the most prevalent form
of freedom in personal relationships and, as I show, presents all the
moral ambiguities of freedom in the institution of heterosexuality.

Negative Choice

Sociologists of modernity have viewed the period ranging from the

sixteenth to the twentieth centuries as one that saw the
generalization to all social groups of the cultivation of new forms of
relationships—the love marriage, the disinterested friendship, the
compassionate relationship to the stranger, and national solidarity, to
name a few. All of these can be said to be novel social relations,
novel institutions, and novel emotions all in one, and they are all
resting on choice. Early emotional modernity was thus a modernity in
which freedom (to choose) was institutionalized and individuals
experienced their freedom in the refinement of the practice of choice,
experienced through emotions. Bonds of “friendship,” “romantic
love,” “marriage,” or “divorce” were self-contained, bounded social
forms, containing clear emotions and names for these emotions,
studied by sociology as definable and relatively stable empirical and
phenomenological relationships. In contrast, our contemporary
hyperconnective modernity seems to be marked by the formation of
quasi-proxy or negative bonds: the one-night stand, the zipless fuck,
the hookup, the fling, the fuck buddy, the friends with benefits, casual
sex, casual dating, cybersex, are only some of the names of
relationships defined as short-lived, with no or little involvement of
the self, often devoid of emotions, containing a form of autotelic
hedonism, with the sexual act as its main and only goal. In such
networked modernity, the non-formation of bonds becomes a
sociological phenomenon in itself, a social and epistemic category in
its own right.47 If early and high modernity were marked by the
struggle for certain forms of sociability where love, friendship,
sexuality would be free of moral and social strictures, in networked
modernity emotional experience seems to evade the names of
emotions and relations inherited from eras where relationships were
more stable. Contemporary relationships end, break, fade,
evaporate, and follow a dynamic of positive and negative choice,
which intertwine bonds and non-bonds.
It is this dynamic I want to elucidate in this book, thereby
continuing my previous preoccupation with the interaction between
love, choice, and the culture of capitalism.48 But while in my previous
study, I shed light on the changes in the very notion and structure of
choice of a mate, here I focus on another and new category of
choice: the choice to “unchoose”—a form of choice that comes after
the various struggles for freedom we saw during the last two
hundred years. If during the formation of modernity actors fought for
their right to have a sexuality unhindered by community or social
constraints, in contemporary modernity they take for granted that
sexuality is a choice and a right, unquestioned and unquestionable
(with the exception perhaps of gay marriage, which has been the
latest frontier of the old struggle). One’s freedom is incessantly
exercised by the right to not engage in or disengage from relations, a
process that we may call the “choice to unchoose”: to opt out of
relationships at any stage.
Although I am not suggesting a straightforward, direct causality,
the analogy between the history of capitalism and that of romantic
forms is striking. In its modern period, capitalism took such economic
forms as the corporation, the limited liability company, the
international financial markets, and the commercial contract. In these
economic forms, hierarchy, control, and contract are central. These
were reflected in the view of love as a contractual relationship, freely
entered, bound by ethical rules of commitment, yielding obvious
returns and demanding long-term emotional strategies and
investment. Insurance companies were crucial institutions to
minimize risks, acting as third parties between two contractors, thus
increasing the reliability of the commercial contract. This social
organization of capitalism evolved and morphed into a ramified
global network, with scattered ownership and control. It now
practices new forms of non-commitment through flextime or
outsourcing labor, providing little social safety nets, and breaking
bonds of loyalty between workers and workplaces in legislation and
practices that decreased dramatically corporations’ commitment to
workers. Contemporary capitalism has also developed instruments
to exploit uncertainty—for example, derivatives—and even makes
the value of certain goods uncertain creating “spot markets,” offering
prices that are incessantly adjusted to demand, thus simultaneously
creating and exploiting uncertainty. Practices of non-commitment
and non-choice enable a corporation’s quick withdrawal from a
transaction and the quick realignment of prices, practices that enable
corporations to quickly form and break loyalties, and the swift
renewal and changing of lines of production and the unhindered
firing of the workforce. All of these are practices of non-choice.
Choice, which was the early motto of “solid capitalism,” then has
morphed into non-choice, the practice of perpetually adjusting one’s
preferences “on the go,” not to engage in, pursue, or commit to
relationships in general, whether economic or romantic. These
practices of non-choice are somehow combined with intensive
calculative strategies of risk assessment.
Traditionally, sociology—symbolic interactionism in particular—
has almost axiomatically focused on the micro-formation of social
bonds, and has by definition been unable to grasp the more elusive
mechanism of how relationships end, collapse, evaporate, or fade. In
networked modernity, the proper object of study becomes the ways
in which bonds dissolve where this dissolution is taken to be a social
form. This dissolution of relationships occurs not through a direct
breakdown of relationships—alienation, reification,
instrumentalization, exploitation—but through the moral injunctions
that constitute the imaginary core of the capitalist subjectivity, such
as the injunction to be free and autonomous; to change, optimize the
self and realize one’s hidden potential; to maximize pleasure, health,
and productivity. It is the positive injunction to both produce and
maximize the self that shapes “negative choice.” I will show that the
choice to unchoose is now a crucial modality of subjectivity, made
possible by a variety of institutional changes: the no-fault divorce
(which made it easier for people to opt out of marriage for their own
subjective emotional reasons); the contraceptive pill, which made it
easier to have sexual relationships without institutional stakes of
marriage and thus without emotional commitment; the consumer
market of leisure, which provides a large number of venues to meet
and an ongoing supply of sexual partners; the technology afforded
by the Internet, especially by dating sites such as Tinder or
Match.com, which turn the subject into a consumer of sex and
emotions, entitled to the right to use or dispose of the commodity at
will; and finally the worldwide success of platforms like Facebook,
which both multiply relationships and which enable the quick
“unfriending” as a technical feature of a software. These and many
other less visible cultural features documented in this book make the
choice to unchoose into a dominant modality of subjectivity in
networked modernity and societies characterized by advanced
processes of commodification, the multiplication of sexual choice,
and the penetration of economic rationality to all domains of
society.49 The question of how and why actors will break, disengage
from, ignore, or neglect their relationships is all the more interesting
because there is powerful empirical evidence that actors in general
are “loss averse,” meaning50 they will go through great efforts not to
lose something they already have or can have. In fact, as chapters 2
and 3 show, in hyperconnective polities actors easily and regularly
overcome loss aversion through the convergence of market,
technology, and consumer forces. “Negative choice” is as powerful
and present in the lives of people in hyperconnective modernity as
was the positive choice to form bonds and relations with others in the
formation of modernity.
The social effects of negative choice are apparent in many
significant ways. One is the fact that many countries cannot maintain
their populations in terms of their birth rates. Young Japanese, for
example, have tremendous difficulties “in pairing up,” with the result
that “the fertility rate has plunged. The number of children a
Japanese woman can expect to have in her lifetime is now 1.42,
down from 2.13 in 1970.”51 Negative population growth rates are
observed in Eastern and much of Western Europe as well, and they
are threatening not only demography but economy as well. The
shrinkage of the population has powerful rippling political and
economic effects, from immigration flows to the difficulty of
guaranteeing pension funds or supporting aging populations. If the
expansion of capitalism was predicated on population growth and on
the family as the structure mediating between economy and society,
that connection is increasingly being undone by the new forms of
capitalism themselves. Capitalism is a formidable machine to
produce goods but is no longer capable of ensuring the social need
for reproduction, what philosopher Nancy Fraser has called
capitalism “crisis of care.”52 Negative relations are apparent in the
conscious decision or non-conscious practices by many men and
women not to enter stable bonds or have children and in the fact that
single households have considerably increased in the last two
decades.53 A second way in which negative choice is made apparent
is by the development of divorce rates. In the United States, for
example, the rate more than doubled between 1960 and 1980.54 In
2014 it was more than 45 percent for people who married in the
1970s or in the 1980s,55 making divorce a likely occurrence in a
large portion of the population. Third,more people live in multiple
relationships (of the polyamorous or other types), putting into
question the centrality of monogamy and attendant values as loyalty
and long-term commitment. An increasing number of people leave
and enter, enter and leave a larger number of relationships in a fluid
way throughout their lives. A fourth, seemingly opposite,
manifestation of non-choice is sologamy, the puzzling phenomenon
of (mostly) women who choose to marry themselves,56 thereby
declaring their self-love and affirming the worth of singlehood.
Finally, negative choice is somehow implicated in what a
commentator has called the “loneliness epidemic”: “An estimated
42.6 million Americans over the age of 45 suffer from chronic
loneliness, which significantly raises their risk for premature death,
according to a study by AARP (American Association of Retired
Persons).57 One researcher called58 the loneliness epidemic59 “a
greater health threat than obesity.”60 The loneliness epidemic has
another form. As Jean Twenge (a psychology professor at San
Diego State University) has suggested, members of the iGen
generation (the generation after the millenials) have fewer sex
partners than members of the two preceding generations, making
the lack of sexuality a new social phenomenon, explained I would
argue, by the cultural shift to negative choice, to the quick withdrawal
from relationships or to the fact that relationships themselves never
get formed.61
In the realm of intimate relationships, choice is exerted in a
context that is very different from the one of Pierre Bezukhov, in
which choice often took place between two clear alternative paths.
Under the massive influence of new technological platforms,
freedom creates now such a large number of possibilities that the
emotional and cognitive conditions for romantic choice have been
radically transformed. Whence the question addressed here: what
are the cultural and emotional mechanisms, voluntary and
involuntary, that make people revise, undo, reject, and avoid
relationships? What is the emotional dynamic by which a preference
changes (leaving a relationship one was engaged in)? Although
many or most live in some satisfactory form of couplehood (or
temporary sexual and emotional arrangement), this book is about the
arduous path of many to reach that point as well as with the fact that
many, by choice or non-choice, do not live in a stable relationship.
This book is not an indictment of the ideal of couplehood or a plea to
return to more secure ways of forming it, but rather a description of
the ways in which capitalism has hijacked sexual freedom and is
implicated in the reasons why sexual and romantic relationships
have become puzzlingly volatile.
Much of sociology has been about the study of the regular, routine
structures of daily life and has developed to that effect an impressive
array of methods. But the contemporary era commands perhaps
another type of sociology, which I would tentatively call the study of
crisis and uncertainty. The orderliness and predictability of modern
institutions have been disrupted for large swaths of the population;
routine and bureaucratic structures coexist with a pervasive and
nagging sense of uncertainty and insecurity. If we can no longer
count on lifelong employment, on the returns of increasingly volatile
markets, on the stability of marriage, on geographical stability, then
many traditional sociological concepts have served their time. It is
high time that we listen to the practitioners of the new culture of
unloving, and therefore I conducted interviews with ninety-two
people in France, England, Germany, Israel, and the United States
from the age of nineteen to the age of seventy-two.62 Their stories
form the empirical backbone of the book—and they all bear the
traces of what Lauren Berlant calls the “crisis of ordinariness,” that
is, the low-key ways in which actors, located in different cultural
contexts and socioeconomic positions, struggle with the minute
dramas of precariousness and uncertainty,63 with the properties of
what I call negative relationships. Negative relationships obviously
take different forms in different social classes and different national
frameworks, but they contain a few recurring elements: they enact
economic and technological features; they do not gel in a stable
social form but are valued as ephemeral and transitory; and they are
practiced even when that entails loss and pain. Whether these two
processes produce pleasure or pain, they constitute, as we will see,
unloving, whereby the prefix “un-” expresses both the willful undoing
of something established (as in “untying” the knot), and the inability
to achieve something (as in “unable”). One form of unloving
necessarily precedes loving (e.g., the one-night stand) and another
follows it (the divorce). Both cases enable us to understand the
conditions of emotions and relationships in the era of radical
personal freedom. It is this condition I decipher in this book.
 2
Pre-Modern Courtship, Social Certainty,
and the Rise of Negative Relationships

After all, if my generation of writers represents anything, if

there’s anything we’ve fought for, it’s a sexual revolution.
—Norman Mailer1

Anthony Trollope’s 1884 novel An Old Man’s Love offers a powerful

literary illustration of the ways in which in the nineteenth century,
emotions were aligned with the social norm of matrimony. The author
tells the story of the young Mary Lawrie, an orphan who has been
taken to live in the household of old Mr. Whittlestaff. Because Mr.
Whittlestaff has never been married, Mary anticipates the decision
she will have to make when he proposes. She muses about her
decision in the following way:

She told herself that he personally was full of good gifts. How different
might it have been with her had some elderly men “wanted her,” such as
she had seen about in the world! How much was there in this man that
she knew that she could learn to love? And he was one of whom she
need in no wise be ashamed. He was a gentleman, pleasant to look at,
sweet in manner, comely and clean in appearance. Would not the world
say of her how lucky she had been should it come to pass that she
should become Mrs Whittlestaff? […] After an hour’s deliberation, she
thought that she would marry Mr Whittlestaff.2
These reflections are not formulated as an interrogation about her or
Mr. Whittlestaff’s feelings. In fact, she knows he will propose
although nothing explicit has been said. Her decision to such
presumed proposal is also clear. In a matter of one hour, Mary has
settled with herself her matrimonial future by invoking and rehearsing
mentally a set of arguments for accepting Whittlestaff’s proposal,
and these arguments have much to do with his virtues and what she
imagines “the world would say” should she become his wife. She
sees in him the same virtues that the world will see in him, thus
suggesting an overlap between private and collective judgement. In
conformity with sociological theories of the “looking glass self,”3
Mary’s decision incorporates the opinion of the world on her choice.
Her own and the world’s evaluation of Whittlestaff are shaped by
known social scripts of the good man, by norms of matrimony, and
by conventions of the proper role of a woman, as her evaluation of
him and affection for him are grounded in common standards. When
she makes up her mind she participates in this known and common
world. Her feelings and her decision incorporate all in one her
sentiments, the economic advantage of a marriage, and the social
expectations of a woman in her situation. Feelings and norms form a
single cultural matrix and shape directly her decision-making.
Mary’s decision and later promise to marry the old man morphs
into a dilemma when the reader is informed that three years earlier,
she had given her hand to John Gordon. The two young people had
a few brief encounters, enough to promise to marry each other after
his return from South Africa where he went to look for a fortune.
Without any news from him for three years, Mary Lawrie releases
herself from her pledge and accepts Mr. Whittlestaff’s proposal and
the drama of the novel starts when John Gordon reappears, thus
making Mary face a second and much more dramatic act of choice,
this time between two people and two different sentiments. She in
particular must choose between breaking a promise to an “old man”
she has affectionate fondness for and acting upon the emotional
pledge made to a young man she was in love with three years
beforehand. Because promise-keeping was a fundamental value to
the nineteenth-century English gentry and middle class, she makes
the honorable decision, and does not desist from her promise.
It would be tempting to view the dilemma constructed by this novel
as one opposing an emotional to a reasonable decision; social duty
to individual passion. But this would be merely confusing psychology
and sociology. In fact, each of Mary’s two choices is emotional—
affection or love—and each is congruent with the norms of her
environment. In both cases, Mary’s sentiments are closely aligned
with a normative order. To marry a man she has met three times
without sexual contact is socially as respectable as marrying the
“old” Whittlestaff. These two different emotional options lead to the
same moral and social pathway of matrimony. In both cases, Mary’s
emotions move in a hierarchized moral cosmos. In fact, it is through
her emotions that she is made to immerse herself in the normative
cosmology of matrimony in the nineteenth century.
Sociologically, rather than psychologically, Mary’s reasoned
affection to Whittlestaff and her impetuous love for Gordon, her
personal feelings and social conventions, form a single matrix.
Moreover, however confused Mary and other characters may be,
they all know the terms of one another’s hesitation. This is a world
where everybody shares the same normative information about how
the personal and the normative should be ordered. In fact, it is
precisely because Whittlestaff knows the normative constraints
under which Mary operates that he ultimately releases her of her
promise. Promise-keeping and the institution of matrimony are
normative orders that pervade desire and love and organize them
from within.
*
Émile Durkheim may be credited for being the first to have grasped
what the collapse of such emotional, normative, and institutional
order was about.4 Infrequently noticed by sociologists is the extent to
which Durkheim’s notion of anomie in his much-famed and now
canonical sociological study on suicide referred to sexual and
matrimonial desire. In extraordinarily prescient words, Durkheim
described the emotional structure of a new social type that had
appeared in French society—the single man:5

Though his [the married man’s] enjoyment is restricted, it is assured and

this certainty forms his mental foundation. The lot of the unmarried man
is different. As he has the right to form attachment wherever inclination
leads him, he aspires to everything and is satisfied with nothing. This
morbid desire for the infinite which everywhere accompanies anomy may
as readily assail this as any other part of our consciousness; it very often
assumes a sexual form which was described by Musset. When one is no
longer checked, one becomes unable to check one’s self. Beyond
experienced pleasures one senses and desires others; if one happens
almost to have exhausted the range of what is possible, one dreams of
the impossible; one thirsts for the non-existent. How can the feelings not
be exacerbated by such unending pursuit? For them to reach that state,
one need not even have infinitely multiplied the experiences of love and
lived the life of a Don Juan. The humdrum existence of the ordinary
bachelor suffices. New hopes constantly awake, only to be deceived,
leaving a trail of weariness and disillusionment behind them. How can
desire, then, become fixed, being uncertain that it can retain what it
attracts; for the anomy is twofold. Just as the person makes no definitive
gift of himself, he has definitive title to nothing. The uncertainty of the
future plus his own indeterminateness therefore condemn him to
constant change. The result of it all is a state of disturbance, agitation
and discontent which inevitably increases the possibilities of suicide.6

Durkheim here offers an extraordinary program for what we may call

a sociology of desire and of emotional decision-making: some
desires translate into direct decision-making and some don’t. The
single man’s desire is anomic because it undermines the capacity to
will an object with a definite purpose. Anomic desire is neither
depressive nor apathetic. It is, on the contrary, restless, hyper-active,
in perpetual quest of something, a state Durkheim goes as far as
calling “morbid.” It is a desire that cannot enter marriage because it
cannot create the psychic conditions to want a single object. It is a
desire that properly lacks an object, and that, in lacking an object, is
insatiable. This creates a particular form of action, one that is at once
in perpetual motion (moves from one object to the other) and lacks
an overarching purpose.
According to Durkheim then, anomic desire has a number of
characteristics: (1) It has no teleology, that is, it does not have a
purpose. It is free-floating, free-circulating, and nomadic. (2) It does
not have a teleology because it is devoid of an internal normative
peg around which one could build an overarching narrative structure.
(3) For the single man, the future is uncertain and cannot provide
guidance for the present. The married man on the other hand has a
known and certain future based on normative knowledge and
participation: He knows which pleasures are waiting for him, and,
through the very institution of marriage, is assured of their continued
possession. In contrast, the single man cannot imagine the future
and is locked in a present that contains only hopefulness—
espérance—a far more vague and amorphous sentiment than one’s
projection in the future. Through espérance one contemplates the
potentiality of a new pleasure likely to be short-lived. This type of
desire displays the properties of anomie: it lacks integration (it does
not emanate from social norms) and one does not aim to participate
in a social unit. (4) Finally, in anomic desire the subject’s inner life—
what Durkheim calls his “mental plate”—becomes indeterminate,
moving from one object to the next, and thus acts in a state of
uncertainty, unable to make a decision because of an inability to
fixate desire on a person and an institution. The married man is the
one who has by definition made a decision, while the single man can
only accumulate, indefinitely, experiences, desires, and partners,
without being able to bring the perpetual motion of his desire to an
emotional and narrative closure or decision. Uncertainty,
accumulation, motion, inability (or unwillingness) to imagine the
future—all of these constitute the essence of what Durkheim views
as anomic desire, unable to appropriate social norms or to identify
with institutions. Anomic desires exist on a plane of horizontal
equivalence. They are not organized by a hierarchized normative
and teleological cosmos, as in Trollope’s story.
 Sexual anomie is thus many things at once: an excess of desire, a
form of desire that originates in the self unmoored from social norms
and, precisely because of that, something indecisive, unable to fixate
on an object. Here a self-centered subjectivity does not have the
trenchant clarity of needs and desires, but on the contrary, is diffuse,
vague, ambivalent, and purposeless. Because such subjectivity is
unable to feel clear emotions, it cannot propel itself forward along a
narrative and normative path. Let me say this differently: The
Durkheimian single man is unable to reach a decision because his
“mental plate” is not organized around certainty. For Durkheim then,
emotions can be a source of certainty and decision-making only if
they are grounded in a clear normative structure.
Durkheim offers here the grounds for a sociology of desire and
emotional decision-making and helps articulate two grammars of
social bonds and of emotional choice: one in which desire is free-
floating, lacking in finality and originating in subjectivity; and one in
which desire is organized through things external to the self, such as
economic interests, norms of matrimony, and gender roles. These
two grammars help formulate the paradox that is at the heart of
sexual liberation: desire liberated from normative constraints and
from ritual structure obstructs emotional choice. The remainder of
this chapter is devoted to exploring these grammars.

Courtship as a Sociological Structure

It has not sufficiently been noticed that the passage from traditional
romance to the sexual order that followed the 1970s was the shift
from courtship as the prevailing mode of interaction between men
and women to an order in which rules of engagement changed
entirely, becoming fuzzy and uncertain and, at the same time, closely
regulated by an ethics of consent. The disappearance of courtship is
a rather striking feature of modern romantic practices and marks a
stark difference between traditional and contemporary romantic
practices. Therefore it deserves a more insistent scrutiny than has
Another random document with
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 TABLE OF FATAL CASES OF INHALATION OF CHLOROFORM.
No. Patient. Age Operation Position Means by Time from the Apparent Pr
in for which the whilst which the commencement mode of inha
yrs. chloroform inhaling. chloroform of inhalation to death.
was inhaled. was the beginning
exhibited. of dangerous
symptoms.
1 Girl 15 Removal of toe- Sitting Towel Half a minute Cardiac Ethe
nail. syncope
2 Married 35 Extraction of Sitting Inhaler About two Cardiac None
lady teeth. minutes syncope
3 Patrick Operation for Lying on the Handkerchief About one minute Cardiac One.
Coyle fistula in ano side syncope
4 Single lady 30 Opening of Lying Handkerchief Probably half a Cardiac None
sinus in minute syncope
thigh
5 Young Amputation of Handkerchief A very short time Cardiac None
woman the middle syncope
finger
6 Young man 22 Transcurrent Inhaler Five minutes Symptoms not None
cauterisation described
of wrist
7 Young man Intended Probably Not stated Death very None
removal of handkerchief sudden
toe-nail.
8 Seaman 31 Removal of Lying on the Napkin About ten minutes Cardiac One.
hæmorrhoids side syncope
9 Miner 17 Intended Lying Handkerchief About five Cardiac None
amputation minutes syncope
of middle
finger
10 Labourer 36 Amputation of Handkerchief Died at the close Cardiac A
toe of the operation syncope att
11 Married 33 Intended Sitting Handkerchief A very short time Cardiac One.
lady extraction of syncope
tooth
12 Porter 48 Removal of toe- Lying Inhaler A little more than Probably None
nail two minutes asphyxia
13 Married Removal of Probably A sponge Died during the Cardiac None
woman eyeball lying operation syncope
14 Young lady 20 Intended Sitting A sponge Just after Cardiac Prev
extraction of enclosed in a beginning to syncope att
tooth napkin inhale
15 A man A sponge Died before the Probably None
operation cardiac
syncope
16 Artilleryman 24 Amputation of Handkerchief Cardiac None
middle finger syncope
17 Bookkeeper 30 Intended Lying Napkin Within five Cardiac None
operation on minutes syncope
testicle
18 Boy 8 Sounding the Lying Piece of lint A few minutes Cardiac None
bladder syncope
19 Policeman 34 Removal of Napkin Died during Cardiac None
portion of operation syncope
hand
20 Man 24 Intended Lying Folded lint in a A few minutes Cardiac None
amputation hollow syncope
of leg sponge
21 Man Intended Lying “Suddenly None
operation on expired”
the penis
22 Married 36 Extraction of Sitting Handkerchief Less than a Cardiac None
 lady teeth minute syncope
23 Mulatto 45 Removal of Lying Napkin About seven Cardiac None
seaman testicle. minutes syncope
24 Married 37 Removal of Lying Handkerchief Eight or nine Symptoms not Two.
woman impacted minutes observed
fæces
25 Man 23 Ligature of Lying Inhaler Five to ten Cardiac One.
vessels near minutes syncope
vascular
tumour
26 Married 32 Intended Sitting Sponge Four or five Cardiac None
lady extraction of surrounded inspirations syncope
tooth by
handkerchief
27 Man Intended Lying Handkerchief Not more than a Cardiac None
operation for minute syncope
fistula in ano
28 Cattle dealer Applic. of Handkerchief Died during Probably None
potassa fusa operation cardiac
to ulcers of syncope
leg
29 Factory Removal of Lying Inhaler About twelve Probably None
operative malignant minutes cardiac
tumour of syncope
thigh.
30 Single 28 Intended Lying Folded lint Cardiac None
woman application syncope
of nitric acid
to ulcers of
pudenda
31 Soldier 25 Removal of Lying Hollow sponge Five minutes Cardiac None
small tumour syncope
from cheek
32 Tobacconist 43 Intended Lying Handkerchief A few minutes Cardiac Two.
perineal syncope
section
33 Woman 40 Intended Lying Folded lint About five Simultaneous None
operation for minutes deep coma
strangulated and cardiac
hernia syncope
34 Single 22 Intended Lying Inhaler About five Cardiac One.
woman application minutes syncope
of actual
cautery to
sore of
vagina
35 Young man 19 Intended Lying Inhaler Fifty seconds Cardiac None
forcible syncope
extension of
knee
36 Girl 13 Removal of Apparently Cardiac None
tumour from sitting syncope
back
37 Married 59 Intended Lying Hollow sponge About five Deep coma and None
woman reductionof minutes cardiac
old syncope
dislocation of
humerus
38 Woman 40 Removal of Lying Folded lint A few minutes Cardiac None
uterine syncope
polypus
39 Married 45 Intended Lying Sponge, Three-quarters of Cardiac None
woman removal of handkerchief, an hour. syncope
breast and inhaler
40 Tailor 18 Intended Lying Inhaler About seven Cardiac None
operation for minutes syncope
 phymosis
41 Labouring 65 Intended Lying Inhaler Between 13 and 14 Cardiac None
man amputation minutes syncope
of thigh
42 Shoemaker 39 Catheterism Lying Folded lint A few minutes Deep coma, None
apnœa, and
cardiac
syncope
43 Woman 56 Intended Lying Folded lint & About three Cardiac None
amputation piece of oiled minutes syncope
of leg silk
44 Man 40 Intended Lying Inhaler About five Cardiac None
excision of minutes syncope
eyeball
45 Married 29 Inhaled to Sitting Inhaler A few seconds Cardiac Two
lady relieve syncope
neuralgia
46 Married 36 Intended Sitting Handkerchief A few seconds Cardiac Four
lady extraction of syncope
teeth
47 Sailor 30 Intended Sitting Sponge and Three or four Deep coma and None
removal of folded lint minutes cardiac
necrosed syncope
bone from
finger
48 Boy 9 Intended Lying Cotton wool & A few minutes Cardiac None
removal of folded lint syncope
tumour of
scapula
49 Labourer 35 Intended Lying Folded lint A few minutes Cardiac One.
amputation syncope
of thigh
50 Young 17 Application of Lying Inhaler Symptoms not Two.
woman nitric acid to observed
syphilitic
sores
There is in a great number of the cases an evident connection between the accident and the probable
strength of the mixture of vapour and air. In six cases the accident occurred just after the
commencement of the inhalation; in two of the cases, Nos. 27 and 37, the fatal symptoms occurred just
after fresh chloroform had been applied on the handkerchief and sponge; and in several cases, in which
the circulation was suddenly arrested just after the patient had been rendered insensible, the
insensibility had been induced so quickly as to prove that the vapour must have been inhaled in a very
insufficient state of dilution.
 THE TWO KINDS OF SYNCOPE.
Dr. Patrick Black has made an objection to the fact of the patients having died of paralysis, or over-
narcotism of the heart, in the accidents from chloroform.[132] He says that paralysis of the heart would be
death by syncope, but that the symptoms before death, and the conditions of the organs met with
afterwards, are not in accordance with such a view of the case. In order to show that both the symptoms
and the after death appearances, in the fatal cases of inhalation of chloroform, are consistent with
paralysis of the heart, it is necessary to point out the difference between ordinary syncope and cardiac
syncope. One of the best examples of ordinary, or what may be called anæmic syncope, is that which
occurs in a common blood-letting, whilst the patient is in the sitting posture. When the bloodvessels,
especially the veins, which at all times contain the greater part of the blood in the body, do not
accommodate themselves fast enough to the diminished quantity of blood, the right cavities of the heart
are supplied with less and less of the circulating fluid; and in a little time are not supplied at all, when
the heart ceases to beat, in accordance with the observation of Haller, that it does not pulsate when it is
not supplied with blood. The moment the heart ceases to supply blood to the brain there are loss of
consciousness and stoppage of respiration; but on the patient being placed in the horizontal position the
blood flows readily into the right cavities of the heart from the great veins of the abdomen and lower
extremities; the heart immediately recommences its contractions; the brain is again supplied with blood,
and respiration and consciousness return.[133]
The blood may remain in the ordinary quantity; but if the bloodvessels do not keep up their usual
support, and exert a sufficient pressure on their contents, the same kind of syncope will occur as that
from blood-letting. The late Sir George Lefevre related the case of a lady who fainted whenever she left
her bed, and assumed the upright posture; no cause could be found for this until it was ascertained that
she suffered from varicose veins of the legs: bandages to these extremities prevented the fainting. It is
obvious that in this case the mechanism of the syncope was the same as that in blood-letting; the
distension of the varicose veins under the weight of the superincumbent blood had the same effect in
preventing the supply to the right cavities of the heart, as if the blood had been entirely removed. The
faintness which often occurs on first rising, when a person has long kept the recumbent posture from
any local cause, is probably of the same kind; the veins not having had to support the weight of the usual
column of blood for some days or weeks, lose their tone we may presume, and yield when they are all at
once subjected to the weight of a column of blood extending from the lower extremities to the heart, so
that this organ ceases to be properly supplied with the circulating fluid.
In cardiac syncope, on the other hand, the cavities of the heart, or at all events the right cavities of this
organ, are always full, whether the syncope depend on paralysis of the heart by a narcotic, or inherent
weakness of its structure, or on its being overpowered by the quantity of blood with which it is
distended. After death from this kind of syncope, if the blood have not been displaced by artificial
respiration or other causes, the right cavities of the heart and the adjoining great veins will be found
filled with blood, and the lungs will in many cases be more or less congested. The appearances in short
will be very much the same as in asphyxia by privation of air, which ends in a kind of cardiac syncope,
the stoppage of the heart being partly due to over-distension of its right cavities, and partly to loss of
power in its structure, from the want of a supply of oxygenated blood through the coronary arteries. In
death by anæmic syncope, on the contrary, all the cavities of the heart are found empty, or nearly so, and
the same is frequently the case with the adjoining great veins, whilst the lungs are usually pale.
The syncope occasioned by some kinds of mental emotion is of the ordinary or anæmic kind, and
consequently the condition of the brain must act first on the bloodvessels, and not directly on the heart.
Certain persons are liable to faint on witnessing a surgical operation. Now if the mental emotion of these
persons acted directly on the heart, whilst the rest of the vascular system was unaffected, the
distribution of the blood would be nearly the same as in asphyxia, where the circulation is first impeded
in the lungs, and is ultimately arrested by loss of power in the heart. If the action of the heart were
weakened, or stopped, in the first instance, by the kind of emotion under consideration, the arteries
would be emptied by their contractility and elasticity, and the blood would accumulate in the right
cavities of the heart and the great veins leading to them. In a medical student fresh from the country,
who is by no means deficient in blood, the jugulars would become distended and the face livid, and the
recumbent posture would probably do but little towards removing the symptoms. The phenomena which
are witnessed, however, indicate a very different condition of the vascular system. The person about to
faint from the cause indicated, frequently becomes pale before he feels anything wrong; and when
requested to retire and sit down, often says that there is nothing the matter with him. In a short time he
faints, and falls, if no one catches hold of him; but the moment he is in the recumbent posture he
recovers. In such a case as this, the effect of the mental emotion must be first exerted on the veins, or the
veins and capillaries, through the nerves which supply these vessels; they allow themselves to become
distended, and the heart ceases to act for want of its supply of blood, as in syncope from blood-letting,
and anæmic syncope from any cause.
Several authors have attributed the empty state of the heart met with after death, in certain cases of
fatal syncope, to want of power in the left ventricle to supply the right cavities of the heart; but this is to
argue as if the blood passed out of the body after leaving the right ventricle, and the left ventricle had to
supply a newly formed fluid. The effects of want of power in the left ventricle are the same as those of an
obstruction at the origin of the aorta; the lungs become congested, and the right cavities of the heart
more or less distended, from the blood not being able to pass readily through the lungs. Patients who die
of heart disease die with the cavities of that organ full. Some patients, indeed, with fatty disease of the
heart, die suddenly of anæmic syncope, and the heart is found empty; but in these cases it is evident that
death is not occasioned by the disease of the heart, but by some condition of the bloodvessels which
accompanies it.
Chevalier was, I believe, the first to draw marked attention to cases of sudden death arising from an
empty state of the heart, in a paper in the first volume of the Transactions of the Royal Medical and
Chirurgical Society; and he rightly attributed the emptiness of the heart to a loss of power in the
bloodvessels. His words are as follow:—
“The disease I have now described may, perhaps, be termed asphyxia idiopathica. The essential
circumstances of it evidently denote a sudden loss of power in the vessels, and chiefly in the minuter
ones, to propel the blood they have received from the heart. In consequence of which, this organ, after
having contracted so as to empty itself, and then dilated again, continues relaxed for want of the return
of its accustomed stimulus, and dies in that dilated state.”
The word asphyxia has become so closely connected by physiologists with death by privation of air,
where the symptoms and appearances are the reverse of those in Chevalier’s case, that it is necessary to
discard his name of the disease which he describes, although it is etymologically correct. His cases come
under the definition of what is now universally called syncope, and what I have called anæmic to
distinguish it from cardiac syncope.
Chevalier speaks of a want of power in the vessels to propel the blood, and as it is not now believed
that the vessels take any active share in the propulsion of the blood, this may be the reason why the
views of this author have received less attention than they deserve; but it is very obvious that a want of
tone in the vessels, or any great diminution of that power which enables them to support and compress
the blood, is an adequate cause why the blood should be unable to reach the right side of the heart. In
the case of varicose veins, previously mentioned, it was physically apparent that the cause of the syncope
lay in the vessels. Disease of the arteries is well known to be usually associated with degeneration of the
heart; the veins are also large and distensible in old people, who furnish the greater number of those
who are liable to anæmic syncope; but the pathology of the veins, as regards both their functions and
structure, is not yet sufficiently known.
Persons with disease of the heart, who die suddenly in a fit of anger, probably die always with the
heart distended; that is, of cardiac syncope. Dr. Joseph Ridge, however, in his able and interesting
remarks on the disease and death of John Hunter,[134] states his belief that that celebrated man, who had
been long subject to attacks of angina pectoris, died at last of syncope, with an empty heart. He died, as
is well known, during a fit of anger, and the coronary arteries were found ossified. It is not said that the
heart was empty, but that it was small, and that there were no coagula in any of its cavities. It is probable
that there was not much blood in its cavities, at the time of the post mortem examination, but the body
of Hunter was conveyed in a sedan-chair, from St. George’s Hospital to Leicester Square, a little more
than an hour after his death, so that the fluid blood would gravitate downwards. It is related that the
stomach and intestines were unusually loaded with blood, and that those parts which were in a
depending position, as in the bottom of the pelvis and upon the loins, were congested in a greater degree
than the others; and that “this evidently arose from the fluid state of the blood.”
In syncope from muscular exertion, the cavities of the heart are distended, and its walls have
occasionally been ruptured, both from violent exercise and fits of anger.
Fear probably occasions each kind of syncope in different cases. In some cases, the right cavities of the
heart become distended owing to impeded respiration, and possibly to a diminution of power in the
heart itself. More frequently, the syncope appears to be of the ordinary or anæmic kind, the effect of the
mental condition acting first on the more distant parts of the circulation. The pallor caused by fright is
proverbial.
Pain is also capable of causing both kinds of syncope. I have alluded to cases (page 55) in which the
patients strained and held their breath till the pulse became intermittent, and the action of the heart was
temporarily suspended by the arrested breathing; on the other hand, patients often become pale, if they
are undergoing any slight operation when seated, and syncope of the anæmic kind occurs, without any
previous disturbance of the respiration, but passes off as soon as they are placed in the horizontal
posture. I have seen an apparently strong man faint in this manner, during the removal of a tumour
from the back not larger than a nut, and where only a few drops of blood were lost. Chloroform was not
employed.
 SUPPOSED CAUSES OF DEATH FROM CHLOROFORM.
Many writers have supposed that the deaths from chloroform have arisen from some peculiarity in the
patient; and when any notable change of structure has been met with after death in any of the vital
organs, this has been thought to afford a sufficient explanation of the event; whilst in the cases in which
the organs were in a healthy state, surprise has been expressed at the occurrence. In looking over the
account of the cases in which the inhalation of chloroform has been fatal, there is reason to conclude,
however, that the subjects of them were, as regards health and strength, quite equal to the average of the
multitude who have inhaled this agent without ill effects. In fifteen out of the fifty cases above related,
there was no examination of the body after death. In one of these fifteen cases, the patient was in a state
of debility, and had hectic fever, apparently from the disease of the ankle-joint, for he had no cough; in
another of these cases, the patient was reduced to a state of great debility from cancerous disease of the
uterus. In fourteen out of the thirty-five cases, in which an examination of the dead body took place, all
the chief organs were found to be healthy, if we except the local congestions of blood connected with the
mode of dying, and a flabby state of the heart in a few of the cases, which probably depended on its being
full of blood at the time of death, or its not being in a state of post-mortem rigidity, at the time it was
examined.
In one case, No. 25, the only morbid appearances were adhesions of the pleura of small extent; and in
No. 47, the only disease was fatty liver. In Case 17, there were signs of chronic disease of the membranes
of the brain; and in two cases, Nos. 16 and 22, there was emphysema of the lungs. In the remaining
sixteen cases, there was some alteration of the heart, accompanied in a few instances by disease of other
organs. In Cases 23 and 32, there was fat on the surface of the heart, but the structure was not
degenerated. In Case 43, the right ventricle was thinned, but not fatty. In Case 44, there were slight
deposits on the mitral valve, the heart being otherwise healthy. In Case 50, there were deposits of lymph
on the mitral valve and also on the surface of the heart, which was somewhat enlarged. In Case 8, the
heart is merely stated to be large; and in Case 27, hypertrophied. In Case 3, the heart was enlarged, pale,
and soft, and the lungs were tuberculous. In Case 15, there was said to be some amount of disease of the
aortic valves, and some amount of fatty degeneration of the heart. In Case 37, incipient fatty
degeneration was present; and in Case 40, that of a youth of eighteen, the heart was slightly enlarged,
with some amount of fatty degeneration. In Case 46, the right ventricle was thinned and slightly fatty.
There remain three Cases, Nos. 30, 33, and 42, in which the fatty degeneration was more decided; and
one case, No. 41, in which it is spoken of as being present in an extreme degree. This was in a man, aged
sixty-five, the oldest person included amongst those who died from chloroform.
When we consider how common is fatty degeneration of the heart, especially amongst old persons and
those for a long time confined to bed, it is very probable that this affection has been proportionally as
frequent, amongst the patients who have inhaled chloroform without ill effects, as in the fatal cases of its
inhalation.
There are nine of the fatal cases in which the age of the patient is not stated. In the other forty-one
cases, the ages, when grouped in decennial periods, are shown in the following table, the last column of
which shows the proportion which the deaths bear at each period to the number living at that period, out
of a thousand persons of all ages in England and Wales.

Under 5 years 0 0
5 and under 15 3 ¹⁄₇₆
15 „ 25 11 ¹⁄₁₈
25 „ 35 10 ¹⁄₁₅
35 „ 45 11 ⅒
45 „ 55 3 ¹⁄₂₇
55 „ 65 2 ¹⁄₂₆
65 and upwards 1 ¹⁄₄₄

The nine persons whose ages are not given were all adults; one is spoken of as a young man, and
another as a young woman, and the rest are mentioned in such a manner that it is certain they were not
old people. It follows, therefore, that so far as is known, there has been a complete immunity from death
by chloroform at both extremes of life. I have already given my reasons for rejecting Dr. Aschendorf’s
case of an infant, and also the case of a gentleman, aged seventy-three, who died whilst inhaling
chloroform. The youngest patient who died from chloroform was seven or eight years of age, and the
oldest sixty-five, being the only death above sixty. The above table of the ages shows that the number of
deaths, in proportion to the number living, increased rapidly after the age of twenty-five, and decreased
rapidly after the age of forty-five. The small number of deaths between fifteen and twenty-five may be
partly due to the circumstance that surgical operations are but seldom required at this period of life; but
the decrease after the age of forty-five cannot be explained in this way; for persons become more liable
to require surgical operations as they advance in years. Operations are often performed in infancy and
old age, periods at which deaths from chloroform have not been recorded. The greatest proportion of
deaths having occurred from thirty-five to forty-five, when the system is often more robust than at any
other period, it cannot be supposed that an inability to bear the usual dose of chloroform, when carefully
administered, is the ordinary cause of death from this agent.
Idiosyncrasy. The accidents from chloroform have frequently been attributed to idiosyncrasy in the
patient. This, it may be observed, is not to give an explanation of them, but merely to state that they
depend on something we do not understand; that something, however, being in the person to whom the
accident happens. This view receives apparent support from the supposition that the chloroform has
been inhaled in exactly the same manner in the fatal cases as in other instances; but this apparent
support fails when it is pointed out that the supposed same manner is only an equally uncertain manner.
The different effects that have been produced on the same patient at different times, and the great
number of instances in which medical men have failed to make the patient insensible, show that most of
the usual modes of exhibiting chloroform are extremely uncertain.
What most completely meets the question of idiosyncrasy, however, is the circumstance that in no
fewer than eleven out of the fifty recorded cases of death from chloroform, the patient had previously
inhaled this medicine without ill effects. In two other cases also, previous attempts had been made to
make the patient insensible without success, on the day on which the accident occurred. In the above
table of the fatal cases, those are indicated in which previous inhalations had taken place. In twenty-nine
cases, I have concluded that the patient had not previously inhaled, for the medical man, having given an
account of the state of his patient, and his reasons for administering the chloroform, would certainly
have mentioned such a material fact as a previous inhalation if it had occurred. There are ten cases of
which only a meagre account is given, and where a previous administration of chloroform may possibly
have taken place without being mentioned; but if only eleven, out of the fifty patients, who died from
chloroform, had inhaled it previously without ill effects, it is very clear that the fact of having inhaled it
with a favourable result, gives no immunity from the possibility of accident. It would be impossible to
say what proportion of the patients who have inhaled chloroform have inhaled it more than once, but it
is not probable that they amount to more than 22 per cent., if so many.
Alleged Impurity of the Chloroform. At one time accidents from chloroform were loosely attributed to
impurity in the medicine, but this was only a guess, and is opposed to the facts. No case of accident has
been traced to this cause, and in nearly all the cases of which the details are given, it is distinctly
recorded, either that the chloroform was examined and found to be of good quality, or else that
chloroform out of the same bottle had been used in other cases without ill effects. I have not thought it
necessary to state this in quoting the individual cases.
Apparatus employed. Accidents were at one time, and in one quarter, attributed to the use of inhalers;
and it is curious that this allegation was made at a time when no death from chloroform had yet
occurred in any cases in which an inhaler was used, except one in America, and one in France, the
accounts of which had not reached this country. It is possible that death might be occasioned by want of
air from the use of a faulty inhaler, and a case will be mentioned in which this apparently occurred in the
administration of sulphuric ether, but there is no recorded case of accident from chloroform in which
death was occasioned in this way. In the cases of death previously recorded, a handkerchief, a piece of
folded lint, hollow sponge, or some such simple contrivance, was used in thirty-four instances; in twelve
cases, an inhaler of some kind or other was used; and in four cases, it is uncertain what were the means
employed.
Alleged Exclusion of Air. The assertion has often been made that death might be caused by the vapour
of chloroform excluding the air, and so causing asphyxia; but it has already been pointed out in this
work that the physical properties of chloroform do not allow it to yield a quantity of vapour which would
have that effect, and in much smaller quantity than this the vapour kills by a quicker way than asphyxia,
I believe that the only elastic fluids which can cause death simply by excluding the atmospheric air are
nitrogen and hydrogen.
Alleged Closure of the Glottis. At the trial which took place in Paris respecting the death of a porcelain
dealer previously mentioned, M. Devergie gave evidence, and after saying that chloroform might cause
death as a poison, if given in undue proportion, he added: “Also it closes the glottis, and offers an
obstacle to respiration. Employed by M. Demarquay on himself, in very small doses, closure of the
glottis was occasioned. It was possible that Le Sieur Breton had experienced that accident, and in that
case the most able surgeon could not prevent death.”
I have not met with M. Demarquay’s account of his experiment, but I am happy to know that he did
not die of the closure of the glottis. It may fairly be denied that a person could commit suicide in this
manner if he wished, for he would either have to give up the attempt, or receive the vapour into his
lungs, and experience its specific effects. When animals are placed in mixtures of vapour and air, they
always breathe them, whatever the strength; and if the vapour amounts to eight or ten per cent., they die
much more quickly than they would of mere closure of the glottis. Vapour of chloroform, when not
largely diluted with air, is apt to cause cough and closure of the glottis, as soon as a little of it reaches the
lungs; but this, so far from being a source of danger, is, as a general rule, a safeguard, by its preventing
the patient from readily breathing air which is highly charged with vapour.
In commenting on the fatal case No. 12, which occurred in St. Thomas’s Hospital, I have suggested
that the accident might have happened from liquid chloroform being dropped into the throat; but liquid
chloroform is very different from the vapour; it causes a lasting irritation if applied to a mucous
membrane; when used for toothache, it often blisters the gums. The irritation caused by the vapour, on
the contrary, is only momentary, and its local action ceases directly it ceases to be inhaled; for what is
left in the air-passages is immediately absorbed or expelled with the expired air. The glottis is not a vital
organ of itself. Its closure only causes death by preventing the access of air to the lungs. The glottis does
not remain permanently closed, I believe, from the contact of any elastic fluid, however irritating;[135] but
it does from the contact of a liquid, and persons who die by drowning, die with the glottis closed, for they
do not fill their lungs with water. Therefore, if the vapour of chloroform did cause persistent closure of
the glottis, and if a person were to hold it by force to the patient, the death it would occasion would be
precisely like that in drowning. Death by asphyxia is a comparatively slow one. I find that when the
access of air to the lungs is entirely cut off, death does not take place in less than three minutes and a
half in guinea pigs, and four minutes in cats. In dogs, the process of asphyxia is still slower. Mr. Erichsen
states, that on taking the average of nearly twenty experiments, the contractions of the ventricles
continued for nine minutes and a quarter after the trachea had been closed, and that the pulsations of
the femoral artery also were perceptible for an average period of seven minutes and a half. The process
of drowning in the human subject is well known to occupy some minutes; and even if the pungency of
the vapour of chloroform should entirely prevent the patient from breathing, and the medical man could
overlook the fact that breathing was not going on, it cannot be supposed that he would use the force, and
have the perseverance to cause his patient to die slowly by asphyxia. If any patient, therefore, has died
from closure of the glottis, it must have been one in whom there was a great tendency to sudden death
from any slight interruption to respiration. I do not know the particulars of the case respecting which M.
Devergie was giving his evidence, but in those fatal cases previously related, in which the symptoms are
sufficiently described, it is not probable that death took place in any instance from closure of the glottis.
In the sudden death at St. George’s Hospital (page 209), it is possible that the slight pungency of the
vapour might assist the fear under which the patient was labouring in impeding the breathing, and thus
add to the distension of the right cavities of the heart, under which the patient apparently died.
In 1855, two years after M. Devergie had given the above opinion, Dr. Black, of St. Bartholomew’s
Hospital, who has had great experience in the administration of chloroform, advanced a similar theory
in the pamphlet previously alluded to. He did not, however, confine the effects of the supposed closure
of the glottis to possibly causing a death here and there, as M. Devergie had done, but he attributed all
the accidents which had happened to this cause, and not to the effects of chloroform in the system. He
says that “the chloroform has not been even inhaled: its pungency was felt at the glottis, and its
inspiration was immediately arrested. The patient would have removed the apparatus, but in this he was
restrained. The struggle forthwith commenced, but up to the moment of his death, not a single
inspiration took place.” These remarks were not applied to a single case, but generally to the accidents
from chloroform. Dr. Black says: “Any concentration of the vapour of chloroform which can be breathed
is safe; any condition of dilution which forces the patient to cough or hold his breath is dangerous, and if
persevered in for even half a minute, may be fatal.... We have only to attend to the breathing; we may
disregard all considerations affecting the relative proportion of the chloroform in the air which is
breathed;... if the patient breathes easily he is in safety, whatever be the amount of chloroform which is
passing into the lungs.”
In Experiment 28, previously related, where the respiration was kept up by a tube in the trachea, there
could be no error in respect to the vapour of chloroform entering the lungs, when a bladder of air
charged with ten per cent. of that vapour was substituted for the bladder of simple air; and the
immediate paralysis of the heart was evident. An examination of the fatal cases, of which the particulars
have been recorded, shows that death did not occur in the manner Dr. Black suggests. In the majority of
the cases, the patients were rendered quite insensible by the chloroform, and the operation had either
been commenced, or was on the point of commencing; when the fatal symptoms set in. In several other
cases, the patients were partially under the influence of the vapour before the symptoms of danger
commenced; and in the six cases where death occurred at the beginning of the inhalation, without loss of
consciousness having been induced, the patients were not restrained in any way, and it was observed
that they did breathe the chloroform; three of them were speaking up to the moment when the pulse
stopped, and one took a full inspiration the moment before the fatal symptoms set in. It is only in
eighteen of the fatal cases that there is any reason to suppose that the patient required to be held, and
then only from mental excitement or muscular spasm, arising from the physiological effects of the
absorbed chloroform. It is hardly possible that the struggles of a conscious patient from inability to
breathe, would be mistaken for excitement or spasm caused by chloroform.
In a case, No. 34, which occurred at St. Bartholomew’s Hospital whilst Dr. Black was present, and long
before his pamphlet was written, the patient inhaled for five minutes, and sank off into a state of
complete insensibility without alarming symptoms. The inhalation was discontinued, the patient moved
into a proper position, and the operation just about to be commenced, when Dr. Black found the pulse to
become extremely feeble and fluttering. Surely this patient breathed the chloroform, and died without
any spasm of the glottis. In Case 48, so minutely related by Mr. Paget, the boy made one long
inspiration, and became suddenly insensible. In a few seconds, the pulse suddenly failed, and then
ceased to be perceptible, but the breathing continued for at least a minute afterwards. There was
certainly no closure of the glottis in this instance.
Alleged Exhaustion from Struggling. In cases where the patients have struggled violently whilst
getting under the influence of chloroform, the accidents have been attributed to a supposed exhaustion
caused by the struggling.[136] This opinion is, however, contrary to experience; for the patients who
struggle violently are precisely those who bear chloroform the best, provided they do not breathe it in an
insufficient state of dilution. They are generally cheerful and exhilarated by it, and are less liable to be
depressed by its prolonged use, than those who come quietly under its influence. Although the patients
who struggle bear the chloroform well, when it is carefully and judiciously administered, it is not
improbable that the struggling has been now and then an indirect cause of accident. The muscular
spasm and rigidity do not occur till about three-quarters as much chloroform has been absorbed as can
be present in the system with safety; and, as the patients often hold their breath whilst struggling, and
take deep inspirations suddenly and at long intervals, the greatest care is required that the vapour be
administered in a very diluted state. In Cases 9, 44, and 47, the fatal symptoms came on whilst the
patients were struggling; and in some other cases, the sudden failure of pulse occurred just after the
struggling had ceased, rendering it probable that the patient inhaled too much of the vapour whilst
struggling, or just as the spasmodic condition of the muscles was subsiding.
The circumstances just mentioned, are probably the cause why so many of the fatal cases occurred at
that period of life when the body is most robust. Very nearly two-thirds (twenty-seven out of forty-one),
of those cases in which the ages are recorded, occurred in persons of twenty years and under forty-five
years of age, although the proportion of persons living at this period of life, in England and Wales, is
only a little more than one-third of the entire population. The majority of the accidents from chloroform
occurred also in the stronger sex, in which muscular rigidity and spasm are most frequent:—twenty-nine
of the fatal cases happened to males, and only twenty-one to females. According to my experience, the
females who inhale chloroform for surgical operations are nearly twice as numerous as the males; and
although this may not be the proportion in every one’s practice, it is probable that females inhale this
agent quite as frequently as the other sex, in every part of the world.
Sitting Posture. In some of the early cases of death from chloroform, the patients were inhaling it in
the sitting posture, and it was surmised that this circumstance was the cause of death.[137] An
examination of the account of the fatal cases, however, does not bear out this supposition. In thirty-one
instances the patients were lying, in nine instances sitting, and there are ten cases in which the position
is not mentioned, and where from the nature of the operation it may have been either one or the other.
In fully one-fourth of the cases of which I have kept notes of the administration of chloroform, the
patients were seated in an easy chair; and as in forty fatal cases in which the position is known, only
nine, or less than one-fourth, were seated, it does not appear that the position of the patient has had any
share either in causing or preventing accidents.
Supposed Effect of the Surgeon’s Knife on the Pulse. Mr. Bickersteth alluded to a peculiar
circumstance,[138] which he thought would account for several of the deaths attributed to chloroform. He
relates three instances in which the pulse suddenly ceased on the first incision by the surgeon, and
commenced again in a few seconds, the breathing going on naturally all the time. All the three cases
were amputation of the thigh, and occurred in the latter part of 1851. Mr. Bickersteth did not observe the
circumstance again during the two following years, and I have never observed it, although I have very
often examined the pulse at the moment when the operation began, especially after reading Mr.
Bickersteth’s remarks. He supposes that the action of the heart was arrested by the shock of the incision,
notwithstanding the patient was insensible. I should attribute the temporary stoppage of the pulse in
these instances to the direct influence of the chloroform on the heart. The moment when the operation is
commenced, is usually a few seconds after the inhalation has been discontinued, and when the effect of
the chloroform is at its height. A portion of that which was left in the lungs having been absorbed, in
addition to that which was previously in the system. And if the vapour inhaled just at last was not
sufficiently diluted, it might paralyse the heart, but not so completely as to prevent the natural
respiration from restoring its action, in those cases where respiration continues. I found in experiments
on animals that, when the action of the heart has been suspended by the effect of chloroform, it can very
often be restored by artificial respiration instantly applied; and it is extremely probable that an accident
of this kind not unfrequently occurs during the administration of chloroform, and is remedied by the
breathing, without being noticed. The pulse recovered itself, in the cases mentioned by Mr. Bickersteth,
just as it does in animals after the heart has been nearly overpowered by chloroform. In the first case,
the pulse remained imperceptible for a period of four or five seconds, the countenance at the same time
becoming deadly pale. As it returned, it was at first very feeble, but in a few seconds, it regained its usual
strength. In the second case, Dr. Simpson administered the chloroform, and after the operation
remarked that the pulse had stopped suddenly just as the knife was piercing the thigh, and had
recovered itself with a flutter almost immediately.
Mr. Bickersteth’s reason for attributing the stoppage of the pulse to the effect of the knife, rather than
the chloroform, was that he had arrived at the conclusion from some experiments which he performed
on animals, that the action of the heart cannot be arrested by chloroform, until the breathing has been
first suspended. One of Mr. Bickersteth’s experiments (No. 5, on a half-grown cat) exactly resembles the
experiment (No. 28 in this work) on a rabbit, which I had published upwards of a year before Mr.
Bickersteth’s paper appeared, with the exception that in my experiment the artificial respiration was
performed with air containing ten per cent. of vapour, and in Mr. Bickersteth’s the vapour was an
unknown quantity. In both experiments, the heart of the animal was exposed. In that which I performed,
three or four inflations of the lungs almost paralyzed the heart; and nine or ten inflations, which did not
occupy half a minute, had the effect of paralyzing that organ irrecoverably. In Mr. Bickersteth’s
experiment, the effect of the artificial respiration was as follows:—“After continuing it for seven minutes,
the diaphragm, hitherto unaffected, began to move very irregularly and imperfectly; then its movements
became slow and hardly perceptible; and, at the expiration of eleven minutes, they had ceased
altogether. During all this time the heart’s action remained strong and regular, but now it got weaker
and more rapid, and, in four minutes from the time the diaphragm had ceased acting, had become so
feeble (still quite regular) that I feared every moment it would stop.” Mr. Bickersteth says he performed
artificial respiration with air saturated with chloroform; but saturated or not, the vapour certainly did
not exceed six per cent., and most likely was only between four and five, if the artificial resembled the
natural respiration in quantity and frequency. The vapour which can be breathed for seven minutes
without causing serious symptoms, and for eleven minutes without arresting the breathing, is of course
incapable of stopping the action of the heart by its direct effect. It is scarcely so strong as that which one
administers every day to patients with impunity. The vapour which is so diluted as to require to be
added by small increments during one hundred and fifty inspirations, before the brain is even
narcotized, cannot act directly on the heart, an organ which can bear a much larger amount of
chloroform. Mr. Bickersteth fell into the error into which the Committee of the Society of Emulation of
Paris afterwards fell, and argued from the rule to the exception. What he witnessed was the mode of
death which would occur, if vapour of chloroform of the strength which can be safely inhaled, were
deliberately continued till the death of the patient. But an accident from chloroform is an exception, and
the mode of dying is as much an exception as the death itself, if the inquiry is extended to what this
agent is capable of doing, instead of confining it to what one endeavours to effect with it in the human
subject alone.
So many of the deaths during the inhalation of chloroform have occurred before the operation had
commenced, or after it had proceeded some way, that Mr. Bickersteth’s explanation would not apply to a
great number, even if it were correct; and when it is remembered that the operation is always
commenced when the effect of the chloroform is expected to be at its height, the number of cases of
cardiac syncope which have happened at the beginning of the operation is not greater than might be
expected as the result of the effect of chloroform.
Sudden Death from other Causes. It has been more than once suggested that the deaths which have
occurred, during the inhalation of chloroform, are of the same nature as the sudden deaths which have
often occurred about the time of surgical operations, apparently without any adequate cause; and that in
fact the accident and the chloroform may be a mere coincidence, and not connected as cause and effect.
It has been already shown that the Commission of the Academy of Medicine of Paris made this
suggestion in treating of the case of Madlle. Stock, and Dr. Simpson has more than once made a similar
remark. On one occasion,[139] he remarked, in speaking of chloroform:—“The first surgical cases in which
it was used were operated upon in the Royal Infirmary here, on the 15th of November, 1847. Two days
previously, an operation took place in the Infirmary, at which I could not be present, to test the power of
chloroform; and so far fortunately so; for the man was operated upon for hernia, without any
anæsthetic, and suddenly died after the first incision was made through the skin, and with the operation
uncompleted.” I should say, so far unfortunately so, for whatever the cause of the man’s death, that
cause could hardly have been present if the patient had been made insensible by chloroform; and so his
life would in all probability have been saved. If he died either from fear or from pain, the chloroform
would have prevented his death, by removing and preventing these causes; and if his death arose from
simple exhaustion, it must be remembered that chloroform is a stimulant, during the first part of its
administration, and, as a general rule, so long as it is actually in the system. Even Mr. Bickersteth, who
thinks that the knife of the surgeon may have a direct influence on the heart when the patient is quite
insensible, expresses his conviction that such an occurrence is far less likely to happen under the
influence of chloroform than in the waking state.
I have omitted from the list of deaths by chloroform two cases which are usually attributed to that
agent, namely, the case of Mr. Robinson’s patient, and the one at St. George’s Hospital, and have
attributed them to fear; and I also rejected the case of the infant on which Dr. Aschendorf operated, for
the reasons I stated; and it is quite possible that amongst the fifty cases I have retained, there may be
one or two in which the death was not caused by chloroform, especially as the details of some of the
cases are very meagre; but when all the circumstances of the cases are examined, and especially when
the mode of death is compared to that which chloroform can be made to produce in animals, it cannot be
supposed that the fatal event was a more coincidence in the whole fifty cases, or in any great number of
them.
There are numerous instances recorded of sudden death during surgical operations, or just before
intended ones, without any evident cause, except fear or pain, before the use of narcotic vapours was
known; and some even since, in cases in which it was not thought worth while to use them. After the
passage quoted above, Dr. Simpson continues:—“I know of another case in Edinburgh, where death
instantaneously followed the use of an abscess-lancet without chloroform,—the practitioner, in fact,
deeming the case too slight to require any anæsthetic.” Such events have, no doubt, often happened
without being recorded; and it is extremely likely that the deaths of this kind which chloroform has
prevented are quite as numerous as those it has occasioned by its own effects, but the medical profession
will very properly not be satisfied with a result of this kind, if more can be done; and the endeavour of
the practitioner of course is, whilst saving life as well as preventing pain by the use of this agent, to avoid
as far as possible having any accident from its use.
Falling back of the Tongue. It has been alleged that the falling back of the tongue into the throat,
under the deep influence of chloroform, might be the cause of death by suffocation; but this appears to
be an error; for the muscles of the larynx and neighbouring parts preserve their action as long as the
diaphragm, and contract consentaneously with it. When the breathing has ceased, the tongue is indeed
liable to fall backwards, if the person in a state of suspended animation is lying on the back, and this
circumstance requires to be attended to in performing artificial respiration.
 STATE OF THE CHIEF ORGANS AFTER DEATH FROM
CHLOROFORM.
A few years ago, I examined the viscera of the chest, and kept notes of the appearances, in thirty-seven
animals killed by chloroform. They consisted of two dogs, twenty-two cats, one kitten, three rabbits,
three guineapigs, two mice, two larks, and two chaffinches. Many of the animals were opened
immediately after death, and the rest within a day or two. The lungs were not much congested in any
instance. In seven of the animals, they were slightly congested; but in the remaining thirty, they were not
congested. They were generally of a red colour, but in a few of the cats they were quite pale. I ascertained
the specific gravity of the lungs of two of the cats, in which they presented the amount of vascularity I
have most usually met with. The specific gravity was 0·605 in one instance, and 0·798 in the other. As
many of the animals died in a way resembling asphyxia, the respiration ceasing before the circulation, it
might at first be supposed that we should meet with the same congestion of the lungs; but by the time
that the respiration is altogether suspended by the action of chloroform, that agent has begun already to
influence the heart, which does not inject the blood into the lungs with the same force as when the
respiration is mechanically prevented, whilst it is in full vigour. Besides, in the gaspings which so often
take place when the heart is ceasing to act, the animal inhaling chloroform draws air freely into the
lungs, whilst the asphyxiated animal is prevented from doing so.
As regards the condition of the heart, it was found in the two chaffinches that the auricles were filled
with blood, whilst the ventricles were empty. The condition of the heart in the larks is not mentioned,
but in all the thirty-three quadrupeds, the right auricle and ventricle were filled with blood. In ten of
them, these cavities were much distended; and in some of these instances, the coronary vessels on the
surface of the heart were distended also. The left cavities of the heart never contained more than a small
quantity of blood, not exceeding a quarter of what they would hold.
The head was examined in only ten of the animals. The substance of the brain was found to be of the
natural vascularity, and the sinuses were not very much distended, except in two instances.
With respect to the state of the blood, it may be mentioned, that in every instance in which the chest
was opened within an hour after death, the blood which flowed from the cut vessels coagulated
immediately and firmly. In eighteen of the animals in which the blood was examined in the heart or
large vessels, a day or two after death, it was found to be well coagulated in ten, loosely coagulated in
seven instances, and quite fluid in one instance. I have not met with air in the bloodvessels, either in the
above thirty-seven examinations, or in any of the numerous other animals that I have opened, after they
have been killed by chloroform. The appearances I have met with in animals killed by this agent have
usually been such as I have described in the above thirty-seven instances; but I long since ceased, as a
general rule, to make careful notes of the appearances, as I did not meet with anything new.
In the fatal cases of inhalation of chloroform previously quoted, the lungs are related to have been
congested more frequently, and to a greater extent, than I have met with in animals. But there is no
standard of what should be called congestion; and probably many of the medical men who made the
examinations were speaking by comparison with cases where persons die after illness, in a state of
inanition. In the human subject, the right cavities of the heart, although generally full of blood, were
found empty in several cases; but as I previously stated, it is almost certain that they were emptied after
death, either by the artificial respiration which was employed, or in some other way.
The blood remained fluid in eighteen out of twenty-five cases of fatal accident from chloroform, in
which an examination of the body was made and the condition of the blood recorded; whereas it was
only quite fluid in one instance out of eighteen of the animals which were killed by chloroform, and not
opened till a day or two afterwards. The fact of the blood coagulating more generally, in the animals on
which I have experimented, than in the human subjects who died from chloroform, is probably due to
their smaller size. I was formerly of opinion that the fact of the body of a small animal cooling more
quickly than the human one was the probable explanation of this, but Dr. Richardson appears to have
proved that the blood is kept in a liquid state by the presence of ammonia; and ammonia, we might
expect, would escape more readily from the body of a small animal than from the human body. However
this may be, it is pretty certain that the blood generally remains fluid in the human body after death
from chloroform, only because it usually remains fluid in every kind of sudden death. When a patient
dies slowly of illness, the body cools gradually before death takes place, and ammonia keeps exhaling in
the breath, if Dr. Richardson is correct, whilst the formation of this alkali must be almost suspended. In
many cases, we know that coagulation of the blood commences before the respiration and circulation
have ceased. The blood which flows during surgical operations coagulates as quickly and firmly when the
patient is under the influence of chloroform as at other times; and, as was mentioned above, the blood
which flows from animals, just after they are killed by this agent, coagulates as well as usual; it follows,
therefore, that if the coagulation of the blood were prevented by the chloroform, and not by the mere fact
of sudden death, it would be by the presence of this agent in the blood after death, and not by any action
which it exerted during the life of the patient.
FURTHER REMARKS ON THE PREVENTION OF ACCIDENTS FROM
CHLOROFORM.
In consequence of the prevailing opinion that accidents from chloroform depended chiefly on the
condition of the patient, the main endeavours to prevent a fatal result have taken the direction of a
careful selection of the persons who were to inhale this agent. It may be doubted, however, whether this
line of practice has had so much effect in limiting the number of accidents, as in curtailing the benefits to
be derived from the discovery of preventing pain by inhalation. In nearly all the recorded cases of
accident from chloroform, it is stated that the patients had been carefully examined, and such proofs of
disease as were met with after death were chiefly those which had not been detected; and, as already has
been stated, were probably not greater on an average than in the cases in which no accident happened.
I have not myself declined to give chloroform in any case in which a patient required to undergo a
painful operation, whatever evidence of organic disease I have met with on careful examination; and
although I have memoranda of upwards of four thousand cases in which I have administered this agent,
I have not, as I believe, lost a patient from its use; the only person who died whilst under its influence
having, in my opinion, succumbed from other causes, as I have already explained.
Many writers have stated that accidents from chloroform might always be prevented by a close
attention to the symptoms, or to some particular symptom, as the pulse or the breathing. Several
authors have attached the utmost importance to feeling the pulse, and have considered this measure of
itself sufficient to avert danger; whilst others have asserted that attention to the pulse is of no use at all.
Mr. Bickersteth, for instance, writes as follows, in the article from which I previously quoted. “But the
pulse should not be taken as any guide during the administration of chloroform. It should be wholly
disregarded except under certain circumstances, when syncope is to be feared from loss of blood during
the performance of a capital operation. The pulse is only affected secondarily in consequence of the
failure of the respiration.”
If the person administering chloroform was always quite sure that the vapour did not constitute more
than five per cent. of the inspired air, it is quite true that the pulse might be wholly disregarded. I can
never produce more certain and uniform results with chloroform than when I am giving it to small
animals enclosed in glass jars, where of course the pulse cannot be felt. In surgical practice, however,
where the amount of vapour in the inspired air is often very uncertain, watching the pulse may be of
great service, irrespective of loss of blood; and although it will not always prevent accident, I am
persuaded that it has saved many lives. In some of the accidents that have happened, the pulse has
ceased suddenly, whilst it was being very carefully watched; but more usually it would show some signs
of failure before entirely ceasing.
In giving chloroform freely to animals from a napkin or sponge, whilst the ear or the hand was applied
over the heart, I have usually found that its pulsations became embarrassed and enfeebled before they
ceased; and by withdrawing the chloroform when the heart’s action first became affected, the life of the
animal could often be saved.
The importance of attending to the respiration of the patient has been previously noticed, and it is so
obvious a symptom that it can hardly be disregarded, if anyone is watching the patient; it speaks,
moreover, almost to one’s instincts, as well as to one’s medical knowledge. It is probable that no patient
has been lost by disregard of the respiration, unless it be one or two whom no one was watching, or in
which the head and shoulders were covered with a towel.
It has already been shown in this work, from experiments on animals, and from the physiological
effects and physical properties of chloroform, that accidents from this agent would arise by its suddenly
paralyzing the heart, if it were not sufficiently diluted with air; and a careful review of all the recorded
cases of fatal accident shows that nearly every one of them has happened in this way, and not from any
neglect in watching the symptoms induced, or mistaking their import.
The first rule, therefore, in giving chloroform, is to take care that the vapour is so far diluted that it
cannot cause sudden death, without timely warning of the approaching danger; and the next rule is to
watch the symptoms as they arise. A description of those symptoms, and what they indicate, has already
been given.
 I have previously stated that the most exact way of giving chloroform to a patient is to put so much of
it into a bag or balloon as will make four per cent. of vapour when it is filled up with the bellows; but I
have not often resorted to this plan, on account of its being somewhat troublesome. I have previously
described (p. 81) the inhaler which I employ. By arranging the bibulous paper suitably, and by
ascertaining, with the inhaler in the scales, how much chloroform a given quantity of air carries off at
different temperatures, I am able to produce very uniform results in the administration of chloroform.
But, as I previously stated, those who do not wish to have the trouble of studying a suitable inhaler, may
give chloroform on a handkerchief without danger, and with results sufficiently certain, by diluting this
agent with an equal measure of spirits of wine. As the spirit (nearly all of it) remains behind, it is
desirable, in a protracted operation, to change the handkerchief or sponge, now and then, for a dry one.
 TREATMENT OF SUSPENDED ANIMATION FROM CHLOROFORM.
It is probable that artificial respiration, very promptly applied, will restore all those patients who are
capable of being restored from an overdose of chloroform. All the patients who are related to have been
restored after this agent has occasioned a complete state of suspended animation, have been
resuscitated by this means. It is only by artificial respiration that I have been able to recover animals
from an overdose of chloroform, when I felt satisfied that they would not recover spontaneously. And
under these circumstances I have not been able to restore them, even by this means, except when a tube
had been introduced into the trachea, by an incision in the neck, before giving them what would have
been the fatal dose.
M. Ricord succeeded in restoring two patients who were in a state of suspended animation by mouth
to mouth inflation of the lungs. The first was a woman, aged twenty-six, who had been made rapidly
insensible by a few inspirations of chloroform from a sponge. He had scarcely commenced the operation
of removing some vegetations, when his assistant informed him that the pulse had ceased. The breathing
also ceased about the same time.
In the second case, he completed the operation of circumcision, and the patient, a young man, not
coming to himself, M. Ricord found that the breathing had ceased, and the pulse was becoming more
and more extinct, and very soon ceased entirely, till restored by the artificial respiration.
After these cases, hopes were expressed that M. Ricord had discovered the means by which all patients
might be restored from the over-action of chloroform; but these hopes have not been verified by events.
In the first of the cases, the heart had probably not been so entirely paralyzed by the action of the vapour
as sometimes happens, and in the second case, that organ was apparently not paralyzed by the
chloroform at all. It was only after the breathing had ceased, that M. Ricord found the pulse was failing.
This was a case, therefore, in which artificial respiration might reasonably be expected to restore the
patient.
The following cases of resuscitation, from the over effects of chloroform, are related by Mr.
Bickersteth in the paper previously quoted. They occurred in Edinburgh:
“Case 1. A boy was cut for stone by my friend Mr. Hakes, on the 29th of March, 1849. Chloroform was
administered on a piece of sponge, and the full anæsthetic effect produced, before proceeding to tie him
up in the ordinary position: the inhalation was continued, without any regard to his condition, until the
operation had been completed—altogether about five minutes from the time he first became insensible.
It was noticed that during the operation scarce a drop of blood escaped. When it was over, the child was
found, to all appearance, dead; the muscles were flaccid; the surface of the body pale; the respiration had
ceased; the pulse could not be felt; the heart sounds were not audible (but the room was by no means
quiet); the eyes were half open; the jaw dropped; the pupils dilated; and the corneæ without their
natural brilliancy. Several means were tried to resuscitate him, but without effect. At length artificial
respiration was commenced; the air escaped with a cooing sound, as if from a dead body. After
continuing it for a while, the breathing commenced, at first very slowly and feebly. Soon it improved. In
two hours the child had quite recovered.”
“Case 2. In December 1851, a child, a few months old, was put under the influence of chloroform for
the purpose of having a nævus removed from the right cheek. As soon as insensibility was produced, the
operation was commenced—the handkerchief containing the chloroform remaining over the face, as
some difficulty had been experienced in keeping up the anæsthetic effect. Suddenly the breathing
ceased; the muscles became flaccid; the countenance pale and collapsed, and the lips of a purple colour.
Artificial respiration was employed, and in less than a minute the breathing returned, and the child was
restored.”
“Case 3. On the 6th of March, 1852, I had occasion to remove the finger of a robust, healthy-looking
young man, in the Royal Infirmary. He was already under the influence of chloroform when I entered
the room, and as there had been some difficulty in producing complete anæsthesia, and the last of the
chloroform in the bottle was already on the handkerchief, it was thought advisable by my friend in
charge of its administration to keep up the inhalation, in order to produce a coma sufficiently profound
to last until the completion of the operation. It was therefore left over his face, and I commenced and
removed the finger, slowly disarticulating it from the metacarpal bone. I distinctly recollect hearing the
man breathing quickly and shortly; and I also remember, that when just about to look for the vessels, my
attention was attracted to his condition, by not any longer hearing the respiration. The handkerchief was
still on his face. I took it off, and found, to my consternation, that the breathing had ceased; the face was
livid; the eyes suffused; the pupils dilated; the mouth half open. He was to all appearance dead; still the
pulse could be distinguished as a small, hardly perceptible thread, beating slowly. Immediately artificial
respiration was commenced. For a minute or two, his condition did not alter in any respect—then the
lividity of the countenance increased, the pulse was no longer perceptible, and the sounds of the heart
could not be satisfactorily heard. During the whole of this time, artificial respiration had been diligently
employed, but still the air appeared to enter the chest very imperfectly. I despaired. I felt certain that the
man was dead, and that no human aid could restore him; and if it had not been that those standing near
me urged me to persevere, I believe I should then have deserted the case as hopeless. Just at this time it
occurred to me to put my finger in the mouth and draw forward the tongue, in order to secure there
being no impediment to the air entering the lungs. Retaining it in this position, we again began the
artificial respiration, and found that then the chest was fully expanded by each inflation. After keeping it
up for a minute or two, the gentleman, who had all along kept his hand on the pulse, exclaimed, to our
delight, that he could again feel it—‘It was just like a slight flutter that reached the uppermost of his four
fingers,’ all of them being placed over the course of the artery. It gradually became more distinct and
firmer, and at the same time, the lividity of the face decidedly lessened. In another minute, the man
made a slight inspiratory effort. I ceased directly the artificial respiration, and merely assisted the
expiration by pressure upon the ribs. Another and another inspiration followed, and in a short time he
breathed freely without assistance. The countenance became natural, and he appeared as if in a sound
sleep. In half an hour, he spoke when roused; then he vomited, and complained of giddiness. In an hour
afterwards, he had recovered sufficiently to walk home.
“Moments of intense anxiety appear much longer than they really are; but even allowing this, I am
quite sure that, at the very least, five minutes elapsed from the time when the man ceased breathing
before the first inspiratory effort took place, and that for not less than one minute the pulse was
imperceptible, and the heart’s action almost, if not altogether, inaudible.”
“Case 4. A few weeks after the occurrence just described, I was assisting Mr. Syme in removing the
breast of a lady. A gentleman, my superior in the hospital, was conducting the inhalation of chloroform.
Anæsthesia was complete, and the breathing good, when the operation commenced. The chloroform was
allowed to remain over the face during the whole time of its performance. Before it was over, I noticed
the respiration become very quick and incomplete, and suggested, in consequence, the propriety of
removing the handkerchief. My remark was neglected for eight or ten seconds, and then, just as it was
taken away, the breathing ceased suddenly. The face became deadly pale; the eyes vacant; the lips livid.
Instant dissolution appeared inevitable (the pulse was not felt). Artificial respiration was immediately
commenced, but the air not entering the lungs freely, the tongue was pulled forwards, and retained so by
the artery forceps. The chest then expanded freely with each inflation, the air escaping with a cooing
sound. In rather less than a minute, the respiratory movements recommenced, but at first so slowly and
imperfectly that it was necessary to assist expiration. When recovery was a little more established, the
operation was completed. Before the putting in of the sutures, sensation had partially returned, and in a
short time the lady had perfectly recovered.”
Mr. Bickersteth very properly adds: “There can be no doubt, that in the foregoing cases, a grievous
error was committed by continuing the inhalation after anæsthesia was produced, and that it was in
consequence of this, the accidents, so nearly fatal, occurred.”
As these accidents seem to have occurred from continuing the inhalation too long, they differ entirely
from nearly all those which were actually fatal, and which, as we have seen, arose from the too great
concentration of the vapour, and not from any want of care in watching the patient, so as to be able to
leave off at the right moment, if it were possible. I have previously stated, that after breathing vapour of
the proper strength for inhalation, animals may always be readily restored by artificial respiration after
the breathing has ceased, provided the heart is still beating. In the cases related by Mr. Bickersteth, the
heart had ceased to beat before the patients were restored; but in the third case, there is distinct
evidence that the heart continued to beat for four minutes after the breathing had ceased. It was,
therefore, certainly not paralyzed by the direct action of the chloroform. The patient was nearly in the
condition of a drowned person, where we know that there is a good prospect of recovery by artificial
respiration during the first few minutes after the breathing has ceased, even if the action of the heart be
imperceptible. In the other three cases, also, it is probable that the breathing ceased before the action of
the heart; and, at all events, this organ was not paralyzed so thoroughly as in the cases in which artificial
respiration was promptly applied without effect.
 Several other cases have been related in the medical journals in which patients have been restored by
artificial respiration, after animation had been suspended, more or less completely, by chloroform; but
the above remarks would, I believe, be applicable to all these cases.
Where patients have recovered under the use of other measures, without artificial respiration, it is
probable that animation was not completely suspended, and that the recovery was spontaneous.
M. Delarue related a case of accident from chloroform to the Academy of Medicine, on August 20th,
1850, which was apparently of this nature. After administering the vapour, and when he was about to
divide some sinuses in the thigh, he found that his patient (a woman) was in a state of collapse, and the
breathing and pulse, “pour ainsi dire”, insensible. The face was injected, and there was a bloody froth at
the mouth. The uvula was titillated, and there was immediate movement of the eyelids, which was soon
followed by copious vomiting, and the patient recovered.[140]
Such measures as dashing cold water on the patient, and applying ammonia to the nostrils, can hardly
be expected to have any effect on a patient who is suffering from an overdose of chloroform; for they
would have no effect whatever on one who has inhaled it in the usual manner, and is merely ready for a
surgical operation, but in no danger. I have applied the strongest ammonia to the nostrils of animals that
were narcotized by chloroform to the third or fourth degree, and it did not affect the breathing in the
least. They recovered just as if nothing had been done. It is difficult to suppose a case in which the
breathing should be arrested by the effects of chloroform whilst the skin remained sensible, yet it is only
in such a case that the dashing of cold water on the patient could be of use. There is, however, no harm
in the application of this and such like means, provided they do not usurp the time which ought to be
occupied in artificial respiration; for this measure should be resorted to the moment the natural
breathing has entirely ceased.
I have only seen two cases in which the patients seemed in imminent danger from the direct effects of
chloroform. One of these occurred in 1853. It was the case of a child, aged six years, but small and
ricketty, which had the greater part of the eyeball removed on account of melanotic disease. The usual
inhaler was employed, and when the child seemed sufficiently insensible, it was withdrawn. The
operation was commenced by introducing a large curved needle, armed with a thick ligature, through
the globe of the eye, in order to draw it forward. As the needle was introduced, the child cried out a very
little, and thinking the parents, who were in the adjoining room, would be alarmed, I poured some
undiluted chloroform hastily on a rather large sponge, and placed it over the nostrils and mouth. The
sponge became pressed by the surgeon’s hand closer on the nose than I intended, but it was removed
after the child had taken a few inspirations. The operation was quickly concluded without any further
sign of sensation than that mentioned above. At the end of the operation, the breathing was natural, but
the face was pale, and the lips blue, and the limbs were also relaxed. I tried to feel the pulse at the wrist,
but did not discover any. The chloroform had at this time been left off half a minute at least. The pallor
and blueness continued, and in a little time the breathing became slow and embarrassed, and appeared
about to cease altogether, the pulse being still absent. The windows were opened, and cold water dashed
freely on the face. The child made gasping inspirations now and then, but they did not follow
immediately, or seem connected with each application of the water. The gasps became more frequent,
till the breathing was thoroughly reestablished, when the colour returned to the lips, and the pulse was
again felt at the wrist. In a minute afterwards, the child was red in the face, and crying violently from
pain, which was relieved by a little more chloroform. It appeared to be a minute or a minute and a half
from the time when the sponge with chloroform was removed, till the breathing became of a gasping
character. There is no doubt that in this case the heart was paralyzed, or nearly so, by the chloroform,
and that its action was restored by the spontaneous gasping inspirations of the child. The accident could
have been prevented by having the chloroform, which was put on the sponge, diluted with spirit.
The other case occurred in the latter part of 1852. I have no notes of it, as it took place at the beginning
of an illness, which prevented me from writing for some time; but I recollect the chief particulars of it
sufficiently well. The patient was a lady rather more than sixty years of age, rather tall and thin. She
required to have a polypus removed from the nose. Mr. Fergusson, who was about to operate, was nearly
an hour after the appointed time, and during this interval she was pacing up and down the room,
apparently in a great fright. She was placed in an easy chair for the operation, and the pulse was small
and feeble when she began to inhale. Nothing particular occurred during the inhalation, but just at the
time when the patient was becoming insensible, the breathing ceased, and the pulse could not be felt.
She appeared to have fainted, and was immediately placed on a bed which was in the room. I applied my
ear to the chest, but could hear no sound whatever. Mr. Fergusson applied his mouth to that of the
patient, and with a very strong expiration, inflated her lungs, so as to expand the chest very freely. I
immediately heard the heart’s action recommence with very rapid and feeble strokes, as I had so often
heard it recommence in animals. The patient soon began to make distant gasping inspirations, and the
natural breathing and pulse were soon reestablished. Mr. Fergusson made only one or two inflations of
the lungs after the first one, which of itself was the means of restoring the patient. It was about twenty
minutes, however, before she became conscious; and during the greater part of this time there were
spasmodic twitchings of the features and limbs on one side. In about an hour, she was pretty well; and
on the following day the operation was performed without chloroform.
The most ready and effectual mode of performing artificial respiration is undoubtedly the postural
method, introduced by Dr. Marshall Hall a little time before his death. It consists in placing the patient
on the face and making pressure on the back; removing the pressure, and turning the patient on his side
and a little beyond; then turning him back on the face and making pressure on the back again; these
measures being repeated in about the time of natural respiration.
Whether the artificial breathing is successful or not must depend chiefly on the extent to which the
heart has been paralyzed by the chloroform, as was previously observed. The fact of the breathing
continuing after the action of the heart has ceased, in some of the fatal cases, shows that the heart may
be so paralyzed as not to be readily restored by the breathing. It is probable that in all cases in which
artificial respiration can restore the patient, its action would be very prompt; still it is desirable to
persevere with this measure for a good while.
As already stated, there is every reason to conclude that the right cavities of the heart are distended
with blood, in all cases of suspended animation by chloroform, and therefore it would be desirable to
open one of the jugular veins if the artificial respiration does not immediately restore the patient. In
opening animals, just after death from this agent, I have observed the contractions of the heart to return,
to a certain extent, when the distension of its right cavities was diminished by the division of the vessels
about the root of the neck. Opening the jugular veins has been resorted to in a few of the cases of
accident from chloroform, but hitherto without success.
I have not succeeded in restoring an animal from an overdose of chloroform, by means of electricity,
in any case where I felt satisfied that it would not recover spontaneously; and I have not heard of any
patient being restored by its means. For keeping up respiration, mechanical means, such as the postural
method, are better; as they cause air to enter the lungs without exhausting the remaining sensibility. If
electricity be used, it should be directed towards restoring the action of the heart. It is probable that the
electric current would not reach the heart without the help of the acupuncture needle; but it would be
justifiable to use this in a desperate case, when other measures had failed. The needles should be coated
with wax, or some other non-conductor of electricity, except near the points.
In the fatal cases Nos. 40 and 48, previously related, the action of the heart partially returned during
the efforts that were made for the restoration of the patient, but did not become thoroughly
reestablished. It is probable that the circulation through the coronary vessels of the heart was not
restored in those cases, or else the blood which must have been freed from chloroform, in its passage
through the lungs, would most likely have enabled the heart to recover completely. Dr. Cockle has
expressed the opinion, which is very probable, that the blood enters the coronary arteries in a retrograde
manner, during the diastole of the ventricles, when the aorta and other great arteries are contracting on
their contents; if so, with a very feeble circulation, the elasticity of the aorta, perhaps, cannot sufficiently
act to cause a backward current; and perhaps, also, the over-narcotism of the heart is itself an obstacle to
the coronary circulation, on account of the congestion of the capillaries which always attends on
narcotism.
The knowledge how seldom anything effectual can be done for a person who has inhaled a dose of
chloroform from which he would not spontaneously recover, ought to impress the rule very strongly on
every one, to use the greatest care in its administration.