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 Copyright © 2017 by Kevin Peraino

All rights reserved.

Published in the United States by Crown, an imprint of the Crown Publishing
Group, a division of Penguin Random House LLC, New York.
crownpublishing.com

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Library of Congress Cataloging-in-Publication Data

Names: Peraino, Kevin, author.
Title: A force so swift / Kevin Peraino.
Description: First edition. | New York : Crown, [2017] | Includes bibliographical
references and index.
Identifiers: LCCN 2017000979 | ISBN 9780307887238 (hbk.)
Subjects: LCSH: United States—Foreign relations—China. | United States—
Politics and government—1945–1953. | China—Politics and government—1937–
1949. | Taiwan—Politics and government—1945–1975. | China—Foreign
relations—United States. | United States—Foreign relations—Taiwan. | Taiwan—
Foreign relations—United States.
Classification: LCC E183.8.C5 P525 2017 | DDC 327.73051—dc23
LC record available at https://lccn.loc.gov/​2 017000979

ISBN 9780307887238
Ebook ISBN 9780307887252

Maps by Mapping Specialists, Ltd.

Cover design by Oliver Munday
Cover photograph by Henri Cartier-Bresson/Magnum Photos

v4.1_r1
a
 ★

In a very short time,

several hundred million peasants

in China’s central, southern,
and northern provinces

will rise like a fierce wind or tempest,

a force so swift and violent that
no power, however great,

will be able to suppress it.

—MAO ZEDONG

★
Detail left
Detail right
 CONTENTS

Cover
Title Page
Copyright
Dedication
Map

PROLOGUE

PART I
1 MISSIMO
2 THE GREATEST FORCE
3 THE OLD DEVILS
4 BEDBUGS
5 THE DEAN
6 ALL THE ACES
7 RIVERDALE

PART II
8 WAIT , LOOK, SEE
9 A NEW WORLD
10 HEAVEN AND HELL
11 A VAST AND DELICATE ENTERPRISE
12 NEVERLAND
13 HEAT
14 KILLING THE TIGER
15 THE GREAT CRESCENT

PART III
16 FIRECRACKER
17 NO DEVIL SHALL ESCAPE
18 DIG UP THE DIRT
PHOTO INSERT
19 FIRST LIGHTNING
20 RISKY BUSINESS
21 THE VOICE
22 THROUGH A GLASS , DARKLY
23 A RATHER SPECTACULAR TRIUMPH
24 A FORCE SO SWIFT

EPILOGUE: THE MILLS OF THE GODS

NOTES
SELECTED BIBLIOGRAPHY
ACKNOWLEDGMENTS
PHOTO INSERT CREDITS
About the Author
 PROLOGUE
OCTOBER 1, 1949, BEIJING

Bodies jostled, elbow to elbow, angling all morning for a spot in the
square. Soldiers clomped in the cold—tanned, singing as they
marched, steel helmets and bayonets under the October sun. Tanks
moved in columns two by two; then howitzers, teams of ponies,
gunners shouldering mortars and bazookas. On the flagstones, in
front of the imperial gate, men and women craned their necks
toward a platform above a portrait of Mao Zedong, painted in hues
of blue, hanging beside tubes of blue neon. Underneath, a sprinkling
of yellow streamers rippled in the crowd. Nearly everything else in
the frenzied square was red.
Shortly after three p.m., a tall figure in a dark woolen suit stepped
up to a bank of microphones atop the gate. He lifted a sheet of
folded paper, pursed his lips, and glanced down at a column of
Chinese characters. A double chin rested against his collar; heavy
jowls had long since submerged his cheekbones. Although Mao was
still only in his mid-fifties, he was not in good health. He rarely
went to bed before dawn. For years he had punished his body with a
masochistic regimen of stewed pork, tobacco, and barbiturates.
Occasionally, overcome by a spell of dizziness, he would suddenly
stagger—one symptom of the circulatory condition that his doctors
called angioneurosis. Still, he had retained into middle age what one
acquaintance described as “a kind of solid elemental vitality”—a
kinetic magnetism that photographs could never quite manage to
convey.
On this day, Mao’s speech, delivered in his piping Hunanese, was
nothing particularly memorable: a few lines praising the heroes of
the revolution and damning the British and American imperialists
and their stooges. But the celebration that followed, marking the
birth of the People’s Republic of China, was a cathartic spectacle.
Mao pressed a button, the signal to raise the flag—yellow stars
against a field of crimson—and a band broke into “March of the
Volunteers,” the new national anthem, with its surging chorus of
“Arise, arise, arise!” An artillery battery erupted in salute; a
formation of fighter jets slashed across the sky.
The sun set, and the party went on: fireworks raced toward their
peaks, rockets of white flame—then fell, smoldering but harmless,
into crowds of giddy children. Red gossamer banners billowed in the
evening breeze, undulating like enormous jellyfish; to one witness,
the British poet William Empson, they possessed a kind of “weird
intimate emotive effect.” Lines of paraders hoisted torches topped
with flaming rags; others carried lanterns crafted from red paper—
some shaped like stars, some like cubes, lit from within by candles
or bicycle lamps. Slowly, singing, the glowing procession bled out
into the city.
Among the marchers was a boy of sixteen, Chen Yong. He held a
small red flickering cube. He had been twelve years old when he
joined Mao’s army, though he had looked even younger—a year or
two, at least. He had studied Morse code, one of the few jobs for a
boy his age, then joined a unit that fought its way through
Manchuria. As the long civil war was coming to a close, Chen’s
father had thrown his boy back in school. But on this night no one
was studying. The war was over; Mao had won. Chen carried his
lantern into the dark.

★
Nearly seven decades after this celebratory light show, I visited
Chen Yong at his home in Beijing, an unfussy apartment block in
one of the city’s western neighborhoods. Chen was now in his early
eighties; his hair had gone white, and a gauzy beard descended from
his chin. In his hand, trembling slightly, he clutched a pair of
eyeglasses. One inflamed eyelid was nearly closed; a furtive
intensity had replaced the calm flat gaze of his teenage years.
One of my favorite parts of researching this book—a yearlong
chronicle of the Truman Administration’s response to Mao’s victory
in 1949—was the opportunity to spend time with some of the
remaining eyewitnesses to the events of those dramatic twelve
months. There are fewer and fewer survivors left; some of the key
figures have been dead for four decades and more. The rest are
elderly, their memories fading fast. In telling this story I have
generally clung to the contemporary documents—the diaries,
memoranda, letters, and newspaper reports that yield the most
accurate portrait of that year. Still, I never passed up the
opportunity to talk with those who were actually there. There was
something magical about these encounters—a living connection to a
bygone China.
In the summer humidity of his apartment, Chen shuffled slowly
across the concrete floor, opened a drawer in his bedside table, and
pulled out a black and white photo. In the picture, his younger self
wore the padded gray tunic of a Chinese Communist soldier—
cinched hopefully at the waist, a size or two too big for his teenage
frame. As we talked, the emotion of that year seemed as present as
it might have been seventy years ago; at one point he quietly began
to sing one of his old marching songs. Yet when I pressed him on
the granular details of his experiences, he was often at a loss. He
would narrow his eyes, looking straight at me, and say with
frustration, “It’s hard to remember.” Still, when I asked him how
often he thought back to the events of that year, he said, “Pretty
much all the time.” And that, of course, is the great paradox of
growing old: the less we can remember, the more time we spend
remembering.
 ★

As with people, so with nations: even as the survivors of the

revolution are disappearing, Chinese leaders are spending more
time trying to recall that era. China’s current president, Xi Jinping,
said shortly after he took power that he considered revolutionary
history the “best nutrient” for a nation making its ascent as a great
power. After years of de-Maoification in the 1980s, China’s
leadership now consciously seeks to reprise some of Mao’s best-
known political themes. When modern Chinese statesmen look to
the past, they gravitate not to the lunacy of the Great Leap Forward,
Mao’s reckless attempt to transform China’s agricultural economy,
nor to the depredations of the Cultural Revolution, the fevered
campaign to solidify Mao’s rule in the late 1960s and early 1970s by
mobilizing China’s disaffected youth. Rather, today’s Chinese
leaders celebrate the triumphs of 1949, with all their emotional
reverberations. Among other tributes, Xi’s government recently
inaugurated a new holiday, called Martyrs’ Day, to be held each
September 30—the date in 1949 that Chinese leaders broke ground
on a major national monument in Beijing.
The China of today remains filled with mementos of 1949. On a
recent spring morning, I took a day trip from Beijing to Xibaipo, one
of the rural base camps that Mao had occupied at the beginning of
the year, as his armies prepared to complete their conquest of the
mainland. Once a bone-jarring voyage across pitted roads, today it is
a painless four-hour drive along superhighways flanked by thick
hanging trees. Although the weather in Beijing had been unusually
sunny and smog-free, the sky grew hazier as we traveled southwest,
into China’s industrial heartland. Out the windows, flashes of the
new China whizzed by: sand pits, smokestacks, solar panels, power
lines, chewed hills that looked as if they had been eaten by a
cosmic-scale monster. And yet in other ways, an older China was
with us still. On the dashboard of his Ford sedan, my taxi driver had
placed a slick white bust of Mao that said, on its pedestal, SAFE AND
SOUND .
 In Xibaipo, now a stark but bustling tourist town, we passed a
restaurant called Red Memory and an information center selling
trinkets emblazoned with portraits of Mao and Xi Jinping. Farther
in, we arrived at a complex of low-slung, dun-colored bungalows
marked with placards written in Chinese and Russian. Wandering
beside the pear and locust trees, visitors paid five yuan to sit in a
replica of Mao’s canvas folding chair; for a little more, twenty yuan,
they could pose for a photo behind an embankment of sandbags,
wearing an old army uniform and hoisting a rifle. The site,
according to a member of the staff, had actually been moved slightly
from its original location, to make way for a reservoir. But nobody
seemed to mind. On this morning the museum was crowded with
tourists filing past glass cases filled with relics of the revolution.
Yet there is another, darker side to this sort of remembrance.
Mao’s victory in 1949 provoked a reaction across the Pacific; by the
end of the year, the United States had extended its policy of
containing Communism, once limited primarily to Europe, to Asia
as well. The Truman Administration crafted an ambitious plan—
including a series of covert operations—to bolster the nations along
China’s periphery. Even as Mao consolidated his control over the
mainland, American operators quietly slipped cash and weapons to
his enemies. These historical events, too, inform Chinese views
about the present, as the nation continues its fitful rise. Anxious
Chinese officials see today’s American policy as a sequel to the
containment strategy hatched in 1949. They fret over American
troop deployments and training missions to East Asia, and they
suspiciously eye flashpoints like Tibet, Xinjiang, and Taiwan for
evidence of modern American perfidy.
That narrative of 1949—a combination of triumph mixed with
grievance—overlooks a great deal. In reality, American policy
makers battled fiercely with one another as they struggled to shape
a response to Mao’s victory. Some wanted to engage him; others
wanted to confront him; still others wanted to ignore him
completely. In between existed a thousand shades of nuance. These
disputes were not simply tactical differences of opinion; they
reflected profound disagreements about the nature of the American
relationship with China and revealed fault lines in the American
character itself. They destroyed careers, reduced a cabinet member
to tears, and in the decades that followed gave rise to some of
America’s most divisive foreign wars, in Korea and Vietnam. The
most disconcerting thing is that these fissures—though now largely
hidden—still exist. Each approach is fueled by its own self-
deceptions, its own brand of remembering and forgetting.
There is no obvious antidote to all this historical make-believe. It
is not a matter of simply setting out the facts; the stories we tell
ourselves about China are too freighted with emotion to be chased
away so easily. Still, by slipping into the participants’ skins and
looking at the dilemmas of 1949 through their eyes, we can begin to
share some of their fears and thrills—and ultimately purge some of
our own anxieties and misconceptions. In other words, the only
cure for a runaway story is another story.
This one begins aboard an airplane, with a glamorous woman
preparing for a fight.
★
PART I
★
Chiang promised to make a good-faith effort to study the tenets of
Christianity, and the Soong matriarch ultimately approved the
match.
By Mayling’s wedding day, December 1, 1927, she had morphed
into a true beauty. At twenty-nine, her face had shed its childish
roundness, accentuating her exquisite features: firm dark eyes, low
sloping nose, tightly controlled smile that suggested both mischief
and restraint. After a small Christian ceremony at home, the
newlyweds hosted a spectacular reception for thirteen hundred
guests at Shanghai’s Majestic Hotel. A Russian orchestra played
Mendelssohn’s wedding march as the couple entered the ballroom.
Mayling wore a delicate dress of silver and white georgette with
orange blossom accents; she gripped a bouquet of pale pink
carnations. Near the Chinese-style altar, next to a shield made of red
geraniums that spelled out the Chinese character for “long life and
happiness,” the couple bowed three times to an enormous portrait
of Sun Yat-sen flanked by Nationalist flags. While the guests
applauded and sipped from their teacups, detectives quietly swept
the ballroom for any sign of a security threat.
Dangers to the Nationalist leader were indeed multiplying.
Chiang, rising rapidly within the republican establishment, had
begun cracking down on internal political enemies; in one
particularly bold operation, he had declared war on Shanghai’s labor
unions, which he accused of taking orders from Moscow. He
enlisted hundreds of agents belonging to the Green Gang—a
powerful fixture in Shanghai’s underworld—to attack picketing
unionists. Teams of assassins wearing blue uniforms and white
armbands fanned out across the city, assailing the picketers with
lethal efficiency. “Heads rolled in the gutters of the narrow lanes
like ripe plums and the weary executioners wielded their swords
with the monotonous rhythm of punka wallahs,” one witness
reported. The next day, during a massive demonstration protesting
the killings, forces loyal to Chiang opened fire with machine guns,
killing sixty-six and wounding more than three hundred. Chiang’s
thugs gored some survivors with bayonets and used rifle butts to
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cases collected by Mouchet, 3 ended in recovery. Another success
has been recently recorded by Turretta. The écraseur has been
used, but its employment cannot be recommended. Compression by
clamps is advised by Schatz of Rostock. Ligation is best adapted to
cases occurring in the cervical and dorsal regions, in which, as
pointed out by Giraldès, nerve-elements are less likely to be
involved. Excision, supplemented by transplantation of a strip of
periosteum from a rabbit, has been successfully resorted to by
Mayo-Robson and by R. T. Hayes of Rochester, N. Y.; and simple
excision, with suture in separate lines of the sac and integuments, by
Mayo-Robson, Atkinson, and Jessop. The Clinical Society's
committee in all refers to 23 cases treated by excision, 16 of which
are said to have been successful.

ANÆMIA AND HYPERÆMIA OF THE BRAIN AND

SPINAL CORD.

BY E. C. SPITZKA, M.D.

Cerebral Hyperæmia.
Up to within a few years it was a favorite mode of explaining the
results of the administration of certain narcotic and stimulant drugs,
and certain of the active symptoms of mental derangement, to
attribute them to an increased blood-supply of the nerve-centres.
This view seemed to harmonize so thoroughly with the physiological
dictum that functional activity depends on the supply of oxygenated
blood that the first attempts at questioning it were treated as
heresies. To-day, however, few authorities can be found to adhere
unreservedly to this once-popular and easy explanation. The drift of
physiological and medical opinion is in the direction of regarding
some subtle molecular and dynamic state of the nerve-elements as
the essential factor in intoxications as well as in maniacal and other
forms of insane excitement: if they be complicated by active or
passive congestions, this is probably a secondary occurrence of
modifying but not of intrinsic determining power. While this change in
our views is the natural result of progress in experimental
pharmacology and pathology, it does not justify the extreme
assertion that there is no disorder of the brain functions deserving
the name of congestion and hyperæmia. This assertion seems to
have been provoked by the careless manner in which these terms
have been employed to designate conditions which are in reality the
most different in nature that can be well conceived. No one familiar
with the extent to which the term “congestion of the base of the
brain” has been abused in this country will marvel that the reaction
provoked by it has overstepped the boundaries of cautious criticism.
That there are physiological hyperæmias of the brain is now
universally admitted; the most recent experimental observations,
indeed, conform most closely to the claims of the older investigators.
It naturally follows that pathological hyperæmias are both possible
and probable, and even if the observations in the dead-house do not
strongly sustain the existence of pathological hyperæmias and
congestions independently of gross disease, clinical analysis and the
gratifying results of appropriate treatment justify us in retaining these
designations in our nomenclature with the limitation here implied.

One great difficulty in determining the precise nature of the disorders

which the physician is called upon to treat on the theory of
hyperæmia lies in the number of factors which may contribute to or
modify its development. If, for example, the action of the heart be
increased through hypertrophy, the result to the cerebral circulation
will obviously be different in a plethoric and in an anæmic person; it
will be also very much different in the event of the stimulation of the
centres which contract the calibre of the cerebral blood-vessels from
what it would be if there were a state of vascular relaxation. Should
the cardiac hypertrophy be associated with renal disease, other
disturbing elements may be introduced, such as arterio-fibrosis, or
the presence in the blood of certain toxic substances having direct
effects of their own on the nerve-elements. The picture may be still
more complicated by variations in the intracranial pressure. It is
impossible to prove, either by direct or indirect evidence, that there is
such a pathological state as a simple cerebral hyperæmia; indeed,
there is one fact which militates strongly against, if it be not fatal to,
such an assumption. Were a physiological hyperæmia to become
intensified to a pathological degree, we should have corresponding
clinical phenomena. In other words, the culmination of the morbid
process should be preceded by an exaggerated physiological
excitation similar to that observed with intoxications. But this is rarely
the case, and we accordingly find that the more cautious writers, like
Nothnagel,1 do not commit themselves to the view that the results of
mental overstrain2 are to be classed as simple cerebral hyperæmia.
Similar restrictions are to be made regarding the established
congestive states, such as those following sunstroke. It has been
usually supposed that insolation directly produces cerebral
hyperæmia, even to the degree of engorgement, and that the after
symptoms in persons who recover are due to the non-return of the
meningeal and cerebral blood-vessels to their normal calibre, and to
other more remote results of vascular stasis. The latter half of this
proposition is in part correct; the former is contradicted by numerous
pathological observations. Thus, Arndt,3 who had the opportunity of
studying over one hundred cases occurring in the course of a forced
march of a division of infantry from Berlin to Pankow, many of which
terminated fatally, found almost uniformly a pale brain, with peculiar
color-changes, denoting rather structural than circulatory trouble.4
The whole list of causes of what is commonly designated cerebral
hyperæmia, congestion, and engorgement may be gone through
with and similar modifying statements be found to apply to them. The
nearest approach to an ideal cerebral congestion is that found with
acute alcoholic intoxication. This is at first accompanied by cerebral
hyperæmia, which, with the comatose climax, becomes an
engorgement; accordingly, many of the results of acute alcoholic
intoxication are attributed to the circulatory condition alone. The
congestive troubles due to alcoholism which come to the special ken
of the physician, however, are those found with the chronic form, and
here a more complex pathological condition is found to underlie it;
the organization of the brain is altered, the vascular channels more
or less diseased, and the vaso-motor mechanism continuously
deranged. This disorder, as well as the apoplectiform states
attributed to vascular stasis, and the active and passive hyperæmias
associated with tumors, meningitic and other gross diseases of the
brain, as well as with the status epilepticus, are usually included in
the discussion of cerebral congestion, and serve to swell up the
chapters devoted to it. They will be found discussed in more
appropriate situations in this volume. In this place it is proposed to
consider only those congestive states which present themselves to
the physician, independently of conditions which, if associated,
preponderate in clinical and therapeutic importance.5
1 Ziemssen's Cyclopædia, “Nervous System,” i. p. 39, 2d German ed.

2 It has repeatedly happened during the past decade that young persons competing
for admission to higher institutions of learning in New York City through the channel of
a competitive examination died with symptoms of cerebral irritation; the death
certificates in several such cases assigned meningitis or cerebral congestion as the
cause of death, and attributed the disorder to mental overstrain. It is not so much the
intellectual effort that has proved hurtful to the pupils as the emotional excitement
attending on all competitive work, the dread of failure, the fear of humiliation, and
anxiety developed by the evident futility of the cramming process. Some years ago I
recorded the results of some inquiries on this head in the following words: “The
mental-hygiene sensationalists, who periodically enlighten the public through the
columns of the press whenever an opportune moment for a crusade against our
schools and colleges seems to have arrived, are evidently unaware of the existence
 of such a disease as delirium grave, and ignorant of the fact that the disorder which
they attribute to excessive study is in truth due to a generally vitiated mental and
physical state, perhaps inherited from a feeble ancestry. Our school system is
responsible for a good deal of mischief, but not for meningitis” (Insanity, its
Classification, Diagnosis, and Treatment). Since then I had an opportunity of obtaining
an excellent description of such a case which had been attributed to the combined
effects of malaria and educational overstrain, presenting opisthotonos, fulminating
onset, and an eruption!

3 Virchow's Archiv, lxiv.

4 The observations of Gärntner (Medicinische Jahrbucher, 1884, 1) harmonize with

this. He found that radiant heat contracts the blood-vessels of the frog's mesentery.

5 The same applies to conditions which are discussed under this head in textbooks,
although they have either only a medico-legal bearing or are inconstant factors, such
as the injection of the brain in death from strangulation. I need but instance the
vascular condition of brains of criminals executed by hanging. In the case of one
where the strangulation had been slow I found an engorgement of all the vessels and
arachnoidal as well as endymal hemorrhages; in a second, where the criminal had
been carried half fainting to the drop, and death ensued quickly and without signs of
distress, the brain was decidedly anæmic.

It has been also considered best to omit treating of the collateral hyperæmia of the
brain sometimes found with erysipelas of the face and scalp. This I regard as
essentially of the same nature as the metastatic meningitis of erysipelas, if it be not in
reality a first stage of the latter.

ETIOLOGY.—An individual predisposition to cerebral congestion was

one of the unquestioned facts of the older medical writers. It
undoubtedly exists, and to-day we attribute it to inherited vascular
conditions either affecting the calibre and coats of the blood-vessels
or the vigor of the vaso-motor apparatus. I have remarked the
transmission of that weakness of the latter which underlies the
congestive phenomena of later life much more frequently in the
female than in the male sex.
It has been claimed that external refrigeration produces hyperæmia
of the brain, as of other internal organs, and that this accounts for
the greater frequency of the disorder in cold weather. Niemeyer
indeed speaks of persons who, suffering from this condition, appear
and act in such a way as to convince the laity that they are
intoxicated; and Andral, Falret, and Hammond note the occurrence
of a much larger number of cases in the winter than in the summer
months. I apprehend that the condition described by Niemeyer must
be extremely uncommon, both from individual experience and the
rarity of its mention as an independently observed fact. With regard
to the alleged greater frequency of the disorder in winter, it must be
remembered that all the three observers cited include in their
computation a number of cases in which congestion was a collateral
feature; they did not limit themselves to the disorder as spoken of
here. Certainly, the physician will see few if any persons who consult
him because of the hyperæmia-producing effects of a cold day.

The suppression of habitual discharges, of the hemorrhoidal flux,

and the cessation of menstruation are associated in many instances
with the more formidable grades of cerebral hyperæmia. Many
phenomena of so-called climacteric insanity depend on congestive
states. The sudden closure of an old ulcer or the removal of
hemorrhoids in advanced life has in some well-established instances
provoked alarming seizures not unlike those noted with paretic
dementia. The chain of proof establishing the direct influence of
physiological and pathological discharges on the vascular controlling
apparatus of the brain is most complete. Not alone cumulative
clinical observation, but the occasional happy result of therapeutical
procedure based on this supposed interdependence, support it.
Thus, the congestive cerebral state is recovered from when the
menstrual or hemorrhoidal flow is re-established, or an issue is
formed in the nape of the neck, or an old ulcer is allowed to reopen.6
6 The treatment of paretic dementia, particularly of the congestive type, is also based
on this relation. The irritating antimonial ointment and issues in the nape of the neck,
etc. have been lauded by older observers, and in two of my own cases had the best
results—in one, indeed, with established restitutio ad integrum of now nearly two
 years' duration. I am inclined to suppose that its abandonment is due to an improper
selection of cases; in the ordinary premature senility and syphilitic types such
treatment is altogether ineffective. It is applicable to but a minority of cases at best,
and to them only at an early period. It is probably to a similar form of congestion that
Bouchut refers when (“Les Nèvroses congestives de l'Encéphale,” Gazette des
Hôpitaux, 1869) he speaks of a cerebral hyperæmia developing under the mask of a
meningitis—an expression that may be allowed if understood in the same sense as
the comparison between hydrocephaloid and hydrocephalus.

The origin of most cases that are brought to the physician's attention
is more or less complicated. A business-man, lawyer, or student
suffering from worry incident to his profession, living so irregularly as
to provoke gastric disturbances, becomes afflicted with insomnia,
and in addition is also constipated. Straining at stool, he finds a dull,
heavy sensation affecting the upper part of his head; attempting to
resume his work, this is aggravated, and after a series of temporary
remissions the condition to be later described becomes continuous.
In such a case the insomnia, usually due to neural irritability, if not
aggravated by an existing dyspepsia, leads to such a one, and a
circulus vitiosus familiar to all physicians is established. Each of the
factors concerned involves strain of the cerebral vaso-motor
apparatus, but none more so than the insomnia. It is not so much the
intensity of the strain as its long duration and the exhaustion of the
centre which in sleep is supposed to be at comparative rest. This
rest is not obtained, and, in conformity to the laws of neural
exhaustion, that centre becomes morbidly irritable. Now, gastric
irritation is competent to produce a reflex influence on even the
healthy cerebral organ; to do so it must be a severe one; but with the
class of persons alluded to the slightest indiscretion in food or drink
is sufficient to set up reflex vertigo or headache. The current theory
regarding these symptoms is that they are due to stimulation of the
vaso-constrictors and ensuing cerebral anæmia; but the subjects
before us will usually be found to flush up instead of becoming pale,
as in simple vertigo a stomacho læso, or if there be initial paleness,
there is a secondary flush, as if the tired arterial muscle had become
exhausted by the effort at obeying the reflex stimulus. In addition, a
profuse perspiration sometimes breaks out on the upper part of the
body.

The influence of traumatic causes and insolation in producing a

tendency to repeated and severe cerebral congestion is recognized,
particularly among alienists. It is supposed that an abnormal
irritability of the vaso-motor apparatus is provoked by these causes.
Abundant evidences are sometimes found in the brains of such
persons of an altered state of nutrition of the brain and its
membranes, and which point in the direction of congestion.

In the conditions thus far alluded to it can be fairly assumed that the
determination of blood to the cerebral blood-vessels is more or less
active. Passive congestion due to impeded return circulation is of
secondary interest, as the primary disease, be it a pertussis or a
laryngeal, cardiac, pulmonary, or surgical condition, will constitute
the main object of recognition and management. Certain quasi-
physiological acts, as coughing, hurried breathing, holding the breath
while straining at stool, and placing the head in a dependent position
while acting in the direction of passive hyperæmia, are to be
considered in connection with the active forms of congestion which
they may momentarily aggravate.

MORBID ANATOMY.—Owing to the non-fatality of the commoner forms

of cerebral hyperæmia, no pathological observations of them are at
our disposal, nor can we assume from analogy that the appearances
would be well marked if they could be made. What little knowledge
we have is derived from a study of more serious conditions of which
cerebral hyperæmia is an initial, collateral, or episodial feature.

In pronounced cerebral hyperæmia the entire brain is, as it were,

tumefied, so that the dura appears tensely stretched over its surface
and the gyri are flattened; both the meningeal vessels proper and
those of the pia are injected. According as the hyperæmia is active
or passive the color of this injection varies, being of a brighter red in
the former, of a purple or bluish color in the latter case. The purest
instances of active cerebral hyperæmia which I have seen were
found in patients dying in the apoplectiform phases of paretic
dementia (progressive paralysis of the insane). Here the cortex on
section exhibited a beautiful rosy tint, which was distributed in darker
and lighter strata in correspondence with the distributional areas of
the short and the long cortical arteries; there were numerous puncta
vasculosa both in the cortex and in the white substance, and in some
instances the arachnoid or the ventricular fluid was tinged with blood,
albeit no vascular rupture could be discovered. The red blood-
corpuscles undoubtedly escape by diapedesis from the surface as
well as the endymal vessels; the same thing occurs in the
intracerebral blood-vessels, whose adventitial spaces are often
crowded with accumulations of red blood-discs, while groups or
single ones are found scattered in the surrounding parenchyma, and
even in the periganglionic spaces. Occasionally accumulations of
pigment found near the vascular channels remain to attest the
former existence of other hyperæmias, and indeed slight
accumulations of this kind are found in the brains of most persons
who have reached adult life. These are to be regarded as remnants
of the physiological hyperæmias to which all active individuals are
subject. It is only when the accumulations become considerable and
numerous, as in the chronic insane, or are associated with those
changes in the blood-vessels which are discussed in the articles on
thrombotic and hemorrhagic cerebral disease, that they can be
regarded as indications of a pathological condition.

Acute simple meningitis is ushered in by cerebral hyperæmia of the

active form. This is not alone demonstrated by the early symptoms of
this disease, but also by the fact, which I have observed in two
cases, that where this form of meningitis originates on one side, as
from extension of the middle-ear trouble, the opposite cerebral
hemisphere exhibited intense congestion of the ideal type.

In that serious form of mental disease known variously as grave or

acute delirium and typhomania (Luther Bell) a form of cerebral
hyperæmia is observed which in its intensity approximates
inflammatory congestion. The surface of the brain appears marbled
and mottled; blood seems to exude from the gyri after the pia is
removed; the cortical lamination is invisible, owing to the hyperæmic
discoloration of the gray substance; and the parenchymatous
elements themselves appear to be in a state of cloudy swelling. In
one case I have observed transudation of a hyaline proteinaceous
substance and an exudation of fibrin around the larger arterioles. In
some cases of typhus fever a less intense but similar congestive
hyperæmia is found. The hyperæmias of paretic dementia, of acute
delirium, and of typhus fever agree in this one feature: that all
districts of the brain, from the cortex and white substance of the
cerebral hemispheres to the medulla oblongata, are involved nearly
to the same degree. In the hyperæmia of simple meningitis of the
convexity it is chiefly confined to the pia mater and the most
superficial cortical strata.

Congestion of the brain from stagnation of the venous return

circulation should not be confounded with active hyperæmia. With
this condition, which may be due to thrombosis of the sinuses,
morbid growths near the jugular foramen or in the neck around the
internal jugular veins, or, finally, to certain cardiac and pulmonary
disorders, there is rather a lesser than a greater amount of blood
sent to the brain; and it is not infrequently found that while the
surface of the brain appears congested, owing to the prominence of
the cerebral veins, the deeper parts are quite anæmic; and if the
injection be general, it will be found that the blood, whether in
arteries or veins, has the venous character. An excellent example of
this form of congestion is afforded by persons dying in the status
epilepticus. In their brains the venous channels stand out, filled to
their extreme capacity with blood almost black in color; and in
prepared sections, particularly such as are taken from the pons and
medulla oblongata, a beautiful natural injection of the vessels is
found. But that rosy color which is so characteristic of active
hyperæmia is absent, the tissues appearing purplish, bluish, or
chocolate-colored.

SYMPTOMATOLOGY.—There are few symptoms attributable to the

nervous system which have not been enumerated among the
characteristics or the occasional manifestations of cerebral
hyperæmia. Thus, Hammond not only follows Andral in enumerating
apoplectic, convulsive, comatose, and maniacal symptoms as acute
manifestations of active cerebral congestion, but assures us that
aphasia may occur under the same circumstances. In the course of
his work on the subject, “an absolute want of power to get correct
ideas of even simple matters,” confusion of ideas, weakening of the
judgment, vacillation of purpose, diminished logical power, illusions
and hallucinations of every sense, delusions, morbid apprehension
of impending evil, imperative, suicidal, and other impulses,
suspicion, hypochondriasis, furious delirium, and the use of profane
and obscene language, are enumerated among the characteristic or
prominent symptoms of various forms and cases of cerebral
hyperæmia.7 Not one but several of the recognized forms of insanity
have yielded a fair quota of their symptoms to this long array. Among
somatic signs he in like manner names neuralgic pains, numbness,
spasms, paralysis, false impotence, hyperæmia of the tympanum,
choked disc, abolition or perversion of the sense of smell, taste, and
sight, fibrillary or fascicular twitches, various states of the urinary
excretions, diplopia, and monoplegias. It is here equally evident that
the initial symptoms of a considerable number of organic and clearly
defined affections have been included. It is on account of the
confusion engendered by this wide interpretation of the meaning of
the term congestion of the brain that I have determined to limit the
term as previously indicated, and to consider only the active form
here.
7 A Treatise on the Diseases of the Nervous System, 7th ed., pp. 1-53. The natural
inference following a perusal of this chapter, as well as the monographs to which their
author refers, is that he has gathered together all states in which cerebral hyperæmia
was an associated factor, as well as those in which he appears to assume its
existence on theoretical grounds, and designated them as cerebral congestion. In
some instances he uses the terms hypochondria and cerebral hyperæmia
interchangeably (p. 50, loc. cit.).

A feeling of head-pressure, associated with a more or less severe

dull pain, aggravated by mental exertion, by stooping down, by
straining at stool, or when out of breath, and accompanied by a
subjective sense of mental dulness, is the most constant feature of
the ordinary cases. There is usually a vertiginous sensation, and an
irritability of the eye and ear not unlike that described in the article on
Cerebral Anæmia. Sleep is at first disturbed by vivid and sometimes
frightful dreams; later, it becomes interrupted, and ultimately
complete insomnia may develop. The action of the heart is
accelerated and exaggerated in some cases; in that event increased
pulsation of the carotids, flushing of the face, injection of the
conjunctiva, and a subjective sense of heat in the head and face are
experienced. Hammond, in accord with Hasse and Krishaber,
believes that febrile symptoms may develop under these
circumstances; most authorities, however, deny this for the
uncomplicated form. I have never found an objective rise of the
general temperature.

Such a condition as that described is usually slowly produced,

several weeks, or even months, being occupied in its development.
At first the unpleasant symptoms occur only at certain hours of the
day, with temporary exacerbations and remissions. It may be
arrested with comparative ease at any time; if neglected, the mental
faculties become affected, not in the grave sense in which Hammond
and the older authors describe it, so as to carry the patient into
actual dementia or delusional insanity, but rather in the way of
diminished working-power. It is more difficult to fix attention, to
recollect words, names, and figures, or to keep up a protracted
mental effort, than in health, but the formal judgment does not suffer.
I have known patients to be in this condition for many months, and
several for more than one year, without any grave deterioration. It is
true that in the prodromal periods of some forms of insanity, such as
acute mania, there is a condition very similar to that of these
patients; and this has led to regarding mania as a possible phase of
cerebral hyperæmia. But the very fact that, typically, mania is
preceded by such a stage—which is always of brief duration—that
maniacal excitement is a constant and unavoidable consequence
upon it, while, as far as known, the condition here described may last
for years without leading to a true psychosis, should prevent one
regarding the two conditions as identical, however similar they may
be for the time being.
In sufferers from cerebral hyperæmia who pass into the chronic state
of this disorder the disturbance of sleep and of the digestive organs
becomes very prominent, and continually reinforces the acting
causes of the disorder. In a large number of cases the head-
sensations become more or less localized; that is, while the general
feeling of pressure or dull ache may continue, a special area, which
can be covered by the palm of one hand, either in the middle part or
to one side—usually the left—of that part of the vertex, is the seat of
a more severe pain, complained of as a hot pressure. The patients
frequently claim that the temperature is higher at this spot, and,
contrary to what might be anticipated on a priori grounds, the
statement will be confirmed, not alone by the coarse method of using
the hand, but by the surface thermometer. The locality where this
occasional rise of temperature and the more common sense of
pressure are experienced corresponds to that part of the longitudinal
sinus where the largest cerebral veins enter. It is a noteworthy fact
that nearly all the important admunctories of this sinus empty into it
within the short space of two inches at this point.

Not all sufferers from cerebral hyperæmia give a history of a gradual

development of their symptoms. A few date their trouble from some
single intellectual, physical, or emotional strain. In one case,
complicated by marked evidences of cerebro-spinal exhaustion, the
patient, a lady, had during an illness of her husband, being deserted
by her servants, and the water-supply having been cut off, carried all
the water required for the invalid and domestic as well as sanitary
purposes up three flights of stairs for two unusually hot days in July.
In two others, strikingly similar in many details of their cases, both
being cornet-players, both attributing their illness to an extra call
upon their instrument, it was brought on in the older patient within a
few hours after playing on a hot day at the State Camp at Peekskill,
and in the second at Narragansett Pier as he left the sultry concert-
room and became exposed to a draught. In both these cases, as in a
large number since examined, some stomach trouble could be
positively determined to have antedated these symptoms. I mention
this because it is only in such cases that I have found the nausea or
vomiting which some writers regard as an occasional occurrence of,
and due to, the lighter form of cerebral hyperæmia.

There are no ophthalmoscopic evidences of cerebral hyperæmia of

this form. I have never found the optic disc presenting variations in
tint beyond those found within normal limits, except in a case of
saturnine encephalopathy with predominant signs of cerebral
congestion. I believe that the statement of Hammond8 as to the
existence of choked disc in cerebral hyperæmia is generally
regarded as due to the interpretation of organic diseases as
congestive states. It is not confirmed by authorities.
8 Loc. cit., p. 41, lines 29-36.

I have never found the tympanic membrane hyperæmic

independently of ear disease, even when tinnitus was marked. It is
claimed to exist by Hammond, and he adduces as analogous the
observation of Roosa that quinine produces an injection around the
handle of the malleus.9
9 It certainly is not necessary to look to the injection of the tympanum as an
explanation for the tinnitus of cerebral hyperæmia, based on such an analogy. The
tinnitus of cinchonism is more central in location, being producible in persons who
have pathological or no tympanic membranes, just as the tinnitus of cerebral
hyperæmia occurs indifferently under like circumstances.

The congestive states which follow traumatism and insolation are

properly considered in connection with the traumatic neuroses and
certain forms of insanity. But there are some milder cases in which
the symptoms remain within such compass as is comprised in this
section. The patient, after a fall or a blow on the head, suffers from
insomnia, has a sensation of fulness and ache in the head,
complains of a pulsating feeling in the occipital region and an
inability to concentrate his thoughts on subjects which previously
were parts of his routine. Under appropriate treatment recovery
ensues, but there remains behind an intolerance of alcoholic
beverages, and at times the patient experiences momentary fits of
abstraction, which may be regarded as mild analogies of the more
serious episodes of the full-blown traumatic neurosis. Thus, he may
be walking along the street and suddenly lose his train of thought for
an instant, to regain it on observing that he has inadvertently made a
misstep. Or in the midst of an address a previously fluent orator in
attempting to find a certain by-law in the rules of a society is unable
to recollect which he was in search of, and is compelled to take his
seat with a rambling apology. But for the fact that similar sequelæ
are noted in cerebral hyperæmia from other causes, it would be
questionable whether it be proper to attribute them to the congestive
element engendered by the traumatic influence. They are usually
noted when the hyperæmic phenomena proper have become latent
or disappear, and, with other symptoms customarily treated of as
mere results of circulatory trouble, may be regarded as signs of
neural exhaustion or inadequacy rather than of insufficient
ensanguination.

A more serious form of cerebral hyperæmia occurs in females in

conjunction with the climacteric period, and in both sexes in
consequences of the suppression of any habitual discharge in
advanced, and exceptionally in middle and juvenile, life. The advent
of the symptoms is rapid, a few hours or days sufficing for the
development of the attack. The face is flushed, the carotids throb
violently, the general cutaneous surface is congested, and the
patient is incoherently talkative. The one side, usually the right, is
heavy and tremulous, the fingers are devoid of their usual skill, and
the speech is more or less thick. The sleep is disturbed or replaced
by a stuporous condition, whose similitude to an apoplectiform
seizure is sometimes heightened by stertorous breathing. After one
or several days the patient emerges from this condition by degrees
or suddenly with complete restitutio ad integrum. But the attack may
recur, and ultimately it is noted in the event of repeated attacks that
the return to the normal state is slower and less complete: the
disorder then undergoes a transition into the congestive type of
paretic dementia described in another portion of this volume.

DIFFERENTIAL DIAGNOSIS.—In some of its clinical aspects cerebral

hyperæmia closely resembles cerebral anæmia. This is not
surprising when we bear in mind that both constitute nutritive
disturbances of the same organ, and that, notwithstanding the
apparent difference in the surface injection of an anæmic and a
hyperæmic brain, the state of affairs in the ultimate capillary districts
may be much more alike than might be anticipated on theoretical
grounds. In congestion we have wider vessels, and perhaps, though
not necessarily, a better quality of blood; but at the same time the
intracranial pressure may be such that the venous emunctories can
labor but slowly: the result will be that although there is more blood
in the brain, the lessened rate of flow places the nerve-elements
under nearly the same nutritive disadvantage that they are placed
under with the narrower and vitiated but more rapid blood-column of
ordinary anæmia.10 It is particularly the symptoms dependent on
those nerve-centres and tracts which are, so to speak, dynamically
sensitive, which resemble each other so much that an intrinsic
difference—both being placed side by side—is not always
determinable. This is true of the aural and optic symptoms. Tinnitus,
photophobia, scotomata, and blurring or darkening of the visual field
occur in both, and in about the same varieties. In my experience the
acuteness of hearing is more apt to be interfered with by the
subjective sounds with hyperæmic than with anæmic tinnitus. The
scotomata of hyperæmia are more distinct and coarser than those of
anæmia; darkening of the visual field is more apt to occur with
sudden rising in anæmia, while in hyperæmia it is provoked by
coughing, straining at stool, or other cause operating directly or
indirectly on the return circulation. It may be stated, as a general
rule, that if any of these symptoms are aggravated on lying down or
stooping, they are due to hyperæmia; while if the same procedures
are resorted to in anæmia, amelioration ensues. But in many chronic
cases these symptoms seem to continue as indications of a
permanently altered activity of the nerve-elements themselves; that
is, as a sort of pathological habit. In that case the position test may
not be decisive. In one respect there is a decided difference between
the anæmic and hyperæmic forms; there is never amaurosis in the
latter, while it is approached, and occasionally fully developed, in the
former. Much more importance attaches to the differentiation of
tinnitus due to nutritive brain disorders and that due to aural disease.
As a rule, the tinnitus from cerebral hyperæmia is symmetrical; if
unilateral, it is of short duration. The procedure of Valsalva11
aggravates the tinnitus of hyperæmia, and relieves that which is due
to the commoner forms of ear disease; the former is aggravated and
the latter relieved by noise.
10 It is also admitted that the blood stagnating in the larger veins and accumulating in
the arteries, the limits of compressibility of the other cerebral contents being passed,
the capillaries will suffer, so that with injected and turgescent arterioles and venules
there may be capillary anæmia.

11 I would caution against Politzer's method in cases of ear disease coexisting with
cerebral congestion. In a patient now under my treatment each session at the aurist's
was followed by a distinct exacerbation of the cerebral symptoms.

In the table on p. 773 I have attempted to formulate the principal

differential relations of the protracted forms of cerebral anæmia and
hyperæmia.

There are a number of so-called functional nervous states which,

aside from the fact that they are unwarrantably confounded with
cerebral congestion, do not require mention in a differential relation.
Such are the masturbatory neurosis, certain hysterical states, and
the asthenia resulting from nervous shock and overwork. These
states have found a provisional resting-place under the
comprehensive and non-committing title of neurasthenia or nervous
exhaustion—a term which includes conditions fully recognized by
Robert Whytt and Isenflamm in the last century.

Symptomatic State. In Cerebral Anæmia. In Cerebral Hyperæmia.

Pupils. Usually dilated and mobile. Usually small or medium.
Respiration. Often interrupted by sighing or Normal.
by a deep breath, even when at
rest.
Headache. Either sharp and agonizing, and If localized, accompanied by a
then in a limited area, or a subjective and objective
general dull ache, intensified in (always?) feeling of heat; if
 the temples and over or behind general, is compared to a bursting
the eyes. or steady pressure.
Activity. There is lassitude. There is indisposition to exertion,
yet patient is restless.
Temperament. Lethargic, with exceptions. Choleric, with exceptions.
Intellect. Inability to exert. Rather confusion than inability of.
Sleep. Insomnia, interrupted by trance- Insomnia, with great restlessness,
like conditions, in which the variegated by unpleasant and
patient is comparatively confused dreams.
comfortable. Dreams often
pleasant.
Influence of upright Aggravates all the symptoms. Either without influence or
position of body. beneficial.
Influence of Amelioration. Aggravation.
recumbent position of
body and dependent
position of head.
Influence of acts If any, a sharp headache may Aggravated.
involving deep ensue, but the other symptoms
inspiration, such as are not aggravated.
blowing, straining at
stool, sneezing, etc.

TREATMENT.—Ergot of rye with its preparations may be regarded as

the cardinal drug in cerebral hyperæmia. There are few drugs in the
domain of neurological therapeutics which are so directly antithetical
to the pathological state as this one. There is scarcely a case of
cerebral hyperæmia that is brought to the physician's attention but
may be regarded as being in part due to an over-distension of the
cerebral vascular tubes. This is directly overcome by ergot, and the
quantity which such patients will sometimes bear without showing
signs of ergotism is something remarkable, in notable contrast with
the subjects of cerebral anæmia, who are usually very sensitive to it.
About three grains of Bonjean's ergotin may be regarded as a safe
trial-dose for an adult, and unless a distinct effect is produced within
two or three days this dose may be raised to six grains twice or three
times within twenty-four hours. It is not advisable to combine
strychnia with the ergotin, as is often done; the effect of that alkaloid
is to increase the psychical and sensorial irritability of the patient.
Chloral hydrate or bromide, or both in combination, is as useful an
adjuvant here as it would be hurtful in cerebral anæmia.

It is not usually necessary to employ special hypnotics in cerebral

congestion. The same drug whose beneficial effect is so potently
marked during the daytime that tinnitus, cerebral pressure, and
subjective drowsiness will disappear before it, if not as rapidly, more
enduringly, than the symptoms of cerebral anæmia disappear before
nitrate of amyl, will also overcome the insomnia in the majority of
cases. Where it fails, warm pediluvia or sitz-baths will prove more
efficient than the majority of hypnotics. Their use, at all events,
involves no hurtful effect on a—possible already—disordered
stomach, and their certainty of action is much more even. Their
temperature should be about 40-42° Centigrade, and the immersion
continue from fifteen to twenty-five minutes.12
12 A number of experiments, the most recent of which were by Musso and Bergesio
(Rivista sperimentale di Freniatria e di Medicina legale, 1885, xi. p. 124), have shown
that in such baths the cerebral pulsations become less excursive and that the volume
of the brain decreases. The same applies to general warm baths.

In those cases where the subject sensations accompanying

hyperæmia, active or passive, are intensified in the posterior
segment of the head or the nuchal region, leeches at the mastoid
process, or cupping, wet or dry according to the severity of the
symptoms, will often give immediate relief. Burning with the actual
cautery, or, what is equivalent and a much neater application, the
heated glass rod, has an equally happy effect in that class of cases
where throbbing and pain are intensified low down. It should be done
as near the spot indicated by the patient's complaints as possible.13
13 In a case of gliomatous hypertrophy of the pons oblongata transition marked by the
development of numerous tortuous and enlarged blood-vessels the episodes of the
disease were found to be of the congestive type, and yielded to no other treatment
than that with the cautery.
The diet of patients who are suffering from or subject to cerebral
hyperæmia should not be stimulating nor difficult of digestion. It is
much more important to avoid distension or overstrain of the
stomach than to reduce the nutritive value of the food in the majority
of cases, for true plethora is much less common than is supposed.
The bowels should be so regulated that the patient have at least
one, and that an easy, movement a day. The saline cathartics,
particularly the Carlsbad salt, are to be used to effect this if
necessary. The clothing around the neck should be free and not
compress the parts.

In those severe forms of cerebral congestion attending the

climacteric period, or occurring in consequence of the suppression of
discharges, and similar causes, the symptoms are often so alarming
as to render energetic measures, such as bleeding, immediately
necessary. This may be affected by applying leeches to the nose,
the temples, or by bleeding at the arm. If due to the suppression of
hemorrhoidal discharges or menstruation, the leeches should be
applied to the anus and hot sitz-baths taken. In the milder forms a pill
composed of aloes, podophyllin, and ox-gall, recommended by
Schroeder van der Kolk, will be found effective.

Cerebral Anæmia.

The oft-confirmed observation of Treviranus, that the brain is paler in

the sleeping than in the waking state, supplemented as it has been
by more elaborate observations, which show that the difference
between the intracranial blood-amounts, as estimated in these
opposite states, is equivalent to one-twenty-fourth part of the total
blood-amount of the body, has been made the basis of much
dazzling theory and premature speculation. Hyperæmia of the
central nervous apparatus or of certain of its provinces becomes
regarded as synonymous with over-activity, and anæmia, general or
provincial, as the expression of the opposite functional state.
Elaborate directions may be found, even in recent treatises on the