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A M E R I C A’ S PA S T O R
A M E R I C A’ S PA S T O R
Billy Graham and the Shaping of a Nation

Grant Wacker

The Belknap Press of Harvard University Press

Cambridge, Massachusetts
London, England
2014
Copyright © 2014 by Grant Wacker
All rights reserved
Printed in the United States of America
First printing

Library of Congress Cataloging-in-Publication Data

Wacker, Grant, 1945–
America’s pastor : Billy Graham and the shaping of a nation / Grant Wacker.
pages cm
Includes bibliographical references and index.
ISBN 978-0-674-05218-5 (alk. paper)
1. Graham, Billy, 1918–. Christianity and culture—United States—
History—20th century. I. Title.
BV3785.G69W33 2014
269'.2092—dc23
[B]
2014014155
 For
Gretchen, Nicholas, and Charlie Stern
Henry and Silas Beck

Children’s children are the crown of old men.

Proverbs 17:6
 Contents

Prologue 1
Introduction 5
1 Preacher 32
2 Icon 68
3 Southerner 102
4 Entrepreneur 137
5 Architect 168
6 Pilgrim 204
7 Pastor 248
8 Patriarch 283
Epilogue 312

Note on the Sources 319

Abbreviations 322
Notes 323
Acknowledgments 397
Index 401
A M E R I C A’ S PA S T O R
But he had in his Pocket a Map of all ways leading to, or from
the Celestial City;
wherefore he struck a Light (for he never goes also without his
tinder-box).
—John Bunyan, The Pilgrim’s Progress, 1678/1684
 Prologu e

Billy and I descended on New York City at the same time, the summer of
1957. He was thirty-eight and about to clinch his reputation as the premier
evangelist of twentieth-century America. I was twelve and about to taste
freedom. But not that summer. One humid night my parents packed them-
selves and me—entirely without my permission—into a subway car bound
for Madison Square Garden. The Great Man was preaching.
I was a kid from a small town in southwest Missouri, and that was the
biggest crowd I had ever seen. I remember that the choir alone seemed larger
than my whole church. After a lot of music, including a dirgeful rendering
of “The Old Rugged Cross” by “Bev” Shea, Graham finally stepped to the
pulpit. The Garden fell silent. The anticipation was electric. He was hand-
some and charismatic and funny. Focusing on the great number of young
folks in the audience, he quipped something about puppy love being utterly
real to the puppy. The audience roared. By the end of the sermon, however,
he had grown deadly serious. When he invited people to stand up and walk
to the front to commit or recommit their lives to Christ, hundreds surged
forward. For a while I thought I should go too, but then I remembered that
I had already been saved when I was four.
Beyond that, not much stuck. Soon our first family trip to the Big Apple
was over and we headed back home. At the time I had no idea what the big
whoop was all about. I eventually realized, however, that Graham’s core
constituents—the millions of mostly white, middle-class, moderately con-
servative Protestants we might call Heartland Americans—did not share
my puzzlement. They knew exactly what it was all about.
America’s Pastor: Billy Graham and the Shaping of a Nation explores
Graham’s place in the great gulf streams of American history in the long
second half of the twentieth century. It is not a conventional biography.
Numerous studies of Graham’s life or aspects of it already grace the shelves
of public libraries, and many of them are excellent. My aim is different. I
try to step back and ask another question. Why does Graham matter? What
does his story say about the construction of charismatic leadership? More
important, what does it say about how evangelical religion became so
2 Prologue

pervasive? Most important, what does it say about the relation between
religion and American culture itself? The short answer to all three of these
questions is, a great deal. Graham’s long life (born 1918) and sixty-year
ministry (roughly 1945 to 2005) offer a means for hearing the conversa-
tions of the age.
But there is more. Graham’s story not only registered other Americans’
stories but also shaped them. I do not suppose that he exercised much influ-
ence in the formation of public policy. For that matter, with the possible
exception of Martin Luther King, Jr., I do not suppose that any clergy per-
son did. But I do think Graham exercised influence in another, subtle, and
deep way. He played a large role in the shaping of public consciousness:
how Americans perceived the world around them, how they interpreted
those perceptions, and then how they acted upon them. He gave them tools
to help them see themselves as good Christians, good Americans, and good
citizens of the modern world all at the same time. He also called them to
accountability on each of those scores. Graham did not speak for everyone.
Millions knew or cared nothing about him. But many millions did. In a very
real sense those millions—the ones I variously call Heartlanders, ordinary
Americans, or simply supporters—constitute along with Graham himself
one of the two main players in this narrative.
The days are long gone when historians can credibly pretend to hold a
mirror up to the past and simply report what they observe. They see what
they are prepared to see. So it is only fair to let readers know ahead of time
what I think I see in Graham’s career. On one hand, Graham ranks with
Martin Luther King, Jr., and Pope John Paul II as one of the most creatively
influential Christians of the twentieth century. One could make a case for
others, too, such as Professor Reinhold Niebuhr, Bishop Fulton Sheen, and
Mother Teresa, but all of them spoke for a more limited constituency and
for a briefer stretch of time. On the other hand, Graham was not a marble
statue, and he was the first to say so. He made mistakes, and some of them
were grievous. “A hero,” said the historian Michael Kazin of three-time
failed presidential candidate William Jennings Bryan, “is not a man whose
life is free of errors and contradictions.” Rather, he is (quoting classicist
Moses Hadas), “ ‘a man whose career has somehow enlarged the horizons
of what is possible for humanity.’ . . . A man without flaws, adds Hadas, ‘is
not apt to possess the determined energy heroism requires.’ ”1 Graham’s
achievements loom all the larger when we recognize that he did not tumble
from the sky fully formed and perfectly chiseled like an American Moses.
 Prologue 3

He grew gradually, and sometimes fitfully, into the imposing figure that
millions of Americans carved for him and that he carved for himself.
Since feelings about Graham run strong, I should say a few words about
my method and point of view. As for method, I hope simply to be fair. That
means that I try to treat him as I hope others would treat me, by giving him
the benefit of the doubt when the evidence allows it but also by telling the
truth without flinching when it does not. Graham made clear to historians
and journalists that he wanted it no other way. I have talked about the
project with members of Graham’s family and several of his close associ-
ates. They caught factual errors and offered perspectives I had not thought
about, but the overall interpretation is mine alone. Readers on Graham’s
left will find my account too positive, and those on his right too negative.
Long ago I decided that I would have to proceed as my grandmother pro-
ceeded onto freeways: buckle up, close your eyes, and just do it.
As for point of view, I count myself a partisan of the same evangelical
tradition Graham represented, especially the irenic, inclusive, pragmatic
form of it that he came to symbolize in the later years of his public ministry.
That identification comes from my upbringing and from adult choice. To
be sure—to steal a line from the historian Ron Wells—I have often thought
of resigning from the movement, but I did not know where to send the let-
ter. Besides, who else would have me? Sunday mornings usually find my
wife and me in our accustomed pew in a small United Methodist Church in
Chapel Hill, North Carolina, seated on the cemetery side of the building.
Just outside the window, the weather-beaten tombstones dating back to
1859 remind me of the enduring power of the gospel message, generation
after generation. At the same time, I know that the eroded tombstones with
no names at all may well mark the graves of Methodist slaves. They remind
me of the tradition’s failings.
I started this Prologue with a personal recollection because I thought my
experience represented many others. I will close the same way and for the
same reason. In the summer of 2009, I escorted my four-year-old grand-
daughter, Gretchen, to the Billy Graham Library in Charlotte, North Carolina.
Mostly, we wanted to see the famous talking cow just inside the entrance.
After a long time—a very long time—admiring the cow, and then walking
through several rooms of exhibits celebrating (and celebrating is the right
word) the evangelist’s life, we ended up, as all visitors do, in a theater with
an enormous cinema screen. Across the screen flashed a five-minute clip of
Graham, in his prime, preaching to a vast stadium audience. Significantly,
4 Prologue

the place and date of the event went unnamed, creating a sense of the uni-
versal and timeless relevance of his message.
When the sermon—a well-rehearsed story of God’s love for broken
humanity—drew to a close, the evangelist encouraged potential inquirers,
as he called them, to stand up and walk to the front. “Come. You come. We
will wait.” And wait he did, as hundreds, perhaps thousands, wordlessly
streamed toward the counselors standing near the podium. When the lights
in the theater came back on, Gretchen demanded in wide-eyed wonderment,
“Grandpa, what’s this all about?” I doubt that any book will ever fully
answer her question, but I hope this one makes a good start.
 In t roduc tion

Billy Graham’s long life started inauspiciously enough on a dairy farm near
Charlotte, North Carolina, on November 7, 1918. The guns of the Great
War in Europe fell silent on November 11. As an adult, Billy Frank—as his
family called him—liked to quip that it took the world only four days to
hear about his birth. Though the comment was typically tongue-in-cheek, it
foreshadowed, with brilliant succinctness, an authentic American nativity
story. By the 1950s, Graham would be a national personality, by the 1960s
an international celebrity, and by the 1970s an icon everywhere. That sta-
tus would stay with him until he effectively retired from public ministry in
2005. By then his name had become common currency in millions of Amer-
ican households.1
America’s Pastor: Billy Graham and the Shaping of a Nation offers an
interpretation rather than a strictly chronological account of the evange-
list’s life. The rise, singularity, and longevity of the career of a lanky farm kid
from North Carolina help us understand how Americans constructed and
experienced leadership. More important, Graham’s story sheds light on the
formation of a moral vocabulary that expressed the grievances and aspira-
tions of millions of people. Graham’s voice helped guide that process. And
most important, his story reveals the influences of religion, especially evan-
gelical religion, on larger trends in the culture. After all, Graham intersected
with many of the most compelling public events of the era, including the
growth of a celebrity ethos, the geographic expansion of Southern habits,
the galvanization of the evangelical movement, the normalization of reli-
gious cooperation, the awareness of military threats, and the quest for global
justice. His tenure also coincided with the public discussion of many of the
most compelling private events of the era—aging, loneliness, broken mar-
riages, wayward children, and, of course, the ever-present fear of death.
Though private experiences of this sort had marked American life from the
beginning, people described them in the vocabulary of the time.
This book provides a tool for making sense of the complexities of Amer-
ican culture in the six decades following World War II. But it rests on a
foundation of basic biographical details. Fortunately the most important
6 Introduction

details are fairly easy to come by. The archival resources are vast. Moreover,
Graham told his story often, as did historians and journalists, and their
renderings show little variation. The differences lie mainly in emphasis and
point of view.2
Perhaps the most remarkable thing about Graham’s childhood and early
adolescence is how unremarkable they really were. The oldest of four chil-
dren, Graham grew up in the security of a moderately prosperous farm fam-
ily. Both parents were, from the time of his birth, members of a nearby As-
sociate Reformed Presbyterian Church. This small but sturdy sect was known
for its rigorous Calvinist theology, strict rules about Sabbath observance, and
tradition of singing psalms instead of hymns. Graham proved an ordinary
student, neither strikingly good nor strikingly bad. He displayed normal
teenage interests, especially, he later suggested, girls, baseball, and fast cars.
The story of Graham’s adolescent conversion has been rehearsed so of-
ten it has acquired the patina of a Damascus Road experience. Still, there is
no reason to doubt the basic outline. In the fall of 1934 an itinerant evan-
gelist named Mordecai Ham set up his tent not far from the Graham farm.
Ham was a classic Southern barnstormer, later associated with anti-Semitism
and right-wing causes, but in 1934 known mostly for excoriating immoral-
ity, upbraiding lax clergy, and calling lost souls to Christ. The revival waxed
for six weeks. Graham visited several times, apparently more from curiosity
than conviction. But Ham’s preaching finally struck a spark. On November 1,
six days before Graham’s sixteenth birthday, the young man made his way
down a sawdust-covered aisle in the revival tent.3 The commitment involved
no tears, no epiphany, and little emotion, but it did produce a granite deter-
mination to commit his life to Christ. Graham and sympathetic biogra-
phers portrayed the Ham revival experience as his conversion to evangeli-
cal Christianity. But there was not much to be converted from. He already
upheld all the major tenets of evangelical Protestant faith, fortified with a
morally upright life. The occasion seems better understood as a moment of
self-definition.
The year 1936 marked major transitions in Graham’s life. After graduat-
ing from Sharon High School in May, he spent the summer selling Fuller
Brushes door-to-door in South Carolina. The young man proved exception-
ally good at it too, earning more money than any other Fuller Brush sales-
man in the state. Someday those selling skills would manifest themselves in
the great stadiums of the world. In the fall of 1936 Graham matriculated at
Bob Jones College in Cleveland, Tennessee, not realizing that the school was
unaccredited.4 Though there was no evidence that he objected to the school’s
 Introduction 7

fundamentalist theology, he did find its regimented social rules as oppres-

sive as President Jones’s authoritarian control. A damp climate, “a flu bug,”
and class work in “a shambles” did not help.5
Sometime that autumn Graham received a letter from a friend at Florida
Bible Institute (FBI, later Trinity College) near Tampa. The note described the
sunshine, orange trees, relaxed atmosphere, and evangelistic focus. Graham’s
mother, Morrow Graham, had read about the school in Moody Monthly. It
was an independent institution with a Christian and Missionary Alliance
flavor. (The CMA, as it was commonly called, flourished as a Northern-based
holiness sect emphasizing divine healing, overseas missions, and Christ’s
second coming.) Morrow Graham liked what she read. Billy transferred in
January.
Florida Bible Institute offered Graham a range of opportunities that
proved crucial for his career. He honed his preaching skills by emulating
the style of fundamentalist warhorses wintering at the school, memorizing
passages from famous evangelists’ sermons, and practicing in front of mir-
rors as well as alligators in the nearby Hillsboro River. Soon he graduated
to street corners, storefront missions, local jails, youth camps, and mobile-
home parks. The aspiring evangelist went on the radio and served as assis-
tant pastor at Tampa Gospel Tabernacle, a start-up congregation affiliated
with the CMA. Astute observers might have suspected that even then his
greatest gift would lie in his ability to persuade his audience to make a deci-
sion for Christ—to “close the deal,” as outsiders put it.
Professional opportunities arose too. In the spring of 1939 Graham re-
ceived ordination from the Southern Baptists, a denominational identifica-
tion he held ever after. The following year a chance encounter with visitors
from Wheaton College near Chicago led to the promise of a scholarship to
that institution. Graham accepted Wheaton’s offer. Armed with an unac-
credited Bachelor of Theology degree awarded in May, the aspiring preacher
headed north in the summer of 1940. Wheaton was fundamentalist but
serious. It gave him only one semester of credit for three years of Bible in-
stitute work.
In many ways Wheaton, not the Ham revival, proved the defining expe-
rience of Graham’s early career. There he met his future wife, Ruth Bell,
the precocious daughter of staunchly Presbyterian China missionaries, Dr.
L. Nelson and Virginia McCue Bell. He majored in anthropology, not Bible or
missions, a choice with portentous implications. At Wheaton, anthropol-
ogy did not signal cultural relativism, as it did in secular colleges, but it did
signal awareness of a wider world. And once again Graham spent a great
8 Introduction

deal of time preaching, both on the road and at a local CMA tabernacle—
“The Tab”—where he served as a pastor for the final two years of college.6
And, critically important, Wheaton introduced Graham to a dense network
of friendships with talented and ambitious evangelical divines very much
like himself.
After graduating in May 1943, the young preacher accepted the pulpit
of a tiny nearby Baptist church. Billy and Ruth married in August. (They
would parent five children: Virginia, 1945; Anne, 1948; Ruth, 1950; Frank-
lin, 1952; and Ned, 1958.) A great pastor he was not, and his term of ser-
vice lasted slightly more than a year. But the incurably restless Graham knew
how to reach a wider audience. First, he changed the congregation’s name
from Western Springs Baptist Church to the more expansive Village Church.
He inaugurated a monthly lunch meeting, significantly dubbed the Subur-
ban Professional Men’s Club, at a local restaurant. It won the support of
celebrities such as the Pulitzer Prize–winning cartoonist Vaughn Richard
Shoemaker.
In January 1944 Graham shouldered a Chicago radio program called
Songs in the Night, which aired every Sunday night from 10:15 to 11:00
over Chicago’s powerful WCFL Radio. Though the broadcast included a
sermonette by Graham, it emphasized organ and vocal music, especially the
dulcet voice of baritone George Beverly Shea. Graham had persuaded Shea,
a Canadian crooner already famous in the Chicago area, to join the program
on a regular basis. As things turned out, the team of Graham and Shea, like
the teams of Dwight L. Moody and Ira Sankey in the late nineteenth century
and then of Billy Sunday and Homer Rodeheaver in the early twentieth cen-
tury, proved for keeps. Graham and Shea stayed together, colleagues and
fast friends, until the end of Shea’s long life in 2013.7
The mid-1940s saw Graham twice applying for service as a military
chaplain. Prefiguring his chronic struggles with ill health (despite remark-
able physical stamina and athletic ability), the army turned him down both
times: once for being underweight and once for a severe case of mumps. Yet
the lack of military service did not harm his reputation, even in times of
nationalistic fervor. That irony may have found resolution in another way:
Graham’s deep involvement in a Protestant movement attuned to the blend
of religious and patriotic zeal that marked the years preceding and follow-
ing the end of World War II. It went by the name Youth for Christ (YFC).
This fledgling nondenominational organization featured entertainment,
patriotic fervor, and spiritual uplift for young adults and returned servicemen
 Introduction 9

and women. Riding a wave of interest in (and sometimes fear of) adoles-
cent culture, YFC paralleled other evangelical organizations founded in the
early 1940s with youth in mind, such as Young Life (1941), InterVarsity
Christian Fellowship (1941), and Word of Life (1940). YFC services show-
cased, as one admission ticket headlined it, “Sparkling Singspiration” and
“Timely Testimonials.” They also offered “all the gimmicks that reason would
allow: famous athletes, stunts, music.”8 In the fall of 1944 Graham became
its first full-time evangelist. Historians debate whether Graham made YFC
or YFC made Graham. Either way, the match was made, if not in heaven,
at least in the cultural effervescence of postwar America. The initial Chica-
goland Youth for Christ Rally, held May 27, 1944, at the city’s prestigious
Orchestra Hall, marked Graham’s first major public meeting. Swallowing
his fears, the twenty-three-year-old firebrand thundered to three thousand
partisans, for by all accounts the young evangelist mixed volume with light
in roughly equal measure. At the end, forty souls streamed forward to give
their lives to Christ. By then Graham, too, surely realized that “closing the
deal” constituted his greatest gift.
The marriage between Graham and YFC flourished. He relentlessly
crisscrossed the northern Midwest preaching under its auspices. In 1945 he
spoke to sixty-five thousand at a YFC rally in Soldier Field, Chicago, and
logged at least 135,000 miles, more than any other civilian passenger on
United Airlines. Between 1946 and 1947 a series of YFC events in Europe
enabled Graham to build his repertoire of sermons, polish his preaching
style, organize large meetings, engage the press, deal with criticism, nurture
support groups, and, again, network with other rising evangelical leaders.9
Graham continued to speak at YFC meetings in the United States off and
on until 1950.
In the late 1940s one of the most important but least analyzed fea-
tures of Graham’s ministry realized its final form: the establishment of the
Graham “Team.” It consisted of Shea, the musical soloist, and Cliff Bar-
rows, the announcer, choirmaster, and unofficial front man. Shea won dis-
tinction for his resonant renderings of favorites such as “Just As I Am” and
“How Great Thou Art.” Barrows—like Graham a YFC man—made his mark
with his seemingly unique ability to organize and lead massive choirs, often
numbering in the thousands. Other associates—preeminently Grady Wilson,
Graham’s childhood friend and Wheaton classmate, and, later, Leighton
Ford, Graham’s Canadian-born brother-in-law—served as regular alter-
nate preachers. Ford sounded so much like Graham on the radio that
10 Introduction

listeners often confused them. But in the public eye Shea and Barrows (who,
like Shea, remained a colleague and fast friend for some seven decades)
formed the irreplaceable wings of the Team.10
The years stretching from December 1947 to February 1952 cradled the
strangest interlude in the evangelist’s life. In 1946 the aging fundamentalist
William Bell Riley repeatedly urged Graham to succeed him as president of
Northwestern Schools—a Bible-training institute, liberal arts college, and
seminary—that he had started in Minneapolis in 1902. Though Graham
initially resisted, he eventually succumbed to the patriarch’s deathbed en-
treaties. So it was that at age twenty-nine Graham became the youngest
college president in the nation. He held only bachelor’s degrees from Flor-
ida Bible Institute and from Wheaton College. Though Graham entertained
no illusions about his credentials, he felt somehow obliged to accept Riley’s
importunate requests. Despite his youth, inexperience, and frequent and
prolonged absences on the itinerant circuit, he acquitted himself in the presi-
dent’s role surprisingly well. He oversaw, or at least authorized, a major
building program, started a radio station, and received credit for dramati-
cally rising enrollments. He learned how to delegate. And he discovered that
he was a preacher, not an administrator. Moreover, Graham again forged
ties to other rising evangelical leaders. Realizing that he could no longer func-
tion as president of Northwestern Schools and remain on the road so much,
he resigned in February 1952, slightly more than four years after taking the
helm.
In the fall of 1947, following two major endeavors in Europe, Graham
held his first urban revival campaign in the United States, independent of YFC
auspices, in his hometown of Charlotte, North Carolina. In many ways this
set of meetings anticipated the hundreds of urban revivals he would lead in
America and elsewhere in the decades ahead. It involved advance planning,
systematic organization, prayer chains, extensive publicity, and sponsor-
ship by local churches and business groups. It also involved Graham’s trade-
mark instinct for maximizing effectiveness with celebrity testimonies. Three
years later one of Graham’s associates changed the name of his meetings
from campaigns to crusades in order to emphasize that the work would con-
tinue after the Team left town.
Enter Modesto. The site looms large in virtually all accounts (including
Graham’s own) of his career in the late 1940s. As the story goes, in the fall
of 1948 the Team met in a motel in this central California town to discuss
revivalists’ historic pitfalls. After extended prayer and thoughtful discussion,
they settled on four: misuse of money, sexual immorality, exaggeration of
 Introduction 11

results, and criticism of other clergy. They determined that they would not
only avoid those snares but also take measures to prevent them in the first
place. The precautionary steps eventually acquired a life of their own and
set the gold standard for other evangelists. They included conducting regu-
lar audits with full disclosure; never traveling or dining alone with a woman
other than family; relying on outsiders’ enumeration of attendance records;
and emphasizing areas of agreement rather than disagreement with other
clergy and Christian traditions. Over the years Graham received intense me-
dia scrutiny, but hardly anyone accused him of violating any of those four
principles. Supporters (though not Graham himself) soon started to call the
agreement the Modesto Manifesto. Modesto Covenant would have been
more apt, for it relied on the tensile strength of mutual accountability.
Charles (Chuck) Templeton also loomed large in Graham’s early career.
Templeton was a man of extraordinary gifts. Born into a working-class
family in Toronto in 1915, he experienced a powerful religious conversion
in a local fundamentalist church in 1936. Though he never finished high
school, he became an itinerant evangelist for YFC. In 1945 Graham and
Templeton met on the YFC circuit. Acquaintance soon blossomed into friend-
ship, and they started traveling and preaching together in Canada, the United
States, and Great Britain. By all accounts, including Graham’s own, the
handsome Canadian was the better preacher.
In the late 1940s, however, Templeton began to experience doubts about
the conservative message that they were preaching. Determined to tighten
his theological grip, he successfully petitioned Princeton Theological Semi-
nary to admit him into a special program. The encounter with modern
theology and biblical criticism only deepened Templeton’s doubts. He chal-
lenged Graham, too, to go to seminary and grapple with these troubling
problems. After a year, Templeton left Princeton and started working for
the National Council of Churches as a Presbyterian evangelist. Later he
hosted a weekly CBS television program on religion. In 1957 Templeton
announced that he had grown agnostic and honorably resigned from
Christian ministry. He returned to Toronto, where he distinguished him-
self as a novelist, journalist, politician, toy designer, and television news
commentator. In 1996 he published a poignant spiritual autobiography,
Farewell to God, which detailed the reasons for his loss of faith. Both
men bravely tried to maintain their friendship into the 1970s. Templeton
died in 2001.11
The Canadian evangelist’s narrative holds significance for its own sake,
of course, but also for what it tells us about Graham. First, Templeton
12 Introduction

challenged Graham to re-examine the theological bases for the views he

espoused. In his own way, Graham accepted Templeton’s challenge. Late in
the summer of 1949 Graham emerged from a short but intense period of
theological self-examination. His old views remained pretty much intact
but were now fortified with faith-based and pragmatic arguments he found
persuasive. Graham’s preaching never veered from a forceful—outsiders
said dogmatic—assertion that the Bible offered authoritative answers for
all of life’s truly important problems. Templeton called Graham’s approach
“intellectual suicide.”12 Second, Templeton appears in most renderings of
Graham’s life, ranging from hagiographic to debunking, as the foil that
defined him. Graham emerges either as an obscurantist who timidly avoided
the hard edge of Templeton’s challenge, or as a man of deep faith who cou-
rageously wrestled it to the ground. Graham’s faith-based approach to the
Bible proved baffling to many partisans of the mainline Protestant—not to
mention the academic—establishment.13 But Graham’s supporters did not
care. Sooner or later everyone had to settle on a few axioms that made daily
life possible.14
In many ways the eight weeks from September 25, 1949, to November
20, 1949, served as the springboard for Graham’s entire career. After un-
successful attempts to evangelize Los Angeles with other preachers, a group
of Christian businessmen working with the local YFC chapter invited Graham
to try his hand. The campaign was centered in a mammoth circus tent
pitched in the heart of the city. The tactics that Graham deployed that fall
dictated the template for virtually all the crusade meetings for the next six
decades. Most of the components had appeared in Billy Sunday’s revivals
before and after World War I, and in nascent form in Graham’s own Char-
lotte campaign in 1947. But in Los Angeles the combination proved more
than the sum of the parts, not least because of the sheer size and complex-
ity of the endeavor. It included extensive planning, lavish publicity, meticu-
lous organization of ushers and choir members, and concerted prayer
chains meeting months in advance. The services featured celebrity testimo-
nies, both old and new music, electrifying preaching, boilerplate evangeli-
cal theology, prayer with converts, and lots of Southern charm—all deliv-
ered with smashing sincerity and effectiveness.
Graham’s early theology represented a tradition of assertions that many
Americans found reassuringly familiar. God had revealed his will in the
Bible, which taught that all humans had sinned. But Christ offered forgive-
ness and new life through faith in his atoning death and resurrection. Per-
sonal transformation did not come cheap, however. It demanded a life of
 Introduction 13

moral rigor, ethical integrity, and readiness to share this good news—or
“gospel”—of salvation. The result was everlasting joy in heaven for the
saved or everlasting separation for the lost.
Graham placed this theological message in a context of domestic and
international threats, especially lawlessness at home and communism abroad.
That context resonated with his audience in Los Angeles and, soon, across
the nation. Less than a month before the crusade began the Soviets had
exploded an atomic bomb, and six days after it started the Reds, as many
Americans called them, took over the Chinese mainland. Graham’s ability
to set traditional theological claims in a setting of national and world crises
would rank as one of the hallmarks of his long career.
Things got off to a slow start—not least because of unseasonably cold
weather and scant attention from the media—but the conversions of celeb-
rities, such as the Country Western singer Stuart Hamblen and the Olympic
track star and war hero Louis Zamperini, as well as the priceless publicity
bestowed by the newspaper magnate William Randolph Hearst, helped
generate a cumulative attendance of 350,000 with 3,000 converts. (Soon
Graham would call them inquirers, not converts, because no one except God
knew the heart well enough to call anyone a convert.) Those numbers likely
exceeded Graham’s previous endeavors put together. The size and publicity
of the Los Angeles project triggered extensive coverage in the national and
international media, including in Time, Life, Newsweek, and the New York
Times. Their stories transformed Graham into a national personality.
If the events of the late 1940s served as the launchpad for Graham’s ca-
reer, those of the 1950s established him as the premier Protestant evangelist
of the twentieth century. We can conveniently group the developments of
the 1950s into three categories: the crusades, the media enterprises, and the
issues of the day.
The crusades steadily grew in size, frequency, and types of venue. Imme-
diately after the Los Angeles meeting Graham opened a crusade in Boston,
with less advance planning but greater media attention and penetration into
both Roman Catholic and mainline circles. The Boston meeting was fol-
lowed by highly publicized ventures in Columbia, South Carolina; Portland,
Oregon; and Atlanta, Georgia, all in 1950. In 1951 Graham introduced a
systematic program of on-site counselors to instruct inquirers in Christian
essentials and then guide them to local churches. To the end, Graham con-
sidered counselors and follow-up guidance fundamental to the crusades.
The year 1954 saw Graham’s massive crusade in London, and then the
most famous extended meeting of his career in New York City in 1957.
14 Introduction

Held in Madison Square Garden, the highly publicized event ran sixteen
weeks, from May 15 to September 1. In the months leading up to the New
York crusade, Graham appeared at a flurry of press conferences and in net-
work television interviews. A gathering in sweltering heat in the middle of
July in Yankee Stadium broke attendance records at the venue. In a telling
portent of things to come, Vice President Richard Nixon visited. At the end
of the crusade, counters recorded a staggering 2,400,000 cumulative at-
tendees and 61,000 inquirers.15
The New York crusade was significant for another reason. Graham’s co-
operation with mainline Protestants and Roman Catholics turned a growing
rift between him and his fundamentalist friends into a permanent and un-
bridgeable chasm. From that point forward, Graham, more than anyone
else, both galvanized and exemplified a rapidly growing faction in American
Protestantism. The new evangelicals, as they sometimes called themselves,
affirmed most of the doctrinal cornerstones that fundamentalists affirmed,
but with less dogmatism and with little inclination to fall into arcane debates
about how the world would end. At the same time, they placed more empha-
sis on evangelism, social reform, and cooperation with other Christians.
In the 1950s Graham moved decisively into his own media enterprises.
The first three years of the decade marked serious expansion into radio,
television, movies, and book publishing, followed in the middle years by
equally serious expansion into high-profile journalism. The Hour of Deci-
sion (actually, half-hour) radio show made its national debut over the ABC
network in November 1950. It consisted of the choir leader, Cliff Barrows,
summarizing crusade activities elsewhere, one or two chestnut hymns from
songster Bev Shea (as he was affectionately known to millions), testimonies
from celebrities (often entertainers or sports stars), a brief and very low-
key appeal for “support” from Barrows, and then a forcefully delivered
sermon from Graham. As before, his message invariably began with a lit-
any of national and world crises. He preached, in the words of one biogra-
pher, “with a Bible in one hand and a newspaper in the other.”16 The litany
soon yielded to a rehearsal of the kinds of personal distress most Ameri-
cans encountered in their daily lives. Those dire words told the “Wondrous
Story,” as one of Shea’s most beloved hymns called it, of God’s redeeming
love for wayward humans. In Graham’s presentation, the transformation
that Christ alone made possible offered peace with God, peace with other
people, and peace within.
Though the Hour of Decision radio broadcast embodied Graham’s best-
known media outreach in those early years (if not of his whole career),
 Introduction 15

other endeavors followed in quick succession. First came a foray into tele-
vision, a half-hour program also called Hour of Decision, recorded and
edited in a studio, which ran from 1951 to 1954. This short-lived venture
yielded to live broadcasts from his crusades, starting on Saturday night,
June 1, 1957, at Madison Square Garden and running for fourteen succes-
sive Saturdays. After the New York crusade, hoping to avoid overexposure
and the staggering cost of a regularly scheduled program, Graham moved
from this format to quarterly network television broadcasts, drawn from
actual crusade meetings.17 Graham’s film ministry, which eventually reached
more than 100 million viewers, began in 1951 with Mr. Texas. Over the years,
more than thirty additional feature-length films appeared. Though none
achieved Hollywood writing or production standards, some, such as The
Hiding Place, ranked highly in the evangelical market. In those various pro-
grams and movies Graham showed once again that he knew how to speak
both for and to ordinary Americans with consummate skill.
Along with radio and television, Graham embraced print media, possi-
bly with even more enduring results. In 1952 he moved into the newspaper
mass market with a daily syndicated Question and Answer column called
“My Answer.” More important was Graham’s remarkably successful entry
into the semi-academic periodical market with the evangelical fortnightly
Christianity Today. Though he rarely wrote for the magazine himself, he
served as its principal founder and theological guiding light. First published
in 1956, Christianity Today had two purposes: to speak to evangelicals in the
mainline and to offer an alternative voice to the mainline’s real or perceived
domination of American theological discussions. By the ninth issue the fort-
nightly’s circulation had eclipsed that of the Christian Century, the main-
line’s principal literary voice. Christianity Today soon became—and in 2014
remained—the most widely read serious Christian periodical in the world.
In 1960 Graham discerned a market for a more popular organ, something
like Guideposts or the Roman Catholic Our Sunday Visitor. This interest
culminated in Decision magazine, a tabloid-sized glossy monthly adorned
with large photos, uplifting stories, and a brief devotional rendering of a
Graham sermon.
The Billy Graham Evangelistic Association (BGEA) managed these mul-
tiple ventures. Established in 1950 as a nonprofit religious corporation to
oversee finances, the BGEA won recognition for organizational efficiency
and financial accountability in the evangelical world.18 The BGEA’s board
of directors consisted of successful business leaders (almost all men) who
knew how to swim in the fast-running rivers of government regulation and
16 Introduction

religious competition. Perhaps the BGEA’s most important accomplishment

lay in its rigorous oversight of Graham’s revenue, a perennial bog for evan-
gelists. As early as 1950 Graham had started to grow uneasy with the real
and perceived abuses of the venerable “love offering” tradition. Two years
later the BGEA placed him and the other Team members on publicly stated
annual salaries—in Graham’s case, a wage pegged to that of a successful
urban pastor, initially $15,000.
The 1950s also marked Graham’s public involvement in matters of com-
pelling political and social concern. Most conspicuously, he preached fre-
quently and often stridently about the peril of communist expansionism
abroad and infiltration at home. Like millions of American Christians (and
non-Christians), including the most respected public figures of the day, he
saw communism as both a military threat and a religious menace. Com-
munism’s spiritual character stemmed from its self-understanding as an al-
ternative worldview that lured gullible minds with promises of material
prosperity. Graham’s fear of communism loomed largest in the early years
of the decade. It continued, with diminishing urgency, into the 1970s.
In the same years the rising civil rights movement also captured Graham’s
attention. Initially he, like most Southern white preachers, had uncritically
followed Billy Sunday’s practice of abiding by local racial customs. In the
South that meant of course that blacks and whites sat separately. By 1951
Graham’s conscience had started to stir. That year he chastised his own
Southern Baptist Convention for their discriminatory admission policy in
Baptist schools. The following year he told a crusade audience in Jackson,
Mississippi, that there was no room for segregation at the foot of the cross. In
March 1953, at a crusade in Chattanooga, Tennessee, he personally removed
the rope separating the races.19 Graham later waffled, allowing a rope to go
back up at the Dallas crusade in May. But after Brown v. Board of Education
in 1954, he never again permitted ropes at his meetings—despite stinging
criticism from many white supporters.
That slow but continually growing awareness of racial injustice persisted.
In 1957 the evangelist boldly invited Martin Luther King, Jr., to offer an
invocation at his New York crusade, and just as boldly King accepted. Three
years later, in a story published in the high-circulation Reader’s Digest,
Graham excoriated America’s churches for making eleven o’clock Sunday
morning the most segregated hour of the week (King often used the same
phrase). To be sure, Graham never felt comfortable with confrontational
tactics about race—or about anything else, for that matter. He never marched
in the streets, and his relationship with King proved unsteady. Yet Graham’s
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subject, how to diagnose, not alone hyperæmia and anæmia of the
brain and spinal cord, but also of special lobes of the former and
particular columns of the latter. These directions are in most
instances based on assumptions which are not supported by direct
or tangible evidence, and the consequence is that they have failed to
stand the tests of experience, where this gauge is applicable, and
necessarily failed to advance in any way either our theoretical or
practical knowledge of those states of the brain mechanism which
are due to alterations in its nutrition.

Much of the unsatisfactory state of our knowledge on this head is

due to the grouping together of the physiological anæmia of sleep
and the pathological anæmia with which the physician has to deal.
The anæmia of the brain in a sleeping person is probably a
secondary factor; it ensues after the person falls asleep, the first step
in the latter process being probably an altered dynamic state of the
brain which lessens the requirements of that organ for blood. This
can be readily demonstrated in the case of infants whose anterior
fontanelle has not yet closed. In deep sleep the fontanelle is deeply
sunken in, but this sinking in does not occur simultaneously with the
child's falling asleep, but shortly thereafter. On the other hand, the
fontanelle does not rise simultaneously with the child's awakening,
unless it cry, which adds a disturbing factor. There are a number of
other facts which show that while a comparison between the
sleeping state and cerebral anæmia may be made for the purposes
of theoretical discussion, yet there are many important points in
which they are at variance. To illustrate this I need but refer to the
fact that in deep sleep the pupils are in a state of immobility and
pinhole contraction,14 while in chronic cerebral anæmia of young
persons a dilated and mobile pupil is the commoner condition. In
acutely-produced cerebral anæmia an initial contraction has been
noted, but it is not then persistent.
14 Inability to counterfeit this feature is one of the most reliable tests of simulation,
and served to convince me that in the well-known case of a colored cadet, who was
tried by a court-martial on charges involving simulation, the latter was proven. There
are persons who can voluntarily contract the pupils, but as they are compelled to
 innervate all the muscles supplied by the third pair, in so doing they are compelled to
converge the optic axes—an act which does not take place in sleep.

One of the main reasons of our imperfect knowledge of the nutritive

disorders of the brain is the unsatisfactory state of their post-mortem
evidence. Little has been learned in this field, except in those
extreme cases where the suddenness and intensity of the circulatory
catastrophe were sufficient to prove fatal. Even where all
observations made during life justify us in supposing that the amount
of blood sent to the brain is small, that the velocity of its current is
reduced, and its quantity poor, the autopsy may reveal conditions
apparently conflicting with the supposition based on ante-mortem
observations. This is amply illustrated by the experience of alienists
who have studied the relation between nutritive states of the brain
and certain forms of insanity. It is generally held that in so far as the
antithetical forms of mental disorder known as anæmia and
melancholia can be connected with nutritive disorders, the former is
indicative of hyperæmia and the latter of anæmia. A number of facts
can be adduced in support of this view, particularly as regards the
latter condition. It is found, however, in some examinations made of
the brains of patients dying melancholic that the brain is apparently
hyperæmic; the length of time elapsing before an autopsy is made,
the form of somatic disease with which the patient dies, the position
of the body after death,—all these may play a part in the production
of cerebral injections which do not correctly indicate the condition of
the brain as it existed prior to the moribund period, and when the
symptoms of supposed anæmia or hyperæmia could be satisfactorily
differentiated.

ETIOLOGY.—The best studied form of cerebral anæmia is that

ensuing after extensive hemorrhages or from compression and
ligature of either of the common carotid arteries.15 In the latter case
symptoms are produced which are in harmony with the doctrine of
localization, and permit us to form a conception of the mode in which
a diminution of the cerebral blood-supply influences the functions of
the brain. The chief symptoms are noted on the side of the body
opposite to that on which the common carotid artery is tied. Thus if
the left artery be tied, there is at first felt a tingling or pricking feeling
on the right half of the body; this is followed by a warm, sometimes a
cold, and ultimately by a numb, feeling. This sensory disturbance
may become of what might be called the capsular type—that is, a
complete hemianæsthesia; but at first it is distinctly like that which is
found with cortical and subcortical disease, being limited to the
muscular sense and the intelligent contact-perceptions of objects,
the æsthesiometer showing but little or no impairment of the
cutaneous space-sense. With the loss of muscular sense the
movements become heavy, and later true paresis may appear with
perhaps total anæsthesia. Aphasia is sometimes noted in such
cases, and, in obedience to the predominant location of the speech-
faculty in the left side of the brain, is rarely if ever found16 when the
right common carotid artery is the one ligated.
15 As the conditions of the cerebral circulation resulting from surgical and other rare
causes are not apt to be brought to the physician's attention separately from
conditions of more immediate importance, their symptoms are discussed in the
etiological portion of this section in order to avoid complicating the semeiological
picture of cerebral anæmia of every-day experience. For similar reasons the
anomalies of the cerebral circulation of an embolic and thrombotic nature, and those
associated with eclampsia and epilepsy, are not mentioned in this connection, as their
full discussion properly belongs to other portions of this work.

16 I am unaware of the record of any case where aphasia occurred with ligature of the
right common carotid artery. There is a singular observation by Hagen-Torn of
permanent paralysis of the right hypoglossal nerve after such an operation, but the
report to which I have access does not state whether this may not have been due to
some peripheral involvement of that nerve.

In this series of symptomatic sequelæ it is seen that the functional

manifestations of the highest centres are the first to be involved, and
this establishes that of all parts of the cerebrum the cortex and
subcortical tracts are the more vulnerable to the influence of a
deficient blood-supply.17 As we shall see, it is precisely to the
insufficient nutrition of these parts that the more important symptoms
of the cerebral anæmia of ordinary practice are attributable.
 17 To this there is an apparent exception: when blindness occurs in consequence of
ligature of one carotid artery, it is monocular and limited to the side of the ligation. The
visual disturbance of cortical and subcortical disease is bilateral, being of the
character known as hemianopsic. The blindness due to tying of the carotid is,
however, not due to cerebral, but to retinal, anæmia, and its monocular character
does not therefore invalidate the observation in the text. Litten and Hirschberg
(Berliner klinische Wochenshrift, 1885, No. 20) found complete bilateral amaurosis in
a chlorotic girl of fifteen, and on ophthalmoscopic examination the peripheral origin of
the blindness was conclusively proven by the existence of an exquisite choked disc.
Both the morbid ophthalmoscopic appearance and the amaurosis disappeared under
tonic regimen. It is well to recollect that choked disc may occur in chlorosis, and thus
be perhaps erroneously attributed to a coexisting hysteria, as was done in some
cases at least by Rosenthal in his textbook.

With bilateral ligature18 of the primary carotids—and this applies in

the main to cerebral anæmia from profuse hemorrhages or sudden
changes in the blood-pressure, such as occur in enteric affections,
ruptures of aneurisms, in obstetric practice, and after brusque
tapping for ascites—the same phenomena noted with unilateral
compression are observed on both sides of the body, and usually in
slighter intensity. In addition, there is a profound and characteristic
disturbance of respiration; a cold sweat breaks out; the senses of
sight and hearing become greatly impaired or perverted; the mind
becomes clouded, consciousness blurred; complete syncope may
ensue, and pass to a fatal termination. In other cases vertigo
preponderates or vomiting, and finally convulsions appear. It would
seem that the respiratory centre exceeds even the cortex in
susceptibility to the evil influence of anæmia. It differs from them in
two features: firstly, it appears to require bilateral involvement of the
brain for its production; secondly, although the respiratory
disturbance precedes that of the higher cerebral functions, it does
not become as intense, for at a time when the intellectual functions
are abolished, as in anæmic coma and syncope, the respiratory
function, however disturbed, is in most cases sufficiently well carried
on to bear the organism safely through the crisis. The disturbance is
marked by the following characters: The respiration is at first deep
and sighing, perhaps frequent; it later becomes slow, and is
associated with a subjective sense of oppression; the patient feels
as if he could not fill his lungs properly; there is an unsatisfied
sensation, as if a deeper breath should be taken, and when, in
obedience to this subjective need, a full deep breath is taken, the
patient feels as if he had stopped short of completing the act, and
remains as unsatisfied as before.19 Yawning and moaning are often
accompaniments of this symptom.20 As we shall see, these signs are
often among the chief sources of complaint in the less grave forms of
anæmia of every-day experience. In the serious condition before us
the Cheyne-Stokes phenomena may follow.
18 I exclude the observations of Flemming, Hammond, and Corning on carotid
compression by external pressure, owing to the difficulty of determining whether or
no, and what, other important structures are compressed at the same time.

19 The occurrence of this functional respiratory trouble is a feature of toxic as well as

of anæmic irritation of the respiratory centre; it is accordingly found in cases of
profound alcoholic poisoning.

20 It is somewhat difficult to understand why in cases of anæmia induced in both

carotid districts the symptoms of anæmia should be marked in the functions of that
part of the brain-axis which through the basilar trunk derives its blood from the
vertebral arteries. Here the blood-current must necessarily be increased. That the
disturbance of breathing, the yawning, and the sighing belong to the group of irritative
symptoms due to anæmia is in harmony with the general physiological law which is
illustrated in the initial contraction of the pupil, which is found in experimental cerebral
anæmia. Observations on anæmia of the brain-axis are too few, and, so far as noted,
have been so rapidly fatal that it is not possible to derive from them any facts bearing
on the physiological reactions of the respiratory centre to high-graded anæmia. One
of the curiosities of medicine appertaining to this subject is the observation recorded
in Virchow's Archiv, lxix. p. 93, of the case of a man who had fractured the base of the
skull in its posterior fossa, and, the basilar artery becoming caught and pinched in the
crack, death occurred rapidly with all the signs of cerebral anæmia, verified by the
post-mortem appearances.

Anæmia of the brain may develop at any period of life, not excluding
the intra-uterine period. Kundrat and Binswanger regard the
deformity of the brain known as porencephaly as the result of an
anæmic (non-embolic) necrosis of brain-substance, developed either
in the fœtal or the infantile period. The occasional symmetry of the
deformity is in favor of this view. That there are other conditions of
cerebral malnutrition,21 masking themselves in defective
development and imperfect isolation of the conducting tracts, and
that the consequent differing rate of maturation of these tracts has
some relation to the absence or presence of a predisposition to
chorea and other disturbances of nervous equilibrium so common at
this period of life, I regard as at least probable. But it is at the period
of puberty that we encounter the most important discrepancies
between the requirements of brain-nutrition and the furnished blood-
supply. The disposition to uncomplicated cerebral anæmia is
greatest at this period of life and in the female sex. Beneke22 has
shown that as the human being grows the arteries, which in children
are very large in proportion to the length of the body, get to be
relatively smaller and smaller toward the period of puberty—that
after this period they widen to again attain a large circumference at
old age. There is thus added to the other and more obscure factors
which may determine general anæmia at puberty a diminished
calibre of the arteries in both sexes. To some extent the
disadvantageous influence of (relatively) narrow vascular channels
may be overcome by increased cardiac action, and the almost
sudden increase in size of the heart about this period is probably the
result of the demand made upon its compensatory power. But, as we
learn from the same observer that the female heart remains
relatively as well as absolutely smaller than that of the male, we can
understand why the female should be less able to overcome the
pubescent disposition to cerebral (and general) anæmia than the
male. Menstruation, which in a certain proportion of girls scarcely
maintains the semblance of a physiological process, acting rather as
a drain than a functional discharge, is added to the anæmia-
producing factors. It is among those who marry in the ensuing
condition, who bring forth child after child in rapid succession,
perhaps, in addition, flooding considerably at each confinement, that
we find the classical symptoms of chronic cerebral anæmia
developed.
 21 I have found in three children under fourteen months of age, who died with
symptoms not unlike those of slowly-developed tubercular meningitis, including
convulsions, strabismus, temperature disturbance (slight), and terminal coma, without
nuchal contracture or pupillary anomalies, a remarkably anæmic brain. The sulci
gaped; there were few or no puncta vasculosa; the cortex extremely pale, and the
white substance almost bluish-white. On attempting to harden the brain of the
youngest of these children, using every precaution and a sufficient number of sets of
hardening fluids, including the chromic salts and alcohol, I found that small cavities
formed in the cortex, varying from the scarcely visible to two-thirds of a millimeter in
diameter. Their existence were demonstrable the day after the death and almost
immediate autopsy performed in this case. There had been no antecedent disease in
any one of these cases; the children had been lethargic, inactive, and the oldest had
made no attempt to walk or talk. There was no morphological or quantitative defect in
cerebral or cranial development, and microscopic examination showed that the
cavities were not perivascular. In all these cases the patients belonged to the
tenement-house population.

22 An excellent abstract of Beneke's original monograph, by N. A. P. Bowditch, will be

found in volume i. Transactions of the Massachusetts Medico-Legal Society.

In the male sex the period of adolescence has not the same
profound influence in producing cerebral anæmia that it has in
females. To some extent, however, habitual self-abuse and early
sexual excess of the former produce results similar to those
occurring in consequence of perverted physiological processes in
the latter. Many of the symptoms presented by the inveterate
masturbator are probably due to cerebral anæmia; there are,
however, in his case and in that of the early libertine certain vaso-
motor complications frequently present which render the clinical
picture a mixed one.23 In addition, abuse of the sexual apparatus has
a direct—probably dynamic and impalpable—exhausting effect on
the central nervous apparatus.
23 Kiernan of Chicago has described peculiar trophic disturbances—dermato-
neuroses, color-changes of the hair, etc.—in a case of masturbatory mental trouble
associated with marked anæmia. The patient whenever he flushed up heard a noise
as of a pistol snapped near the mastoid region. In the case of a young man of
 eighteen who—the pampered son of wealthy parents—became his own master at
fifteen, and had at that age indulged in sexual orgies which were continued to an
almost incredible extent, it was found that he gradually lost his memory, and on one
occasion had a violent epileptiform attack. During his convalescence from the
stuporous state which followed it was noted that the patient was quite bright in the
morning, but that after he had been up a while he relapsed into a state of apathy, with
amnesia, which, decreasing in intensity from week to week, was eventually only noted
toward evening, and finally disappeared, the case terminating in complete recovery.

In the vast majority of cases anæmia of the brain is but a part of

general anæmia, and all conditions which tend to impoverish the
character of the blood and to reduce the rapidity of movement and
fulness of the cerebral blood-column are apt to be associated with
signs of cerebral malnutrition. As early an observer as Addison
noticed the wandering of the mind in pernicious anæmia, in which
disorder anæmia and wasting of the brain have been found post-
mortem. In two cases of extreme chlorosis I heard the sound known
as the cephalic soufflé with great distinctness;24 this sound, when the
other morbid conditions that may lead to it can be excluded,
indicates a high degree of anæmia. Both patients were somnolent
and subject to fainting-spells. In leucocythæmia a rambling delirium
is not infrequently noted toward the close of the patient's life, and the
habitual sadness and depression of many leukæmic patients is due,
as are also certain phases of melancholia, to cerebral malnutrition. In
some stages of most, and in all stages of some, forms of renal
disease the conditions of cerebral anæmia are present; and it is
reasonable to attribute to it some share in the production of the head
symptoms of Bright's disease; but here, as in cases of cardiac
disease, symptoms due to other influences—uræmia in the former,
and insufficient oxygenation of the blood in the latter instance—
obscure or conceal those due to the anæmia strictly speaking.
24 When an anæmic murmur at the base of the heart coexists with the cephalic
soufflé, the latter may be regarded as an evidence of anæmia; but where the former is
absent—that is, when the cephalic soufflé is an isolated, independent symptom—
there is reason to suspect the existence of a tumor or some other cause of
compression of the carotid artery at or after its entry into the cranium. In one of the
 cases referred to in the text, pressing on one or the other carotid produced numbness
and tingling in the opposite arm, leg, and cheek. Similar observations were made by
Tripier (Revue de Médecine, March, 1881), who strenuously maintains the existence
of the cephalic soufflé in the adult, against Henry Roger, and in consonance with the
observations of Fisher and Whitney. In the last-mentioned case of mine the sound
could be heard a distance from the head.

All exhausting diseases, many febrile affections, notably typhoid,

starvation from any cause, and exhausting discharges, may produce
cerebral anæmia. Under the latter head belong the diarrhœal
affections of childhood, which not infrequently lead to an aggravated
form of anæmia of the brain known as hydrocephaloid. In addition to
the provoking causes of cerebral anæmia there are certain
accessory ones: prominent among these is the upright position and
sudden rising. The reason of this influence is self-evident, as is also
the fact that it is most apt to manifest itself in cases of cardiac
enfeeblement. Many a convalescent from an exhausting fever or
other disease has on rising from bed fainted; some have fallen dead
from cerebral anæmia already existing, but fatally intensified by this
sudden change of position. A number of cases are on record by
Abercrombie, Forbes Winslow, J. G. Kiernan, and others where
persons manifested the symptoms of cerebral anæmia only when in
the upright position and even in lying on one side or the other; these
are, however, far rarer than is claimed by some later writers.

The purest form of acute cerebral anæmia, aside from that produced
by surgical interference with the cerebral circulation or extensive
hemorrhages, is that induced by mental influences, such as fright, a
disagreeable odor, or a disgusting or harrowing spectacle. Some
persons, not suffering from general anæmia or any diseased
condition thus far mentioned, on experiencing the emotional
influences named will be observed to turn pale, to breathe heavily,
and either sink into a chair or fall on the floor partly or entirely
unconscious. They are then suffering from a spasm of the cerebral
arteries resulting in acute and high-graded cerebral anæmia or
syncope. This condition is marked by some of the symptoms
previously mentioned as occurring with bilateral ligature of the
carotids: thus, the feeling of oppression on the chest, vertigo,
heaviness of the limbs, nausea, and vomiting are characteristic; a
cold sweat breaks out on the forehead; the visual field becomes
darkened; and hearing is rendered difficult by the tinnitus.25 The
pulse is small and of low tension, but regular.
25 Most authors claim that the sense of hearing is blunted, as that of vision is. This is
so in some, but certainly not in a large number of other cases. I have now under
observation a girl whose physical conformation—her neck is very long and her
shoulders tapering—and extreme susceptibility combine to favor the occurrence of
syncope. She faints in my office whenever an examination is made, even though it be
entirely verbal; and after recovering frequently lies down to answer by deputy, as
experience has shown her that she is less likely to faint in this position. I have
repeatedly satisfied myself from her subsequent statements that she heard what was
said, while she appeared to be quite unconscious and “saw everything black or
through a cloud.” It is not improbable that the impressions which most writers on the
subject convey were derived from the experience of novices in fainting; these, in the
alarm and anxiety of their condition, and confused by the tinnitus, might well fail to
hear what the bystanders said, particularly as on many such occasions the fainting
person is apt to be surrounded by a confused Babel of tongues. While the auditory
nerve is as sensitive to the irritative influence of anæmia as any, and there is a case
of a boy on record (Abercrombie) who could only hear well when lying down, and was
deaf when he stood up, yet the conclusions of other authorities who have studied the
subject would lead one to think that there are individual differences in this respect.
How often does not the dying person, after feeling for the hands of a relative whom he
cannot see, converse with him responsively! And how much need is there not of the
humane physician to remember that the sense of hearing is the last intellectual sense
to die, lest he speak unguardedly at the bedside!

As a rule, the subjects of simple syncope recover, the horizontal

position, which is assumed perforce in most cases, carrying with it
the chief remedial influence—namely, the facilitating of the access of
a fuller blood-supply to the brain. While, as stated, the tendency to
syncope may exist in healthy non-anæmic individuals, it is far more
common with those who suffer either from chronic cerebral anæmia
or from many of its predisposing conditions. The arterial spasm
which causes syncope is an exaggeration of what occurs within
physiological limits26 in all persons when subjected to emotional or
violent external impressions of any kind.
26 It has been experimentally determined by Istomanow (St. Petersburg Dissertation,
1885) in persons whose brain-surface had become partially accessible to observation
through traumatic causes that pain, warmth, pleasant smells, and sweet tastes cause
a contraction of the cerebral vessels and a sinking in of the brain-surface, while
tickling, unpleasant odors, bitter and sour tastes, produce the reverse condition; that
is, bulging of the brain-surface and increased injection of the vessels. Istomanow's
results are verified by other observations, particularly by the fact that with the latter
class of impressions there is an increase in the general blood-pressure, with sinking
of the surface-temperature, and, as measured by Mosso's method, decrease in the
volume of the extremities. While there is a general correspondence between these
observations and clinical experience, there are a few unexplained discrepancies.

MORBID ANATOMY.—In those severe cases of cerebral anæmia which

terminate fatally the entire brain appears bloodless. Since the color
of this organ under ordinary circumstances is in great part due to the
vascular injection, it appears very different when this admixture is
lessened or removed. Then the gray substance, instead of
presenting a reddish-gray tint, is of a pale buff color in infants, and a
pale gray in adults who have died of acute or intense cerebral
anæmia. The white substance exhibits few or no puncta vasculosa,
and there is no indication of the faint rosy tinge which even the white
substance has in the normal brain. All these appearances can be
imitated in the brain of an animal that is bled to death; they are also
met with in those who have died of inanition, particularly in cases of
melancholia attonita, the subjects of which had long refused food.
Most writers state that the ventricular and subarachnoid fluids are
increased in amount,27 and that the sulci appear wider in anæmic
than in normal brains. That these fluids must be increased to
compensate for the diminished blood-amount is evident. But it is not
unlikely that exaggerated estimates of the increase have been made;
and for this reason: Since the meninges and choroid plexuses are
comparatively bloodless, the cerebro-spinal fluids are more likely to
present themselves free from that admixture of blood which renders
the obtaining and measuring of their quantity so difficult under
ordinary circumstances. The gaping of the sulci has not been verified
by me either in animals that had been bled to death or in cases of
cerebral anæmia in rapidly-fatal atonic and phthisical melancholia. In
protracted cases of this nature I frequently found gaping of the sulci:
here, from the nature of the cases, the patients dying either from
self-starvation, imperfect assimilation, or wasting diseases, the
occurrence of a certain amount of atrophy of the brain-substance
proper could not be excluded.28
27 Hammond, on the other hand (Diseases of the Nervous System, p. 77), has the
ventricles generally empty.

28 Up to within a very short time ago it would have appeared heretical to claim that
any considerable amount of brain-wasting could ensue from starvation alone, as the
oft-cited experiments of Chossat seemed to show that mammals, birds, reptiles, and
amphibians lose in body-weight while being starved, but that the brain-weight is not
disturbed to any appreciable extent. Six years ago I examined the brain of a tortoise
(Cestudo Virginica) which had starved fully a year through ignorance of the keeper of
an aquarium. The atrophy of the brain was so marked that it had undergone
demonstrable changes of contour. Since then Rosenbach (Archiv für Psychiatrie, xvi.
p. 276) has demonstrated that brain-wasting and other changes do occur in starved
rabbits.

With protracted fevers accompanied by inanition—and this applies

particularly to the later period of typhoid fever—a condition of
cerebral anæmia is found which is of the greatest interest to the
clinician. The brain as a whole is bloodless; there may or may not be
apparently hyperæmic districts, but the injection is altogether on the
surface; the consistency of the brain is considerably diminished, and
this organ is often distinctly œdematous. In exceptional cases the
œdema is so great that softening results, the white substance
becoming fluidified at the cortical limit near the base of the sulci and
at the ventricular walls. This is due perhaps as much to post-mortem
maceration as to pre-mortem œdema, but that the latter condition
exists is shown by the condition of the brain as a whole. The loss of
memory, the difficulty of correlating the past and present, the
rambling, incoherent conversation, and anenergic stupor observed in
the decline of typhoid and other exhausting fevers, especially in
older subjects, may be properly attributed to the injurious effects of
post-febrile anæmia and anæmic œdema of the brain. Aside from
fevers, œdema is apt to be associated with anæmia where venous
stagnation is a complicating feature; consequently, it is not
uncommon with certain uncompensated valvular lesions,
emphysema, and other chronic pulmonic troubles.

Positive observations of tissue-changes from simple cerebral

anæmia have not been recorded. Even in extreme cases the
essential nervous structures, the ganglionic bodies, the nerve-fibres,
their sheaths, and the neuroglia, appear healthy. The adventitial and
pericellular spaces are sometimes enlarged, and variations in the
number and distribution of the free nuclei of the neuroglia and the
border bodies of the periadventitial districts have been observed by
me, but not with such constancy as to justify more than this mere
mention. In his researches on starvation Rosenbach found the brain
œdematous and the ventricles dilated; there were also microscopical
changes which indicated a profound disturbance of nutrition; the
large cells of the anterior spinal horn and cerebellum had lost their
transparency, being in a condition resembling cloudy swelling. The
neuroglia appeared to be in a similar condition as that of nerve-cells.
Singular as it may appear on first sight, the capillaries were found
crowded with blood-corpuscles, and there were many evidences of
diapedesis of such. This may indicate a passive accumulation due to
deficient cardiac and vascular contractility. The changes, as a whole,
were not unlike those found in myelitis,29 except in so far as no
actual inflammatory signs were present.
29 Several distinguished neurologists, notably Westphal, who were present when
Rosenbach presented his conclusions, were unable to recognize so profound a
deviation from the normal structural conditions as he claimed (Archiv für Psychiatrie,
xvi. p. 279).

SYMPTOMS.—The clinical phenomena of acute cerebral anæmia have

been in the main related in connection with the etiology of this
disorder. We shall now proceed to detail those which occur with
cases more likely to engage the attention of the practitioner either on
account of their gravity or protracted duration.

Uncomplicated Chronic Cerebral Anæmia of Adolescents and

Adults.—This condition is one of the common manifestations of
general anæmia. Most anæmic persons are languid, drowsy, suffer
from insomnia, tinnitus aurium, and other signs of imperfect cerebral
irrigation. In some these troubles become alarmingly prominent and
may approach the confines of mental derangement. This is
particularly apt to occur with women who have borne and nursed a
large number of children. In addition to the typical signs of cerebral
anæmia, they exhibit depression, may suffer from hallucinations, and
even become afflicted with lachrymose or suicidal melancholia
(insanity of lactation of the somato-etiological school). Depression of
the mental functions is the most constant symptom of cerebral
anæmia, and the one which most frequently directs the physician's
attention to its existence; its subjects appear mentally blunted, the
apperceptive powers are diminished, and it is difficult for the patient
to interest himself in anything, or when interested to keep up a
mental effort—that is, his attention—any length of time. In more
severe grades of the trouble the patients become somnolent in the
daytime. Contrary to what those who regard sleep as essentially due
to cerebral anæmia might expect, sleep is disturbed, and the patient
is wakeful or suffers from vivid and frightful dreams, or even deliria.
Others pass a quiet night, but are rather in a trance-like condition
than a healthy sleep. Lethargic as the cerebral anæmic person is on
the whole, and unable as he feels himself to exert his will-power
(aboulia), yet he is often irritable, perverse, and petulant in
consequence of that morbid excitability which is a universal attribute
of the overworked or imperfectly nourished nerve-element. The
younger the patient the more likely is the condition apt to impress
one as a stupor, while with older patients irritability is more
prominent. In the former the obtuseness is often rapidly overcome
when the patient assumes the horizontal position.

It was supposed by Abercrombie that an acute exacerbation of

cerebral anæmia of this form in weakly and aged individuals might
terminate in death. This condition corresponded to the so-called
serous apoplexy of the old writers. With increasing accuracy in our
autopsies this condition is more and more rarely recorded, although
the possibility of its occurrence as a pathological rarity cannot be
denied. As a rule, the chronic form of cerebral anæmia when it
terminates fatally, which is exceptional, is marked by a deepening
coma and gradual extinction of the vital processes, the Cheyne-
Stokes phenomenon preceding this.

Patients suffering from chronic cerebral anæmia are afflicted with

morbid irritability of the optic and auditory nerves. Loud sounds and
bright lights are very annoying to them. Roaring, buzzing, and
beating sounds in the ear are common, and scintillations, muscæ
volitantes, and temporary darkening of the visual field—particularly
noticed when the head is suddenly raised—are complained of in all
cases. It is often found that the tinnitus disappears and the hearing
power improves on assuming the horizontal position.

Headache of greater or less severity is found in the majority of

cases: it is more severe in the rapidly-developed forms, and I have
found it to be complained of in agonizing intensity by women who
had risen from childbed and who had flooded considerably. As a
rule, the headache, whether severe or mild, is symmetrical and
verticalar, in some cases associated with an ache subjectively
appearing as if it extended to the back of the orbit. It is remarkable
for its constancy, and its exacerbations are often complicated with
vertigo and nausea, so that it is not infrequently interpreted as a
reflex evidence of gastric disorder. A stitch-like feeling, located in
both temples, is often associated with it.

Occasionally sufferers from chronic cerebral anæmia experience

seizures, or rather exacerbations, of their disorder which approach in
character, while not equalling in degree, an attack of syncope.
Whether in bed or in a chair, they then feel as if their limbs were of
lead; they deem that they cannot stir hand or foot; the other
symptoms related are aggravated; they yawn and breathe deeply,
but hear all that is said by those near them, and do not lose
consciousness. They express themselves as feeling as if everything
around them were about to pass away. One of my patients would
frequently find that if this condition overtook her while lying on one
side, that side would remain numb for some time and be the seat of
a tingling sensation which disappeared on the parts being rubbed.
The same was noticed when she awoke in the morning in a similar
position. To what extent these features were due to the general
anæmia is doubtful. As previously stated, true syncope occurs in
chronic cerebral anæmia, but much less frequently in those subjects
of this disorder who have reached middle life than in adolescents.

The radial pulse in cerebral anæmia does not necessarily show the
anæmic character; not infrequently the general blood-pressure is
increased at the onset of the acute form, and if long continued this
may be followed by a decrease of the same. The pulse-character
may therefore vary greatly in frequency, resistance, and fulness. In
protracted cases it is soft, easily compressible, and rapid.

It is not uncommon to find indications of a slight unilateral

preponderance of the signs of cerebral anæmia. In one case which
terminated in recovery, and was otherwise pure, vertigo was not
produced on turning from the left to the right, but it was produced to
a distressing degree on turning in the opposite direction; in a second,
equally typical, there was for a long time a subjective sensation of
falling over toward the right side.

There appears to be much less constancy in the relationship of the

deficient blood-supply to the severity of the symptoms than is usually
supposed. Much depends upon the time of life at which the disorder
develops: a brain that has acquired stability through education and
exercise is less vulnerable to the influence of general anæmia than
one that has not. The nerve-centres appear, to some extent at least,
to regulate their own blood-supply; and whether it be through a
change in the blood-current rapidity or some other factor neutralizing
the evil effects of the intrinsically inferior quality of the blood, we
must attribute to the self-regulating nutrition power of the brain the
not uncommon phenomena of an active mind in an anæmic body.
And where the general anæmia reaches so high a degree as to
involve the brain, under such circumstances we find that irritability to
sensory impressions and fretfulness are more prominent than the
lethargy and indifference which characterize the juvenile chlorotic
form. Although this distinction is less marked between these two
classes in regard to acutely-produced anæmia, yet it is observable
even there. If in a youth or girl while undergoing phlebotomy cerebral
anæmia were to reach such a degree as to cause subjective sounds,
they would either approach or fall into a faint; but Leuret, the
distinguished cerebral anatomist, while being subjected to the same
procedure, hearing a hissing sound, did not lose consciousness, but
complained that some one must have upset a bottle of acid on a
marble table in the same room, as he supposed he was hearing the
sound of effervescence thus produced.

Much, too, appears to depend on dynamic and other thus far

undiscovered intrinsic conditions of the brain-tissue itself,
irrespective of the mere amount and rapidity of the blood-current. If
the subject be exposed to wasting diseases, to blood-poisons, or to
vicissitudes of temperature and to physical exhaustion in addition to
the causes producing cerebral malnutrition, deliria of a cortical
nature are more apt to characterize the case than in simple anæmia.
These are known as the deliria of inanition, and present themselves
under two forms. The first has been frequently observed in sailors,
travellers, and others who have undergone starvation in exposed
situations, and is tinctured by the psychical influences incident to
such a condition. Just as the Greeley survivors at Cape Sabine,
when reduced to their miserable rations of seal-skin boot-leather and
shrimps, entertained each other with the enumeration of imaginary
culinary luxuries, so others who have suffered in the same way
declaim about gorgeous banquets in the midst of a howling
wilderness, or, as occurred to a miner who lost his way in Idaho a
few winters ago, experienced hallucinatory visions of houses, kitchen
utensils, and persons with baskets of provisions. In others the terror
of the situation leads to the development of rambling and incoherent
delusions of persecution.
The second form, regarded as a variety of starvation delirium, is
found in the post-febrile periods of typhoid and other exhausting
fevers. In aged persons it may even develop shortly after the onset
of the disease. It is usually unsystematized, of a depressive cast,
and may be associated with a condition resembling melancholia
agitata. In a small proportion of cases insanity of the ordinary types,
but more commonly of the special kinds comprised in the group of
post-febrile insanity, develops from the anæmic fever delirium as its
starting-point.

The spurious hydrocephalus (hydrocephaloid, hydrencephaloid) of

Marshall Hall and Abercrombie, referred to in the section on Etiology,
is an important condition for the diagnostician to recognize. A child
suffering from this disorder presents many symptoms which are
customarily regarded as characteristic of tubercular meningitis or of
chronic hydrocephalus; thus the pupils are narrow—sometimes
unequal;30 there is strabismus, and there may be even nuchal
opisthotonos, while the somnolent state in which the little patient
usually lies may deepen into a true coma, in which the pupils are
dilated, do not react to light, nor do the eyelids close when the
cornea is touched. Ominous as this state appears, it may be
completely recovered from under stimulating and restorative
treatment. On inquiry it is found that the symptoms above mentioned
were preceded by cholera infantum or some other exhausting
complaint, such as a dysentery or diarrhœa, and that the somnolent
condition in which infants are often found toward the close of such
complaints passed gradually into the more serious condition
described.31 The infants thus affected do not, however, sleep as
healthy children do, but moan and cry, while apparently unconscious
of their surroundings. The surface of the body is cool and pale; the
pulse and respiration are normal, except in the comatose period, but
the former is easily compressible. The chief points distinguishing
hydrocephaloid from true hydrocephalus and other diseases
associated with similar symptoms are the following: 1st, There is no
rise of temperature; 2d, the pupils are equal; 3d, the fontanelle is
sunken in; 4th, the pulse and respiration, with the exception stated,
are natural; 5th, there is an antecedent history of an exhausting
abdominal disorder; 6th, also a facial appearance characteristic of
the latter.
30 This is not admitted by most writers, but does occur exceptionally.

31 It should not be forgotten, however, that very similar symptoms occur after cholera
infantum, with a much graver pathological condition—namely, marantic thrombosis of
the sinuses.

One of the gravest and rarest forms of cerebral anæmia is one which
occurs as a result of extreme general anæmia in very young infants.
In a remarkable case which I have had an opportunity of studying,
the abolition of certain cerebral functions reached such a degree that
the opinion of a number of physicians was in favor of tubercular
meningitis.32 There was at the time of my examination complete
extremity hemiplegia, and there had been conjugated deviation,
restlessness in sleep, and dulness in the waking hours: all these
symptoms except the hemiplegia disappeared whenever a more
assimilable and nutritious food was used than the one previously
employed. On one occasion there were evidences of disturbed vaso-
motor innervation; on several, convulsive movements. This history,
associated with ordinary evidences of general anæmia, covered a
period of eighteen months, without the slightest abnormality of
temperature being noted or discoverable during that period. The
mucous surfaces of this child were almost colorless, certainly without
any indication of the normal tinge; the mother had nursed it, and her
milk had been found to possess scarcely any nutritive value. The
case terminated fatally at the age of twenty months.
32 It was stated by an experienced practitioner that death occurred with unmistakable
symptoms of tubercular meningitis. Certainly, the absence of temperature disturbance
at the time of the hemiplegic and other exacerbations, as well as other important
features for a period exceeding a year, shows that whatever favorable soil the earlier
condition may have furnished for the secondary development of such or other gross
structural disease, tubercular meningitis did not exist at the time; while the absence of
pupillary and optic-nerve symptoms, as well as the rapid changes from day to day or
week to week under dietetic treatment, militate against the assumption of any other
organic affection incident to childhood.
Partial Cerebral Anæmia.—Most writers on cerebral anæmia discuss
a number of varieties of partial cerebral anæmia as distinguished
from the acute and chronic general forms. Some of the conditions
thus described properly appertain to the angio-spastic form of
hemicrania, others to epilepsy, and the majority to circulatory
disturbances dependent on arterial disease. Aside from the partial
cerebral anæmia resulting from surgical causes, I am acquainted
with but one evidence of limited cerebral anæmia which can be
regarded as independent of the neuroses or of organic disease, and
that is the scintillating scotoma. This symptom, in the only case in
which I observed it, occurred in a medical student, accompanied by
pallor and nausea in consequence of the disgust produced in him by
the combined odors of a dissecting-room and of a neighboring
varnish-factory. The totally blind area of the visual field was strictly
hemianopsic in distribution and bounded by a colored zone
scintillating, to use the sufferer's words, like an aurora borealis. The
attack, probably protracted by his great alarm at being blind in one-
half of the visual field, lasted three hours. As the cause in this case
was a psychical impression and accompanied by the ordinary signs
of that fainting which is not an uncommon occurrence in the
dissecting-room; as, furthermore, the individual in question never
had a headache except in connection with febrile affections, and
then in the lightest form, and is neither neurotic himself nor has a
neurotic ancestry or relatives,—I regard it as the result of a simple
arterial spasm intensified in the visual field of one hemisphere,
analogous to the more general spasm of ordinary syncope.33
33 It may be remembered that Wollaston had scintillating scotomata, and that after his
death a small focus of softening was found in the one visual field. Ordinarily, this
disturbance is associated with hemicrania.

DIAGNOSIS.—There is so little difficulty in recognizing the nature of

those cases of acute cerebral anæmia which depend on
recognizable anæmia-producing causes that it is unnecessary to
point out their special diagnostic features. With regard to chronic
cerebral anæmia, and its differentiation from other circulatory brain
disorders, I refer to the last article. In this place it will be necessary