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Populist Authoritarianism
 Populist
Authoritarianism
Chinese Political Culture
and Regime Sustainability

Wenfang Tang
University of Iowa

1
 1
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Library of Congress Cataloging-in-Publication Data

Names: Tang, Wenfang, 1955– author.
Title: Populist authoritarianism : Chinese political culture and regime
sustainability / Wenfang Tang, University of Iowa.
Description: New York, NY : Oxford University Press, 2016. |
Includes bibliographical references and index.
Identifiers: LCCN 2015025430| ISBN 9780190205782 (hardcover : alk. paper) |
ISBN 9780190205799 (pbk. : alk. paper) | ISBN 9780190205805 (ebook)
Subjects: LCSH: Political culture—China. | Populism—China. |
Authoritarianism—China. | China—Politics and government.
Classification: LCC JQ1516 .T353 2016 | DDC 306.20951—dc23
LC record available at http://lccn.loc.gov/2015025430

1 3 5 7 9 8 6 4 2

Printed by Courier Digital, USA

To my parents
 CO N T E N T S

Acknowledgments  xi

1. Chinese Political Culture and Regime Sustainability   1

Why Does Political Culture Matter?   2
Mass Line: The Origin of the Populist Authoritarian Political
Culture  5
Primitive Accumulation of Social Capital in China   9
Political Culture in Post-Mao China   11
The Plan of the Book   12
Political Support: Local vs. Center   12
Regime Stability and National Identity   13
Social Capital   13
Political Trust in China and Taiwan   14
Protest and Regime Sustainability   14
Labor Dispute Resolution   14
Political Trust: An Experimental Study   15
Populist Authoritarianism: A Theoretical Discussion   15
Using Survey Data to Study Political Change in China   15
2. Authoritarian Regime Sustainability   20
The Coming Collapse of China: How Soon?   20
Modernization and Democracy   20
Regime Crisis   21
Regime Durability   23
Horizontal vs. Vertical Supports   26
How Satisfied and Happy Are the Chinese?   28
Government Dissatisfaction and Life Dissatisfaction   33
Public Anger, Political Action, and Democratic Change   36
Conclusions  39
3. Nationalism and Regime Sustainability   42
Theories of Nationalism   42
Nationalism in China   44
 (viii)  Contents

Sources of Chinese Nationalism   48

The Political Consequences of Chinese Nationalism   52
Conclusions  56
4. Interpersonal Trust and Regime Sustainability   58
The Puzzle   58
Interpersonal Trust and Democracy   61
Origins of Interpersonal Trust   63
Confucian Tradition   63
Socialist Legacy   63
Economic Growth and Marketization   64
Findings I: Classification of Interpersonal Trust   65
Three Types of Interpersonal Trust   66
Three Types of Trust and General Interpersonal Trust   67
Findings II: Trust and Political Attitudes and Behavior   69
Conclusions  73
5. Political Trust in China and Taiwan (with Joseph (Yingnan) Zhou
and Ray Ou Yang)   74
What Is Political Trust? 74
Competing Theories of Political Trust 76
Political Mobilization 76
Economic Satisfaction 77
Internal Efficacy 77
External Efficacy 78
Confucian Tradition 79
Comparing China and Taiwan: Methods and Data 80
Measuring and Comparing Political Trust in China and
Taiwan 82
Measuring and Comparing the Sources of Political Trust in China
and Taiwan 85
Multivariate Analysis of Political Trust in China and
Taiwan 90
Conclusion and Discussion 98
6. Regime-Inspired Contentious Politics 100
The Rise of Contentious Politics in China 100
The Contentious Politics Literature 101
Regime-Mobilized Contentious Politics in China 102
Institutional Deficiencies and Populist Authoritarianism 104
Examples of Regime-Mobilized Contentious Politics 106
Case Studies and Large-N Analysis 108
The Scope of Collective Action 108
Group Leaders 109
 Contents  (ix)

Regional Distribution 110

Multivariate Analysis 112
Central and Local Governments 114
Targets of Group Action 115
Unfair Treatment 115
Age 115
Education 116
Gender 116
Urbanization and Ethnicity 116
Conclusions and Discussion 116
7. Individual Dispute Resolution 118
Scope and Type of Disputes 119
Channels of Dispute Settlement 121
Established Official Channels 121
Emerging Institutional Channels 122
Non-Institutional Channels 123
Hypothetical and Actual Channels 123
Socio-Economic Characteristics of Dispute
Resolution 125
Economic Organizations and the Politics of Dispute
Resolution 127
Conclusion and discussion 132
8. Political Trust: An Experimental Study (with Yang Zhang) 134
List Experiment 136
Data and Methodology 137
Findings 140
Overt Measures 140
Unobtrusive (Covert) Measures 141
Who Hides Their Opinions? 143
Robustness Check 145
Conclusions and Discussion   150
9. Populist Authoritarianism: A Preliminary Theoretical
Discussion  152
Key Components of the PA Model   152
The Continuity of the Mass Line Ideology   152
Social Capital and Interpersonal Trust   154
Political Contention and Participation   155
Weak Institutions   156
The Hyper-Responsive Government   157
Strong Political Support   159
The PA Model and Civic Culture   161
 (x)  Contents

The PA Model and the BA State   162

The PA Model and the Existing Studies of Mass Politics   163
The PA Model and the Study of Comparative Politics   165

Appendices  167
Notes  191
References  197
Index  213
 AC KNOW L E DG M E N T S

In 1986 I took a course with professor Tang Tsou on the Chinese Commu-
nist movement as a graduate student at the University of Chicago. I wrote
a paper about the Mass Line ideology and forgot about it. At the time, I
thought that China was moving away from the radical revolutionary policy
and toward a modern, rational, and rule-based stable bureaucratic society.
Nearly 30 years later, amid the tremendous changes on the surface in Chi-
nese politics and society, I kept seeing the continuity from China’s recent
political past. I found my Mass Line paper and reread the literature, which
formed the foundation of chapter 1. I want to thank the late professor Tang
Tsou, whose broad vision and comprehensive understanding of the nature
of Chinese politics encouraged me to study contemporary Chinese politics
with a historical perspective.
In the process of writing this book, I benefited from the comments and
suggestions of many people. John Kennedy, Jie Chen, and the two anon-
ymous reviewers at Oxford University Press read the entire manuscript
and made numerous suggestions and corrections. They also urged me to
include much relevant literature that I missed in the early drafts.
I want to express my respect and condolence for my friend and college
classmate Tianjian Shi, who passed away unexpectedly in 2009 and cre-
ated an unfillable hole in the study of Chinese politics. Tianjian’s interest
in traditional Chinese culture and its role in contemporary Chinese poli-
tics inspired me to think about the role of the Chinese Communist Party’s
governance style in formulating China’s political culture, together with
Tianjian’s study on traditional values and beliefs.
My colleagues in Taiwan strongly disagreed with me on my compari-
sons of political trust in China and Taiwan and prompted me to revise
chapter 5 and add chapter 8 on survey reliability in China.
William Parish read chapter 5 on political trust in China and Taiwan
and challenged my empirical findings. His comments made me strengthen
the methodological discussion of the causal relationship between govern-
ment responsiveness and regime support.
 (xii)  Acknowledgments

Melanie Manion and her students at the Comparative Politics Seminar

at the University of Wisconsin at Madison read chapter 2 and grilled me
on political support. Their comments made me go beyond the ad hoc find-
ings and think about the theoretical significance of political trust.
Susan Shirk introduced me to the most recent literature on authori-
tarian politics. Her study on public opinion and foreign policy in China
motivated me to write chapter 3 on the role of popular nationalism in do-
mestic politics.
In writing chapter 6 on protest, I benefited from comments made by
Mary Gallagher, Elizabeth Perry, and Steven Angle. They urged me to
trace the origin of contentious politics beyond the Communist movement
and in traditional Chinese cultural values and beliefs.
Professor Cai He and his colleagues at Sun Yat-Sen University chal-
lenged my findings in labor dispute. Their criticism made me realize the
difference between perceived and real disputes.
Ronald Inglehart made generous comments on chapter 4 on interper-
sonal trust, even though the findings challenged his own work on democ-
racy and civic culture.
My colleague William Reisinger at the University of Iowa read the first
and last chapters. He cautioned me in applying the civic culture litera-
ture to China, provided me with additional literature on ethnosymbolism
in chapter 1, and forced me to think about the relationship between the
CCP’s intra-party democracy and the concept of populist authoritarian-
ism in chapter 9.
The graduate students in my Chinese Politics Seminar and the under-
graduate students in my Honor’s Comparative Politics Seminar at the
University of Iowa read the manuscript and made helpful comments and
suggestions. Sometimes their spontaneous and intuitive reaction to cer-
tain findings and conclusions provided refreshing perceptions that led me
to look at the subject matters differently.
The East Asian Institute at the National University of Singapore
granted me a visiting position in the summers of 2013 and 2014. These
visits provided me with the time and the ideal intellectual environment
in which to complete the manuscript. I presented the findings on protest
(chapter 6), labor dispute resolution (chapter 7), and survey reliability
(chapter 8) and received very helpful comments from my colleagues at
the East Asian Institute, particularly from Drs. Zheng Yongnian, Sarah
Tong, and Qian Jiwei.
I wish also to thank the following individuals and organizations for
their generosity in sharing the data and supporting my own effort at col-
lecting data for this book. Professor Cai He and Sun Yat-Sen University’s
Center for Social Survey shared the 2012 China Labor Dynamic Survey.
 Acknowledgments  (xiii)

Professor Robert Harmel and the China Archive at Texas A&M Univer-
sity made available the 2008 China Survey. Professor Yun-han Zhu and
the Academic Sinica in Taiwan granted me permission to use the Asian
Barometer Survey II. Professor Wang Weidong and the National Survey
Research Center at Renmin University generously shared the data from
the Chinese General Social Surveys.
The Chiang Ching-Kuo Foundation, the Stanley Hua Hsia Endow-
ment, and the University of Iowa provided me with generous financial
support to cover the 6th Wave World Values Survey China from 2012
to 2013. The Institute of Public Policy at the South China University of
Technology provided a grant that allowed me to conduct four telephone
surveys on public policy satisfaction from 2013 to 2015.
David McBride, the Editor-in-Chief in Social Sciences at Oxford Uni-
versity Press was patient and supportive during the review process of the
manuscript. His comments made me rewrite the opening paragraphs of
chapter 1 in order to capture the readers’ attention by highlighting the
theoretical framework and the key empirical findings.
Finally, I wish to express my deep appreciation for the Stanley Hua
Hsia Endowment for allowing me to take many research trips, to hire
graduate research assistants, and to receive a reduced teaching load that
provided me with much needed time to write.
 CH A P T E R 1

Chinese Political Culture

and Regime Sustainability

I n 2013, the residents of a community in the city of Xiamen protested

and demanded additional compensation from a land transfer legal agree-
ment that was signed 24 years prior between the community and a golf club
owned by overseas investors. The protesters released their anger against lo-
cal authorities by injuring several police. They also decided to publicly hu-
miliate a female district government official by stripping her topless and
making her stand on her knees and apologize to the public for not serving
their needs. As a result, the district government allegedly agreed to build
new roads and bridges, as well as a garbage processing center for the com-
munity. None of the protesters was arrested.1
Such a scene is almost a daily occurrence in today’s China, leading
many observers to believe that such events indicate the increasing possi-
bility of democratization and the declining popularity of the Chinese au-
thoritarian government. These observers seem to forget another, equally
well-known fact in the post-Mao Chinese political life—the strong public
support for the Communist Party by the majority of people in all walks of
Chinese society. Why and how these two seemingly contradictory trends
coexist and interact with each other in contemporary Chinese politics re-
quire further theoretical and empirical analysis.
The event in Xiamen exemplifies several important features that are
characteristic of Chinese political life. It shows a regime operating in the
ideological tradition of Mass Line that directly connects the state with
the public, often bypassing administrative regulations and the legal pro-
cedure, resulting in weak institutions and civic organizations. The state
often encourages the public to participate in local politics in an effort
to correct unpopular policies and purge incompetent officials. Conse-
quently, the mass public demonstrates a high level of political activism
 (2)  Populist Authoritarianism

and is eager to confront local authorities and engage in contentious po-

litical behavior. Such high-risk behavior, which may be subject to local
government retribution, is reinforced by a high degree of interpersonal
trust, which is a product of community solidarity nourished under so-
cialist central planning. In an authoritarian political system where com-
petitive elections are missing, the government struggles to maintain its
political legitimacy by responding to public demand more quickly than
in an electoral cycle. All of these phenomena explain the high degree of
regime support at the Center.
In the remaining chapters, I develop a preliminary theory of populist
authoritarianism, which includes the following elements: the Mass Line
ideology, strong interpersonal trust and rich social capital, individual po-
litical activism and political contention, weak political institutions and
an underdeveloped civic society, an often paranoid and highly responsive
government, and strong regime support. While such a theory of Chinese
political culture can explain how and why the seemingly conflicting com-
ponents are holding together for the time being, it cautions that such a
process is highly unstable due to the lack of institutional guarantee.
This chapter discusses the historical and institutional context of the
evolving Chinese political culture. Any discussion of “Chinese culture”
can easily go back to the dynastic history. The focus of this chapter, how-
ever, is the political culture that was formed during the Chinese Commu-
nist movement in the early 20th century and continued to evolve after the
Chinese Communist Party (CCP) seized political power in 1949.

WHY DOES POLITICAL CULTURE MATTER?

The concept of culture can be defined as social and psychological orienta-

tions. It is a “data container” including symbols, ideas, beliefs, norms, cus-
toms, knowledge, values, and attitudes (Sabetti 2007). Almond and Verba
defined political culture as “the psychological or subjective orientations
toward politics” (Almond and Verba 1963). Before examining political cul-
ture in China, it is necessary to establish political culture as a worthy sub-
ject for research. Political culture needs to assert itself against at least three
sources of competition: institutionalism, rationalism, and ethnosymbol-
ism. First, institutionalism believes that political institutions, not individual
attitudes and values, determine political outcome ( Jackman 1987; Jackman
and Miller 1996a, 1996b; Tsebelis 2002; Rhodes, Binder, and Rockman
2008). While an institutional environment sets important parameters and
constraints for individual behavior, political actors’ personal beliefs still
lead to different outcomes. It is not difficult to find examples of different
 C h i n e s e P o l i t i ca l C u lt u r e a n d R e g i m e S u s ta i n a b i l i t y    (3)

political leaders occupying the same institutional post but producing dif-
ferent policy outcomes.
Second, rationalism downplays the importance of individual beliefs,
feelings, and emotions. It argues that people make political decisions
based on information gathering and the calculation of benefit and cost
(Rowgoski 1976; Ferejohn and Kuklinski 1990; Popkin 1991; Sniderman,
Brody, and Tetlock 1991; Page and Shapiro 1992; Lupia, McCubbins, and
Popkin 2000). The study of political culture shares two things in common
with rationalism. First, both stress the importance of individual political
actors, their motivation, and their behavior. Second, both believe that
individual motivation and behavior can be measured objectively, either
through surveys, focus group studies, or lab experiments.
One problem for the rationalist view is its assumption that people can
process information and take actions that lead to the optimal ratio be-
tween cost and benefit. Yet some studies show that people are not really
capable of making objective decisions by using newly gathered informa-
tion. Instead, new information is selectively used to reinforce people’s
preconceived beliefs (Taber, Lodge, and Glatha 2001; Lodge and Taber
2005). Further, voters who are given all the necessary information may
make worse decisions than those who don’t have the information but
use their intuition instead (Lau and Redlawsk 2006). There is simply too
much information, and it is too complicated to process.
A number of rational choice scholars have recognized this problem of
information flooding. They introduced the idea of “bounded rational-
ity” in which people take shortcuts to make “low-information” decisions
(Elster 1983; Simon 1991; Popkin 1991). They seem to think that people
are rational as long as they make self-satisfying decisions based on ste-
reotypes, political ideology, consensus, and so on. By emphasizing the
importance of these subjective orientations, however, these rationalist
scholars are also suggesting the necessity of studying political culture.
The third challenge to the study of political culture using public opin-
ion survey data comes from ethnosymbolism. Ethnosymbolism is best
articulated by Clifford Geertz in his anthropological study of cultures
(Geertz 1973) and is also advocated by some political scientists (Eck-
stein 1988; Laitin and Wildavsky 1988). At the core of ethnosymbolism is
the assertion that cultures are represented by their symbols, such as lan-
guages, religions, rituals, and historical narratives. Understanding these
symbols through participant observation and ethnography is crucial in
studying how culture influences political outcome (Laitin and Wildavsky
1988). Ethnosymbolists are highly suspicious that subjective cultural ori-
entations can be detected by public opinion survey questions. For them,
the same concept or action can mean different things in different cultural
 (4)  Populist Authoritarianism

contexts (Geertz 1973). For example, a survey question about interper-

sonal trust cannot detect the meaning of trust in different cultures, which
can vary from trusting family members, community members, to strang-
ers. Neither do the ethnosymbolists think countries can or should be
compared based on survey questions (Eckstein 1988). For them, compar-
ing the percentages of people who trust other people in different societ-
ies simply misses the variation in interpersonal trust between different
subcultures within a country.
While ethnosymbolism makes important contributions in showing
that subjective cultural orientations are linked to political actions and in
expressing its well-founded concerns about the accuracy of survey data,
relying exclusively on the ethnosymbolist notion is likely to run into sev-
eral problems. First, cultural symbols can be overly interpreted, and uni-
versal human experiences are often overlooked. In the Chinese context,
for example, the concepts of guanxi (relationship or personal network)
and mianzi (saving face or pride) have been described as cultural symbols
that carry particular importance in Chinese culture (Yang 1994; Mann
2000). Yet it wouldn’t be an exaggeration to say that the necessity of per-
sonal networks and the need to satisfy one’s pride can be found in any
society, not only in China. Dwelling on such cultural symbols like guanxi
and mianzi makes China seem unique and difficult to compare with other
societies, while the meanings of these symbols are universal and can be
easily compared across countries.
Further, relying on cultural stereotypes can blind the researcher from
recognizing the diversity and the changing reality in a society. For ex-
ample, the concept of guanxi may no longer capture the reality in China
when more formal rules are developed during rapid economic growth.
Another problem with the overemphasis on cultural symbols is to
overlook the outcome. Sometimes people in different cultures do differ-
ent things or use different symbols to achieve the same outcome. For ex-
ample, people show their agreement by shaking their heads in India, and
nodding in China. Focusing on the difference in this case is a waste of
time if one’s research interest is whether people agree or disagree, regard-
less of whether they do so by nodding or shaking their heads.
Finally, while the ethnosymbolists’ early criticism of survey research
methodology is valid, such methodology has made tremendous progress
since the 1970s. Survey researchers are capable of drawing more repre-
sentative national samples in a large number of countries, which makes it
possible not only to compare countries but also to examine the variation
between subgroups within a country. In addition, survey researchers have
developed more detailed measures of concepts than before. For exam-
ple, they now ask people not only whether they trust each other but also
 C h i n e s e P o l i t i ca l C u lt u r e a n d R e g i m e S u s ta i n a b i l i t y    (5)

the specific type of people they trust, such as their family, community,
or strangers. Further, the same surveys have been repeated over time, al-
lowing the researchers to approach their topics from a historical perspec-
tive as well as at a cross-section of time. Finally, survey researchers have
made exciting progress in tackling the difficult problems of respondent
truthfulness and establishing causal links between survey questions by
embedding experiments in representative surveys. In short, even though
the survey method still has many problems, it has the undeniable advan-
tage of drawing conclusions based on representative samples that enjoy a
level of generalizability superior to the ethnographic method that relies
on in-depth case studies.
Following the tradition of political socialization and psychology
(Almond and Verba 1963; Dahl 1966; Almond 1989, 1990; Lane 1992;
Jennings 2007; Shi 2015), this study takes a behaviorist approach and
holds that beliefs, feelings, and values play important roles in shaping po-
litical behavior and political outcomes. These beliefs, feelings, and values
are the results of political socialization, as well as social and economic
changes in a society. A particular political culture is a specific configura-
tion of these beliefs, feelings, and values.
Political culture can be concretely defined and measured by a set or
“rubric” (Reisinger 1995) of concepts that should be able to travel across
country borders. These concepts include one’s identity to the country
and/or to one’s own community, the level of confidence in political insti-
tutions, the relative importance between individual interest and group in-
terests, respect for authority and the law, relationships with other people
(trust and tolerance), belief in the modes and consequences of conflict res-
olution and political participation, and so on. These concepts are widely
measured in the cross-country public opinion surveys such as the World
Values Surveys (WVSs), the surveys conducted by the International
Social Science Programme, and the Chinese public opinion surveys used
in this book (more on those later).

MASS LINE: THE ORIGIN OF THE POPULIST

AUTHORITARIAN POLITICAL CULTURE

Contemporary Chinese political culture is shaped by the theory of the Mass

Line. The term “Mass Line” (qunzhong luxian) was first used by Li Lisan, a
Communist Party leader, in a speech in 1928 (Han and Ji 2013). It served
as a powerful theoretical and organizational principle for political mobi-
lization by the CCP during the Communist movement in the first half of
the 20th century. The theory of the Mass Line was most clearly articulated
 (6)  Populist Authoritarianism

by Mao in 1943. In the article “Some Questions Concerning Methods of

Leadership,” Mao writes:

In all the practical work of our Party, all correct leadership is necessarily “from the
masses, to the masses.” This means: take the ideas of the masses (scattered and unsys-
tematic ideas) and concentrate them (through study turn them into concentrated and
systematic ideas), then go to the masses and propagate and explain these ideas until the
masses embrace them as their own, hold fast to them and translate them into action, and
test the correctness of such ideas in action. (Mao 1967, 119)

The key phrase in Mao’s statement is “from the masses, to the masses”
which assumes a close and direct relationship between the Party and
the masses, or between political power and society (Tsou 1986, 290).
This direct relationship requires both accessible elites and available
non-elites if it is to exhibit a high rate of mass behavior and elite–mass
interaction.
The Mass Line bears certain similarities to the mass society described
by Kornhauser in his study of social movement and state-building in the
West. In a mass society, according to Kornhauser, elites are accessible and
non-elites are available in that there is a lack of independent groups be-
tween the state and the family. In the absence of social autonomy at all
levels of society, large numbers of people are pushed and pulled toward ac-
tivist modes of intervention in vital centers of society; and mass-­oriented
leaders have the opportunity to mobilize this activism for the capture of
power (Kornhauser 1959, 41).
In China, the Communist Party weakened and even destroyed the tra-
ditional intermediate groups such as the rural gentry class and landown-
ers, and it relied on the Mass Line as a method of political mobilization to
win over the popular support by the peasantry and eventually defeated
the Nationalist government in 1949.
The CCP’s populist orientation continued after 1949. It was so effec-
tive for the CCP to gain political power that it continued to rely on the
Mass Line in state-building, government policy making, economic de-
velopment, and social restructuring. From 1949 to 1976, Mao and his
followers in the CCP launched a series of political campaigns in order to
consolidate the communist regime and promote social and economic de-
velopment. One such campaign was the People’s Commune Movement,
launched in 1958, in which agricultural production was collectivized and
rural communities played important roles in social, economic, and polit-
ical life, partially replacing the role of the traditional family. Another im-
portant campaign was the Great Leap Forward Movement in 1958. Mao
and other radical leaders of the CCP believed that the Mass Line could be
 C h i n e s e P o l i t i ca l C u lt u r e a n d R e g i m e S u s ta i n a b i l i t y    (7)

used to promote China’s industrial development by mobilizing the public

enthusiasm rather than relying on the educated elites.
The most extreme mass political campaign in the early years of the
post-1949 Communist regime was the Great Proletariat Culture Revo-
lution, which lasted from 1966 until Mao’s death in 1976. The Cultural
Revolution was a massive social and political movement. Mao and his fol-
lowers bypassed and destroyed the intermediate bureaucratic institutions
and professional organizations and attempted to reach and mobilize the
very bottom of Chinese society in order to achieve economic growth and
social and political egalitarianism.
Some observers see the totalitarian nature of the Mass Line. For ex-
ample, Graham Young argues that Party leadership is central in the con-
ception of the Mass Line, in which the Party must provide the policy
guidance at all levels and over all areas of activity of state and society, and
the Party’s policy can be effected only through Party leadership (Young
1980). In his study of the Communist movement in eastern and central
China from 1937 to 1945, Y. Chen (1986) contends that the Mass Line
is merely the Party’s “techniques of controlled polarization” between the
peasant and landlord classes. By drawing a sharp line and by intensify-
ing the tension between the two classes, the CCP was able to mobilize
the peasant class and successfully destroy its potential rivalry—the tradi-
tional rural elites, and eventually rely on the support of the rural masses
in defeating the Nationalist Party in the civil war. In short, the essence of
the Mass Line is a relationship between the CCP as the manipulator and
the masses as the manipulated.
Other scholars, however, see the empowerment of society under the
Mass Line. For example, Meisner (1978) observed that under the so-
cialist economic system, the Mass Line is ideally accompanied by the
formation of more and more self-governing communities of producers.
Politically, these “associations of producers” are capable of standing
up against bureaucratic or political hierarchies, while at the same time
recognizing their own interests that also tend to enhance the overall
development of the society. Effective adaptation of the Mass Line may
require political activism within grass-roots communities, which en-
hances solidarity, enthusiasm, and broadened awareness of social goals.
It can also mobilize and strengthen community power in relation to
higher political or bureaucratic authorities (Meisner 1978). Therefore, it
is at the community level where the democratic nature of the Mass Line
is realized.
Others describe the Mass Line as a democratic decision-making proc-
ess (Blecher 1979). In the spirit of the Mass Line, statements on policy
put forward by local leaders would not be regarded as final decisions or
 (8)  Populist Authoritarianism

firm directives but as provisional formulations which the masses would be

able to discuss, clarify, modify, or reject. Moreover, the masses could also
influence the policy by their decisions about specification or implementa-
tion. A process of this sort could be described as the politics of consensus
in which formal voting would be unnecessary (Blecher 1979, 109).
According to Blecher, the existence of this process of consensus poli-
tics can be proven by the facts that policy directives are generally clearer
about the goals than the concrete forms; that new policies undergo con-
siderable testing before promulgation; the frequency of “summing-up,”
“consolidation,” and “rectification” campaigns at the mass level; and the
frequent shifts of direction and emphasis in Chinese policy. These facts
are all consistent with the Mass Line view that policy decisions are always
somewhat provisional, subject to revision according to the masses’ objec-
tions, suggestions, and interpretation (Blecher 1979, 108–109). Therefore,
under the Mass Line, mass participation and influence are extensive and
substantive. Angle compares democratic centralism—the guiding princi-
ple of the Mass Line, with Rawls’ “decent society” (Rawls 1999, 64–66),
in which people are rational, responsible, cooperative participants of
social and political life (Angle 2005, 521).
While the Mass Line seems to resemble a democratic style of lead-
ership, it is fundamentally different from liberal democracy. Liberal
democracy consists of an elaborate set of institutions and game rules
to implement the principle of “consent of the governed” and to compel
rulers to take into account the interests, wants, preferences, and aspira-
tions of the citizens more fully than under other forms of government
(Tsou 1986, 271–272). On the other hand, the Mass Line is different
from totalitarianism. Totalitarianism focuses on the total control of soci-
ety by the state, while the Mass Line can be described as “totalist politics”
which is built on the full-scale interaction between the state and society
(Tsou 1986).
Another key difference between a mass society and a civil society is
the role of social organizations. In a civil society, these organizations
enjoy autonomy and the freedom from state control. In a mass society like
China, social organizations such as trade unions, political parties, profes-
sional associations, and NGOs are co-opted under the same principle of
democratic centralism (Salmenkari 2010).
Regardless the debate about whether the Mass Line embodies dem-
ocratic or totalitarian nature of governance, it is undeniable that it pro-
foundly shaped the political culture in contemporary Chinese society.
Inherent in the Mass Line ideology are its three key components: (1) a
direct link between the state and society with minimum interference of
intermediate organizations and institutions, (2) a thorough mobilization
 C h i n e s e P o l i t i ca l C u lt u r e a n d R e g i m e S u s ta i n a b i l i t y    (9)

of the masses in political participation, and (3) an implicit concept of

social contract in which the elites serve the interest of the masses who in
return grant political support for the state.2 As is shown later in this chap-
ter, the Mass Line continues to serve as a linkage between the state and
society in the post-Mao Chinese political culture and a powerful instru-
ment for political mobilization and regime legitimacy.

PRIMITIVE ACCUMULATION OF SOCIAL CAPITAL

IN CHINA

While the Mass Line provided the political capital for the CCP’s rule, the
radical social and economic transformation in the early years of the social-
ist regime produced the social capital that became an important part of the
Chinese political culture.
Marx (1867) used to describe the early stage of capitalism as a process
of primitive accumulation of capital in which the capitalists acquired the
means of production by force, such as the enclosure of land by capitalists
in England. This process laid the foundation for the later development of
the capitalist economic system. To use a similar metaphor, one can see the
early stage of the communist regime in China as a process of the primi-
tive accumulation of social capital which in turn laid the foundation for
its political rule. After the Communists defeated the Nationalists in 1949,
the new regime attempted to establish an egalitarian society under the
dictatorship of the CCP. In their pioneer studies based on interviews with
Chinese immigrants in the 1970s, William Parish and Martin Whyte
detail the CCP’s effort to build such an egalitarian society in rural and
urban China. According to their studies (Parish and Whyte 1978; Whyte
and Parish 1984), this equalitarianism is represented by public ownership
of land, reduction of the role of the family, and the promotion of social
equality.
The CCP first abolished private ownership of land, and collectivized
both agricultural and industrial productions, in the 1950s. During the
radical years of the Cultural Revolution in the 1960s and 1970s, the tra-
ditional role of family as the basic economic unit was weakened by the
expansion of social services, such as public education, employment se-
curity, public health care, and pension programs. Social services drasti-
cally reduced parental influence and promoted equal access to education
and employment, and greater equality in household income distribution.
Although some traditional practices in gender discrimination persisted,
the expansion of social services further promoted gender equality in edu-
cation, female labor force participation, reduced fertility rates, improved
 (10)  Populist Authoritarianism

health care, increased income, and a higher social and economic status
among women.
The collectivization of land ownership, the weakened role of family, and
the spread of social equality also changed the traditional way of social in-
teraction. Family-centered social and economic life was replaced by rural
farming communities based on collective land ownership, and urban resi-
dential communities based on the work unit. Although with considerable
urban–rural gap and great regional variation, these new communities at-
tempted to provide their members and their families with cradle-to-grave
services, including guaranteed employment and income, child care, pen-
sion, health care, housing, rationed consumer goods, pension, and so on.
Work unit-based housing and job security made these communities close-
knit and stable. Public ownership and social equality further encouraged
community sharing among their members. As a result, residents often
developed strong identity and solidarity with their communities. Such a
system of collective ownership had serious problems, such as economic
inefficiency due to the lack of market incentives both at the group and
individual levels. Yet it fundamentally changed the interpersonal relation-
ship in Chinese society (see Parish and Whyte 1978; Whyte and Parish
1984; Womack 1991).
For many traditionally privileged social elites, such an egalitarian so-
ciety was a pure nightmare. These social elites were downgraded to or-
dinary manual workers while those at the bottom of the social hierarchy
were promoted to managerial and administrative positions. The talented
students could not fulfill their potential by getting into schools through
competitive exams because these schools had to provide room for those
who would not have had the opportunity to receive formal education
under the old system. The new system was sustained by political terror.
Anyone who dared to oppose it was criticized, put in jail, and even tor-
tured and beaten to death.
Yet this new system was a mass society in which the ordinary citizens
were directly mobilized by and accessible to the leadership, as discussed
in the previous section (Kornhauser 1959). The rank-and-file peasants
and workers had the opportunity to participate in the destruction of the
upper echelon, who would otherwise have enjoyed their privileges for the
rest of their lives. Such unprecedented political participation by those at
the bottom, though often extremely destructive and violent, nevertheless
provided a sense of political efficacy among the poor. Further, the CCP
seized political power in China under the slogan of national independ-
ence from the influence of Western powers. Hence a strong appeal of na-
tionalism further strengthened the CCP’s popularity among the Chinese
people.
 C h i n e s e P o l i t i ca l C u lt u r e a n d R e g i m e S u s ta i n a b i l i t y    (11)

POLITICAL CULTURE IN POST-MAO CHINA

In the post-Mao era since the late 1970s, China experienced significant
social and economic transformation. Economic planning was replaced by
market competition, rural People’s Communes were abolished, job secu-
rity was replaced by performance-based labor contract, work units were
stripped off many social functions, urban housing was privatized, merito-
cratic school entrance exams were restored, parental influence returned,
and income inequality widened.
While many people focus on the explosive growth and transforma-
tion in post-Mao China, it is also important to point out some features
of continuity. It is true that the CCP itself has gone through important
organizational and personnel changes since the late 1970s, yet its political
monopoly has persisted. It is still the only legitimate ruling party and it
does not allow electoral challenges from other political forces. It still up-
holds Marxism–Leninism as its official ideology. It still uses nationalism
to mobilize political support. Mao, whom many consider a tyrant and dic-
tator, is still officially defined as a great leader whose tenure consisted of
70% contribution and only 30% mistake. While the CCP tightly controls
the media and suppresses any political dissidents, it continues its tradition
of populist authoritarianism by encouraging within-system direct popu-
lar political participation by using new technologies such as the online
chat room dialogues between government officials and ordinary citizens.
While it is true that China has experienced four leadership changes
since Mao Zedong (Hu Yaobang/Zhao Ziyang in the 1980s, Jiang Zemin
in the 1990s, Hu Jintao in the 2000s, and Xi Jinping since 2012), and some
describe the current leadership as the fifth generation (Li 2007), a closer
look at the current leadership reveals that many of them are the sons and
daughters of China’s first-generation leaders. These new leaders completed
their political socialization in the socialist era (1950s–1970s) before the
post-Mao economic reforms in the 1980s, and they were strongly influ-
enced by China’s revolutionary tradition. In this sense, the current Chi-
nese leaders are only the second generation.
One example of the political continuity in the post-Mao era is the re-
newal of the Mass Line. As mentioned previously, the Mass Line was
widely adopted as an organizational principle and a tool for political mo-
bilization before the CCP took power in 1949. It emphasizes the direct
linkage between the CCP and the public with the slogan “from the mass,
to the masses.” It continued its popularity during the Cultural Revolution
in the 1960s and 1970s when Mao relied on the same policy and mobi-
lized the masses to overthrow the bureaucratic establishment. The post-
Mao leaders all experienced their political socialization in this populist
 (12)  Populist Authoritarianism

authoritarian political tradition and decided to devote an entire website to

carry on the Mass Line after the 18th Party Congress in 2012 (qunzhong
luxian wang). 3 One of the featured stories on the website was the CCP
Secretary General Xi Jinping’s two visits to Lankao County in Henan in
2014, where Jiao Yulu, a model party official, worked in the 1960s and
was known for his populist work style.4 Xi Jinping urged the Communist
Party to continue to carry on the Mass Line because it is the “family trea-
sure” (chuan jia bao) and the lifeline of the CCP (Xi 2014, 27).
Large-scale mass political campaigns also continued in the post-Mao era,
including the national campaigns against prostitution and corruption (see
chapter 9). Even though the leaders launched these campaigns in the name of
“the rule of law,” these campaigns represent a clear Mass Line style; they are
large in scale with mass participation and swift punishment. Many victims
were “presumed guilty” without proper trials (Jacobs and Buckley 2014).
Even though the post-Mao leaders expressed their desire to strengthen the
rule of law, they often referred to such policy as resembling the Confucian
idea of group interest taking over individual rights (Buckley 2014).
Finally, China’s demographic characteristics further suggest political
continuity. As many as 52% of the population in the beginning of the 21st
century were born in or before 1970, 5 who still had memories of the pre-
reform egalitarian collective lifestyle (Bryant 2005). One only needs to
visit one of the crowded Beijing restaurants featuring live performance
of the Cultural Revolution songs and dances to see the nostalgia for some
aspects of the revolutionary zeal from that era. These features of continu-
ity will inevitably leave their mark in the political culture of today’s China,
mixed with the many recent changes.

THE PLAN OF THE BOOK

The remaining chapters of this book discuss several aspects of the Chi-
nese political culture, including political support, national identity, inter-
personal trust, political support in democratic and authoritarian societies,
contentious politics, and labor dispute resolution.

Political Support: Local vs. Center

For a political culture to work smoothly with the political system, one of the
most important elements of such political culture is political support. As
discussed in chapter 2, when political support is measured by confidence in
the key political institutions, such support in China was the highest among
 C h i n e s e P o l i t i ca l C u lt u r e a n d R e g i m e S u s ta i n a b i l i t y    (13)

the selected countries in the 2005–2007 WVS. One common explana-

tion of this strong political support is the Chinese government’s successful
performance in promoting economic growth and people’s life satisfaction
(Norris 2011). Yet public dissatisfaction with various issues in everyday life
has grown steadily over the past two decades, in some cases reaching and
in other cases surpassing the levels of public dissatisfaction that triggered
massive urban protests in 1989. The answer to the seemingly contradictory
trends of strong political support and high levels of life dissatisfaction may
lie in the different levels of government. While people showed strong sup-
port of national government and political institutions, they may express
much less satisfaction with the performance of lower levels governments,
and such dissatisfaction may significantly increase people’s collective polit-
ical action, particularly against county-level governments.

Regime Stability and National Identity

While the number of collective political actions against the local govern-
ments may have increased rapidly in recent years, these actions are most
likely ad hoc activities focusing on specific issues such as pay delays and
disputes over real estate property development. Participants in these activi-
ties may not demand systematic changes in the political monopoly of the
CCP. What the CCP is concerned about is the dissatisfaction with the cen-
tral government. Such dissatisfaction, though relatively low at the moment,
may be significantly related to people’s desire to challenge the CCP’s power
monopoly and for their support for multi-party political competition.
One tactic by the CCP to channel away people’s attention to challenging
its political monopoly is by mobilizing political support through national-
ism. Chapter 3 compares national pride between Chinese survey respon-
dents and the selected countries and analyzes how nationalism affects the
demand for democratic change against the central government.

Social Capital

In addition to maintaining political support and national identity, the CCP also
needs to utilize the social capital that it accumulated during the earlier years
for social solidarity and political support. Chapter 4 compares social capital
measured by interpersonal trust between China and other countries in differ-
ent public opinion surveys. The chapter further dissects the meaning of in-
terpersonal trust by using additional survey questions about the respondents’
trust of 13 different groups of people and analyzes three types of interpersonal
 (14)  Populist Authoritarianism

trust in China: family-based parochial trust, community-based trust, and so-

cietal trust (civic trust). Finally, the chapter examines how these three types
of interpersonal trusts are related to regime support, national pride, and law-
abiding behavior. The goal of the chapter is to find whether community-based
social interaction that was created during the early years of socialism is still
alive and functioning in promoting regime stability in the reform era.

Political Trust in China and Taiwan

Chapter 5 compares political trust in autocratic China and democratic

Taiwan. The two societies share a similar cultural and political tradition but
very different recent political experiences. Any difference between the two
societies in political trust is likely the consequence of the different polit-
ical systems, rather than cultural tradition (most similar systems design).
The chapter compares political trust between China and Taiwan, which will
be measured by institutional trust, national identity, leadership trust, and
support for the political system. The chapter explores several competing
theories of regime trust, including political mobilization, economic benefit,
Confucian values, and political efficacy.

Protest and Regime Sustainability

Chapter 6 continues to tackle the seemingly contradictory trends of strong

regime support and the growing public protests discussed in chapter 2.
Through both case studies of several high-profile protests and analyzing
large-N survey data, the chapter looks at how widespread public protests
are and the specific targets of such protests, such as local versus central
governments, economic and other social organizations, and the specific
government officials and government policies. The goal of the chapter is to
examine whether protests are purposefully used by the regime to promote
regime support while allowing public anger to be released at the local level
and on specific policies rather than on regime-challenging reforms.

Labor Dispute Resolution

Chapter 7 continues the discussion of contentious politics from chap-

ter 6 but with a focus on the workplace. With more detailed survey data
than in chapter 6, chapter 7 further examines the frequency and type of
labor disputes. It compares what types of disputes are more likely to be re-
solved than others and the problem-solving rates among different types of
Another random document with
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 These are inflicted as are wounds elsewhere, and, while always
serious, have an importance proportionate to the infection which may
have occurred with the injury or afterward. In practise it may be
assumed that the skin, like the clothing outside, is always dirty and
infected, and that every penetrating wound should be regarded as an
infected wound. Not every wound in the vicinity of a joint is
penetrating, and it is advisable to ascertain whether a joint cavity be
actually open, as much of the method of treatment will depend upon
this fact. The majority of these injuries are of the punctured or small
incised variety. The actual joint opening is usually smaller than that
in the skin. It may be so small as to escape observation. Outflow of
blood is not pathognomonic, but escape of synovial fluid always
indicates that some serous cavity, possibly a bursa or tendon sheath,
has been opened. Immediate accumulation of fluid within a joint after
probable wounding of the synovial membrane is quite suggestive, as
it is likely to imply that the joint is filling with blood. After any injury
which may loosen them the epiphyses should be carefully examined,
in order to determine if they have been loosened, while it should be
estimated, so far as possible, whether the epiphyseal junction has
been disturbed or is probably infected. The student should
remember that punctured wounds of joints are not necessarily made
from without inward. A spicule or fragment of bone may, by
protruding, produce exactly the same condition, only in this case
there may be a compound fracture to complicate it. Infection does
not invariably follow these injuries. Their gravity is in large degree
measured by the presence or absence of a suppurative synovitis.
This does not necessarily instantly follow the injury, but develops
within the ensuing two or three days. Therefore the fate of such a
joint is not necessarily determined by inspection within the first few
hours. Esmarch’s dictum regarding gunshot wounds may here be
paraphrased. The fate of every punctured joint depends upon the
man who first takes care of it. If the proper thing be done promptly a
good result may usually be obtained.
The first indication in every such case is sterilization of the parts,
including the area of the wound. If by a small elliptical incision the
wounded skin can be excised, it may perhaps very much improve
the prospect. A small punctured wound may be watched for a day or
two, especially if it be believed that the first attention were prompt
and antiseptic. Should no unpleasant features appear little need be
done except to apply ice externally and maintain rest. On the first
appearance of sepsis or of increasing trouble in the joint it should be
promptly incised, irrigated, and drained.
In the larger openings of joints it should be assumed from the
outset that infection has occurred. In such a case the wound margins
should be trimmed, the joint cavity thoroughly irrigated, and explored
for foreign bodies, by enlarging the existing opening. After thorough
irrigation a drain should be inserted for at least a few hours. For this
purpose a catgut strand or a drainage tube may be employed.
As soon as the presence of pus (acute pyarthrosis) is made clear
the case takes on a larger aspect, in that drainage not alone at one
point is indicated, but probably at two or three. Nothing is so
disastrous to an involved joint as pus retained within its hidden
recesses. Almost every other consideration is sacrificed to its
discovery and to affording a means for its escape. Counteropenings
in numbers sufficient for the purpose are, therefore, indicated, and it
will often be best to draw through the affected joint a drainage tube,
of a size sufficient to prevent its occlusion by thick pus or debris.
Daily and continuous irrigation may be practised to great advantage,
or, as is possible with the ankle, the wrist, or elbow, continuous
immersion may be substituted as a still better measure. Wherever
infection and destruction to this degree have taken place it may be
presumed that the future of the joint is seriously compromised. There
will, therefore, be room for display of judgment as to when to begin
passive and when active motion; moreover, a guarded prognosis
concerning restoration of function should be given.
Gunshot fractures of joints constitute almost a category by
themselves. Under the old regime, and in the pre-antiseptic era,
gunshot wounds of joints condemned one to amputation and loss of
at least the part below. The mortality attending injuries of this kind,
with the resulting amputations, during our Civil War, and all others
previous to it, was extreme. The Continental surgeons first
appreciated the value of antiseptic occlusion, and taught the rest of
the world that this wholesale sacrifice of limb, and often of life, was
unnecessary and could be avoided. Reyher’s first papers on this
subject revolutionized previous views and practises, and established
on a firm basis the general principle of primary antiseptic occlusion
of those injured joints. The accumulated experience of military
surgeons since his time, as well as of civil surgeons all over the
world, has demonstrated that if a gunshot wound of a joint be
afforded prompt antiseptic occlusion and rest the chances are in
favor of restoration of function, with a minimum of disturbance and a
maximum of result. It was because of these results that soldiers
were provided with the “first aid to the injured” packets, so that a
punctured wound might be protected immediately after its reception.
Even the complete tunnelling of a joint, which the Mauser bullets so
often accomplish, does not seem to be so serious an injury today as
was the puncture of a needle or an awl in the pre-antiseptic era.
Therefore the best thing to do with a gunshot wound is to practise
antiseptic occlusion. If it become troublesome it should be treated in
accordance with the advice given above.
This relegates the matter of amputation or of primary excision of
an injured joint to those cases of extensive and mutilating injury
where not only the soft structures are widely opened and infected,
but the joint ends of the bones also are seriously involved. When it
comes to the treatment of compound dislocations it is difficult to lay
down principles which shall be universally applicable. As a general
rule primary excision will usually be indicated, and prove not only
life-saving but limb-saving. In compound dislocations of the
astragalus its removal will be nearly always indicated. Only in cases
of extensive damage will amputation be necessary.
Inasmuch as it is infection, leading to suppurative synovitis or
arthritis, which gives to all serious cases their greatest dangers, it will
be sufficient at this point to remind the reader to this effect and to
describe the condition itself a little later.

SYNOVITIS AND ARTHRITIS.

The various surgical affections of a joint may be of primary or
secondary origin, and of rapid or chronic type. The acute are usually
expressions of serious infection, while the chronic are frequently of
toxemic origin, including under this heading manifestations of a
particular diathesis or defective metabolism. Others are so
exceedingly slow in their course and are so intimately connected
with other indications of disease of the central nervous system as to
be called neuropathic. (See below.)
Nearly all the acute affections begin in the synovial sac proper.
From this they may spread and involve the adjoining parts. The
acute toxic lesions also arise within the synovial cavity, such as
those which follow gonorrhea, typhoid, scarlatina, pneumonia,
influenza, etc. Tuberculosis may primarily affect either the synovia, in
which case we have a condition corresponding to tuberculous
peritonitis, or it may take its origin in the expanded bone ends or in
the epiphyseal cartilages. Syphilitic affections of the joints are rarely
acute. They lead rather to chronic disintegrations or hypertrophy. No
matter how the lesion may have arisen it will nearly always extend to
and involve other parts; thus in acute suppurations the articular
cartilages are soon attacked, while in the more chronic forms, which
have their origin in the bone, the joint cavity is slowly encroached
upon and its integrity impaired or destroyed.
So long as the type of joint disease be not destructive a complete
or nearly complete restoration of function can be expected, provided
suitable treatment be given early. If, however, a case occur only after
fibrinous outpour has organized into adhesions, muscles have
withered from disuse, and the entire joint become distorted or
disarranged, then it may be too late to cure, and it is a question then
of how much improvement can be effected. Even after acute
suppuration, if the case be properly managed from the outset, very
useful joints can be regained.
Dry Synovitis.—In synovitis, as in pleurisy, there may be a
minimum of serous outpour, such exudate as
escapes into the joint being exceedingly rich in fibrin and coagulating
easily. This material is variously disposed of, and may form
adhesions which will limit motion, or masses of condensed fibrin
which may be broken up into shreds or rounded off into seed-like or
rice-grain bodies. When tenderness subsides sufficiently to permit it
these may sometimes be felt within the joint. At other times they lead
later to an hydrarthrosis, which may prove more or less disabling and
require subsequent operation. Another form of synovitis sicca is met
with in acute and perhaps chronic rheumatism, where masses of
fibrin become loosened and can be felt as foreign bodies, or fringes,
beneath the joint covering.
Acute Synovitis.—The ordinary acute synovitis is characterized
by more or less effusion, and corresponds to
pleurisy with effusion. It is the result usually of external injury, or it is
combined with what has already been described as sprain. The fluid
outpour is watery, is rarely blood-stained, save in cases of
lacerations, usually distends the joint capsule, often to a painful
degree, but represents nothing more than the consequences of
hyperemia. If this fluid collection can be protected from
contamination by germs it will disappear under suitable treatment,
with a return to almost normal original conditions. Let it once become
contaminated, however, and the type of disease is quickly changed,
for there will then be an acute inflammation with its attendant
phenomena and consequences.
Treatment.—Cases of simple character are of short duration, i. e.,
one to two weeks. If seen early they should be treated by gentle
compression and the application of ice-cold, wet compresses. Heat
applied at this time may give temporary comfort, but will encourage
effusion. Even if a joint thus affected be not seen until the swelling is
extreme, wet compresses will still afford the simplest and the most
comforting method of treatment, although they need not now be kept
cold; in fact, gentle heat may now promote absorption. If the
compresses be moistened in salt solution, to which a little alcohol
has been added, the stimulating effect will probably be still greater.
Such a joint needs to be placed at rest, save perhaps in the case of
an ankle-joint or wrist-joint, which may be snugly strapped after
injury. In some of these latter cases the patient can resume use of
the joint almost at once.
Purulent Synovitis.—This rarely begins as a purulent condition,
but may be the result of the non-inflammatory
and non-purulent form. In such a case the character of the fluid
outpour soon merges into the seropurulent, and later become almost
nothing but pus. If the interior of a joint could be inspected, under
these conditions, the intensity and extent of the vascularity and
cellular changes going on within the synovial membrane and
beneath it would present a different picture from that of the non-
purulent form. The appearance of a joint interior, under these
circumstances, is similar to that of a well-marked purulent
conjunctivitis. Articular surfaces are quickly eroded or perforated,
while cartilages thus once affected are often loosened from their
attachments through necrosis and remain as foreign bodies in the
fluid collection. Even strong ligamentous tissues will melt down and
become so weakened as to permit a looseness of motion foreign to
the natural joint. In fact, as between purulent synovitis and acute
suppurative arthritis it is but a matter of extent of destruction, not of
character of lesion. In this way pathological dislocations are
produced, sometimes even within a few days, being the combined
result of destruction of ligaments and the pull of muscles which are
thrown into reflex spasm by the presence of intra-articular disease.
Not only do we see caries of the exposed bone ends, but epiphyseal
separations are not uncommon in the young, while every structure
around and outside of the joint participates, even to the extent of
abscess formation. Abscesses may form without the joint and work
into it, or the purulent collection within may escape at points of least
resistance and burrow, forming perhaps numerous foci at some
distance from the joint first affected. If such a case is to be saved it
will require numerous openings and counteropenings, with free
drainage, while even then there can be no expectation of restoring
joint function. There is, then, in these cases at least a sacrifice of
joint, sometimes of limb, and in neglected cases of life itself.
Symptoms.—Of the large joints only the shoulder and hip,
especially the latter, are placed so deeply as not to permit of easy
examination and diagnosis. Pain, swelling, and loss of function, with
or without history of injury, will predominate in well-marked cases,
while very early in most, and promptly in all, there will occur reflex
spasm of those muscles which have to do with motion of the affected
parts, by which they become more or less fixed and beyond
voluntary control of the patient. This condition has been described by
Sayre as “muscles on guard.” It is a significant feature, and has as
much to do with active joint disease as has abdominal rigidity with
surgical intra-abdominal conditions. Swelling will be proportionate to
the acuteness of the case. Tenderness is nearly always extreme,
especially along the articular line. The joint capsule is frequently
distended to its extreme and the normal contour of the part
completely obliterated.
The most common position in which limbs are held is midway
between extremes; thus when the knee is involved the leg will
become flexed upon the thigh, at about 75 degrees. If the shoulder
be at fault the arm is maintained close to the body. In disease of the
elbow the forearm is carried midway between the right angle and
complete extension. This is partly due to the fact that the flexors are
always stronger than the extensors, as it represents a compromise
between the antagonism of the opposing groups of muscles.
Pus, when present, is commonly also manifested by the usual
signs of its existence. There will be pitting on pressure or edema of
the overlying parts, while an acutely inflamed joint may be at any
time so swollen as to impede return circulation and lead to edema of
the parts beyond. To the local signs of phlegmon, then, we simply
have to add in greater detail those mentioned above. Along with
these there will be constitutional septic disturbances, usually
proportionate to the gravity of the local condition. The opportunities
for absorption afforded by a large synovial surface are great, and the
lymphatics are sure to carry toxins in abundance. The signs, then, of
septicemia, sometimes even of pyemia, are often pronounced. In the
presence of a joint full of pus the prognosis may be regarded as
exceedingly grave. Pain and tenderness seem to bear but little
relation to the swelling. Usually pain is an expression of distention,
yet some of the non-inflammatory forms of apparently milder type
are extremely painful. Pain is influenced by the position of the joint,
and the patient instinctively seeks that position in which suffering is
minimized. In a joint disorganized by the presence of pus there is
less sensitiveness, except on rough handling, unless the trouble
have extended far beyond the joint limits, and cellulitis be present,
with suppuration threatening. In metastatic joint abscess tenderness
rather than pain is the common rule.
In the presence of an acute inflammation in the joint end of a long
bone the other joint structures will participate to an extent
proportionate to its acuteness. With an acute osteomyelitis—e. g.,
near the articular surface—the synovial membrane will participate,
just as does the pleura in many cases of pneumonia, and we may
look for fluid in the joint in one case as we do for fluid in the chest
cavity in the other. Moreover, pictures of acute or chronic tuberculous
affections of the synovia correspond very closely to those of the
pleura. Tuberculous disease is liable to spread in every direction in
both diseases. The reverse of this, however, is not true in all
diseases of the chest, and there are many synovial as well as pleural
affections which are confined to their respective sacs.
The same statement, almost, can be made concerning the bursæ
and tendon sheaths in proximity to infected joints. Particularly is this
true when any of these connect with joint cavities.
The metastatic forms of pyarthrosis, as a collection of pus within
the joint capsule is called, are more insidious, though sometimes
equally destructive. They are by no means confined to one joint, and
in pyemia especially many of the joints will become involved. (See
Pyemia.) These secondary affections seem to be purulent from the
outset. In gonorrhea the effused fluids will often be found nearly pure
cultures of the gonococcus; after typhoid they contain typhoid bacilli,
etc. Such expressions are less frequent after pneumonia, influenza,
and the acute exanthemas, but may be seen even after smallpox. It
is often in these severely destructive joint lesions that spontaneous
dislocation occurs (Fig. 193).
—In the presence of a single joint lesion indications for treatment are
quite clear. When we have multiple and pyemic or gonorrheal
pyarthrosis it is often exceedingly difficult to determine what is for the
best interest of the patient. In general it may be said that pyemia
progressed to this extent will almost certainly be fatal, and we may
rest content with aspirating the affected joints, or perhaps in leaving
them alone; because we may feel that they constitute but a small
proportion of the metastatic foci which eventually determine death.
On the other hand, in other infections with pyarthrosis it would be
better to aspirate or to open and drain, because these cases are
slow and chronic, and the exudate is sometimes so rich in fibrin as to
lead to quite firm spurious ankylosis.
Thus gonorrheal synovitis is usually monarticular, although several
joints may be involved. It is readily recognized in the presence of the
active disease, but there are times when recognition is made difficult
 Fig. 193 Treatment.by the
latency of urethral
symptoms or the
concealment of their
existence. The knee
is usually the joint
most often involved;
next the joints about
the foot, and
sometimes the
tendon sheaths and
bursæ adjoining
them.
Syphilitic arthritis is
a chronic and mildly
but steadily
progressive affection.
It rarely assumes
purulent form without
some secondary
infection. It is
frequently combined
with gumma along the
epiphyseal border. In
hereditary syphilis
numerous joints may
be involved in
Pneumococcus infection of ankle; rapid destruction of changes of the
all joint structures. Child aged nine months. (Lexer.) rachitic type.
Gout or some of its
allied rheumatoid manifestations may lead to a dry form of synovitis,
with deposit of urates or of lymph, and the formation of tophi in the
neighborhood, or it may assume the form of a chronic and intractable
hydrarthrosis. The acute forms are accompanied by great pain, with
redness and swelling, peri-articular and intra-articular. The tendency
of these cases is to chronicity and recurrence.
General Treatment.
—Upon the nature of the condition will depend the treatment of joint
diseases. The questions of when to operate and when to abstain,
when to enforce rest and when to begin passive and when active
motion, call for discriminating judgment. An acute or even mild
traumatic synovitis should, first of all, be protected from becoming
purulent. Should injury be accompanied by a bruise, the greatest
care should be given to antisepsis, and the part sterilized and
dressed with every precaution. Should there be no external injury we
may rely ordinarily upon cold, wet compresses, with suitable elastic
compression and physiological rest. Should two or three days of this
treatment fail to bring about nearly complete resorption the aspirator
may be employed to withdraw the fluid. If this should be found to be
bloody or too thick to run through the needle, it will be advisable to
make small incisions on either side, under the strictest precautions,
and to practise thorough irrigation, by which the joint cavity will be
completely cleared of foreign material. As soon, however, as the
presence of pus is indicated, or even suspected, the whole character
of the treatment should change. The surgeon should now endeavor
to be as radical as possible. The more purulent the collection the
more are free incision, irrigation, and drainage indicated and the
more complicated the condition the more he should make
counteropenings here and there, wherever joint pockets may be
emptied.
When muscle spasm not only seriously disturbs the patient but
threatens to draw the limb into an undesirable position it should be
overcome, either by employment of traction with weight and pulley,
or by forcible reposition and fixation in suitable splints, such as
plaster of Paris. Some of the most extensive operations that are
called for are necessitated by neglect to observe these precautions
early. Often nothing will afford so much relief as the use of traction,
with sufficient weight, tiring out contracted muscles, and thus not
actually separating joint surfaces, but overcoming that muscle spasm
which brings them tightly together and thus gives pain.
In the more chronic form of cases absorption may be promoted by
elastic compression, by massage, by wet compresses, and
sometimes by blistering. Ordinarily, and especially in those cases
characterized by pain, more can be accomplished with the actual
cautery drawn lightly and rapidly over the surface of the joint than by
blistering. This application is referred to as the flying cautery, and it
is one of the most effective agents known for the relief of deep-
seated pain, as well as of cutaneous hyperesthesia. Its use causes
little if any unpleasant sensation, and should be repeated at daily
intervals until the primary object is attained.
Should aspiration of a distended joint be practised at any time, one
should atone for the loss of intra-articular pressure thereby produced
by external compression, preferably with an elastic medium.
In the writer’s opinion it is not advisable to use a small aspirating
trocar in those cases which are likely to call for irrigation. The
aspirating needle should be confined to the non-purulent collections
of fluid, although some surgeons advise and practise throwing into a
mildly infected joint, through such a needle, some reasonably strong
antiseptic fluid or emulsion, hoping thus to gain its bactericidal effect
without external incision.
The active manifestations of disease being mastered, one
addresses himself naturally to the greatest possible prevention of
deformity and restoration of function. Indeed, these should be kept in
view from the outset, although we have, for a time, to disregard them
in favor of more imperative indications. If ankylosis appear inevitable
the joint should be kept in that position in which, when stiff, it will be
most useful. This position will be, at the elbow, at a right angle; at the
hip or knee, nearly complete extension. When, on the other hand,
restoration of function is hoped for it will be obtained through a
combination of massage, active and passive movements, with the
use perhaps of some sorbefacient ointment, such as the compound
ichthyol-mercurial, or by the nearly constant use of cold, wet
compresses, combined with the other measures. The greatest care
should be exercised in determining the time when absolute rest
given to an inflamed joint should be changed to the gentle or more
forcible movements required for restoring use to previously inflamed
joint surfaces.
Chronic Synovitis and Arthritis.—A chronic serous effusion into
a joint is given the term
hydrarthrosis. This condition is never primary; it is always the residue
of some previous acute lesion, or else it is the result of neuropathic
or rheumatoid changes going on in and about the joint, accompanied
by relaxation of membranes permitting passive distention with fluid.
The contained fluid is ordinarily pure serum. It may contain a little
blood or numerous particles or shreds of fibrin, while in rare
instances there will be found in it drops of oil or even fat crystals.
The degree of distention of a joint capsule is the measure of the
gravity of the case, as this membrane, like any other, will yield to
gradual distention, although it at the same time undergoes thickening
as a protective measure. Thus the synovia may, under certain
circumstances, become as thick as the pleura. The result is a tough,
leathery condition of this membrane, which makes it exceedingly
difficult to manage. The joint thus involved will appear more
prominent than it should, because of the atrophy of the surrounding
structures. Accurate comparisons can only be made by measuring
corresponding joints. Neighboring bursæ and tendon sheaths often
participate in the distention. These collections are ordinarily painless,
or nearly so, but interfere, to varying extent, with the function of the
joint. Anatomical outlines disappear or are concealed by the bag of
fluid. It is rare that there are any constitutional symptoms except
perhaps those of the disease which causes the disturbance. The
amount of fluid which may be contained in a long-distended knee-
joint, for instance, is relatively very large. The prognosis in these
cases will depend much upon the underlying cause, as well as upon
the age, vitality, and docility of the patient.
Treatment.—Removal of the fluid is always the indication. After
reasonable effort has shown that this is not possible by the
employment of massage, the actual cautery and elastic
compression, combined with functional rest, it should be withdrawn
by the aspirating needle or trocar. The more experience, however,
we have with affections of this class the more we will realize that the
interior of the synovial membrane is frequently studded with
deposits, fringes, etc., which are not affected by mere aspiration, and
the more cogent argument will be gained for sufficiently free incision
to permit inspection of the interior of the joint, removal of tags of
tissue, thorough washing out and sponging, by which a change in
circulation and nutrition is certainly affected; and this may be
combined with excision of a liberal portion of the thickened
membrane, by which the dimensions of the joint may be materially
reduced when the opening is sutured. For long-standing cases of
well-marked hydrarthrosis, especially in the knee, the writer would
urge this method of treatment. Drainage, if called for at all, can be
made with strands of silkworm, or some temporary material which
will quickly disappear or be promptly removed. This is particularly
applicable for the milder forms of tuberculous synovitis, in which the
joint is thus treated on the same principle that is applied in washing
out a tuberculous peritoneal cavity.

ARTHRITIS DEFORMANS AND OSTEO-ARTHRITIS.

Under this general name have been grouped a number of
conditions, including the so-called rheumatoid arthritis, and referring
to a variety of chronic progressive lesions of joints which involve the
articular cartilages and synovial membranes, later the bones, and
which produce more or less loss of function and deformity. Although
often spoken of as “rheumatoid,” the condition has nothing to do with
rheumatism as such, whatever that may be. It moreover presents no
analogies to the forms of acute synovitis already described. These
lesions are more common in women than in men, occurring oftener
in those who have been sterile, and during or after the menopause.
So far as their etiology and pathology are concerned, it is true,
though it seem trite to say it, that they are the result of disturbed
nutrition, which itself may be referred back to perverted trophic
influences. Exposure, bad hygienic surroundings, improper food,
mental perturbation, and depression are more or less potent factors
in most of the cases. In some instances occurring in advanced age
they seem to be due to changes ordinarily regarded as senile. When
joint lesions are multiple and symmetrical, and accompanied by
other nutritive changes, we may refer the cause back to the central
nervous system. When monarticular they are more likely to be the
residue of some previous infection or injury, such as gonorrhea,
influenza, or an acute exanthem. If in connection with the joint
manifestations we find the spleen and lymphatics enlarged, then the
case may be regarded as doubtless infectious in nature.
 Fig. 194 The pathological changes
within these joints include almost
every imaginable alteration.
Bones soften and atrophy at one
point, or at another become
enlarged and thickened, and
throw out osteophytic projections
by which the whole shape of the
joint is materially changed.
Cartilages atrophy here and
thicken there, and disappear, at
times, to an extent by which
bone is exposed, the exposed
surfaces frequently becoming
polished or eburnated. The
position of the joint and its
general contour may be
materially altered by these
changes, and marked deformity
or notable enlargement result.
Subluxations are not infrequent,
while the ligamentous structures
are sufficiently strong to perform
their function, and the joint yields
or “wabbles.” Meanwhile the
synovial membrane undergoes
corresponding changes, and
becomes distended with fluid so
that hydrarthrosis is a frequent
accompaniment.
On the other hand, there is
another type of analogous
changes where the tendency is
Arthritis deformans, knee. (Ransohoff.) atrophic throughout and little if
any extra fluid accumulates.
Such a joint may become smaller rather than larger, especially if, as
in some cases, some part of the bone practically disappears.
 At all events muscle atrophy, sometimes with pseudo-ankylosis,
sometimes with actual ankylosis, will characterize most of these
cases, and muscles naturally disappear as they functionate less and
less.
Pain is an irregular feature, some of the lesions being quite
painful, others almost free from it. The lesions are essentially
progressive in their character, unless the whole body condition and
environment can be changed for the better. Consequently individuals
become more and more crippled. Muscle spasm is rarely present,
but when such changes occur in the intervertebral joints the
individual becomes gradually bent over or deformed, partly because
the muscles no longer have strength to maintain the erect posture,
and partly from actual changes in the bones and joints. Most of the
instances, however, are characterized by tenderness, while a
general myalgia or malaise is a frequent complaint. There are
sometimes exacerbations, during which both severe neuralgic pains
and mild fever are quite pronounced. Not infrequently on handling
the affected joint pseudocrepitus or actual crepitus will be obtained.
Sometimes the joint surfaces are roughened, and then this sensation
is most pronounced. When the synovial membrane is proliferated, in
pannus form, over the cartilages, its enlarged fringes will give a soft
crepitus which is quite distinctive. Fragments of these fringes, as well
as of cartilage, may become detached, and loose objects of this kind
in the joint may be recognized by the sense of touch.
While this is going on within the joint, adjoining tendon sheaths
and bursæ become more or less involved, and even the periosteum
will undergo considerable thickening.
The monarticular type is more frequent in men than in women, and
occurs more often in a large joint or in the spine, in which latter case
it is hardly to be considered monarticular. The changes that may
occur in the spine are distinctive, varying from trifling stiffness and
limitation of motion to pronounced deformity, by which, for instance,
not only the kyphosis of acute spondylitis may be imitated, but the
body flexed to an angle with the axis of the pelvis and fixed there, so
that the individual is bent to nearly a right angle. Some of the other
deformities of this condition are more or less characteristic. In the
hands the fingers are bent toward the ulnar side, and often strongly
flexed, perhaps even Fig. 195
overlapped, thus
giving the hand a
peculiar claw-like
appearance. The feet
are extended
completely, the joints
rigid, the toes turned
outward, and also
overlapping. By such
changes in the hip
and knee the legs
and thighs may be
flexed and the hips
perhaps so ankylosed
as to prevent
separation of the
knees. While these
changes are, as
stated, most common
in the later years of
life, children are not
exempt, girls being
more frequently
affected than boys,
the condition coming
on at first with more
or less acute
symptoms. These
children will often be
found to have
enlarged spleens and
lymph nodes, to show
malnutrition, while
some of them will
display certain
symptoms of
exophthalmic goitre.
In other words, they
are in that condition General osteo-arthritis, with multiple synostoses
included under the (“ossified man”).
term status
lymphaticus, to which subject the reader is referred. (See p. 163.)
It would appear, then, that we can expunge the term chronic
articular rheumatism, since by it is not meant the ultimate result of an
acute rheumatic affection, but rather one of the vague conditions
described above.
Fig. 195, taken from a skeleton in the author’s possession,
illustrates an extreme condition of this kind, characterized by multiple
synostoses, nearly all of the principal joints being involved.
As between the terms osteo-arthritis and arthritis deformans it is
not practicable to make such accurate distinctions as shall be
acceptable to all. In a general way the more the bone participates
the more we may use the former designation, whereas when other
joint structures are chiefly involved we may resort to the latter.
In general, then, all these conditions are evidenced by joint
deformity, especially by irregularities, by more or less effusion, by
considerable tenderness, by creaking of the joints when used, by
pain which is a variable feature and may be referred to nerve
disturbances, occasionally by muscle spasm, but always, in cases of
long standing, by muscle atrophy. A view of the interior of joints thus
affected will give a complex picture of atrophy here and hypertrophy
there of each or all of the component structures of the joint,
sometimes with a gradual overgrowth of articular bone surfaces,
sometimes with more or less complete disappearance of the same,
e. g., in the acetabulum.
Treatment.—So far as treatment of these conditions is concerned,
it should be recalled, first of all, that the disease itself is
exceedingly chronic in its tendency, and due to conditions which
have probably been of long standing. Constitutional treatment is as
essential as local, and must consist in restoring the environment and
the nutrition of the patient to normal standards. Elimination is
deficient in such cases, and should be stimulated by hot-air baths,
massage, and such exercise as may be possible, as well as by the
use of diuretics and laxatives to the degree indicated. The local
treatment may consist also of massage, elastic compression,
aspiration in rare instances, the use of wet packs, and, in many
cases, the use of hot, dry air. Various forms of apparatus are now
upon the market by which almost any of the joints may be subjected
to the influence of dry, hot air at a temperature of 280° F. When
properly used, great relief and improvement may be expected. Their
use, however, calls for the best of judgment and a combination of the
measures already mentioned.[31]
[31] The following types of arthritis bear little, if any, relation to true
rheumatic disease, though often spoken of as rheumatoid:
The chronic villous form, most common in the knee, purely local, without
effusion, and giving dry crepitus or creaking. The joint fringes are
numerous, and sometimes vascular. If the crepitus be marked and the
fringes too extensive the latter may be relieved by operation. Otherwise this
form is to be treated by early local stimulation, with some support, at least
with a bandage.
The atrophic form, of unknown etiology, causing progressive and finally
crippling swelling, with later atrophy. There is little if any fluid present. Here
the changes occur in both bone and cartilage, with a tendency to abnormal
calcification. In this form rest and hypernutrition, especially with normal
proteids, are called for, and every possible stimulus to elimination through
all the emunctories.
The hypertrophic arthritis, by which cartilages are first thickened and then
ossified, interfering with motion and with contour. This form causes great
limitation of motion and sometimes pressure on nerves, with referred pains.
It seems to have some relation to cold, exposure, and injury. Detachment of
pieces of cartilage is not uncommon, so that there are loose bodies in the
joint cavity. Treatment here consists of fixation, with improvement of
nutrition and elimination. This form may subside under proper treatment.
The chronic, gouty arthritis, with deposits of sodium urate in and around
the joint tissues, with perhaps some bone absorption beneath them, which
are not connected with the bone. In the digits entire phalanges may
disappear by absorption. The treatment here is essentially constitutional
and directed toward the gouty diathesis.

NEUROPATHIC JOINT DISEASE.

 This received its first full and classical description from Charcot in
1868. The term refers to joint lesions which follow and are apparently
connected with certain injuries and diseases of the spinal cord, or
the peripheral nervous system. The non-traumatic forms are mostly
associated with locomotor ataxia and syringomyelia. Some of them
have an abrupt onset, while others come on very insidiously. Pain is
usually notable by its absence, and the involved joints show few, if
any, evidences of hyperemia or inflammation. They become
unnaturally mobile and relaxed and usually much, sometimes
enormously, distended with fluid. The morbid changes within the
joints comprise imaginary combinations of atrophy and hypertrophy,
with proliferative formations in bone cartilages. Osteophytes and
exostoses are met with, and ossification may occur in the
neighboring tendons and ligaments. Surprising alterations take place
in certain joints; thus, as shown in Fig. 197, the head of the humerus
may disappear and corresponding changes may occur in other
joints. While it is the knee which suffers most frequently, no joints,
not even those of the spine or jaw, are exempt.
 Fig. 196 Fig. 197

Charcot’s disease of elbow. Atrophic disappearance of bone after

chronic joint disease.