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Responding to Domestic Violence
5 Edition
To the millions who endure and survive and to those who protect and
support.
Responding to Domestic Violence
The Integration of Criminal Justice and Human
Services

5 Edition

Eve S. Buzawa
University of Massachusetts Lowell
Carl G. Buzawa
Attorney
Evan D. Stark
Rutgers University–Newark
FOR INFORMATION:

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permission in writing from the publisher.
Printed in the United States of America

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Brief Contents
1. Acknowledgments
2. Chapter 1 Introduction: The Role and Context of Agency Responses to
Domestic Violence
3. PART I. What Is Domestic Violence?
1. Chapter 2 The Nature and Extent of Domestic Violence
2. Chapter 3 Matters of History, Faith, and Society
3. Chapter 4 Theoretical Explanations for Domestic Violence
4. PART II. The Criminal Justice Response
1. Chapter 5 Selective Screening: Barriers to Intervention
2. Chapter 6 The Impetus for Change
3. Chapter 7 Policing Domestic Violence
4. Chapter 8 Prosecuting Domestic Violence: The Journey From a
Roadblock to a Change Agent
5. Chapter 9 The Role of Restraining Orders
6. Chapter 10 The Judicial Response
5. PART III. The Societal Response
1. Chapter 11 Mandated Institutional Change
2. Chapter 12 Community-Based and Court-Sponsored Diversions
3. Chapter 13 Domestic Violence, Health, and the Health System
Response
4. Chapter 14 Domestic Violence, Children, and the Institutional
Response
5. Chapter 15 Conclusion: Toward the Prevention of Domestic
Violence: Challenges and Opportunities
6. References
7. Index
8. About the Authors
Detailed Contents
Acknowledgments
Chapter 1 Introduction: The Role and Context of Agency Responses to
Domestic Violence
Chapter Overview
The Domestic Violence Revolution: Taking Stock
Is the Domestic Violence Revolution a Success?
The Challenges Before Us
Challenges to a Criminal Justice Approach
Should Criminal Justice Intervention Be Victim-Centered?
The Evolution of This Text
Organization of This Edition
Conclusion
PART I. What Is Domestic Violence?
Chapter 2 The Nature and Extent of Domestic Violence
Chapter Overview
The Nature and Extent of Domestic Violence
Official Domestic Violence Data Sources
Unofficial Survey Data
Controversies Over Definitions
Statutorily Defined Relationships
Domestic Violence Offenses
Stalking as Coercive Control
Who Are the Victims?
The Role of Gender
Same-Sex Domestic Violence
Age
Marital Status
Socioeconomic Status
Racial and Ethnic Variations
The Impact of Domestic Violence
Injuries
Psychological and Quality-of-Life Effects on Victims
Monetary Costs
Domestic Violence in the Workplace
 The Impact on Children and Adolescents
The Specialized Problem of Stalking in Intimate Relationships
The Impact of Stalking
Summary
Discussion Questions
Chapter 3 Matters of History, Faith, and Society
Chapter Overview
Historic Attitudes on Domestic Violence
English Common Law and European History
Early American Strategies and Interventions
Enforcement in the Mid-1800s
The Continuing Importance of History
The Historical Pull Back
The Religious Basis for Abuse
Why Religion Remains Important
The Effect of Religion on Potential Batterers
The Effect of Religion on the Behavior of Domestic
Violence Victims
Domestic Violence Rates Among the Faithful
Can Religion Become Part of the Solution?
Do Societies Hold Different Standards for Some
Religious Communities?
The Social Critique Perspective on History and Religion
The Feminist Perspective
Coercive Control and Domestic Violence
Conclusion
Summary
Discussion Questions
Chapter 4 Theoretical Explanations for Domestic Violence
Chapter Overview
The Complexity of Analyzing Intimate Partner Abuse
Individual-Focused Theories of Violence
The Role and Use of Batterer Typologies
Classifying Batterers by Severity and Frequency of
Abuse
Typing Batterers by Their Generality of Violence and
Psychopathology
Who Is Most at Risk of Battering?
Biology and Abuse: Are Some Batterers “Pre-Wired” for
Abuse?
A Question of the Mind?
Biological- and Psychological-Based Fear and Anxiety
Can Psychology Explain Domestic Abuse?
Personality Disorders and Mental Illness
Anger Control and the Failure to Communicate
Low Self-Esteem
Conflict Resolution Capabilities and the Failure to
Communicate
“Immature” Personality
Is Substance Abuse the Linkage Among Sociobiological,
Psychological, and Sociological Theories?
Are Certain Families Violent?
Social Control—Exchange of Violence
Family-Based Theories
The Violent Family
Learning Theory
Is Domestic Violence an Intergenerational Problem?
Sociodemographic Correlates of Violence and Underserved
Populations
Poverty and Unemployment
Ethnicity and Domestic Violence
Domestic Violence in the African American Community
Native Americans
Coercive Control
The Limits of Equating Partner Abuse With Domestic
Violence
The Theory of Coercive Control
The Technology of Coercive Control
Coercion
Violence
The Continuum of Sexual Coercion
Intimidation
Surveillance
Degradation
 Control
Isolation
The Materiality of Control
Coercive Control and Risk of Fatality
Implications of Coercive Control for Changing Policy
and Practice
Summary
Discussion Questions
PART II. The Criminal Justice Response
Chapter 5 Selective Screening: Barriers to Intervention
Chapter Overview
Victim Case Screening
The Failure to Report Crime
Who Reports and Who Does Not
Why Has Victim Reporting Increased?
Does Social Class Affect the Decision to Report?
Bystander Screening
The Police Response
Police Screening
Why Police Did Not Historically Consider Domestic
Abuse “Real” Policing
Organizational Disincentives
Are Domestic Violence Calls Extraordinarily Dangerous
to the Police?
Structural Impediments to Police Action
The Classical Bias Against Arrest
Prosecutorial Screening Prior to Adjudication
Traditional Patterns of Nonintervention by Prosecutors
Prosecutorial Autonomy
The Reality of Budgetary Pressures
Prioritizing Prosecutorial Efforts to Targeted Offenses
The Impact of These Constraints on the Prosecutorial
Response
Unique Factors Limiting Prosecutorial Effectiveness
Screening as a Result of Organizational Incentives
Case Attrition by Victims: Self-Doubts and the Complexity of
Motivation
 Victim Costs in Prosecution
The Impact of Victim-Initiated Attrition
A Judicial Annoyance: Handling Battling Families
Case Disposition by the Judiciary
The Decision to Access Victim Services
Summary
Discussion Questions
Chapter 6 The Impetus for Change
Chapter Overview
Political Pressure
The Role of Research in Promoting Change
Early Research
The Evolution of Research Supporting the Primacy of Arrest
Deterrence as a Rationale for Police Acton
The Minneapolis Domestic Violence Experiment
Methodological Concerns of the MDVE
The Impact of the MDVE
Deterrence Theory and the MDVE
The Replication Studies
Omaha, Nebraska
Milwaukee, Wisconsin
Charlotte, North Carolina
Colorado Springs, Colorado
Miami, Florida
Atlanta, Georgia
A New Analysis of the Data
The Reaction to the Replication Studies
Legal Liability as an Agent for Change
Summary
Discussion Questions
Chapter 7 Policing Domestic Violence
Chapter Overview
How Do Police Decide Whether to Arrest?
Discretion to Arrest in Domestic Violence Cases
Key Situational and Incident Characteristics
Offender Absence When Police Arrive
Characterization of a Crime as a Misdemeanor or a
 Felony
Who Called the Police?
Presence of Weapons
Incident Injuries
Presence of Children
Existence of a Formal Marital Relationship
Perceived Mitigating Circumstances
Victim-Specific Variables in the Arrest Decision
Victim Preferences
Victim Behavior and Demeanor
Victim Lifestyle
Police Perception of Violence as Part of Victim’s
Lifestyle
Sex of the Victim and Offender: A Changing Story?
Increased Female Arrests
Offender-Specific Variables in the Decision to Arrest
Criminal History
Offender Behavior and Demeanor
Variations Within Police Departments
Gender Differences
Officer Age and Arrest
Officer Race
Organizational Priorities
Dedicated Domestic Violence Units and Arrests
Community Characteristics
Urban–Rural Variations
The Controversy Over Mandatory Arrest
Advantages for Victims
Societal Reasons Favoring Mandatory Arrest Practices
Controversies Regarding Mandatory Arrest
Have Increased Arrests Suppressed Domestic Violence?
The Costs and Unintended Consequences of Arrest
The “Widening Net” of Domestic Violence Arrest
Practices
Unanticipated Costs of Arrest to the Victim
Arrests and Minority Populations: A Special Case?
The Role of Victim Satisfaction in Reporting Revictimization
 The Increase in Dual Arrests
The Violent Family and Dual Arrests
Is a Uniform Arrest Policy Justified in the Context of Victim
Needs?
Victim Preferences
Does Failure to Follow Victim Arrest Preferences Deter
Future Reporting?
The Limitations of Police Arrests in Response to Stalking
Summary
Discussion Questions
Chapter 8 Prosecuting Domestic Violence: The Journey From a
Roadblock to a Change Agent
Chapter Overview
The Varied Reasons for Case Attrition
Case Attrition by Victims
Self-Doubts and the Complexity of Motivation: Changes
in Victim Attitudes During the Life Course of a Violent
Relationship
Traditional Agency Attitudes Toward Prosecution and
Case Screening
The Role of Victim Behavior and Motivation in the
Decision to Prosecute
Prosecutorial Assessment of Offender Likely to
Recidivate
Organizational Factors Within Prosecutor’s Offices That
Affect Prosecution Decisions
Imposing Procedural Barriers: Why the System
Encouraged Victims to Abandon Prosecution
How Did Prosecutor Offices Initially Respond to New
Pro-Arrest Policies?
The Changing Prosecutorial Response
Have Prosecution Rates Actually Increased?
Victim Advocates
Potential Limits of Victim Advocates
The Impact of No-Drop Policies
Description of No-Drop Policies
Current Use of No-Drop Policies
 Rationale for a No-Drop Policy
Protection of Children as a Rationale for No-Drop
Policies
Evidence That No-Drop Policies Might Be Effective
Limitations of No-Drop Policies
Can No-Drop Policies Be Justified Based on Superior
Results?
Does a No-Drop Policy Disempower Victims?
Victims Charged With Child Endangerment
The Likelihood of Conviction
Are There Effective Alternatives to Mandatory Prosecution?
Summary
Discussion Questions
Chapter 9 The Role of Restraining Orders
Chapter Overview
The Role of Domestic Violence Restraining Orders
The Process of Obtaining Protective Orders
The Explosive Growth of Restraining Orders
The Early Use of Restraining Orders: The Massachusetts
Experience
Potential Advantages of Protective Orders
Why Protective Orders Are Not Always Granted
Are Restraining Orders Denied to Many Groups of
Domestic Violence Victims?
The Limitations of Protective Orders
Should Violations of Restraining Orders Be Judged by
Criminal Courts?
The California Case
North Carolina
When Will Women Use Restraining Orders?
Are Restraining Orders Effective?
Can Restraining Orders Be Misused?
The Complex Problem of Restraining Order Violation
Judicial Enforcement of Restraining Orders
Judicial Enforcement of Restraining Orders in the Face of
Police Misconduct
Enforcement of Restraining Orders After Gonzales
 Is There a Best Practice for Obtaining and Enforcing
Restraining Orders?
More Potential Enhancements to Restraining Orders
Summary
Discussion Questions
Chapter 10 The Judicial Response
Chapter Overview
The Process of Measuring Judicial Change
The Judicial Role in Sentencing
Case Disposition at Trial: Variability in Judicial Sentencing
Patterns
Why Does Such Variation Exist?
Sentencing Patterns for Domestic Compared With Non–
Domestic Violence Offenders
Domestic Violence Courts: The Focus on Victim Needs and
Offender Accountability
The Variety of Domestic Violence Courts
Types of Domestic Violence Courts
The Structure and Content of Domestic Violence Courts
The Goals of Domestic Violence Courts
What Factors Contribute to a Successful Domestic
Violence Court?
Domestic Violence Courts: A Long-Term Solution?
Can a Family Court Be Effective as a Domestic Violence
Court?
Innovations in New York State
Implications of the New York State Innovations
Integrated Domestic Violence Courts and Their Impact
on Convictions
Summary
Discussion Questions
PART III. The Societal Response
Chapter 11 Mandated Institutional Change
Chapter Overview
State Domestic Violence–Related Laws
Early Changes in Laws
More Recent Statutory Amendments
 Statutes and Policies Mandating or Preferring Arrest
Rationale for Mandating Police Arrest
Variations in Police Use of Mandatory Arrest
State Anti-Stalking and Cyberstalking Legislation
Initial Statutes
The Model Code Provisions and the Second Wave of
Anti-Stalking Statutes
Recent Trends in Stalking Laws
Are Anti-Stalking Statutes Constitutional?
Gaps in Current Laws
The Federal Legislative Response
Initial Efforts
The Violence Against Women Act of 1994
The VAWA Reauthorization Act of 2000
The VAWA Reauthorization Act of 2005
The VAWA Reauthorization Act of 2013
Federal Efforts to Combat Stalking
The Affordable Care Act
Future Legislation
International Legal Reform and Human Rights
The Context for a Broader Response to Woman Abuse
Coercive Control in Europe
Broadening the Application of Human Rights Doctrine
Local Activism: Opuz v. Turkey
Addressing the Normative Gap
Turkey: An Example of Trickle-Down Reform
Reform in the UK: England and Wales
Do Organizational Policies Mediate the Impact of Mandatory
and Presumptive Arrest Statutes?
Impact of Policies
The Importance of Training
Current Training
Summary
Discussion Questions
Chapter 12 Community-Based and Court-Sponsored Diversions
Chapter Overview
Restorative Justice Approaches
 Domestic Violence Mediation Programs
Advantages of Mediation
Does Mediation Actually Reduce Violence?
Limits of Mediation
When and How Should Pretrial Mediation Occur?
Family Group Conferencing and Peacemaking Circles
Batterer Intervention Programs
The Role of Batterer Intervention Programs in a
Divergent Offender Group
Program Characteristics
Alternatives to the Duluth Model
Advantages of Batterer Intervention Programs
Do Batterer Intervention Programs Work?
Program Completion as a Marker for Successful
Outcomes
When Should Batterer Intervention Programs Be Used?
Summary
Discussion Questions
Chapter 13 Domestic Violence, Health, and the Health System
Response
Chapter Overview
The Role of Health Services
The Need for and Use of Health Services by Battered Women
The Significance of Abuse for Female Trauma
The Importance of Primary Care
The Minor Nature of the Injuries Caused by Abuse
The Markers of Partner Violence in the Health System
The Frequency of Abusive Assaults
The Duration of Abuse
The Sexual Nature of Partner Violence and Coercion
The Continuum of Sexual Coercion
The Secondary Consequences of Abuse
Medical Problems
Behavioral Problems
Mental Health Problems
Battered Woman Syndrome
Post-Traumatic Stress Disorder
 Explaining the Secondary Health Problems Associated
With Partner Abuse
Populations at Special Risk
Pregnant Women and Reproductive Coercion
Women With Disabilities
Defining Woman Battering in the Health Setting
Measuring Partner Abuse: Prevalence and Incidence
Medical Neglect
Reforming the Health System
The Major Challenges Ahead: Screening and Clinical
Violence Intervention
Barriers to Identification
Screening
Mandatory Reporting
Clinical Violence Intervention
Summary
Discussion Questions
Chapter 14 Domestic Violence, Children, and the Institutional
Response
Chapter Overview
What About the Children?
Domestic Violence and Children’s Well-Being
Child Abuse
Child Sexual Abuse
Witnessing
Developmental Age: Special Risks to Infants and
Preschool Children
Adverse Childhood Experiences: Domestic Violence and
the Developing Brain
Indirect Effects of Exposure to Domestic Violence on
Children
Separation
Diminished Capacity for Caretaking
Changes in Parenting
Changes in the Victimized Parent
Mothering Through Domestic Violence
Perpetrator’s Use of the Child as a Tool
 Offender Interference in a Victim’s Parenting
Modeling
The Limits of the Research and Future Direction
Putting Exposure in Context
The Child Welfare System
The Family Court Response
Domestic Violence in Custody Cases
The Significance of Custody Decisions for Victims and
Children
The Family Court Response
The Three Planet Model
The Battered Mother’s Dilemma
The Future of Child Welfare and the Family Court Response
Summary
Discussion Questions
Chapter 15 Conclusion: Toward the Prevention of Domestic
Violence: Challenges and Opportunities
The Problem of High-Risk Offenders
The Use of Risk-Assessment Tools
Risk Factors for Intimate Partner Homicide
Using Risk Factors to Target Recurrent Domestic Violence
Are Several Risk Profiles Needed?
Implementing Risk Reduction Strategies
References
Index
About the Authors
Acknowledgments

We would like to thank Brittany Hayes, Ph.D, Assistant Professsor, College

of Criminal Justice, Sam Houston State University, for providing background
research on health and domestic violence.

The authors and SAGE also would like thank following reviewers:

Susan Calhoun-Stuber, Colorado State University–Pueblo

Laurie Drapela, Washington State University Vancouver
Cathy Harris, SUNY Oneonta
Jana L. Jasinski, University of Central Florida
Richarne Parkes White, MA, LPC, HSBCP
Dr. Rochelle Rowley, Emporia State University
J. J. Spurlin, Missouri Southern State University
1 Introduction The Role and Context of
Agency Responses to Domestic Violence
Chapter Overview
The movement to end domestic violence in the United States began more
than a century ago. In 1885, volunteers working with a coalition of women’s
organizations in Chicago started a “court watch” project designed to monitor
proceedings that involved female and child victims of abuse and rape. In
addition to providing legal aid and personal assistance, they also sent abused
women to a shelter run by the Women’s Club of Chicago, the first shelter of
its kind. The Chicago initiative was short-lived, however, and the idea of
using emergency housing as a first-line protection did not take hold until a
May afternoon in 1972 when the first call to a shelter was made to Women’s
Advocates in St. Paul, Minnesota. As recalled by Sharon Vaughan (2009), a
founder of the St. Paul program and a pioneer in the battered women’s
movement:

The call was . . . from Emergency Social Services. A worker said a

woman was at the St. Paul Greyhound bus station with a two-year-
old child. To get a job, she had traveled 150 miles from Superior,
Wisconsin, with two dollars in her pocket. What were we expected
to do? Where would they stay after two days at the Grand Hotel?
One of the advocates borrowed a high chair and stroller and we
took them to the apartment that was our office. These were the first
residents we sheltered. The two-year-old destroyed the office in
one night because all the papers were tacked on low shelves held
up by bricks. His mother didn’t talk about being battered; she said
she wanted to go to secretarial school to make a life for her and her
son. She tried to get a place to live, but no one would rent to her
without a deposit, which she didn’t have. . . . After a couple of
weeks, she went back to Superior, and every Christmas for several
years sent a card thanking Women’s Advocates for being there and
enclosed $2.00, the amount she had when she came to town. (p. 3)

During the next 3 decades, the use of shelters for women escaping abusive
partners became widespread in the United States and in dozens of other
countries. The shelter movement helped to stimulate a revolution in the
societal response to domestic violence victims and offenders that has circled
the globe, stirring women from all walks of life; of all races, religions, and
ages; and in thousands of neighborhoods, to challenge men’s age-old
prerogative to hurt, demean, or otherwise subjugate their female partners
virtually at will. In addition to the proliferation of community-based services
for victims, the revolution consists of the three other major components that
are the focus of this text: (a) the criminalization of domestic violence; (b) the
mobilization of a range of legal, health, and social service resources to protect
abused women and their children and to arrest, sanction, and/or counsel
perpetrators; and (c) the development of a vast base of knowledge describing
virtually every facet of abuse and the societal response. By 2010, police in
the United States were arresting more than a million offenders for domestic
violence crimes annually, and shelters and related programs for battered
women in more than 2,000 communities were serving more than 3 million
women and children. Most of those arrested for domestic violence are male,
although a large number of women also are arrested for abusing male or
female partners and both partners are arrested in many cases. So-called dual
arrests are a controversial practice that has stimulated much debate.
The Domestic Violence Revolution: Taking Stock
At the heart of public reforms is an ambitious conceit: that violence in
intimate relationships can be significantly reduced or even ended if it is
treated as criminal behavior and punished accordingly. Given this goal, it is
not surprising that the societal response has rested so heavily on reforming
criminal justice and legal intervention with offenders and victims. From the
start, it was assumed that the primary responsibility for supporting individual
victims would be borne by domestic violence organizations and other
community-based services and that the role of public agencies like the police
and the courts was to provide the legal framework for this support and to
manage offenders through some combination of arrest, prosecution,
punishment, rehabilitation, and monitoring (i.e., much in the way that other
criminal populations are managed). An unfortunate side effect of the focus on
individual offenders and victims is that relatively little attention has been paid
to identifying and modifying the structural and cultural sources of abusive
behavior. Mapping the societal response to domestic violence requires that
we place the criminal justice and legal systems center stage. But it also means
recognizing the limits of addressing a major societal problem like abuse with
a criminal justice approach to individual wrongdoing.

Since the opening and diffusion of shelters, the policies, programs, and legal
landscape affecting victims and perpetrators of partner abuse have changed
dramatically. Reforms run the gamut from those designed to facilitate victim
access to services or to strengthen the criminal justice response to those
aimed at preventing future violence by rehabilitating offenders. A range of
new protections is available for victims from civil or criminal courts.
Conversely, a distinct domestic violence function has been identified in
numerous justice agencies and is increasingly being carried out by
specialized personnel. Examples include dedicated domestic violence
prosecutors, domestic violence courts, and domestic violence police units.
Complementary reforms have attempted to enhance the predictability and
consistency of the justice response by restricting discretion in decisions about
whether to arrest or prosecute offenders, making domestic violence a factor in
decisions regarding custody or divorce, integrating the criminal and family
court response to domestic violence by creating “consolidated” courts, and
constructing “one-stop” models of service delivery for victims. In hundreds
of communities, once perpetrators are arrested, they are offered counseling as
an alternative to jail through batterer intervention programs (BIPs). Several
thousand localities now host collaborative efforts to reduce or prevent abuse
in which community-based services such as shelters join with courts, law
enforcement, local businesses, child protection agencies, and a range of
health and other service organizations. The rationale for these reforms in the
United States is straightforward: Under the Equal Protection Clause of the
Fourteenth Amendment to the Constitution, women assaulted by present or
former partners are entitled to the same protections as persons assaulted by
strangers.

At the basis of these reforms is the hope that they will make the societal
response to domestic violence more effective. But the efficacy of new laws,
practices, or programs is hard to measure directly. Moreover, there is only a
tenuous link between whether a program is effective and whether it receives
institutional support. Legal and criminal justice agencies have a variety of
interests in new policies, programs, or practices other than whether they meet
the goals of protection and accountability. To win acceptance by the criminal
justice or legal systems, institutional reforms must meet a variety of internal
or system needs as well as satisfy public demands. These needs include
facilitating an agency’s capacity to attract resources or to add personnel or to
achieve greater public visibility and political support. Conversely, police and
other public agencies may continue to promote programs or policies that meet
these needs long after they have been proved ineffective. Understanding why
the police and other justice agencies respond to domestic violence as they do
means appreciating how the given practice converges with the agency’s
norms, values, and system needs as well as how it is received by the public or
affects the problem at hand.

This point is illustrated by the propensity for courts, police, or prosecution to

develop specialized functions when confronted with high-demand problems
like domestic violence. Examples of specialization in the domestic violence
field include consolidated domestic violence courts as well as police teams or
prosecutorial units dedicated to misdemeanor domestic violence cases. In
theory, these reforms benefit victims by standardizing and streamlining
arrest, processing, and case disposition. The assumption is that better
outcomes will result from case handling by more knowledgeable and
experienced agents. Regardless of whether this assumption is supported by
evaluation research, specialization is appealing because it serves the system
maintenance functions described earlier. For example, specialization helps
ration scarce resources by making expenditures on a problem predictable,
attracts new resources, adds status to routine functions by reframing them as
special, and helps protect other elements of the system from being
overwhelmed. In the past, the large proportion of police calls involving
domestic violence posed little threat to routine policing because these cases
could be dismissed as “just domestics.” If they reached the courts, they
received the lowest priority and were routinely dismissed. But as public
pressure raised the profile of this class of criminal behaviors and agencies
were held accountable for intervention, it became increasingly difficult to
respond appropriately while maintaining business as usual with respect to
other types of crime. Specialization has helped criminal justice and law
enforcement manage this problem, albeit with added costs for administration
and training. Thirty years ago, few justice officials would have openly
identified themselves with domestic violence cases. Today, being an expert in
this area has become an important route to promotion and professional
recognition.

A major limit of services for domestic violence victims is that they are
delivered piecemeal, forcing victims to negotiate for needed resources at
multiple and often distal sites. Moreover, the lack of dialogue or coordination
among service providers often means that systems respond in very different
and even contradictory ways to victims and offenders. Common examples are
cases where the child welfare system threatens to place children in foster care
whose mothers continue contact with an abusive father while the custody
court threatens them with contempt if they deny the father access.
Furthermore, there is a growing appreciation that things can be made worse if
one element of the system improves its response, but others do not. For
instance, a victim’s risk of being seriously injured or killed may increase if
she is encouraged to seek a protection order but police and the court fail to
enforce it.

A recent round of programs has attempted to address the fragmentation and

lack of coordination of services in the field as well as the obvious obstacles to
access created when victims must traverse multiple portals to get the support
they need to be safe. Since the late 1990s, several thousand localities have
initiated a “coordinated community response,” where shelters and a range of
local agencies meet regularly to plan the local response. Meanwhile, more
than 60 communities have used federal funds to support “Family Justice
Centers,” a one-stop model of service delivery originally developed in
Alameda County, California. These centers bring crisis intervention together
in one building with medical and mental health services, legal assistance, law
enforcement, and often employment help as well. Prevention, too, has
commanded increased attention. In 2002, the Centers for Disease Control and
Prevention (CDC) funded 14 state coalitions to implement the Domestic
Violence Prevention Enhancement and Leadership Through Alliances
(DELTA) program, which focuses on reducing first-time perpetration by
addressing the risk factors associated with domestic violence and by
enhancing protective factors. A secondary effect of this initiative has been to
foster evidence-based strategic planning by the state coalitions as well as
closer working relationships with researchers.

The success of these efforts at coordination and planning, like the durability
of programmatic reform within agencies, depends on the larger political and
economic context as well as on a substantive commitment to end domestic
violence. In the current climate of austerity, an ideal response would involve
economies of scale, where agencies sustain cooperative work by eliminating
duplication, pooling resources, and sharing personnel. Far more often,
however, austerity fosters a much more short-sighted strategy in which
funders home in on sustaining traditional or basic services, local agencies
return to a self-protective stance of competing for scarce resources against
their erstwhile partners, and policymakers redraw their priorities in response
to political pressure. In this climate, cooperation and coordination are put off
as desirable in the long run, but unrealistic in the near future, and whatever
benefits they may have provided for victim groups can erode quickly.
Is the Domestic Violence Revolution a Success?
Never before has such an array of resources and interventions been brought
to bear on abuse in relationships or families. But are these interventions
effective?

By most conventional standards, the domestic violence revolution has been

an unqualified success. This is true whether we look at the amount of public
money directed at the problem, the degree to which politicians across a broad
spectrum have embraced its core imagery of male violence and female
victimization, the vast knowledge base that has accumulated about abuse, or
the degree to which law and criminal justice (and, to a lesser extent, health
and child welfare) have moved the heretofore low-status crime of domestic
violence to the top of their agenda. Indeed, it would be hard to find another
criminal activity in these last decades that has commanded anything like the
resources or manpower that have flowed to law enforcement on behalf of
abuse victims.

A persuasive case also could be made that the revolution has shifted the
normative climate, if ever so slightly, so that partner violence has become a
litmus test for the integrity of relationships. Male violence against women (as
well as against other men) continues to be a media staple, as the durability of
the James Bond, Rambo, Halloween, and Scream franchises illustrate. Even
when a slasher takes an equal-opportunity approach to his victims (as Freddie
Kruger does occasionally in the Nightmare on Elm Street movies) or violence
against women is treated ironically, as it was in the Scream trilogy or I Know
What You Did Last Summer and its sequel, woman-killing tends to be
protracted and sexualized in ways that the killing of men is not, pointing to
the underlying stereotypes perpetuated by this work (Boyle, 2005).
Moreover, rape and woman-killing remain key themes in other forms of mass
culture, most notably in video games (Dill, 2009) and in the brand of rap
known as “gangsta rap,” which peaked in the songs of Eminem (1999–2005;
Armstrong, 2009).

But if violence continues to compete with sexual conquest as the ultimate test
of manhood, male violence against women has increasingly had to share the
Another random document with
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know, there is no proof that it possesses any virtue in meningeal
tuberculosis. It has the high authority of Charles West,14 however,
who thinks the remedy is more encouraging than any other, and who
mentions one instance in which recovery took place under its
employment. He recommends that two grains be given every four
hours to a child three years old, the bowels being kept free. Most
authorities recommend much higher doses, such as ten or fifteen
grains, three or four times daily.
14 Op. cit., p. 102.

Counter-irritation to the head or back of the neck was formerly much

employed, but is now generally abandoned, as giving rise to much
discomfort without obvious beneficial effect. In the cases reported by
Hahn, already alluded to under the head of Prognosis, recovery is
attributed to the energetic application of tartar-emetic ointment to the
scalp, producing extensive ulceration, which in one of them lasted
more than ten months before cicatrization took place. A careful
examination of the reports of these cases satisfies me that but two
out of the seven were really examples of tubercular meningitis. How
far the recovery in the successful cases is to be attributed to the
treatment is very doubtful. Small blisters applied to the vertex or
back of the neck are alluded to favorably by West, but he quotes no
observations in which they were followed by benefit.

Tubercular Meningitis in the Adult.

Tubercular meningitis may occur at any age, but after the period of
childhood it is most frequent between the ages of sixteen and thirty
years. About 75 per cent. of the patients are males, and 25 per cent.
females.15 The disease does not differ essentially in its course and
symptoms from that in children. A family history of tuberculosis is
common, or the patient may be already suffering from phthisis,
scrofulous glands, cheesy deposits in various organs, caries of the
bone, syphilis, or other constitutional affections. According to Seitz,
in 93.5 per cent. out of 130 cases with autopsies chronic
inflammatory conditions or caseous deposits were found in various
organs of the body. Many cases are examples of acute tuberculosis
in which the brunt of the disease has fallen upon the brain rather
than the other organs.
15 Seitz, op. cit., p. 9.

When cerebral symptoms supervene upon acute disease, such as

typhoid fever, pericarditis, acute rheumatism, pneumonia, the
exanthemata, etc., the diagnosis between tubercular and simple
meningitis is important, because the latter is not necessarily fatal,
while the former is almost never recovered from. If the patient were
previously healthy and presumably free from tubercular disease, the
chances would be in favor of the simple form. A rapid course of the
disease would also speak for acute meningitis, and recovery would
almost certainly preclude tubercular meningitis. In some cases the
diagnosis is difficult or impossible in the beginning.

In cases beginning without acute antecedents—in adults as in

children—there is no pathognomonic symptom, but the combination
and succession of the phenomena are usually sufficient for the
diagnosis. Headache, depression or irritability of temper, delirium,
half-closed eyes, ptosis of one lid, squinting, inequality and
sluggishness of the pupils, moderate fever, sunken belly, vomiting,
constipation, slow and irregular pulse, sopor gradually deepening to
coma, with occasional convulsions or paralysis of the limbs, followed
in the course of two or three weeks by death, especially if occurring
in a patient who has already presented signs of tuberculosis in other
organs, point almost unmistakably to tubercular meningitis. Some of
the symptoms may not be strongly pronounced, one or two may be
absent, but the general picture will suggest no other disease.
According to Seitz, tubercle of the choroid is rare in tubercular
meningitis of the adult. It is usually associated with tuberculosis of
other organs, the pia being free. The subjoined cases are
illustrations of the disease in adolescence and adult life:
Case I.—A lad sixteen years old, always somewhat delicate, with a
cough and morning expectoration of some months' standing, exerted
himself immoderately in gymnastic exercise on the afternoon of
Sept. 24, 1875. That night he was awakened by cough and
hæmoptysis. Signs of consolidation were found at the apices of both
lungs. In three months there were swelling, induration, and
suppuration of one testicle. Some months later, pain in the right arm,
stiffness of the shoulder-joint, and an abscess communicating with
the joint, from which small spicula of bone were discharged. He was
about, and even attended school, for more than a year from the time
of the attack of hæmoptysis. About Jan. 1, 1877, he began to
complain of severe pain in the forehead, with nausea (but no
vomiting) and constipation. Jan. 27th he took to his bed, complaining
chiefly of pain in the forehead and eyes. Feb. 1st he was drowsy,
irritable, and delirious. Feb. 3d incontinence of urine and constant
delirium. Up to this time the pulse had not been above 76 in the
minute, and on this day it was 64. The next day, Feb. 4th, he was
wholly unconscious; pulse 96, pupils dilated. Feb. 5th, left hand in
constant motion; pulse 112. From this time the pulse steadily
increased in frequency. Feb. 6th he swallowed food, notwithstanding
his stupor. Feb. 7th he answered questions; there was oscillation of
the eyeballs, and epistaxis from constant picking of the nose. He
died Feb. 9th, the pulse being 144 and the respirations 60 in the
minute for several hours previous. The temperature never rose
above 101.7° F. There was never any vomiting. The duration of the
case was thirteen days, in addition to the prodromic period of twenty-
seven days.—Autopsy by R. H. Fitz: The pia of the base of the brain
from the medulla to the optic thalamus contained a large number of
gray miliary tubercles, old and recent, and the same condition was
found in the surfaces of the fissure of Sylvius. Ventricles distended
with fluid, ependyma thick and translucent. A moderate-sized cavity
in the apex of the left lung, with cheesy contents. Both lungs
contained an abundance of hard, gray, miliary tubercles. Left kidney
contained a wedge-shaped, cheesy mass of the size of a walnut,
with numerous tubercles. Left testicle contained a cheesy mass of
the size of a walnut; both epididymes were cheesy. The mucous
membrane of the bladder contained tubercles near the neck. The
vesiculæ seminales contained softened cheesy masses with
openings into the urethra. There was a fistulous opening into the
right shoulder-joint.

Case II.—Emeline K. L——, 32 years old, single, nurse, had become

much exhausted by taking care of a difficult case, and entered
Massachusetts General Hospital March 6, 1883, complaining since
four days of a little cough, slight expectoration, and chilliness, but no
rigor. She seemed hysterical. There was complaint of severe pain in
the head, chest, and abdomen. A slight systolic murmur was found
at the apex of the heart, and a few moist râles at the base of the
chest on both sides behind. The urine was normal. Temperature,
103° F. Three weeks after entrance she began to be delirious,
especially at night. April 13th, five weeks and three days after
entrance, she was semi-conscious, but would put out her tongue and
open her eyes when requested to do so; the abdomen was
distended, the pupils were dilated and unequal; there was twitching
of the muscles of the right side of the face. Careful examination only
disclosed occasional fine râle at the base of right chest. She died
April 16th, having been completely unconscious for twenty-four
hours. There was no vomiting throughout the case. The temperature
was very irregular, ranging between 100° and 103° F., and once as
high as 104° F.; it was usually one or two degrees higher at night
than in the morning. Pulse, generally from 100 to 110; it rose steadily
during the last few days to 160 at the time of death.—Autopsy: Pia
mater of brain œdematous, slightly opaque; its lower surface,
especially at the base of the brain, showed numerous minute gray
tubercles; enlarged cheesy glands at the base of the neck; small,
opaque, gray tubercles scattered rather sparsely throughout both
lungs. There was also miliary tuberculosis of the liver, spleen, and
kidneys.
CHRONIC HYDROCEPHALUS.
 BY FRANCIS MINOT, M.D.

SYNONYMS.—Dropsy of the brain, Dropsy of the head.

DEFINITION.—A gradual accumulation of serous fluid in the brain,

occupying either the ventricles or the cavity of the arachnoid, or both,
occurring chiefly in infants or very young children.

The term hydrocephalus, which was applied by the older writers to

accumulations of serous fluid both within and also without the
cranium, termed distinctively internal and external hydrocephalus, is
now restricted to dropsical effusions either between the meninges or
within the ventricular cavities. These may be acute or chronic, and
they arise from the same conditions which are followed by the
effusion of serum in other parts of the body; that is to say, from an
alteration in the serous membrane lining a cavity, from an obstruction
in the capillary circulation with increased tension in the larger
vessels, from an altered condition of the blood, etc.

Chronic hydrocephalus is almost entirely confined to young children,

and is probably due to an arrested development of the brain, as
shown by its being usually congenital, by the dwarfed intellectual
condition of the patient, and by its frequent association with spina
bifida. The pathogeny of the disease is, however, still obscure.
Whether the abnormal accumulation of serous fluid is to be ascribed
to a chronic alteration of the ventricular walls or of the choroid
plexuses, allied to inflammation, such as occurs in the pleura, for
example, causing an increased secretion, or to a closure of the
communication between the ventricles and the spinal cavity, as
suggested by the late John Hilton, resulting in dropsy by retention, or
to some other cause, is not yet determined. Hilton says:1 “In almost
every case of internal hydrocephalus which I have examined after
death I found that this cerebro-spinal opening [between the fourth
ventricle and the spinal canal] was so completely closed that no
cerebro-spinal fluid could escape from the interior of the brain; and,
as the fluid was being constantly secreted, it necessarily
accumulated there, and the occlusion formed, to my mind, the
essential pathological element of internal hydrocephalus.” Sieveking,
commenting upon Hilton's theory, says:2 “While giving these facts
due weight, it must be pointed out that we are yet far from
understanding either how the fluid is poured into the cerebral cavities
or how it is removed, and that we do not positively know that the
spinal canal has any better means of getting rid of an excess of fluid
than the cerebral cavities have.” An arrest of the growth of the brain
is supposed by some pathologists to account for ventricular as well
as arachnoidal dropsy by the creation of a vacuum in the cavity of
the cranium, which is filled by exudation of the more fluid portion of
the blood from the vessels or of lymph from the lymphatics.
1 John Hilton, Lectures on Rest and Pain, etc., 2d ed., New York, 1879, p. 22.

2 Jones and Sieveking's Pathological Anatomy, 2d ed., London, 1875, p. 248.

ETIOLOGY.—That chronic hydrocephalus in young children is in a

large proportion of cases an hereditary disease is shown by the fact
that it is frequently congenital, that more than one child in a family is
occasionally affected by it, and that while one child is hydrocephalic
others may be idiotic. A scrofulous taint in the family history is
noticeable in many cases, the evil effect of which is frequently
enhanced by unfavorable sanitary conditions of life, especially by
residence in dark, damp, ill-ventilated, and badly-drained apartments
and by insufficient or unwholesome food. Hence the disease is more
frequently met with among the poor than in the well-to-do classes of
society. There is a difference of opinion as to whether it ever arises
in consequence of external violence, such as a blow on the head, or
of some strong impression, like fright or grief, acting on the mother of
the child during pregnancy. The probability is that such causes would
not be efficient except in cases where a predisposition to
hydrocephalus had already existed. West3 mentions the case of a
healthy child five months old who fell out of the arms of her nurse,
and was taken with a fit the same day. She apparently recovered,
but when a year old had frequent returns of convulsions. At the age
of fifteen months the head began to enlarge, and it continued to
increase in size until she was three years old, when she was
attacked by measles, and died in a few days with convulsions and
coma. The symptoms, both bodily and mental, were typical of
hydrocephalus, and the diagnosis was fully confirmed by the
autopsy.
3 Op. cit., p. 127.

The causes of chronic hydrocephalus in older subjects and in adults

are, in addition to the above mentioned, chiefly mechanical. Any
lesion which hinders the exit of venous blood from the cranium may
be followed by dropsy of the arachnoid cavity or ventricles. The
principal ones are tumors of the brain or its membranes, the effusion
of lymph in the neighborhood of veins, thrombosis of the cerebral
sinuses, compression of numerous small vessels by tubercular
granulations, obstructions outside the cranium, including tumors of
the neck, aneurisms, obstructive disease of the heart, emphysema
and cirrhosis of the lungs, besides diseases giving rise to general
dropsy, as the different forms of nephritis, marasmus, the various
cachexiæ, etc.

SYMPTOMS.—When the disease is already somewhat advanced

before birth, the head is often abnormally large, the cranial bones
are separated, the fontanels are distended and fluctuating, and it
occasionally happens that delivery of the distended head can only be
effected after the fluid has been evacuated by puncture. Even when
there is no abnormal increase in the size of the head, indications of
cerebral disturbance are sometimes apparent from birth, such as
strabismus or convulsions recurring with more or less frequency,
along with signs of failure of the general health. In the course of
some weeks, or, it may be, months, the attention of the parents is
attracted to the prominence of the child's forehead, strongly
contrasting with the comparatively diminutive size of the face. Soon
an enlargement of the fontanels is perceived, the sutures between
the cranial bones become broader, and the head assumes a globular
shape from the pressure of the contained fluid. The separation of the
bones at the vertex of the skull causes the os frontis to protrude
forward, the parietals backward and outward, and the occipital
backward and downward. The orbital plates of the frontal bone yield
to the pressure of the fluid behind them, and from a horizontal
position tend to assume a vertical one, protruding the eyeballs,
which have a peculiar downward direction. The sclerotica is visible
above the iris, and the latter is partially covered by the lower eyelid.
The enlargement of the head is progressive, though not uniformly so,
there being pauses of weeks or months during which it is arrested. If
it be considerable, the cranial bones are usually thinned, so that the
skull becomes translucent when opposite a bright light. When there
is a wide separation of the bones there is an unusual development of
ossa triquetra in the sutures.

In cases in which the ossification of the cranium is considerably

advanced before the beginning of the disease, the enlargement of
the head is apt to be correspondingly less. If all the sutures are
consolidated, there may be no increase in size, and this is especially
true of the mechanical dropsy of adult life. The dropsical effusion,
which is then moderate in amount, finds room through compression
of the brain-substance, and part of it escapes into the spinal canal.

The size of the hydrocephalic head varies considerably. Where there

has been an early arrest of the disease it may be but slightly above
the normal. On the other hand, the dimensions are sometimes
enormous. In the Warren Museum of Harvard University is a cranium
which measures 27½ inches in its greatest circumference, and 20½
inches from one auditory foramen to the other over the top of the
head. Its internal capacity is 257 cubic inches. The patient, who died
at the age of three years, was never able to sit up and support the
head, or even to turn it from the left side, on which she continually
lay; she never spoke, and seemed to have no intelligence. The skull
of the celebrated James Cardinal measured 32¼ inches in its largest
circumference.4 Even more remarkable instances are on record. The
dimensions of the fontanels, particularly the anterior, usually
correspond with those of the skull in general. During any strong
muscular effort on the part of the patient the membrane covering
them is seen to be bulged out by pressure from the fluid beneath.
The enlargement is not always uniform; it may be in part or wholly
confined to one side, owing to consolidation of the sutures of the
opposite side, or because only one of the lateral ventricles is
affected. The scalp is traversed by numerous distended veins. The
hair is very scanty. The head has a soft, fluctuating feel, and the
walls sometimes seem to crackle beneath the fingers, like
parchment.
4 Reports of Medical Cases, etc., by Richard Bright, M.D., London, 1831, vol. i. p.
431.

In cases of moderate severity there may be few or no symptoms of

active cerebral disturbance, such as convulsions or paralysis, but the
child does not learn to talk, to walk, or to control the sphincters even
at the age of three or four years, and the signs of imperfect mental
development are evident. He is apt to be irritable or mischievous,
and even when not actually idiotic is very backward in evincing signs
of intelligence. There are, however, not a few exceptions to this, and
some children with large hydrocephalic heads are intelligent and
amiable. The cranium of a girl who died at the age of sixteen years is
preserved in the Warren Museum. It measures 24¼ inches in
circumference and 17¼ inches from one auditory meatus to the
other over the vertex, and the bone is in no place more than one-
eighth of an inch in thickness. The child was an inmate of a house of
industry, where she was instructed in the usual branches of
knowledge taught in our common schools, until at length, such was
her capacity, she was entrusted with the teaching of the other pauper
children, and she had an excellent character for intelligence and
moral worth. She died of phthisis. On post-mortem examination “the
brain was found floating, as it were, in a large collection of water.” As
in other chronic diseases, there are often pauses, from time to time,
of variable duration, in which there is some improvement in the
condition of the patient, as well as a temporary arrest in the
enlargement of the head. The growth of the child in stature is often
retarded, and when life is prolonged the individual is more or less
dwarfed. In some cases there is a considerable increase in the
amount of adipose tissue, and the appetite is often voracious. L.
Fürst reports5 the case of a hydrocephalic girl, sixteen years old,
whose height (or, rather, length, for she was unable to stand) was 81
centimeters (nearly 32 inches), corresponding to the stature of a
child between three and four years old. The periphery of the head
measured 511/5 centimeters (20¼ inches). The anterior fontanel was
still open. The age was verified by reference to the registry of birth at
the police-office.
5 “Exquisite Wachsthumshemmung bei Hydrocephalus chronicus,” von Dr. Livius
Fürst, Virchow's Archiv, June, 1884.

The symptoms of cerebral disturbance in chronic hydrocephalus are

much less striking than one would expect, doubtless because the
increase of pressure upon the brain is so gradual. Actual paralysis,
especially of the limbs, is rare, but convulsions are not infrequent, as
is the spasmodic constriction of the glottis known as laryngismus
stridulus or spasmodic croup. A general state of uneasiness and
restlessness is common. Vision is often impaired and sometimes
wholly lost. Strabismus is frequently present, or there may be an
involuntary rolling movement of the eyeballs. The pupils are often
dilated and insensible to light. In consequence of the increased
weight of the head, the child is unable to support it, and in most
cases is compelled to keep the bed. Vomiting is common. The
digestive functions are disturbed. Constipation is an almost constant
symptom, and the sphincters are relaxed in the advanced stages of
the disease. Although in some cases, as already stated, the child
may grow fat, the reverse of this is the rule; there is usually
progressive emaciation, especially of the lower extremities.

The duration of the disease varies much in different cases. The

earlier the characteristic symptoms manifest themselves the more
rapid is its course. Most children born hydrocephalic survive but a
few days or weeks. In cases which are more slow in their
development the patient may live some years, and in rare instances
attain adult life. But his feeble vitality usually makes him an easy
prey to the ordinary complaints of childhood, and a large proportion
of cases succumb to inflammation of the lungs or of other organs, to
diarrhœa, whooping cough, or the eruptive diseases. Most of those
who escape these intercurrent maladies perish from defective
nutrition, the result of malassimilation of food, or else are cut off by
acute cerebral inflammation, with convulsions, etc.

PATHOLOGICAL ANATOMY.—It is rarely that a large amount of serum is

found in the cavity of the arachnoid unless a free communication has
been established between it and the ventricles by the destruction of
cerebral tissue. In the pia the quantity may be more abundant than
normal, filling the subarachnoid spaces, separating the convolutions
from each other, and occasionally forming little sac-like elevations on
the surface of the membrane; but it should be borne in mind that a
certain amount of serous infiltration of the tissue of the pia is by no
means rare in cases of death from various diseases, owing to the
obstruction to the circulation during the last hours of life, and should
not be considered pathological unless it exceed the usual limits. The
amount of effusion into the ventricles varies between very wide
limits, from some ounces to two or three pints. It may be transparent,
or turbid from particles of cerebral tissue or epithelial or pus-cells,
and is occasionally slightly tinged with blood. Its specific gravity is
nearly identical with that of water, and it contains a trace of albumen.
The effusion usually occupies the two lateral and the middle
ventricles. Less frequently the dropsy is unilateral, in consequence,
apparently, of an obliteration of the foramen of Monro. The tissues
composing the walls of the ventricles are compressed and hardened.
The ependyma of the walls and of the plexus is thickened and
roughened by the formation of minute elevations, which the
microscope shows to be composed of proliferated and sclerosed
connective tissue. The brain in cases of large effusion is reduced to
a membranous sac, flattened, with hardly any trace of its original
structure at first sight apparent. In the case of James Cardinal,
before alluded to, Bright says, “The brain lay at its base [of the skull]
with its hemispheres opened outward like the leaves of a book.”
Closer inspection shows that all the parts are present, although
atrophied by pressure. The convolutions are flattened and the brain-
substance is pale and softened. The cranial nerves are often
softened and flattened.

In the dropsy of the head in adults which is the result of mechanical

pressure or of cachexia the appearances are widely different. The
effusion may occupy the cavity of the arachnoid, and even the space
between the dura and the skull, as well as the ventricles. The
amount of fluid is much less than in the chronic hydrocephalus of
children. The ventricular walls present no signs of inflammatory
changes.

DIAGNOSIS.—Chronic hydrocephalus is usually recognized without

difficulty. The chief points of diagnostic importance are the
progressive enlargement of the head, the separation of the cranial
bones, with their peculiar change of position, as already described,
and the evident signs of arrested intellectual development. If the
head be but little enlarged, the case might be mistaken for that of
chronic hypertrophy of the brain, but this is a very rare disease, and
is not accompanied with defective mental development.

PROGNOSIS.—The elements of prognosis include the size of the head

at birth, its rate of enlargement, the general condition of the child,
both physically and intellectually, his hereditary antecedents, and the
hygienic influences to which he may be subjected. A large proportion
of children born hydrocephalic live but a short time; a few survive
one or more years. The number of those who reach adult life is
extremely small. The favorable indications are a tardy appearance of
the dropsy and its slow progress, without marked evidence of
defective mental and bodily development.

TREATMENT.—The treatment of chronic hydrocephalus is general and

local, the first being the most important, although in many cases it is
difficult to enforce it, from lack of intelligence and of means on the
part of those in charge of the patient. Proper ventilation, good
drainage, and cleanliness are essential. The child should be bathed
daily, and should be protected against changes in temperature by
suitable clothing. If his strength allow, he should be taken into the
open air daily in fine weather. A wet-nurse should be provided for
infants whose mothers are unable to suckle them. Older patients
should take milk, cream, animal broths, farinaceous substances,
etc., with wine or brandy. Tonics, especially cod-liver oil,
hypophosphite of lime, and some preparation of iron or of the iodide
of iron, are important, the choice being determined by the effect
apparently produced. The internal and external employment of
mercurial preparations, once in vogue, is now almost entirely
abandoned by the best authorities. The evacuation of the fluid by
puncture, followed by compression of the head by bandaging, has
been occasionally resorted to, and in a few instances with success,
but the cases in which it is indicated are rare. Thomas Young
Thompson6 reports a case in which puncture was followed by
recovery. The child, fourteen days old, fell, apparently without ill
effects, but three weeks afterward a protuberance appeared on the
crown of the head which continued to enlarge, and the signs of
chronic hydrocephalus were unmistakable. In three months the
circumference over the parietal eminences measured 20 inches, and
a year afterward 24½ inches. In spite of energetic internal and
external treatment the enlargement continued to progress, until the
head was punctured, and about three hundred grammes of a clear,
transparent fluid, free from albumen, were evacuated. Five weeks
later a second puncture was made, and sixty grammes of a milky
fluid withdrawn. The child recovered, and two years later was in
good health, the head not being disproportioned to the rest of the
body. West considers the cases in which the effusion is apparently
external—that is, confined to the arachnoid cavity, rather than
ventricular, and in which there are no indications of active cerebral
disease—to be the most favorable for the operation. The proper
situation for the puncture is the coronal suture, about an inch or an
inch and a half from the anterior fontanel. A few ounces of fluid only
should be withdrawn at a time, and compression should be carefully
applied both during the escape of the fluid and afterward.
6 Med.-Chir. Transactions, vol. xlvii., 1864.
 CONGESTION, INFLAMMATION, AND
HEMORRHAGE OF THE MEMBRANES OF THE
SPINAL CORD.

BY FRANCIS MINOT, M.D.

Congestion of the Spinal Membranes.

The blood-vessels of the spinal membranes communicate freely with

the general circulation, and there is less opportunity for their
obstruction than in the case of the meninges of the brain.
Hyperæmia of the dura and pia mater is therefore seldom met with,
except in connection with disease of the cord; and, indeed, but little
is known on the subject, which is only alluded to as possible by
authorities of the present day, although the affection was formerly
supposed to be a common one, giving rise to various symptoms,
such as numbness and formication of the extremities, muscular
weakness, and even paraplegia—symptoms which are now known
to be caused by structural diseases of the cord only. As Erb1
remarks, “It is hardly possible that any considerable hyperæmia of
the meninges should exist without a similar condition existing in the
cord also, as the vascular supply of both is the same.”
 1 “Krankheiten des Rückenmarks,” von Wilhelm Erb, in Ziemssen's Handbuch,
Leipzig, 1876; Am. trans., vol. xiii. p. 99.

ETIOLOGY.—Hyperæmia of the spinal membranes is found after death

from convulsions, especially in cases of tetanus, hydrophobia,
eclampsia, strangulation, poisoning from narcotics, etc., in which the
effect is evidently due to asphyxia. An interesting case of extensive
hyperæmia of the spinal membranes, as well as of those of the
brain, complicating mania, is reported by M. R. G. Fronmüller.2 A girl
of eighteen years, previously well, being accused of theft, fell into a
state of melancholia, passing into mania, with frequent convulsions,
screaming, etc. There was no spinal tenderness. The urine
contained no albumen. The temperature was never elevated. No
opisthotonos. The sphincters became relaxed, and she died at the
end of about three weeks. The dura was found to be normal, but the
pia mater of the brain, cerebellum, medulla oblongata, and cord was
strongly injected. The brain and cord were normal; no ventricular
effusion. Here the meningeal hyperæmia was doubtless caused by
asphyxia resulting from the convulsions.
2 See Schmidt's Jahrbücher, 1883, No. 7.

Congestion of the spinal membranes has been attributed to sudden

suppression of the menstrual flow or of hemorrhoidal bleeding, and
to portal obstruction, but the evidence of this is very meagre.
Exposure to cold and wet, as from sleeping on the damp ground, is
an alleged and plausible cause.

The SYMPTOMS attributed to hyperæmia of the spinal membranes are

pain in the back extending to the legs, with numbness and tingling of
the toes, sensation of weight in the limbs, muscular weakness,
appearing suddenly without fever and usually of transient duration.
There is no evidence that it gives rise to paralysis. Considering that
temporary congestion of the membranes must occasionally happen
from convulsions, as in epilepsy, etc., it is remarkable that no
symptoms attributable to it have been observed under these
circumstances.3
 3 See Epilepsy and other Chronic Convulsive Diseases, etc., by W. R. Gowers, M.D.,
London, 1881, p. 106.

MORBID ANATOMY.—We must be careful not to mistake post-mortem

staining of the tissues from imbibition of the coloring matter of the
blood—the result of decomposition aided by the position of the body
—for true congestion. The latter is recognized by fine vascular
arborization covering the surface of the dura or pia, often
accompanied with small punctate hemorrhages. More extensive
extravasations in the connective tissue, surrounding and between
the membranes, are sometimes found. The spinal fluid is usually
increased in amount, and often tinged with red. On account of the
free vascular connection between the membranes and the cord the
latter almost always partakes of the congestion.

DIAGNOSIS.—From what has been said it follows that simple

hyperæmia of the spinal membranes can hardly be distinguished
from that of the cord. (See the article on DISEASES OF THE SUBSTANCE
OF THE BRAIN AND SPINAL CORD.) When the symptoms are
unaccompanied by fever, are of very moderate severity, and of short
duration, we may perhaps infer that the lesion is confined to the
membranes.

The TREATMENT is the same as that for congestion of the spinal cord.

Acute Inflammation of the Spinal Dura Mater.

SYNONYM.—Acute spinal pachymeningitis.

Acute inflammation of the spinal dura mater is chiefly confined to the

outer surface of the membrane (peripachymeningitis), and is almost
always consecutive to either injury or disease of the vertebræ
(fracture, dislocation, caries), to wounds penetrating the spinal
cavity, or to suppurative disease in neighboring organs or tissues,
which makes its way into the peridural space through the
intervertebral openings. The symptoms are complex—in part caused
by the original disease, and in part by the pressure of the products of
inflammation exercised upon the nerve-roots, and even upon the
cord itself. Pain in the back, corresponding to the seat of the
disease, is rarely absent, and all movements of the trunk are
extremely painful. When the exudation is sufficient to compress the
nerve-roots, the pain will extend to the trunk and the limbs, and other
signs of irritation, such as a feeling of constriction by a tight girdle,
and tingling, numbness, and cutaneous hyperæsthesia in the limbs,
will be observed, varying in situation according to the seat of the
lesion. In some cases the compression of the cord may be sufficient
to cause paraplegia. General symptoms will vary according to the
complications of the case. Severe injury or extensive disease of the
vertebræ will be accompanied with high fever; but if the external
inflammation be moderate and the meningeal complication be limited
in extent, the fever may be subacute.

MORBID ANATOMY.—The connective tissue between the dura and the

bone is the seat of inflammatory exudation, usually purulent, of
greater or less extent, and more abundant in the posterior than the
anterior part of the spinal cavity, owing to the position of the patient.
A more or less abundant exudation, either of pus or of dry caseous
matter, is found upon the outer surface of the dura or infiltrating the
connective tissue between it and the bony walls. The dura is
thickened, and sometimes the exudation is seen upon its inner walls,
but the pia is seldom involved in the inflammation. The cord may be
compressed or flattened when the amount of exudation is large, and
may in consequence show signs of inflammation in its vicinity. The
spinal nerves likewise are sometimes compressed, atrophied,
softened, and inflamed. The disease rarely occupies the cervical
region, on account of the close union of the dura with the bones of
that part; hence there is an absence of pain in the neck and of
retraction of the head.

DIAGNOSIS.—The diagnosis is founded on the presence of general

symptoms of spinal disease—pain in the back, but not extending to
the neck, increased by movements of the trunk; cutaneous
hyperæsthesia, tingling, or numbness in various parts of the surface
of the body; paresis or paralysis of the lower extremities in severe
cases; along with a history of vertebral disease or injury or of
suppurative disease in the neighborhood of the spine. The history of
the case will generally be sufficient to exclude myelitis, tetanus, or
muscular pain (rheumatism, lumbago). From acute leptomeningitis
the diagnosis must also be made by the history, but it should be
borne in mind that the pia may be involved at the same time with the
dura.

PROGNOSIS.—In complicated cases the prognosis is grave if the

spinal symptoms are well marked and severe, especially when there
is evidence of much pressure on the cord (paraplegia). If the signs of
spinal irritation were moderate, the danger would depend upon the
nature and extent of the external lesion.

TREATMENT.—This would be addressed mainly to the primitive

disease. For the spinal symptoms the treatment would not differ
materially from that of inflammation of the spinal pia mater.

Chronic Spinal Pachymeningitis.

This affection generally coexists with chronic inflammation of the pia.

Like the acute inflammation of the dura, it is seen in connection with
disease or injury of the vertebræ, and it may also arise from tumors
of the membrane (chiefly syphilitic) and from myelitis. It is frequent
among the chronic insane, and in them is sometimes associated with
hemorrhagic effusions analogous to the hæmatoma of the cerebral
dura mater. Chronic inflammation of the spinal dura is of unfrequent
occurrence, and but little is known of its history and pathology. In a
case reported by Wilks4 the membrane was thickened to nearly its
whole extent, and in the cervical region presented numerous bony
plates. The pia was also thickened at this part and adhered closely
to the dura. The symptoms, which seemed chiefly due to disease of
the cord from compression, were retraction of the lower limbs and
violent jerking from excessive reflex action.
4 Transactions of the Pathological Society of London, vol. vii., 1856.

A special form of the disease, occupying chiefly the cervical region,

was first described by Charcot.5 The membrane is thickened by a
deposit of successive layers of fibrin, compressing the cord, which is
flattened from before backward and inflamed. The nerve-roots are
also more or less compressed. The course of the disease may be
divided into two stages: First, that of irritation of the spinal nerves,
with pain in the back part of the neck, extending to the head and
along the upper limbs. The pain is permanent, but liable to
exacerbations, and is accompanied with stiffness of the neck and a
feeling of numbness and tingling, with muscular weakness of the
arms. Sometimes the skin of the arms is the seat of trophic changes,
as shown by the presence of bullæ or pemphigus. The second
period is that of extension of the disease to the cord. The pain
ceases, and is followed by paralysis or muscular atrophy, especially
in the domain of the ulnar and median nerves, resulting in extension
of the hand on the forearm, with flexion of the fingers toward the
palm, giving rise to a claw-like appearance (main en griffe). In some
cases an upward extension of the disease implicates the root of the
radial nerve, and the hand then assumes a prone position from
paralysis of the extensor muscles. The lower portion of the cord may
also become involved, with similar results in the lower extremities.
Although the disease is generally progressive, it is not always so,
and Charcot cites one case in which great improvement took place in
the course of some years, though not apparently in consequence of
any special treatment.
5 Leçons sur les Mal. du Syst. nerv., par J. M. Charcot, Paris, 1875, vol. ii. p. 246.
See, also, Maladies du Syst. nerv., par A. Vulpian, Paris, 1879, p. 127; and Clinique
méd. de l'Hôpital de la Charité, by the same.