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COMPARATIVE STUDIES OF POLITICAL AGENDAS

Morality Politics
in a Secular Age
Strategic Parties
and Divided
Governments in Europe

Eva-Maria Euchner
Comparative Studies of Political Agendas

Series Editors
Christoffer Green-Pedersen
Aarhus University
Aarhus, Denmark

Laura Chaqués Bonafont

University of Barcelona
Barcelona, Spain

Arco Timmermans
Leiden University
The Hague, The Netherlands

Frédéric Varone
Université de Genève
Geneve, Switzerland

Frank R. Baumgartner
University of North Carolina at Chapel Hill
Chapel Hill, USA
The series publishes books on policy agenda-setting dynamics broadly
understood. This includes for instance books dealing with the policy
effects of agenda dynamics, the relationship between the political agenda,
public opinion and the media agenda, and agenda dynamics in relation
to particular issues. The series publishes both comparative books and
books dealing with single countries if these single countries are placed
in a comparative context. The books can be either monographs or edited
volumes.

More information about this series at

http://www.palgrave.com/gp/series/14908
 Eva-Maria Euchner

Morality Politics
in a Secular Age
Strategic Parties and Divided Governments
in Europe
Eva-Maria Euchner
Geschwister-Scholl-Institut für
Politikwissenschaft
Ludwig-Maximilians-Universität
(LMU)
Munich, Germany

Comparative Studies of Political Agendas

ISBN 978-3-030-10536-5 ISBN 978-3-030-10537-2 (eBook)
https://doi.org/10.1007/978-3-030-10537-2

Library of Congress Control Number: 2018965231

© The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer
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on microfilms or in any other physical way, and transmission or information storage and
retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and
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The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
For my family.
 Acknowledgements

This manuscript is based on my dissertation project which I devel-

oped at the Department of Politics and Management at the University
of Konstanz. I substantially extended and revised the project at my
new working base, the Geschwister-Scholl-Institute of Political Science
at the Ludwig-Maximilians-University in Munich. So, sincere thanks
go to faculty and staff at both departments for providing a very pleas-
ant and inspiring working environment. I owe a debt of gratitude to
many people in these departments who have been crucial to my success
in completing this book. First of all, my Ph.D. supervisor and current
mentor, Christoph Knill, has been extremely generous with his time and
helpful advice. His insistence that I start to write down ideas instead of
discussing it too extensively helped me a great deal in structuring my
time and balancing teaching duties, project work, and this manuscript.
Moreover, I am very grateful that I have been part of the MORAPOL
project funded by the European Research Council. Although participa-
tion in this ambitious research program involved a considerable work-
load with regard to data collection, coding, and coordination, witnessing
the cooperation of so many individuals on one team was very inspiring
and enriching. Many thanks to all those involved. In this vein, I am
very grateful for the generous funding provided in terms of student
assistantships, proof-reading services, and participation in international
conferences.
My second mentor, Christoffer Green-Pedersen from the University
of Århus in Denmark, has likewise been a source of enormous inspiration

vii
viii    Acknowledgements

and motivation. Christoffer’s insistence on spending a great deal of time

on both research design and conceptualization of variables has proven
invaluable, not only for this project, but also in realizing the research
standards for which political science should aim. I greatly appreciate
his accessibility and the ease of communication despite the geographi-
cal distance. Moreover, I admire his manner of supervising, a combina-
tion of critical discussion and encouragement. He also introduced me to
the community of comparative agenda-setting researchers in Europe, to
whom I owe many thanks for all their valuable comments and sugges-
tions at various conferences. This includes especially Christian Breunig
who came to University of Konstanz at a later stage, Laura Chaqués
Bonafont, and Stefaan Wagenaar commenting on my project in differ-
ent instances. Now, I am particularly happy that this book is published
in one of the most prestigious book series of this community. So, many
thanks go to the series editors, including besides Christoffer Green-
Pedersen and Laura Chaqués Bonafont, also Arco Timmermans, Fréderic
Varone, and Frank Baumgartner.
This book has allowed me to experience the implications of a com-
parative study. I do not regret it for a moment, not least because it pro-
vided me with the opportunity to spend time doing research in Spain.
The inter-university Institute of International Studies in Barcelona
(IBEI) served as my working base there, and I am very grateful to Jacint
Jordana, Laura Chaqués Bonafont, and for my officemates for creating
a welcoming atmosphere. In this regard, I am additionally thankful for
the generous research grant from the DAAD that enabled all of this. My
gratitude extends also to the political experts and interest-group activists
who were interviewed for this study for their generosity with their time.
Special thanks go to my former officemate Caroline for the highly
inspiring discussions on moral questions and our common projects,
which showed me again and again how much fun it can be to work col-
laboratively in the field of comparative public policy analysis. In addition,
many thanks to all my good friends at the University: Yvonne, Simeon,
and Thomas; as well as to Jale Tosun seriously inspiring me to start a
Ph.D. Finally, I am extremely appreciative of the support of my parents,
who are unfamiliar with the academic world but nevertheless encouraged
me along this unknown path. I should not forget my little sister, whose
positive attitude cheered me up over the course of many telephone calls.
 Acknowledgements    ix

My deepest gratitude goes to David; I am so grateful for his love, sup-

port, and especially his patience in bearing both my repeated absence
from home and my preoccupation with my work.

Munich, Germany Eva-Maria Euchner

November 2018
 Contents

1 Introduction 1

Part I Secularization, Morality Policies, and Party

Conflicts in Europe

2 Morality Policy as a Party Issue in a Secular Age 21

3 A New Framework of Attention on and Change of

Morality Issues in Parliaments of the Religious World 53

4 Comparing Attention and Change in Morality Issues 83

Part II Religious-Secular Divide and Politicization

of Morality Policies

5 The Rise and Fall of Morality Policies in Austria,

Germany, Spain, and the Netherlands 121

6 Mechanisms of Wedge-Issue Competition 157

xi
xii    Contents

Part III Linking Parliamentary Attention and Change

in Morality Policies

7 Explaining Patterns of Morality Policy Change

in Austria, Germany, Spain, and the Netherlands 191

8 The Indirect Effect of Parliamentary Attention on

Morality Policy Change Through the Stimulation
of Venue Shifts and Changing Policy Images 207

Part IV Conclusions

9 Morality Politics in a Secular Age 235

Appendix 265

Primary Sources: Press Articles 287

Index 291
 Abbreviations

AFD Alternative für Deutschland (Alternative for Germany)

ART Artificial Reproduction Techniques
BFSFJ Bundesministerium für Familie, Frauen, Senioren und Jugend
BR Bundesrat
BT Bundestag
BVerfG Bundesverfassungsgericht
BZÖ Bündnis Zukunft Österreich (Alliance for the Future of Austria)
CAP Comparative Policy Agenda Project
CC Coalición Canaria (Canary Coalition)
CD Congreso de los Diputados España
CDA Christen Democratisch Appèl (Christian Democratic Appeal)
CDS Centro Democrático y Social
CDU Christlich Demokratische Union (Christian Democratic Party)
CE Constitución Español
CiU Convergència i Unió (Convergence and Unity)
CMP Comparative Manifesto Project
COGAM Colectivo Gai de Madrid
CSA Core-sentence approach
CSU Christlich Soziale Union (Christian Social Union)
CU ChristenUnie (Christian Union)
D66 Democraten 66 (Democrats 66)
DE Germany
Die LINKE Die Linke (The Left)
Drs. Drucksache
EC European Commission
ECHR European Court of Human Rights

xiii
xiv    Abbreviations

ECJ European Court of Justice

EKD Evangelical Church in Germany
EM El Mundo
EP El País
ERC Esquerra Republicana de Catalunya (Republican Left of
Catalonia)
ES Spain
EU European Union
EVS European Value Survey
FAZ Frankfurter Allgemeine Zeitung
FDP Freie Demokratische Partei (Free Democratic Party)
FPÖ Freiheitliche Partei Österreichs (Freedom Party of Austria)
GDR German Democratic Republic
GG Grundgesetz Bundesrepublik Deutschland
GL GroenLinks (GreenLeft)
Greens Bündnis 90/Die Grünen (Alliance 90/Greens)
Gruene Grüne Alternative Österreich (Green Alternative)
ICMPD International Center for Migration Policy Development
ICV Iniciativa per Catalunya Verds (Initiative for Catalonia Greens)
IU Izquerda Unida (United Left)
LIF Liberales Forum (Liberal Forum Austria)
LP Legislative period
LPF Lijst Pim Fortuyn (Fortuyn List)
LSU Lesben und Schule in der Union
MORAPOL ERC-funded research project “Moral Policy Change” led by
Professor Knill
NaBai Nafarroa Bai (Navarre Yes)
NEOS NEOS-Das Neue Österreich (NEOS—The New Austria)
OECD Organization for Economic Cooperation and Development
OLS Ordinary least squares regression
ÖVP Österreichische Volkspartei (Austrian People’s Party)
PCA Political claim analysis
PDP Partido Demócrata Popular
PDS Partei des Demokratischen Sozialismus (Party of Democratic
Socialism)
PoliMoral Dataset on parliamentary attention on morality policies in
Continental Europe
PP Partido Popular (Popular Party)
PROS Prostitution
PSC Partit dels Socialistes de Catalunya (Socialists of Catalonia)
PSOE Partido Socialista Obrero Español (Spanish Socialist Workers
Party)
 Abbreviations    xv

PvdA Partij van de Arbeid (Labour Party)

PVV Partij voor de Vrijheid (Party for Freedom)
SD Senado des España
SED Sozialistische Einheitspartei Deutschland
SP Socialistiese Partij (Socialist Party)
SPD Sozialdemokratische Partei Deutschlands (Social Democratic
Party)
SPÖ Sozialdemokratische Partei Österreichs (Social Democratic Party
Austria)
SSM Same-sex marriage
SZ Süddeutsche Zeitung
UCD Unión de Centro Democrático
UK United Kingdom
UN United Nations
US(A) United States of America
VG Verwaltungsgericht
VVD Volkspartij voor Vrijheid en Democratie (People’s Party for
Freedom and Democracy)
WVS World Value Survey
 List of Figures

Fig. 1.1 Two-stage model of morality politics in the religious world

(Source Author’s conceptualization) 7
Fig. 2.1 Development of religiosity and share of unaffiliated
Europeans (1990–2010) (Source MORAPOL 2016 based
on WVS 2015. For Italy, longitudinal data of religiosity are
missing) 23
Fig. 2.2 Development of the parliamentary representation of religious
parties (1960–2010) (Source MORAPOL 2016; WVS
2015; Austria: ÖVP, CSA; Belgium: CDH, CVP, CSP,
PSC; Denmark: K (KrF); Finland: KD (SKL); France: CD
(CDS, CDP); Germany: CDU, CSU; Greece: -; Ireland:
FG (CG, NCP, RI); Italy: CD (DC, CCD, DE, CS, Rete);
Netherlands: CdA (ARP, CHU, RPF), CU, KVP; Norway:
KRF; Poland: AWS (KOS, BBWR, PO, ROP); Portugal:
CDS; Spain: -; Sweden: KD (KDS, Ks, Kd); Switzerland:
CVP; Turkey: ANAP (AKP); UK: -) 25
Fig. 2.3 Salience of morality policies in party manifestos in Europe
(1940–2015) (Source Author’s own compilation based on
Volkens et al. 2016a) 28
Fig. 2.4 Morality policy salience across political parties’ manifestos
(1940–2015) (Source Author’s own compilation based on
Volkens et al. 2016a) 29
Fig. 3.1 Two-stage model of morality politics in the religious world
(Source Author’s conceptualization) 54
Fig. 4.1 Linking positional congruence and policy images
(Source Author’s own compilation) 107

xvii
xviii    List of Figures

Fig. 5.1 Regulation of same-sex partnerships in Europe

(1960–2018) (Source Based on Preidel (2015) in Knill et al.
(2015)). N = 16. Data Source MORAPOL. Germany (DE),
the Netherlands (NL), Spain (ES) and Austria (AT) are
marked in bold) 123
Fig. 5.2 Regulation of prostitution in Europe (1960–2018)
(Source Based on Euchner (2015) in Knill et al. (2015).
N = 16. Data Source MORAPOL) 129
Fig. 5.3 Morality policy politicization across country and time
(1994–2014) (Source PoliMoral. N = 1370. AT = Austria,
DE = Germany, ES = Spain, NL = Netherlands) 133
Fig. 5.4 Politicization pattern across actors and type of policy
(1994–2014) (Source PoliMoral. Left-hand figure:
n1 = 1348 (22 non-partisan initiatives are excluded).
Right-hand figure: n2 = 1333 = 100% (37 unclear initiatives
are excluded). SSM = Rights of single homosexual
individuals and couples, PROS = Prostitution policy,
including regulation regarding sex-work, human trafficking
and forced prostitution) 135
Fig. 5.5 Development intra-party conflicts on morality
policies across mass parties (1994–2014) (Data PoliMoral.
N = 1370. Based on the analysis of 504 newspaper articles
and 921 actor-object relations across all four countries
and the main religious parties (i.e., CDU/CSU, CdA,
ÖVP, PP) and the main secular parties (i.e., SPD, PvdA,
SPÖ, PSOE). Minimum = 0.0 (low conflict level),
maximum = 1.0 (high conflict level)) 137
Fig. 5.6 Intra-party conflict and issue position of mass parties across
countries (1994–2014) (Data PoliMoral. N = 1370. Based
on the analysis of 504 newspaper articles and 921 actor-
object relations across all four countries and the main
religious parties (i.e., CDU/CSU, CdA, ÖVP, PP) and
the main secular parties (i.e., SPD, PvdA, SPÖ, PSOE).
Minimum = 0.0 (lowest conflict level), Maximum = 1.0
(highest conflict level)) 138
Fig. 5.7 Intra-party conflict religious mass parties and opposition’s
engagement (Data PoliMoral) 141
Fig. 5.8 Intra-party conflict and engagement secular parties
(Data PoliMoral) 144
Fig. 5.9 Engagement of opposition parties over government
coalitions (1994–2014) (Comments Distribution of
government formats: no mixed coalitions n = 37 country
 List of Figures    xix

years, religious-secular coalition n = 23 country years. Total

initiatives of the opposition n = 793. Other opposition
parties include religious parties but also non-partisan actors
(e.g., expert commissions). Data PoliMoral) 146
Fig. 5.10 Engagement rate of opposition parties over coalition
types (Note N (total) = 793. N (not mixed) = 148, N
(mixed) = 645. Data PoliMoral) 148
Fig. 5.11 Attention patterns separated by policy (1994–2014)
(Source PoliMoral) 150
Fig. 6.1 Parliamentary attention on same-sex partnership rights
in Germany (1994–2012) (Source PoliMoral) 159
Fig. 6.2 Position of German political parties on same-sex partnership
rights in the 17th LP (Note Coding of 54 newspaper
articles and 79 actor-object relations. CIntra = Continuous
black line = level of intra-party conflict, Dotted line = level
of intra-party conflict. Data PoliMoral) 163
Fig. 6.3 Parliamentary attention prostitution policy and same-
sex partnership rights in Germany (1994–2012) (Data
PoliMoral) 168
Fig. 6.4 Distribution of parliamentary instruments on German
prostitution policy and same-sex partnership rights
(2005–2009) (Source PoliMoral) 168
Fig. 6.5 Position of German political parties on prostitution policy
in the 16th LP (Source Author’s compilation on the basis
of newspaper analyses. Coding of 25 newspaper articles and
40 actor-object relations. Continuous black line = intra-
party conflict, Dotted line = inter-party conflict. Data
PoliMoral) 171
Fig. 6.6 Parliamentary attention on same-sex partnership rights in
Spain (Source PoliMoral) 176
Fig. 6.7 Position of Spanish political parties on same-sex partnership
rights in the 8th LP (Source Author’s compilation on the
basis of newspaper analyses of 47 newspaper articles and 82
actor-object relations. Continuous line = level of intra-party
conflict) 179
Fig. 7.1 Evolution and extent of change in same-sex partnerships
across countries (1994–2015) (Source PoliMoral. Note
Exclusively regulatory changes adopted at the national level
are considered. Regulatory permissiveness: 0 = non-
recognition, 1.0–1.9 = registration model, 2.0–3.0 = same-
sex marriage. AT = Austria, DE = Germany, NL = The
Netherlands, ES = Spain. Ssm = same-sex partnership rights) 192
xx    List of Figures

Fig. 7.2 Evolution and extent of change in prostitution policy

in the religious world (1994–2015) (Source PoliMoral.
Note Exclusively regulatory changes adopted at the national
level are considered. Regulatory permissiveness:
0 = prohibition, 1.0–1.9 = abolitionist regime, 2.0–2.9 =
permission without recognition, 3.0–4.0 Permission
with recognition. AT = Austria, DE = Germany, NL = The
Netherlands, ES = Spain. Pros = prostitution policy) 192
Fig. 7.3 Parliamentary attention and extent of morality policy
change (1994–2014) (Data PoliMoral. N (initiatives) =
1370. N (reforms) = 12) 194
Fig. 7.4 Bivariate regression analysis of parliamentary attention and
policy change (1994–2014) (Data PoliMoral. N = 1370.
Extent of policy change: y = 1 means no change, y > 1 means
minor or major change) 197
Fig. 8.1 Extent of policy change (same-sex partnerships, 17th LP)
(Source Author’s compilation on the basis of the dataset
PoliMoral) 209
Fig. 8.2 Policy positions on same-sex partnership rights in Germany
(1994–2014) (Source Author’s calculation. Data PoliMoral) 210
Fig. 8.3 Extent of policy change (prostitution, 9th LP) (Source
Author’s compilation. Data PoliMoral) 218
Fig. 8.4 Policy positions on prostitution policy in Spain
(1994–2014) (Source Author’s calculation. Data
PoliMoral) 219
Fig. 9.1 Dynamics of wedge-issue competition on morality policies
(Note Author’s own compilation) 238
Fig. 9.2 The dynamic relationship between parliamentary issue
attention and morality policy change (Source Author’s own
compilation. (−) = negative effect; (+) = positive effect) 240
Fig. A.1 Relative actor salience across national newspapers
(Germany) (Source Author’s compilation on the basis of
coded newspaper articles. FAZ = Frankfurter Allgemeine
Zeitung; SZ = Süddeutsche Zeitung) 280
Fig. A.2 Average issue position of actor groups across national
newspapers (Germany) (Source Author’s compilation on
the basis of coded newspaper articles. FAZ = Frankfurter
Allgemeine Zeitung; SZ = Süddeutsche Zeitung. Gov. =
Government; Opp. = Opposition) 281
 List of Figures    xxi

Fig. A.3 Average issue position of actor groups across national

newspapers (Spain) (Source Author’s compilation on the
basis of coded newspaper articles. PROS = prostitution;
SSM = same-sex partnerships; EM = El Mundo; EP =
El País) 283
 List of Tables

Table 4.1 Government composition across countries and time

(1994–2014) 89
Table 4.2 Relevant independent variables when comparing
the four countries 90
Table 4.3 Dataset for issue attention in parliament 93
Table 4.4 Measurement of policy change in the field
of same-sex partnerships 94
Table 4.5 Measurement of policy change in the field
of prostitution policy 95
Table 4.6 Overview of indicators for measuring party positions 104
Table 4.7 Summary of the dataset of coalition considerations
and intra-party conflict 105
Table 4.8 Summary statistics of the main variables 110
Table 5.1 Correlation analysis of intra-party conflict
and opposition’s engagement 139
Table 5.2 Correlation analysis of intra-party conflict
and engagement of secular opposition 143
Table 5.3 Correlation analysis of intra-party conflict
and engagement of small religious opposition 145
Table 5.4 Correlation analysis of opposition’s engagement
and coalition type 147
Table 5.5 Correlation analysis of the type of opposition party
and the coalition type (mixed vs. not mixed) 149
Table 7.1 Correlation analysis of parliamentary attention
and extent of morality policy change 196
Table 7.2 Correlation matrix key variables 198

xxiii
xxiv    List of Tables

Table 7.3 Impact of parliamentary attention on the extent

of morality policy change 200
Table 7.4 Impact of parliamentary attention on the evolution
of morality policy change 201
Table 9.1 Support of the theoretical framework and its expectations 242
Table A.1 Overview of keywords indicating parliamentary attention 265
Table A.2 Overview of keywords used in the newspaper analysis 266
Table A.3 Codebook parliamentary attention 267
Table A.4 Codebook media analysis 270
Table A.5 Results of the pre-test for German newspapers 280
Table A.6 Results of the pre-test for Spanish newspapers 282
Table A.7 Guidelines transcription 284
Table A.8 Correlation analysis of intra-party conflict
and engagement of small secular opposition 285
 CHAPTER 1

Introduction

Morality policies have attracted increasing societal and political attention

over recent decades in Europe. Even in times of serious economic
­pressure and societal secularization, policies characterized by strong con-
flicts in religious values have remained prominent. One well-publicized
example was the debate over adoption rights for same-sex couples in
France and Germany. Other cases include the decriminalization of abor-
tion in Spain and the referendum on same-sex marriage and abortion in
Ireland. These legislative projects have sparked far-reaching political and
societal controversies; more than ten thousand people participated in
demonstrations in Paris and Dublin (New York Times 26.05.2013; The
Guardian 21.02.2014; NewsHub 11.03.2018).
These value-loaded issues have provoked heated debates and painful
dilemmas not only in the societal arena but also within national govern-
ments, where a variety of strategies are deployed to overcome the delica-
cies of such complex and deeply felt topics. In Spain, Minister of Justice
Alberto Ruiz-Gallardón publicly defended the new proposal of the con-
servative cabinet that restricted abortion on demand to cases of rape,
fetal abnormality, and risk to the mother’s health (El País 20.12.2013).
President Mariano Rajoy later asked his cabinet members to avoid pub-
lic debates on the issue and suggested that discussions of new economic
data represented much safer talking points (El País 05.01.2014). In the
end, the government abstained from any reform plans.

© The Author(s) 2019 1

E.-M. Euchner, Morality Politics in a Secular Age,
Comparative Studies of Political Agendas,
https://doi.org/10.1007/978-3-030-10537-2_1
2 E.-M. EUCHNER

In Germany, the discussion on adoption rights for same-sex c­ouples

jeopardized the government coalition between the Liberals and the
Christian Democrats at the end of 2012 (Die Welt 06.06.2013), as
well as the coalition formation between the Social Democrats and the
Christian Democrats after the national election in September 2013. The
negotiations were interrupted on 12 November 2013 following serious
disagreements over adoption rights for same-sex couples. The vice chair-
man of the Social Democrats, Manuela Schwesig, explained that under
the circumstances, she could not recommend signing the coalition agree-
ment (Handelsblatt 12.11.2013).
These events exemplify the fact that in Europe, morality policies regu-
larly find their way onto political agendas and cause significant value con-
flicts. This phenomenon is puzzling for several reasons. First, one would
have expected that other societal problems—economic crises and refugee
flows, for example—would have been the priority issues, consuming most
of the scarce time available to politicians. Second, strong trends of secu-
larization should have reduced the polarization on issues that are closely
related to religious norms and values.1 A shrinking number of citizens in
Europe attend religious services or consider the church to be the moral
authority, particularly in questions of same-sex marriage and sexual con-
duct (Norris and Inglehart 2012). And this trend is visible not only in
Northern Europe but in many Western and Southern European countries
as well. One would therefore expect that fewer people would base their
opposition to liberal regulations of morality issues on their religious norms
and that overall, there would be much less societal mobilization and par-
liamentary politicization in response to these issues. However, the contrary
is the case—explosive and highly value-loaded debates on morality issues
are the norm rather than the exception, not only in Spain, France, and
Germany, but also in some countries of Eastern Europe (e.g., Poland).
Two groups of scholars have taken up this puzzling phenomenon and
offer first answers. The first group of researcher stems from the broad
and interdisciplinary field of religion and politics (e.g., Casanova 1994;
Fox 2015; Habermas 2008; Haynes 2010; Joppke 2015; Liedhegener
and Pickel 2016; Norris and Inglehart 2012; Davie 2006). In gen-
eral, these scholars conclude that the primary argument of seculariza-
tion theory must be revised. Religion, they argue, has not disappeared.
Rather, it remains a “potent and vibrant political social force in the
world” (Fox 2015, 17), especially in less developed countries and in the
 1 INTRODUCTION 3

USA (Norris and Inglehart 2012; Wald and Calhoun-Brown 2014).

Some of the authors specify that although religion has lost its relevance
in society, it has become more important in politics (e.g., Foret 2015;
Fox 2015; Liedhegener and Pickel 2016; Habermas 2008; Stoeckl
2011). Fox (2015), for instance, revises the secularization theory and
proposes a new perspective: secular-religious competition. Instead of
focusing on processes of secularization such as decreasing religiosity and
loosening state–church relationships, Fox (2015, 32) suggests that we
analyze “political secularism,” which he describes as “a family of political
ideologies that advocates that governments must at the very least remain
neutral on the issue of religion.”
These political ideologies compete with religion to influence gov-
ernment policy. Foret (2015) explores the role of religion in European
institutions (e.g., the European Parliament, the European Commission,
and the European Court of Justice). His findings speak to Fox’s perspec-
tive but also illustrate the limited impact of religion today. Foret (2015)
argues that religion is a “symbolic resource” for the political elite in
Europe, no longer able to structure a collective identity and hence to
build a foundation for the development of the European polity. Religion
helps deepen divides between nationalists and other political families,
but it does not create a fundamental political cleavage in European insti-
tutions. Therefore, Foret considers the spreading of culture wars—as
we find in the USA—an unlikely phenomenon for European countries
(ibid., 10). Nevertheless, Foret (2015, 4, 10) confesses that religion is
still a kind of “scandalizing factor” that is able to attract political atten-
tion, particularly with regard to morality policies. Emphasizing religious
values is useful for symbolic posturing and sending reassuring mes-
sages. Davie (1993, 2006, 2007) provides an alternative explanation by
defending a less pessimistic view on the role of religion in Europe today.
Specifically, based on the concepts of “vicarious religion” and “believ-
ing without belonging,” she argues that religious standpoints are openly
articulated by a minority of citizens who are silently supported by a
much larger group of people as one might expect.
Overall, the new perspective on political secularism and its related
findings offer a first conceptual foundation from which to understand
why policy debates on issues related to religious values (i.e., morality
policies) still attract so much societal and political attention in a secular
age. It takes only a few religious agents to stimulate conflicts with actors
4 E.-M. EUCHNER

defending secular ideologies for state policies and to attract significant

political and societal attention.
The second literature stream encompasses researchers from the
field of morality policy analysis. The research on morality policies orig-
inally emerged in the USA (e.g., Meier 1994; Mooney 2001; Leege
et al. 2002; Smith and Tatalovich 2003; Tatalovich and Daynes 2011;
Schwartz and Tatalovich 2018) and found only recently more attention
in Europe (e.g., Engeli et al. 2012, 2013; Hennig 2012; Knill 2013;
Knill et al. 2015; Ozzano and Giorgi 2016; Euchner et al. 2013; Schmitt
et al. 2013; van Kersbergen and Lindberg 2015; Studlar et al. 2013).2 In
the USA, the debate is known by the term “culture wars,” defined as the
deep divide between progressives and conservatives fighting about the
“right” way to live (Leege et al. 2002, 13; Smith and Tatalovich 2003).
In Europe, this term is rarely used; most scholars speak instead of a bat-
tle between religious and secular actors, and research in Europe focuses
either on agenda-setting processes (e.g., Engeli et al. 2012; Euchner
and Preidel 2016) or on morality policy change (e.g., Knill et al. 2015;
Studlar et al. 2013). The work of Engeli et al. (2013) is one of the few
exceptions that links political attention with policy outputs. The authors
argue that the permissiveness of morality policies in Europe depends on
the way such issues are processed in politics. In countries with a strong
cleavage between religious and secular parties (the so-called religious
world), morality policies are governed by macro-politics and are likely to
be changed substantially in the case of governmental change. In coun-
tries without such a religious-cleavage structure (the so-called secular
world) by contrast, instead of macro-party conflict structuring morality
policy processes, there are specific dynamics for each issue.
Religion is a much more popular factor than issue attention for
explaining morality policy change (e.g., Budde et al. 2017; Fink 2008,
2009; Grzymala-Busse 2015, 2016; Hennig 2012; Budde et al. 2017;
Minkenberg 2002, 2003; Knill and Preidel 2014; Knill et al. 2014,
2018; Schmitt et al. 2013; Hildebrandt et al. 2016). However, the
impact of religion on morality policy reforms is controversially discussed.
With regard to the explanation of morality policy attention, the picture
looks different. Engeli et al. (2012) discover that religion influences the
extent of the political attention that morality policies attract. The authors
illustrate that morality policies are likely to be politicized in countries
with a strong religious-secular party cleavage (the religious world),
where secular political parties may challenge their religious opponents
 1 INTRODUCTION 5

with morality issues because these value-loaded questions are difficult

to answer without frightening the increasingly secular voter base. In
European countries without such a religious-secular cleavage structure
(the secular world), the politicization of morality policies is less likely. As
a result, morality policy researchers consider religion a driving force of
politicization patterns in politics and society. However, not every country
in Europe has a favorable-actor constellation and institutional setup that
motivates competition dynamics around issues related to religious values.
In consequence, both streams of literature—from the field of religion
and politics and the field of morality policy analysis—provide answers to
the empirical research puzzle already introduced. First, morality policies
still attract attention in Europe because secularization has not resulted
in a demise of religion in modern times. Instead, religion has remained
a potent force in society and politics. A minority of European citizens
are still religious, and there are several religious communities that have
preserved their privileged status. More importantly, some countries have
a secular-religious competition structure in party systems (the so-called
religious world in Europe), which motivates secular parties to politicize
morality policies and may result in very permissive policy outputs.
Two aspects of the puzzling phenomenon described above remain
unanswered. First, we must ask, How can we explain the variance in
political attention across time and among morality policy issues within the
religious world? Prostitution policy in Spain, for instance, attracted less
political attention than the question of same-sex partnership rights in the
early 2000s. This picture changed radically in the 9th legislative period
(2008–2011). Within those three years, Spanish deputies tabled over
one hundred initiatives on prostitution and human trafficking, a legis-
lative process that involved secular parties and religious-party MPs alike.
In the Netherlands, for instance, the issue of same-sex partnership rights
attracted intermediate levels of attention in the late 1990s during the
reform process, while ten years later, much higher levels of politicization,
caused also by the engagement of religious actors, were visible.
Second, we ask, Why does religion—particularly the secular-religious
conflict structure—fail to explain morality policy change? One would
expect that a similar extent of political attention in countries with a lively
religious-secular party cleavage would result in a comparable permissive
policy output as morality policies are processed according to a macro-
political logic (Engeli et al. 2013). However, we see that European
countries with similar party-political competition structures often
6 E.-M. EUCHNER

have very different reform dynamics and degrees of policy permissive-

ness (cf. Knill et al. 2015). In Spain, for instance, same-sex partnership
rights were debated extensively in parliament and were reformed com-
prehensively. In Germany and Austria, by contrast, although there have
been single peaks of political attention on same-sex partnership rights
in the last few years, none of these moments coincided with major pol-
icy change. On the contrary, morality policy reforms seem to have been
facilitated during more “silent” legislatures.
In sum, the excellent interdisciplinary literature on religion and pol-
itics and the cutting-edge scholarship on morality policies are inspiring,
since they sketch the broad lines of the interplay between secularization,
political attention, and morality policies. So, we have a theoretical funda-
ment of macro-level dynamics, but we miss a thoughtful theoretical elab-
oration integrating the meso- and micro-levels (i.e., behavior of political
parties and their members). The main purpose of the integration of the
macro-, meso-, and micro-levels is to explain the rise and fall of religion
in policy making more generally and the variation of political attention
across similar countries and similar policies, as well as the consequences
in terms of policy change. In detail, we miss an analytically more dif-
ferentiated perspective on the conflict behavior of religious and secular
parties, as well as among their individual members, as we observe large
empirical variance within countries of the religious world. Moreover, we
need a theoretical link explaining the interplay between political atten-
tion and policy change beyond the emphasized policy-process logic
(Engeli et al. 2013). Finally, in providing answers to the key questions
formulated above, this book will help explain a much broader phenom-
enon, namely the question of when religion rises and falls in visibility in
policy-making processes in a secular age.

1.1  Main Argument: Strategic Parties and Divided

Governments in a Secular Age
This book contributes to this research gap by introducing a new explan-
atory framework for understanding religion and morality politics in
Europe today. The primary argument is that the visibility of religion
in policy-making processes of secular societies is dependent on the
presumed competitive advantage that secular and religious political
parties expect when politicizing morality issues. This presumed com-
petitive advantage strongly depends on the power position of these
 1 INTRODUCTION 7

political parties (i.e. being in government or not) and the unity in policy
preferences toward morality issues within the government. This argu-
ment is based on the assumption that morality policies are closely asso-
ciated with religious doctrines and that political parties therefore can
easily emphasize religious values and norms when discussing these issues.
Moreover, political parties and MPs are considered office- and vote-
seeking actors for whom policy aims are important but rank second
behind political empowerment (Strom 1990). Thus, the book employs a
rather functional understanding of when morality policies are politicized
and reformed and of how religion still influences the political sphere in
Europe: Religion is more a strategic resource for political parties than a
fundamental normative doctrine shaping political parties’ policy-making
behavior in a systematic and coherent way (cf. Foret 2015).
To investigate this argument, the present project disentangles two
stages of the policy-making process: the initial agenda-setting stage and the
final decision-making stage. Hence, two dependent variables are explored:
the degree of morality policy attention in parliament and morality policy
change (see Fig. 1.1). Such a two-stage approach is necessary because the
pre-decision (agenda-setting) stage offers political parties and MPs room
for a wider range of behaviors (i.e., different parliamentary activities) than
is available to them in the decision-making (i.e., issue voting) stage; this
allows us to more systematically assess the parties’ and MPs’ strategic
behavior. In other words, the parliamentary instruments that are used by
political parties and MPs to politicize policies can better help us under-
stand when issues related to religious norms are considered strategically
attractive; and with this insight on morality policies, we can also better
understand the rise and fall of religion in politics more generally.
The first stage explores the incentive structure of secular and reli-
gious political parties to politicize morality issues. I argue that if minority
Parliaments of the
Religious World

Venue shifts + Morality

Logic of wedge Parliamentary Image changes
Policy
issue competition Issue Attention
Change

1 st stage 2 nd stage

Fig. 1.1 Two-stage model of morality politics in the religious world (Source
Author’s conceptualization)
8 E.-M. EUCHNER

parties are able to challenge more powerful opponents on morality

issues, they will politicize a topic in parliament in order to blame the
opponent and disrupt existing power structures by driving a wedge
between its members (Van de Wardt 2014; Van de Wardt et al. 2014). In
other words, opposition parties are expected to have a particularly strong
incentive to politicize morality issues when policy preferences within
the ruling party or between government partners deviate because then
they can easily weaken the government by blaming it for the i­nability to
formulate policy solution. This means that there are two key c­ onditions
that determine the incentive structure of political parties to politicize
these issues: the power position (i.e., whether in the opposition or in the
government) and the unity in policy preferences toward morality issues
within the government. Thus, the book proposes that both secular and
religious parties “use” morality issues in party competitive terms when
they are in opposition and therefore, we can observe an instrumen-
tal nature in appeals to morality issues even in the religious world in
Europe.3
The second stage of the analysis deals with the effect that parliamentary
attention to morality policies has on morality policy change. The book
argues that this effect is very complex as it varies over time and with the
institutional opportunity structure of a country. In detail, on the short
run, high parliamentary issue attention is negatively related to the extent
of morality policy reforms, because parliamentary attention is mainly
driven by opposition parties, and therefore reform proposals often lack
a parliamentary majority. Moreover in such instances, governments may
shift the issue into alternative institutional venues (e.g., expert arena),
which further delays policy reforms. On the long run, however, high par-
liamentary attention indirectly fosters morality policy change by stimulat-
ing changes in responsible institutional venues (Baumgartner and Jones
1991, 1993).4

1.2  Theoretical and Empirical Contribution

The book contributes to two different literature streams. First, the argu-
ment substantially advances the state of the art in morality policy research,
because such research lacks a sound theoretical foundation explaining
why secular parties sometimes politicize and at other times ignore moral-
ity issues in the religious world, why religious parties become active,
and how political attention interacts with policy reforms. In particular,
Another random document with
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growth is concerned, however, it must not be forgotten that curious
and unexpected conditions sometimes occur. Thus, in one case
(Case 16) a myxoma at the level of the sixth and seventh cervical
vertebræ caused constriction sense about the legs and abdomen,
and in another (Case 44), a glioma of the filum terminale,
constriction of the chest.

The paralytic phenomena of spinal tumors have certain peculiarities

which are not exhibited by any other spinal or by cerebral affections.
A glance at the clinical history of a number of cases shows that
many of them began with paresis of a single limb or part of a limb, in
addition to the irritative phenomena. This paresis deepens after a
time into complete paralysis, or before this occurs one or more of the
other extremities become paretic. The progress toward bilateral
paralysis may be comparatively rapid. The appearance and progress
of the paresis or paralysis vary somewhat according to the level of
the cord at which the tumor is located. In tumors of the cervical cord
the paresis usually, but by no means invariably, first attacks the
upper extremity. The fact that the arms are first the seat of irritative
phenomena and paresis is in a case of spinal tumor indicative of a
cervical location or a location in the upper dorsal region; but, on the
other hand, not a few cases are recorded in which in tumors in these
locations the loss of power first exhibited itself in one or both of the
lower extremities. These cases are to be explained by the manner in
which the descending motor tracts are affected directly or by
pressure. In mid-dorsal tumors and those below this level the paresis
shows itself first in the legs, and generally becomes before long a
complete paraplegia.

To Brown-Séquard, more than to any other observer, we owe our

accurate practical knowledge of unilateral lesions of the spinal cord,
both in the cervical and other regions. When the lesion is localized in
one lateral half of the cord and is situated in the cervical region, we
have the affection known as spinal hemiplegia. The main symptoms
of this affection are motor paralysis of the arm and leg on the side of
the lesion and anæsthesia of the opposite limbs. Sensory fibres
decussate in the cord soon after entering it, while the motor tracts
cross at the anterior pyramids of the medulla oblongata; in which
physiological facts we have a simple explanation of the peculiar
motor and sensory phenomena presented by such a case. When the
lesion is below the cervical portion of the cord, instead of spinal
hemiplegia we have the affection known as spinal hemiparaplegia, in
which the paralysis and hyperæsthesia in one lower extremity stand
out in strong contrast to the anæsthesia and retained muscular
power in the other. With a lesion so strictly localized as a spinal
tumor it might be expected that these crossed phenomena would
present themselves in some cases. They are recorded, more or less
distinctly, in Cases 4, 16, and 38, and it is probable that they would
have been more frequently observed if they had been anticipated
and looked for carefully.

Ataxia does not seem to have been a frequent symptom in reported

cases. It has probably been sometimes overlooked or confounded
with paresis. In a case of myxoma of the dura mater in the left dorsal
region ataxia of both leg and arms was present; but in this case,
however, the dura mater of the brain contained fluid and lymph. In
the light of the commonly accepted views as to the physiology of the
spinal cord regarding the posterior columns, as related in function
both to co-ordination and sensation, ataxic manifestations might be
frequently expected. Owing, however, to the narrowness of the
spinal canal, compression of the entire cord takes place so early as
to make paretic symptoms displace those of ataxia.

Atrophy which varies in distribution according to the extent of the

destructive involvement of the cord is frequently present. In a few
instances the atrophy will be of certain muscles or muscular groups.
When true atrophy is present the anterior horn will be involved
directly or indirectly, and accompanying changes in the electrical
reactions will also be found.

The electrical condition of the atrophy of the paralyzed parts will vary
with the extent of the trouble produced by the tumor. In a case of
tumor of the cervical enlargement, for instance, producing more or
less paralysis both of the upper and lower extremities, reactions of
degeneration will be present only in the muscles supplied by the
nerves which spring directly from the seat of lesion.

Spontaneous twitchings or spasms due to irritation of motor-centres

or tracts are comparatively frequent. More or less permanent
contracture in a limb or part is of frequent occurrence, particularly
after the growth has advanced. Forms of torticollis or retraction of the
head, strong flexures of the arms or legs, and, late in the history of
many cases, complete and extremely painful drawing up of the limbs
upon the body, may occur. Persistent subsultus was observed in one
case, a glio-myxoma involving the gray columns from the medulla
oblongata to the cauda equina. Fibrillary twitching is rare, and in our
tabulated cases was observed only in one instance, a glioma of the
filum terminale. General convulsions with unconsciousness are
exceedingly uncommon. In one case, however, a round-celled
sarcoma at the level of the seventh, eighth, ninth, and tenth cervical
vertebræ, the patient is recorded as having died in a fit. Nystagmus
was observed once, but probably had no significance so far as the
spinal affection was concerned, as the cerebral dura mater exhibited
evidences of inflammation.

The condition of the reflexes, both cutaneous and tendinous, is often

peculiar and almost diagnostic, but varies greatly according to the
position and extent of the lesion. Increase of reflex action is
sometimes a marked symptom. The slightest irritation of the soles of
the feet, the calves of the legs, palms of the hands, or other special
regions will often produce decided contractions, and sometimes that
symptom which has been designated by Brown-Séquard as spinal
epilepsy, in which both lower extremities are thrown into violent
clonic spasms, which may last for many seconds or even minutes. In
tumors of the dorsal region causing marked compression and
preventing cerebral inhibition, clonus and knee-jerk are also
markedly exaggerated. The so-called diplegic contractions—that is,
contractions in one extremity from irritation of the other—are
observed, especially when a transverse area of the cord, large or
small, is involved in an irritative or inflammatory process. They
probably result from the abnormal facility of transmitting impressions
which has been acquired by the cord. When the cervical or the
lumbar enlargement of the cord is completely compressed or
destroyed by a tumor, reflex activity is diminished or abolished in the
region supplied by nerves originating at the seat of lesion.

Alterations in the body-temperatures have been frequently noted in

lesions of the spinal cord, such as fractures of the vertebræ and
inflammatory changes in the cord and its membranes. Some of the
observations are almost incredible, as that of J. W. Teale,4 who
records an axillary temperature of 122° F. The subject has been
somewhat obscured by physiological speculations. Thus, it has been
asserted that paralysis of motor centres and strands causes an
increase of temperature, while paralysis of sensory tracts produces a
diminution. The accepted clinical facts apparently are as follows:
after crushing the cervical cord a uniform rise in temperature occurs
if peripheral cooling is prevented. This rise is caused by a paralysis
of the vaso-motor nerves, which permits a paralysis of the vessels
and floods the parts with blood. This assumes, of course, that mere
increase of blood in a part means increase of heat. After a variable
period this increase is followed by a decrease which is permanent.
Hutchinson records5 a case of fracture of the cervical spine at the
fifth vertebra in which the patient's body felt almost as cold as a
corpse and the rectal temperature was only 95° F. In Cases 4 and 16
the affected parts are recorded as cold, just as in atrophic and other
lesions of the cord. The tabulated cases do not show many exact
thermometric observations, but in Case 8 the average temperature
for two weeks before death is given as slightly below normal, while
Case 7 shows a sudden rise on the day preceding death. It is
probable that the permanent decrease following crushing and
compressing lesions would also be found in cases of spinal tumors.
The following exact observations, made by one of us6 upon a case of
injury to the cervical cord, are directly illustrative of this subject. The
case was of several months' standing. The patient could walk
imperfectly, and the right arm was more paretic than the left. The
observations were made at 10 o'clock A.M. on six successive days:

Right Axilla. Left Axilla.

 First observation 98.2° 97.3°
Second observation 99.8° 98.2°
Third observation 96.4° 96.2°
Fourth observation 95.6° 96.4°
Fifth observation 97.2° 96.8°
Sixth observation 95.2° 93.8°

It will be seen that the temperatures range higher in this series on

the more paretic side; but this did not hold in a series taken a few
weeks later. The fact is to be noted that all these temperatures, with
one exception, are below the normal.
4 Lancet, March 6, 1875.

5 Ibid., August, 1875.

6 Hospital Gazette, Nov. 7, 1879.

Cystitis, pyelitis, and pyelo-nephritis are usually secondary

symptoms, due to retention of urine, distension of the bladder, etc. in
consequence of paralysis of this viscus. Bed-sores result in two
ways: in the first place, they may be due to emaciation and
immobility and the uncleanliness which it is almost impossible to
prevent; or, in the second, trophic eschars may arise because of the
involvement of nutritive regions of the cord. The so-called sacro-
ischiatic eschars are of this character. Febrile phenomena, such as
chills, increased temperature, increased respiratory action, are
frequently secondary phenomena due to bed-sores, cystitis,
continued pain, exhaustion, or septic infection.

Priapism was recorded in two of the fifty cases, both tumors of the
cervical cord. Impotence was only recorded once, a dorsal myxoma.
It is probable that both priapism and impotence, particularly the
latter, were present, but overlooked in other reports.

Headache was present in three of fifty cases. One of these was a

fibro-sarcoma at the level of the fourth cervical nerve; the other two
were low down in the spinal axis, one in the lumbar enlargement,
and the third, strange to say, in the filum terminale. Vertigo is a rare
symptom in the spinal tumors. In one case in which the growth was
located at the position of the third cervical vertebra its presence was
recorded.

Out of five cases in which vomiting was present, two were in the
cervical regions, one in the dorsal, one in the lumbar, one in the filum
terminale.

Tumors involving the upper cervical and bulbar region of course will
give rise to special symptoms indicating more or less involvement of
cranial nerves.

Unfortunately, very few ophthalmoscopic observations have been

made in cases of spinal tumor. Optic neuritis has been found in a few
cervico-dorsal cases, and in other cases located in the same region
no ophthalmoscopic alterations have been discoverable.

Mental disturbances were only especially recorded in four of the fifty

cases. Such symptoms were certainly not of frequent occurrence,
except those emotional manifestations which were due to the great
suffering which the unfortunate patient was called upon to endure.
These emotional disturbances, as in all forms of painful disease,
varied according to the mental stamina of the patient. In one case
the mental symptoms, in association with other phenomena and a
probability of dog-bite, led to the suspicion of hydrophobia.

In one case (31) an interesting observation was made of an anal

sphincter reflex, with frequent stools. The tumor in this case is
reported at the level of the tenth dorsal vertebra, which would be at
the level of the eleventh dorsal segment. The tumor was tubercular,
and therefore probably meningeal, so that the irritation to the anal
centre, which is in the lumbo-sacral segment, may have been
caused by extension of inflammation along the meninges.

PATHOLOGY.—We present in tabulated form the various kinds of

tumors as found in the fifty cases which have been collected:
 Aneurism 1 Myxoma 2
Cancer (?) 2 Neuroma 1
Carcinoma 1 Organized blood-clot 1
Cysticercus and hydatids 3 Osteoma 1
Cyst (Dermoid?) 1 Phlegmon 1
Fibroma 5 Psammoma 2
Glioma 5 Sarcoma 7
Gumma 5 Tubercle 4
Myo-lipoma 2 Unclassified 6

It will be observed that the predominance in this list is decidedly in

favor of the sarcomata and structures which are likely to be
associated with or to graduate into them, such as the gliomata,
myxomata, and the psammoma. In one instance the resemblance
(Case 15) to psammoma is referred to by the reporter. The
comparatively large number of unclassified, and the two cases
referred to vaguely as cancer, would probably, on more exact report,
have added several more to the group of the sarcomata. The table
shows that next in frequency come the fibromata and gummata,
while the carcinomata have but a single representative in the group.
Tubercular tumors occurred with comparative frequency, no less
than 8 per cent. being recorded. Although the exact origin of only
somewhat more than one-half (29) of all the tumors is given, it is
stated of this fraction that 17 sprang from the membranes, while of
the remainder 8 were located in the cord itself and 4 in the vertebræ.
Of the 3 oases of parasitic invasion, it is recorded of one (Case 43)
that a hydatid cyst was also found in the liver; and it is probable that
in any given case the spinal cord would not be the only part to suffer.
Cobbold's work refers to one case of hydatid of the spinal cord. Erb
refers to 13 cases, all but 2 external to the dura mater. In Case 43 of
the table pains in the back and hip, simulating rheumatism, were
present early.

The dimensions of the spinal tumors of whatever character are never

very great, for the reason that they have but little space in which to
enlarge, and that their presence soon causes such grave changes
as to be incompatible with life. They rarely exceed an inch in their
longest diameter, and not unfrequently are smaller than this. There is
usually about them a more or less marked meningitis and an area of
vascular fulness. Œdema of the membranes is sometimes noted.
The substance of the cord beneath is compressed, atrophied, or
softened, and this softening sometimes extends for a considerable
distance both above and below the neoplasm. These changes were
reported in Case 8, in which there was the addition of an abscess.
Secondary degenerations would probably be found in all cases,
unless very recent; and these changes, following the Wallerian law,
would ascend the posterior and descend the lateral columns. Such
degenerations are reported in some of the cases. The spinal nerves
are sometimes compressed and atrophied. Old or recent
hemorrhages are found, as in Case 18. Among the changes which
occur, probably at a late stage, are the formation of cysts, either
large or small, either in the substance of the cord or consisting
simply of a dilatation of the central canal of the cord. This condition is
known as syringo-myelia, and is of exclusive pathological interest. In
Case 1 is recorded, apparently, a well-marked dilatation of the
central canal (hydromyelus), and cyst-formation is recorded with
gliomata, sarcomata, and gummata in other cases. Caries of the
vertebræ is recorded in a number of cases, and occurred both in
cases of gumma (Case 8) and carcinoma (Case 14). These cases
were, however, exceptions to the general rule that the bony envelope
of the cord does not furnish external evidence of the location of the
tumor. It is worthy of note that the one instance of phlegmon or
inflammatory exudate (Case 20) also presented infiltration of the
tissues of the throat and mediastinal space. A case of organized
blood-clot (Case 39) has been included in the list, although, properly,
a spinal hemorrhage, because it became and acted as a tumor. The
location of the single case of aneurism (Case 48) is not given. The
symptoms were those of tumor in the dorsal spine.

As sequelæ of tumors of the cord may be mentioned especially bed-

sores, which sometimes commit frightful ravages, as in a case (37)
in which the spinal canal was laid open. The bronzing of the skin and
diseased condition of the suprarenal capsules, as recorded in Case
41, were mere coincidences, and not probably at all connected in
pathological sequence with the spinal lesion. Cystitis, pyelitis, and
pyonephritis are not uncommon in cases of tumor of the cord, just as
they are observed in other compressing and destructive lesions of
that organ. In those cases in which the tumor is the result of a
general taint, as in gummy and tubercular growths, the evidence of
this taint is not usually wanting in other organs; thus in Case 37, of
tubercle of the cord, tubercles were also found in the lungs, bowels,
and uterus. In gummata of the cord it would not be likely to escape
careful inquiry that the patient's history or his body presented
evidence of the disease.

In a case (47) of congenital sacral neuroma amyilinicum the infant

was also hydrocephalic and had a bifid spine—conditions of faulty
development with which the patient cannot long survive.

In one case of psammoma (Case 5) a resemblance to endothelioma

is noted, while in another (Case 15), already referred to, a sarcoma
is said to have resembled a psammoma.

Vascular changes are usually notable. In addition to the congestion

already spoken of, it is recorded in one case (No. 14) that the right
vertebral artery was obliterated. This was a carcinoma which had
partly destroyed one vertebra.

Virchow's case (No. 50) of a stillborn child with a large tumor of the
size of the head of a child of two years, and containing bone, has
some analogies in three cases, referred to by that author, in which
both hair and bone were found.

In several cases a brown or yellow exudate (plastic lymph?) is

mentioned as extending along the cord far beyond the immediate
neighborhood of the tumor.

The histology of tumors of the whole cerebro-spinal axis will be

found described in the article on Tumors of the Brain.
DIAGNOSIS.—The diagnosis of tumors of the spinal cord presents
itself naturally under two heads—the differential, or general, and the
local diagnosis. The conclusions reached in this paper are based on
a careful study of the cases appended, two of which were personal
observations, and the remainder were collected from American,
English, French, and German literature. It cannot be denied that
much obscurity rests upon the diagnosis of tumors of the spinal cord,
and that the doubts expressed by Erb and other writers have much
to support them. It is hoped that the systematized study presented in
this table will do something to dispel this obscurity.

(1) General Diagnosis.—The differential diagnosis has regard first to

certain general phenomena which are broadly indicative of a spinal
disorder as distinct from a cerebral or peripheral one. Thus, mental
symptoms are absent, or if present are an accompaniment of tumors
high up in the spinal axis, are the results of suffering, or appear very
late in the disease because of progressive weakness. Briefly stated,
the phenomena which point with comparative certainty to the
existence of spinal tumors are symptoms of meningeal irritation
gradually increasing, and symptoms of slow compression of the
cord. These have been sketched at the beginning of
Symptomatology. As to duration, the data in the cases studied were
somewhat meagre. The usual duration is from six months to three
years.

The differential diagnosis of spinal tumors will be considered in

reference to the following affections: congestion, hemorrhage,
meningitis (simple and specific), caries, traumatisms, sclerosis,
aneurisms, neuritis, metallic and infectious disorders, and hysteria.
Spinal tumors, it will be recalled, are from constitutional or special
causes, as syphilis, cancer, and tuberculosis. The onset is gradual
and irregular. The duration is comparatively long. The progress is by
irregular advances toward a fatal termination. The symptoms are
inclined to be at first unilateral or local; later, bilateral. Special
symptoms, as paralysis, spasm, sensory and visceral disorders,
occur irregularly as to time. Decubitus and trophic changes are
common late in the history. Reactions of degeneration are often
present. Gowers refers to the fact that two morbid processes often
occur, one consecutive upon the other, as a secondary degeneration
or a hemorrhage, after the establishment of the morbid growth, with
characteristic increase of symptoms.

In spinal congestion a constitutional cause is not likely to be present.

The onset is usually sudden and after exposure. The duration is
shorter than in tumors, and is from a few days to four months. The
disease is stationary for a while; then retrogression of symptoms
toward recovery occurs. The symptoms are more uniformly bilateral,
and motor and other symptoms develop about the same time.
Decubitus is rare. Reactions of degeneration are rare (?). It is
desirable that cases of so-called spinal congestion should be
differentiated from the forms of peripheral neuritis above referred to,
the most characteristic symptom of which appears to be tenderness
of nerve-trunks.

In spinal hemorrhage there is no special history, or a history and

signs of cardiac and vascular degeneration may be present. The
onset is quite sudden and the progress of the case regular. The first
symptoms persist, and secondary degenerations follow, and differ
according to the extent and location of the lesion, but are most likely
to be uniformly bilateral.

In meningitis the symptoms of localized compression are absent.

The girdle symptom is absent. The affection is sometimes curable,
and especially so if it has been of syphilitic origin. The reactions of
degeneration are not marked.

In caries of the spinal vertebræ deformity is rarely absent, especially

if the case has continued a few months. Rigidity of the muscles of
the back is an important symptom, which, however, is occasionally
found with tumor. Jarring of the spinal column by tapping upon the
head or jumping from a chair or stool is more likely to elicit pain in
caries than in tumors. Strumous symptoms and evidence of
tubercles in the lungs or other organs are often present.
In traumatisms usually a history of the injury can be obtained. The
symptoms are those of caries, myelitis, meningitis, or of
combinations of these, according to the character of the case.

In sclerosis the symptoms are usually those of progressive systemic

affections, with absence of compression symptoms. The duration is
longer. The progress is gradual and more regular.

Aneurisms are only to be distinguished when extra-spinal, causing

erosion and compression.

In neuritis there is the soreness of the nerve-trunk already referred

to, while compression symptoms and visceral disorders are absent.
The motor and sensory symptoms are confined to the area of
distribution of the affected nerve. It is amenable to treatment. In
advanced stages the reactions of degeneration are marked. In the
form of general peripheral neuritis, the existence of which, as a
distinct disease, is being at present claimed, the characteristic
symptoms are as yet not sufficiently determined or the pathology
demonstrated by post-mortem research to admit of much discussion.

In metallic and infectious disorders a history of definite causation is

present. Metallic disorders may present special distinctive signs,
such as lead-line, wrist-drop, etc.

In hysteria a precedent characteristic history is usual. The onset is

often sudden and an emotional element is present. The symptoms
are bilateral and protean. Trophic changes are absent. No reactions
of degeneration are present.

(2) Local Diagnosis.—It may be said of spinal tumors in a modified

sense, as it can be said of brain tumors, that they are not good
pathological experiments for illustrating the functions of the exact
areas which they occupy. The spinal canal has such narrow limits,
the tumor itself soon attains such a relatively large size and causes
such wide vascular engorgement, and the different tracts and
systems of the cord are so closely packed together, that the tumor
does not often invade only one functional area and escape another.
Hence the regional diagnosis presents special and greater difficulties
than the diagnosis of the level of the cord at which the tumor
presents itself. A tumor which destroys the trophic centres for the
arm in the anterior cornua might exert sufficient backward pressure
to paralyze the motor tracts running to the leg; or a cervical tumor, as
in Case 5, might produce symptoms which are almost wholly
observed in the legs. It will be seen, however, by reference to the
table, that in Case 3, reported by Wilks, we have a tumor whose
exact anatomical seat could have been predicted, and which seems
to have reproduced almost the upper-arm paralysis of Remak. When
we compare these two cases, in which the pathological conditions
are so similar, it will be observed that the paralyzed arm is much
wasted, which indicates a lesion of its trophic centre, whereas the
affected legs in the other case are irritated by pressure and by
isolation, but are not wasted, because their trophic centres are far
below the point of lesion. The invasion of the trophic centres, and the
accompanying wasting of particular groups of muscles, especially
when this occurs early in the case, with the consequent reactions of
degeneration in these muscles, would furnish very valuable
indications both as to the region and the level of the cord involved
(Case 29). Unfortunately, the exact observations are wanting in most
of the cases as reported.

M. Allen Starr, in a recent paper,7 has devoted much labor to the

elucidation of the functions of different segments and regions of the
cord. He demonstrates the existence of groups of cells in the gray
matter, especially in the anterior horns, each of which he believes
constitutes a physiological unit. He affirms that these cell-groups
preside over certain associated movements or combinations of
certain muscles, and, quoting from Spitzka, says that “the nearer a
muscle is to the ventral aspect of an animal the nearer will its
nucleus be to the median line of the cord; and the nearer the muscle
is to the dorsal aspect of the animal the nearer will its nucleus be to
the lateral cornua of the cord. Flexor nuclei are therefore in internal,
extensor nuclei in external and posterior, cell-groups.” The only light
that such a theory throws upon the subject of diagnosis is by
affording a possible explanation of the fact that spastic flexion is
much more common than spastic extension, and may be due to the
fact that the cell-groups for flexion lie deeper and are more protected
than those for extension; and the additional fact above referred to,
that a paralysis of associated muscles or groups of muscles, with
degeneration, as in the types of Remak, would indicate with great
clearness the destruction of the cell-group which presides over them.
Starr, in his article, also tabulates the various reflexes and their seats
in the cord. As this subject is of much importance in any exact study
of spinal-cord diseases, we will state here some of the facts as given
in that article: The neck-pupil reflex (dilatation of the pupil on irritation
of the neck) has its seat from the fourth to the seventh cervical
segment; the elbow-tendon reflex in the fifth and sixth cervical; the
wrist tendons from the sixth to the eighth cervical; the palmar in the
seventh and eighth cervical; the epigastric and abdominal skin
reflexes in the fourth to the eleventh dorsal segments; the
cremasteric reflex in the first to the third lumbar; the patellar tendon
in the second to the fourth lumbar, and bladder and sexual centres in
same; the rectal centre in the fourth lumbar to the third sacral; the
foot-clonus and Achilles-tendon reflex in the first sacral. A
destructive lesion, such as a tumor, at any one of these points would
cause abolition of that particular reflex, and this would probably
occur early in the case. Our table of cases does not present any
such observation, whereas exaggerated reflexes, such as occur from
a compressing lesion above the seat of the excited centre, are
recorded in abundance. Many of these deductions are of course only
possible early in the history of the case, as at a late stage the
secondary degenerations have caused too widespread havoc to
admit of any exact localization. The distinction must also be sought
for between a destructive lesion and the symptoms of irritation which
it may project to distant parts. Fürstner's cases of syringo-myelia,8 in
which were marked vaso-motor changes, such as pallor, flushings,
copious sweat, and trophic disorders in the integument and its
appendages, seem to show that a lesion in the gray matter just
posterior and external to the central canal is necessary for such
phenomena. Similar vaso-motor changes may be observed in some
of the tabulated cases, as in No. 4, in which there were islands of
heat and cold in the leg, with a hydromyelia in the cord. Sensory
symptoms are very common in cases of spinal tumor, but they
furnish indications rather of the exact level of the lesion than of its
region.
7 “Localization of the Functions of Spinal Cord,” Am. Journ. Neur. and Psych., 2-3, p.
443.

8 Quoted by Starr.

FIG. 45. FIG. 46.

 Sarcoma compressing Cervical Cord,
Case 17 of Table (E. Long Fox).

Diagram of Spinal Column, Cord,

and Nerve-exits (after Gowers).

Before considering briefly the indications which point to the various

levels of the cord as a possible seat of spinal tumor, it will be
necessary also to make plain a few anatomical facts. It must be
borne in mind, first, that the nerve-origins in the cord are never at the
same level as their exits from the spinal canal, or, in other words,
that the spinal segments do not correspond with the bodies of the
same numerical vertebræ, and that there is, in fact, one more
cervical segment than there are cervical vertebræ. The tendency is
for the nerve-trunks to run downward before passing out of the
canal, so that in every instance, without exception, from the medulla
oblongata to the filum terminale the segments of the cord are above
the corresponding vertebral body. This discrepancy increases as we
descend the cord; whereas it is approximately correct to say of the
cervical and dorsal regions that every segment is opposite the
vertebral body which is numerically just above it, this difference
becomes much greater in the lumbar and sacral regions. The cord
itself terminates in the lumbar enlargement which ends opposite the
interval between the first and second lumbar vertebræ. All the
remainder of the canal is occupied by the descending trunks of the
lumbar, sacral, and coccygeal nerves as they pass to their respective
foramina, constituting the cauda equina. It must be recalled,
however, that the vertebral bodies, lying very deep, cannot serve as
guides, but that we are dependent upon the spinous processes as
landmarks in diagnosis. These again differ in their levels from their
respective vertebral bodies, as they are deflected at somewhat
different angles at different regions of the spine. Gowers has
illustrated these facts by a very graphic wood-cut9 (Fig. 45), from
which the general rule may be drawn that each vertebral spine is
about opposite the spinal segment which is numerically two places
below it; thus the eighth dorsal spine is opposite the tenth dorsal
segment, etc. The indications afforded by this exact anatomical
knowledge have reference largely to the existence of pain on
pressure and to any deformity of the bony structures. The cases as
reported do not indicate that this method of research has been
utilized, and it may possibly be of only theoretical importance; but it
has been considered worthy of reference as an indication in
diagnosis.
9 Diagnosis of Diseases of Spinal Cord, p. 6.

Sarcoma of Lower Cervical Cord, Case 13 of Table (Adamkiewicz).

It will be seen by reference to the table that usually certain general

features in the symptomatology indicate the seat of the lesion. Thus
in tumors of the cervical region pain and stiffness of the neck occur,
while the first appearances of paresis and sensory disturbances are
usually observed in the arms and about the chest. The centres for
the forearm and hand lie in the lower portion of the cervical
enlargement; that for the upper arm, including the supinator longus,
in the upper portion. Mental symptoms are more marked, and in
Case 4 several of the cranial nerves were implicated. In the lower
cervical and upper dorsal region there are symptoms of dyspnœa,
fixation of the chest (Nos. 20, 22, 24), and cough. The girdle
symptom is an important indication at any level, as it is due to
irritation of the nerves at the lowest level of healthy cord just above
the transverse lesion. It has already been discussed under
Symptomatology. In many of the dorsal cases (Nos. 32, 37, 38, 39,
and 45) the symptoms are almost entirely confined to the legs and
lower trunk, the arms escaping entirely. The condition of the bladder
is usually given in the table as one of paralysis; this does not indicate
whether automatic evacuation existed at the beginning of the case;
which condition would indicate that the centre for micturition was
below the lesion, and intact. It is probable that later in these cases
the bladder is actually paralyzed by destruction of its centre in the
cord, and this even when the tumor has been situated some distance
above.

FIG. 51. FIG. 52.

 Fibroma of Lower Dorsal Cord, Case
32 of Table (W. Cayley).

Tumor of Cauda Equina, Case 45

of Table (W. W. Fisher).

With reference to tumors of the cauda equina, Erb10 says that they
have in every respect a great resemblance to those which are
situated higher and affect the cord proper. “They are hard to
distinguish from the latter, but may be in many cases perhaps, if it is
borne in mind that tumors of the cauda produce exclusively nerve-
root symptoms, and that the signs of compression of the cord, of
secondary myelitis, etc. are absent. The higher the tumor, the nearer
it approaches the lumbar portion of the cord, the harder will it be to
draw the distinction. In respect to tumors seated lower the following
points may be attended to: the seat of the pains (which in such
cases often attain enormous violence) is strictly localized in certain
nerve-districts; all nerves leaving the spinal canal above the tumor
are free; thus in myxo-sarcoma telangiectodes of the cauda I
observed the pain strictly limited to the district of the sciatica, while
the crural and the dorsal nerves were perfectly free; constant violent
pain in the sacrum. If palsy occurs the reflex actions necessarily
cease at once. Spasms are seldom observed, more frequently
contractures. Atrophy of the muscles occurs rather frequently. The
palsy and anæsthesia by their localization often give us the
opportunity of fixing the upper limit of the lesion. Increase of the
reflex acts and marked tendinous reflexions do not occur.
Paraplegia, palsy of the bladder, bed-sores, etc. may develop exactly
as in tumors occupying a higher seat, but the symptoms of paralysis
do not seem to belong necessarily to the disease, as is shown in my
case (just mentioned), which terminated fatally before paralysis or
anæsthesia occurred.”
10 Op. cit.