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 OUP CORRECTED PROOF – FINAL, 11/6/2019, SPi

M O D E L S O F Q U A N T U M M AT T E R
OUP CORRECTED PROOF – FINAL, 11/6/2019, SPi
 OUP CORRECTED PROOF – FINAL, 11/6/2019, SPi

Models of Quantum Matter

A First Course on Integrability and the Bethe Ansatz

Hans-Peter Eckle
Humboldt Study Centre
Ulm University

1
OUP CORRECTED PROOF – FINAL, 11/6/2019, SPi

3
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries
© Hans-Peter Eckle 2019
The moral rights of the author have been asserted
First Edition published in 2019
Impression: 1
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a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
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address above
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and you must impose this same condition on any acquirer
Published in the United States of America by Oxford University Press
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British Library Cataloguing in Publication Data
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Library of Congress Control Number: 2019930263
ISBN 978–0–19–967883–9
DOI: 10.1093/oso/9780199678839.001.0001
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Links to third party websites are provided by Oxford in good faith and
for information only. Oxford disclaims any responsibility for the materials
contained in any third party website referenced in this work.
OUP CORRECTED PROOF – FINAL, 11/6/2019, SPi

Für Irene
OUP CORRECTED PROOF – FINAL, 11/6/2019, SPi
 OUP CORRECTED PROOF – FINAL, 11/6/2019, SPi

Preface

Why study Bethe ansatz? The Bethe ansatz provides one of the very few methodologies to
calculate the physical properties of models for strongly interacting quantum matter non–
perturbatively. Arguably it is the only such method we have which is exact. This means,
once we have set up the model, there are no approximations or further assumptions
necessary: we can exactly compute physically relevant properties of the model. There is,
furthermore, an infinite set of conserved quantities: the quantum mechanical model is
integrable.
This makes the search for quantum models which are amenable to an exact solution by
the Bethe ansatz methodology so important and rewarding. Even if—as is sometimes, but
certainly not always, the case—the model with an exact solution is not the most physically
relevant one, the exact solution will provide important benchmarks for other models that
may occasionally be closer to physical reality, but do not admit an exact solution. Hence,
for a plethora of cases, the Bethe ansatz solution provides valuable insight into the physics
of strongly interacting quantum matter.
Since Hans Bethe provided the eponymous method to solve the Heisenberg quantum
spin chain, many more models of low-dimensional quantum systems have been found to
be integrable by the Bethe ansatz.
Moreover, these models and their integrability have been and continue to play an influ-
ential role in many subfields of physics, which include classical and quantum statistical
mechanics, quantum field theory, and quantum many-particle and condensed matter
physics, the latter in recent times especially in connection with modern developments in
physics on the nanometre scale and in low dimensions. Quantum optics has also benefited
from studying integrable models, especially in investigations of ultracold Bosonic and
Fermionic quantum gases and Bose–Einstein condensates in artificial crystals of light,
the so-called optical lattices. Recently in string theory and cosmology there is a hype
of activity involving conjectures of Bethe ansatz integrability in the framework of the
celebrated anti-de-Sitter space/conformal field theory (AdS/CFT) correspondence.
Of course, Bethe ansatz and integrability are discussed in Mathematical Physics, but
there is also an ongoing cross-fertilization with various subfields of pure Mathematics.
Some prominent examples of integrable models include: various variants of the
Heisenberg quantum spin chain whose physical realizations are probed by neutron
scattering; the Hubbard model and its variants which inter alia have been discussed
in connection with high-temperature superconductivity; the Kondo model which has
recently seen a renaissance because of the development of tunable quantum dots;
interacting Bose and Fermi gases which can now be produced in very pure and tunable
form in optical lattices.
 OUP CORRECTED PROOF – FINAL, 11/6/2019, SPi

viii Preface

But, what is the Bethe ansatz? In its original form, devised by Bethe, it is an ingeniously
guessed form for the wave function of a one-dimensional quantum system. However,
why this wave function is correct and even exact remained an open question which has
only been answered much later through the algebraic form of the Bethe ansatz. This
method enables us to construct an integrable quantum model in one dimension from
a two-dimensional statistical mechanical model. The construction reveals the reason
for quantum integrability and delivers the infinite set of conserved quantities together
with the wave function which Bethe guessed. In our exposition of the Bethe ansatz
methodology, we shall therefore start, somewhat unhistorically, but more systematically,
with the algebraic Bethe ansatz.
Who is this book for? Interestingly, a look at Richard Feynman’s last blackboards (Paz,
1989) reveals that he may well have been interested. In one of his last publications (1988),
Feynman in fact wrote:

‘I got really fascinated by these (1 + 1)-dimensional models that are solved by the Bethe
ansatz and how mysteriously they jump out at you and work and you don’t know why. I
am trying to understand all this better.’ Cited after Batchelor (2007).

In view of the exciting developments in Bethe ansatz of the last two decades, Richard
Feynman’s fascination would certainly have continued.
The most helpful prerequisites for present readers are a good grounding in quantum
mechanics, statistical mechanics, and the basics of quantum many-particle theory,
especially second quantization. However, we shall comprehensively discuss the necessary
tools and background in part I of the book. Through this approach, the book should
be smoothly accessible for Master’s students who look for an area of specialization as
well as for beginning graduate students. Moreover, to paraphrase Paul Halmos (in the
preface of his book on Measure Theory (Halmos, 1978)), the novice to the Bethe ansatz
methodology should not be discouraged if she or he finds that she or he does not have the
prerequisites to read the preliminaries. After all, as Max Born reminds us, where would
quantum physics be if Werner Heisenberg had been discouraged that he did not know
what a matrix was when he developed the matrix form of quantum mechanics?
The book grew out of lecture notes the author prepared for an invited graduate lecture
series at the Indian Institute of Science in Bangalore in 1995, summer school courses
at the University of Jyväskylä in Central Finland in 1997 (on Bethe Ansatz Methods in
Many–Body Physics) and 1999 (on Conformal Invariance in Statistical Physics), a graduate
course at the same University which, together with an amiable group of students,
made the extremely cold Finnish winter of 1999 actually an enjoyable experience, and
postgraduate courses at the University of New South Wales in Sydney in 2000, and
within the Mathematics–Physics MP 2 Platform at Göteborg University in 2009, as well
as summer school lectures in Turkey: 2013 in Turunç, 2014 in Izmir and 2013 in Ireland
in Dungarven under the auspices of the School of Theoretical Physics of the Dublin
Institute for Advanced Studies.
 OUP CORRECTED PROOF – FINAL, 11/6/2019, SPi

Acknowledgements

The author’s working knowledge of the topics and methods on which this book focuses
was shaped through collaborations with several people who are gratefully acknowledged
in chronological order: Ferenc Woynarovich, Tuong Truong, Chris Hamer, Rudolf
Römer, Bill Sutherland, Alexander Punnoose, Henrik Johannesson, Charles Stafford,
Tim Byrnes, Robert Bursill, Anders Sandvik, and Johan Nilsson. Gratefully acknowl-
edging discussions with many others, especially my thesis advisor Dieter Schotte and
with Ingo Peschel and Karol Penson, I shall not attempt to mention all of them for fear
that someone’s name might escape my attention.
I learned coordinate Bethe ansatz from and during a fruitful collaboration with Ferenc
Woynarovich. We both were initiated to the algebraic Bethe ansatz by Tuong Truong.
I also often enjoyed stimulating discussions with Holger Frahm as well as mutual visits
with Fabian Essler, Andreas Klümper, and Andreas Schadschneider.
My deeply felt thanks go to Henrik Johannesson for his kind invitations to prepare and
deliver lectures in Göteborg and, very especially, for our long-standing collaboration and
friendship.
Great thanks are also due to Henrik again and Alexander Stolin for organizing
and co–lecturing the course on ‘Integrable Models and Quantum Groups’ within the
Mathematics–Physics MP 2 Platform at Göteborg University.
Jussi Timonen’s initiative is highly appreciated for suggesting and encouraging my
lectures in Jyväskylä.
Valuable discussions with Balazs Hetényi, especially in connection with the co-
organization of the summer schools in Turkey, and with Daniel Braak, are gratefully
acknowledged. Many thanks also go to Karsten Seifert who volunteered to undertake
the altruistic task of proof-reading parts of this book at various stages of its formation.
Many thanks are due to Natan Andrei, Nikolay Bogoliubov, and the late Anatoli
Izergin for their hospitality at Rutgers and in Sankt Petersburg, respectively, and the
sharing of their knowledge in stimulating personal discussions and in the written form
of lecture notes, and also to Vladimir Korepin for encouragement on many occasions.
Many thanks are also due to Peter Horsch, Joachim Stolze, and Johannes Voit, and
the late Heinz Barentzen and Hellmut Keiter for discussions and hospitality in Stuttgart,
Bayreuth, and Dortmund, respectively, and the sharing of pertinent sets of lecture notes.
The team at Oxford University Press cannot be praised highly enough, especially their
friendly patience and cheerful spirit, which appear to be inexhaustible. The incentive of
April Warman got this project under way and helped it along in its early infant steps.
Sönke Adlung supplied fresh guidance to help the project along whenever there seemed
to be an impasse. Ania Wronksi never tired of providing motivation and momentum for
the book project and, of course, all the necessary information.
OUP CORRECTED PROOF – FINAL, 11/6/2019, SPi
 OUP CORRECTED PROOF – FINAL, 11/6/2019, SPi

Contents

1 Introduction 1

Part 1 Methods and Models in the Theory of Quantum Matter

2 Quantum Many-Particle Systems and Second Quantization 5
2.1 Many-particle Hilbert spaces 8
2.2 Occupation number representation: Bosons and Fermions 19
2.3 Creation and annihilation operators for Bosons 21
2.4 Basis transformation 26
2.5 Quantum field operators 27
2.6 One-particle operators 29
2.7 Two-particle operators 33
2.8 Second quantization of the Schrödinger equation: Bosonic case 35
2.9 Creation and annihilation operators for Fermions 36
2.10 Second quantization of the Schrödinger equation: Fermionic case 40
2.11 Second quantization formalism and the many-particle wave function 41
2.12 Normal ordering 43
3 Angular Momentum 45
3.1 Angular momentum of a single quantum particle 45
3.2 Angular momentum of several quantum particles 56
4 Equilibrium Statistical Mechanics 63
4.1 Fundamental postulate of equilibrium statistical mechanics 64
4.2 Microcanonical ensemble 66
4.3 Entropy 67
4.4 Second law of thermodynamics 68
4.5 Temperature 69
4.6 Pressure and chemical potential 69
4.7 First law of thermodynamics 70
4.8 Canonical ensemble 70
4.9 Partition function 72
4.10 Grand canonical ensemble 75
4.11 Gibbs entropy 77
4.12 Density matrix 78
4.13 Non-interacting quantum gases 82
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xii Contents

4.14 Classical lattice models in statistical mechanics 93

4.15 Interacting magnetic moments: mean-field theory 97
4.16 Transfer matrix 106
4.17 Exact solution of the one-dimensional Ising model 108
5 Phase Transitions, Critical Phenomena, and Finite-Size Scaling 111
5.1 Phases, phase diagrams, and phase transition 113
5.2 Critical behaviour 116
5.3 Landau–Ginzburg theory 120
5.4 Scaling 126
5.5 Renormalization group 131
5.6 Finite-size scaling 147
5.7 Quantum phase transitions 154
6 Statistical Mechanics and Quantum Field Theory 177
6.1 Connection between statistical mechanics and quantum field theory 177
6.2 Thermal fluctuations and quantum fluctuations 181
7 Conformal Symmetry in Statistical Mechanics 188
7.1 From scale to conformal invariance 189
7.2 Conformal symmetry 194
7.3 Conformal transformations in dimensions larger than two 195
7.4 Conformal transformations in two dimensions 202
7.5 Order parameter fields and correlation functions 205
7.6 Energy-momentum tensor 209
7.7 Energy-momentum tensor in two dimensions 212
7.8 Conformal Ward identities 213
7.9 Energy-momentum tensor and the Virasoro algebra 218
7.10 Finite-size corrections revisited 234
8 Models of Strongly Interacting Quantum Matter 241
8.1 Bose fluid 242
8.2 Electronic correlations 255
8.3 Coulomb gas 269
8.4 Landau Fermi liquid theory 278
8.5 Luttinger liquid theory 289
8.6 Magnetism 313
8.7 Hubbard model 356
8.8 Heisenberg model 366
8.9 Magnetic quantum impurity models 372
8.10 Quantum Rabi model 395
 OUP CORRECTED PROOF – FINAL, 11/6/2019, SPi

Contents xiii

Part 2 Algebraic Bethe Ansatz

9 Ice Model 425
9.1 Physical motivation for the square lattice ice model 425
9.2 Definition of the ice model 428
10 General Square Lattice Vertex Models 430
10.1 Vertex models in two dimensions 432
10.2 Sixteen- and eight-vertex models 432
10.3 Vertex Boltzmann weights and the partition function 432
10.4 R-matrix: matrix of Boltzmann weights of a vertex 434
10.5 Integrability and the transfer matrix 438
10.6 Commuting transfer matrices 438
10.7 Monodromy matrix 440
10.8 Further to the L-operator 446
10.9 Yang–Baxter relations 447
10.10 More on Yang–Baxter relations 449
10.11 Exploiting Yang–Baxter integrability 451
11 Six-Vertex Model 454
11.1 Yang–Baxter relation for the six-vertex model 455
11.2 Parameterization of the six-vertex model 456
11.3 Algebraic Bethe ansatz solution of the six-vertex model 459
11.4 Quantum Hamiltonians from the transfer matrix 467
11.5 Inhomogeneous Yang–Baxter quantum integrable models 470
12 Quantum Tavis–Cummings Model 474
12.1 Algebraic Bethe ansatz revisited 474
12.2 Modified quantum Tavis–Cummings model 475
12.3 Transfer matrix of the modified quantum Tavis–Cummings model 476
12.4 Commutativity of the transfer matrix 479
12.5 Simple quantum Tavis–Cummings model 481
12.6 Bethe ansatz solution of the quantum Tavis–Cummings model 484

Part 3 Coordinate Bethe Ansatz

13 The Anisotropic Heisenberg Quantum Spin Chain 491
13.1 Description of the XXZ Heisenberg quantum spin chain 492
13.2 Special cases of the XXZ Heisenberg quantum spin chain 495
13.3 Basic properties of the XXZ Heisenberg quantum spin chain 498
14 Bethe Ansatz for the Anisotropic Heisenberg Quantum Spin Chain 502
14.1 Verification of the Bethe ansatz 503
14.2 Periodic boundary conditions 508
14.3 Parameterization of the quasi-momenta 511
 OUP CORRECTED PROOF – FINAL, 11/6/2019, SPi

xiv Contents

14.4 Ground state of the XXZ Heisenberg quantum spin chain 517
14.5 Excitations of the XXZ Heisenberg quantum spin chain 522
14.6 Excitations of the isotropic antiferromagnetic spin chain 537
15 Bose Gas in One Dimension: Lieb–Liniger Model 545
15.1 Classical non-linear Schrödinger equation 546
15.2 Quantum non-linear Schrödinger model 547
15.3 Lieb–Liniger model in the hard core limit: gas 549
15.4 δ-potential as boundary condition 552
15.5 Form of the Bethe eigenfunctions 553
15.6 Construction of the Bethe ansatz wave function 558
15.7 Unrestricted configuration space 562
15.8 Periodic boundary conditions: Bethe ansatz equations 565
15.9 Ground state of the δ-Bose gas in the thermodynamic limit 568
15.10 Excited states 573

Part 4 Electronic Systems: Nested Bethe Ansatz

16 Electronic Systems 585
16.1 Fermi gas in one dimension 586
16.2 One-dimensional Hubbard model 598
16.3 Kondo model 600
16.4 Algebraic Bethe ansatz for the spin eigenvalue problem 612
16.5 Magnetic impurities in nanostructures: Bethe ansatz results 625

Part 5 Thermodynamic Bethe Ansatz

17 Thermodynamics of the Repulsive Lieb–Liniger Model 633
17.1 Thermodynamic limit, particles, and holes 633
17.2 Bethe ansatz equations for particles and holes 634
17.3 Entropy and thermodynamic Bethe ansatz 636
18 Thermodynamics of the Isotropic Heisenberg Quantum Spin Chain 641
18.1 Summary of Bethe ansatz for the isotropic spin chain 641
18.2 Preparation of the thermodynamic Bethe ansatz: particles and holes 644
18.3 Thermodynamic Bethe ansatz equations 649
18.4 Thermodynamics 652
18.5 Thermodynamics for small T and h 653

Part 6 Bethe Ansatz for Finite Systems

19 Mathematical Tools 657
19.1 Euler–Maclaurin formula 657
19.2 Wiener–Hopf technique 661
 OUP CORRECTED PROOF – FINAL, 11/6/2019, SPi

Contents xv

20 Finite Heisenberg Quantum Spin Chain 667

20.1 Bethe ansatz for the finite Heisenberg quantum spin chain 668
20.2 Finite-size corrections 669
20.3 Application of the Euler–Maclaurin formula 673
20.4 Application of the Wiener–Hopf technique 675
20.5 Higher order finite-size corrections 685

References 687
Index 705
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 OUP CORRECTED PROOF – FINAL, 11/6/2019, SPi

1
Introduction

A journey of a thousand miles begins with a single step.

– Lao Tzu

This brief introductory chapter’s purpose is to direct you, the reader, quickly to those
places in the book where you can find general introductory information that may be
helpful for an overview of and the orientation within the book. It is deliberately kept
short to avoid redundancies.
The general motivation for the writing of the book and the main targeted readerships
as well as the levels of sophistication assumed and detail aimed at in the presentation
of the various parts of the book are outlined in the preface. There, we also attempt a
delineation of an assessment of the relevance of the book’s topics for current and potential
future research.
The list of contents, by its nature in the form of key words and key phrases, provides
a more comprehensive orientation of all the topics treated and their mutual dependence.
The book is divided into six major parts and, including this short introductory chapter,
into twenty chapters. Each part and each chapter begins with a description detailing
their respective subject matter. The part descriptions supply the bigger picture, while the
outlines at the beginnings of each chapter point more specifically to the topics treated.
Wherever this seemed to be helpful, we have attempted to supply further signposts about
what we have achieved and where we plan to go from there.
At various places, we also remark on the depth with which the topics are treated, what
may have been left out or will only be mentioned in passing, the relation to other parts
and chapters and the book’s intentions as a whole, and where to find alternative and
further specialized treatments of these topics.
In order to supply a rough overview, let us briefly summarize the major parts of the
book and their interrelationship.
Part I ranges from the fundamental concepts and tools required for an understanding
of strongly interacting quantum matter to the fundamental models that represent the
physical systems of strongly interacting quantum matter. In this book, we want to
investigate selected aspects of these models with a particular emphasis on the uses of
the exact methodology of the Bethe ansatz and of quantum integrability.
Part II is devoted to the quantum inverse scattering method and the algebraic Bethe
ansatz that demonstrate the quantum integrability of certain one-dimensional strongly
interacting quantum models and provide their exact solution. Our approach makes
decisive use of the intimate connection between these models and two-dimensional

Models of Quantum Matter: A First Course on Integrability and the Bethe Ansatz. Hans-Peter Eckle,
Oxford University Press (2019). © Hans-Peter Eckle. DOI: 10.1093/oso/9780199678839.001.0001
 OUP CORRECTED PROOF – FINAL, 11/6/2019, SPi

2 Introduction

models of classical statistical mechanics. The concrete models we shall be enlisting in

this part are the Heisenberg quantum spin chain as one-dimensional quantum model
and the six-vertex model as two-dimensional classical statistical model.
In part III, we introduce the coordinate Bethe ansatz, the original approach Bethe
used to solve the Heisenberg quantum spin chain. Since this approach does not allow
us to understand why the models are quantum integrable, we shall address it only after
we discuss the algebraic Bethe ansatz and the quantum inverse scattering method. The
coordinate Bethe ansatz approach is, however, still extremely useful. We demonstrate this
again for the Heisenberg quantum spin chain and also for a gas of Bosons interacting via
δ-function potentials in one dimension.
Part IV is concerned with strongly interacting quantum models where the fundamen-
tal constituents have internal degrees of freedom. Our examples, the one-dimensional gas
of Fermions interacting via δ-function potentials, the one-dimensional Hubbard model,
and the Kondo model of a magnetic impurity interacting with conduction electrons, are
all electronic models where there is only one internal degree of freedom in addition to the
particle degree of freedom, which is electronic spin. We shall find that these models can
be solved by two interconnected Bethe ansätze. The method is thus called nested Bethe
ansatz.
Thus far, the Bethe ansatz methods discussed were mainly investigating the low-lying
and therefore zero temperature properties of the quantum models. In part V we examine
how to extend the Bethe ansatz to finite temperatures. Again, our quantum models of
choice will be the Heisenberg quantum spin chain and also the Bose gas interacting via
δ-function potentials in one dimension.
In part VI, the final part of the book, we relinquish another assumption we made
or had to make in order to find solutions of the Bethe ansatz equations, equations which
generally hold for a finite system. So far, we usually considered the thermodynamic limit,
the limit of an infinite system size. This limit allowed us to rewrite the Bethe ansatz
equations as linear integral equations for certain densities whose solutions characterized
solutions of the Bethe ansatz equations, but only, of course, for the thermodynamic limit.
The Bethe ansatz for finite systems attempts to find corrections to the Bethe ansatz
solutions and physical quantities, e.g. the ground state energy of the thermodynamic limit
that takes into account the finiteness of a system. Again, we inquire into how this can be
achieved using the Heisenberg quantum spin chain as our exemplary model system.
The focus of this book is on selected concepts, methods, and mathematical techniques
in the area of strongly interacting quantum matter systems, especially the various
Bethe ansatz techniques discussed. We hope that these techniques will prove useful
in future research in the area of strongly interacting quantum matter. We also hope
that some physical insight will be gained from the models of quantum matter used as
examples to demonstrate the concepts and techniques and will provide guidance for the
understanding of other systems not treated here.
For the most part, we shall use natural units where the speed of light, Boltzmann’s,
and Planck’s constants are

c = k ≡ kB = h̄ = 1, (1.1)

except when including the constants explicitly will render the results more transparent.
 OUP CORRECTED PROOF – FINAL, 11/6/2019, SPi

Part 1
Methods and Models in the
Theory of Quantum Matter

Cannot we be content with experiment alone? No, that is impossible; that would be a
complete misunderstanding of the true character of science. The man of science must
work with method. Science is built up of facts, as a house is built of stones; but an
accumulation of facts is no more a science than a heap of stones is a house.
– Henri Poincaré (1854–1912)

This first part of the book presents an overview of the most important methods
indispensable for an understanding of the theory of strongly interacting quantum matter.
Moreover, we introduce a selection of quantum mechanical many-particle models and
the related concepts that form the background of the theory of quantum matter,
especially in view of the quantum integrable models, whose exact Bethe ansatz solutions
are discussed in later parts of the book. These methods and models are relevant also in
many other parts of theoretical and mathematical physics. It is therefore recommended
that readers review this material to judge how familiar they are with it.
These chapters, however, do not treat and do not attempt to treat their topics in a fully
comprehensive manner. There is always a lot more that could be covered. In fact, there
is a vast literature specifically devoted to these topics. Nevertheless, we attempt as clear
and comprehensible a treatment as possible of the aspects we cover with the intention to
render those aspects that we do cover self-contained. Where a self-contained treatment is
beyond the limitations of this book, we provide appropriate hints to the literature specially
devoted to these topics.
More specifically, in chapter 2, basic facts are reviewed from the quantum mechanics
of many-particle systems, in particular leading from the Hilbert spaces representing
quantum many-particle systems to a discussion of second quantization, which is the
language most useful to formulate the models of strongly interacting quantum matter.
Moreover, in chapter 3 we address the quantum mechanical theory of angular
momentum, especially for many quantum particles, which is indispensable for an
understanding of the magnetic properties of the models of strongly interacting quantum
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.