(eBook PDF) Transport Economics, 3rd

Edition
Go to download the full and correct content document:
https://ebooksecure.com/product/ebook-pdf-transport-economics-3rd-edition/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Rotary Kilns, Second Edition: Transport Phenomena and

Transport Processes Boateng - eBook PDF

https://ebooksecure.com/download/rotary-kilns-second-edition-
transport-phenomena-and-transport-processes-ebook-pdf/

Progress in Heterocyclic Chemistry Volume 29 1st

Edition - eBook PDF

https://ebooksecure.com/download/progress-in-heterocyclic-
chemistry-ebook-pdf/

(eBook PDF) Translational Medicine in CNS Drug

Development, Volume 29

http://ebooksecure.com/product/ebook-pdf-translational-medicine-
in-cns-drug-development-volume-29/

(eBook PDF) Business Economics 3rd Edition

http://ebooksecure.com/product/ebook-pdf-business-economics-3rd-
edition/
(eBook PDF) International Economics 3rd Edition

http://ebooksecure.com/product/ebook-pdf-international-
economics-3rd-edition/

Managerial Economics 3rd Edition Geetika - eBook PDF

https://ebooksecure.com/download/managerial-economics-ebook-
pdf-2/

(eBook PDF) Multimodal Transport Law by Michiel

Spanjaart

http://ebooksecure.com/product/ebook-pdf-multimodal-transport-
law-by-michiel-spanjaart/

Mass Transport in Magmatic Systems 1st edition - eBook

PDF

https://ebooksecure.com/download/mass-transport-in-magmatic-
systems-ebook-pdf/

(eBook PDF) Economics 3rd Edition By Dean Karlan

http://ebooksecure.com/product/ebook-pdf-economics-3rd-edition-
by-dean-karlan/
Transport Economics, 3rd Edition
viii TRANSPORT ECONOMICS, 3RD EDITION

12.4 Sequential travel demand forecasting 405

12.5 Disaggregate modeling 412
12.6 Interactive and stated preference modeling 415
Further reading 418

13 Transport and Development 419

13.1 Transport and economic development 419
13.2 Economic growth theory and transport 420
13.3 Transport infrastructure investment and economic productivity 426
13.4 The multiplier impacts of a transport investment 429
13.5 Transport economics in less developed countries 434
13.6 The transport policy of the European Union 441
13.7 Transport and regional and urban development 452
Further reading 459

14 The Economic Regulation of Transport 461

14.1 The broad issues 461
14.2 Theories of regulation 463
14.3 The regulation of monopoly power 469
14.4 Priorities in transport policy 473
14.5 Alternative paths for regulatory reform 483
14.6 Studying regulatory reform 488
14.7 Coordination via the market, or by direction? 493
Further reading 497

Index 499
Preface

Publishers are always pressing for new editions of books, and particularly text-
books. This is logical, after all they are commercial enterprises, and new editions
of a book make the old ones redundant and the used books, collectors’ items. The
more editions they publish, the larger the sales checks. Authors get paid royalties
and are often enthusiastic collaborators. In practice, however, one should never
rush into writing a new edition; there should be motivation besides money.
A new textbook becomes important when the old one becomes outdated.
In subject areas such as economics, much of the basic theory is well established,
although not always liked or accepted, by policy makers; perhaps this unpopu-
larity is not surprising, after all Thomas Carlyle did call economics ‘The dismal
science’ some two centuries ago. There are, however, movements forward in
our basic understanding of the economics, including that which is particularly
germane to transport matters. There are also developments in the techniques
available for estimating the effects of transport on society, and conversely on the
way social change impacts on transport. This, combined with a continual accu-
mulation of data over time, and the ability to mine previous studies to look at
time trend affects or, in exceptional cases, adds to our knowledge.
There are also continual shifts in the way that policy makers treat transport;
the political economy of the subject. Just consulting daily newspapers clearly
shows the importance of transport in public perception. Transport issues of all
kinds fill the column inches of these publications, as does the time spent on trans-
port and travel in television news programs and documentaries. This public inter-
est inevitably draws the attention of policy makers sensitive to the perceptions of
their constituents.
Since the last edition of the book, some 14 years ago, quite a lot has changed.
Our understanding of the factors influencing demand for transport services has
moved forward, and our approaches to modeling and estimating the ways in
which a variety of factors influence the use of transport has evolved. Challenges
that were pertinent in the early 1990s remain but many, such as global warming
emissions and concerns over terrorism, have grown in importance. International
transport is now more important, as globalization has grown, driven in part
by institutional changes, but also facilitated by developments in such things
as information technology. The role of logistics, which has a major economics
component, has grown as trade has expanded.
Of course, not all things have changed. The basic economic principles of
supply and demand remain as valid as ever; it is the context and focus that has
changed. Nevertheless, more up-to-date examples make their understanding
easier; context helps the assimilation of ideas. Equally the scale and details of
x TRANSPORT ECONOMICS, 3RD EDITION

the transport system have inevitably responded to internal and external factors
over nearly a decade and a half, and it is time to update the factual background
against which transport economics is set, even if it does not materially affect the
underlying theories.
So this new edition takes on board these important changes. But it also has a
different physical form. It is longer. This is because the original edition was aimed
mainly, although far from completely, at the UK market where universities nor-
mally had a 10-week term. There was basically a chapter per class. Changes have
taken place in the educational world, and the earlier edition seems to have found
a wider market than expected. This edition is thus longer, some 14 chapters and
more suited to a semester system. This is not just padding added to fill in students’
time; there is serious restructuring, redrafting of material seen in editions one and
two, and new material.
Additionally, the referencing is slightly different. The Harvard Manual, with
its author–date format, which forms the basis of most economics journal and
monograph referencing has been set aside for a simple Chicago approach. There
are no extensive lists of references but rather a few important citations are offered
together with a brief section of further reading at the conclusion of each chapter.
This is in response to comments from users of the earlier editions who found the
Harvard system distracting in what is essentially a textbook.
As before, the book is a mixture of prose, tables, figures and equations. The
aim is to help understanding rather than to overpower, or impress, the reader with
technique.
I hope that teachers, students and other readers find the new edition useful.

Kenneth Button
1 Transport and Economics

Economics is extremely useful as a form of employment for economists

— John Kenneth Galbraith

1.1 Transport* Economics

Over a quarter of a century ago I opened the first edition of Transport

Economics with a quote from an address to the UK’s Chartered Institute of
Transport by K.J.W. Alexander1 which made the rather sober point that despite
the importance of transport in the economy, ‘the number of academic econo-
mists who specialize exclusively in transport could probably be counted on two
hands. If one adds to these economists the applied economists employed in the
transport business and the specialist consultants working exclusively in that
field I would be surprised if the total number exceeded sixty or seventy’. This is
actually rather strange given the fascination that transport has held more gener-
ally for very eminent economists; indeed John Maynard Keynes once confessed
when young, ‘I find economics increasingly satisfactory, and I think I am rather
good at it. I want to manage a railway, or organize a trust or at least swindle the
investing public’.
Unfortunately, the situation as seen by a knowledgeable expert in the mid-
1970s, continued to largely pertain in the 1990s when the second edition of
Transport Economics was published. One may now have to bring one’s feet and
toes into Alexander’s calculations, but even in 2009 there are still relatively few
academics that specialize in the subject. There still remains, however, quite a lot
of, often not very helpful, dabbling by those whose interest lay more in lobbying
for a favorite mode of transport than social welfare, and who try to use economics
to justify their own personal prejudices.
Alexander’s statement also highlighted the fact that many transport eco-
nomic issues have traditionally been under-researched and often poorly under-
stood, particularly by non-economists. The situation has changed somewhat
since that time, as witnessed by the introduction of a number of serious academic
journals over the years that regularly publish papers on transport economics.

* The word ‘transport’ is used throughout this book rather than the US ‘transportation’
despite the use of American vocabulary elsewhere. This is to avoid confusion for British
readers, and it avoids obvious problems for Australians for whom the term ‘transporta-
tion’ has peculiar connotations.
1 K.J.W. Alexander, ‘Some economic problems of the transport industry’, Chartered
Institute of Transport Journal, 36, 306–8, 1975.
2 TRANSPORT ECONOMICS, 3RD EDITION

Most notable of these are the Journal of Transport Economics and Policy, which
first appeared in 1967, and the International Journal of Transport Economics.
Both of these date back to that general era, but so do journals such as the Journal
of Urban Economics and Regional Science and Urban Economics which also often
carry transport material. In addition, mode-specific journals have emerged, such
as Maritime Economics and Logistics, which focus on particular transport indus-
tries. But, nevertheless, compared to many areas of economic study, transport still
remains remarkably neglected.
This does not mean that there have not been periodic surges of interest in
some particular aspects of transport economics. Indeed, in the mid-1980s Clifford
Winston,2 when examining developments in transport economics, was able to
comment on ‘a current intensity [of interest in the field] not witnessed for more
than fifty years’. This surge was mainly related to the analysis of the impacts of
more liberal, or to use the American term, ‘deregulated’, transport markets that
were emerging. More recently, the role of transport as a facilitator of economic
growth has attracted attention both at the micro and at the macroeconomic levels.
Matters of transport security and the financing of transport networks have been
themes attracting attention in the early part of the twenty-first century, as has the
role of transport in international trade.
This relative lack of contemporary academic interest in transport economics
is surprising because transport problems have in the more distant past stimulated
major developments in economic theory (including the development of the notion
of consumer surplus by French economists/engineers, such as Jules Dupuit, in the
1840s; the refinement of cost allocation models by such famed US economists
such as John Bates Clark and Frank Taussig in the early part of the last century;
and the examination of the marginal cost pricing principle to improve the charg-
ing of rail service and work on congestion and the environment by Arthur Pigou
in the 1920s).
More recently, the advent of computers has encouraged work on applied
econometrics (for example, the development of discrete choice models in con-
sumer theory by Dan McFadden, and refinements to flexible form cost functions)
and on mathematical programming (for example, the use of data envelopment
analysis to assess the relative efficiency of different suppliers) using transport case
studies as a basis for analysis. Nonetheless, transport economists in universities
are thin on the ground, and their numbers in businesses and government are not
much larger.
In part, the relatively small number of clearly identifiable specialist transport
economists may be attributed to the diverse nature of the industries involved in
their work which range from taxi-cabs to oil transportation, with their various
institutional and technical peculiarities. Non-economists – lawyers and engineers
– often have specialist knowledge of the industry and a limited background in
economics. At the applied level, numerous, small firms do not have the resources

2 C. Winston, ‘Conceptual developments in the economics of transportation: an interpre-

tive survey’, Journal of Economic Literature, 23, 57–94, 1985.
 TRANSPORT AND ECONOMICS 3

to employ full-time specialists that characterize a ‘transport economist’ although

that does not mean they do not have individuals that fulfill some economics role
in the organization.
It may also be explained by the tendency, which to some extent still remains,
for physical planners and transport engineers to dominate substantive investment
and policy decision making within the sector. The emphasis in this case is, on
the personal transport side, more to do with the physical manifestation of travel,
namely trips and journey numbers, rather than the demand for movement and
the ability of the system to meet these aspirations. Where economics is used, it is
often within the engineering framework and carried through by engineers – the
so-called ‘engineering economics’. This situation has only gradually been chang-
ing with innovations in management and planning, and in the way that political
institutions have evolved. So what is ‘modern transport economics’, how did it
evolve and what are the intellectual and practical driving forces behind it?

1.2 The Emergence of Modern Transport Economics

Economics is not easy to define.3 Famously the Chicago economist Jacob Viner is
meant to have said, ‘economics is what economists do’; not exactly helpful to the
outside. But it is generally agreed that it is about human behavior and resource
allocation, and in particular about the allocation of scarce resources. It focuses a
lot on the role of markets in doing this, but not exclusively so. Various aspects of
it border on a variety of other disciplines such as law, sociology and engineering,
often making boundaries vague. It also may be essentially descriptive in the sense
of it approaching a value-neutral science – it tells us that in most conditions the
quantity demanded of something will fall if its price rises – but it can also contain
elements of prescription: it is a ‘good’ thing for social welfare for prices to be low.
The latter is often called ‘political economy’. All these elements, and some others,
become important when studying the economics of transport.
What has been called ‘Modern Transport Economics’ by Michael Thomson4
in his book of the same name, began slowly to take shape about 45 years ago. Up
until that time, as Rakowski5 points out, ‘the field had essentially been in a state
of semi-dormancy since the 1920s’, and while considerable institutional studies
had been conducted, very little analytical work as we would understand it today
had been attempted. Indeed, the two standard American textbooks on transport
economics into the late 1960s were D.F. Pregrum’s Transportation: Economics and
Public Policy, and Philip Locklin’s Economics of Transportation, which had only
five or so line drawings between them and no equations.

3 R.E. Backhouse and S.G. Medema, ‘On the definition of economics’, Journal of
Economic Perspectives, 23, 221–33, 2009.
4 J.M. Thomson, Modern Transport Economics, Harmondsworth: Penguin, 1975
5 J.P. Rakowski, Transport Economics: A Guide to Information Sources, Detroit: Gale
Research Co., 1976.
4 TRANSPORT ECONOMICS, 3RD EDITION

If one looks for a watershed in the history of modern transport economics it

would probably be the publication of John Meyer, Meston Peck, Walter Stenason
and Charles Zwick’s Economics of Competition in the Transportation Industries in
1959, which provided a state-of-the-art review of resource allocation problems in
the sector coupled with rigorous statistical analysis. There had been a number of
seminal economic papers relating to transport that appeared prior to this, includ-
ing James Buchanan’s re-examination of congestion and Martin Beckmann and
co-workers’ set of studies, but Meyer et al.’s book really set the tone for the way in
which transport issues are analyzed.
Interest in transport issues expanded throughout the 1960s with, for example,
William Vickery’s analysis of road charging and the role of public transit subsidies,
Ian Little and James Mirrlees’s development of work on investment appraisal,
and in particular on cost–benefit analysis, Richard Quandt and William Baumol’s
improvements in methods of transport demand modeling based on Daniel
McFadden’s work and the ideas of Kelvin Lancaster, Leon Moses and Harold
Williamson’s development of innovative methods of travel time evaluation, and
so on. All these are topics that we shall return to later, albeit in their more modern
manifestations, and in many cases with some real-world examples of applications.
The changes were not all academic. This period also saw public policy
makers become more interested in the role of economics in improving actual
decision making. In many countries, specialist departments were established in
national or municipal governments to examine the economic implications of
various transport policy options.
The 1960s and early 1970s saw a slew of official reports appear, for
example, in the United Kingdom, including studies on Road Track Costs, the
Smeed Report on The Economics of Road Pricing, the Beeching Report on The
Reshaping of British Railways and the report of the Commission on the Third
London Airport, which set out the framework for ways in which economics helps
in mega-project investment appraisal. The European Union, then just established
as the European Economic Community, produced reports and plans in the early
1960s for integrating and coordinating economic approaches to transport pro-
vision across much of Europe. In the United States this was the period of the
large land-use transport studies that included the Chicago Area Transportation
Study from the late 1950s, the Puget Sound Regional Transportation Study, and
the Detroit Regional Transportation and Land-use Study. These were essentially
engineering studies seeking to deal with mounting congestion problems, but eco-
nomic analysis was part of the assessment process.
While it is never easy to explain the timing of change, the renewed research
interest in transport in the 1960s, especially in the United States, Rakowski
attributes to ‘the problems of physical distribution and the development of a
new field which has come to be called business logistics’, ‘expanded interest in
all phases of urban transportation’ and ‘a great deal of research in the areas of
transportation in the developing countries’. Ken Gwilliam6 echoes these themes

6 K.M. Gwilliam, ‘Review of “Transport Economics”’, Economic Journal, 90, 677–8, 1980.
 TRANSPORT AND ECONOMICS 5

but places particular emphasis on the growing problems of urban transport in the
1960s and the recognition that land use and transport needed to be considered
together, and usually simultaneously, if the problems were to be tackled success-
fully. As a result of this, he argues, ‘the boundaries between transport economics
and urban and regional planning were obscured’.
While the broad underlying intellectual thrust of modern transport analysis
has not changed significantly since the 1970s and early 1970s, namely the use of
economic theory to enhance transport efficiency, in the broadest sense the topics
of focus have shifted to some extent and the economic tools used have been
improved and fine-tuned. The late 1970s saw particular concern in many parts
of the world with the macroeconomic problems associated with ‘Stagflation’: the
simultaneous occurrence of high levels of unemployment and poor economic
growth with inflation. The failure of a large part of the US railroad industry
may be seen as a catalyst for some of the particular changes in transport. The
adoption of Reaganomics in the United States, and Thatcherism in the United
Kingdom, involving similar approaches towards what became known as ‘supply-
side economics’, led to a honing-in on reducing costs in heavily regulated indus-
tries such as transport.
The empirical analysis of those such as Bill Jordan and Michael Levine pro-
vided evidence of excess costs associated with regulation, the theories of Baumol
and others on contestable market structures offered a new way of looking at
competitive forces, and Harold Demsetz’s work provided a basis for enhancing
the efficiency with which transport infrastructure is provided and maintained.
Work by a variety of Chicago economists, including George Stigler and Sam
Peltzman, began to focus on the motivations of those responsible for framing and
administrating economic regulatory regimes, arguing that they seldom served the
public interest. The outcome was what some have called the ‘Age of Regulatory
Reform’,7 which focused on removing distorting regulations and allowing greater
market flexibility.
More recently, public concern combined with academic curiosity has led to
economists switching more of their attention to matters pertaining to the envi-
ronmental implications of transport supply, the role that economics can play in
enhancing the transport logistics supply chain, and the financing of infrastruc-
ture. Transport, as we shall see later in the book, can impose considerable strains
on the environment and, although this has long been recognized, the scale and
nature of transport has changed, as has scientific knowledge on the implications
of these strains – and especially in the context of global impacts.
Equally, globalization, internationalization and domestic economic growth
within many countries have been, in part, the result of improved logistics, includ-
ing just-in-time supply chain management. Although often not appreciated, many
of these improvements in logistics are the result of the application of basic eco-
nomic principles. Finally, modern transport requires an extensive infrastructure

7 K.J. Button and D. Swann (eds), The Age of Regulatory Reform, Oxford: Oxford
University Press, 1989.
6 TRANSPORT ECONOMICS, 3RD EDITION

of roads, rail tracks, ports, air traffic control systems, bridges and so on. The
construction and the maintenance of this infrastructure have to be paid for.
While in the past transport economics has focused primarily on deciding which
elements to build or repair, the taxpayer bearing much of the financial burden,
there is now concern about the methods of finance to use and the overall amount
of national resources that have to be devoted to this type of infrastructure. This
issue is increasingly important in many developed economies as old infrastruc-
ture becomes obsolete or needs maintenance, but is perhaps more critical in
lower-income nations that lack many key transport networks.
When considering this background, it is important to emphasize that trans-
port economics is not distinct from all other branches of economics. Indeed,
many of the seminal papers on the subject have appeared in the general econom-
ics literature and have often been produced by individuals with a broad interest
in economics rather than transport specialists. Nevertheless, in most areas of
study, as our knowledge has increased, it has become difficult, if not impossible,
for economists to follow developments in all branches of their discipline; the
Renaissance man or woman of economics is in the past. There has been an inevi-
table increase in specialization. Transport economics has, in general terms, a long
history but, as Rakowski and others suggest, it was only in the 1970s or so that it
become a major field of academic study within universities and only subsequently
did a substantial body of specialists emerge. So the modern transport economist
is a relatively new beast. But what is it that he/she studies?

1.3 The Scope of the Subject

The scope of each of the subdisciplines within economics (for example, agricul-
tural economics, development economics and public sector economics) is deter-
mined not by particular schools or philosophies but rather by the type of subject
matter examined and the problems tackled. Transport economists are interested
in the economic problems of moving goods and people – they are not normally
so concerned with either the industries producing the vehicles and infrastructure
(aircraft manufacturing, road construction companies, ship building and so on)
or with some of the very wide implications of transport policy (for example, on
the balance of payments), although matters to do with the environment certainly
attract increasing amounts of their attention. Of course, this does not mean that
transport issues are viewed in complete isolation from their wider context, but it
does mean that the main emphasis and thrust of analysis is directed towards the
more immediate transport implications.
While much of the economic analysis of transport issues is at the micro level
(for example, looking at the decisions of individuals or firms) or at the meso level
(focusing on transport industries or the importance of transport or a specific
region) there is also some interest in the macroeconomic impacts of transport, for
example, on its effects on national productivity, globalization of trade, or labor
force migration.
 TRANSPORT AND ECONOMICS 7

This book seeks to give adequate coverage to all levels of aggregation.

Initially, however, we step back a little and spend time considering the economic
institutions within which transport services are supplied and individuals and firms
seek its services. Much of the theoretical economics that we encounter is rather
abstract and largely assumes away the role of economic institutions, although this
is now changing gradually. But institutional structures are important. Elementary
economics, for example, talks about such things as perfect competition, but such
markets could not exist without laws giving property rights to their suppliers
and without contracts between sellers and buyers. As the Nobel Prize-winning
economist Ronald Coase8 said in the context of economic reforms in the former
USSR countries, ‘These ex-communist countries are advised to move to a market
economy, and their leaders wish to do so, but without the appropriate institutions
no market economy of any significance is possible’.
Traditionally, however, within economics, institutions have been treated as
endogenous and man-made – sometimes deliberately, sometimes not – rather
than something that is to be given. Few economists spent time studying them
and those that did, such as Thorstein Veblen and John Kenneth Galbraith, were
treated in their day as rather marginal to main-stream economics – some even
considering them to be ‘sociologists’! However, this view is changing, and as
Oliver Williamson9 observed: ‘We are still very ignorant about institutions. . . .
Chief among the causes of ignorance is that institutions are very complex. That
neoclassical economics was dismissive of institutions and that much of organiza-
tion theory lacked scientific ambitions have also been contributing factors’.
The so-called ‘New Institutional Economics’ has moved the economic study
of institutions away from being a largely descriptive, legalistic and traditional his-
torical way of viewing the world to one that offers microanalysis of such issues as
to why economic institutions have emerged the way they have. It has also moved
away from a largely negative way of looking at neoclassical economics, to one with
its own theoretical constructs and tools of analysis. This approach importantly
sets the neoclassical economics that underlies most of the work in transport eco-
nomics up until the 1990s, into a larger context. Figure 1.1 is a simplified diagram
that sets out four levels of social analysis. It is fairly self-explanatory except that
the thick arrows show constraints that come down from higher levels of analysis,
while the dotted arrows indicate the direction of feedbacks. The data offered in
the figure are the rough frequency in years over which change takes place.
Long-term issues tend to receive less attention in transport economics the
further one moves from narrow resource allocation matters. Their importance
cannot be neglected, however. There have been, perhaps, two major societal
changes that have impacted on culture in the broadest sense over the past century
or so, and have had important ramifications for transport.

8 R.H. Coase, ‘The institutional structure of production’, American Economic Review, 82,
713–9, 1992.
9 O.E. Williamson, ‘The new institutional economics: taking stock, looking ahead’,
Journal of Economics Literature, 38, 595–613, 2000.
8 TRANSPORT ECONOMICS, 3RD EDITION

Resource allocation and

Neoclassical economics/agency
employment:
theory
continuous

Governance, especially
contracts: Transaction cost economics
1 to 10 years

Institutional environment,
Economics of property
formal rules:
rights/political economy
10 to 100 years

Embeddedness, customs
and traditions: Social theory
100 years or more

Figure 1.1 Institutions and economics

First, there was the demise of the Soviet Union and the move away from cen-
tralized planning, together with the gradual uptake of capitalism in China. These,
and similar developments elsewhere, represent major shifts in the embedded atti-
tude of these countries and with this have come new ways of thinking about the
role of transport in society and the ways in which it should be provided. Second,
there have been changing attitudes towards free trade, and with these have come
‘globalization’. The resultant approach to tariffs and other barriers to interna-
tional economic policies have had profound effects on shipping, air transport, and
many forms of surface transport. Going back to the global conflict of 1914–18,
the subsequent establishment of the League of Nations paved the way for this
in modern times, and it has extended since the end of the Second World War.
It is not just that such global institutions as the World Bank, the International
Maritime Organization, and the International Civil Aviation Organization exist,
but rather that there is now a belief that they have a durable role to play in society.
This forms a basis for new economic systems and an embedded global view on
how business can be conducted.
The institutional environment involves formal laws, regulations and rules,
and at a higher level, ‘constitutions’. It is also concerned with the instruments
of law – legislatures and bureaucracies – and mechanisms of enforcement. For
example, it relates to legal reforms such as the 1978 Airline Deregulation Act
which liberalized domestic aviation in the United States, or the Single European
Market Act in Europe in 1986 that led to a phased deregulation of transport
and other markets within Europe. But it also importantly includes the issue of
property rights and their enforcement. So-called ‘Pigouvian externalities’, such as
pollution, and ‘club good’ problems of traffic congestion, are the most obvious
areas of interest for transport economists in this regard. From an economics of
 TRANSPORT AND ECONOMICS 9

transport perspective, the question becomes one of getting the rules right to meet
societal demands.
Governance, basically the way business is done, is important, and here the
economic emphasis is on notions of contracts. Strictly, it is about crafting order,
and thereby mitigates conflict and realizes mutual gains. There are many factors
– cultural, structural, cognitive and political – that influence the way in which
these formal and informal institutions develop. If we take shipping as a case
study, governance here may be seen as embodying such things as the evolving
structure of coordination of shipping activities that began with ‘conferences’ –
essentially cartels – in the 1970s and has developed through consortia into stra-
tegic alliances, whereby changes occur discretely rather than continuously. These,
like their brethren in the airline industry, can involve agreements on such things
as schedules and rates with flexibility about which vessels carry any particular
assignments.
There are also contractual issues within the larger integrated supply chains
that, for example, tie, to varying degrees, shipping with other elements in the
logistics system, most immediately ports but extending beyond this. Governance
is different from government in the sense that the former involves informal agree-
ments within a legal structure. As an example, the United States deregulated its
domestic airline industry by an Act of Congress, whereas the United Kingdom
essentially got the same result because the Civil Aviation Authority reinterpreted
the existing set of laws. Because of high transaction costs, the recent trend has
been for a considerable amount of contract management and dispute settlement
action to be dealt with directly by the parties involved – in other words, within
market frameworks rather than by legal actions.
Finally, there are the ongoing processes involving the day-to-day activities
that take place involving transport. This is essentially the traditional bread-and-
butter of micro- and mesoeconomic analysis taking into account the specific
nuances of transport. Resource allocation issues have since the days of Adam
Smith, and more particularly Alfred Marshall in the late 1890s, centered on
getting the marginal conditions right. To assess how this might be achieved in
theory, and how it materializes in practice, requires some notion of the nature of
the relevant cost and demand conditions – the guts of most introductory econom-
ics courses. The basic principles, although the nuances are still being refined, are
well understood, and much of the recent attention in transport economics has
therefore been on quantification and application in a network context.
Historically, however, this has not always been the case. Much of the analysis
of market structures in transport, for example, paid scant heed to the network
nature of the industry and ipso facto to network externalities. Much of the
interest until 50 years or so ago, as we have hinted at previously, had been on
traditional economic parameters such as market concentration ratios, the degree
of product differentiation and the level of vertical integration. While all these
can be important instruments in the economist’s tool bag, the network nature
of the transport, and the service nature of its outputs, received much less direct
attention in the analysis. Much of the early work on transport demand modeling
10 TRANSPORT ECONOMICS, 3RD EDITION

was also either devoid of any of these network features, or embraced them in a
mechanical fashion. But network features are important, although they often add
complexity to useful analysis.
All network service industries have essentially identical economic charac-
teristics. Their output is non-durable, although they normally require significant
amounts of infrastructure. There are also often very significant external benefits
which, tied with various forms of scale effects, produce network economies. From
the consumer’s perspective, these external economies are related to the fact that
the larger the number of links in a network the greater the degree of connectivity,
and with this the larger the choice set available to him/her – often called ‘econo-
mies of market presence’. On the cost savings side, the ability, where this is most
efficient, to channel traffic through hubs, rather than carry traffic directly between
origins and destinations, creates economies of scope (cost savings by combin-
ing traffic) and of density (the more intensive use of the mode). But complex
networks can also create costs, and most especially congestion can develop on
link roads or flight paths, or at hubs such as sea- and airports in the shipping and
aviation context.
So what does all this mean regarding the day-to-day work of transport
economists? In summary, an understanding of economic institutions is now gen-
erally seen as important for analyzing broad transport issues; nevertheless, the
main ‘tools’ of the transport economist are still taken directly from the kit-bag
of standard micro- and mesoeconomic theory, although one should add that
the actual instruments used have changed significantly over the years. The pre-
Second World War emphasis centered on the transport industries (that is, the
railways, road haulage, shipping and so on.) and, in particular, on ways in which
the transport supply could be improved within a largely regulated structure so
that maximum benefit would be derived from public and private transport opera-
tions. The situation was summarized by one geographer who felt that transport
economics at that time was concerned almost entirely with ‘matters of organiza-
tion, competition and charging, rather than with the effects of transport facilities
on economic activities’.10
To some extent – particularly in relation to international transport and,
to a lesser extent, inter-urban transport – this interest has remained. However,
more recently it has been supplemented by concern with the wider welfare and
spatial implications of transport. Greater emphasis is now placed on the envi-
ronmental and distributional effects of the transport system and, in some cases,
market efficiency is seen as an undesirably narrow criterion upon which to base
major decisions. As Alexander argued, in the speech cited at the beginning of
the chapter, one of the most important roles for economists is to make clear the
overall resource costs of transport rather than just the accounting costs. It is no
accident, perhaps, that much of the early work in cost–benefit analysis (CBA) was
in the transport field.

10 A.M. O’Connor, Railways and Development in Uganda, Oxford: Oxford University

Press for the East African Institute of Social Research, 1965.
 TRANSPORT AND ECONOMICS 11

Transport economics has, like virtually all other branches of economics,

become more quantitative in recent years. The dominant pre-war idea that eco-
nomics is concerned mainly with establishing broad principles (for example, that
the quantity demanded rises, ceteris paribus, as price falls) has given way, with the
advent of econometric techniques and the computer age, together with improved
data sources, to attempts at detailed measurement (that is, a rise of x tons in
the quantity demanded will, ceteris paribus, follow from a $y fall in unit price).
Transport economists are now heavily involved in trying to assess the precise
quantitative effect of different policy options and with forecasting likely changes
in transport demand.
At the public policy level, the increasing sophistication of transport opera-
tions, combined with both the long lead times that are required for full policy
implementation and the financial costs involved, place mounting strains upon
economists to produce useful, quantified predictions of future trends. The
increased appreciation of the commercial benefits of better forecasting and
costing as part of the supply-chain management process, has led to greater
employment of numerate economists in the private sector.
From the relatively small base of the 1960s, transport economists have now
become more established in most areas of transport policy making at all admin-
istrative levels. Their increased interest in the overall welfare consequences of
different transport strategies, together with a willingness to attempt some form of
quantitative assessment, has led to transport economists becoming more closely
involved in major transport planning exercises. They have an established role in
advising on appropriate actions at the national policy formulation level, but this
has also spread down to a more specific function at the local planning level. At
the strategic level, transport economists, for example, have made a significant
contribution to the urban transport planning in industrial countries since the late
1960s, and have been involved in many detailed appraisals of traffic investment
and management schemes in developed countries.
The particular advances made in transport investment appraisal – most
notably the development of CBA techniques as practical tools of analysis – led to
the adoption of economic criteria for the assessment of many large-scale invest-
ment projects in the 1960s and 1970s (for example, the Third London Airport
scheme and Victoria Underground Line in the United Kingdom). Recent refine-
ments have resulted in rather more standardization, and uniform CBA procedures
are employed as a standard method of small-scale transport project appraisal (for
example, the COBA package used in UK trunk road investment appraisal and
the procedures favored by the World Bank for appraising transport schemes in
low-income countries).
As argued earlier, the surge of regulatory reform and market liberalization
from the late 1970s, which will be discussed later in the book stems, at least partly,
from the empirical work of applied economists, and the regulatory regimes that
subsequently emerged are largely economics based.
The dichotomy between the wealth of the industrial nations and the poverty
of Third World countries has resulted in large-scale programs being initiated to
12 TRANSPORT ECONOMICS, 3RD EDITION

stimulate the economic development of the Third World. Much of this aid has
been in the form of monies and resources to improve transport provision. Over 20
percent of World Bank lending, for example, goes on transport projects, as does
about 15 percent of total Bank assistance – grants, expertise and so on. Although
it is not altogether agreed that aid actually stimulates growth11 nor that, if it does,
transport investments are the most suitable projects to finance, it is nevertheless
important that within the narrow confines of transport efficiency these monies
are spent wisely. Transport economists have become increasingly involved in the
Third World in transport project appraisal work.
Large private transport businesses often employ economists but more often
they, and smaller enterprises, make use of the many specialist consultancy com-
panies that offer expert advice. The growth in interest in supply-chain logistics,
which spans all movement and storage of raw materials, work-in-process inven-
tory, and finished goods from point of origin to point of consumption, and
within that just-in-time management, has led to a much more implicit incorpora-
tion of economics into transport activities.
One way of looking at this is through the notion of ‘value chain’ initiated
by Michael Porter.12 A value chain is a chain of activities. Products pass through
all activities of the chain in order, and at each activity the product gains some
value. The chain of activities gives the products more added value than the sum
of added values of all activities. Capturing the value generated along the chain is
the new approach taken by many management strategists. For example, a manu-
facturer might require its parts suppliers to be located near its assembly plant to
minimize the cost of transport, or it may require regular delivery of components
to keep production going, while holding minimum stocks of the component. By
exploiting the upstream and downstream information flowing along the value
chain, the firms seek to bypass intermediaries creating new business models, or in
other ways create improvements in its value system.
Figure 1.2 provides a simplified generic value chain. The key point about it is
the extensive number of linkages required through a production process from the
initial extraction of raw materials to the final delivery of goods to a market and
their subsequent servicing. Transport is, at various levels of aggregation and in
different forms, important at all stages. Just-in-time management is, as we see in
Chapter 10 when we look at the links between transport economics and transport
logistics, important in ensuring that as few resources as possible are tied up in the
process at any one time so that inventory holdings are optimized.
The remainder of this introduction is concerned with setting the scene for the
body of the book. Initially, some of the main economic features of the transport
sector are discussed. The intention is, however, not to point to the uniqueness
of transport but rather to highlight the particular characteristics of the sector
that pose special problems for economists. Recent trends in transport are then

11 P. Baer, Dissent on Development, London: Weidenfeld & Nicholson, 1971.

12 M.E. Porter, Competitive Advantage: Creating and Sustaining Superior Performance,
New York: Free Press, 1985.
 TRANSPORT AND ECONOMICS 13

Primary activities

Inbound Outbound Marketing and

Operations Services
logistics logistics sales

Support activities
Procurement, human resource management,
infrastructure, technological development

Figure 1.2 The simple notion of the value chain

reviewed and commented upon. To keep the subject matter manageable, much of
the focus will be on the UK and US situations, although experiences elsewhere
will not be neglected. This is followed by a brief review of what appear to be some
of the longer-term factors that are going to attract the attention of transport
economists. Finally, a detailed contextual section explains the format of the book
and outlines briefly the rationale for the structure adopted.

1.4 The Economic Characteristics of Transport

Possibly the most important characteristic of transport is that it is not really

demanded in its own right. As Munby13 put it 40 years ago, ‘Only the psychologi-
cally disturbed or inadequate want transport for its own sake’. In other words the
demand for transport is a derived one, but its appropriate provision enables the
benefits of a myriad of other, final benefits to be enjoyed. It is a major facilitator
for enhancing personal welfare and for such things as economic development.
People wish, in general, to travel so that some benefit can be obtained at the
final destination. The trip itself is to be as short as possible. Of course, there are
‘joy riders’ and ‘tourists’ but they tend to be in the minority. Similarly, users of
freight transport perceive transport as a cost in their overall production function
and seek to minimize it wherever possible. The derived nature of the demand for
transport is often forgotten in everyday debate, but it underlies all economics of
transport.
While the demand for transport has particular, if not unique, features, certain
aspects of supply are entirely peculiar to transport. More specifically, part of the
plant is ‘mobile’ – almost by definition – and is entirely different in its characteristics
from the fixed plant (for example, rail track, airports and so on). The fixed compo-
nent is usually extremely long-lived and expensive to replace. While most factories
in the manufacturing sector may be thought to have a physical life expectancy of
a hundred years at most, we still use ports and roads constructed in Roman times.
Further, few pieces of transport infrastructure have alternative uses: some former
waterways have been turned into leisure areas but these tend to be exceptions.

13 D. Munby, Transport, Harmondsworth: Penguin, 1968.

14 TRANSPORT ECONOMICS, 3RD EDITION

In contrast, most mobile plant is relatively short-lived and replacement

usually occurs with physical rather than technical obsolescence as with the fixed
components. It is also cheap, with the prospect of alternative employment if
demand declines in one market; for example, a bus can be transferred to another
route or another form of service – in technical terms, transport operators have
few ‘sunk costs’. Also, unlike fixed plant, the mobile components of transport are
generally subject only to minimal scale economies. (Ships and aircraft may be seen
as exceptions to this in some cases.)
The fixed component, on the other hand, is normally subject to quite sub-
stantial economies of scale. Once a rail track is laid, the marginal cost of using it
falls until some maximum capacity is reached. This means that generally there is
a minimum practical size below which the provision of transport infrastructure is
uneconomical. There are minimum traffic flows, for example, below which it is not
economically practical to build motorways.
As Michael Thomson14 has pointed out, it is these features of the fixed
and mobile components of transport that have influenced the present institu-
tional arrangements in the sector. The high cost of provision, longevity and
scale economies associated with the fixed components create tendencies towards
monopoly control, while the ease of entry, flexibility and lack of scale effects
tend to stimulate competition in the mobile sector. In common with many other
countries, official reaction in Britain to this situation has, in the past, tended to
be the nationalization and public ownership of transport infrastructure and the
regulation of competition in the mobile sector. Nations differ in the degree to
which fixed transport assets are publicly owned (there are entirely private railways
in some countries such as the United States while several European states have
privately operated motorways) and in the types of regulation imposed on mobile
factors, but the overall impression is consistent.
While the rationale of directly controlling the provision and sale of the fixed
components of transport can be linked to the containment of any monopoly
exploitation which may accompany private ownership (although British experi-
ence in the nineteenth century suggests that control might equally well be enforced
through price regulation), the need to regulate the mobile component stems from
another aspect of transport operations. Transport generates considerable external
effects (most obvious of which are congestion and pollution); as Thomson says,
it is an engineering industry carried on outside the factory. It is, therefore, felt to
be important at least to contain the harmful effects of transport and at best to
ameliorate them. Coupled with this is the imperfect knowledge enjoyed by opera-
tors and, in particular, their inability to foresee relatively short-term change in
demand.
Regulation is, therefore, often justified to ensure that excessive competition at
times of depressed demand does not reduce the capacity of the transport system
to an extent that it cannot meet higher demand during the upturn. Finally, there
are political-economy arguments that transport is a social service that should

14 J.M. Thomson, Modern Transport Economics, Harmondsworth: Penguin, 1974,

 TRANSPORT AND ECONOMICS 15

meet ‘need’ rather than demand and, hence, traditional market forces need to be
supplemented to ensure that this wider, social criterion of transport operations is
pursued rather than the simple profit motive.

1.5 The Framework of the Book

The remainder of the book is concerned with the application of economic theory
to the transport sector. These are many books that concentrate on particular
modes of transport, such as the railways or shipping, or specific sectors, such
as the nationalized transport industries, or have a geographical bent such as, the
transport policy of the European Union or urban transport problems. One of
the main aims of this book, however, is to show that most challenges in transport
are common to all modes (albeit with minor variations) and cover many different
circumstances. Consequently, the approach is to show how economic theory may
be applied to improve the overall efficiency of the transport sector; examples are,
therefore, drawn from all forms of transport and many contexts.
Also while it is unavoidable, not to say desirable, that official transport
policy must be implicitly incorporated in the analysis, this is not a book explicitly
about transport policy. Economic forces do not operate in a vacuum but within
the context of laws and governance structures. Indeed, economists of the public
choice persuasion such as James Buchanan and Gordon Tullock put particular
emphasis on this political economy dimension.15
It is felt useful, on occasions, to give brief details of institutional arrange-
ments since they inevitably influence the type of economic analysis to apply (for
example, a thumb-nail sketch of the historical and institutional framework of
urban transport planning is included for this purpose), but, again, this is prima-
rily for contextual reasons. The closing chapter is explicitly concerned with policy
and institutions, and in particular with the matter of the economic regulation of
transport markets.
At the theoretical level, the discussion is couched in terms of verbal and
diagrammatic analysis. Mathematical expressions are not shunned, but equations
are included rather as references, permitting readers to look up practical working
models should they subsequently wish to undertake their own empirical investiga-
tions. There are virtually no mathematical derivations, but important equations
are ‘talked around’ and the reader should find no difficulty in following the book
even if his/her mathematical education has been neglected or forgotten.
Indeed the philosophy of the approach adopted here is very much akin to
that espoused by the great economist, Alfred Marshall in a letter to a colleague,
A.L. Bowley, in 1906,

But I know I had a growing feeling in the later years of my work at the subject that a
good mathematical theorem dealing with economic hypotheses was very unlikely to

15 J.M. Buchanan and G. Tullock, The Calculus of Consent: Logical Foundations of

Constitutional Democracy, Ann Arbor, MI: University of Michigan Press, 1962.
Another random document with
no related content on Scribd:
 11 “Nephritis et Arthrites saturnines: coincidence de ces Affections paralleles avec la
Nephrite et l'Arthrite goutteuse,” Arch. gén. de méd., Decembre, 1881.

4. Lead Palsy; Lead Paralysis; Paralysie Saturnine; Bleilähmung.—

This condition is fourth among the affections due to chronic lead-
poisoning, both in frequency and in the order of succession.
Nevertheless, like each of the others, it may be the first in the order
of appearance after disturbances of nutrition which are in some rare
cases of very slight degree. As a rule, however, the paralysis has
been preceded by colic or by joint affection, or by both. Tanquerel12
found that in 88 cases of lead palsy 25 had been preceded by an
attack of colic, 15 by two attacks, 3 by ten attacks, 1 by fifteen
attacks, and that in single cases as many as twenty, and even thirty,
attacks of lead colic had occurred before the appearance of
paralysis.
12 Loc. cit.

The length of time over which habitual exposure to lead without the
development of palsy may extend was found by the same observer
to vary from eight days to ten, twenty, or even twenty-five years. One
individual first suffered from paralysis after fifty-two years of
exposure.

Without dwelling upon the sources of error in statistics of this kind, it

must be conceded that they establish in a general way the
extraordinary differences in the susceptibility of individuals. There
are persons who every time they are attacked with colic, of whatever
degree of severity, suffer also from paralysis. Others, on the contrary,
suffer from repeated attacks of violent colic without the development
of paralysis.

Lead palsy is an affection of adult life. Of 102 cases, 2 only occurred

in individuals below twenty years of age.

Like the other specific lead affections except the encephalopathy,

palsy is more common in the summer than at any other season.
Those who have once suffered are very liable to successive attacks.
Tanquerel and Maréchal have observed many returns of paralysis,
presenting the characters of the original attack, many years after the
patient had withdrawn from exposure to lead.

Perverted sensations of the parts about to be affected, such as

coldness, numbness, and hyperæsthenia, may precede the attack.
Impairment of motor-power, manifested by feebleness, stiffness, or
awkwardness and tremor, also appears in the prodromic period. This
trembling consists in slight agitation of the muscles, rather than in
well-marked rhythmical contractions. These precursors may indeed
constitute the attack, which occasionally, and especially under
treatment, terminates at this point. The prodromic symptoms are less
severe during the day, while the patient is at work; at night they are
aggravated. After some days they end in the characteristic paralysis.
Colic is a common precursor. After the attack some stiffness of the
muscles is experienced, which terminates by rapid loss of power or
abruptly in actual palsy. Occasionally encephalopathy precedes the
paralysis. It is rare that prodromes are wholly absent.

In the great majority of the cases the upper extremities and the
extensor muscles are first attacked. If the paralysis be slight other
muscles may escape. The characteristic form of lead paralysis
consists in loss of power in the extensors of the hands and fingers,
especially of the extensor communis, without implication of the
supinator longus. The muscles affected are in the region of
distribution of the musculo-spinal nerve. The deformity is known as
wrist-drop. Next in order, the triceps and deltoid are most frequently
attacked. The lower extremities commonly escape for a considerable
time. When attacked, the extensor muscles of the feet and toes are
the first to suffer.

Paralysis of the dorsal muscles occurs in rare instances. It gives rise

to a peculiar stooping, uncertain, and tottering gait. Paralysis of the
intercostal and laryngeal muscles was observed by Tanquerel.
Paralysis of the muscles of the face or of those of the eye has never
been observed in consequence of lead-poisoning. The loss of power
never corresponds strictly to the distribution of the branches of a
single nerve-track.

The paralysis, as a rule, affects both sides, and frequently the

corresponding muscles of the two extremities. Sometimes, however,
the affected muscles of the two sides are not the same, and it
occasionally happens that the affection is limited to one side. In very
rare cases, the arm and leg on the same side being paralyzed, the
affection resembles hemiplegia.

Local paralysis may be limited to the extensor muscle of a single

finger or may involve all the muscles of a limb. There may be slight
impairment of power in the flexor muscles. The enfeeblement of
certain flexor muscles, especially of those of the fingers, may,
Naunyn suggests, be only apparent, the position of the hands being
in pure extensor paralysis unfavorable to the exercise of the flexors
and limiting their function.

Sensation is not, as a rule, affected in lead paralysis. Pains in the

paralyzed muscles, in neighboring muscular masses, and in the
structures about the joints often precede the attack of paralysis.
Anæsthesia of the skin is rare. When present, it is usually of slight
degree, and corresponds to the region of the paralysis. Deep
anæsthesia has also been observed.

Atrophy of the paralyzed muscles is constant and rapid. It frequently

reaches a high degree, causing characteristic deformities, which are
rendered more marked by the fact that the adjacent non-paralyzed
muscles preserve to a great extent their original state of nutrition. As
the neuro-muscular lesion progresses other deformities arise, in
consequence of derangements of the balance of force between
opposing muscles and from other causes. Among these deformities
are partial or complete dislocations of the more movable joints, as
the shoulder and phalanges, with the formation of tumors, which,
when they occupy the dorsum of the hand, might be carelessly
mistaken for the nodosities of gout. It is to be noted that the latter are
occasionally present as complications.
There is rapid diminution, and finally complete loss, of the reaction to
the faradic current. With the galvanic current the reaction of
degeneration is usually well marked. The reaction of degeneration
may be demonstrated in the extensors of the limbs in lead-poisoning
before wrist-drop has occurred.

The course of lead palsy is very variable. In a few cases it is

progressive. When local emaciation or atrophy arrives at the last
degree of marasmus, the skin seems glued to the bones, to such an
extent are the paralyzed parts wasted; the muscles especially are so
thinned that the contour of the bones is easily distinguished. If the
paralysis attack the whole of the limb, then this organ, abandoned to
its own weight, stretches the ligaments and permits the head of the
bone to leave its cavity. In other rare instances the paralysis remains
stationary for long periods of time, only to grow worse after each new
attack of lead disease. Much more frequently lead paralysis
disappears spontaneously or under treatment in the course of some
days or weeks. The convalescence is gradual, and usually rapid,
when the gravity of the lesion is considered; occasionally it is
complete in the lapse of a few days.

The prognosis depends upon the degree of lead cachexia present,

the possibility of withdrawing the patient from the exposure, and
finally upon the degree and extent of the paralysis and of the
atrophy. It is rendered unfavorable by the necessity of the prolonged
exposure of the patient to lead, by a high degree of disturbance of
the general nutrition of the patient; and by the fact of his having
presented for a considerable period the evidences of lead disease,
with occasional attacks of colic or arthralgia; by the complete loss of
power and electrical reactions in the affected muscles; and, finally,
by absolute wasting of the muscular masses. The prognosis is less
favorable in relapses than in the primary attack.

Progressive muscular atrophy has been frequently observed in

patients suffering from lead disease (Naunyn).

5. The Encephalopathy; Encephalopathia Saturnina.—This term was

suggested by Tanquerel to designate collectively the various morbid
cerebral phenomena produced by chronic lead-poisoning. It
embraces, therefore, those affections due to the action of lead upon
the central nervous system, and occasionally described as lead
insanity, delirium, convulsions, epilepsy, coma, etc. It is, of all the
disorders produced by lead, the most rare. Tanquerel met with
seventy cases only. It occurs only in those individuals who are
exposed to large quantities of lead, and in such a manner as to favor
the absorption of the metal and its compounds by the digestive and
respiratory tract. Hence house-painters and the workers in lead-
factories supply the greater number of cases. The time of exposure
elapsing before the manifestations of the special morbid action of the
poison upon the nervous system show themselves varies from a few
days to many years. In a large proportion of the cases the time has
been less than one year.

Women are much less liable than men—a fact clearly due to the
nature of their occupations even when involving exposure to lead.

The majority of the cases have occurred between the ages of twenty
and fifty. Alcoholic habits, insufficient and unwholesome diet,
privations, exposure, and an irregular life especially predispose
those working in lead to the affection. Lead encephalopathy has
developed with nearly equal frequency in warm and in cold weather.
Relapses are frequent.

Among the prodromes are headache, vertigo, agitated and

interrupted sleep marred by distressing dreams, and troublesome
insomnia; derangements of the special senses, dimness of vision,
alterations of the pupils, tinnitus aurium; dysphagia and a sense of
constriction of the pharynx have also preceded the attack of cerebral
disorder. It is usually preceded likewise, and often by a considerable
lapse of time, by the other lead affections above described—namely,
colic, arthralgia, and palsy. Psychical derangements—stupor, apathy,
or excitement—also precede the attack. In a small number of cases
lead encephalopathy has occurred abruptly without prodromes.

The symptomatology is exceedingly variable and irregular. Three

forms, the delirious, the comatose, and the convulsive, have been
described. These conditions may succeed each other in the same
attack. The delirium is variable in kind. It is apt to be at first tranquil;
after some time it becomes paroxysmal and furious. It is broken by
intervals of somnolence. At length true sleep supervenes, and the
patient awakes restored almost completely to his reason.

Coma may develop suddenly, even instantaneously. In a very few

cases the comatose form has developed itself alone during the
course of chronic lead-poisoning. As a rule, however, it is preceded
by delirium or convulsions.

The convulsive form is the most common. The convulsions may be

partial, involving the face or the one side of it, a single limb, or one
side of the body. They may be general, without loss of
consciousness. These incomplete attacks are apt to be followed,
after a period of dulness or unconsciousness, by acute eclampsia.
Epileptiform attacks may now follow each other in rapid succession,
ending in more or less profound coma. The attacks are sometimes
separated by intervals of uneasiness, restlessness, or delirium.
These attacks continue several days. If they are very violent and
frequent death may rapidly supervene. In favorable cases
consciousness is gradually restored, or the patient may awaken
suddenly from his drowsiness after some hours or a day.

These attacks are not preceded by an aura.

Amaurosis is among the more important of the symptoms produced

by the action of lead upon the nervous system. It is usually
accompanied by dilatation of the pupils. The amaurosis gradually
disappears as the other symptoms subside, and with the
improvement in sight the pupils contract. Recovery is frequently
complete. Occasionally vision does not return with the improved
general condition. Norris13 saw, in two cases of lead-poisoning due
to the use of white lead as a cosmetic, marked choking of the discs
in connection with severe cerebral symptoms. The terminal
condition, when recovery does not take place, is that of nerve-
atrophy.
 13 See this System of Medicine, Vol. IV.

Albuminuria is common in this as in other lead affections. It may be

of moderate amount and due to the rapid breaking-down of the
blood-corpuscles which marks the exacerbation of the general
condition. Albuminuria may be a direct consequence of the
eclampsia. Finally, it may be due to coexisting nephritis.

The prognosis is in a high degree unfavorable.

MORBID ANATOMY AND PATHOLOGY.—There are no well-characterized

anatomical lesions in chronic lead-poisoning. Lead has been found
in almost every organ and tissue in the body. It exists in combination
with the albumen of the tissues. The changes in the nervous system
that have thus far been described are neither constant nor
characteristic. The same is true of the lesions of the intestines. The
paralyzed muscles are found to have undergone atrophy, with loss of
the striæ and increase of connective tissue. The nerve-trunks are
also the seat of atrophic degeneration.

The mode of action of lead is not yet determined. The view of Henle,
that lead acts chiefly upon the unstriped muscular fibre, was at one
time generally accepted, and served to explain many of the
characteristic phenomena of the disease. On the other hand, there is
much in the clinical history to support the opinion of Heubel, that its
primary action is upon the nervous system. Whether the peripheral
degeneration by which the paralysis is to be explained is primary or
secondary to central degeneration in the anterior cornua of the gray
matter of the spinal cord, is yet in dispute. Some of the forms of
encephalopathy are doubtless due to the nephritis which is found in
many cases of chronic lead disease, and are, in fact, symptoms of
uræmia. In the great majority of the cases this is not the case. The
morbid condition must be explained by the direct toxic action of lead
upon the central nervous system. No theory adequate to account for
all the cerebral manifestations has yet been suggested. Naunyn has
pointed out the resemblance between the nervous and psychical
derangements in lead encephalopathy and those which characterize
chronic alcoholism, and suggests that lead, like alcohol, produces
these effects not as a direct poison, but indirectly in consequence of
abnormal nutrition of the whole system, brought about by the
continued circulation of a foreign poisonous material in the blood.

Chronic Lead-Poisoning in Animals.—Animals exposed to lead

under conditions favorable to the development of the lead affections
in man suffer in like manner. Instances of this kind are of frequent
occurrence in and about large lead-factories. The drinking of water
containing lead also gives rise to these affections in animals. Horses,
dogs, cats, and fowls have frequently suffered from lead colic.
Horses used in lead-factories suffer from a form of laryngeal
obstruction due to lead paralysis of the muscles of the larynx. Relief
has followed tracheotomy and the introduction of a canula, and
removal to an atmosphere free from lead has resulted in recovery.
Cats who spend some time in red-lead workshops frequently are
paralyzed. Even the rats in lead-factories become paralytic
(Tanquerel).

DIAGNOSIS.—The diagnosis of the affections due to chronic lead-

poisoning is, as a rule, unattended with difficulty. The malnutrition,
anæmia, poor digestion, foul mouth, stubborn constipation, and the
gingival line, considered in connection with the history of prolonged
or habitual exposure to lead, would warrant the assumption that the
relation between this poison and the symptoms is a causal one.
When there is added colic, arthropathies, and paralysis, or the
cerebral states having the characters above described, the
assumption becomes a certainty. The absence of any one of the
ordinary phenomena, such as the blue line or constipation, would still
leave the clinical picture sufficiently full to justify the diagnosis. The
reaction of degeneration, which is usually marked in saturnine wrist-
drop, with the escape of the supinators, distinguishes it from
pressure paralysis of the musculo-spiral.

TREATMENT.—A. Prophylaxis.—Free ventilation and scrupulous

cleanliness constitute, in general terms, the most efficient
safeguards for those whose occupations involve prolonged exposure
to lead. Workmen employed in lead-factories and those otherwise
exposed to lead should be compelled to wash their hands and
change their outer clothing before eating; they should also bathe
regularly every day on leaving work; under no circumstances should
they be suffered to eat or sleep in or near the workshops. As all
kinds of work in the manufacturing of lead preparations are not
attended with equal risk, the workers should from time to time be
transferred from one department to another or from in-door to out-
door work. In order to prevent the constant rising of dust, the floors
are to be kept constantly sprinkled or covered with moist sawdust. It
is unnecessary to go into further details in regard to the hygiene of
the subject. It is probable that towels and sponges worn over the
mouth, or other forms of respirators, because of the inconvenience
which they occasion and the false sense of security which attends
their use, are of less value than has been generally supposed.

It appears scarcely needful to here insist upon the avoidance of

cosmetics and hair-dyes containing lead, or upon the exercise of
reasonable prudence in the matter of the manufacture, sale, and use
of articles of food or drink which are liable either by accident or
design to become adulterated with lead compounds.

The use of sulphuric-acid lemonade is a measure of prophylaxis of

less real value than was at one time supposed, seeing that the
sulphate of lead is in itself capable of producing the disease.
Occasional doses of magnesia sulphate are of use where a
tendency to constipation exists. Workmen who begins to show signs
of chronic lead-poisoning should without delay abandon their work
and seek some occupation free from its peculiar dangers.

The precautions against the use of water contaminated with lead

have been pointed out under the heading Etiology.

B. Curative Treatment.—When the disease shows itself, no matter in

what form, the primary indication is the discontinuance of exposure
to lead. Chronic cases of malnutrition, constipation, functional
nervous disorder, will occasionally be found upon careful search to
depend upon long exposure to lead in some unsuspected way. The
cause being removed, such cases often promptly recover.
Measures aimed first at the separation of the lead from the tissues,
and then at its elimination from the body, constitute a rational
treatment. Sulphur baths and the internal administration of sulphur
may be employed with a view of converting the lead eliminated by
the skin and mucous membranes into an insoluble sulphide, and
thus preventing its resorption. Repeated laxative doses of castor oil
will remove unabsorbed lead from the intestinal canal. The plan of
treatment at present in general favor consists in the combined use of
potassium iodide and magnesium sulphate. From five to twenty
grains of the iodide are to be given in not less than six or eight
fluidounces of water three times daily, the stomach being empty: two
hours after each dose one or two drachms of the magnesium
sulphate are to be taken; after this dose an ordinary meal.

This treatment is designed to dissolve the lead deposited in the

tissues, and cause its elimination by the mucus of the alimentary
canal in part, and to a slight extent also by the urine. The
magnesium sulphate tends to remove such lead as finds its way into
the alimentary canal thence with all possible rapidity. These
measures, together with the removal of the patient from further
exposure, exert of themselves a favorable influence upon the
malnutrition and anæmia. Quinine, strychnine, iron, cod-liver oil may
be advantageously administered as the toxic effects of the lead pass
away.

The colic demands the administration of opium or its derivatives to

relieve the pain, which is commonly excruciating. For this purpose
the hypodermic injection of morphia is our most efficient remedy.
Alum in doses of twenty to thirty grains every four or six hours is
useful in lead colic.

For the relief of the local paralytic affections local as well as general
treatment is necessary. Massage is of great use, especially when
combined with passive movements. Galvanism, one large electrode
being applied to the cervical vertebræ, the other to the extensor
surface of the affected limbs, is followed by excellent results. Labile
currents of fifteen or twenty cells should be thus applied, the poles
being changed several times at each sitting. As the nutrition of the
muscles improves faradic currents may be occasionally substituted.
Persevering treatment is necessary to obtain the best results.

For the present relief of the arthralgia gentle frictions with or without
anodyne liniments must be employed. The hypodermic use of
morphine may become necessary in cases in which the pain is
urgent. It is, however, here as elsewhere, to be if possible avoided.
The tendency to recurrent joint-pains rapidly disappears as the
poison is eliminated from the organism.

For the relief of the severe cerebral symptoms which are described
under the term Encephalopathy special treatment is of little avail. All
observers agree in recommending an expectant plan. The measures
of treatment directed against the general condition, as above
described, must be steadily continued. The influence of chronic lead-
poisoning upon pregnancy is very deleterious. Constantine Paul14
and others have shown that the early death of the fœtus very
constantly occurs. The prompt removal of women who have become
pregnant, from all exposure to lead, and energetic medicinal
treatment, are needed to obviate the danger of abortion.
14 Arch. gén. de Méd., vol. xv., 1860.

PROGRESSIVE UNILATERAL FACIAL ATROPHY.

 BY CHARLES K. MILLS, A.M., M.D.

DEFINITION.—Progressive unilateral facial atrophy is a disease

characterized by progressive wasting of the skin, connective tissue,
fat, bone, and more rarely muscles of one side of the face.

SYNONYMS.—Progressive facial hemiatrophy, Neurotic atrophy of the

face (Virchow), Facial trophoneurosis (Romberg),
Prosopodismorphia (Bergson), Atrophy of the connective tissue of
the face or Laminar aplasia (Lande).

HISTORY AND LITERATURE.—This disease has been known to the

medical profession since 1825, when, according to Eulenburg, it was
first described by Parry. The Index Catalogue contains references to
thirty books and articles on the subject in various languages.
Eulenburg gives a bibliography which contains thirteen references
not given in the Index Catalogue. One personal case, which will be
detailed later, has fallen under observation. In all, I have collected
from fifty to sixty cases. The number of reported cases is slowly
increasing; nevertheless, the disease must still be regarded as rare.
Carswell,1 according to Lasègue,2 first arranged scientifically the
various lesions which might arise in consequence of a retardation
and arrest, or even inverted action, in nutrition, and at the same time
that he assigned their causes pointed out the several forms of
atrophy. Aran3 has written a contribution on the subject, furnishing
valuable material for classifying atrophies. Romberg called general
attention to the disease in his clinical researches, published in 1846.
He described the disease under the name of a new form of atrophy
of the face, and took the position that it was a primary
trophoneurosis. Of contributions by American writers, a paper by
Bannister4 is the most complete and valuable. This not only contains
two fully and carefully reported cases, but also a thorough discussion
of special symptoms and the pathology of the disease. The chapter
of Eulenburg5 contains an excellent sketch of the disease, and is
especially valuable for the discussion of the various theories as to its
nature.
1 Illustrations of the Elementary Forms of Disease, 1836.

2 Archives générales de Médecine, May, 1852, p. 71.

3 Ibid., Sept. and Oct., 1850.

4 Journal of Nervous and Mental Disease, vol. iii., No. 4, Oct., 1876, p. 539.

5 Ziemssen's Cyclopædia of the Practice of Medicine, vol. xiv., 1877.

ETIOLOGY.—The disease is of much more frequent occurrence

among females than males. Out of 25 cases which I have been able
to classify, 9 were in men and 16 in women. It is an affection of
comparatively early life. The following were the ages of 25 patients:
under ten years, 7; from ten to twenty years, 11; from twenty to thirty
years, 6; over thirty years, 1.

Graefe6 reports a case due to syphilis, in which there was also

paralysis of the left oculo-motor externus and trigeminus. In one of
Bannister's cases the patient had suffered repeatedly from slight
frost-bites. Among the causes which seem to be thoroughly
established traumatism holds the first place. The affection could be
traced to injury in a fair number of the published cases. A case is
reported by Maragliano7 of a child who had a fall in which she struck
the left half of her face, and in consequence of which a
circumscribed swelling appeared near the external angle of the left
eye and remained for a few days. Shortly after this the left half of the
face began to grow smaller than the right. Schuchardt8 speaks of a
fall on the head which left a cicatrix on the right parietal bone below
the coronary suture, the injury being followed by facial atrophy.
Panas9 reports a case in which the wasting of the face followed a
fracture of the lower jaw. In one of two cases reported by Bannister,10
a man, aged forty-two, is stated to have been thrown from a stage-
coach, falling on his head, and not losing consciousness, but
receiving a scalp wound over the coronal suture. Subsequent to this
time he had cerebral symptoms, physical and mental, and unilateral
facial atrophy developed.
6 Quoted by Rosenthal.

7 Note di Clinica Medica, Genoa, 1881, translated by Joseph Workman, M.D.—

Alienist and Neurologist, vol. ii. No. 2, April, 1881, p. 146.

8 Quoted by Eulenburg.

9 Bull. Soc. de Chir. de Par., 1869, 1870, 2d S. ex., 198, and Gaz. des Hôpitaux,
1869.

10 Journ. Nerv. and Ment. Dis., Chicago, 1876, iii. pp. 539-560.

SYMPTOMATOLOGY.—Before discussing the symptomatology I will give

brief notes of the following case, which has not been before
reported, and which was observed by me while in charge of the
Nervous Dispensary of the Hospital of the University of Pennsylvania
several years since.

C——, aged seventeen, white, a mill-operative, had a good family

history. Three years before coming under observation a white spot
appeared in the skin over the right malar prominence, and since that
time this side of the face had gradually atrophied. When this patient
was first examined the skin had a mottled appearance. Close
examination showed that the skin, connective tissue, and bone were
decidedly wasted, and there seemed also to be some loss of
substance in the muscles of the right side of the face. The mouth,
however, could be closed properly, the lips showing no puckering or
drawing to one side. The right half arches of the palate were
atrophied. The uvula was drawn slightly but positively to the left.
Careful examination of the membrane of the drum of the right ear
showed it to be atrophied. An ophthalmoscopic examination of both
eyes was made, but no changes were discovered. No changes were
noted in the hair of the patient on the affected side. He was able to
perform all movements with the facial muscles, but the creases and
contours of the face in repose and in motion were less marked on
the right side than on the left. The skin of the right side of the face
seemed to be bound closely to the bone. The muscles on the same
side responded well to the faradic and galvanic current. The patient
had at times a peculiar sensation of stinging in the atrophied half of
the face. He was treated with electricity, local massage, and tonics,
and did not improve, but did not get worse while under observation,
a period of several months.

At the Hospital of the University of Pennsylvania I also observed one

well-marked case of unilateral atrophy of the tongue without atrophy
of the face, of which, unfortunately, I have not preserved the notes.
The patient was a middle-aged man with a syphilitic history. The
atrophy in the reported cases has occurred much more frequently
upon the left than upon the right side of the face.

Changes in the skin are among the most constant and striking
phenomena. By some dermatologists the disease is regarded as a
form of morphœa, the keloid of Addison. Morphœa as described by
Duhring11 occurs in the form of patches, rounded, ovoid, or irregular
in outline, small or large, tough or leathery, smooth or shiny, and may
also manifest itself in the form of atrophic pit-like depressions in the
skin. The skin alterations differ somewhat in character; frequently
one of the first signs of the disease is the appearance of a white spot
on the cheek. This was the first noticeable phenomenon observed in
the above case. After a time this spot or patch may change in color,
becoming of a yellowish or brownish hue. A number of spots
appearing and undergoing change, the skin after a time assumes a
mottled appearance. In some of the reported cases a yellowish, or
yellowish-gray, or brownish appearance is recorded as having been
present. In these the observations were probably made after the
affection had existed for some time, and in them the white spots or
patches were probably at first present. In one of Romberg's cases,
first recorded when the patient was nine and a half years of age, he
noted the deposit of a yellowish-gray pigment which began at the
median line and extended to the angle of the jaw across the lower
half of the face and neck, divided here and there by portions of
healthy skin. Discoloration, varying in intensity, also existed in
irregular patches on the upper part of the face and on the forehead.
The discolored tissues were glossy and greasy-looking. The skin
adhering to the bone often gives the patient an aged appearance.
Pruritus has been several times observed.
11 Medical News, vol. xlv. No. 4, July 26, 1884, p. 85.

Changes take place in the hair. Sometimes it simply changes color;

at other times it falls out or ceases to grow. The beard or hair of the
head will thus be gray or white upon one side, or in one or two
locations of one side and not of the other; or the hair may be absent
or simply thinned out. Peculiar limitations in the extent to which the
hair is affected are sometimes observed. In one of Romberg's cases,
for example, complete absence of the eyelashes from the inner
angle of the eye to the middle of the lids was noted; the hair was
very thin, and in some parts altogether wanting, and the left eyebrow
was almost entirely devoid of hair. The changes which take place in
the color of the hair in some severe cases of chronic trigeminal
neuralgia will be recalled in this connection. I have known of several
instances in which a few locks of hair were turned gray or white on
the neuralgic side. Anstie, author of the work on Neuralgia, was a
sufferer from supraorbital neuralgia, and the eyebrow of the same
side contained a white tuft. Facts of this kind serve to corroborate
and emphasize the view that unilateral facial atrophy is a tropho-
neurosis.

Anidrosis, or absence of perspiration, on the atrophied side of the

face is a nearly constant phenomenon. In one of Bannister's cases,
a printer, attention was first called to the patient by the fact that in
working a hand printing-press in the hot weather he perspired only
on the right side of his face. The left side remained perfectly dry, no
matter how warm the temperature or hard the labor. This hemidrosis,
or unilateral sweating, was confined only to the right side of the
forehead, the right cheek, side of the nose, and lip. On the chin it
encroached a little on the left. Under the chin and in the throat there
was a little excess of perspiration on the right side; on other portions
of the body no difference was noted. Nicati12 considers a
combination of symptoms, several of which were present in a
recorded case—namely, lowered temperature, stoppage of
perspiration, and wasting of the side of the face—as indicating a
paralysis of the sympathetic nerve in what he calls its second or
more advanced stage. In true facial hemiatrophy, however, other
phenomena of such paralysis are wanting. Brunner13 gives a case in
which perspiration, tears, mucous secretions, and temperature were
all diminished on the affected side, and in which were also present
exophthalmos and dilatation of the pupil. The cervical sympathetic in
this case was irritated by a tumor. I agree with Bannister, however,
that while we cannot exclude the possibility of the participation of the
sympathetic in hemiatrophy of the face, the evidence is not
sufficiently positive. Mechanical interference with the sweat-glands
by pressure or otherwise has been suggested. The true view to take
would seem to be that the perspiratory disorder is due to the same
central or peripheral neurotic affection which gives rise primarily to
the atrophy. Eulenburg says that the secretion of the sebaceous
follicles is in most cases diminished or stopped on the atrophied
side, while the sweat-glands often act in a normal manner; but his
experience does not seem to correspond with that of the majority of
other observers.
12 Sur Paralysie du Nerf sympathetique-cervical, Lausanne, 1873, quoted by
Bannister.

13 St. Petersburger Med. Zeitschr., ii., 1871, quoted by Bannister.

Seguin, Dreschfeld, and others have found no notable differences in

surface temperature between the two sides of the face. In one of
Bannister's cases the temperature was tested in both ears, and a
difference of six-tenths of a degree Fahrenheit in favor of the ear of
the unatrophied side was found, that of the left ear being 97.6°, and
that of the right 98.2°. This examination was repeated on another
occasion with nearly the same result.

Weakness of pulsation in the carotid of the affected side has been

observed. Sometimes the power to blush is lost on the affected side,
but this may return. In one instance the cheek, having been
reddened by electrical stimulation, so remained for an hour or more.

Paræsthesiæ, such as pain, numbness, and stinging sensations, are

not uncommon. A diminution of the general tactile sensibility of the
skin of the affected side has been observed by Tanturri14 and by
Vulpian,15 and perhaps by others, but anæsthesia is not commonly
present.
14 Il Morgagni, 1872, quoted by Bannister.

15 L'Appareil vaso-moteur, ii. p. 430.

Eulenburg and Guttmann found atrophy of the muscles supplied by

the motor branch of the fifth nerve—namely, the masseter and
temporal. The changes which take place in the muscles of the
affected side are, so far as can be judged, not of the character of
fatty degeneration. Probably a general and uniform shrinkage of
calibre of muscular fibres and bundles occurs. Certainly, this would
seem to be true of the muscles supplied by the portio dura. The
muscles on the atrophied side respond to both the faradic and
galvanic currents, reactions of degeneration not being present. The
absence of the reactions of degeneration in the facial muscles shows
that normal muscular fibres remain. In one reported case the facial
muscles seemed at first to react more readily than in normal
conditions. The muscles of the upper lip sometimes appear to have
wasted, preventing full closure of the mouth on this side. Fibrillary
twitchings have been observed only very rarely. Voluntary control
over the muscles of the affected side is not impaired.

In one of Bannister's cases the first upper molar of the left side
sometimes ached, and the gum and bone were so wasted as to
expose its roots for a considerable distance. Falling out of the teeth
has been observed in a few other cases.

Atrophy of the tongue is associated with the facial wasting in a

certain percentage of cases, and the uvula and soft palate are also
sometimes wasted. On the other hand, atrophy of the tongue has
been observed as an isolated phenomena.

Atrophy of the bones of the face is frequently present, and has been
determined by careful measurements. It will show to a greater or
lesser extent according to the age of the patient. When the disease
arises after the bony development has been fully acquired, there will
be little external evidence of osseous involvement; when it begins
during the time of active growth of the bone, as it does not
infrequently, the arrest in the skeleton will be very apparent. Thus in
a number of cases beginning in early childhood bone atrophy has
been a very marked feature.

Eulenburg says that the functions of taste, smell, hearing, and

seeing are not interfered with in any of the reported cases; but
Bannister reports impairment of the sense of taste in both of his
cases. In one the whole left half of the tongue was involved, in the
other only the left posterior third. In the first of these, in which the
whole left half of the tongue was involved, both the glosso-
pharyngeal and the chorda tympani nerves were affected. According
to Bannister, the significance of this observation is that either the
glosso-pharyngeal and fifth nerves are both involved, or that the
taste-fibres for the base as well as tip of the tongue are derived from
the last-named nerve. In this case, however, which was due to a
severe injury, the headache, mental confusion, loss of hearing, etc.
more probably indicated a widespread intracranial lesion, affecting to
some degree the nucleus of the glosso-pharyngeal. In the other
case, which was apparently a typical one of unilateral facial atrophy
in its early stage, no history of traumatism was present, and the
sense of taste, which was carefully tested several times, was
seriously impaired over the left posterior third of the tongue.

Bannister discusses the probable cause of impairment of taste in

each case, as follows: “The atrophy seemed to involve the region
supplied by the second division of the fifth nerve as much as, or
more than, the other divisions; and on this is situated the spheno-
palatine ganglion which gives off the Vidian nerve, the upper division
of which, the superior superficial petrosal nerve, is supposed by
Schiff to contain the taste-fibres, which return from the lingual nerve
through the chorda tympani. The usual theory of this disease is that
it depends upon an affection of the trophic fibres contained in the
fifth nerve or one or more of its divisions. Accepting this theory,
Baerwinkel,16 noticing a case of unilateral atrophy of the face
affecting only the second division of the fifth, and, as he held,
indicating trouble with the spheno-palatine ganglion, its trophic
centre, mentions the fact that there was no impairment of taste in the
anterior portions of the tongue as rather against the hypothesis of
Schiff as to the course of the taste-fibres. At the same time he gives
two other observations of lesions of the trifacial and the seventh
nerve that favor it. In our patient I should have expected a priori to
have found the taste affected in the anterior portion of the tongue, if
anywhere, but the reverse was the fact. It is difficult to suppose an
accidental lesion of the glosso-pharyngeal coexisting with the one of
the trigeminus that produces the atrophy when there are no more
signs of nervous disorder than there were in this case. On the other
hand, the taste-fibres of the glosso-pharyngeal are not generally
supposed to have such connections with the fifth nerve as to be
involved in its disease, while those of the chorda tympani, of the
connections of which with the trigeminus there is much more
physiological evidence, escape. The observation is a contradictory
one, and I cannot at present explain it.”
16 Deutsch. Archiv f. klin. Med., xvii. 1, 1875.

So far as I know, ophthalmoscopic changes have never been noted.

In a few cases enophthalmos, or sinking in of the eye, doubtless due
to the disappearance of orbital fat as the disease advances, has
been recorded.

Defects of hearing, and even partial deafness, have been reported in

a very limited number of cases, making it questionable whether this
symptom is a coincidence or a complication. In the case reported by
me careful examination of the membrane of the tympanum by W.