geons and opticians, proved ineffectual. At the end of the recital of his troubles, I drew a bow at a venture, and asked, "What about your fear of the dark?" The effect was electrical. He admitted that he was terrified in the dark, and said that even when shooting in the jungle, he would arrange his plans very carefully so that he might reach his tent by sunset. He would then retire for the night with a lighted lamp, and not venture forth until daybreak, but he took elaborate precautions to hide the cause of his conduct from his servants. All his life he had kept his phobia a close secret, even from his wife. It dated from early childhood, and he could not explain it. If he had had a genuine fear of the light, it is very unlikely that he would have chosen India for his life's work.

It may be added that he had also an intense fear of dogs, and could not bear one to come near him.

If such a man would take so much trouble to conceal what he considered to be unmanly, it is clear that much understanding and sympathy are necessary in order to arrive at the truth. So many similar histories, though of course less striking than the foregoing, have been obtained, that I am convinced that fear of the light as a manifestation of a concealed fear of the dark is a genuine instance of the ambi-valency of

emotion.

In this connection another case comes to my mind. Two years ago I was called to see a child of three, who had been unable to face the light for some weeks. The mother feared some serious inflammation, and yet must have had some doubts, or she would have sought advice earlier, for they were wealthy folk, and the child was heir to a large estate. The child entered the room with every appearance of photophobia. Some time was necessary to win his confidence, but at length he allowed me to make an examination, and to my astonishment nothing abnormal could be found. He bore the strong light of a focused lamp without difficulty or discomfort. During the examination he repeatedly pushed his hand into his mother's bosom, which awakened my suspicions. He slept with his nurse. I asked to see her. She looked a healthy country girl, but enquiry revealed that she had had charge of the boy for only a week. The previous nurse, a woman of forty-five, had left a week before, and the mother under pressure gave an unsatisfactory account of her. She had behaved strangely. She was infatuated with the child, declaring that he was as sweet and holy as the Infant Jesus, and that people ought to approach him on their knees. On several occasions the mother had heard the child panting, and thinking he wished to relieve his bowels had taken him to the lavatory, but he had shown no desire to avail

himself of the opportunity. There was reason to believe that the mother was concealing other significant facts. The child's photophobia persisted for many months, and then gradually disappeared without treatment. I look forward with much interest to developments in adult life.

Another case which illustrates ocular symptoms associated with sexual difficulties beginning in childhood is the following. A lady, then thirtyfive, was given + 2 Spheres for constant wear nine years ago. These made her comfortable. Four years ago the eyes again gave trouble. Owing to the war she could not consult me, and within a period of two years she sought the advice of six London oculists, and received six different prescriptions for glasses. The discomfort continued. Eventually I was able to examine her. The various prescriptions were compared, and small fractional differences in them were found. I invited her to talk about her emotional life. She graphically described a terrific struggle against masturbation since the age of nine, and from the age of twentyseven homosexual relations with a woman older than herself, until she was over forty. Moral considerations had then caused her to abandon the life, and the eye trouble coincided with this period of renunciation. When I last saw her, she had returned to glasses which did not differ practically from those which had relieved her in the first instance.

In support of the view that the mental state of the patient determines the onset of symptoms from a practically unchanging error of refraction, is the periodicity of recurrence. Frequently it has been noticed that patients come for advice in the same month of the year, at intervals of several years. They are unaware that they have done so, and when their attention is drawn to the fact, they cannot explain it. The following case may be cited: A lady consulted me in March 1918 for headache and eye-strain of six months' duration. She had done so previously, in March 1915, and then gave the same history. Her health had suffered in other ways in the previous September. She knew no reason for this, but soon recollected with much emotion that she had been married twelve years previously in March, and in September had discovered that her husband was a chronic drunkard, and a ne'er-do-weel. Beyond the emotion shown, I have no reason for assuming that the association of her distress with those months had any bearing on the case; such an association has happened on so many occasions however that I am convinced that it was a factor.

Naturally these coincidences led to an examination of the type of individual affected by these stresses, and it soon became easy to distinguish between those patients whose eyes were a genuine source of dis

comfort, and those to whom the pinprick of a small error caused excessive reaction. The latter were one and all of the kind commonly known as the highly strung. Sensitive, inwardly shy, though outwardly very selfpossessed, obviously shrinking from meeting the unpleasant side of life, often giving clear signs of physical bravery and moral cowardice, yet with a strong sense of duty and conscience which impels them to make efforts to overcome their ethical shortcomings, they are continually in a state of unconscious conflict. A glance at the face is sufficient to reveal their stresses to an observant eye. An appearance of anxiety frequently is present, whilst the tight lips and turned down corners of the mouth show the struggle for self-control, and the disappointing results thereof.

In order to determine what proportion of the cases had other than ocular symptoms, I asked all patients who came to me for glasses if they suffered from insomnia, depression, cold extremities, and giddiness, and in order to get some idea how they spent their unconscious hours, to what extent they dreamt. One hundred consecutive cases gave the following results:

13 were males, 87 females. This sexual disproportion is very significant. Six were under twenty years of age, 19 were between twenty and thirty, and 75 were thirty years and over.

Headache. In 16 headache was not complained of. 84 were affected, five very severely; the pain was often associated with other symptoms of migraine.

Insomnia. Only eight were satisfied with their sleep. 69 slept badly. 23 slept heavily, but were not refreshed afterwards. Morning headache was common in the heavy sleepers.

Depression. 93 patients complained of this symptom, and seven of them described it as very severe. In most of the cases the depression was of such a character as to make the patient eloquent upon the matter.

Cold extremities. 61 suffered from cold hands, and 78 from cold feet. A history of chilblains was common. Hot hands occurred in five cases, and hot feet in three. One woman who complained of cold hands, was much troubled by hot feet. It frequently happened that on the coldest nights in winter she was compelled to push her burning feet outside the bedclothes, before she could get to sleep. This unequal action of the vasomotor system needs further investigation.

Giddiness was present in 60 cases.

Dreams. 44 patients stated that they dreamt much, 35 only occasionally, and 21 said they never dreamt. It was noticed that the bad sleepers.

usually had nightmare, whilst the dreams of the heavy sleepers were generally of the innocent variety.

Judging from certain cases which were more fully investigated, a similar frequency of other neurasthenic symptoms would have been found in the patients who attend the ophthalmic out-patient department in such large numbers. An error of refraction could be found in nearly every instance, and glasses were prescribed, but it was with a sense of impotence to deal with the whole condition adequately, since the diseased state was clearly not local, but general.

In addition to giddiness, there is sometimes a definite fear of falling, accompanied by a sense of unsteadiness of objects looked at. Thirteen years ago I was consulted by a woman who suffered from such a fear. She had a moderate degree of astigmatism, for which glasses were prescribed. A month ago I saw her again. For years she has been completely helpless and horribly deformed, owing to rheumatoid arthritis. In a talk with her husband, I learned that after bearing two children, and before the disease had started, she had unaccountably become sexually anaesthetic. The disease started in the second and third fingers of the right hand. Can it be that the Freudian explanation of the fear of falling in dreams applies equally to this phobia?

It has become a habit to ask every patient with headache, and other vague ocular symptoms, "When did you have a nervous breakdown?" It is astonishing how often a history can be obtained. Want of adaptation in varying degree to the stresses of life can be observed in every case, and a serious want in a very large number. In this connection I would like to relate the following: A woman of about thirty went into a nursing home for a rest cure. She formed a strong attachment to her night nurse, who would sit on her bed during the wakeful hours, conversing on various matters. Suddenly one night they both became much moved, and found themselves in each other's arms in an ecstasy of sexual emotion. She was much ashamed the next morning, but the friendship grew. When she left the home, the relationship was broken on moral grounds. She was better mentally, but her eyes began to give trouble, and she consulted me. I prescribed glasses. A month or two later, I wrote enquiring as to her progress. She replied that she had relapsed, and was again going into a nursing home for a rest cure. I asked her when she first came, if her doctor knew about her experiences. She said "No," and refused to allow me to tell him.

Many, if not most of my adult patients have suffered from "neuritis," whatever that may mean. Scores of them have had abdominal operations

for conditions such as floating kidney, and uterine troubles of an uncertain nature. Mucous colitis, disordered action of the heart, neuralgia, skin lesions, such as eczema and pigmentary disturbances, tics, chorea, wryneck, have succeeded each other at varying intervals. The alternation of manifestations of illness has not received the attention it deserves. A case illustrating it is the following. A young lady of twenty-six consulted me in February, owing to headache and aching of the eyes after reading for a short time. Examination showed that the refraction had not changed in the slightest degree since a visit five years previously. The symptoms had arisen in the previous December. In October she had complained of abdominal pain, and had been under observation in a nursing home for two months for suspected appendicitis, but the symptoms disappeared without a definite diagnosis having been made. Before this illness she had been suffering from neuritis in her arms, which in turn had followed some other ailment. She was certain that she had been perfectly well before the previous March. When asked if she had experienced any emotional stress at that time, she became much agitated, and declared that it was impossible to discuss or even think of it. It seemed to me possible that her various illnesses, for which no organic lesion had been found, served to express an unassimilated emotional experience. She has since married, and is now in good health.

Glaucoma.

The effect of emotion on glaucoma has been known for a long time, though the occurrence of the disease in later middle life has tended to obscure the frequency of the association. An interesting case is the following. A lady who had had an operation on one eye five years previously, suddenly developed acute pain in and around the second eye, whilst staying with her mother. Examination revealed no increase of tension, and a diagnosis of neuralgia was made. She was staying in the house of a medical man, who was interested in the Freudian theory. Whilst discussing dreams, she declared herself a disbeliever in their significance, and she was invited to put the matter to a practical test. She had had two innocent dreams. A superficial analysis rapidly brought both dreams to a consideration of the father, who was much loved, and who had been dead two years. The patient became emotional and suddenly asked that her eye should be examined, as it felt very uncomfortable. I saw her, found the pupil dilated and the tension raised, and operated upon her the following morning. Her mother, grandmother, and probably her great-grandfather had suffered from acute glaucoma.