uncomplicated. Thus, refractive errors, such as hypermetropia or myopia, are often associated with muscular insufficiencies, either of those directing the eyes laterally, or of those which move them in the vertical direction. Again, insufficiency of either of these muscles may be associated with weakness of the muscle of accommodation. These are but a few of the complications which may be found, and, in many of these nervous complaints in which the predisposing irritation is found in the eyes and their motor apparatus, the simple correction of a refractive error is by no means sufficient to bring relief to the nervous condition. When once a neuralgic, choreic, or epileptic habit has been long established, not only may it be necessary to remove the principal source of irritation, but all irritation, before the habit will be discontinued. It must not, therefore, be supposed, even if the hypothesis that refractive and muscular errors of the eyes constitute a very important factor in the neuropathic condition, that the simple adjustment of a pair of glasses, or the simple relaxation of a muscle, must of necessity establish the cure of a nervous disease.

The irritation experienced in and about the eyes, and in the forehead and temples, as a result of ametropia or muscular anomalies, is called asthenopia. It is a complaint for which oculists are very frequently consulted, and doubtless yields more readily than complaints arising from the same cause more distantly located, or of more severe nature; yet it is well known to oculists that even asthenopia does not al

ways yield to such simple measures as have been mentioned.

Hence the highest skill and most patient effort may be demanded for the removal of ocular disturbances which may cause nervous troubles, and the failure of efforts directed only to some prominent ocular defect would not of necessity argue against the probability that the eyes may, after all, be the seat of trouble. Bearing this in mind, we are prepared to examine more in detail a few forms of neuroses and their relations to ocular defects.

CEPHALALGIA OR HEADACHE.

The form of nervous disturbance more common than any other, perhaps, is headache. The habitual sufferers from this complaint are everywhere, and, inasmuch as the subjects of the disorder are usually able to be about, and generally to attend to the ordinary duties of life, they are forced to surrender themselves to the ever-returning torture with as much resignation as possible; and, after trying many remedies, almost all of which may, for a brief period, seem to modify their sufferings, they at length submit passively to their fate, with the comforting assurance that the disorder is constitutional, and that nothing can be done.

Although headaches take a variety of forms, an outline of the most characteristic features of the disorder may be drawn in such a general manner that the details of the picture may be easily filled in for an individual case.

The pain most usually attacks the temples, the supra-orbital and the occipital regions, the parts within the orbit, and more rarely the top of the head. It is more or less paroxysmal, sometimes occurring with comparative regularity, but frequently arising after a period of anxiety, care, worry, or excitement. In many cases the pain is continuous, and paroxysms consist simply of increase of the ordinary suffering. In the majority of females examined who have been habitual sufferers from headache, there has been found habitual pain at the origin of the trapezius muscles, at the point over the extremity of the spinous process of the seventh cervical vertebra, and at the lower angles of the scapula. Less common, but quite characteristic pains accompanying headache are between the angles of the scapulæ and at the lower part of the dorsal region. It is worthy of observation that in general, if pain is habitually experienced at the lower angles of the scapulæ, it is rarely found at the point over the spinous processes of the vertebræ situated between those points; and, again, if pain is habitual over the spinous process of the seventh cervical vertebra, it may be presumed to exist, although it is not invariably found, at one of the other locations below it. These pains occur much less frequently in men, who, more than women, suffer from dull pains at the occipital region. This occipital pain, which is invariably located in the scalp and occipital muscle, is very frequently and incorrectly spoken of, sometimes even in medical literature, as "pain at the base of the brain.”

Other sympathetic pains are, at the turn of the shoulders and along the course of the triceps muscle, and in the upper portion of the chest.

Patients suffering from headaches are frequently dyspeptics; they often suffer from insomnia, and habitual constipation is also a not infrequent attendant condition.

To the various conditions just named, the headaches are often attributed, and many patients feel sure that they can account for their headaches as of stomachic origin, because they habitually suffer from disturbance of the stomach at the time of, or just before, the paroxysm of headache. That these are simply attendant symptoms and not causative influences, will be seen as we advance, and the fact that an indiscretion in diet, or an enforced loss of sleep, may act as an immediate cause, will be found to be explained on the principle of increased demand upon nervous energies already rendered inadequate to the ordinary demands of the system, and that this increased demand acts in the same manner as would other calls upon the nervous energies.

Habitual sufferers from headaches, although often persons of highest mental culture and of superior intellectual endowments, are liable to suffer from chronic lassitude and inaptitude to set themselves about any employment, especially if it demands much mental exercise. In some cases a confusion of ideas is so conspicuous a symptom that patients express fears of approaching insanity. There is, in a large proportion of instances, a general nervous irritabil

ity, inability to continuous exertion, and mental depression. Still other cases are so characterized by general impaired functional activity, that the principal local manifestation, the headache, is apparently a secondary subject of attention. Such patients exhibit symptoms varying in a considerable degree, according to the sex of the individual, and the cases are known as spinal irritation, neurasthenia, etc., conditions to which attention will be presently directed.

Chronic headaches are common among those who inherit a neuropathic tendency; by far the greatest number of subjects acquiring the predisposition by inheritance. Certain collateral influences modify the disease in a marked degree. Thus, a residence in a malarial district may give to the complaint a more distinctly periodical tendency, and subjects of headache passing an active life in the open air will, in general, experience less of the associated neuralgic pains in the back and sides than persons of sedentary habits.

The most important facts relating to the etiology of the complaint may be briefly recapitulated as follows: It is an exceedingly chronic disorder, often relieved temporarily, but rarely, if ever, permanently cured by medicines. It is often traceable to the earliest years of the patient. The tendency is frequently, if not generally, hereditary. It is usually intermitting, and demands upon the nervous energies, slightly in excess of those ordinarily required, act as immediate causes. We also find that other symptoms of nervous disturbance, such as insomnia, dyspepsia, and