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Eating-related distress (ERD) is one type of psychosocial distress among advanced cancer patients and family caregivers. Its alleviation is a key issue in palliative care; however, there is no validated tool for measuring ERD.The purpose of this study was to validate tools for evaluating ERD among patients and family caregivers. The study consisted of a development and validation/retest phase. In the development phase, we made preliminary questionnaires for patients and family caregivers. After face validity and content validity, we performed an exploratory factor analysis and discussed the final adoption of items. In the validation/retest phase, we examined factor validity with an exploratory factor analysis. We calculated Pearson's correlation coefficients between the questionnaire for patients, the Functional Assessment of Anorexia/Cachexia Therapy Anorexia Cachexia Subscale (FAACT ACS) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Cachexia 24 (EORTC QLQ-CAX24) and Pearson's correlation coefficients between the questionnaire for family caregivers and the Caregiver Quality of Life Index-Cancer (CQOLC) for concurrent validity. We calculated Cronbach's alpha coefficients (Cronbach's alpha) and intraclass correlation coefficients (ICCs) for internal consistency and test-retest reliability. We performed the Mann-Whitney U test between the questionnaires and cancer cachexia based on criteria from the international consensus for known-group validity.In the development phase, 162 pairs of patients and family caregivers were asked to participate, and 144 patients and 106 family caregivers responded. In the validation/retest phase, 333 pairs of patients and family caregivers were asked to participate, and 234 patients and 152 family caregivers responded. Overall, 183 patients and 112 family caregivers did the retest. Seven conceptual groups were extracted for the ERD among patients and family caregivers, respectively. Patient factors 1-7 correlated with FAACT ACS (r = -0.63, -0.43, -0.55, -0.40, -0.38, -0.54, -0.38, respectively) and EORTC QLQ-CAX24 (r = 0.58, 0.40, 0.60, 0.49, 0.38, 0.59, 0.42, respectively). Family factors 1-7 correlated with CQOLC (r = -0.34, -0.30, -0.37, -0.37, -0.46, -0.42, -0.40, respectively). The values of Cronbach's alpha and ICC of each factor and all factors of patients ranged from 0.84 to 0.96 and 0.67 to 0.83, respectively. Those of each factor and all factors of family caregivers ranged from 0.84 to 0.96 and 0.63 to 0.84, respectively. The cachexia group of patients had significantly higher scores than the non-cachexia group for each factor and all factors.Newly developed tools for measuring ERD experienced by advanced cancer patients and family caregivers have been validated.

BACKGROUND For cancer patients nearing death, the prediction of their prognosis by physicians is crucial. This study examined the usefulness of the 1-Day Surprise Question (1DSQ). METHODS This study was conducted as part of a multicenter prospective observational study. The physicians answered the 1DSQ "Would I be surprised if this patient died in the next 1 day?" when patients have palliative performance scale (PPS) ≤20. We calculated the sensitivity and specificity of the 1DSQ. Moreover, using multivariate analysis, we evaluated the characteristics of patients who died among those whose physicians answered the 1DSQ as "not surprised". RESULTS Overall, 1,896 patients were enrolled, and 1411 (74.4%) were analyzed between January and December 2017. Among these, 847 (60.0%) patients were placed in the "not surprised" group. The sensitivity, specificity, and positive and negative predictive values of the 1DSQ were 82.0% [95% confidence interval (CI): 77.5-85.8%], 45.5% (95% CI: 44.4-46.4%), 27.4% (95% CI: 25.9-28.7%), and 91.0% (95% CI: 88.9-92.9%), respectively. Multivariate analysis revealed that urine output over last 12 hours

Purpose All five senses (i.e., sight, smell, hearing, taste, and touch) are used to enjoy meals; however, impairments in sensory perception, which are common among cancer patients, seriously impact health and cause eating-related distress. Methods Using a self-report questionnaire, we surveyed patients with advanced cancer undergoing treatment at 11 palliative care centers. Multivariate analyses were conducted to explore the impact of taste and smell disturbances on dietary intake and cachexia-related quality of life (QOL). Dietary intake was assessed using the ingesta-Verbal/Visual Analog Scale, while taste and smell disturbances were assessed using an 11-point Numeric Rating Scale (NRS). Cachexia-related QOL was assessed using the 12-item Functional Assessment of Anorexia/Cachexia Therapy (FAACT) Anorexia/Cachexia Subscale. Results Overall, 378 patients provided consent to participate. After excluding patients with missing data, data were analyzed for 343 patients. Among them, 35.6% (n = 122; 95% CI 0.28–0.38) and 20.9% (n = 72; 95% CI 0.17–0.25) experienced disturbances in taste (NRS ≥ 1) and smell (NRS ≥ 1), respectively. Multivariate analyses revealed that, independent of performance status and cancer cachexia, taste and smell disturbances were significantly associated with worse FAACT Anorexia/Cachexia Subscale scores and dietary intake. Conclusion More severe taste and smell disturbances were associated with poorer dietary intake and cachexia-related QOL. Diagnosing and treating such disturbances may improve dietary intake and cachexia-related QOL, regardless of performance status and cachexia. Additional research is required to establish effective treatment strategies for disturbances in taste and smell.

Background The study aimed to clarify the efficacy of the “3‐Day Surprise Question (3DSQ)” in predicting the prognosis for advanced cancer patients with impending death. Patients and Methods This study was a part of multicenter prospective observational study which investigated the dying process in advanced cancer patients in Japan. For patients with a Palliative Performance Scale ≤20, the 3DSQ “Would I be surprised if this patient died in the next 3 days?” was answered by their physicians. In addition to the sensitivity and specificity of the 3DSQ, the characteristics of patients who survived longer than expected were examined via multivariate analysis. Results Among the 1896 patients enrolled, 1411 were evaluated. Among 1179 (83.6%) patients who were classified into the “Not surprised” group, 636 patients died within 3 days. Among 232 (16.4%) patients of “Yes surprised” group, 194 patients lived longer than 3 days. The sensitivity, specificity, positive predictive value, and negative predictive value of the 3DSQ were 94.3% (95% confidence interval [CI]: 92.7% to 95.8%), 26.3% (95% CI: 24.8% to 27.6%), 53.9% (95% CI: 53.0% to 54.7%), and 83.6% (95% CI: 78.7% to 87.7%), respectively. Multivariate analysis showed palpable radial artery, absent respiration with mandibular movement, SpO2 ≥ 90%, opioid administration, and no continuous deep sedation as characteristics of patients who lived longer than expected. Conclusions The 3‐Day Surprise Question can be a useful screening tool to identify advanced cancer patients with impending death., Survival prediction in cancer patients with impending death is important for patients, families, and physicians. The 3‐Day Surprise Question can be a useful screening tool to identify advanced cancer patients with impending death.

BackgroundThis study aimed to investigate the effectiveness of anticholinergics (AC) for death rattle in dying patients with cancer.MethodsThis is a prospective cohort study enrolled Terminally ill adult (20 years or older) patients with cancer who developed substantial death rattle (Back score ≥2) from 23 palliative care units in Japan. AC treatment for death rattle was prescribed according to primary physician’s decision. The primary outcome was the proportion of patients whose death rattle improved, which was defined as a Back score of ≤1. We compared the proportion of improved cases in patients treated with (AC group) and without (non-AC group) AC, controlling potential confounders by employing propensity score weighting.ResultsOf the 1896 patients enrolled, we included 196 who developed a substantial death rattle. Of these, 81 received AC. 56.8% in the AC group and 35.4% in the non-AC group had an improved death rattle at 8 hours after baseline. In the weighted analysis, AC group showed significant improvements in death rattle, with an adjusted OR of 4.47 (95% CI 2.04 to 9.78; p=0.0024). All sensitivity analyses achieved essentially the same results. In the subgroup analysis, ACs were strongly associated with death rattle improvement in men, patients with lung cancer, and type 1 death rattle (adjusted OR 5.81, 8.38 and 9.32, respectively).ConclusionsIn this propensity score-weighted analysis, ACs were associated with death rattle improvement in terminally ill patients with cancer who developed substantial death rattle.Trial registration numberUMIN-CTR (UMIN00002545).

BackgroundThe definition of sudden unexpected death (SUD) in patients with advanced cancer near the end of life (EOL) was unclear.MethodsThis study was conducted as a single-center retrospective analysis. We analyzed 1,282 patients who died of advanced cancer from August 2011 to August 2019 retrospectively. We divided into patients who died within 24 h after the acute change of general condition or others and analyzed risk factors by a multiple logistics method. The reason for SUD was found, the reason is detected by using an electronic medical record retrospectively. The risk factors in SUD were analyzed using age, sex, EOL symptom and treatment, the primary site of cancer, metastatic site of cancer, comorbidly, chemotherapy, and Eastern Cooperative Oncology Group Performance Status. The primary endpoint was to identify the frequency and risk factors of SUD in patients with advanced cancer near the EOL.ResultsAs a background, the median age is 73 years old, 690 males, 592 females, 227 gastroesophageal cancers, 250 biliary pancreatic cancers, 54 hepatocellular carcinomas, 189 colorectal cancer, 251 lung cancers, 71 breast cancers, 58 urological malignancies, 60 gynecological malignancies, 47 head and neck cancer, 31 hematological malignancies, and 22 sarcomas. The number of patients who died suddenly was 93 (7.2%) at EOL. In a multivariate analysis, Age (ORs 0.619), sex (ORs 1.700), patients with EOL delirium (ORs 0.483), nausea and vomiting (ORs 2.263), 1L or more infusion (ORs 3.479), EOL opioids (ORs 0.465), EOL sedations (ORs 0.339), and with cardiac comorbidity (ORs 0.345) were independent risk factors.ConclusionsThe frequency of patients who died suddenly was 7.2% (n = 93) at EOL. Age, sex, EOL symptom, EOL treatment, and cardiac comorbidity were independent risk factors in patients with advanced cancer near the EOL. Information on these risk factors is useful to explaining their EOL in advance.

Purpose A sudden unexpected death has significant negative impacts on patients, family caregivers, and medical staff in hospice/palliative care. This study aimed to clarify the incidence and associated factors of sudden unexpected death according to four definitions in advanced cancer patients. Methods We performed a prospective cohort study in 23 inpatient hospices/palliative care units in Japan. Advanced cancer patients aged ≥18 years who were admitted to inpatient hospices/palliative care units were included. The incidence and associated factors of sudden unexpected death were evaluated in all enrolled patients according to four definitions: (a) rapid decline death, defined as a sudden death preceded by functional decline over 1–2 days; (b) surprise death, defined if the primary responsible palliative care physician answered “yes” to the question, “Were you surprised by the timing of the death?”; (c) unexpected death, defined as a death that occurred earlier than the physicians had anticipated; and (d) performance status (PS)‐defined sudden death, defined as a death that occurred within 1 week of functional status assessment with an Australia‐modified Karnofsky PS ≥50. Results Among 1896 patients, the incidence of rapid decline death was the highest (30‐day cumulative incidence: 16.8%, 95% CI: 14.8–19.0%), followed by surprise death (9.6%, 8.1–11.4%), unexpected death (9.0%, 7.5–10.8%), and PS‐defined sudden death (6.4%, 5.2–8.0%). Male sex, liver metastasis, dyspnea, malignant skin lesion, and fluid retention were significantly associated with the occurrence of sudden unexpected death. Conclusion Sudden unexpected death is not uncommon even in inpatient hospices/palliative care units, with range of 6.4–16.8% according to the different definitions., A sudden unexpected death has significant negative impacts on patients, family caregivers, and medical staff in palliative care settings. In our prospective multicenter cohort study in inpatient hospices/palliative care units in Japan, we found that the 30‐day cumulative incidence of sudden unexpected death ranged 6.4–16.8% depending on four previously proposed definitions, which revealed that sudden unexpected death is not uncommon.

BackgroundIn recent years, the use of both molecular targeting agents (MTAs) and immune-checkpoint inhibitors (ICIs) tend to occupy important positions in systemic anticancer therapy (SACT). The objective of this study is to describe the predictors of SACT include both MTAs and ICIs near the end of life (EOL) and the effect on EOL care in patients with advanced cancer.MethodsWe analyzed all patients who died of advanced cancer from August 2016 to August 2019, and we analyzed the survival time of patients who underwent anticancer agents excluded due to the loss of information about the last administration of SACT. The primary endpoint of this study was to identify predictors during the last administration of SACT near EOL.ResultsIn a multivariate analysis, the Eastern Cooperative Oncology Group performance status (ECOG-PS) (ORs 33.781) was significantly related factors within 14 days of death from the last administration of SACT. Age (ORs 0.412), ECOG-PS (ORs 11.533), primary cancer site of upper GI cancers (ORs 2.205), the number of comorbidities (ORs 0.207), MTAs (ORs 3.139), and ICIs (ORs 3.592) were significantly related factors within 30 days of death. The median survival time (MST) of patients with PS 3–4 was 29 days, while that of patients with both PS 0–2 was 76 days. The prevalence rate of delirium with MTAs was 17.5%, which was significantly lower than that of patients without it (31.8%). The prevalence rate of the mean dose of opioids in patients with ICIs was 97.9 mg/day, which was significantly higher than that of patients without it (44.9 mg/day).ConclusionsAge, ECOG-PS, primary cancer site, the number of comorbidities, MTAs, and ICIs use were significant associated with SACT near EOL. Information on these factors may aid clinical decision making in referral to palliative care institutes.

The benefits of artificial nutrition and hydration in patients with advanced cancer remain unknown. Therefore, we conducted a prospective study to evaluate effects of enteral nutrition (EN) and parenteral nutrition and hydration (PNH) on survival in palliative care units.This study involved a secondary analysis of a multicenter cohort study. Data of primary nutritional administration routes during the first week after admission (oral intake, enteral tube feeding, parenteral nutrition, parenteral hydration, poor oral intake) were obtained. Data of averaged calorie sufficiency rate/total calorie intake [high (75% ≤ or 750 kcal/day ≤), moderate (50-75% or 500-750 kcal/day), low (25-50% or 250-500 kcal/day), very low (25% or250 kcal/day)] were also obtained. After investigating the implementation of artificial nutrition and hydration, participants were divided into three groups according to the nutritional administration route and calorie sufficiency rate/total calorie intake: EN, PNH, and control. We conducted time-to-event analyses using the Kaplan-Meier method, log-rank test, and univariate and multivariate Cox regression analyses.Patients were divided into the EN group (n = 730), PNH group (n = 190), and control group (n = 533). Differences in survival rates among the three groups were significant (Log-rank P 0.001). Median survival times were 43.0 (95% CI 40-46), 33.0 (95% CI 29-37), and 15.0 (95% CI 14-16) days, respectively (P 0.001). In the multivariate-adjusted model, a significantly lower risk of mortality was observed in Cox's proportional hazard model in the EN group and PNH groups (HR 0.43 [95% CI 0.37-0.49], P 0.001; and HR 0.52 [95% CI 0.44-0.62], P 0.001, respectively) than in the control group.This study indicated the clinical benefits of EN and PNH for patients with advanced cancer. Nevertheless, managing symptoms to improve oral intake is essential before initiation of PNH, because EN was superior to PNH.

e24061 Background: Advanced cancer patients complain of highly distressing symptom at the end-of-life, and important reasons for palliative intervention to relive symptoms. Methods: We analyzed 1282 patients who died of advanced cancer from August 2011 to August 2019 retrospectively. We divided into patients who complain of symptom include fatigue, dyspnea, nausea and vomiting, and cancer pain, or didn’t for 3 days prior to death, and analyzed predictors by multiple logistics method. The primary endpoint of this study was to identify frequency and predictors of end-of-life symptoms in advanced cancer patients. Results: As a background, the median age is 73 years old, 690 males, 592 females, 227 gastroesophageal cancers, 250 biliary pancreatic cancers, 54 hepatocellular carcinomas, 189 colorectal cancer, 251 lung cancers, 71 breast cancers, 58 urological malignancies, 60 gynecological malignancies, 47 head and neck cancer, 31 hematological malignancies, and 22 sarcomas. Number of patients who complained of dyspnea, fatigue, nausea and vomiting, and cancer pain were 235 (18.3%), 318 (24.8%), 81 (6.3%), and 322 (25.1%) at the end-of-life. In a multivariate analysis, peritoneal metastasis (ORs 1.812), with mental (ORs 0.549), palliative referral (ORs 0.680), Eastern Cancer Organization Group Performance Status (ECOG-PS) (OR0.679) and consciousness level (ORs 0.610) was independent predictors in patients with fatigue at the end-of-life. Chest cancer (Odds Ratio 2.635), lung (ORs 2.159), brain (ORs 0.431) and peritoneal metastasis (ORs 0.602), with mental (ORs 0.429), respiratory (ORs 1.960) and metabolic disorder (ORs 0.520), palliative referral (ORs 0.645) and consciousness level (ORs 0.468) was independent predictors in patients with dyspnea. Lung metastasis (ORs 0.480, peritoneal metastasis (ORs 1.812), with anti-cancer therapy (OR 2.244) and consciousness level (ORs 0.610) was independent predictors in patients with nausea and vomiting. Brain metastasis (ORs 0.435, liver metastasis (ORs 1.374), and consciousness level (ORs 0.599) was independent predictors in patients with cancer pain. Conclusions: We reported frequency and independent predictors of end-of-life symptoms in advanced cancer patients. Information on these predictors be useful to explaining about their end-of-life in advance.

Tess of the d'Urbervilles is undoubtedly the most famous novel of Thomas Hardy's numerous works. The novel's shocking representations of woman's sexuality made it controversial in Victorian society, which, in turn, made the author more well-known. Through its fierce representations of sexuality, however, the novel revealed problems in Victorian culture surrounding morality, sexuality and marriage. In Victorian culture, women were confined by strict codes of etiquette regarding proper manners, clothing and behavior. Those concerned with sexuality, especially, were most serious. Women were thought of as faithful and asexual beings like pure angels. In the novel, Hardy challenged this view of woman by attempting to depict the truth. In the strictness of Victorian society, however, strict censorship in publishing world made it quite difficult to honestly represent women's sexuality. Hardy, therefore, chose to use metaphorical representations to depict it indirectly. Tess of the d'Urbervilles is filled with metaphorical representations. Representations of light and darkness, particularly, which surround the body of the main character, hold the most important function in the novel. Employing chiaroscuro Hardy visually emphasizes the bodily presence of characters. Meanwhile, he also uses the technique to depicts their emotions about corporeal problems. Through such characteristic expressions, the complex consciousness on the body and sexuality is revealed to readers. The novel's narrative lies in revealing the life of Tess, the history of her love affairs, and growing awareness of her sexuality. She was a woman loved by two very different men, Alec D'Urberville and Angel Clare. Her relationships with the two men awaken her to both the sexuality within her body, something she had never known before, and awareness of the guilt surrounding that awakening. The light and darkness is often used to express her suffering and conflict connected with sexuality. Alec is portrayed as Tess's seducer. He holds strong sexual desire for her physically, and through his strong lust, tries to dominate her. As ways of showing his desire, Alec stimulates her physically using means such as continually touching her body as well as teaching her to whistle. With such curious practices and experiences, her sexual sense of pleasure is awakened, visually emphasized with shining light. Tess is perplexed regarding such unknown bodily enjoyment. Feeling such pleasure, she suffers, bound by a moral consciousness of having violated the something inviolable. Conflicted, she also anxiously desires to be dominated by such pleasure Alec offers. Inevitably this anxiety brings her consciousness to a crisis. To defend her soul from the crisis Alec has brought, she sinks her soul into an abyss of darkness, secluding her consciousness from her body. In this way, she attempts to resist Alec's lust. Whenever he expresses his desire for her, by forcing her awareness away from her from body, she strives to protect the peace within herself. Such movement of consciousness is represented quite visually, especially in the scene where Alec forces himself upon her. Dramatic scenes such as this, which surround her, are darkened, when her soul is separated from her body. The darkness acts to express the absence of her soul in her body, and her will to resist against Alec's domination. Through her experience of life with Alec, she comes to know the forbidden pleasure of her sexual self and an awareness of guilt surrounding such feelings. She suffers through this conflict on sexuality. After the parting from Alec, she meets Angel Clare, a man of very different qualities compared to Alec. Angel is intellectual and philosophical, and Tess gradually becomes more fascinated with him. Her soul feels sympathy for his soul. But Angel also attempts to dominate her, not by bodily lust but by his ideas of womanhood. Though he is welleducated man, his mind is confined by a quite conservative view of women. In this the Victorian view, he idealizes Tess as a pure angelic woman. His desire for her reflects to the scenery of the place where they rendezvous. She is surrounded by misty twilight, the somber space making her appear like a goddess. For Tess, who now has experienced the corporeal pleasure and its sins, this was quite unacceptable. She, therefore, refuses to be the divine female. Her refusal is also represented visually. When she denies Angel's idealized image of herself, her bodily presence is emphasized by light representing her refusal. But she cannot help being attracted to Angel. Aware of her guilt, she feels lust for him. The sexual urge, which Alec awakened in her, pushes her on. She secretly longs for bodily contacts with Angel. Like Tess, Angel is also gradually fascinated by her corporeal beauty. Through such bodily desires they become attracted to each other. As with Alec, the lust between Tess and Angel is also represented by shining light. Light emphasizes the presence of their bodies and their beauty, implying the secret pleasure between them. For both Tess, however, who experienced both love and violation with Alec, and Angel, with his conservative view of women, the pleasure they share inevitably makes them conscious of guilty and suffering. After Tess confesses her secret past, the conflict and suffering over sexuality become decisive. For Angel, Tess's body, which experienced such raw sexuality with Alec, becomes an object of fear. Her sexuality, overwhelming his mind, is expressed by visually by light. Ironically, Tess's experience with Alec becomes the cause of Angel's mental anguish. After this incident, Tess is filled with a growing desire to take responsibility by destroying her sexual self to make Angel suffer. She unconsciously longs for death, but cannot kill herself because she also knows how much she enjoys sexual pleasure. The pleasure prevent her from leaving the body easily, filling her with ambivalent emotions about her sexual body. As a way of resolving this crisis within, Tess idealizes the darkness as a place of rest. The darkness diminishes her bodily senses to a minimum, bringing her an experience of pseudodeath, a temporal rest of mind. The darkness becomes a symbolic expression of her rest and liberation from the body. The last scene expresses this well, where Stonehenge is shrouded in darkness as Angel and Tess meet for their last rendezvous. The darkness symbolizes her rest and liberation, but is quite transient. As time passes, light inevitably intrudes into the darkened space, making her body visible and aware of its presence. Even in the last scene, the light flows into the darkness. Her rest is inevitably broken, indicating the cruel fact that as long as she lives, she cannot escape from the presence of her sexual body. Throughout the history of her love affairs with the two men, the use of chiaroscuro indicates Tess's conflict of mind and emotion over her sexuality. Her sexual sense or desire is metaphorically represented with light. The light strengthens the presence of her sexual body and reveals her hidden sexual desire for men. But feeling such pleasure, Tess suffers a guilty conscience. She feels ambivalent emotions concerning her body. To liberate herself from such suffering, she seeks to destroy her body believing it to be the cause of her distress. As a way to destroy her physical self, she longs for darkness. The darkness temporarily makes her body invisible and diminishes her bodily senses, allowing her to briefly experience bodily liberation and oblivion. Consequently, this becomes a metaphor for her mental rest. Through his expression of visible light and darkness, Hardy expresses visually for reader the suffering that women endured under the strict moral code of the Victorian era. His novel also spotlights the absurdity and double standard of Victorian oppression of sexuality on women.

The Woodlanders was published in 1887. The novel is one of Thomas Hardy's famous works along with Tess of the D'urbervilles and Jude the Obscure. The main theme of the novel concerns the tragedy of men and women in rural Wessex. All Hardy's novels contain many detailed expressions ; not only detailed representations of men and women but also detailed descriptions of those characters in their natural setting; especially, the first appearance of characters is closely linked with the description of nature where characters metaphorically disclose their hidden emotions within the natural scene. Among the descriptions of nature in the novel, the most impressive is chiaroscuro, the contrast between light and dark, particularly, noteworthy. In all his works, the light and dark reflects the emotion of his characters. For instance, whenever the characters are depressed, the darkness is inserted around the characters. Conversely, whenever the characters are in high spirits, a light imagery is used. This contrast is one of important keys for understanding his novels. One of the conspicuous examples in The Woodlanders is the expression of the psychological contrast between two women: Marty South and Grace Melbury. This paper chiefly considers the interrelation of the chiaroscuro of the two women. Through the light and the dark, their consciousness and unconsciousness against men are represented. For Marty South, the light means man's desire for her body. This is well represented when the merchant Percomb, who wants to buy her hair for a wig, looks at her in her cottage. The light emphasizes her physical beauty, especially her hair. But it also implies his focused gaze on her hair. The light shows his desire to get the beautiful hair for his own commercial purposes. However, she does not want to sell it, because she knew that the hair would be used for Mrs. Charmond's wig to draw man's attention to her. Marty is disgusted to be an object of man's desire. (But the reason why she kept her hair is very paradoxical. In fact, Marty kept it for Giles Winterborne whom she loved, so subconsciously she wanted to be the object of man's desire albeit one man in particular. However, after she cut off her hair, the hair served to attract men's eye as a possible wig for Mrs. Charmond. Marty inevitably attracts men's desire.) However, through cutting her hair herself she undergoes a form of metaphorical castration, which reveals her attempt to get away from being a commercial or sex object. After this incident, Marty avoids to be thrown by the light, since, to her, all light is a metaphorical representation of men's eyes, not only Percomb's. As a result, she hides herself in the darkness. The darkness shutters her off from men; in the last scene, when she stands before the grave of Giles, her appearance is hidden in mist and darkness. The darkness here symbolizes her rejection of being an object of men's desire. For Grace, the chiaroscuro is very different from Marty. She was born in Hintock, but following her father's will was educated in the urban culture. She is close to being an outsider as far as regional culture is concerned. In addition, her personality is very passive toward men (her father and husband). Therefore, her attitude toward light and dark is different from that of Marty. For instance, when she returns to her home, she meets her father Melbury in the light, which implies his joy to see his daughter as a refined lady. The light also represents his desire for her to be such a refined lady. Grace is also aware of his eye and desire. She does not reject the desire of men that the light represents : rather, she bends to it rather than rejecting. For example, she dresses herself to attract men surrounded by the illumination of candles. Her illuminated appearance also symbolizes a womanhood that men desire. Grace subconsciously tends to become the type of woman that men want. She is not disgusted to be the object of men's desire as Marty is. And for Grace, the light frequently appears as a representation of male superiority. For instance, in the night when she came back to her native countryside from the school, she sees at a mystic light, which is revealed from Fitzpiers's house. By this light Grace imagines his superior knowledge and power, which enhances her interest in him. As a result they eventually marry. And, when she has a fever, Fitzpiers helps her with medicine. The bottle of medicine reveals an image of light with opaline hue. The light has become a symbolic phenomenon that represents superiority over her. Grace accepts his superiority and she adjusts herself to a world that is not friendly toward women. The light represents men's desire and her obedience. Thus light and darkness represent two ways of woman's life in a men's world. Marty rejects men's desire. Conversely, Grace passively accepts their desire and vigilance. But neither succeeds to obtain a happy marriage. Marty cannot unite with Giles, because she feels that Giles should marry Grace according to the promise of Grace's father, and has spoiled her beauty by cutting her hair. Grace marries Fitzpiers following the will of her father. However, Fitzpiers is not capable of being the superior man that she expected. Consequently she also fails to achieve a happy marriage. The unfortunate marriage is one of the important themes in Hardy's works. Hardy seemed to portray freedoms even within an oppressive society. Through the impressive visual representation of woman's misfortune, he accuses contemporary society where men's one-sided oppression dominates women as defective and evil. Through the achievement of this novel, he appears to continue to investigate the problem till the achievement of Tess of D'urbervilles in which he represents fiercely oppressed women and the sexual tyranny of men.