Ever since 1870 when massage was introduced by such an influential advocate as Donders it has been employed by eye-specialists; he used it, as Heiberg of Christiania did shortly after him, for corneal opacities. But it was Pagenstecher who did most for the introduction of massage into ophthalmic surgery (since 1878).* There is no doubt that massage is now and for the future of considerable importance as a part of ophthalmic treatment.

The technique of eye massage is exceedingly simple. In the majority of cases, whichever part of the eye one wishes to massage, mechanical treatment by means of kneading over or through the eyelid is used. As regards technique there are several not unimportant variations and different opinions thereon. In my opinion it is best to press the eyelid with the tip of the middle finger and massage with this. Pagenstecher, who has a right to be heard on all these subjects, in massage of the eyeball grasps the upper or lower eyelid near the edge between thumb and finger and performs gentle kneadings with this, always with the minimum of pressure. Pagenstecher distinguishes in this between radiating and circular kneadings, and considers the first to be the more important; they are performed from the centre of the cornea towards the equator of the eyeball. In circular massage, again, the kneadings are performed over the corneo-sclerotic margin. In radiating massage one can only work upon a sector of the front of the ball at a time, and can in this manner cover the whole area, if necessary, succes-sively in four parts. During massage of the upper sector the patient must direct his gaze downwards; when later the outer sector is being done he must look inwards, etc., and in this treatment only the under sector is kneaded by means of the lower lid, all the other three sectors with the upper lid. In order to be certain which part of the ball one is to massage through and by means of the eyelid, a clip may be used to hold the patient's other eye open. The kneading takes place, as has been said, in rather quick time. Kiaer tells us that he performs 120 to 150 kneadings a minute, i.e., in radiating massage he performs this number of kneadings towards the centre of the cornea and back again, over the whole corneal margin in circular massage. Personally I have found that my own time is somewhat quicker and that I perform about 200 "strokes" a minute.*

* "Nothing is new under the sun," and many statements are to be found on the use of eye massage in early ages, besides which it has for long been used in many places even by professional men of our time in the clinics, as, e.g., in Bohemia (according to Schenkl) and in Italy (according to Gradenigo). Even the Swedish gymnasts have contributed to this (Nicolaysen), which is not surprising considering their great readiness in every case of disease to lend a helping hand, and considering the universality of diseases of the eyes.

For massage of the eyeball I always find it most comfortable to use the tip of the middle finger pressed gently against the eyelid, while I perform the movements necessary for the manipulation for the most part at the wrist joint, though the whole of the forearm also plays some part (see p. 27). This must, however, be Pagen-stecher's method, as the diagrams showing his radiating massage in Reibmayer's "Technique of Massage" show the middle finger as the one performing the kneadings. It is best that each should use the finger which suits him best.

But one may make a few justifiable and helpful remarks concerning the pressure and form of the kneadings. The radiating kneadings follow more the direction of the vessels of the sclerotic and episclerotic coats, and they assist, therefore, the circulation in these vessels more than other kneadings and work more or less like effleurage. They are therefore chiefly useful in the (comparatively few) acute diseases of the eye which ought to be treated by massage, and must be performed most lightly so as to not to produce irritation. But the difference with regard to the effect on the local circulation between kneadings in different directions on the eyeball cannot be very great, when the tip of the finger covers at one time so large a part of the whole area over which its excursions are made. The aim of the manipulations in eye massage is, like that of friction, to promote absorption. It is therefore practically indifferent in which direction they are performed, and therefore, in company with other doctors who have far greater experience in eye massage than I myself, I have attached very little importance to the direction of the manipulations, and when circular kneadings have seemed easier to perform I have used them preferably, and also in many cases, e.g., in pannus or in cloudiness of the cornea, have quite simply kneaded the anterior part of the ball with the eyelid from side to side.

In many (and in most) cases one should remember in massaging the eyeball that if on the one hand there can be no question of strong pressure here for obvious reasons, on the other hand, in some pathological conditions, a certain amount of pressure is necessary to produce any effect. It is necessary to produce reabsorption of infiltrations and formations due to exudations and to induce retrogressive changes in more or less organised new tissues, and one often has to deal with changes of very long standing. In such cases gentle kneadings are of no use, and if one bears in mind all the contra-indications and is careful to produce no irritation of the iris, there is no danger in using a moderate but definite pressure. Marked hyperaemia is temporarily produced; this does no harm, but in its turn assists the process of absorption.

* Dr. Kiaer of Copenhagen has written a treatise on "The Value of Mechano-Therapy in the Treatment of Diseases of the Eye" (1885), and it is a pleasure to me to acknowledge the great use I have made of this work, though my opinion in many respects differs from that of Dr. Kiaer. On the whole massage has done well in ophthalmic surgery, generally in medical hands.