Tenonitis (of the right eye), or that disease to which this name is usually applied, was treated by Gradenigo * with massage. The case presented marked exophthalmos and a hard, resistant prominence of the whole orbit, swelling of the eyelid, chemosis, severe pains, insensibility of the cornea, immobility of the eyeball, no perception of light, besides general lassitude and repeated attacks of fever. The symptoms had gradually developed in an otherwise entirely healthy woman, who was taken into the clinic to have her eye enucleated. Luckily massage was tried first; it immediately produced improvement, and "after a short time" complete recovery. Both Scellingo and Klein have used massage with good results in a case of tenonitis. It is also reasonable to believe that in these cases massage is able to hasten the removal of the symptoms, which certainly, even without treatment, often give way fairly soon. Before beginning the treatment one must, however, in the usual way (stated in all text-books on ophthalmology) make a differential diagnosis from orbital cellulitis, and from panophthalmitis or thrombus in the cavernous sinus.

I must draw the attention of the reader in a special note to this chapter to the importance of massage for a number of anomalies in the eyes which arise from overflow of impulses, or reflex processes beginning in other peripheral parts. It has long been known that eye symptoms may arise in this way, and the more complete knowledge of extra-ocular pathological-anatomical causes for such symptoms has to some extent helped to limit the number of the cases considered as purely "eye neuroses," a limitation which has taken place for similar reasons in other directions.

It has for a long time been known that inflammatory conditions of irritation in the teeth or in the cavities of the nose and ears or in the genitalia of women are able to cause complex eye symptoms which in earlier days would have been considered as primary diseases of the eye. Similarly, we know that neuritis, particularly in the ophthalmic division of the trigeminal nerve and its branches, may cause similar phenomena. For this reason many have connected supra-orbital neuritis (or neuralgia) and migraine with its frequent eye symptoms. It is important to remember that neuritis or perineuritis may only be partial phenomena in more extensive subcutaneous, so-called "rheumatic," chronic inflammatory processes. Lastly, it has recently been stated by several doctors, quite independently of each other, that they have noticed that similar changes in the muscles of the head and neck (occipito-frontalis, temporal, sterno-cleido-mastoid, and trapezius are mentioned by Rosenbach) may cause the same sensory and functional disturbances in the eye.*

* Atti del associazione ottalmoligica italiana, sessione di Padova, Settemb., 1882 (Annali di Ottahnologia, 1883; quoted by Kiaer).

The eye symptoms which usually arise from central impulses from extra-ocular, more or less remote, foci of irritation are pain, sensitiveness to light, scotoma, weight in the eyelid, hyperaemia, lacrimation, even chemosis. The most usual seem to be indefinite pains in and around the eyes and asthenic trouble when reading. The case may resemble an attack of migraine in that it has exacerbations, still more than the nervous or hysterical cases, and there is also a muscular or accommodative asthenopia, this last especially in combination with anomalies of refraction, such as astigmatism or hypermetropia.

Moreover, in my opinion, which still needs confirmation from the experience of others, peripheral infiltrations may even produce motor reflexes, especially over the centre of the facial nerve, and in this way cause blepharospasm.

From the above it may be seen that with these sensory and functional disturbances in a patient's eye it is often a complicated task to make a diagnosis. One ought first to examine for a number of eye diseases, above all for anomalies of refraction, and for accommodative and muscular asthenopia, and bear in mind general causes (chlorosis, anaemia, neurasthenia), intracranial processes of different kinds, not forgetting the purely nervous asthenopia (Forster's copiopia hysterica); and one must further carefully examine for foci of irritation in the mouth, nose, ears, or in the female genitalia. Externally one should palpate the head in the manner already described, especially the forehead over the supraorbital nerve, looking for rheumatic infiltrations and neuritis, as well as for myositis, especially in the above-mentioned muscles.

* In the year 1884 I had in my own practice a case of a young woman who, without other objective changes in or outside the eyes, suffered from pains in the eye and asthenic trouble, with simultaneous widespread double-sided infiltrations in trapezius. The muscle infiltrations yielded to massage and the eye symptoms disappeared without other treatment. The patient herself, as is often the case, considered that the two were connected. I did not at that time know of any other observation, and dared not draw any conclusion from one case. Some time after I saw one or two cases which reminded me of the above. I heard then from Dr. Widmark in Stockholm, to whom I stated the case, that he had just then seen a similar case for the first time. Since then, in a treatise on "Eye Symptoms from Peripheral Trigeminal Affections" (Nord. Ophthalm. Tidskrift, 1889), he tells us that he has met with various interesting cases, among which myositis may also be a cause of eye symptoms. Long after my own first observation I found that it was not at all new, as several ophthalmologists had made similar observations, and that Rosenbach had brought the subject forward before either Widmark or myself (see "Ueber die auf myo-pathischer Basis beruhende Form der Migrane" (Deutsch. Med. Wochenschr., 1886), referred to, among others, by Hirt, p. 51, in"Patol. u. Therapie der Nervenkrankheiten").

Finally, one must never forget that several causes may be combined, and that when there are several pathological changes in one case it is impossible to say a priori which is responsible for the eye symptoms.

The use of massage is chiefly in those cases where subcutaneous infiltrations, neuritis and perineuritis or myositis are present, and can be got rid of in the way which has been described in several places in this book, and which I need not repeat. Similarly, massage may be used when pelvic diseases, e.g., parametritic exudations, are to be found. The eye symptoms may persist even when the massage has cured the pelvic trouble, and one must then look further for the true cause of the former.