Massage is part of the means by which one attempts to shorten the time which passes between commencing opacity of the lens, with consequent interference with vision, and the "ripening" of the cataract, or that stage when the lens can be most easily removed from its capsule without leaving any remains of its own cortical substance.

As is well known, it has been attempted to bring about complete obscuring of the lens by exposing it to the action of the vitreous humour by the discission of the anterior wall of the capsule. It has been attempted to reach the same goal by means of a preparatory iridectomy, which has an undoubted effect though difficult to explain.

It occurred to Forster of Breslau that preparatory iridectomy hastens total obscuring (i.e., the ripening of the cataract), that the lens, when pushed forward by the movement of the aqueous humour, undergoes some change in shape, some movement of its small particles among themselves, and that the disintegration of these small particles of the cataract is consequently assisted. He considered that a similar movement between the elements of the lens could be promoted by means of massage performed on the lens over the empty chamber immediately after iridectomy. Upwards of 500 cases showed the correctness of his opinion, and the said massage of the lens performed in one treatment immediately after iridectomy in order to further ripening of the cataract was introduced under the name of "cortex massage" into ophthalmic surgery, in which its position is now established.

* A good work on this subject is "Om konstgjord starrmognad" (Nordman, Helsingfors : 1885).

Forster uses massage of the cortex only for cataract with hard nuclei; for chorioidal cataract, which leaves a large part of the lens transparent and has no hard nuclei, and only consists of a thin opacity at the posterior pole, he does not consider it suitable. At the Congress in Copenhagen Meyer demonstrated (on a rabbit) that even a quite normal lens may be totally obscured by strong massage of the cortex, and considers that the method may be used also for chorioidal and generally for soft cataracts, for which it has already been used with good results by several eye specialists. The majority, however, are agreed that it works best in senile and nuclear cataracts. The method, however, has strong adversaries, among whom are Alfred Graefe and de Wecker, as well as Fuchs, who consider that ripening of the cataract is of little importance for the extraction of the lens, and therefore are not inclined to adopt means of hastening it. This opinion has of late years gained ground, and massage of the cortex is therefore little used now.

Massage is performed, immediately after the iridectomy (done under cocaine as an anaesthetic), with a squint hook, Graefe's or Daviel's spoon, a spatula or special little roller-shaped instrument (Meyer), performing kneadings over the cornea, or also, as so often for eye massage, by kneading the eyelid with the finger for about one, at the most two minutes, and afterwards dropping in atropine (not eserine, which increases the irritation of the iris). Forster waits for four to eight weeks, though most other eye specialists wait a shorter time, before the operation for cataract after a preparatory iridectomy is performed. But ripening takes place a few days after massage of the cortex; according to Meyer it is sometimes seen directly after massage of the lens. If the massage does not prove effective it may be repeated after a few weeks, and after puncture of the chamber, with greater vigour, or discission may be used for ripening of the cataract, or one may wait for this to occur "naturally," or it may be dispensed with altogether and operation performed without.

Wicherkiewicz and Schnabel used massage for simple glaucoma, partly to reduce the intra-ocular pressure, partly (Schnabel) to counteract the accompanying cloudiness of the cornea. It is certain that it is possible to reduce intra-ocular pressure temporarily, the effects in this respect lasting several hours and then passing off. Schenkl found that they lasted twenty-four hours; in secondary glaucoma he found massage produced permanent improvement. Enterprising persons have attempted massage for inflammatory glaucoma, but it has not been tolerated by the patients.

Schenkl used massage with benefit for hyphaema.

Just (Zittau) by massage produced reabsorption of hypopyon ( = exudation in the anterior chamber) in one case of serpiginous ulcer of the cornea, when the hypopyon, 3mm. high, disappeared after five treatments (twice daily with gentle kneadings), and Saemisch's operation which had been thought of was therefore unnecessary. One must of course remember that an exudation in the anterior chamber may equally well originate from iritic as from keratitic processes : in the first has been stated several times, massage is absolutely contra-indicated.

Pagenstecher used massage in a case of disease of the ciliary body, with the happy result of complete recovery after fourteen days. The disease he considered to be a limited exudation round a ciliary nerve. Even Klein is inclined to use massage for "substantive ciliary neuralgia ("Centralbl.," 1882, p. 159).

Mauthner, Hirschberg, Priestley-Smith, Mules, Perles, and others order massage for recent embolus in the central artery of the retina (usually in arterio-sclerosis and in elderly persons, sometimes also in young people with heart disease). It is only when one gets the case before twelve hours after the sudden blindness that one may expect anything from massage, which in these cases should be performed over the eyeball for some time. In Hirsch-berg's clinic this is massaged twice daily "externally" for as long as fourteen days, making the patient direct his gaze so that the position of the embolus may be reached as much as possible. According to Mauthner, one should cut open the conjunctiva, insert a hook into the optic nerve, and massage the posterior part of the ball. R. Fischer massaged for over three hours with short breaks. It seems as if the introduction of massage to a large extent brightens the otherwise dismal prognosis in such cases of embolism, as various cases of reabsorption due to this treatment have now been recorded.