Massage of the eyelid is often performed in the same way by kneading it against the eyeball. If it is a question of changes in the edge of the eyelid, this is kneaded from the external to the internal canthus. When the changes were of such a nature that I wished to use strong pressure, especially when the upper lid was affected, for example in trachoma, I massaged with the tip of the little finger (smeared with yellow ointment or some other agent) inserted between the eyelid and the eyeball with the dorsum of the nail turned towards the latter, and then massaged the lid between my little finger and the index finger of the other hand, performing kneadings with the little finger in the conjunctival sac and using the index finger outside as support. The method has this advantage, that it admits a much firmer pressure than any other; the massage is also very much more effectual; the patient after a little time can bear this by no means painless manipulation fairly easily. A short, rather flat glass rod, rounded at the end, is also well adapted for massage in the conjunctival sac. Kostomyris of Constantinople has directly massaged the conjunctiva of the everted eyelid, using the little finger covered with boracic acid, and gives his results as excellent (surprising, to say the least of it). Some use paper capsules for kneading the conjunctiva palpebrarum, when each must be used only once. Others (with Neustatter) use wooden rods wrapped in cotton-wool.

Maklakoff in 1893 introduced vibrations in ophthalmic treatment. For diseases of the eyeball he gives vibrations either directly upon it or over the closed upper lid by means of Edison's instrument; the little ivory button attached to a feather spring performs 9,000 small vibrations a minute. Piesbergen uses a similar electric vibrator, in which the number of pendulum swings, usually about 2,000 a minute, can be increased or diminished.

The vibration therapy of Maklakoff has been used in blephar-adenitis and ulcers of the eyelids, in ulcerating keratitis, leukoma, serous iritis, irido-cyclitis, glaucoma, and traumatic cataract. Piesbergen has used his vibrator in the above complaints, but chiefly for chronic irido-chorioiditis and (especially in syphilitic) chorioretinitis, haemorrhage in the macula, and optic atrophy following neuritis.

Domec (Dijon), especially in hypermetropia, but also in myopia, uses massage, performed by placing the tip of the thumb over the upper lid against the middle of the cornea, while the other fingers rest upon the patient's temple, and performs a series of pressures (about 100 a minute) for five minutes at a time. Darier, who has done much for eye massage, commends the method, the good effects of which he explains by the stretching of the zonule of Zinn, and the mechanical effect upon the lens, the toning up of the ciliary muscle and accommodation, and its influence upon the vessels and circulation. Domec's massage is used with good results for (primary and secondary) glaucoma, and considerably increases the effect of iridectomy, which of itself is insufficient.

Eye massage (except in the case of Maklakoff's vibrations) is usually combined with medical treatment in that some ointment is used in massaging; and of these there is a veritable embarras de richesse. One must be careful in making a choice. Fresh lard and lanoline are good. The best vaseline is the white American • vaseline. Yellow ointment as well as a mixture of yellow wax, cold cream, and oil of almonds have their warm adherents. Paraffin ointment is a firm substance consisting of four parts liquid paraffin and one part solid paraffin; it has the disadvantage of being rather hard.

To these constituents are added different substances. I would mention first yellow precipitated oxide of mercury. The yellow ointment thus made is used of a strength from 1 in 200 to as much as 1 in 10. Lowegren of Lund recommended yellow oxide of mercury 0.2, cold cream 2. Iodide of potassium ointment, introduced by Heisrath, is also commonly used (pot. iod. 1, sodae bicarb. 0.5, white vaseline 10). Grey ointment containing equal parts of vaseline and mercury is also in common use. Mitvalsky uses ung. hydr. ciner. 3, white American vaseline 6, purified lanoline 3. Protargol, a silver albuminate, is used by Emmert in 5 to 10 per cent. ointment with vaseline or lanoline in blennorrhoea due to dacryocystitis (but not with eczema or erosions), and by Darier in blepharo -conjunctivitis, partly in a 10 per cent. solution, partly as an ointment (protargol 1.5, zinc oxide 1, starch 1, vaseline 15). Darier advocates protargol as a specific (with massage) in chronic conjunctival blennorrhoea. Protargol seems to have been most successful especially in conjunctivitis and keratitis of different kinds; it is used in solution 2 per cent. to 10 per cent. Sublimate ointment is fairly common (0003 : 10); ichthyol ointment is also used by some. Arlt of Graz massages for trachoma with a cupric oxide ointment with 5 to 10 per cent. citric acid.* Elsching massages at first daily, later every other day and every third day, either with the fingers or with a glass rod and cotton-wool saturated with a solution of oxycyanide of mercury 1 : 4,000. Boracic ointment is still used by many (2 to 3 per cent.). One can also massage with cocaine or eserine ointments. At present, however, the yellow precipitate ointment is used more than any other for eye massage.

Subconjunctival injections, which are now used for their disinfectant and absorbent effects, are usually followed (except when tuberculosis is present) by massage. In diseases of the cornea, iris, corpus vitreum, optic nerve, retina, and chorioid one of the following injections may be given as close to the equator of the eyeball as possible: - half or even a whole syringeful of distilled water, sublimate solution, 2 to 4 per cent. salt solution or sodium iodide solution, 1 per cent. solution of hetol (= sodium cinnamylicum), or a solution of cyanide of mercury .01, chloride of sodium 1, sterile distilled water 50 (Daricr). Specialists appear to differ as to the amount of lotion injected, the number of injections and their composition. But the great majority of them use massage after * the injections, with the tip of the middle finger performing light, quick kneadings on the outside of the upper eyelid.

In explanation of the physiological effects of eye massage there is not much to add to what has already been said. The eye fluid is filtered mostly through the vessels in the sclero-corneal margin (venous plexus in the canal of Schlemm); the blood stream in the vessels is accelerated, although for anatomical reasons not very strongly; pathological tissue elements undergo retrogressive changes and are absorbed, vaso-motor and other nerves and the cells are mechanically stimulated. Besides the effects upon the circulation, absorption, etc., so often pointed out (and in many cases the strengthening influence on the orbicularis), eye massage also lowers the intra-ocular pressure for a time, which diminishes quite apparently owing to the flowing away of the liquids (Pagen-stecher); according to Kiaer the diminishing of the pressure after two minutes' massage may take two to three hours to be entirely equalised.+ Reibmayer states that when one eye is massaged one notices at first a reflex dilatation of the pupil of the other eye, that this dilatation is quickly replaced by a contraction, and that at the end of three minutes the pupil of the eye massaged is more strongly myotic than that of the other eye, even if both eyes have been closed during massage and are opened at the same time (which the reader will often find it difficult to notice).

* For further details I refer the reader for the very various substances to Ohlemann's "Neueren Augenheilmittel": Wiesbaden, 1902.

+ According to Ovio, massage of the eyeball has scarcely any effect upon the circulation or its metabolism. I can scarcely believe this opinion to be correct.

Contraindications are those generally referred to. In my first Swedish massage book (as in the German) I mentioned iritis and irido-cyclitis as constituting absolute contra-indications to all massage of the eye, as ever since my student days I have been accustomed to consider the absence of all irritation to be of the utmost importance in these diseases. I have since learned, however, that a well-known oculist, Dr. Boekmann (Minneapolis, Minnesota), considers massage to be of great importance during the later stages of serous or plastic iritis or irido-cyclitis. "Massage," he says, "has only a good effect in irido-cyclitis when the eye is able to bear the manipulations, and one ought to be neither too sparing nor too gentle with the finger." Conscious of my own lack of experience, I give Boekmann's opinion, and only draw attention to the fact that it refers to the last stages of the process, when the violence of the symptoms has subsided. One must always be careful not to persist obstinately with this treatment in those cases where it produces continuous violent injection of the vessels or other symptoms of irritation; it is a fact that some patients react violently to massage, and for them it would be an unsuitable treatment when for others it would be indicated. In eye massage one must always be most attentive and careful, and follow the case in every detail. If such treatment is left to any other than a doctor, who has at least his knowledge of ophthalmology to help him, this other should by preference be the patient himself. Similarly, in cases of corneal opacities in children I have once or twice taught (carefully and by means of several lessons) quite uneducated, though capable and intelligent, individuals how to perform the massage, which in these cases must often be persisted in for several months, involving great waste of the doctor's time.