G. 275.--Lympho-sarcoma of Neck.

(Mr. D. M. Greig's case.)]

_Fibroma_ originating in the ligamentum nuchae, or the periosteum of
the vertebral processes, is of slow growth, but it may attain
considerable size, and on account of its deep attachments the
operation for its removal may be difficult.

_Mixed tumours_ like that described as occurring in the vicinity of
the parotid, and taking origin from branchial rests, are sometimes met
with in the upper part of the anterior triangle.

_Osseous_ and _cartilaginous tumours_ occasionally grow in connection
with the transverse processes of the lower cervical vertebrae.

_Sarcoma_ and _fibro-sarcoma_ of the slowly growing type may develop
from any of the fascial structures in the neck, or from the connective
tissue surrounding the blood vessels. In those taking origin beneath
the sterno-mastoid, there is difficulty in removing them completely on
account of their deep attachments, and when they are found to
infiltrate the surrounding tissues the attempt should be abandoned.
This rule may be relaxed in view of the aid that may be afforded by
the insertion of a tube of radium, which is capable of rendering inert
such portions of the growth as are not capable of being removed.
Sacrifice of the common carotid artery is attended with the risk of
hemiplegia and cerebral softening, especially in persons over fifty;
resection of a portion of the vagus is less dangerous to life than
stimulation by irritation of its fibres; resection of the internal
jugular vein and of the cervical sympathetic cord are factors which
add to the shock of the operation but do not carry with them any
special risk.

_Carcinoma._--The commonest form of primary cancer is the _branchial
carcinoma_, a squamous epithelioma which originates in connection with
the second visceral cleft (Fig. 276). It appears as a rule under the
sterno-mastoid at the level of the hyoid bone, and extends towards the
submaxillary region, infiltrating the muscles and the sheath of the
vessels.

[Illustration: FIG. 276.--Branchial Carcinoma--subsequently removed by
operation.]

It is more common in men than in women, and there is often a history
of a small swelling having been present for many years, or even since
birth. About middle life more active growth begins, the swelling
becomes more fixed and is painful, and once it begins to grow, it
increases rapidly and within a month or two may reach the size of a
child's head. In