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osmosis. (See It's All About Pressure, page 44, for more information on osmosis and hydrostatic pressure.) In addition, lymph vessels can take in cellular debris that is too big to reenter circulatory capillaries. These molecules are often hydrophilic, meaning they attract water. The lymph capillaries carry ISF—now called lymph—toward larger collector vessels, and ultimately toward lymph nodes, where everything is filtered and shunted through the largest lymphatic vessels and back into the circulatory system, where it becomes plasma again. The junction between the cleaned-up lymph and the circulatory system occurs at the left and right subclavian veins, just above the superior vena cava. A large portion of lymphatic capillary activity occurs in the superficial fascia. The tiny lymph vessels here process an enormous amount of fluid, feeding it into the collector vessels that take it toward the lymph nodes. Other lymphatic capillary activity takes place in the muscles and viscera, but when obstructions anywhere in the system occur, the backflow almost always leads to congestion in the most superficial tissues. Under ideal conditions, the forces that move fluid into and out of circulatory capillaries and lymphatic capillaries are equal. The plasmaISF-lymph cycle continuously repeats, and the flow of material from one container to another is even, controlled, and balanced. What Is Edema? According to Stedman's Medical Dictionary, the definition of edema is "an accumulation of an excessive amount of watery fluid in cells or intracellular tissues." Notice that this definition does not identify a cause for the excessive amount of watery fluid. The most common kind of edema that massage therapists see is probably the swelling that occurs in minor injuries: think of a sprained ankle or an infected hangnail. This kind of edema is part of the inflammatory process, when our bodies produce chemicals that promote capillary dilation and the migration of white blood cells to fight potential infection. Other forms of edema are likely to be connected to systemic infection or organ dysfunction. Pulmonary edema, for instance, refers to the accumulation of fluid in and around the lungs. Glaucoma describes edema in the eye that can pose a risk to the optic nerve. And of course, heart and kidney dysfunction can cause backups throughout the entire system if these key organs cannot keep up with demand. The uniting factor in all these forms of edema is that, while the forces that promote the production of ISF outweigh the forces that reverse it, the condition is triggered by something other than damage to lymphatic vessels. By contrast, lymphedema occurs specifically because some aspect of the lymph system itself is impaired. Lymphedema: An Incompetent Lymph System Primary lymphedema—lymphedema caused by an anatomical anomaly—is relatively rare, and usually involves the absence of major collecting vessels. Much more common is secondary, or acquired, lymphedema, which is a result of Because breast cancer is the most common reason for lymph node removal, we usually think about lymphedema affecting the upper extremities, but lymphedema of the leg can develop, too, usually as a result of treatment for cancer of the bladder, ovaries, prostate, testes, uterus, or vulva. In addition, lymphedema can be related to burns, fractures, orthopedic surgery, vein stripping for varicose veins, or other trauma. Twelve years ago, I lost 26 lymph nodes in my left axilla. Lymphedema resulted and my left arm is considerably larger than my right. I had one physical therapist talk about how massage was contraindicated for me and I resented it deeply. I was "too bad to be helped!" I think I am still alive because of help from people who didn't refuse to work on me. I believe in serious consideration of contraindications, but I also do want to be worked on. So my suggestion to massage therapists is to receive all the education on the lymphatic area that you can so you can work on cancer survivors with confidence. Helen Stembridge, Earth Angel Oils www.abmp.com. See what benefits await you. 43