BOUGHT WITH THE INCOME 
 FROM THE 
 
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 THE GIFT OF 
 
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 1891 
 
 A.'3iS'x-).xv xiltlt5 
 
The original of this book is in 
 the Cornell University Library. 
 
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 http://www.archive.org/details/cu31924012167783 
 
THE SKIAGRAPHY OF THE ACCESSORY 
 NASAL SINUSES 
 
CViaVEIfl'SVRRRTE^REPEim 
 
 TRINTED BY 
 
 ■\VILLIA^^ CRKKX AND SON'S 
 
 FJiINliCRfirr 
 
FRONTISPIECE. 
 Antcni-posterior skiagram of human skull. 
 
THE SKIAGRAPHY OF THE 
 ACOESSORY NASAL SINUSES 
 
 BY 
 
 A. L()(IAN TURNER, .M.D., F. R.O.S.E., F.lt.S.E. 
 
 SURf^EON TO THK EAR AND THROAT DEPARTJIENT, THE ROVAL IXFIRMARY, EDINI!i;R(iH ; LKCTTRER 
 OX JIISEASES OP THE EAR, NOSE AXP THROAT, UNIVERSITY OF EDINIU'ROH 
 
 AND 
 
 AY. U. POJITETU M.B., B.Sc, F.R.C.S.E. 
 
 SUR(iEON TO THE EYE, EAR AND THROAT INFIRMARY, EDINBUROH 
 
 EDINBUKGH AND LONDON 
 WIRLU\M GREEN c^^ SoNS 
 
 PUBLISHERS 
 
DEDICATED TO 
 PETEE M'BEIDE, M.D. 
 
 BY 
 
 TWO OF HIS PUPILS 
 
PREFACE 
 
 During the last four years we liave employed the X-rays as a routine 
 method of examination in our cases of accessory sinus disease. As we 
 have undoubtedly obtained much useful information and practical assist- 
 ance in our Avork from their use, we wish to record our experience in 
 this volume and place it at the disposal of others who are interested 
 in the same branch of surgery. We hope that it may prove useful to 
 them. 
 
 We are engaged upon similar work in connection with the mastoid 
 region of the skull, and it is our intention to publish it at some future 
 time. 
 
 We desire to express our thanks to Professor Arthur Robinson, of the 
 University of Edinburgh, for the loan of some of the skidls which have 
 been reproduced. 
 
 A. LOGAN TURNER. 
 
 W. G. PORTER. 
 
 EnixBintGH, 1912. 
 
TABLE OF PLATES 
 
 Frordis'piece Plate. — Antero-posteiior view of skull. 
 
 Plate I. — Antero-posterior ^-iew of skull, with key. 
 
 „ II. — Antero-posterior view of skull reproduced from the negative. 
 
 „ III. — Antero-posterior view of skull (stereoscopic). 
 
 „ IV. — Antero-posterior view of skull showing the sphenoidal siiuises. 
 
 ,, V. — Profile view of skull showing sphenoidal sinus. 
 
 „ VI. — Basal view of skull showing sphenoidal sinuses. 
 
 „ VI f. — Basal view of the head showing the sphenoidal sinuses. 
 
 „ VIII. — Antero-posterior view of skull showing malposition. 
 
 ,, IX. — Antero-posterior view of skull showing large frontal sinuses and extension of 
 
 ethmoidal cells into roof of orljits. 
 
 „ X. — Antero-posterior view of normal sinuses in living person. 
 
 ,, XL — Antero-posterior view of normal siiuises reproduced from the negative. 
 
 ,, XII. — Antero-posterior view of head (stereoscopic). 
 
 ,, XIII. — Profile view of skull, with key. 
 
 ,, XIV. — Profile view of skull reproduced from the negative. 
 
 ,, XV. — Profile view of skull (stereoscopic). 
 
 ,, XVI. — Profile xiaw of normal sinuses in living p)erson, with key. 
 
 ,, XVII. — Antero-jjosterior view of skull at liirth. 
 
 XVIIL— Skull of child, *t. 1. 
 XIX.— Skull of child, mt. 3-4. 
 „ XX. — Head of child, a;t. 5, showing maxillary sinuses. 
 
 XXI — Head of child, a^t. 5, showing well-developed frontal sinuses. 
 ,, XXII. — Head of child, ast. 7, showing a left frontal sinus. 
 
 XXIII. — Head of child, tet. 12, showing frontal sinuses with orliital extensions. 
 XXIV.— Head of adult with V-shaped palate. 
 
 XXV. — Head of adult sho^'ing the maxillary sinuses encroached upon 1iy the nasal 
 cavities. 
 XXVI. — Head of adult with chronic suppuration in the left frontal, ethmoidal, and 
 maxillary sinuses. 
 
 XXVII. — Head of adult with chronic suppuration in the left frontal, ethmoidal, and 
 maxillary sinuses, reproduced from a negative. 
 
 XXVIII. — Head of adult with chronic suppuratio)i in the right maxillarv sinus. 
 
 XXIX. — Head of adult with suppuration in all the sinuses. 
 
xii TABLE OF PLATES 
 
 Plate XXX. — Head of adult with ftetid atrophic rhinitis (ozaeiia). 
 
 XXXL — Head of adult with a mucocele of the right frontal sinus. 
 XXXIL — Head of adult with a suppurating mucocele of the right frontal sinus 
 XXXni — Head of adnlt with a dental cyst in the right maxillary sinus. 
 XXXIV. — Head of adult with a naso antral (choanal) polyi^ns on the left side. 
 XXXV.— Head of adult with a naso-antral polypus on the left side and suppuration in 
 
 the light maxillary sinus. 
 XXXVL — Head of adult with malignant disease involving the right side of the nose.' 
 
 XXXVn. -Profile view of head of adult with malignant disease involving the posterior 
 
 ethmoidal and sphenoidal sinuses. 
 XXXVni. — Head of adidt after a Killian operation upon the left frontal sinns. 
 XXXIX. — Head of adult after a radical operation upon the left maxillary sinus. 
 
INTRODUCTION 
 
 WiJiLE no one will dispute the statement tliat our knowledge of the etiology, 
 diagnosis and treatment of the inflanniiatory afi'ections of the accessory nasal 
 sinuses has greatly increased during the last twenty years, tlie fact remains 
 that upon all these points further information is still refphred. Difficulties in 
 accurate diagnosis by means of the ordinary clinical methods at our disposal 
 are still frecpiently met with, while considerable uncertainty is sometimes 
 experienced in dealirjg with the sinuses surgically owing to an imperfect 
 acc|uaintance with their actual size and with the exact anatomical relations 
 of one cavity with another. 
 
 It is a matter of connnon experience that cases of frontal, ethmoidal, 
 sphenoidal and even of maxillar)^ sinus suppuration are from time to time met 
 with in which the surgeon is unal)le to make up his mind regarding the con- 
 dition of the sinus without first carrying out some small intra-nasal surgical 
 procedure. It may be necessary to remove the middle turlnnated bone, to 
 catheterise the frontal sinus, to open the ethmoidal and sphenoidal cavities, 
 and to puncture and wash out the antrum for diagnostic pm-poses alone. 
 If it were possible to arrive at a correct diagnosis in doubtful cases wdthout 
 such preliminary investigation it would prove, in some cases at any rate, advan- 
 tageous to tlie patient. If, at the same time, the surgeon could obtain 
 information regarding the size and relations of the suspected ca\'ity the gain 
 would be a twofold one in the event of operative interference being- 
 carried out. 
 
 AYith the discovery in 1895 of the X-rays by Professor Ilontgen, and 
 their application to medicine and surgery, it was natural that attempts 
 should be made to utilise them in tlie domain of nasal surgery. In I8d7 
 Scheier puljlished the results of his attempts to facilitate the diagnosis of 
 accessory sinus suppui-ation with the aid of the X-rays {ArcJi. f. Laryiigol., 
 Bd. vi., Berlin). The results, however, were not satisfactory, partly on account 
 
2 INTRODUCTION 
 
 of the defective cliaracter of the apparatus at that time and partly from tlie 
 fact tliat ail exposure of ten to fifteen minutes was required wlien the rays 
 were passed tlirough the antero-posterior diameter of the liead. In this 
 country i\racint}-re was the first to demonstrate the practical application of 
 tlie ravs in the diao-iiosis of simis disease, and in some cases he found them 
 of iindonljted value for this purpose where other methods had failed [British 
 Ldv. and OtoJ. Assoc, 1900). The puhlicatious of Winckler in lUOl increased 
 our knowdedge of the usefulness of the rays in the study of rhinology 
 [FortscJir. uvf dem Gchiet. dcr Rojitijcnstrahl., Bd. v. and ^'i.). It was not, 
 however, until 1903, with the appearance of Gustav Killiau's plates depicthig 
 the accessory sinuses of the nose, tliat a more general interest was taken in 
 the application of the X-rays to nasal sui'gery [Die Neheidivldoi dcr Nase anf 
 15 Tdfchi d':iri'/esfel!t., Jena, 1903). Amongst those who have contrihuted in 
 more recent years to the literature of the suhject, and who have undoubtedly 
 improved the teclmic and assisted in the interpretation of the X-ray plates, 
 must he mentioned in addition to Killian the names of Goldmann, Coakley and 
 Caldwell, ]Mosher, AUirecht, Burger, Pfeiffer and Haike. We desire to draw 
 s})ecial attention to the valualjle atlas of Kuttner, published in 1908, dealing 
 with the inflammatory affections of tlie sinuses. In the same year Johnson 
 Symington and Ilankin produced an atlas of skiagrams illustrating the 
 development of tlie teeth and at the same time demon stratino- in a strikiup- 
 way the relation of these organs to the maxillary sinus. In America, Joseph 
 C. Beck has devoted considerable attention to the study of the radiography 
 both of the mastoid region and of the nasal accessory sinuses, and his work 
 lias recently been suiniiiarised in the form of an atlas, vdiich was published 
 in 1910. 
 
 Impressed with the value of this method of investigation, we turned our 
 attention to a study of the subject, and installed the necessary apparatus in 
 the Ear and Throat Department of the Royal Infirmary, Edinburgh, in 1907. 
 The pictures now reproduced illustrate |)art of the work which has been carried 
 oat in the Department. Some of tlie plates have been exhibited from time 
 to time at the annual and branch meetings of the British Medical Association. 
 We have systematically used the X-rays in connection witli the diagnosis 
 and treatment of affections of the nasal sinuses during the last four years. 
 
THE APPAEATUS AND TECHXIC ■" 
 
 and more recently also in relation to the mastoid region of tlie skull. ^^ e 
 have no hesitation in saying that in accessory sinns work we have learnt to 
 appreciate tlie assistance wliicli radiogra})liy undoubtedly gives. The object 
 which we mainly have in view in this volume is to demonstrate this fiict, and 
 to endcavoTir to simplify the interpretation of what must be regarded by 
 many as the somewhat complicated skiagram of the head. The original 
 ]3botographs have been rejjrodiiced by the half-tone process. 
 
 THE AlT'AItATU.S AXI) TEOHNIC 
 
 In the skiagraphy of the head a good apparatus and careful teclinic is 
 very essential. The iirstrument which we have employed is "The Kotax," 
 supplied l)y tbe Sanitas Electrical Company of Berlin. The pliotograplii(;, 
 apparatus consists of a " safety lx>x '' impenetrable to the rays and provided 
 at one end with a compression tube into wliicb an iris-diaphragm is fitted. 
 The box is attached to a stand in such a way that it can he tilted as desired 
 in order to photograph the patient either in the sitting or recnmljent posture. 
 Moderately liard tubes were, as a rule, used, giving a spark gap of 15 cm., 
 while a i)rimary current of 5 amperes was employed. The X-ray tube is fixed 
 iirside tbe "safety box," with the anti-catliode placed as nearly as possible 
 opposite to tbe central jjoint of the iris-diaphragm, the diameter of which, a,'- 
 a rule, was about 10 cm. The distance from tlie anti-cathode to the distal 
 margin of the con)})res.si()n tube must Ijc a constant one ; in our work tlie 
 distance was lU inches. 
 
 With verv lew exceptions the patients were placed in the sitting posture 
 in preference to the rei uml)ent, as we found that in the former the posing 
 could be more correctly judged. In the case of a male patient tbe coat, collar 
 and tie should be remo\-cd in order to give freer play to the head, while a 
 woman slioidd remove aU hair-pins iind hair ornaments, and loosen the neck 
 of her dress. Tn the pb<il igra})hy of the nasal and accessor}' cavities two views 
 of the head mav be taken, the antero-posterior or sagittal, and the lateral or 
 profile view. Vei'tex pictures have recently been demonstrated by Pfeitt'er with 
 tbeobjcct of depicting the two sphenoidal sinuses side by side {ArcJi.f. Ldri/iif/oL, 
 Bd. xxiii., IDIO). (Ireat c;u-e nuist lie exercised not only in accurately adjusting 
 the head in front of the compression tube Init also in poising the head upon 
 
 s 
 
4 THE APPARATUS AND TECHNIC 
 
 the spinal column. If an antero-posterior picture is desired the occipital 
 region of the skull is placed against the compression tube in such a way that 
 the external occipital protuberance is opposite the centre point of the iris- 
 diaplu'agm, so that the rays fall })erpendicularly upon it. On account of the 
 difficulty in judging of the accuracy of this when the back of the head is 
 against the tube we have made use of the zygomatic process as a guide to 
 the correct ])Osition of the head upon the spinal coknnn ; in other words, the 
 zygomatic process should oceupj? approximately a horizontal plane opposite the 
 centre of the rim of the compressor. The chin of tlie patient should be tlirust 
 very slightly forwards. The platediolder is now brought in contact with the 
 face, touching the forehead and the tip of the nose, and fixed in that position 
 bv means of an elastic baud. The sensitised side of the neiiative is in every 
 instance placed next to the patient. Wlien a lateral or profile view is required 
 tlie sitting posture has usually been adopted. The compression tube is placed 
 against one cheek, the plate-holder Ijeing fixed against the other. In 
 adjusting the head to the correct position care shoidd be taken that the 
 centre of the rays passes through a line which bisects the zygoma. 
 
 We have found some difiiculty in the application of the tube to the 
 vertex, as suggested by Pfeiflter for the purpose of radiograpliing the sphen- 
 oidal sinuses. The plate-holder is laid flat upon a table, and the patient, sitting 
 on a low stool, is brought close up to the edge of the taljle. His chin is then 
 thrust forwards as for as possible over the plate, great care being taken at 
 the same time that the base of the skull maintains the hoiizontal and remains 
 parallel with the plate. Tlie compression tube is then inverted upon the 
 vertex of the head in such a position that tlie axis of the rays passes throuo-li 
 the skull in the ^'ertical plane at a point 2 cm. anterior to the central point 
 of the external auditory meatus. As an alternati^'e procedure to this the 
 patient may be laid upon his Ijack with the head hanging over the end of the 
 table, and with its vertex resting upon the plate-holder, which is placed upon 
 a stool. The compression tulje is adjusted against the under surface of the 
 extended chin, the same care Ijeing taken as before to direct the rays throuob 
 the same vei'tical plane. 
 
 For the purpose of obtaining stereoscopic views a skiafix apparatus is 
 used, so that the head may thus remain quite stationary while the two pictures 
 
THE APPARATUS AND TECHNIC 5 
 
 are taken. The same apparatus is also useful in dealing- with youno- children 
 when there is a risk of movement The method of procedure in stereoscop\' 
 is as follows ; — The patient and the compression tube are in the first instance 
 arranged in the same way as has Ijeen desci'ibed in comiection with the taking 
 of a single skiagram. The c(.)mpression tube is thou moved one inch to the 
 right, and the first exposure is made. Tlie plate-holder is removed and a 
 fresh plate is inserted into it and again laid against the head. The com- 
 l)ression tube is now moved two inches to the left, and the second exposure 
 is made. In other words, each exposure is carried out witli the rays passing 
 through a point one inch to either side of the point through which they pass 
 when a single skiagram is being taken. Special apparatus for tlie accurate 
 adjustment of the compression tube in taking the two positions may be 
 attached to the photogi'aphic machine. 
 
 The duration of tlie exposure is a matter of considerable importance 
 not only to the patient but also as regards tlie life of the X-ray tube. It 
 must be borne in mind that in dealing with the head a longer exposure is 
 recjuired than is the case with the lim])s or the thorax. The duration of the 
 exposure of the macerated skull is of course less than that of the head. In 
 our earlier work it was found necessary in tlie case of antero-posterior 
 exposures to give 80 to 100 seconds, and in the lateral positions 45 to GO 
 seconds. With the intr<.)iluction of the " iSunig " screen, however, a consider- 
 able reduction in time became possible ; tlius in the antero-posterior views an 
 exposure of 10 to 15 seconds, and in the lateral views 8 to 1() seconds only 
 are necessary, the vai'iations in time suggested hy these figures depending 
 upon the sex and age of the individual. Good skiagrams may he obtained 
 by instantaneous exposures, but M'e liave not practised this method. 
 When the screen is employed its sensitive surliice is placed in contact with 
 the sensitised surface of the negative within the same plate-holder, care lieing 
 taken that there should be no dust between the surfaces, so as to avoid tlie 
 production of " pin-holes." If the sensitive surfaces of the screen and the 
 negative are not placed in direct apposition a lilurring of the picture results : 
 the screen must be put between the patient and the sensitive plate in order 
 to prevent the skiagram becoming reversed in the })0sitive. It will l)e 
 readily understood that a mistake of this kind nnght lead to errors in 
 
6 THE INTERPRETATION" OF THE SKIAGRAM OF THE 
 
 diagnosis when we are exauiiiiing the positive in u case of suspected 
 unilateral sinus i.lisease. The mistake was accidentally made in the case of 
 the patient })hotooraphed upon Plate XXXVIII. 
 
 The X-ray negatives are deve]o})ed in the same way as ordinar\^ photo- 
 graphic plates. We have used rodinal as a developer, as it appears to 
 be of more \'alue than otlier forms of developer when the cxposiu'e has not 
 been altosxetlier satisfactory. 
 
 THE INTERl'KETATION OF THE SKLKIRAM OF THE NASAL AND 
 ACCESSORY NASAL CAVITIES 
 
 A. The AxTEiio-PosTEiiioit SKiAoiijur of the Skull 
 
 When we study a skiagrani of any part of the human body it is neces- 
 sary to bear in mind that structures of varying density and lying upon 
 different ])lanes are seen as if upon one plane wlien portrayed in the |)icture 
 before us ; whether studied in the negative or in the positive a somewhat 
 complex picture is _[)resented. It is necessary, theref(.)re, to devote much 
 careful study to the interpretation of the normal appearances presented 
 not only by the macerated bones but in the li\'ing subject. A better 
 knowledge of the details is oljtained l)y inspection of the skull in the first 
 Instance, because with the soft parts superadded clearness and definition 
 are to a considerable extent reduced. Whether we have to deal with an 
 antei'o-posterior or witli a lateral view of the skidl we must ditferentiate 
 between the contour lines and shadows representing the parts nearest tlie 
 X-ray tul)e and those which are in innnediate ap})Osition to the photo- 
 graphic plate. The latter are the more clearl)^ depicted, so that in an 
 antero-posterior \'iew we have mainly a I'epresentation of tlie facial skeleton. 
 Tliere is no doubt that in tlie stereoscopic ])icture we have a better means 
 of instructing ourselves than in the single skiagram, but when we have 
 o)ice master-ed the details it is no longer necessary to employ stereoscopy 
 in every case. For that reason we have only reproduced a few stereo- 
 sco2)ic plates of the skull. An outliiie kev has been introduced alono- with 
 certain of the plates in order to facilitate their interpretation and sujiple- 
 ment the verbal description. 
 
NASAL AND AC0ESS01;Y XASAL CAVITIES 7 
 
 On Plate I. we have an antero-posterioi' view of tlie adult skull with- 
 out the lower jaw l)Ouc. In the application of the X-rays to accessory 
 sinus disease the auter(j-posterior picture must be regarded as the one 
 which is of most service for diagnostic purposes. It must be borne in 
 mind tor descriptive pin-]»oses that tlie skiagram I'epreseuts the subject as 
 facing tlie ol)server. Conspicuous in the centre of the skiagram and readily 
 defined by reason of its dark outline is the pyritbrm anteri<.)r apertrn-e of 
 the nasal cavities. As the nasal bones offer little obstruction to the I'ays 
 they present no very obvious shadow. The osseous nasal septum, some- 
 what deflected to the left in its auteri(_ir and lower part, forms a vertical 
 line subdividing the nasal ca^'ities m<jre (jr less equally. Lying in the 
 same vertical plane as the se|)turn but at a higher level and within tlie 
 cranium is the crista galli. Tins structure is slightly expanded, and the 
 cleai'cr area in its centre represents the cancellous bone which lies within it. 
 In the skiagrams of one di- two heads which we have taken tlie ap[)ear- 
 ance of the crista galli suggested the presence of an air space within it. 
 In a dissected specimen in our collection an air cell in the crista galli com- 
 municates through a small aperture with an anterior etlinioidal cell lying 
 in the floor of the left frontal sinus. As tliis anatomical connection does 
 therefore occur, it is obvious that the diagnosis of an air space in the 
 crista galli liy means of the X-rays may be of clinical iinp(jrtaiice in cases 
 of ethmoidal suppuration. 
 
 The posterior free margin of the nasal septum is seen as a fainter line 
 in the mesial plane, and passing upwards and outwards from its superior 
 extremity on each side the outline of the r(.)of of the two clioan;i? or pos- 
 terior nares can fie recognised. Similarly, at its inferior extremity the 
 lower margins of tlie same apertures fijrmed by the posterior margins of 
 the bard palate are visible. The projecting inferior turbinated bone can be 
 recognised upon the lower part of each lateral wall of tlie nasal cavity. 
 
 The SjiliciuiidaJ Sin uses. — Within the upper and narrower part of the 
 pyriform aperture and above the choanal margins lies the body of the 
 sphenoid lione containing the two splienoidal sinuses. It is impossilile to 
 say whether the dark vertical line of the nasal septum in this region also 
 indicates the bonv partitinn l)etweeii the two sjihenoidal cavities, but in all 
 
8 THE INTEEPEETATIOX OF THE SKIAGKAM OF THE 
 
 probability it does so. A small oval clearer area to the left of the mesial 
 plane ma])S out the position of the left ostium sphenoidale. On Plate IV. 
 the situation of the two sinuses has I:)een more clearly defined by filling them 
 witli bismuth paste. It is interesting to observe that the cavities extend 
 above the plane of the transverse, curvilinear line, to which reference will 
 presently be made and which represents the lesser wings of the sphenoid bone. 
 This is explained by the anatomical fact that the upper surface of the body 
 of the sphenoid, which forms the roof of the sphenoidal sinus, lies on a 
 higher plane than the lesser wings. Plate Y. has been similarly treated in 
 order to give a profile view of the sphenoidal sinuses ; their relation to the 
 sella turcica is thus seen. On Plate IV. a portion of the ethmoidal cell area 
 is visible external to the sphenoidal area on each side, while on Plate V. it 
 forms an. anterior relation to the latter. On Plate VI. a vertical skiao-ram 
 has been taken, and the sphenoidal sinuses are viewed from the basal aspect 
 of the skull in relation to the posterior edge of the hard palate ; the basi- 
 occipital bone and foramen magmnn lie posteriorly. 
 
 A striking feature in every antero-posterior view of the skull, and 
 visible to a considerably lesser extent in the living subject, is the slightly 
 curved, dark, transverse line which crosses the apex of the j^yriform aper- 
 ture (Plate I.). It tra\'erses the upper third of the orbital cavities and 
 passes externally on to each lateral aspect of the skull. The structures 
 thus defined are the lesser wings of the sphenoid bone and the posterior 
 free edge of the orbital i)late of the frontal bone. The importance of this 
 line becomes ob^'ious when we remember that it indicates the plane of the 
 posterior edge of the floor of the anterior cranial fossa. It must be borne 
 in mind, however, that the position of the line in the skiagram will vary 
 with any slight alteration in the poise of the head. When the head is 
 correctly placed the line should fall within the upper third of the orbital 
 cavities. A faulty position is well seen on Plate VIIL, where in consequence 
 of the upward tilting of the facial skeleton the line of tlie lesser sphenoid 
 wings bise<;ts the orbital cavities and tlie nasal cavities are considerably 
 distorted. 
 
 T/ic Orhit. — The orlnts are well defined, the superior and inferior 
 orbital margins l)cing strongly marked. The external margin of each 
 
XASAL AND ACCESSOlfV NASAL CAAITIES 9 
 
 cavity is .sti-eiigtliened l.iy tlie Ijroad .sLadow wljicli is produced by the frontal 
 process of the niahtr bone as it ascends to articuhite with the external 
 angular process of the frontal Ijone. Tlie inner margin of the orbit is 
 less well defined owing in part to tlie fact that the X-rays traverse the 
 air spaces of the ethmoidal bone and thus make this region brighter. The 
 thickened posterior edge of the frontal process of the superior maxilla, how- 
 ever, forms a slightly curved dark line which eompletes the internal orbital 
 margin. Sometimes a narrow zone of liglit, brighter than the surrounding 
 ethmoidal region, indicates the position of the groove for the lacluymal 
 sac. At the apex of the orbit the sphenoidal fissure is clearly defined, 
 while immediately below it the foramen rotiuidum is seen through the orbital 
 floor. The optic foramen may he observed upon the left side immediately 
 above the inner end of the sphenoidal fissure (Plate I.). 
 
 7'/ie Etlnnoi(Jal Air Celh. — These cells occupy the inner wall of the 
 orbit. Within the brighter area wliicli represents them in that situation 
 three dark vertical lines are seen ; these are most evident on the left side on 
 Plate I. Tlie most anterior probably represents the thickened edge of the 
 frontal process (.)f the superior maxilla, the middle one the ridge upon the 
 lachrymal bone, while the most posterior represents the articulation of the 
 OS planum of the ethmoid with the sphenoid Ijone. Ujion fioth sides, 
 especially on the left, however, the cells are seen extending doA^-rnvards to 
 the upper inner angle of the maxillary sinus with which they are con- 
 tiguous. Superiorly and anteriorly the ethmoidal cell area is seen in relation 
 to the floor of the frontal sinus. 
 
 In a considerable proportion of skulls the ethmoidal cells extend into 
 the roof of the orbit within the orljital plate of the frontal l)one. Plate 
 IX. lias Ijceii introduced in order to illustrate this point. i)\\ the left side 
 of the picture tlie anterior wall of the frontal sinus has been removed, and 
 along with it the floor of a large ethmoidal extension into the orbital roof. 
 The dark line which crosses the caA'it}' of the orliit obli(piely from within 
 outwards indicates the extent of the ethmoidal air space in this case. It 
 is evident that a similar condition exists on the right side nf the skull. 
 
 TJic Frontal S>inis(_'s. — The frontal sinuses are clearly defined on Plate I. 
 above the nasal cavities and tlie inner third of the supra-orliital margins. They 
 
10 THE IXTEliriiETATIOX OF THE SKIAGRAM OF THE 
 
 are comparativel}' small, asymmetrical cavities with the inter-siiius septum 
 obliciue and deviated to the right. The dark vertical line continued upwards 
 from the crista o-aUi and traversina,' the left sinus is the thick crest of bone 
 which gives attachment to the falx cerebri upon the cereJjral aspect of the 
 frontal bone. The outline of both sinuses presents a clearly marked definite 
 margin devoid of any irregularity. The varied contour of tlie frontal sinus, 
 however, is well illustrated in the different plates both of the skull and of the 
 living subject. The irregular outline is well seen on Plates A^III., XXXIV., 
 and XXXV., the small "bays" with their intervening septa being very 
 obvious on Plates XXXIV. and XXXV. 
 
 Within the area of both Irontal sinuses on Plate IX. and in the lower part 
 of the cavities a few wavy, short, dark lines are visible. At first we experienced 
 considerable difficulty in interpreting the meaning of these lines. We are of 
 the opinion tliat they represent some of the irregular bony elevations which 
 ai'e present upon the cranial surface of the orbital plate of the frontal bone. 
 A slight increase in the thickness of the walls of the sinus produces a corre- 
 sponding increase in the shadow of the skiagram. 
 
 Killian has drawn special attention to a clearer area which frequently 
 presents itself in the lower part of the frontal sinus, innnediately above the 
 supra-orbital margin. This area is usually demarcateil above by a dark line, and 
 is very well brought out in the skull figured in the frontispiece and in the head 
 on Plate XXIII. and in the right sinus on Plate XX^^L, though it is seen to a 
 lesser degree in other jjlates in the series. Wlien present it indicates the 
 existence of an orbital extension of the fr-ontal sinus. The density of the 
 shadow in a healthy air sinus depends mainly u|ion the depth of the air space 
 through which the X-rays pass. If the antero-jiosterior diameter of the 
 orbital extension of a normal frontal sinus exceed the diameter of its vertical 
 poi'tion the shadow presented by the former will be less dense than that of the 
 latter : the deeper the orbital extension, therefore, the more marked is the 
 contrast between the shadows of the vertical and liorizontal parts of the 
 sinus. 
 
 Tlw M'ixdlafij Siiutsrs. — The maxillary simrses arc well delineated as 
 pyramldal-sliaped ca\-ities beneath the orl)its. The nasal wall of each sinus is 
 seen extending from the anterior to the posterior nares. The roof corresponds 
 
NASAL AND ACOESSOEY NASAL GAAnxiES 11 
 
 to the floor of the orljit ; the infra-orbital margin can be traced as a chirk hne 
 continuous at its inner end with the margin of the anterior nares, while on 
 a somewhat higher plane the posterior edge of the roof is seen to be continnons 
 with the line representing the external margin of the posterior nares. This 
 is best illustrated on tlie right side" of the skiagram on Phite I. In the roof 
 itself and close to tlie postero-lnternal angle of the antrum is tlie foramen 
 rotundiun. The external wall of the siirus in its upper half is almost 
 completely concealed from view, in pai't by the intervention of the deep 
 shadow of the peti'ous tem|)oral bone lying upon a deeper plane and partly 
 by the denser malar bone lying anteriorly to it. The floor of the maxillary 
 sinus or tlie als'eolar I'ecess is vei'y shallow in this skull, and lies almost on 
 the same plane as the floor of the nasal cavities. The deep alveolar recess, 
 which is more commonly met with, is well seen on Plates IX., XXVIIL, and 
 XXXIV., where the floor of the antrum lies on a lower level than the nasal 
 floor. An extension of the floor of the sinus beneath the nasal cavity into 
 the palatal process of tlie superior maxillary hone — tlie palatal recess — is some- 
 times met with, and is well shown on Plate XXXY. 
 
 In studying the cavity of the maxillary antrum in the skull (Plate 1.) 
 we find variations in tlie density of its shadow in dift'erent areas. Tin's is 
 due to the fact that shado\\'s produced liy certain structures lying posterior 
 to tlie sinus may fall within the cavity. Thus the petrous portion of the 
 temporal bone forms a dense shadow acro.ss the upper half of each sinus. 
 Killian has drawn sjiecial attention to this, and points out that the relation of 
 the petrous temporal to the maxillary sinus depends upon tlie ])Osition of the 
 head and its relation to the axis of the X-rays as tliey f;dl ujion the occiput. 
 Care should be taken to bring these shadows as far as possible within the 
 retnon of the orbits, where they will not interfere with the interpretation of 
 the true shadow of the antra. This is attained by causing the rays to fall 
 perpendicularly over i\v.t external occi})ital protuberance. If the shadow 
 of the jietrons temiiorrd falls within the orliit, tlie deep shadow of the 
 inferior part of the occii>ital l:)one will rjccu^iy the lower part of tlie antral 
 cavity. On Plate I. the shadow of the occipital lione is lying across the 
 sliadow cast by the teeth of the upper jaw. The external pterygoid process 
 of the s[)lienoid bone throws a vertical shadow within the inner half of the 
 
12 THE INTEi;ri!ETAT[ON OF THE SKIAGRAM OF THE 
 
 antvuni, wliicli is more readily seen in tlic right sinus on Plate 1. As already 
 indicated, the malar l:)one assists in ohscuring the antral cavity at its superior 
 external anole. 
 
 When an antero-posterior skiagram of the head of the living subject is 
 studied, another shadow falls within the lower and mesial p(.)rtion of each 
 maxillary sinus. Killian has satisfied himself that this is produced by the 
 cervical vertebral cohunn. 
 
 B. The AxTERO-PosTEiaoii Skiaguam of the Heah in the Livixo Persox 
 If the skiagram of the skull just described in detail (Plate!) be compared 
 with any of the antero-posterior pictures of the living subject it is at once 
 oljvious that with the addition of the solt parts a good deal of the clearness of 
 detail is lost. At first sight many of these pictures raise a feeling of dis- 
 appointment, and produce the impression that little can lie learnt from them. 
 With the knowledge pre^'iously gained from a study of the skull, however, and 
 with closer observation, it Ijecomes evident that this is not tlie case unless a 
 really pooi' skiagram has been obtained ; under such circumstances a second 
 one should Ije taken. Even the best results may often leave something to be 
 desired. It is more ditiicult to obtain good results ^\•ith the head than with 
 any other part of the lj(jdy. Plate X. represents the head of an adult in 
 which there was no pathological condition present, consequently it may be 
 taken as a good illustratidii of the usual appearances presented in the skiagram 
 of the normal sinuses. The nasal septum is a prominent landmark in this as 
 in the majority of the heads in the series, and is more strongly marked than 
 in tlie macerated skull. Tlie same remark applies to the inferior turbinated 
 bodies, their mucous covering causing a broader, deeper sliadow tlian the Ijony 
 plate. The middle turbinated bodies upon a higher plane are not always well 
 defined, Ijut tliev may Ije seen in some of the plates. The iiarrow l:)rio-ht area 
 inunediately adjacent to tlie highest part of the septum upon each side is 
 probably produced liy tlie passage of the X-rays through the sphenoidal air 
 sinuses. 
 
 The transverse curvilinear line rein^esenting the le.sser wino-s of the 
 sphenoid is faintl}- visible as it crosses the anterior nasal aperture, and lies 
 within the npjier third of the orbital cavities. 
 
NASAL AND ACGESSOKY NASAL CAVmES 1?> 
 
 A striking feature ou Plate X, is the clear area upon the inner aspect of 
 each orbit due to the presence of the etliinoidal air cells. As we shall indicate 
 later, variations in the density of the ethmoidal shadow are of very considei-able 
 significance in the detection of disease in this area. 
 
 The frontal sinuses in this case ai-e ver}? small cavities ; both present an 
 almost equal degree of density of shadow, Init their outlines are not clearly 
 defined. Vaiiations in the density of the shadcjw in healthy fi-ontal sinuses 
 depend upon the aidero-posterior deptli of the cavities ; that is to sav, upon 
 the diameter of the air space traversed by tlie rays. If the sinus on one side 
 is slightly shallower than that upon the other some inequality between the 
 two sides will be recognised. It nnrst not he forgotten, also, that in a 
 comparison of tlie X-ray shadow upon the two sides of the face in normal 
 individuals some asymmetry in the thickness of the facial Ijones must be taken 
 into account. The appearance presented by the outline of the frontal sinus 
 is of great clinical importance. In the ca.se of the healthy sinus the outline, 
 even though in one instance it may be faint, is nevertheless, as a rule, clearly 
 defined, whereas when the lining mucous membrane is inflamed or thickened 
 the outline of the cavity becomes Ijlurred and hazy. 
 
 The shadow of the maxillary sinuses in the living subject also presents 
 ariations in density. We have already referred in our descri2)tion of the skull 
 to the various causes which may lead to changes in the shadow of the healthy 
 maxillary sinus, and it is unnecessary to rejieat them. r)n Plate X. the 
 shadow of the petrous temporal Ixjue is seen on the plane of the roof of the 
 antrum. The riglit cavity is larger than tlie left, and has an aheolar recess, 
 so tliat its floor is on a plane l)elow the le^'el of the floor of the nasal cavity. 
 On the left side the alveolar process consists of dense Ijone, and the floor 
 of the antrum is slightly higher than tlie nasal floor. The outline and arch 
 of the hard palate are well delineated by the dense shadow of an u])])er 
 denture. On Plate XII. a stere<iscoj)ic view of a head has been reproduced. 
 
 'S' 
 
 C. The I'r^oFn.E Skiacuia.m of the Skull 
 Though the lateral or profile view of the head is not of so much clinical 
 value in the study of the accessory sinuses as the aiiteroqwsterior skiagram, 
 ueverthele.ss it furnislies information on certain points which cannot be other- 
 
14 THE INTEUriiETATION 0¥ THE SKIAGIIAT^t OE THE 
 
 wise ascertained. Plate XIII. represents tlie profile of the left side of an adult 
 skull, while on Plate XVI. we have figured the right side of the face of an 
 adult. A key has heen provided to each of the plates. The primary difficidty 
 in collection with the interpretation of the lateral skiagram is due to the 
 fact that the sinuses of one side are superimposed upon those of the other. 
 While in some instances tlie outlines of the right and left cavities correspond, 
 in other cases they do not do so, and it may he difiicult, if not impossihle, 
 to say whether we are tracing the outline of the sinus upon the right or upon 
 the left side of the fiice. By means of the stereoscopic picture, however, 
 our knowledge of the relationshij) of the parts on the two sides is greatly 
 increased, and what is ditficidt to interpret in the ordinary skiagram will at 
 once hecome clear. Plate X^^. is a stereoscopic profile view of the skull. 
 
 If we proceed to examine in detail the skull figured on Plate XIII. we 
 have no difticulty in defining the facial contour. The fi'ontal region is 
 marked by prominent supra-ciliary ridges ; underneath them the nasal bones 
 with the subjacent anterior nasal aperture terminating below in the pro- 
 nnnence of the anterior nasal spine are clearly shown. Below the S])Ine 
 the premaxillary portion of the upper jaw bones inclines downwards and 
 forwards, au<l the shadow of the projecting I'ight lateral incisor tooth is 
 seen at its lower end slightly overlapping the corresponding tooth in the 
 lower jaw. Both the right and left halves of the lower jaw are seen, the 
 left l_)ody and ramus presenting a darker and more clearly defined shadow 
 than the rioht. Behind the rami are the shadows of the rig-ht and left 
 mastoid processes. 
 
 TJie Frtiitffil Suuiscs. — The interpretation of this region may, in some 
 cases at any rate, pro^'e by no means easy, tlie two frontal cavities being 
 often of unecpial size. Certain dark lines running antero-posteriorly in the 
 floor of the anterior cranial fossa strike the eye. A glance at the interior 
 of the base of a skull reveals the fact that eacli lateral portion of the anterior 
 fossa — the orbital plate — is slightly dome-shaped, and is not a plane surface 
 Both the highest and the lowest part of each oiliital plate may he repre- 
 sented in the lateral skiagram by antero-posterior lines. Consec|uently we 
 may have as many as four of these extending somewliat oliliquely from 
 before backwards, On the other hand, owing to tlie fact that the summits 
 
NASAL AND ACCESSOIIY NASAL CAVITIES 15 
 
 or the lowest parts of tlie floor on the two sides maj occupy corre- 
 sponding le^'els, the Hnes may blend in the skiagran], so that their 
 iiumher is reduced. If I'lates XIII. and XVI. be compared it will be 
 seen that while three lines can he difl'erentiated in the former — that is, in 
 the skull — only two are olj\ious in the living head on Plate XYI. In the 
 neoative of the skull, however, four lines can l)e made out on account of 
 the greater clearness in detail (Plate XIV.). A glance at the key tracing 
 of Plate XIII. will sliow tlie reader the interpretation whicli has been 
 put upon these lines. 
 
 Wlien the frontal sinus lias a liorizontal extension into tlie roof of the 
 orbit, or, in other A\ords, into the floor of tlie anterior fossa of the skull, it 
 necessarily follows that the lines whicli we have just descriljed Avill also 
 indicate the upper and lower boundaries, i.e. the roof and floor of the 
 orbital extension. This is c\ident when we attem|)t to map out the two 
 frontal sinuses on Plate XIV., each of wliich has a well-marked orljital 
 extension. The left or near frontal sinus, Ijotli in its vertical and horizontal 
 portions, is indicated on the l^ey by the darlv lines marked with the letter B, 
 while tlie letter A indicates the outlines of tlie corresponding parts of the 
 right or more distant sinus. It will he observed that the orljital extension 
 of the left sinus reaches almost to the a})ex of the orbit, while that of the 
 right sinus does not extend so far backwards. We ^vere al_)le to satisf}' 
 ourselves of the correctness of these jioints by dissection. On a plane 
 corres})ondiiig to the fronto-nasal suture in front and to the anterior clinoid 
 process posteriorly the position of the cribriform plate of the ethmoid hone 
 is faintly indicated. 
 
 T/h' FAlimoida.1 CcU.'^. — In the anterior part of the ethmoidal region 
 the extei-nal margins of the orbits, strengthened by tlie frontal process of 
 the malar bone, are outlined. They interfere to some extent with the 
 interpretation of this region. The anterior ethmoidal cells are situated 
 within the cavity of the orbits, but it is impossible to difl'ereutiate their 
 outlines in this pictm-e. In the negative, however (Plate XIV.), the cells 
 can Ije to some extent defined. The posterior ethmoidal region, on the 
 other hand, lying behind the orbital margin, presents better definition. 
 
 T/tc Sji/iciioidal Suui.'<('s. — Beneath the sella turcica and in the body of 
 
16 SKlAdKAM OF THE KASAL AND ACCE.SWOEY NASAL CAVITIES 
 
 the splieiioid bone the light and left sphenoidal cavities, evidently unequal 
 in size, are well seen, one sinus extending somewhat further forwards than 
 the other. Beneath the posterior part of the sella tiu'cica and the posterior 
 clinoid process the cancellous structure of the splienoid bone is evident. 
 
 Tlie Maxillary Sinuses. — The two niaxillaiy sinuses lie beneath the 
 orbits, between them and the dark lines which indicate the position of 
 the hard palate. The interpretation of these cavities is consideral)ly inter- 
 fered with by the dense shadows of the malar bones ; the narrower 
 V-shaped shadow represents the left malar, while the broader and more 
 anterior shadow is that of the malar bone of tlie right side (Plate XIII.). 
 
 I). The Profile Skiagkaji ix the Livixr; Peksox 
 
 The head of a normal adult is represented u})on Plate XVI. with 
 tlie riglit side of the face towards us. It is unnecessary to repeat wliat 
 has already been detailed in the description of the skull. One or two 
 points, however, require special reference. Two frontal sinuses are seen in 
 the vertical portion of the frontal bone, but there is no evidence that either 
 has an orbital extension. In consequence of this the dark lines in the 
 base of the anterior cranial fossa have a different arrangement from that 
 seen in the skull. The dark broad line extending backwards to the anterior 
 clinoid process is formed by the blending of the highest parts of the floor 
 of the fossa on each side, while at a lower level a line of lesser density 
 indicates the position of the lowest parts of each fossa. 
 
 The sphenoidal sinuses are very large, Ijut unequal in size ; the anterior 
 wall of one of the cavities is well defined, and although that of the other 
 cavity is less clearly indicated, it can nevertheless Ije traced upwards as 
 it lies a short distance behind the former. The whole of the body of 
 the sphenoid bone is occupied by the sinuses. 
 
 The maxillary sinuses, unlike those in the profile view of the skull, are 
 not obscured by the malar bones, though the triangular outline of the right 
 malar can be defined. It is interesting to note that the outlines of both 
 the sinuses can he followed, but we do not feel able to express an opinion 
 as to which is the right or the left cavity. 
 
THE VALUE OF THE SKIAGIUM IN AXATOIMY AND SFRGEKY 17 
 
 THE A^ALUE OF THE SKIAGEAM IN ANATOMY AND SUItGEUY 
 No one will now dispute the fact that in the skiayraphy of the head the 
 anatomist and the surgeon |)ossess a valuable means of studying the nasal and 
 accessory nasal cavities. Doubtless the anthropologist too will derive useful 
 information from a comparative study of crania by this method. It is not 
 our intention, however, to do more than emphasise in the first instance the 
 anatomical points which have a direct bearing upon the surgery of the sinuses 
 and then to illustrate the value of the skiagram in tlic detection of diseased 
 conditions. 
 
 Anatomical Coiisid<n-atious. — Under this heading we propose to deal 
 first with the development of tlie sinuses in children, and secondly with their 
 anatomical configuration and relations in the adult. 
 
 1. DEVELOPMENT OF THE SINUSES 
 
 It is self-evident that a knowledge of tlie early development and growth 
 of the various accessory canities )uust undoubtedly be of value to the clinician. 
 From time to time in the course of his work he is faced with the problem as 
 to wdietlier a sinus actual])- exists in tlie child whom he is examining, or if 
 present, as to its probable size. It is true that these points are dealt with 
 in the various textdjooks of anatomy and in monographs upon diseases of the 
 nose and throat. As the statements made therein, like the sinuses themselves, 
 are subject to consideral)le variation, it is often difficidt for the surgeon to 
 accui'ately estimate their value in any given case. If a skiagram of the head 
 Ije taken, howe\er, as a supplenientary means of diagnosis, the difficulties will 
 be overc(_)me. 
 
 It is probaljly in connection with the frontal simis that the cpiestion 
 most frecpiently arises as to the age at which the sinus is first found as 
 a. distinct cavity in tlie frontal l)one. It is generally held that the sinus 
 commences to develop at the end of the first or at the beginning of the 
 second j'ear of life, as an upward extension of the ethmoidal cell labyrinth 
 or as a recess developing upwards from the anterior end of the middle 
 meatirs. Onodi's recent researches, however, appear to show [Die Nchcn- 
 lioldeib iler Nasc heim Kinde, liUf) that develcjpment actually conunences 
 
IS DEVELOPMENT OF THE SINUSES 
 
 at birth. It is sometimes ditliciilt to deteriiiine in very young children 
 
 whether the air cavity represented in the skiagram is a frontal sinus or an 
 
 anterior etlimoidal cell. If, however, skiagrams are taken at dilFerent periods 
 
 of time in the same cliildren, as has been done by Haike [Arch.f. Laryiigol., 
 
 Bd. xxiii., Ht. 2, Berlin, 1910), the commencement and growth of the frontal 
 
 sinus may thus be determined. Killian [Zeitschr. f. OhrenJil-., 1908) opened 
 
 a diseased frontal sinus in a child aged one year and three months ; 
 
 Wertheini [Ai'ch.f. Laryiifjol., Bd.xi.) found at a post-mortem examination a 
 
 well-developed frontal sinus in a child aged two years and two months ; 
 
 Haike radiographed a girl aged two, and failed to detect any evidence 
 
 of a sinus, but a second skiagram, taken when she was two years and 
 
 nine months old, revealed a right frontal sinus ; Edmiuid Meyer (Berl. 
 
 liia. Woch., 1905) has published the case of a child aged three upon 
 
 whom he operated and found pus in the frontal sinus ; Onodi [Die Nehen- 
 
 holdeib der Nasc heim Kiiide, 1911) fio-ures the skiao-ram of the skull of 
 
 a child aged three and a half in which both frontal sinuses are present, 
 
 extending for a distance of 6 mm. l)oth in the vertical and horizontal 
 
 directions ; Haike has in two instances observed small frontal sinuses in 
 
 cliildren of three and a half years by means of the skiagram. 
 
 Our own observations upon very young children have been somewhat 
 interfered witli on account of their timidity wliilc being photographed. We 
 have introduced on Plate XIX. the skull of a child Ijetween the age of three 
 and four. In contradistinctioii to tlie skull figured by Onodi at three and 
 a half years, it presents no evidence of a frontal sinus. Air spaces are 
 seen in tlie ethmoidal region on each side, but they are distinctly demarcated 
 from the frontal bone. On the other baud, on Plate XX., which repre- 
 sents the head of a child aged five, two small frontal cavities are seen 
 in an early stage of development, tliat upon the left side being slightly 
 the larger. Here the air spaces occupy the lowest part of the frontal bone. 
 Haike has drawn attention to a })ossible source of error in connection with 
 tlie diagnosis of a frontal sinus by skiagraphy in very young children. In 
 rare instances the frontal diploe may be of such a loose texture {n'eitmu.scJiig) 
 that the sliadow which tliey present resembles that of a distinct ca^-ity. In 
 our description of the crista galli on Plate I, we drew attention to the loose 
 
DEVELOPMEXT OF THE SIXUSES 19 
 
 cancellous texture of the bone, and pointed out how it might give tlie 
 impression that an air cell was contained within it. 
 
 On Plate XXI. the head of another child ao-ed five is shown where 
 
 O 
 
 the frontal sinuses have attained a very considerable development. On 
 Plate XXII. the head of a child aged seven shows the left frontal siiuis 
 extending outwards above the supra-orljital margin. There is no evidence 
 of an air ca^•itv upon the riodit side. 
 
 Uidess a very large numl:)er of skiagrams are made from children 
 under se\'en years of age no valuable deductions can be drawn as to the 
 relative frerpieucy with which frontal sinuses exist between the tables of 
 the frontal l)one in tlie early j^ears of life. If we regard as exceptional 
 the occurrence of sinuses before or at five years of age we may legitimately 
 say that at and after the seventh and eighth year the presence of a sinus 
 is the rule rather than the excei^tion. At this age the ca\'itv mav assume 
 very considerable proportions. 
 
 T/ie ]\faxiJIari/ Sirins. — As the maxillary sinuses are present at birth 
 they naturally become cavities of considerable size and of cliineal importance 
 at an earlier age than the frontal sinuses. At Ijirth the siiurs forms a 
 slit-like indentation upon the outer wall of the nasal chamber, with 
 a transverse diameter of 2 mm., a vertical diameter' of 3 nun., and an 
 antero-posterior or sagittal diameter of 7 mm. For the purpose of studying 
 the growth of the sinus in the earlier years of life we have introduced the 
 skiagrams of two skulls, one of a. child aged one and another of a child 
 between three and four years of age (Plates XVIII. and XIX.) On Plate 
 XVIII. the nurxillary sinuses are seen as small cavities Ijeneath the most 
 internal part of the infi-a -orbital margin. Tlie infra-orbital fijramen is seen on 
 each side, just external to the outline of the sinus. The body of the upper 
 iaw bone, owing to its cancellous texture, otters little oljstruction to the 
 passage of tlie rays. The cavity of the sinus, therefore, is distinguished 
 from it mainly by the darker line of demarcation. This is better seen upon 
 the left side of the skulh On Plate XIX., the skull of a child aged three 
 to four, well-formed triangular sinuses are seen. Even at this age, however, 
 the cavities do not extend beyond the infra-orbital foramen. The dense 
 shadows of the petrous temporal bone and of the un-erupted permanent 
 
20 DEVELOPMEXT OF THE SINUSES 
 
 teeth conceal the caiicellou.s texture of the rest of the body of the superior 
 niaxiUa. On Phite XX. we have the head of a child aoed five showing 
 ^vp|[_i|eYel()pe(l maxillary sinuses extending outward.s to tlie junction of the 
 middle and outer thirds of the infra orbital margins, and now reaching below 
 to the plane of the floor of the nasal ca^'ities. Tlie dense sliadows of the 
 permanent teetli are seen immediately below each sinus. 
 
 Hailve gives the following measurements for the maxillary sinus in 
 vonno- skulls : — 
 
 Age. Transverse. Aiitero-Posterior. 
 
 1 J- year.? 4-5 mm. -0 mm. 
 
 2 ' „ 8 „ -25 „ 
 5 „ 16 „ 26 „ 
 
 At the age of seven the transverse diameter of the maxillary sinus has 
 increased, and tlie cavity now extends outwards to a plane midway between 
 tlie infra-orbital canal and the malar or zygomatic process of the superior 
 maxilla. At the ninth year the cavity exists in tire malar process of the 
 bone, l)ut owing to the dense shadow of the malar Itone this extension 
 of the cavity is not visible in the skiagram. The age at which tlie alveolar 
 recess develops is of clinical inrporfcance in connection with any operative 
 procedure upon tlie sinus by way of the nasal cavity. Haike points out that 
 we cannot determine this point by a study of an antero-posterior picture 
 because the second and third molar teeth throw a dense shadow upon the 
 floor of the sinus. On the otlier hand, if a profile view of the cliild's face be 
 taken this point can be demonstrated. He illustrates tlie presence of this 
 recess in the anterior part of the floor of tlie antrum in a child aged eight 
 by means of a lateral skiagram of the bead. The alveolar recess, however, 
 is not completely developed until all the permanent teetli have erupted. 
 
 llie EtJimotdal Aw Cells. — The ethmoidal cells commence to develop 
 duriiiM' fietal life. It is diflicnlt even in the skiati-ram of the macerated skull 
 to ditt'erentiate the shadow cast hx these cells at birth or even at the ao-e 
 of one year to judge from the appearances seen on Plates XVII. and XVIII. 
 As tlie cells are small, and as they are still surrornided Ijy the osseous structure 
 of the lateral mass of the ethmoid in which they are developed, the shadow 
 of the ethmoidal region closely re.sembles that of the other fjxcial bones in the 
 immediate neighbourhood. With the growth of the skull, liowcA'cr, and the 
 
ANATOMICAL COXFIGUEATIOX AND liELATIOXS OF THE SINUSES 21 
 
 further development of the air spaces in the etlimoid Ijone, we are aljle to 
 observe the tiradual broadenintj,- of the ethraoithrl rco-ion, wliilc the ho'hter 
 shadow produced by the enlaro'iiig air spaces becomes progressive!}' more 
 obvious. If Phites XIX., XX., and XXI. are compared with Plates XVII. 
 and XVIII. the development of the ethmoidal air cells can be observed. 
 
 Tlie SplK'iundal Sinus. — A'arious statements have been made as to the 
 period at which the sphenoidal sinus connnences to develop. According to 
 Onodi the siiurs at birth is the size of a pin's head, while during the second 
 and third years of life it has attained the size of a ])ea (Zuckerkandl). 
 Onodi gives the measurements of the sphenoidal sii^us during the tirst year of 
 life, and states that its height varies from 1 to 9 mm., its depth or antero- 
 posterior diameter from 1 to 5 mm., and its breadth from I to G nun. In the 
 early stages of its development no information regai'ding its size can be 
 obtained from the skiagram because the bone in which it develops tlu'ows too 
 dense a shadow. Haike first differentiated tlje sinus in the skiagram at the 
 age of three and a half years, the cavity presenting a l)righter area within 
 the dark shadow of the body of the sphenoid. Profile views of the head are 
 necessary for the study of the growtli of this cavity. Onodi's measurements 
 of the sinus in a child aged three and a half are : — Height, from 4J to G mm. ; 
 depth, 3J to 5 mm. ; breadth, 7 nnn. Tlie same writer saw in a child aged six 
 a sphenoidal sinus the size of a lieau. It is necessary, liowever, in studying 
 skiagrams of this region in very j'oung peojde to bear in mind that we may 
 he deceived by tlie lighter shadow presented b}? the cancellous tissue of 
 the body of the s})henoid bone. 
 
 2, THE ANATOMICAL CONEIOULATKJN AND LLLATIONS (JE THE SINUSES 
 IN THE ADULT ELOM A CLLXICAL STANDI'UINT 
 
 It is unnecessar}' for irs to i-epeat wliat has already l)een described 
 in the section upon the intei'pretation of the skiagram in the skull and 
 in the living person. We wisli, however, to emphasise certain anatomical 
 points wliich l)ear more directly u[)on the chnical value of tlie X-ray pictiu'e. 
 
 (a) The Fi-()iital Sinus. — Altliough tlie older method of investigating 
 the frontal sinus l)y electric transillumination inidoubtedly possesses some 
 
22 ANAT(JMICAL GONFIGUEATIOX AND EELATIONS OF THE 
 
 value as a means of delineating the vertical portion of the cavity in the 
 frontal bone, it frequently fails us when it is most desirable that we should 
 obtain definite information as to whether the sinus is present or not. 
 Further, it is quite useless as a means of ascertaining the existence of 
 a horizontal or orbital extension of the cavity or fjr the purpose of 
 definino- its relations with the ethmoidal cells. If a frontal sinus exists 
 it is possible to demonstrate its presence b}^ skiagraphy, provided that the 
 picture is a good one and tliat the rays have passed through the head 
 at tlie correct angle. .Should the skiagram not be satisfactory a second 
 or even a tliird one should be taken in order to settle this point. 
 
 If the rays have been incorrectly directed through the sagittal diameter 
 of the head from a point too far above the external occipital protuberance 
 a small frontal sinirs may, in conseipience, be invisible in the lower part 
 of the frontal bone. If, on the other hand, tlie rays have been transmitted 
 through the skull from a point some distance below that landmark, the 
 ethmoidal cells may be projected on to the frontal sinus area, and thus 
 deceive us as to the true condition. Coakley has pointed out that a small 
 frontal sinus lying parallel \\ith the supra-orbital margin may escape 
 detection upon the skiagram {Anns, of OtoL, etc., 1905). Apart from 
 these faulty or exceptional conditions, if a frontal sinirs exists the antero- 
 posterior skiagram will re\'eal it, and if there should still be any doubt 
 in the observer's mind a profile view of the head will jn-ove of further 
 assistance. From time to time the surgeon has operated upon the frontal 
 sinus area and found that the cavity was absent ; witli a preliminary 
 use of the X-rays this mistake sliould no longer be made. 
 
 In the head figured on Plate XXV. tliere are no frontal sinuses, while 
 on Plate XXXIII. the riglit frontal sinus is absent, hence the appearance 
 pre.sented by tlie skiagram in the altsence of a frontal sinus can l)e 
 compared in these two Plates witli what is seen in many others in the 
 series in which frontid sinuses are depicted. On Plate XXXIII. tlie 
 contrast can be the more readily noted because a small left sinus is 
 present. 
 
 In addition to the value of tlie knowledge which is derived from 
 ascertaining that a sinus exists, further useful information is obtained. 
 
SINUSES IX THE AUULT FKOM A CLIXICAL STAXDPOIXT 23 
 
 Thus we become acquainted with the size of the cavity, the presence of 
 recesses or pockets, the existence of a supra-orbital extension, the position 
 of the septum l)et\veen the two sinuses, and tlie relation of tlie anterior 
 ethmoidal cells to tlje floor of the frontal sinus. We have already dealt 
 with the appearances which the skiagram reveals when re(;esses are present 
 and when a well-marked orbital extension exists (p. 10, also Plates 
 XXIII. and XXVL). Variations in the position of the inter-sinus septmn 
 can be readily demonstrated. We have not been able to sliow iii our 
 series of plates any marked deviation of the septum f'r(_)m the mesial 
 plane. It is well known, liowever, that occasionally it assumes a very 
 oblique position, so that one sinus, the right for example, uiay occu})y a 
 limited area above the siqjra-oi'bital margin, and the left may in con- 
 sec[uence extend across the mesial plane almost to the supra-orbital margin 
 of the other side. Under such circumstances the left sinus might be 
 accidentall}' ojiened l)y tlie remo^'al of the anterior table of bone in an 
 operation planned for dealing with a diseased right sinus. The preliminary 
 use of the X-rays would prevent tliis mistake. On Plate XXXIV. we have 
 an example of a deviated septum, the right sinus being considerably 
 smaller than the left. 
 
 The relation of the floor of the frontal sinus to the underlying 
 antei'ior etlimoidal cells is a factor of very considerable importance in 
 determining the possihility of establishing drainage between the sinus 
 and the nasal cavity. The inq)ortance of this point and its detection by 
 means of the skiagram has l)een enqjhasrsed ]jy i\bjsher [TIic Lari/iii/oscojic, 
 St. Louis, ]!)0()). For this purpose the proflle view is necessaiy. We 
 know fi'0)n anatomical study that the nasal portion of the floor of the 
 frontal sinus in the region of the ostium froutale may have a very small 
 antero-posterior diameter ; tliat is to say, the ^)Osterior wall of the cavity 
 may appi'oximate so closely to the anterior wall in this situation that 
 there is not room for more tlian the ostium. On the other hand, its 
 antero-posterior depth may be very considerable ; conscipiently we may 
 And that a part of the anterior ethmoidal cell area lies subjacent to the 
 floor of the sinus, the removal of which will permit of the establishment 
 of a large opening lietween the sinus and the nasal cavity. The lateral 
 
24 AXATOMICAL COXFlGUliATION AXD EELATIONS OF THE 
 
 view of the skull fisjured on Plate XIII. illu.stvrttes the existence of a wide 
 comnuinication Ijetweeu these t\\'o cavities. 
 
 It is obvious, therefore, tluit if the surgeon can make himself acquainted 
 before operation with all the anatomical flxcts which we have just enumerated 
 he is able to consider the question of operative procedure from a broader 
 standpoint than he could otherwise do. Thus the difficulty in deciding 
 anatomically as to the expediency of carrying out an intra-nasal operation 
 upon the frontal sinus will he lessened if it is known that the cavity is 
 small and contains no recesses or partial septa, if there is no orbital 
 extension, and if there is naturally a considerable area of the sinus floor 
 in direct contiguity witli the anterior ethmoidal cells. Such aiiatomlcal 
 factors at any rate A^'ould conduce to a more favourable result than would 
 be obtainable if the siims were large and irregularly shaped, owing to the 
 formation of pockets and septa. Moreover, good access to it by reason of 
 its relation to the ethmoidal cells woidd not only diminish the risk of tljc 
 intra-nasal operation but it would also tend to ensure more favourable 
 drainage during the after-treatment. 
 
 Again, if the frontal sinus were large, and if a well-marked orbital 
 extension existed, a Killian operation might be decided upon. Conse- 
 quently the long skin incision and the mapping out of the supra-orbital 
 " bridge " with pi-eservation of its periosteum would be carried out at 
 once, while the anterior wall of the siiurs could be completely removed 
 without the necessity of first dividing its lining mucous membrane and 
 finding out the extent of the cavity by proljing. If the profile skiagram 
 demonstrated a very deep sinus the surgeon would realise that consider- 
 able disfiguren)ent would probably follow the Killian procedure, and he 
 would tlms be able to warn his patient beforehand of the probable effect 
 that such an operation would have upon his appearance. It may also 
 he expedient in the event of the skiagram demonstrating the possibility 
 of r'emoval of the anterior ethmoidal cells through the floor of the frontal 
 sinus to carry out a modified Killian operation without removino- the 
 frontal process of the superior maxilla. We have done this in more than 
 ne case where the skiagram has demonstrated that the relationship of the 
 
 as 
 
 o 
 
 floor of the sinus to the anterior ethmoidal cells was a large one. It wf 
 
SIXUSES IN THE ADULT FliOM A CLIXICAL STAXDPOINT 25 
 
 sufficient to remove tliese cells from aljove by eulargiiio- the ostium froiitale. 
 If tliis modificatioii is intended it is unnecessary to carry the preliminary 
 skiu incision down the side of the nose and beneath the inner canthus. 
 
 Further, in dealing with ethmoidal suppuration, if we are able to 
 recognise the extension of the ethmoidal cells into the roof of the orbit 
 it is useless to attempt their radical treatment l)y any intra-nasal 
 procedure. 
 
 While the X-rays are undoubtedly of most therapeutic assistance in 
 connection with the frontal sinus an<l fronto-ethmoidal region, they may 
 also prove servicealjle prior to operati(jns upon the ni'(.rillt(ri/ .simi.'i. We 
 have already referred to their value in cliildhood, Ijut even in the adult 
 they may furnish useful information. Thus on Plate XXV. we are aide 
 to determine the position of the n;isal walls of the two maxillai'y sinuses. 
 On the right side the outer nasal wall Ijulges considerably into the cavity 
 of the antrum. For this reason the removal of the inferioi' meatal wall 
 by the intra-nasal route w mid present greater difficulties than upon the 
 right side, being less easily accessible. It is also more closely approximated 
 to the orljital and facial \\ alls of the ca\'ity. Again, the relation of the 
 floor of tlie sinus to the floor of the nasal cavity, that is to say the 
 presence or absence of an ah'eolar recess, has a bearing both upon intra- 
 nasal and alveolar operations upon the cavity. This can )je investigated Ijv 
 a preliminary use of tlie X-rays. A. knowledge of the existence of a palatal 
 recess, as shown on Plate XXXV., would also prove of service to the surgeon 
 before commencing operation. 
 
 In connection with the spJiriioKhd siiuis preliminary information mav 
 be obtained by means of a profile skiagram as regards the antero- 
 postei'ior de})th of the ca\ity ; that is, the distance between the anterior 
 wall of the sinus and the cranial floor can be ascertained. Some idea 
 may also l)e gamed of the tliickness of the anterior wall of tlie sums, 
 a point of some importance in connection with the clioice of instruments 
 and the possiljility or otherwise of making a large opening into the 
 cavity. 
 
 In relation to this part of our subject it will not l)e out of place to 
 briefl}' refer to the \alue of skiagraphy in estimating tlie exact positi(jn 
 
26 THE SKIAGEAM IX DISEASE 
 
 of probes and caimulte in dealing with intra-nasal operations upon tlie 
 ethmoidal and frontal sinuses, more particularly in connection with the 
 latter sinus. In the treatment of the frontal sinus by intra-nasal lavage 
 it is often difficult to say whether the end of the cannula has entered 
 that cavity or is merely lying in an anterior ethmoidal cell immediately 
 below the floor of the sinus or in an ethmoidal cell projecting into the 
 cavity of the frontal sinus (frontal bulla). Again, in connection with the 
 establishment of intra-)ia8al drainage of the frontal cavity the introduction 
 of probes or pilots preliminary to drilling and the insertion of drainage 
 tubes should be carried out under the guidance of the X-rays. For these 
 purposes the fluorescent screen is used, and the exact position of the 
 instruments is noted. 
 
 THE SKIAGRAM IX DISEASE 
 
 (ii) The Diacxostic N'alue of SKiAGiiAruY in iNFLAjniATiox AND SurruitATiox 
 
 IN THE Sinuses 
 
 In the light of what we have already said regarding the skiagram as 
 a means of studying the anatomy of the sinuses in the living its usefulness 
 would be sufficiently established. But it is not in tliat respect alone that 
 it has found a place in nasal surgery. Its value as a diagnostic agent in 
 disease must now be accepted, and the difficulties previously experienced in 
 arriving at a correct diagnosis in many cases of frontal sinus and ethmoidal 
 disease have to a very large extent been overcome. In connection with 
 maxillary sinus suppuration and other diseases of the antrum much valuable 
 information can Ije acquired, but here it is not so necessary for us to make 
 use of it, because a diagnosis can usually be made by the ordinary clinical 
 methods wdiicli are at our disposal. Our experience Mdth skiagraphy in 
 connection with the sphenoidal sinus is comparatively small, but we believe 
 that its more extended use will demonstrate its value in the diagnosis of 
 sn})[)uratioii in tliat (;avity. 
 
 In connection with the diagnosis of pathological conditions in a sinus 
 we ha^'e to note and endeavour to appreciate the clianges which take 
 place in what we have learnt to regard as the normal shadow. The 
 
THE SK1AGI;A]\I in disease 27 
 
 cbaiio'C niav be descril)e(l as a cloudiness or foo-o-iim' of tlie area occupied 
 ])y the siuus. In the case of the frontal sinus particular attention must 
 also be paid to the alteration in the character of its outline. The clear, 
 well-defined margin which we associate witli the normal Ijecomes blurred 
 or hazy, and in some cases the blurrino- of the outline is of more diao- 
 nostic value than the increased density of the shadow. Certain variations 
 m tlie noi'mal ai'c natural ownig to varying anatomical conditions such 
 as the depth of tlie cavity and the thickness of its walls. Similai-ly, 
 when pathological conditions are present tlic shadow significant of disease 
 will vary with the contents of the sinus and with the intensity of the 
 change in its lining membrane or Iwny Avails. 
 
 In order to estimate at their true A-alue tire alterations fronr the normal 
 shadow experimental work was carried out by Sclieier, and later l^y Ohis- 
 hfdm and Alhrecht. It was found that glass tubes filled with water or 
 normal saline interrupted tlie passage of the X-rays and produced a denser 
 shadow than that which was cast by a tulie whii'b only contained air. A 
 still denser shadow vas ol)tained Avlien tlie tube was filled witli pus. 
 Having demonstrated that alterations resulted from a change in the 
 contents of a cavity, Cliisliolm experimented witli intestinal mucous mem- 
 brane and found tliat when moistened it produced a much deeper shadow 
 than when exposed to the rays in a dried condition, and that its density 
 increased in proportion to the thickness of the moist mucosa. Further 
 experiments were then made upon skulls. The frontal sinuses were skia- 
 graphed, and then one of the cavities was filled witli gelatine and a second 
 exiiosure was made. Tlie sinus thus treated no\v gave a very dense 
 shadow, in striking contrast to that upon the opposite side. He found, 
 too, that an empty frontal sinus witli a normal mucous membrane presented 
 a clear, sharp outline, liut when filled with fluid, even when its lining mem- 
 brane was normal, it gave a cloudy appearance with its outline less well 
 defined. From his experiments with the moist intestinal mucosa Cliisholm 
 considered that we might justly infer that a frontal sinus lined with 
 thickened so-called polypoid mucous membrane will present the sanre 
 blurred appearance as when filled with fluid. 
 
 Albrecht's experiments upon the maxillary sinus furnish additional 
 
28 THE SKIAGEAIM IN DISEASE 
 
 evidence of the probalile eiieet of inflammation upon the appeai'aiice of 
 the shadow [AjvJl f. Lari/nr/ol, Berhn, 1907). A slviagram of the skull 
 was made, and the appearance of the antrum wa.", noted. A quantity of 
 pus was then injected into the cavity, and a second exposure was carried out. 
 An increase in the density of the shadow of the sinus thus treated was 
 observed. After a still larger quantity of pus had been injected an even 
 darker shadow was produced. Albrecht found clinically, however, that when 
 the maxillary sinus with a thickened lining membrane nud with purulent 
 contents was washed out and immediately skiagra})hed there was practically 
 no diti'ei'ence between the shadows befoi'e and after syringing. It is evident, 
 therefore, from what has been said that inflammatory changes in a sinus '\^■ill 
 produce a cloudiness or an increase in the density of its normal shadow, but 
 no definite statement can be made as to wdiether the chano-e is due to the 
 presence of secretion in the cavity or to an alteration in the thickness of its 
 lining membrane. 
 
 Unless more extended experience can throw furtijer light upon this 
 subject it will not be possible for us to draw any definite conclusions as to 
 whether the pathological changes in the lining mucous membrane have pro- 
 ceeded further in one patient than in another. Again, where more than 
 one cavity is afiected in the same patient, as for instance the frontal and 
 maxillary sinuses on the same side, we are not in a position to say from a 
 study of the skiagraphic shadows that one sinus has been aflected for a longer 
 period of time than the other, and that one lias probably infected the 
 other. Careful skiagraphy of diseased sinuses with sulisetjuent microscopical 
 examinatio]L of the fining mucous membrane nfight prove a useful subject 
 of research. 
 
 The diagnostic value of the skiagram in sinus suppuration may be 
 illustrated by the study of a typical case of disease sucli as is fio-ured on 
 Plate XXVI., in which operation was perlijrmed and the diagnosis confirmed. 
 The patient was a young man v.ho had complained of discharge from the 
 left side of the nose for at least three years. (.)n more than one occasion 
 he had had nasal polypi removed. Suppuration in the left maxillary sinus 
 was diagnosed by the ordinary clinical methods. The cavity was opened 
 tlirough the outer wall of the inferior meatirs and lavage commenced. In 
 
THE SKIAGEAM IX DISEASE 29 
 
 spite of the iinproveuient wliicli followed tlie operation pus coutiuued to 
 appear in the middle meatus, and be A\'as conscious of discomfort in the 
 left frontal region and occasional lieadaclie. Some pin-ulent dischai-ge 
 continued to come from the antrum. The skiagram on Plate XXVI. was 
 then taken, and Ijy its aid the full extent of the disease can Ije recognised. 
 On the right side of the picture we can clearly distinguish the normal 
 shadow presented by the frontal sinus, ethmoidal cells, and maxillary sinus, 
 and if they are com|)ared with the (corresponding areas u[)on tlie left 
 side a marked contrast in the density of the shadows is at once 
 ap|)arent. 
 
 If we examine the frontal area in the first instance we can define the 
 inter-sinus septum occu])ying the mesial })lane. The right sinirs is large ; 
 its upper two-thirds j)resents a sliadow of moderate density which is 
 unequally sub-divided l)y a dark vertical line denoting tlie presence of a 
 partial septum within the cavity. The lower third of the sinus, lying 
 parallel with the supra-orbital margin, is a distinctly clearer area demar- 
 cated above by a dark, somewhat irregular, line. This clear ai'ea, as already 
 pointed out, mdicates the existence of the supra-orbital extension of tlie 
 sinus. The contour line of the sinus is clearly defined. The left frontal 
 sinus is smaller than the riobt, and to the unpractised eve it mav at first 
 sight be ditiicult to define. Careful ol)servation, however, will reveal tlie 
 fact tliat it does not extend so far up^-ards upon the forehead as the 
 right sinus, while its extension outwards above the supra-orbital margin is 
 practically the same as that of the opposite side. Tlie outline of the 
 cavity has lost its definition, and preseids a lihn-i'ed, somewhat indistinct 
 ajipearance. The shadow of the sinus is dark and contrasts markedly 
 with that of the opposite side. There is no evidence of an\' incomplete 
 sejita or recesses in the sinus. The sliadow immediately above the supra- 
 orbital margin is le.ss dense than that of the general area of the sinus, 
 and this would indicate an orl)ital extension of the cavity. The appearances 
 thus presented confirmed our sus})icions that the Ifontal sinus was diseased. 
 
 In the left ethmoidal region, also, a dark shadow is observed, and when 
 compared with the corresponding area on tlie opposite side the contrast is 
 obvious. A diagnosis of fronto-etlmioidal sinus suppuration was made, 
 
30 THE SKIAGKAM IN DISEASE 
 
 and a Killian operation was pertbi-nied. The frontal siims contained a 
 small quantity of pus, and the lining- mend)rane had a thickened (edematous 
 appearance. Tlie sinus extended along the roof of the orbit and formed a 
 tairly well marked recess in that situation. There were no incomplete' 
 septa or pockets in the cavit)'. A well-developed ethmoidal cell or "frontal 
 bulla " projected into the floor of the sinus. AVith the exception of this 
 the anatomical appearances and the pathological changes suggested by a 
 study of the skiagram were confirmed by what was found at the o[)eration. 
 In the anterior etinnoidal cells pus and thickened mucous membrane were 
 also met with. 
 
 The left maxillary sinus presents a very dense shadow in which all 
 detail is lost, and it is somewhat difiicult to follow the outline of the cavity. 
 It oft'ers a distinct contrast to the sinus upon the other side. The actual 
 change in tlie mucous memljrane of the left antrum was not observed, how- 
 ever, because no further operation upon it was re(juired. The cavity ceased 
 to discharoe after the otbei' sinuses had been treated, thouoh it was necessary 
 to continue washino- it out for a consideral)le time throuub the openiup- which 
 had previously been made in the outei' wall of the inferior meatus. 
 
 We have reproduced on Plate XXVII. the negati\'e from a case of 
 left-sided frontal, ethmoidal and maxiUary suppuration. 
 
 While the case jirst descril)ed is an illustrative example of man}^ similar 
 cases wliich we have from time to time skiagraphed and proved the accuracy 
 of the skiagram by subsequent operation, the actual appearances suggestive 
 of disease presented in difl'erent })ictures have not always lieen the same 
 as in this case. We are anxious to emphasise this point, namely, that a 
 diseaseil sinus, wlietlier frontal, ethmoidal, or maxillary, does not always 
 show the same degree of fogging as we see on Plate XXVI. We have already 
 indicated bow the shadow r)f the sinus in liealtli will vary; similarly the 
 degree of fogging vrill ^'ary in diseased conditions. If we compare Plate 
 XXIX. with Plate XXVI. we find that the diseased ethmoidal cells in 
 the former case pi-eseut a deeper shadow than the diseased left ethmoidal 
 cells on Plate XX^'I. In the same way the diseased right antnun on Plate 
 XXXII. does not present nearly so dense an ap})earance as tire afiected 
 antrum on Plate XX\'III. If we examine Plate XXA'IIL, in which there is 
 
THE SKIAGliAM IX DISEASE 31 
 
 illustrated chronic ^siipjjuratiou in the right maxillary sinus, we ohserve 
 that the right ethmoidal cells present a darker shadow than those upon 
 the left side ; nevertheless, in spite of this degree of shadowing tliere was 
 no clinical evidence to warrant a diagnosis of right ethmoidal cell suppura- 
 tion. The shadows of the frontal snnises in this case are dark, and even 
 their outlines are not so ^vell defined as we might naturally expect to see 
 them in the healthy state ; they are, however, identical upon the two sides. 
 The statement has heen made tliat the shadow of a shallow frontal sinus 
 may closely simulate a diseased condition, so that due care nurst be taken 
 in estimating the exact xalue to lie placed upon the interpretation of tlie 
 skiauTam in some cases. A profile view will be of assistance when we are 
 in doubt as to this point. Tlie depth of tlie sinus will thus Ije ascertained. 
 
 As Killiau has pointed out, all the snmses in the same skiagram may 
 appear sliglitly fogged without any special significance being attached to 
 such an a[)pearance. If a marked degree of shadowing be jn'esent all over 
 the picture we must assume either that all the sinuses are aft'ected or that 
 the whole plate is technically faulty. In such a case a second skiagram would 
 be advisaljle before any conclusion is drawn. If, on the other hand, there is a 
 considerable degree (jf shadowing all o^'cr the }date and certain sinus areas are 
 particularly dense it would l)e fair to assume that the latter were diseased. 
 
 When bilateral drsease is present a difficulty in the interpretation of 
 the skiagram arises because we no longei' have a cori-esp(_)nding healthy 
 cavity lor purp(.)ses of coinparison. On Plate XXIX. \\'e have illustrated 
 a case of so-called "pansinusitis" in which all the sinuses were diseased, 
 and where })roof of tliis was obtained by operation. In the case of the 
 frontal sinuses some d(_)ul)t might naturally he expressed as to tlieir exist- 
 ence, but a stud)' of the negative in tliis case would admit of no doubt 
 upon this point, and operation demonstnited their purulent contents and 
 thickened mucous membrane. We would take this opportunity of 
 emphasising the value of a careful study of the negative in all cases, 
 especially in those in wliich any difi'erence of opinion existed as to the 
 actual condition present. On Plate XXIX. there is a uKire or less uniform 
 shadowing of all the sinuses, and a comparison with the a})pearan(.'e in a 
 normal head leaves no room for douljt as to their diseased condition. 
 
32 THE SKIAGRAM IN DISEASE 
 
 In stiulyiuo' this suljject the question must naturally arise, Can the 
 skiagram always be reg-avdod as a perfectly i-elial)le aid in diagnosis ? To 
 this we must I'eply in the negative, not only from our own experience but 
 from the evidence of others. It is true that in our experience we \A'Ould 
 appear to have l^een very fortunate, as we can only cite two examples in 
 which we liave been deceived by the appearance of the skiagram. It is 
 necessary, however, to qualify this statement by saymg that all the cases 
 which have been skiagraphed in whicli the appearance of the shadow led us 
 to believe that disease was present have not come to operation, consequently 
 we have not been able to prove the correctness or otlierwise of all our 
 observations. In one of the two cases referred to the clinical signs pointed 
 to frontal sinus suppuration ; the shadow on the skiagram suggested that 
 possibly disease miglit be present ; at the same time neither the density 
 of the shadow nor the character of the contour line of the sinus was of such 
 a nature as to lead us to feel certain that suppuration existed. At the 
 operation, however, the frontal sinus was found markedly affected. On the 
 other hand we have notes of two cases in each of which one of the froutal 
 sinuses was opened on account of the very suggestive clinical manifestations 
 of siiuis suppuration. In neither case was any disease found. If the surgeon 
 had placed greater confidence in the a})pearaiice presented by the skiagram 
 in each of the cases he would not have oj)erated. In both cases the frontal 
 sinus shadow and outline were those of a normal cavity. On Plate XXX., 
 a case of oztena, the appearance presented by the left maxillary sinus in con- 
 trast with that on the right side seemed to justify the diagnosis of antral 
 suppuration. The cavity was punctured and washed out, Ijut the solution 
 returned cpiite clear and free from any suspicion of discharge. Deceptive 
 appearances in the skiagrapliic sliadow in the case of the maxillary sinus are 
 not of such great inq)ortance, Ijecause we can more readilv arrive at a 
 correct conclusion by other clinical methods. In the case of young children, 
 however, where puncture and washing out of the ca\'ity is naturally attended 
 with difficulties, and nia}^ indeed be impossible under local antestbesia, skia- 
 graphy is of vidue, and hence a correct knowledge of antral shadows is 
 important. 
 
 AllDrecht from his experience is unable to regard the shadow of tlie 
 
THE SKrACilfAM IX DISEASE 33 
 
 skiascram as an infallible means of diao-nosis because be lias found tbe 
 X-rays disa})])ointing as a I'esult of observations np(jn tbe cadavef and in 
 the living subject. The importance of this point justifies us in (pioting 
 his expeiience. The head of a cadaver was skiagraphed ; both frontal 
 sinuses were etpially clear and tbeir margins were sharply defined. The 
 cavities were then opened and inspected. On one side a normal thin, 
 smootli mucosa was found, and the sinus contained no secretion ; on the 
 other side the mucous membrane was (.edematous and irregularly thickened, 
 and in the lower part of the cavity it was covered with muco-purulent 
 secretion. There was no free secretion in tlie cavity. Microsco})ically small 
 cell infiltration, thickened ctjiuiective tissue, and in some areas a tendency 
 to pol3'[)US formation were noted. In anotlier cadaver where unilatei'al 
 frontal sinus disease existed the skiagram filled to show the a[)pearances 
 suggestive of disease. In l)otli these cases, tberefoi-e, the pathological changes 
 in tbe frontal sinuses were asssociated with skiagraphic sliadows recognised 
 by experience as normal. In tw(_i patients, also, who were operated upon 
 by him the appearances presented by tbe skiagram did not correspond 
 with what was found in the sinirs. Here, however, the appearance of the 
 shadow upon the suspected side seemed to corroborate the clinical diagnosis 
 of frontal sinus disease Ijy I'eason of its density, while the sinus on the 
 opposite side presented a sbarpl}' defined normal appearance. When the 
 suspected sinus was o})ened it was found t(j be healthy, its lining mucosa 
 being smootli and glistening. The dense slmdoM' of the skiagram could not 
 be explained on the ground of the cavity lieing shal](.iwer than its iieigbbour, 
 nor did there appear to Ije any special thickening of its (jsseous wall. It is 
 evident, therefore, from these cases that the skiagram may present an 
 apparently normal shadow when disease exists in tbe frontal sinus ; and 
 again, the shadow may simulate a diseased condition when no pathological 
 changes have taken place. 
 
 It will not be out of place to briefly refer at this stage to the })ossibi]ity 
 of a diseased ethmoidal cell simulating an affection of tlie frontal sinns. It 
 is well known that an anterior ethmoidal cell may extend fir some distance 
 into the cavity of the frontal sinus constituting what has been termed the 
 " frontal Ijulla." Suppuration may be present in this cell in association with 
 
34 THE SKIACUIAM IX DISEASE 
 
 disease in tlie ethmoidal labyiintli, and the frontal sinus may remain free 
 from infection. It will he readily understood how such a cell lying in the 
 vertical part of the frontal bone may produce a shadow in the skiagram 
 which miffht simulate disease of the frontal sinus itself Albrecht indeed 
 descril)cs a condition of this kind which he found in a cadaver. The 
 skiagram showed on both sides in the frontal sinus areas an indistinct, 
 hazy shadow, and the frontal sinuses could not l)e differentiated. The 
 ethmoidal labyrinth appeared to extend upwards in an unusual degree, and 
 its upper boundary could be recognised within the frontal l)one. A dissec- 
 tion was made, and on each side a large frontal bulla was recognised. On 
 the left side the cell contained sero-nmcous secretion, and its lining- mem- 
 brane was swollen and redeniatous ; on the right side the cell was filled 
 with thick, stringy pus. The frontal sinuses were of moderate size, and 
 showed no evidence of disease. 
 
 It is probably in connection with the ethmoidal cells that we obtain 
 the greatest satisfictiou in diagnosis by the employment of tire skiagram. 
 Under normal conditions the ethmoidal reo-ion is clearly defined ; o\\'ino- to 
 the extent of its antero-posterior diameter and on account of the thinness 
 of the osseous laminie by which it is built up the normal shadow is as a 
 rule a fiiint one, consequently any departure from the normal readily shows 
 itself in the skiagram. A clear impression will usually signify a condition 
 of health, and a dense shadow will usually imply a pathological change. The 
 latter need not necessarily mean that pus is present in the cells, Ijut it will 
 indicate an infiammatory change in the lining mucous memljrane of some 
 at any rate of the cells. The difficulty in making up our minds as to the 
 
 presence of ethmoidal cell disease — especially in the posterior group in 
 
 some of tliose cases associated with serious ocular changes, and the necessity 
 of making a diagnosis in these cases, increases the importance of carefully 
 studying any new method which may facilitate diagnosis. We have had 
 practical ex|)erience of the value of the skiagram in a case of this kind in 
 wlncli persistent headache, a unilateral retro-bulbar neuritis, and subse- 
 quently tlie development of paralysis of the fourth nerve led to a careful 
 exanunation of the accessory sinuses. In spite of repeated nasal examina- 
 tion no trace of pus or cedema of the ethmoidal mucous membrane could be 
 
THE SKIAGKAM IX JJISEASE 
 
 ■jO 
 
 detected, and the patient liimself denied the existence of na.sal or post-naisal 
 discharge. On two diiJ'erent occasions a skiagram revealed a chstinct 
 shadow in the ethmoidal region on one side, the other sinnses presenting 
 a normal appearance. The middle turbinated bone was therefore removed 
 and the posterior ethmoidal cells and the sphenoidal sinus investigated. 
 No pns was detected, but an (edematous condition of the mucous membrane 
 in the posterior ethmoidal cells and inflammatory changes in the osseous 
 larainte were observed by microsco})ical examination of the tissue. A some- 
 wlurt similar case is recorded by Albrecht in which headaclie and early 
 optic atrophy on one side, associated with diminution in the visual field, 
 raised the suspicion of sinus disease. No trace of ])us could be found in 
 the nasal cavities, but the skiagram revealed a dense shadow in the corre- 
 sponding ethmoidal region. After opening tlie ethmoidal cells no pus could 
 be detected, luit their lining mucous meml)rane was swollen and (edematous. 
 After the operation the headache disappear'ed, and there was a marked 
 improvement in vision. In both these cases the skiagi-am proved of 
 valual)le assistance. 
 
 We have not been able to satisfy ourselves of the jiossibility of differen- 
 tiating between disease of the anterior and posterior groups of cells l)y this 
 method. Albrecht, ho\ve^'er, speaks of the great im})ortance of skiagraphy in 
 determining the presence of disease in tlie anterior group of cells, but he is 
 vuiable to claim the same for it in the diagnosis of the postei'ior group. Nor 
 does the profile view appear to map out the area of disease, because the pro- 
 jection of the clear healthy cells upon the other side of the nasal cavity 
 apparently interferes with the recognition (_)f a imilateral affection. Possibly 
 we may in the futrn-e obtain more relialjle information upon this point by 
 employing Pfciffer's method of taking tlie skiagram through the vertical 
 diameter of the head, whereby the ethmoidal cells on each side may be 
 inspected throughout their antero-posterior diameter. 
 
 In connection with the diagnosis of sphenoidal sinus suppiu'ation, both 
 from our own ex|)eriencc and from that of other workers in this field, it i,s 
 obvious that there is still more work to be done. Neither the antero-posterior 
 nor the profile skiagram gi\es reliable data. In the former the shadow ()f the 
 ethmoidal cells, wliether healthy fir diseased, interferes with the interpretation 
 
36 THE 8KIAGEAM IN DISEASE 
 
 of the sphenoidal area, wliile in the profile view the projection of one sphen- 
 oidal cavity npon the other is necessarily a disadvantage. If the ethmoidal 
 cells are affected in conjnnction with the sphenoidal sinns, as they so frequently 
 are, the shadow which the former produce will lead the surgeon to explore 
 them. At the same time the sphenoidal sinus is probahly brought under his 
 observation, and he is tlius enabled to investigate it. Pfeiffer's method of 
 depicting the sphenoidal ca^'ities certainly appears to offer facilities for the 
 diagnosis of disease, and a more extended experience of tlie slviagram taken 
 through the vertex will probably give us more assistance. In his paper on 
 this subject he illustrates a case in which a solution of Ijismuth was injected 
 into one of the cavities ; the dift'ei'ence lietwcen tlie density of the two 
 shadows is clearly depicted in the skiagram. A control picture of the same 
 patient prior to the injection of the bisnnith shows both canities equally clear. 
 In anotlier case in which the mucorrs membrane of tlie left sphenoidal and 
 ethmoidal cells was thickened and (inlematous tlie shadow of these cavities 
 offers an ob^'ious contrast to that of the healthy sinuses upon the opposite side. 
 
 (h) The Diagnostic Value of the Skiackaji in Other Conditions of the Sinuses 
 
 U}) to this point we have dealt solely witli the use of skiagraphy in the 
 inflammatory affections of the accessory sinuses. Our object now is to 
 illustrate its employment in some of the less connnon conditions which ai-e 
 from time to time met with in this region. Some of these we liave been able 
 to illustrate from our own experience. 
 
 Mucocele of the Frontal Sinns. — On Plate XXXI. an example of this 
 condition is shown. B}- the term mucocele we understand a distension of the 
 cavity and the accumulation within it of a mucoid or sero-mucoid secretion, 
 resulting from a partial or com})lete obstruction of its normal outlet ; one or 
 more of the bony walls of the cavity become thinned and absorbed. The 
 case illustrated on Plate XXXI. was a condition of this kind affecting the 
 right frontal sinus. The patient was a woman with a painless, somewhat 
 elastic, swelling in the upper and inner angle of the right orl)it, causing a 
 downward, forward, and outward disjilacement of the eyel)all. She gave no 
 history of any nasal discomfort. A study of the skiagram will show that the 
 
THE SKIAGEAM IX DISEASE .'17 
 
 left frontal «inu8 does not exist, so that we arc unable to compare tlie shadow 
 of the mucocele with that of a normal sinus upon the op})Osite side. If com- 
 pared, however, with the normal frontal sinuses in other heads, we are struck 
 with the fact that tire shadow is distinctly less deirse than that presented })y 
 a healthy cavity ; the outline is well defined. At the operation the frontal 
 sums was found to contain a large quantity of clear serous fluid. Its lining 
 memhr'ane was thin and smof)th. The floor f)f the sinus had l)eeu completely 
 al;)sorhed ; the posterior or cerehral wall slKn\ ed a largo defect, exposing the 
 dura mater over a very considerahle area,. Notwithstanding the fact that the 
 cavity was filled witli fluid, and for that reason alone would give a darker 
 shadow than a normal empty sinus, the skiagram, as we have said, shows it 
 to he lighter than normal. The explanation of this is to he found in the 
 absence of the posterior or cereljral wall of the simis. In other woids the 
 X-rays in this case had traversed only one osseous ^\n\l, namelv the anterior. 
 If we compare the left frontal sirurs area oir Plate XXXVIII. , where a Killian 
 operation has been performed, and where, consecpiently, the anterior wall of 
 the sinus has been removed, we see a ^'ery similar, and indeed eveir a lighter 
 shadow than that presented by the mucocele. This is due to the removal 
 of the anterior osseus wall of the sinus, which, on accoimt of its thickness, is 
 even a greater cause of obstruction to the rays than the posterior wall. We 
 have been able to dcmonsti-ate this appearance of the shadow in other cases 
 after the Killian operation. A similar appearance niay Ije f>l)served upon 
 Plate IX., where the anterior wall of the left frontal sinus has l)cen I'emoved. 
 
 AVhile the skiagram of a, frontal mucocele presents the appearance which 
 is shown on Plate XXXI. It does not do so in every case ; the changes in tlie 
 bony walls of the sinus are not always the same, and tlie character of the 
 contents of the cavity varies. The latter may he of an opalescent character 
 and of thicker consistence than in the case just recorded, and this will naturallv 
 interfere to a greater extent with the tran.smission of the rays and produce 
 a denser shadow. A^ain, if tlie mucocele becomes infected, as it mav he, with 
 pyogenic organisms, and the contents become })urulent, a denser shadow will 
 be produced, such as is illustrated upon Plate XXXII. Here we have a 
 mucocele of the riglit ii'ontal sinus in a woman. She had coni})laine(l of a 
 painless swelling in the upper, innei' part of the right orbit for at least one 
 
38 THE 8KIAGEAM IN DISEASE 
 
 year. The eyeball was displaced dowjiwards and outwards. There had never 
 Ijeen any discharge from the nose. Shortly before her admission she com- 
 plained of pain above the right eye, and for that reason she had sought advice. 
 At the operation it was found that the entire floor of the sinus Ijad been 
 absorbed, and there was no trace of the posterior or cerebral bony wall of the 
 cavity. The lining membrane of the sinus was thin and smooth, presenting 
 an appearance similar to that which we have seen in mucoceles of these 
 cavities. The cavity, however, was full of thick, creamy 2}us. The history 
 and the appearances, therefore, led irs to the coiiclusi(jn that an old-standing 
 mucocele had recently become infected with pyogenic organisms. The density 
 of the skiagraphic shadow was produced by the character of the contents in 
 spite of the fact that the whole of the posteiior wall of the sinus had dis- 
 appeared. It is interesting to observe that even though the lining membrane 
 of the sinus appeared unaltered the outline of the cavity was blurred, and had 
 lost its well-defined cliaracter. In the previous case, however (Plate XXXI.), 
 where the lining membrane was thin and the contained fluid was clear, the 
 outline of the sinus remained sharply defined. This last observation does not 
 tally with that made by Cliisholm in his experimental work upon the frontal 
 sinus (p. 27). 
 
 Dental Cy^its Invading the MaxiUary Sinus. — We have had the oppor- 
 tunity of skiagra2:)liing a number of cases in which dental cysts of considerable 
 size had gradually enlarged at tlie expense of the antral cavity, causing thin- 
 ning and bulging of the canine wall, and sometimes also producing a similar 
 change in the lo\^'er part of the iiasal wall of the sinus. On Plate XXXIII. 
 we have figured one of these cases, and the skiagram demonstrates the cavity 
 of tlie cyst occupying the greater part of tlie right maxillary sinus. The cyst 
 presents a darkly-sliadowcd area in tlie lower two-thirds of the antrum, and is 
 separated from the up})er part f»f that cavity, which is clearer, by a well-defined 
 dark line. In this case there is no evidence to show that the mesial wall of 
 the cyst had bulged into the nasal cavity, a point which we had already 
 satisfied ourselves upon by anterior rhinoscop}', and which was coi^roborated 
 at the operation. The cyst contained a tenacious, milky fluid, and its upper 
 wall presented the vaulted appearance wliich is indicated by the dark liiie in 
 the skiagram. In order to satisfy ourselves of the correctness of the skiagram 
 
THE SKIAG1;Aj\I in disease 39 
 
 the siiperior \vall of the cyst was reiiioved, and the up})er part of the niaxihav)' 
 sinus was opened hito. This was found to Ije healthy and hned l)y normal 
 mucous membrane. The operation was concluded by removing the whole of 
 the cyst wall and draining the cavity into the nose by establishing an opening 
 through the outer wall of the inferior meatus. In another case of a very 
 large dental cyst we were unable to differentiate between tlie cavity of the 
 cyst and the cavity of the sinus, and we concluded that the whole of the 
 maxilhu'y sin\is was pr(.)l)ably replace<l by the cyst. This view was confirmed 
 at the operation. No profile skiagram was taken in any of our cases, so that 
 we had no opportunity of dctermuiing the extent to whicli the c}'st had 
 develo})ed in tlie posterior part of the sinus. 
 
 Naso-Aiiti'al or Clioanal Polypi. — From time to time we meet with what 
 is now a well-recognised type of case characterised by the presence on one side 
 of the nose of a single polypus occupying tlie posterior part of the nasal 
 cavity and passing through the choana into tlie naso-pharynx. The polypus 
 may even appear below the soft palate, and in some cases it sends a prolonga- 
 tion forwards in the nasal ca\'ity whicli may reach the anterior nares. These 
 polypi occur most frecpiently in young peo})le, and a large cyst is usually 
 present in their interior. Their origin from the mucous membrane of the 
 maxillary sinus was first pointed out by Killiaii. The cystic polypus passes 
 out of the antrum through an accessory ostium in the membranous wall of 
 the middle meatus. It is sometimes ptjssible to distinguish by anterior rhino- 
 scopy the stalk of the pol}'})us as it lies beneath the posterior part of the 
 middle turbinated body. It consists, therefore, of a large cystic portion within 
 the sinus and an expanded portion ni the nose and naso-pharynx, the t\\'0 
 being connected by a narrow, stalk-like neck. 
 
 A number of these cases have passed through oiu- hands, and we have 
 had an opportunity of taking a skiagram in eight instances. Our ])urpose 
 liei'e is not to discuss their pathology, but merely to draw attention to the 
 alteration wdiicli they produce in the normal shadow of tlie maxillary sinus. 
 In all our cases the skiagram showed a denser shadow than that of a normal 
 maxillary sinus. It is interesting in tiiis connection to note the ;ippearance 
 which is presented liy the antral cavity in these cases in ordinary electric 
 transillumination. In seven of the eight cases in tlie series the transilluni- 
 
40 THE SKIAGEAM IN DISEASE 
 
 illation upon the afiected side was bi-lgliter than that upon the opposite side. 
 Witli one exception the other sinus was a normal cavity ; in the exception 
 we had to deal with suppurati(_)n in the maxillary sinus on the side opposite 
 to the choanal polypus. In the eit^'htli case the two antra illuminated equally. 
 rVn explanation of this phenomenon of transilluinination has been suggested 
 by Brown Kelly [Tlie Lancet, London, 1909). In the normal antrum the 
 concave bony walls and the smooth, shining lining membrane cause a con- 
 densation of light, and thus favour transillumination. As tlie polypus within 
 the maxillary sinus is of a cystic nature transillumination is still further 
 favoured by two factors — first, the decrease of diffuse reflection by the 
 obliteration of the irregularities of those portions of the antral wall with 
 whicli the sac of the cyst is in contact, and secondly, further condensation 
 of the light caused )jy refraction due to the presence of fluid in the sac. 
 
 If we bear in mind what lias already been said regarding the effect of the 
 presence of fluid upon the skiagrai)hic shadow of a sinus we can readily under- 
 stand why in the skiagram the antrum containing the cystic polypus produces 
 a denser shadow than that of the normal sinus. This occurred in all our 
 cases, although the general lining membrane of the antrum presented a 
 normal, thin appearance, and there was no pus or free fluid within the sinus. 
 Plates XXXIV. and XXXV. represent two examples of naso-antral polypi upon 
 the left side. On Plate XXXV. liotli maxillary sinuses present shadows 
 suggesting a pathological condition. The left antrum contained a cystic 
 polypus which passed into the nasal cavity and naso-pharyiix through a large 
 opening in the memliranous wall of the middle meatus. Tlie appearance of 
 the shadow in the right side led us to })uiicture and wash out the cavity. A 
 muco-purulent secretion was obtaineil from it. On Plate XXXIV. the left 
 antrum was found to contain the attachment of the choanal polypus, the sac 
 occupying a considerable part of the cavity. The shadow of the antrum 
 is darker than that of the healthy riglit sinus. In another case, which we 
 have not illustrated, the polypus was a large one, and sent a prolongation 
 forward to the anterior nares. In the skiagram not only was the antral 
 shadow upon the aft'ected side distinctly darker tlian that of the opposite 
 healthy sinus, but tlie nasal cavity occupied by the polyjDus was also darker 
 than the opposite normal nasal cavity. From our experience of these cases 
 
thp: skiagilvm in disease 41 
 
 we have come to the conclusion that if any doubt should exist as to the 
 seat of origin of these single polypi a skiagram will pro\'e of considerable 
 diagnostic value. 
 
 Malignant Disease of the Aeressoi-i/ ,Sii/iises and Na,sal Cavities. — In 
 the diagnosis of malignant disease in this region it is often "\'ery ditKcult, 
 and indeed it may be impossible, to determine the extent of the growth Ijy 
 the ordinary clinical niethods at our dis})Osal. It is obvious that if tlie 
 surgeon can satisfy himself as to whetlier the tumour is confined to the 
 interior of the nose, or whether, starting in the ethmoidal labyrinth or 
 maxillary sinus, it has not }'et invaded neighbouring cavuties, his methofl of 
 operative procedure will Ije considerably infiuenced. We have not had many 
 opportunities of skiagraphing cases of this kind, but in six instances we were 
 able to assist the surgeon in determining the extent of the disease by this 
 iiiethod of examination when other clinical niethods failed to give us the same 
 amount of information. On Plate XXXA'I. one of these cases is figured. Tlie 
 patient was a woman, aged fifty-three, who complained of complete obstruc- 
 tion of the right side of the nose of three months' duration ; during the same 
 time she had l)een troubled \vith the passage of the tears over her right cheek, 
 but the history of a nasal discharge extended over a much longer period. 
 The right nasal cavity was oljstructed ])y a grey sloughy mass. The right 
 choana was free, with the exception of a small area in its roof where a sinnlar 
 grey patch was visible. A slight fulness could be detected in the I'ight canine 
 fossa, and the cheek ap})eared a little swollen. The right eyeball was not 
 displaced. 
 
 The skiai'-ram indicates cleai-lv the unilateral nature of the disea.se. The 
 ifosition of the nasal septum is defined, and on the left we can differentiate 
 the normal nasal, maxillary, ethmoidal, frontal, and orbital ca\dties. On the 
 rio'ht side tlie contrast is very striking. A shadow of more or less iniiform 
 density occupies the position of all tlie caAities, lilurring their outlines and 
 renderiii"- their definition difficult. We wisli to draw particular attention to 
 the inner aspect of tlie right orbit and the inner third of its supra-orbital 
 maroin, because it was found at the o})eration tliat the tumour not only 
 involved the right nasal, maxillary, and ethmoidal cavities, lint it invaded the 
 OS planum of tlie ethmoid upon its orliital aspect and also the roof of the 
 
42 THE SKIAGRAM IX ESTIMATING THE EESULT OF TREATMENT 
 
 orbit in the vegiou of the floor of the frontal sinus. A study of the skiagram 
 will, we think, demonstrate to the observer tliat this extension of the disease 
 can be recognised. It was further found during the operation that the disease 
 had invaded the body of the sphenoid bone, but no profile skiagram had been 
 previously made. We wish to draw attention to the valuable information 
 which may be gained by studying both an antero-posterior and lateral 
 view in cases of malio-nant disease in this situation. In another of our cases 
 we were able to show by a profile skiagram that the tumour had involved the 
 sphenoidal siiuis (Plate XXXVII. ). 
 
 Foreif/ii Bodies iih the Aeeesxory Sinvses. — A few words may be added 
 in reference to the detection of foreign bodies in the maxillarj^ or frontal 
 sinuses. Occasionally, though not so frequently as formerly, drainage tubes 
 have Ijeen lost in the frontal sinus. AA^e say not so frequently as formerly 
 because with our modern metliods of dealing with the frontal sinus drainage 
 tubes have l_)een largely dispensed with. Tlie skiagram, however, will serve 
 a useful purpose shoidd any suspicion arise as to the ])0ssil)ility of a foreign 
 body of this kind Ijeing present. Tlie same remarks would apply equally to 
 the disappearance of an antral oljturator. A case of this kind recently came 
 under our notice wliere a patient asserted that the obturator which she had 
 been wearing attached to her toothqjlate had been accidentally broken off. 
 The skiagram which was taken showed plainly its position within the cavity 
 of the antrum ; it was removed through an opening in the canine fossa. 
 
 THE SKIAGRAil IN ESTIMATING THE EESULT OF TIIEATMENT 
 
 It is possilde to utilise the skiagram in estimating the progress of the case 
 during treatment. It has long l^een our practice to employ electric trans- 
 illunnnation for this purpose in cases of acute frontal sinus inflammation, and in 
 maxillary sinus suppiiration undergoing treatment Ijy lavage, and we have 
 been al.ile to ol)serve the gradual disappearance of the opacity previousl}^ noted 
 before the commencement of treatment. We have found it possible by means 
 of the skiagram to make similar observations, and we have seen the shadow 
 significant of disease disappear, and finally haxe Ijeen able to produce a picture 
 in \\'hich the ap]jearances presented on tlie two sides have been the same, that 
 
THE SKIAGEAM Ii\ ESTIJIATINCt THE EESULT OF T];EAT]\IENT 4;'> 
 
 oil the previously atf'eeted side ])tu\<j; consistent witli a iionnal coiiditioii 
 of the cavity. 
 
 Skiagraphy, however, ofiers greater advantnges in this respect tliau trans- 
 ilhunination, because it not only furnishes information regarding the progress 
 of cases which are treated hy lavage, hut it enables us to estimate the con- 
 dition of a frontal or maxillary sinus which has been treated Ijy radical 
 methods. In other words, we are aide t(_) learn ^\■llether the ca\'ity has l)ecome 
 partially or completely obliterated. Moslier has drawn attention to this 
 point ill connection A^-itli the frontal sinus. He illustrates two cases in which 
 a radical oiieration had Ijeeii performed and the sinuses alloA\'ed to obliterate 
 by the tbrmation of gi'anulation tissue. Both cases were cured in the sense 
 that discharge had ceased, but in one it was evident from the skiagram that 
 the frontal sinuses liad not been completely obliterated. In each sinus area 
 a shadow was depicted which clearl}' showed that a year after tlie operation a 
 small unobliterated area remained. (Jn Plate XXXVIII. we have illustrated the 
 left frontal sinus area after a Killian o})eration ; the supra-orbital margin of bone 
 or "bridge" is seen as a dark line. The clear area above it is uniform, and 
 there is no dark area within it wliich might suggest that a small portion of the 
 cavitv' had been left unobliterated. On Plate XXXIX. we liave illustrated 
 the appearances presented after a radical operation upon the left maxillary 
 sinus. In this case the antrum was opened through the canine fossa, its lining 
 meml)raiic removed, and a nasal oiiening establislicd through the outer wall 
 of the inferior meatus. The anterior end of the inferior turbinal was removed. 
 The skiagram shows the inferior meatus of the nose on the left side with the 
 shadow of the inferior turbinal more fiuiitly portrayed than upon tlie right 
 side. The lower part of the outer nasal wall is seen, and external to it a 
 small clear area limited cxternall}" by a well-defiued margin. We were able 
 to satisfy ourselves bv the introduction of a probe through the naso-antral 
 opening that this area re})rcsented the remains of the ma.xillary sinus. With 
 the exception of this the cavity had ])een obliterated. If ^ive compare the 
 shadows of the two siijierior maxillary bt)nes a striking contrast is oliscrved 
 between them. On the right side the normal maxillar}' sinus can be defined, 
 while a dense shadow occupies the greater part of what was the area of the 
 left sinus. 
 
44 GENEitAL CONCLUSIONS EEGAEDING THE VALUE OF THE 
 
 GENERAL CONCLUSIONS 1;E( J ADDING THE VALUE OF THE 
 SKIAGEAM IN ACCESSORY SINUS DISEASE 
 
 We have come to tlie foUowiiiu- conclusions as the result of a considerable 
 experience in the application of the X-rays to the accessory nasal sinuses. It 
 is well to again enii)hasise the fact that an inferior apparatus should not be 
 employed, that the X-ray tubes should be correctly tuned, that great care 
 must be taken in posing tlie patient, and that the exposure sliould be cori'ect 
 These are difficulties which may be overcome b}' practice. Further, we must 
 again draw attention to the necessity of stud\'ing a good negative. Lastly, 
 a correct interpretation both of the anatomical detail an<l of pathological 
 changes is best obtained from the actual study of a large series of skiagrams, 
 both negatives and positives, and not fi'om descriptions in books. 
 
 1. Skiagraphy is a valuable aid in the study of the development of the 
 
 air cavities, and it is the only method by which we can determine 
 in the living, and without any ojjerative intei-ference, the existence 
 of all the air sinuses. 
 
 2. By means of the skiagram we can define the size of the frontal sinuses, 
 
 the position of the inter-sinus septinn, tlie presence of subsidiary 
 partitions in the cavity, and a supra-orbital extension of the sinus. 
 To some extent, also, the relation of the sinus to the anterior 
 ethmoidal cells can also be determined. 
 
 3. From the anatomical knowledge derived from skiagra|)hy we are placed 
 
 in a better position to decide as to the kind of operation wdrich 
 sliould be carried out upon tlie diseased frontal sinus, and, to a 
 lesser extent, also upon the ethmoidal (/ells. 
 
 4. A preliminary study of the skiagram may also be of anatomical assist- 
 
 ance ])rior to ojierations upon the maxillary and sphenoidal sinuses, 
 but it is not of such imp(jrtance as in the case of the frontal sinus. 
 
 5. Skiagraphy is of undoubted diagnostic value in cases of inflammation 
 
 and sup})uration of the nasal sinuses, but it must be used in con- 
 junction with other methods of diagnosis. It cannot, however, 
 be regarded in every case as perfectly reliable. 
 (3. Its diagnostic value is greatest in connection with disease in the 
 
SKIAGRAM IN ACCESSORY SINUS DISEASE 45 
 
 frontal and ethmoidal simises, but we believe that further experience 
 will demonstrate its usefulness in the detection of sphenoidal sinus 
 suppiiration. 
 
 7. In children in whom it may be inexpedient or impossible to carry out 
 
 intra-nasal diagnostic procedures, it will prove of undoul^ted advan- 
 tao'e to obtain a skiagram of the sinuses. 
 
 8. The skiagram does not allow us to draw any conclusion as to tlie 
 
 exact nature of tlie patliological contents of a sinus or as to the 
 degree of inflammatory change which has taken place in its nmcoTis 
 membi'ane. 
 
 9. By means of the fluorescent screen we are al)le to ascertain the position 
 
 of cannulae or other instnunents introduced into tlie siniises for 
 therapeutic purposes by way of the nasal cavity. 
 
 10. The skiagram may be usefully employed for ascertaining the size of 
 
 dental cysts occupying the maxillary sinus, in determining the 
 origin of choanal polypi, and for assisting us in defining the 
 limitations of malignant growths in the sinuses. 
 
 11. It is a valuable diagnostic aid in the detection of foreign bodies in 
 
 the siimses. 
 
 12. It is of service in determining the eftect of treatment upon the 
 
 inflanunator}' aft'ections of tlie accessory sinuses. 
 
 PRINTED UY WILLIAM GRKEX AND .SONS, EDINBURGH 
 
Keij U, face I'Inte I. 
 
PLATE I. 
 
 Skull of adult ; a.ut-Ln'O-lio.sterior view sliuwiiif,' all the accessory sinuses. The positiou nf the (.liHereiit 
 cavities ami of the more jiroiuineut lamlmarks is indicated upon the key. 
 
PLATE 11. 
 
 Skull iif .■ulult : tliis is a reiiroductiou of the negative from \vliicli the frontispiece was taken : 
 is light in the positive is dark in the negative and vice versa. 
 
 oonsecpieutly M'hat 
 
Fio. 1. — A steriioscopir yivw of tli(_' .sauiL- skull as shown on Plate 1. The siiuises are 
 vie^^•ed fnjm befoie backwards. 
 
 Fli.i. 2. — The sinuses are viewed from behind iVnward.s. 
 PLATE III. 
 
ri.ATK IV. 
 
 Skull iif luluK, aiitero-iiosteriur \ic\v sliuwiiij^' (In- .sjilieiioidal .sinuses lilluil \\illi liismutli. 
 
PLATE V. 
 
 Siuiie skull :i,s on PUite IV., lateral view, slinwiui^' tlie spln'iioiilal sinus in relatiuu f-i> thf sella turcica 
 
 abuve ami (n tlie Tuaxillai'y sinus Ijeluw. 
 
k 
 
 PLATE VI. 
 
 Same skull as i>ii tlio two inx-viijus Flatus, vii-weil I'roiii In-low : the area re|ireseiitiu,L;' llu- splieuni.ial sinuses is 
 seen behind the liaril jialate. The basi-uceipital ami the fomnieu niaguiuii lie posterior to the sinuses. 
 
PLATE VII. 
 
 Basal view of tlii' lipail of an adult skiagraiilicil liv PffiHV'f's inctliofl ; the two sjiliciioiilal siuusi'S arc seen, the right cavity 
 liciiig larger than tlic left. Tlie iiiili\ iilual is \\eariiig a 'leiital plate on the [lalate. 
 
PLATE \TII. 
 
 Auturo-pnstei'ini' view iif iiilnlt skull (k'UKnistral iii^ iiialinipitidii (i\\'iiig to lilliiiy' Ujiwarils of llu' f'ari'. 
 Till.' line I'cJil't'SC'iililig the le.sser wiuf^s of llic splieiiniil lioiie liisecls tlie mliilal i;a\ilies an 1 nnsse.s 
 tlie lower ]iait of the ethinoiflal region ; tlie petrous tenijiorals are sei'ii against tin- lower ]iail of 
 the maxillary simrses. The floor of (lie nasal (.'aN'ities pvesenls an e\tensi\e surfare from liefnre 
 liaekwanls. instead of a narrow strip. 
 
PLATE IX. 
 
 Skull with large frontal sinuses, in wliicli the autevior wall of tlie left fi-outal sinus li:is lieeti removed The 
 ethmoidal cells extend into and occupy a large part of the roof of each orliit : the llnnv of the orbital 
 extension of the ethmoid has heen vemoved upon the left side. 
 
PLATE X. 
 
 Hfrtd of ;iilulL ; ;iiit.L-ni-|insl,rii(iv \iu\v ; tin.' .siiiusus ai'e iioriiinl. TLi- t'i'ijiit:il i;:i\'itii--s ar.' .small ; llir elliinuidal 
 ctll areas an' rli-av. Tli!' rin'lit iiia\illai-y sinus lias an alveular rertss, IjuL llii.s is alisL'Ul upmi tlie lul't. side. 
 The imliviilual is weaiaiig an uii[jer t(jolli plate. 
 
PLATE XL 
 A i-upruductiun uf tlie negativu from -wliich Platu X. Avas made. 
 
j^^HM 
 
 
 m^^i 
 
 B^H 
 
 H^^^ 
 
 
 ^1 
 
 
 ^H 
 
 M 
 
 S 
 
 
 ^^^^H 
 
 
 ^^^^^1 
 
 ^^■8 
 
 ^^^/ 
 
 
 1 
 
 
 H 
 
 1 
 
 P 
 
 
 1 
 
 
 H 
 
 I 
 
 
 ^ 
 
 1 
 
 
 i 
 
 1 
 
 
 
 % , 
 
 
 E 
 
 ^ 
 
 
 
 1 
 
 
 1 
 
 1 
 
 1 
 
 
 platp: xii. 
 
 Sterudsrojiiij \iew (jf liea'l of ,nirl ajt. 15. Tlie .sliiulnw in tlic rii;]it iii.'ixillary sinus is ihu' (i> 
 a lai'gi.- i:3'stic pnlyims wliicli passed tliroiigli lliL- niidJlu niualal wall and ].ii'esunte<l in the 
 I'i'jlit clioana. 
 
Kcii to fare I'hite XIIL 
 
]'LATE XIH. 
 
 L;i(l'1'il1 ^■iL■\v ul' ;uhilt slaill slmwiiii^' lliu siini.se.s in iinililu. Xnti_' tlic ,i;rr;it ilrptli ol' tin- rr(iut;i 
 siuusus ami llirir rxtuii.siou alniiL;- Liu; runf of lliu ui'bit. 
 
PLATE XIY. 
 
 Profile view of tlie skull (left siile) reproduced from the negative. Tlie wliite lines indiratiii,i;' tlie \va" 
 
 sinuses and their orhital extensions are •\\ell seen. 
 
 Is of tlie rrnnl.il 
 
PLATE XV. 
 Sti^i-eoxcojiif ]irofile view of tin- Au[]] (k-fl; si:]L'). 
 
Kill fu f:lrc I'Jilfc XVI. 
 
PLATE XVI. 
 Prnllle \'icw of iinnual IrvuI uf ailult (riglit sidu). 
 
J'LATK XVII. 
 
 Skull (if full-lilllr fn-fus, 
 
 etliiiiniilal air r 
 
 Iir slo'a.niam shows im eviilnirc nf maxillaiy sinuses o 
 , altliiaiuli tlirsu ra\itiL's all' prrsait al liirtli. 
 
PJ.ATE XVIII. 
 
 Skull 
 
 iM, aged 1 3'car. Tlie iiiaxillai'V siuiisrs avo scrii as small ca\ilii's lirueafli tlie 
 iuiiei- enils of tliu inl'm-orldtal inarijiiis. 
 
PLATE XIX. 
 
 Skull of (■liiM, :rt, 3 to 4. Tlic muxillaiT .siuuses aru st-eii as ,-iiiall triangular ravitii-s ln-ui-atli 
 tliu inner third of tlie iufra-ialiital uiargius. Tliey an- si-cu extcinling out«arils as far 
 as the infra-orliital foramina. Tin- ethuioidal ei-lls .arc .seen lielow the frouto-ua.sil sutuie, 
 hut there is ud e\'iileiiee of any sinus ilewloimient in the frontal hone. 
 
Hrad nf rllilil, ,t(. 
 
 small Fi 
 
 PLATE XX. 
 
 ;"). Aiilcii)-]i(:,sli'i'ii)r virw, sliDwiiin- wuH-iIi-vi'IiijiimI maxillaiy siimsep. Twu 
 iiilal siiuisi's an.' st'iai ocrujiyiiig llic lowei' Jiaii of (lie t'l'nutal Ikjiic 
 
PLATE XXI. 
 
 Ht-;iil nf cliili.l, a't. ;■), slinwing wull-ilfvelopcil fmiital .siiiUHrf 
 
PLATE XXII. 
 Hc'Hfl of t'liilfl, a't. 7, showing a small luit well-developed left frontal sinus. 
 
PLATE XXIII. 
 
 Head of clii]d, tet. 1^, slii.\\-iii£;- \vel]-(ie\-elopf(l frontal siiiu.ses. The narrow clearer aivii iu llie 
 lower part of eaeli frontal ,sinu,s indicates tlie extension of the ca\'ity along the root of the 
 orljit. 
 
PLATE XX TV. 
 
 Wr]] iiuivkLMl \/-Avd]n;i\ ]<:\]:dr. Tile septum is iierpendirular. Tile lluor <if earli maxilLiiy 
 sinus lying lielow tlie level of llie roiTesimniliiig nasal ll.inr (lr,es not extiaid fnv any 
 distance into the al\-eulav prores-. 
 
PLATE XXV. 
 
 HlmiI fif yoiiiiL;' wriiiiaii, ;i't. IS. Tlir nasal cavities are lai'ye I raiiswrsely. Tin; inaxillaiv siimse^ are 
 eiirriiacliL-il iijiuu I13' tlie Imlgiiig outwards nf tlie nasal \valls. I'lic frout.'il sinuses are aliseiit. 
 
I'LATE X.Wl. 
 
 C'hionic suinnivatiou ill llii' It'ft frniil;il, ctliuioiiLiI ami iiia\ill;iry siiuisi'S : tlir ilee]n.-r sliailows 
 u|ioii 111!' alfcrtcd siili' ]ii'i-seiit a iiiai'l;ril ('finl I'asI In tliosc ii|hju llir lu-allliy rif^lit side. Tin- 
 iiarro«- clrarer aira lyiiii'; iiiiiiu'ilialcly alin\'i' (lie lanlit .sii|ii'a-niliital margin ili_']iirls llic 
 orliilal I'Xiciisiiiij (if llir IVmilal sinus. ^V siiiiilai' rxt(_'iisinii in llic li-l't I'lnntat sinus is also 
 iiuliralcil. 
 
PLATE XXVII. 
 
 Eepioilurlinii (if tin- )i('i;:it.i\X' nf lliu ilK/ad cif a. youiii; adult witli sinipiuatiini in tin- left IVniilal, 
 ethmoidal ami jiiaxillai-y simises. The skia,^i'aiii siii^i^ebts tlie existeiiee nf an ail' spare in llie i-rista 
 galli anil a. "frontal bulla" in tlie riglit frontal sinus. 
 
PLATE XXA'III. 
 
 (,'lii(iijir ,sii[i|iur:ilii)ii ill till- lii^lit iiiaxillaiv sinus : ailiilt iiiak' ; a wcII-iIi-wIujumI ahcolai' 
 icci'.ss is seuu ill tin.' liualtliv left iiiaxillai-\' sinus. 
 
PLATE XXIX. 
 
 C'liroiiic suppuration in liotli frontal, (.•tlimoidul, splieuoiilal and maxillary sinnses : botli fronlal sinusi-s 
 show dense shadows and lilurved outlines not easily dillerentiated. The existence of disease in all 
 
 the sinuses was proved by operation. 
 
PLATE XXX. 
 
 Patient "\\itli ))ilatei-al fn/tiil atrcipliic rhinitis (ozaena) : the rooiiu^ charaetei- of the na^al (in'itie.s 
 ^vith the ati'0]ihicd luitldle and lower turliiiiated bodies is -well represented. Altliough the 
 .sliadow of the left maxillary sinus -when I'lmipaTed with that of Ihe right side suggests .suppura- 
 tion, jiroof puneture of the eavity gave a negative result. 
 
PLATE XXXI. 
 
 ilucocele of tlu- right frontai sinus : tliere is no left fvoiital sinus. Tlio nasal septum is con- 
 siderably deflected to tlie right : the hard palate is Hat. The sinus area is lirighter than 
 that usually ohserved in a health)' frontal sinus owing to the ahsorplion uf the ]«isteiior or 
 eeveliral "wall of the sinTis. 
 
PLATE XXXII. 
 
 Mucocele of tlie right frontal sinus "\\liiili liail recently lieconie infected witlr ])j'Og'enic 
 organisms. Supjairation lias als(j occurred in tlie right ethmoidal and maxillary 
 sinuses. 
 
PLATE XXXIII. 
 
 I'utiuiit witli a ileiit.il ryst inviifliii::; tlie rii;lit iiiaxillaiy sinus. Tlie cyst, wliich coiitaiiicil milky, 
 sticky tUiid, is seen as a dark sliadow in tlic Idwer and inner part (jf tlie riglit antral area. 
 The upper and outer (larts of the antral ca\aty are not occu]aed hy the cyst, ami present a 
 clearer area. 'J'lie X-ray ajipearances were continued liy opei'ation. 
 
PLATE XXXI \". 
 
 Patient -witli a iiasn-aiitial (clKvUial) polypus on tlie left side. In all tin- casL'S of lliis alfertion which weie 
 Hubniittu'I to the X-iws the atlecled niaxillaiy sinus showed a Jee[ier shadow than the healthy sinus. 
 The same eases «dieu examined hy traiisiUunnnatiou showed the atl'eeleil eavity to be lirightev than 
 the healthy (jue on the previous page. 
 
PLATE XXXY. 
 
 Ailiilt fL'iiiak- \\itli a iiaso-aiitral iHilypus on tin' Irft siilr- and with ■lirnnic su]ipnratinn in tlie ri,i^lit 
 niaxillai'V sinns. A wi'll-inarkt'd ]ialatal vect'ss is sei'n in each maxillarv sinns. 
 
PLATE XXXVI. 
 
 Patiuiit Avilli a iiiali<^iiaiit tniiinnr iuvolviii^t;- tlu' liglit nasal cavity. i'iL;lit, maxillary siiuis, 
 ctliiiinidal CL'll.s ami (irliit. At Ilit- (.qit-ratinii the tuUKnir was fnuial to invade the uihilal 
 I'lale (if the frontal houe nn the riLjlit siile. 
 
PLATE XXXVII. 
 
 Profile vie\\- of head of adult female u]:>oii whom operation had been performed for malignant disease of the right upper jaw. 
 Recurrence of the disease is evident in the posterior ethmoidal and sphenoidal sinuses. 
 
PLATE XXXVIII. 
 
 Patient after the Killiau operation ujiou the left frontal sinus. The accentuated hrightness 
 of tlie frontal sinus area o])erate(l upon is flue to the renio\al of the anterior hony wall 
 of the cavity. The supra-orhital margin or "Ijridge" is evident. 
 
PLATE XXXIX. 
 
 Patient after a radical operation upon the left maxillary sinus in wliirli the lining mucous menihrane was 
 removed. The small clear area immediately external to the (juter wall of the inferior meatus of the 
 nose represents what remains of the ca\'ity of the siiuis. The anterior end of the left inferior 
 turbinated body has been removed. 
 
Cornell University Library 
 
 RF 421.R94 
 The skiagraphy of the accessory nasal si 
 
 3 1924 012 167 783 .i,. 
 

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