979CLINICAL NOTES.

sphenoidal sinus with a Watson Williams trocar (a skiagramwas taken showing the trocar passing over the bullet in,and its tip resting against the roof of the sinus). An

attempt was then made to introduce cutting forceps with aview to enlarge the opening in the anterior wall. It wasat this stage that I met with difficulty and delay. Neitherthen nor at any of the attempts I subsequently made was Iable to introduce any instrument of this kind. Whether thiswas due to the position of the bullet or to faulty techniqueon my part, I am unable to say, but it became evident thatif the foreign body was to be removed some other method

FiG. 2.

Skiagram taken transversely.

than that usually adopted must be tried. After maturedeliberation I decided to make a final attempt with thepatient under a general anaesthetic and upon the X ray table.This I did on June 30th last. The patient having beenansesthetised, the lights were turned out. and in all the stagesof the operation one was entirely guided by the image onthe X ray screen. The trocar was first passed up the leftnostril into the sinus, showing that the opening previouslymade in the anterior wall was patent. This being withdrawn,a Watson Williams "rasp " was introduced and slipped overthe bullet with its cutting surface downwards. Turning itso that this surface pointed to the middle line, and keepingthe side of the instrument in contact with the upper surfaceof the bullet, I rasped away the bone, cutting through theseptum between the sinuses, and, as far as one could judge,almost to the tip of the bullet. The next step was to removethe remaining portion of the anterior wall. I asain tried to ’’

introduce cutting forceps, but failed. Taking a hammer and a narrow rounded chisel, from the cutting edge of which I had previously measured 3 1/4 inches, I passed the latter

up to the bone, and by a series of regulated strokesI broke down all that was in front of the bullet.Having done as much of this as appeared necessary,the chisel was withdrawn and a blunt hook was passedon the flat through the opening above the foreignbody, until it reached the roof of the sinus. It was thenturned downwards, and the hook was felt to embrace thebullet. After gently sliding it along until it was seen to bequite near the base, gentle traction was made. At first therewas no response, the base of the bullet appearing to be fixedagainst the outer wall, but after persevering for a short time,it yielded, and was turned down into the nasal cavity ; thereit was seized with forceps and pulled down to the floor of thenose and was subsequently recovered. The man made anexcellent recovery ; on the third day after the operation hewas up assisting in the ward.My thanks are due to Mr. Smallcombe, skiagraphist to the

hospital, for the skiagrams and also for the most valuableassistance his experienced eye rendered me at the operationin localising the relative positions of the bullet, instruments,and adjacent parts.

Bristol.

Clinical Notes :MEDICAL, SURGICAL, OBSTETRICAL, AND

THERAPEUTICAL.

RETAINED PLACENTA IN A RUDIMENTARYHORN OF THE UTERUS.

BY M. C. S. LAWRANCE, M.B., CH.B.VICT., &C.

THE patient was a primipara, aged 24, and had a very hardlabour. The presentation was a vertex one in the rightoccipito-posterior position. I had to rotate manually andapply forceps. After waiting 40 minutes for the placentaafter the birth of the child, and as no sign of it was forth-coming I tried to express it manually by compression andfailed. I then introduced my hand into the uterus andfound the placenta in a rudimentary horn ; the shape of theuterus abdominally was peculiar and led me to expect anabnormality. The placenta was adherent all round andcould not be peeled off, but had to be removed piecemeal.Two days later the patient passed a piece of placenta aboutthe size of a watch, but as there was no preceding hxmor-rhage I concluded it had been detached before and hadbeen lying loose in the uterus or vagina. The patient madean absolutely uneventful recovery.

A CASE OF CONGENITAL ABSENCE OF NAILS.

BY BERNARD O’NEILL, B.A. CANTAB.,M.R.C.S., L.R.C.P. LOND.

A WOMAN, aged 26, came to me in July of this year as apatient suffering from dental caries and anæmia. She wasof frail appearance and pale and weighed only 6 st. 10 lb.

FiG. 1,

Right hand, showing absence of finger-nails.

She had no nails at all on the thumbs or fingers or great toesand only tiny fragments of nails on some of the other toes. Thenail-beds were present on all the digits of the hands andfeet, and the fragments of nails found on some of the toeswere placed round the edges of the nail-beds or on the nail-beds themselves. The thumbs, fingers, and great toes hada hooded appearance at the extremities. In the fingers andthumbs the nail-bed had an upper paler part and a lowershining and more vascular part, the latter corresponding to