cess of the ilium, 10 inches; from umbilicus to left anterior superior spinous process of the ilium, 10 inches. On making digital examination per vaginam the cervix uteri seemed small, apparently having undergone senile atrophy, and it was pushed backward and high in the pelvis, the whole uterus being pushed backward. I thought the fundus looked forward, but the uterine sound did not pass readily, hence its use was not persisted in. What seemed to be a fluctuating tumor was appreciated per vaginam to the right of the uterus and above the brim of the pelvis, and a small, tender mass was felt in the right parametrium. The patient complained of pain and tenderness when touched, especially if touched on the right side. Diagnosis, fibrocystic tumor of, probably, the uterus. After the usual preparation the patient was etherized and the abdominal cavity opened. On opening the peritoneal cavity the omentum was found to be greatly thickened and congested, and extensively attached to the tumor beneath it and to the pelvic walls. It was necessary to ligate and cut in many places, and upon pushing the omentum aside the tumor looked pale and it felt and looked like a fluctuating mass. A trocar and canula being used, I was surprised that no fluid flowed through the canula. The incision was now extended in the abdominal wall upward sufficiently to admit of the withdrawal of the mass entire. A small, nodular mass attached to the lower part of the tumor, having the shape and size of the uterus and being furnished with what seemed to be the uterine appendages, was drawn out of the lower end of the wound, and was found to be attached by a small, cord-like pedicle to the pelvic brim a little below the crest of the left ilium. Another body, to all appearances a uterus with its appendages, was found in the pelvic cavity and fixed by the usual attachments, but had been crowded into Douglas' pouch. The slender pedicle, not larger than a pencil, which tethered the smaller mass to the pelvic wall, was ligated and cut. The tumor being now freed from its attachments, which were omental entirely, was lifted from its bed. This tumor must have derived most if not all its nourishment from the establishment of the circulation through the omentum, for it had almost severed its attachment from other structures, and the omental vessels were enormously enlarged. There was no connection whatever with the uterus in the pouch of Douglas. The abdominal cavity was cleansed and the opening closed with silk sutures, the dressings applied, and the patient was put to bed. Reaction was prompt and good. The temperature for the first four days ranged from 99° F. to 100.4° F; it then rose, and on the sixth day reached 102.6° F., and on the ninth day 105.4° F., when she died of sepsis. The autopsy showed purulent infiltration at various points in the pelvic cavity. There was also found at the autopsy a uterus and its appendages in a healthy condition and in the proper position. Sections from the little body which hung from the large tumor were sent to two pathologists. One reported the specimen as being a fibromyoma. The other pronounced it uterine tissue and some structure resembling the endometrium. If this is a separate and distinct uterus-and I think it is-it is an unusual case, a unique case. We know that bodies which are not properly situated are not well organized and very readily take on disease. This second uterus had developed from its cervix this fibromyoma. As it grew to be too large for the pelvic cavity and rose above the brim, the little organ was inverted and so hung suspended from it. It measures from the internal os to the fundus one and onequarter inches. The length and size of the cervical portion are exaggerated evidently, from the tension upon it. It was cut open, and in the fresh state showed quite distinctly the arborvitæ arrangement of the mucous membrane lining the canal, and the lips and cervical canal were quite natural in appearance. The os uterinum on the left side admits of the passage of a small probe, which passes a short distance along the Fallopian tube. On the opposite side the opening would not admit the probe. There are two ovaries, small, which on being cut open showed on macroscopical inspection ovarian tissue. No microscopical examination of this tissue has yet been made. In the cervical canal, just below the os internum, is a small calcareous deposit. The didelphic uterus we have seen, and these cases are actually two uteri, separated as far as the cervix, and including it, and not two bodies more or less divergent, as in the case of the uterus bicornis. Ollivier's specimen of a uterus didelphys and divided vagina, with a distinct cervix uteri looking each into its own vagina, was taken from a woman who had been pregnant five times. Each segment presented the appearance of a complete uterus, seeming to be two unicorn uteri equally developed and apposed without fusion. Bonnet and Heitzmann had cases similar. In these cases it is reported there was but one set of appendages to each uterus, and but one broad ligament. It used to be thought that this malformation occurred only in non-viable embryos with deformities of other organs. It has been seen with ectropion of the bladder, with imperforate anus, and other malformations. But an entire organ, far removed from one in the usual location, I have not seen mentioned. Calcified Corpora Lutea.-Another specimen is this little body, which I at first thought was a lithopedion, but, seeing Bland Sutton's note on calcified corpora lutea, find it to correspond very closely with the description of two specimens which had been sent to him at about the same time. He considered them very rare pathological specimens. Dr. Voelcker secured one from an ovary of a woman who died of mammary cancer very widely disseminated, and he supposed the two little bodies in the ovary to be secondary deposits, but, cutting into them, found them to be concretions. One was encysted and had outwardly the appearance of mulberry calculus of the bladder; the other was embedded in the ovarian tissue and was of irregular shape. When this specimen which I now show was fresh, it was of a bright-yellow color, very characteristic of a recent corpus luteum. It cut in some parts of it as would wax-perhaps of firmer consistence. Those specimens which Bland Sutton describes consisted of dense tissue impregnated with lime salts. Mr. W. A. Meredith speaks of examining a patient and distinctly feeling the hard body through the vagina, and it gave rise to the impression that the swelling might be the sac of an ectopic gestation containing fragments of bone. Dr. Coe, of New York, recently described a similar body under the impression that it was a bony nodule. 1525 WALNUT STREET. THE CAUSES OF SHOULDER PRESENTATION. WITH THE REPORT OF A CASE. BY SIGMAR STARK, M.D., I PRESENT this case with the view of eliciting a discussion as to the causation of shoulder presentation. In the majority of text books this subject receives but very little consideration, and the opinions regarding the importance of the various agents at play are diverse. April 17th, 1891, I was called to see Mrs. S., æt. 22, primipara. Upon my arrival I learned that she had been in actual labor about three hours, the pains having been severe only the last three-quarters of an hour. Upon examination I found an elongated pouch, containing the right upper extremity, presenting at the vulva. There was almost complete dilatation of the cervix. Bimanual version was resorted to, the membranes ruptured, and a small child weighing hardly four and a half pounds was extracted by the foot; the procedure, all told, not occupying more time than it takes to tell it. The subsequent course of the puerperium was normal, the child also developing well. Two years and a half later I was summoned in haste to see her, and found that the membranes had ruptured and that the woman was in great pain. An examination disclosed transverse presentation with prolapse of the whole upper extremity, beginning impaction of the shoulder, and the umbilical cord dangling |