174 PROFESSOR CHRISTOPHER ADDISON. 



pushed up, as already described, by distended intestine — chiefly 

 the colon. 



Group 3.— The five cases in which the highest point of the 

 duodenum was situated helow the level of E.F.,— namely, respec- 

 tively, No. 30, 1 cm.; No. 36, 2 cm.; No. 7, 2-5 cm.; No. 15, 

 4 cm., and No. 2, 4-5 cm., — were all cases in which the stomach 

 was distended (least so in No. 30) and was lowly situated; 

 this being accompanied by a low position of the liver. 



Conclusion. — Combining these three groups of cases it becomes 

 clear that lowering, or increase in size downwards, of the liver 

 is the chief determining agent in depressing the first part of the 

 duodenum, as it is that of the pylorus ; and that distension of the 

 stomach alone is not sufficient to produce that effect. Further, 

 it appears that the causes that push up the liver and stomach 

 also push up the first part of the duodenum. (The significance 

 of the firm attachment of the beginning of the duodenum to 

 the liver has been previously pointed out.) 



Gysto-colic Fold. — Sometimes the peritoneum is prolonged 

 further to the right than the usual position of the right border 

 of the lesser omentum, and extends from the transverse fissure 

 of the liver along the under surface of the gall-bladder, 

 superiorly, along the upper border of the first part of the 

 duodenum, inferiorly, to the hepatic flexure of the colon, 

 and form.s, at this place, a fold stretching from the gall- 

 bladder to the colon, presenting a free border directed more 

 or less to the right. This fold, representing a right prolonga- 

 tion of the lesser omentum, was present in 12 cases, and is 

 considered in the section on the peritoneum. 



The Duodenum and the Bight Kidney. — In connection with 

 the level of the duodenum, reference may be made to a remark 

 of Prof. Cunningham's (13) in his Practical Anatomy. He 

 says, speaking of the relative levels of the duodenum and right 

 kidney, that " the duodenum, moulded as it is on the front of 

 the vertebral column and around the head of the pancreas, is 

 not subject to much variation in position. The differences seen 

 in the figures are probably due to variations in the positions 

 of the kidney." The cases in this series do not quite support 

 this statement. The duodenum is subject to very considerable 



