. Transactions of the Western Surgical Association. s. The recti muscles are displaced, and, whilesomewhat attenuated in some cases, do not enter intothe parts that have given way. The umbilicus, according to Cunningham,^ is sit-uated normally below the mid-point between the in-frasternal notch and the symphysis pubis. It is op-posite the fourth lumbar vertebra. In most of thecases referred to in this article it was opposite orbelow the symphysis pubis. If an opening is made at the umbilicus and the handinserted into the abdomen of one of these huge pendul-ous cases, a definite internal ring c
. Transactions of the Western Surgical Association. s. The recti muscles are displaced, and, whilesomewhat attenuated in some cases, do not enter intothe parts that have given way. The umbilicus, according to Cunningham,^ is sit-uated normally below the mid-point between the in-frasternal notch and the symphysis pubis. It is op-posite the fourth lumbar vertebra. In most of thecases referred to in this article it was opposite orbelow the symphysis pubis. If an opening is made at the umbilicus and the handinserted into the abdomen of one of these huge pendul-ous cases, a definite internal ring can be felt, whichmight be compared to the internal ring of an ordinaryhernia. This ring is bounded laterally by the mar-gins of the recti muscles, below by the point of decus-sation of the recti muscles about one and one-halfinches above the pubis, and above by the margin ofthe linea alba, which has not yielded to the stretchingcorresponding to the lower lineae transversse of therecti muscles. It will, therefore, be seen that, while at first sight. MACLEAN 51 the stretching of the structures appears to be universalto the whole anterior abdominal wall, it is entirelylimited to a definite area. This area in the normalanatomy corresponds to a narrow line, the linea albaand that part of it lying between a point very littleabove the umbilicus and a point about one and a halfor two inches above the symphysis pubis. (Fig. 1.) SURGICAL TREATMENT Surgical treatment should not be lightly undertaken,and is called for only when the condition is causingtroublesome symptoms. The operative mortality hasbeen high in this type of patient. McGlannan^ placesit at 6 per cent for massive non-strangulated, and 50per cent for massive strangulated, hernias. Thesefigures convey only a relative idea of the mortality,for we do not know what type of operation was done,or whether anything was done beyond a simple um-bilical-hernia operation without any attempt at reduc-ing the protruding abdominal wall. Th
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