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SENIOR RESIDENT MEDICAL OFFICER, ROYAT, RITSSCX ('OTTTY HOSPITAL, DRIGHTOX.ISTEKXAL hcrnia: are relativcly uncommon. They niay be said to comprise :(1) Hernia into peritoneal fossz, cspccially paraduodenal ; ( 2 ) Hernia through foramen epiploicum ; (3) Hernia through aperture in ( a ) onientum, ( 0 ) broad ligament, (c) falciform ligament, (d) mesocolon, (e) mcsentery. Of these, probably the last type is tlie inost rare, few cases having been recorded.Romankcvitch' quotes two cases of the mcsenteric type as well as one inesocolic. Hamilton Bailey2 dcscribcs a personal csasc of thc mesenteric type, and he has assisted also a t a second case : it is iiitercsting t o note that in both these cases reduction was facilitated by aspirating some of the contents of the strangulated loop. Folliasson3 at thc end of his extcnsive article on internal herni:e mentions the type ; he states that the hiatus is probably congenital, and usually occurs 1ica.r the ciccum (as in this case). He quotes one case only, a patient of Lafourcade ; no record of the publication of this case can be found.Thc prcseiit case is that of a youth of 17, mlio was admitted from the country at 5 a.m. on a Sunday morning complaining of vcry scverc abdoininal pain.Hrs,row---Thc patient l i d been in normal good hcaltli till 11 p.m. the iiight before. when there was a rapid onset of severe generalized abdominal pain, which at t,inics made him roll about. He vomited five or six times. Tlic bowels had becn open that day, but not after the onset of pain. Pain persisted and increased. H e felt its if he wished t o bring up wind, but could not. Micturition was normal.Past History. -Left orchidectoiny a t the age of 3, probably for tuberculosis. 0 s EXAM rwa~~os.-The p t i c n t looked grey and ill : temperature 974", pulse 78, respirations 20. At intervals he was absolutely unable t o be still, hut rollcd about in agony.H e pointed to the lower abdomen as the site of the pain, and palpation elicited rigidity and trnderness here, inost marked in thc right iliac fossa, where there was slight distension and a doughy sensation on prcssure. Rectal examination showed no abnormality. The lcft testis was absent, the right somewhat enlarged and accompanied by a small hydrocele of t h e tunica vagirialis. The hernial orifices were normal. IJrine showed some acctorie and a considerablc aniount of sugar (this disappeared immediately aftcr opcratioii), but no albumen or organisms .A provisional diagnosis was made of acute appeiidicitis, probably with a concretion giving rise to colic, and morphia and warmth werc applied t o tlie patient.O r E K A T I o N (6.45 a.m.).-on opening the abdomen through a right loWCr paranicdian in&ion, free blood-stained fluid exuded. On looking further i t There was no history of a. previous attack.The tongue was thickly furred.

SURGEON, HOVE GENERAL HOSPITALAN investigation in 1931 of the literature suggested to the writer that in the majority of the papers on inguinal hernia the high percentage of recurrence after operation constituted a reproach to modern surgery, and the inadequacy of the average follow-up led one to presume that the true recurrence figure might be still higher.This paper shows the results of a personal consecutive non-selected series of 163 elective (non-strangulated) operations for inguinal hernia with as adequate a follow-up as possible. I have set out to stress the need for fuller after-investigation and to advocate the more extensive use of the fascia lata graft technique. HISTORICAL As far back as 1901McArthurZ7 started to use fascia to supplement the methods then in use. He freed one end of a strip from the external oblique aponeurosis, and with it he darned across between the falx inguinale and the inguinal ligament. With a second similar strip, tethered still at one end to the parent external oblique, he closed the incision in that muscle.In 1910 Kirschner20 recorded a number of successes with free flap transplants of fascia lata sutured across the weak posterior wall of the inguinal canal. He claimed for fascia lata its accessibility, abundance, strength, inelasticity, and readiness to heal in when transplanted, and that it could be cut to fit an opening of any shape. It was in 1921 that Gallie and Lemesurier14 demonstrated the survival of long free fascial strips (6 or 7 in. by in.), and advocated their use in preference to flaps of fascia. They introduced a special curved, large-eyed needle on which the strip is threaded, and using this material a ' darn ' is made across the weak area. He published his findings in 1904.This work laid the foundation of the modern graft operation. METHODS OF TREATMENT

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