A NOTE ON TWO CASES ILLUSTRATING SOME MINOR 
DIFFICULTIES IN THE DIAGNOSIS OF HERNIAS. 
By J. William White, M. D., 
Surgeon to the Philadelphia and German Hospitals, Assistant—Surgeon to the 
University Hospital, etc. 
Case i. Mrs. , aged 69 years, was admitted to the Philadelphia 
Hospital, on the evening of December 16th, 1887, suffering with a painful 
tumor situated a little external to the middle of Poupart’s ligament, on the 
right side. She had nausea and vomiting, but said she was frequently subject 
to these symptoms as a result of indigestion. The tumor had been of slow 
formation, seemed quite mobile, and was not larger than a hickorynut; the 
skin was red and adherent. There was no distinct impulse on coughing. It 
was evident that pus had formed in the region of the swelling. During the 
night after her admission her vomiting ceased, and she had two larged formed 
stools. The following day she was given a few whiffs of ether, and I proceeded 
to dissect down to the swelling, believing probably that it was but a periaden- 
itis or an enlarged and inflamed lymphatic gland, but recognizing the possibility 
of error in the history of the case and therefore proceeding carefully. After 
going through the skin and superficial fascia and opening the deep fascia, there 
was a free discharge of pus, but at this time, two points attracted my atten- 
tion. The finger failed to recognize the gland, which usually forms the centre 
of such a purulent collection, and the pus which was discharged, was filled 
with bubbles of gas and was of a slightly feculent color. I at once suspected 
and announced to the class that I was dealing with a case of the so-called 
Ifittre Hernia, in which a portion only of the segment of the bowel is involved, 
the entire lumen of the intestine not being obliterated. 
The history of the case seemed, therefore, in this light to be read as 
follows: Such a portion of the bowel had engaged in but had not passed 
through the internal abdominal ring becoming fastened there by inflammatory 
adhesion. Strangulation of a limited portion of its wall had occurred through 
contraction of lymph-bands. This was followed by minute ulcerations with 
escape of gases and of microscopical portions of liquid feces into the surround- 
ing connective tissue. By this theory the slow appearance of the swelling, 
the absence of fecal vomiting, the free movements of the bowels, and the pres- 
ence of pus were all readily understood. After reaching this conclusion, I 
might have proceeded to expose tlm gut by dissecting it away from its adhesions WHITE, DIFFICULTIES IN THE DIAGNOSIS OF HERNIAS. 
to the margin of the ring, and then freshened and sutured the margins of 
any aperture I found ; or I would have had the alternative of performing a 
formal enterectomy. Considering, however, the age and feebleness of the 
patient, and the fact that she was as comfortable in the hospital as she could 
ever hope to be elsewhere, I determined not to interfere with the barrier which 
nature had established between the affected portion of the gut and the general 
peritoneal cavity. I therefore applied simply a compress of antiseptic cotton 
with a spica bandage and sent her back to the ward. The following day the 
diagnosis was fully established by the development of a fecal fistula, which 
from the character of the discharge probably communicated with the ilium. 
This remained open intermittently for some months, gradually becoming less, 
and now has entirely healed without further interference, the patient having 
retained her strength and health uninterruptedly. 
The case is full of interest on account chiefly of the deceptive resem- 
blance to suppuration of the inguinal glands, a condition which is usually so 
easily diagnosed from all forms of hernia that a mistake would be regarded as 
almost inexcusable. Yet in such a case as this the operator could hardly 
have been blamed if he had laid the little swelling freely open, knowing it to 
contain pus and all hernial symtoms having disappeared. Such a procedure 
would of course have made necessary an immediate operation upon the gut and 
might not have been attended with so favorable result. ■ 
‘ ‘ Eittre ’ ’ hernias are of comparatively rare occurrence, and but few cases 
have been recorded. In one case, elaborately reported by Schiffer ( Wien. Med. 
Presse, December, 1865) the diagnosis of incarcerated crural hernia with exten- 
sive serous effusion into the hernial sac was made prior to operation. There 
was no vomiting and there were thin watery evacuations. At the operation a 
peritoneal cyst was found running in front of the sac of the hernia, but the 
latter, together with a portion of the wall of the small intestine which was 
adherent to it, were opened during the operation. The entire lumen of the gut 
was not involved. A fecal fistula of course resulted ; the patient died of 
exhaustion shortly afterward. Schiffer concludes that the cyst was formed by 
a process of local irritation obliterating the original connection with the general 
peritoneal cavity and thinks that this, together with the tight adhesions 
between the gut and sac, may have been due to an ill-fitting truss worn by the 
patient, which he also thinks accounted for the occurrence of the peculiar form 
of hernia under consideration. He believes that in such cases early operations 
are markedly indicated. 
Zwicke has reported three cases of lyittre hernia. In one (Charite 
Annalen, 1882, page 444) the hernial tumor was apparently perfectly reduced, 
but the patient died the following day asphyxiated while the bowels were being 
moved after enema. At the autopsy an intestinal loop from the lower portion 
of the ilium was found reaching into the internal inguinal ring, forming a 
hernia the size of a cherry ; the mesentery was not at all involved and the 
intestinal wall only through a part of its circumference so that a stream of 
water could easily be made to pass the constricted portion of the gut. That WHITE, DIFFICULTIES IN THE DIAGNOSIS OF HERNIAS. 
portion was firmly adherent, and its small sac was dark red and was not 
gangrenous. 
In another case {Ibid, 1883, page 404) he operated for an apparent inguinal 
hernia, but found only a hernia of a portion of the intestinal wall about the 
size of a bean, It was reduced and the sac ligated and excised. The patient 
died on thirteenth day with general septic peritonitis. In still another {Ibid, 
page 408) the patient had for years worn no truss believing the little tumor to 
be a swelling of the gland. On the occurence of symptoms of strangulation 
herniotomy was performed and a Uittre hernia was discovered. This case 
resulted favorably. In a fourth case {Ibid, page 409) a badly fitting truss was 
believed to be the cause of a similar condition. The gut was reduced, but the 
patient died on the fourth day in collapse, and the autopsy showed a slough 
extending nearly around the circumference of the intestine, but with its centre 
and origin at the point of constriction. Keetly reported {Medical Times and 
Gazette, vol. 11, 1884) a fatal case in which the gut was found narrowed for 
twelve inches, the greatest narrowing being at the point of strangulation. 
Other cases have been reported, one by Dr. Nancrede of this city. As a rule 
the mortality has seemed to be exceptionally great, doubtless from the fact 
that in these hernias of circumscribed portions of the intestinal walls the inter1 
ference with the blood supply of the constricted portion is exceptionally 
complete. Small hernias as a rule are more dangerous than larger ones and for 
the same reason. 
On the night of March 9th, 1888, Mrs. , aged 68 years, was admitted 
to the wards of the German Hospital with a tumor situated over the right 
saphenous opening, about half the size of a child’s fist, tense and very tender 
on pressure and not accompanied by discoloration of the skin. She was appar- 
ently in a condition of mild shock, with a cool, moist skin, feeble frequent 
pulse, and with a countenance expressive of great anxiety and distress. The 
tumor could scarcely be handled on account of her complaints of severe 
pain, but no impulse on coughing was discoverable. She was vomiting 
freely and had had obstinate constipation for two days. She said that the 
tumor had appeared suddenly forty-eight hours previously, while she was 
doing some laborious house work, and said it was precisely similar to one 
which she had had in London some years ago, and which had been reduced by 
taxis at that time after a long period of trial. It will be observed that the his- 
tory (which the patient repeatedly insisted upon), as well as the most promi- 
nent symptoms, simulated closely those of a strangulated femoral hernia, cer- 
tainly at least as definitely as in the preceding case the history and svmptoms 
seemed to exclude hernia. 
' The following morning the patient was etherized, vomiting and constipation 
having persisted together with all the above symptoms. The moment, how- 
ever, that her insensibility permitted palpation of the tumor, it was found by 
deep pressure that it was lobulated and extended down the thigh in the con- 
trary direction from that ordinarily taken by femoral hernias, which tend to 
curve upwards over the tense edge of the falciform process. The diagnosis of WHITE, DIFFICULTIES IN THE DIAGNOSIS OF HERNIAS. 
lympliadenoma was easily made, although it was recognized that if the history 
were true there was a bare possibility of the co-existence of an omental hernia 
containing a small knuckle of gut. I proceeded at once to remove the mass of 
lymphatic glands, finding no hernia. The patient's symptoms disappeared en- 
tirely with the removal of the tumor and were undoubtedly hysterical in their 
character, though there is no reason to believe her guilty of any intentional 
deception. She made an uninterrupted recovery from the operation. 
These two cases contrast so markedly and present such exceptional pecu- 
liarities in relation to the ordinary symptoms of hernia, that they have seemed 
to me worthy to be placed on record.