Intraperitoneal sepsis producing pus and presenting as a pain­ful distended hernial sac is an important differential diagnosis of strangulated hernia; in these circumstances the hernia is behaving as a peritoneal recess in which pus can loculate. Zuckerkandl fi rst described this phenomenon in 1891. His patient was a 55-year-old male with a 6-day history of a pain­ful irreducible right inguinal hernia. At operation the hernial sac contained pus only, and the perforated appendix lays in the peritoneal cavity just above the sac. The appendix was not removed and the patient recovered [ 90 ] . Cronin and Ellis reported fi ve patients from Oxford in which a pus- fi lled her­nia misled surgeons into a preoperative diagnosis of strangu­lated hernia [ 40 ] . This complication of pus in a hernial sac most frequently occurs in right inguinal [ 91 ] , then right femo- ral [ 92 ] , then left inguinal, and, least often, in left femoral hernias [ 93 ] . The syndrome has been encountered in epigas­tric and umbilical hernias. Underlying pathologies include acute appendicitis (the most common), perforated peptic ulcer, pneumococcal peritonitis, acute pyosalpinx, acute pan­creatitis, and biliary peritonitis [ 40, 94 ] .