_Hernial protrusions_ are dealt with elsewhere. _Hernia cerebri_ requires some consideration. Its development, by reason of its usual bacterial agency, must always be regarded as of serious import. The congested brain bulges through the aperture in the skull and presents on the surface as a purple--sometimes black--fungating mass, bleeding freely, and associated with a considerable discharge of cerebro-spinal fluid, serum, and pus. The effects produced by this condition vary according to the extent of the cerebritis, and the question of associated meningeal infection. When associated with meningitis those symptoms which might result from the hernial protrusion are more or less obscured by those dependent on the meningeal infection. Under other circumstances, the symptoms vary according to the extent and position of the area involved. Thus, when the infection is limited to the surface of the brain in the immediate vicinity of the aperture in the bone, the patient may merely complain of some headache and present some symptoms of cerebral irritation. More usually, the infection spreads rapidly to the surrounding brain substance, and the patient evidences the most acute stage of cerebral irritation, passing thence rapidly into a stuporose, typhoid-like condition. [Illustration: A FIG. 86. A CASE OF HERNIA CEREBRI. A, The abscess after removal (natural size), cut so as to show the thickness of capsule.] =Treatment.= With the object of reducing the infectivity of the protruding brain, fomentations have been advocated. From my own experience, however, it would appear that their application tends to increase the degree of protrusion, and that better results may be obtained by keeping the exposed brain as dry as possible, painting over with a 2¹⁄₂ per cent. solution of iodine in rectified spirit, dusting with antiseptic powder, and protecting with dry dressings, frequently replaced. In the event of failure to improve the condition by means of these minor remedies--a too-frequent occurrence--excision of the protruding mass may be regarded as a perfectly justifiable procedure, providing that the hernia does not include the cerebellum or motor cortical region. The protrusion is shaved away flush with the level of the skull, the raw surface of the brain lightly painted with iodine, dusted with iodoform or other antiseptic powder, and protected with gauze and wool. The prognosis is necessarily most grave, but the most astounding recoveries have taken place under this mode of treatment. [52] _Archiv für Ohrenheilkunde_, vol. xxix, p. 17. [53] _Diseases of the Ear_, Oxford Medical Publications, p. 257. [54] _Pyogenic Diseases of the Brain and Spinal Cord._ [55] _Some Points in the Surgery of the Brain_, p. 95. [56] Macewen, _Pyogenic Diseases of the Brain and Spinal Cord_. [57] _Pyogenic Diseases of the Brain and Spinal Cord_, p. 247. [58] _Pyogenic Diseases of the Brain and Spinal Cord._ CHAPTER IX BULLET-WOUNDS OF THE SKULL AND BRAIN