A man suffered from a severe fracture of the middle fossa. Three weeks later there was a sudden and profuse discharge of cerebro-spinal fluid from the nose. Meningitis developed and the patient died. The basi-sphenoid was extensively comminuted, the overlying membranes torn, whilst a probe could be passed readily from the cranial cavity into the naso-pharynx.
_Special points in prognosis and treatment._ The question of cerebro-spinal discharges has been discussed previously (see p. 91). It is therefore merely necessary to lay further stress on the fact that syringing of the ear is absolutely contra-indicated, for reasons already stated. The ear should be cleaned out with wool and gauze and _lightly_ packed with strips of gauze, these to be renewed when soaked with fluid. When the cerebro-spinal discharge is long continued, acute eczema of the side of the neck may develop as a result of the irritating effect of the fluid. Under these circumstances it is advisable to adopt precautionary measures, painting the skin with ‘new skin’ or collodion. Ointments are of but little use. The eczema will clear up so soon as the discharge ceases.
=Escape of brain-matter.= The conditions needful for the discharge of brain-matter from ear or nose have been enumerated previously (see p. 93). There are but few cases recorded in literature, and one case only has come under my own observation:--
A lad, 11 years of age, fell some distance out of window on to his head. He was admitted under the care of my colleague, Mr. Lockwood. On admission he was unconscious, and was bleeding freely from the right ear and nose. Shortly afterwards it was noticed that brain-matter was issuing from the right external auditory meatus, sufficient brain-matter being obtained to fill a teaspoon. The extensive nature of the brain-injury was confirmed by the fact that the left arm and leg were paralysed for some days. On the fourth day the boy regained consciousness and recognized his relations. From this period onwards he made an uninterrupted recovery. I have seen the lad on various occasions, the last time one year after the accident. At that time he was an exceedingly bright and intellectual boy.
_Special points in treatment and prognosis._ The brain-matter should be gently wiped away from the ear, and the meatus cleansed and lightly plugged with gauze. Operative measures are required in the event of the development of symptoms pointing to brain compression. The prognosis must necessarily be unfavourable, but, as the conditions are almost entirely confined to the young, the most astonishing recoveries are reported.