As regards the _prognosis_, it is interesting to note that the escape of cerebro-spinal fluid implies of necessity that the subarachnoid space is opened up to the exterior, with all attendant dangers of meningeal infection, yet that the prognosis is generally favourable. One might even go further and state that the prognosis in such cases is rather more favourable than under more ordinary circumstances. Thus, Battle records 36 cases with a mortality of 25 per cent., the general mortality of fractured base being about 44 per cent. My own experience tallies with these statistics. The more favourable result hinges no doubt on the fact that the prolonged outflow tends to wash away organisms existent in the aural and nasal passages.
With regard to any special points in treatment, it is obvious that syringing of ear or nose is absolutely contra-indicated. The cavities should be _lightly_ plugged with gauze, the dressings to be renewed as soon as they are soaked. The patient must also be prevented from interfering with the dressings.
With regard to the routine use of urotropin to guard against the advent of meningitis, see p. 116.
=Escape of brain-matter from the nose.= This diagnostic symptom is of very rare occurrence. For its development the following factors are requisite:--
Great comminution and destruction of the anterior fossa.
Severe local laceration of the brain (frontal lobes).
A copious discharge of blood and cerebro-spinal fluid.
A general increase in the intracranial pressure.
One case only of this nature has come under my own observation, that of a man whose right nostril was blocked with brain substance. He died shortly after admission into the hospital, and at the post-mortem examination the above conditions were found.
=Escape of air from the air-sinuses into the surrounding regions.= When the fracture involves the frontal, ethmoidal, and mastoid sinuses, any sudden increase of the intrasinus air-pressure, such as is caused by sneezing, blowing of the nose, &c., may force air into the surrounding tissues. A distinction must be made between those cases in which the pericranium overlying the seat of fracture is torn and those in which it remains intact. In the former case, the escaping air may spread widely into the neighbouring loose tissues, leading to a condition of ‘surgical emphysema’. In the second case, the air remains confined to a smaller area, giving rise to a soft, more or less rounded swelling. Gentle palpation of this swelling imparts to the fingers that crackling sensation peculiar to the condition. Firm pressure results in diminution in the size of the tumour, the contained air being forced back into the sinus cavity. Such localized collections of air are known as ‘pneumatoceles’.