A Case of Fracture of the Temporal Bone, 
with Remarks on Trephining for 
Fracture of the Base of 
the Skull. 
BY 
J. COLLINS WARREN, M. D., 
Associate Professor of Surgery in Harvard University; Surgeon to the 
Massachusetts General Hospital. 
PROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
May, 1890. Extracted from 
The American Journal of the Medical Sciences for May, 1890. 
A CASE OF FRACTURE OF THE TEMPORAL BONE, WITH 
REMARKS ON TREPHINING FOR FRACTURE 
OF THE BASE OF THE SKULL. 
By J. Collins Warden, M.D., 
ASSOCIATE PROFESSOR OF SURGERY IN HARVARD UNIVERSITY ; SURGEON TO THE 
MASSACHUSETTS GENERAL HOSPITAL. 
The object of reporting this case is to call attention to the advantage 
of drainage as an aid to the process of repair after fracture of the base. 
Until quite recently this grave lesion has been regarded as beyond the 
pale of surgical interference. The latest literature shows, however, that 
hospital surgeons are endeavoring to apply the principles of antiseptic 
surgery to this almost inaccessible region, and the recent advances in 
brain surgery encourage the hope that more attention will be paid to the 
lesions of the different fossse of the skull and their contents, and that 
valuable suggestions may from time to time be forthcoming as to the 
management of the complications to which they give rise. 
T. K. L., seventeen years of age, a tall and slender man, was riding 
in the saddle about dusk of the afternoon of October 20, 1889, and had 
separated from his companions, having ridden rapidly ahead of them 
when the accident occurred. According to the statement of a passer-by, 
he was observed turning a corner in the road at a moderate pace, when 
suddenly horse and rider were seen struggling in the dust. The horse 
soon regained his feet and ran away. It is supposed that as the corner 
was turned the horse shied suddenly, throwing the rider and falling 
upon him. 
When the patient was approached he was found to be comatose and 
bleeding profusely from the nose and left ear; a narrow strip of brain 
substance was found upon the sleeve of his coat. The accident occurred 
about 6 p.m. On my arrival (about 10 p.m. the same evening) I found 
the patient comatose with heavy breathing. There was, apparently, no 
paralysis of any kind ; the pupils were normal and reacted to light; the 
pulse was of good strength and about 100 beats to the minute; hemor- 
rhage from the nose had ceased, but the patient had vomited blood an hour 
or so before. Blood was still oozing from the left ear, and on close inspec- 
tion two fragments of brain substance, each about the size of a pea, were. 
found at the external auditory meatus. There was a contusion on the fore- 
head just above the glabella, forming quite a prominent tumor. Careful 
examination of the scalp failed to reveal any depression of the bone. 
There was a boggy swelling of the integuments of the left temporal bone 
above and behind the ear, and a faint depression about two inches above 
the external meatus, which, however, was thought not to be due to dis- 
placement of bone. Pressure on these parts produced a fresh flow of WARREN, FRACTURE OF TEMPORAL BONE. 
blood from the ear, the flow ceasing between the intervals of examin- 
ation. No external wound was visible anywhere. The presence of brain 
in the discharge from the ear, the contusion of the neighboring scalp, 
and the profound coma pointed to serious injury at the base of the brain 
and in the left temporal bone. 
The evidence of grave injury at this spot seemed so pronounced, and 
the prognosis of the case seemed so unfavorable, that although no de- 
pressed fragments of bone were felt, it seemed justifiable to depart from 
the ordinary rule of non-interference in fracture of the base and to make 
an exploratory incision for the purpose of arresting hemorrhage, affording 
drainage, or removing clots and fragments of bone. 
The operation was performed shortly after midnight—that is, about 
six hours after the accident—in the presence of Drs. Hall Curtis, S. J. 
Mixter, and John Homans, 2d., the latter having charge of the case 
subsequently. The scalp on this side of the head having been shaved, a 
curved incision was made, starting from the auriculo-bregmatic line at a 
point about two and one-half inches above the external auditory meatus 
and returning to the level of the meatus. The flap thus made, when 
reflected forward, exposed the posterior half of the squamous portion of 
the temporal bone. A nearly vertical fracture was found at about the 
juncture of the middle and posterior thirds of that bone: at its upper 
end the fracture terminated in several radiating cracks, about one-half 
inch in length each, which crossed the squamous suture and involved 
the adjacent parietal bone; it ran downward and slightly forward to the 
external auditory meatus, where it could be seen running along the wall 
of the auditory canal. .(Kg-1.) There was no depression of the bone, but 
the edges of the cleft were slightly sprung at the lower portion. Consider- 
able dark-colored fluid blood with small clots welled up from beneath on 
slight pressure on the bone. A one-inch trephine was placed directly 
over the line of fracture a short distance above the meatus, and a button 
of bone removed, the lower edge of which was nearly on a level with 
the floor of the middle fossa. The dura was found torn at this point, and 
the finger being introduced, could follow the fracture along the petrous 
portion of the temporal bone, and on being turned upward found its way 
to the depth of the second kunckle into a lacerated wound of the middle 
lobe. There were a few small clots only removed from the wound, but a 
considerable quantity of fluid blood escaped which had evidently been 
confined beneath the bone; an arterial branch had been torn at this 
point, as shown by the groove in the button removed, and bled freely, 
but wras easily controlled by pressure. The decalcified bone drainage- 
tubes which I had brought with me were found to be too much softened 
for use, and a strip of bichloride gauze was accordingly pushed gently 
along the floor of the skull, and a number of strands of catgut tied to- 
gether were pushed up into the lacerated brain tissue; a small strip of 
gauze was placed in the auditory canal. A dressing of bichloride gauze 
and absorbent cotton, fortified by a folded towel wrung out of the di- 
luted solution, was applied and held firmly in place by a figure-of-eight 
bandage. Antiseptic precautions were observed throughout the opera- 
tion. 
Immediately after the operation the patient was cold and pale and WARREN-, FRACTURE OF TEMPORAL BONE. 
3 
the pulse weak; the coma remained as before; urine was passed invol- 
untarily. During the night the dressing being stained, was reinforced. 
The temperature the next morning was 100.8° F., but fell to normal on 
the morning of the second day ; he then appeared stronger. The dressing, 
on being changed, was found saturated with bloody serum. As it was 
quite a voluminous dressing, the amount of cerebro-spinal fluid and 
bloody discharge which it had absorbed must have been considerable. 
The drains were not disturbed and an iodoform gauze and absorbent 
Fig. 1. 
Line of the fracture through the squamous portion of the temporal bone. The dotted 
line shows the point at which the trephine was placed. 
cotton dressing was applied. A strip of iodoform gauze was placed in 
the auditory canal, which at each dressing was carefully syringed out 
with sublimate solution, 1:5000. The temperature rose on the evening of 
the second day to 100.9°, the highest point reached, and fell steadily from 
this point to normal on the sixth day. On the fourth day the dressing 
was changed again : the catgut drain came away and the gauze was re- 
moved, and was replaced by a small strip of iodoform gauze inserted just 
within the margin of the cranial cavity ; all the scalp stitches except one 
were removed. This dressing was allowed to remain three days, and on 
the 27th, just a week after the accident, all stitches and the gauze drains 
had been removed. During this period coma had been complete, but 
on this day, for the first time, the patient opened his eyes and recognized 4 
WARREN, FRACTURE OF TEMPORAL BONE. 
his mother. The expected subconjunctival ecchymosis did not occur, 
it being evident that the effusion had had ample opportunity to escape 
through the drain established. 
Careful attention was paid to the condition of the mucous membrane 
surrounding the opening of the Eustachian canal. A small amount of 
iodoform was blown into the left nostril with an “insufflator ” once daily, 
and the nostril and pharynx were sprayed once or twice a day with a four 
per cent, solution of boracic acid. The hygiene of the mouth was also 
carefully attended to. It was hoped that in this way septic infection of 
clots in the middle ear from the side of the pharynx might be prevented. 
On the tenth day the gauze drain, which had been pushed less deeply 
into the wound, was removed altogether, and the granulating wound 
healed completely a few days later. A dressing of iodoform gauze was 
continued over the auditory meatus, which was syringed out with a 
sublimate wash every few days. 
The mental condition of the patient during the the second week under- 
went little change. Beyond moaning and crying in a childish way, and 
staring with a puzzled expression when disturbed, there was little to indi- 
cate a knowledge of his surroundings. In the third week there was a 
decided improvement, the patient being able to recognize and name indi- 
viduals about him and to remember me after an interval of several days. 
With returning consciousness a marked degree of sensory aphasia showed 
itself. 
The temperature during this period was slightly subnormal and the 
pulse rose rapidly to 115 on any excitement. Sleep and appetite were, 
however, excellent. About this time it was noticed that the tongue, 
when protruded, curved slightly to the left, and the muscles of the right 
side of the face were not quite so powerfully contracted as those of the 
left. Beyond this, however, no sign of paralysis was oberved anywhere. 
There was a slow but steady improvement in all symptoms from this time 
on. A statement written out by his nurse on December 6th, about six 
weeks after the accident, gives a good idea of his mental condition at 
that time: 
“ In language he improves and generally can easily be understood, 
though there are many words whose meaning he has forgotten. ‘ Hilarity ’ 
had to be repeated or explained several times. . . . He will some- 
times talk in French or German, but cannot explain or translate it. 
In trying to write the shortest or simplest words he cannot remember 
what letters to use. . . . He often says, or asks for, things opposite 
to what he means; for instance, he will say, ‘ myself and the other girls.’ 
In some ways his senses are keen, while in others he is very child-like.” 
It should be mentioned in this connection that the patient had been a 
brilliant scholar. 
On December 8th the ear was examined by Dr. Clarence J. Blake, 
who made the following report: “ The walls of the canal are but slightly 
reddened; there is very little discharge from the ear, and the hearing is 
gratifyingly good, as the tuning-fork which he heard sixty-five seconds in 
the sound ear is heard between thirty five and forty seconds in the left ear. 
By bone conduction the fork is heard better in the left ear. In this ear also 
the hearing for high tones remains as good as could be expected under 
the existing conditions, including rupture of the membrana tympani. 
The condition of the ear indicates fracture of the superior wall of the WARREN, FRACTURE OF TEMPORAL BONE. 
5 
external canal longitudinally and rupture of the membrana tympani, 
but no injury to the labyrinth.” 
There is little to be said about the further progress of the case, except 
that the mental improvement was rapid during the month of 1 Jecember, 
and by January 1st the aphasia had almost entirely disappeared. Under 
date of March 2d Dr. John Homans, 2d., writes me: “The tongue is 
still protruded slightly to the left; there are some hesitancy and stammer- 
ing in the speech and an incapability of continuous mental exertion— 
that is, he cannot read aloud for more than half an hour without mis- 
pronouncing badly and having slight pain in the head, but in all these 
defects there is a steady, though slow, improvement.” 
On February 4th Dr. Blake writes : “ To-day young L. has no dis- 
charge from the ear, the granulations have disappeared, the membrana 
tympani is intact, but somewhat opaque, from the thickening of the inner 
coat, the Eustachian tube is free, and the hearing after catheterization is 
for a Politzer acoumeter yW” 
The question of diagnosis is of importance in this case, as it is, of 
course, desirable to determine definitely whether we have a “ fracture of 
the base ” to deal with. So far as the appearances observed within the 
ear and the complete restoration of the hearing serve as evidence, it 
would appear that there had been a widely spreading fracture of the 
superior wall of the bony external auditory canal, stopping at the inner 
end of the canal. But such an assumption is highly improbable when 
we consider the anatomical peculiarities of the temporal bone and the 
structures which lie in the direct line of the fracture. The petrous por- 
tion of the bone is, it is true, largely composed of dense bony tissues, 
but the bony covering, of the middle ear, which lies in the anterior por- 
tion of the petrous portion and near its junction with the squamous por- 
tion, is extremely thin. There are other structures which tend to make 
the bone particularly weak at this point. 
Passing a probe through the Eustachian tube and the auditory canal 
of a dry specimen, and looking at the under surface of such a bone, we 
see that the probe marks a line of division between the squamous portion 
on the one side and the mastoid and petrous portions on the other. Along 
this line lie the canals for the Eustachian tube and tensor tympani muscle, 
the external auditory canal, and the Glaserian fissure. The carotid 
canal, although not on this exact line, is quite near it, and weakens this 
portion of the petrous bone. A fracture descending from the squamous 
portion and passing along the wall of the external auditory canal, paral- 
lel with its long axis, would, if continued onward in the same line, pass 
through the structures just mentioned ; and, moreover, piercing the mem- 
brane of Schrapnell would pass in front of the apparatus for hearing. 
It is true that rupture of this membrane implies the opening of the tym- 
panic cavity, but the membrana tympani is placed at an extremely 
oblique angle with the long axis of the canal, which runs forward and 
inward, and a longitudinal fracture through the roof of the canal, if 6 
WARREN, FRACTURE OF TEMPORAL BONE. 
continued in the same direction, would rupture the membrane of Schrap- 
nell, traverse the anterior portion of the tympanic cavity, and, avoiding 
the delicate structures of the middle ear, terminate somewhere in the 
angle between the petrous and the squamous portions of the bone—that 
is, at the point where the temporal bone articulates with the posterior 
angle of the great wing of the sphenoid bone. (Fig. 2.) 
Fig. 2. 
The probable route of the fracture terminating in the carotid canal at the margin of the 
foramen lacerum medium. The dotted circle shows the seat of the trephine hole. 
Experiments on the cadaver to show what kind of violence probably 
caused the lesion of our patient demonstrated that such fractures could 
be produced by blows with a blunt instrument applied directly above 
the external auditory meatus. 
The head of a fresh cadaver was tested in this way in the autopsy- 
room and a number of dissecting-room subjects were also used for this 
purpose. In all cases the fracture ran down the anterior and external 
portions of the petrous bone to terminate either in the external margin of 
the foramen lacerum medium or the junction of the posterior angle of 
the great wing of the sphenoid with the temporal bone—that is, near the 
foramen spinosum through which the meningeal artery passes. In some 
cases the broken edges were closely in contact; occasionally ‘the fissure 
was broad so that one could look down into the tympanic cavity where 
the bones of the ear could be seen still maintaining their normal positions. 
(Fig. 3.) 
It seems highly probable, therefore, that this is the type of fracture 
ordinarily produced by blows received over the external ear. But in WARREN, FRACTURE OF TEMPORAL BONE. 
7 
the present case the bone was not only broken, but the brain was also 
severely lacerated and the dura ruptured. My explanation of the injury 
is as follows : In falling from his horse the patient struck upon the fore- 
head producing the contusion already noted. This accounted, probably, 
largely for the hemorrhage from the nose and vomiting of blood. The 
horse in falling struck him a severe blow on the side of the head, pro- 
ducing the fracture of the temporal bone, and at the same time the 
weight of the animal pressing heavily upon the cranium, forced apart 
the edges of the fracture and forced out the cranial contents, rupturing 
the dura. As the bones sprang back into place the protruded brain was 
nipped and expelled through the ear, thus accounting for the narrow 
strip of brain found on the patient’s coat-sleeve. 
Fig. .3. 
Fractures through the petrous bones into the foramen lacerum medium on each side, 
produced experimentally by blow of a mallet before opening the head. A glass rod is 
placed in the left external auditory canal. 
The laceration of the brain extended deeply into the middle lobe, 
reaching as far as the first temporo-sphenoidal convolution and possibly 8 
WARREN, FRACTURE OF TEMPORAL BONE. 
involving a portion of the inferior frontal convolution. The lesion 
must have involved the peripheral portions of the centre for speech, and 
the effects of the injury must have been felt as far as the centres for the 
face and tongue. 
We have in this case an example of fracture of the temporal bone, 
involving the base and communicating with the external and middle ear, 
and possibly the Eustachian canal, but not opening directly into the vault 
of the pharynx. As a complication, we have laceration of the middle 
lobe and rupture of the posterior branch of the middle meningeal artery. 
The symptoms of fracture of the base were characteristic, consisting 
of profound coma, bleeding from the ear, and the escape of brain-sub- 
stance. The presence of cerebro-spinal fluid was not noticed at the time 
of the injury, owing to the free hemorrhage, and later was, naturally, 
not seen flowing from the ear, owing to the establishment of suitable 
drainage. 
The escape of brain-tissue is not a common occurrence in fractures of 
the base, but when observed is regarded as an unfailing sign of that 
lesion. Yon Bergmann1 says: The escape of brain-substance from the 
fracture of the base is an undoubted symptom of this injury, and at the 
same time of laceration of the membranes; it may escape from the ex- 
ternal ear or the nose. 
Nancrede2 says: The escape of brain-substance by the ear or nose, of 
course, definitely settles the fact of basal fracture, but is of rare occurrence. 
The treatment of fractures of the base, until recently, has been 
largely expectant. Even long after antiseptic treatment of wounds had 
been established, surgeons do not appear to have realized that in this 
form of fracture they often had a compound fracture to deal with. 
Recent literature, however, has taken cognizance of the claims of this 
region to the benefits of antisepsis. Keen3 advises disinfection of the 
ear, filling it with boracic acid, and covering the scalp with sublimate 
gauze. He recommends opening the roof of the orbit or nostril in pene- 
trating wounds of those regions, to provide for free drainage. He also 
advises tamponing the nostrils with sublimate gauze to prevent passage 
of infective air through these passages. 
Dennis4 lays down rules for the treatment of this fracture. He thinks 
the entire scalp should be shaved and disinfected. He also irrigates the 
external auditory canal and the nasal passages. “ Both of these should 
be rendered thoroughly aseptic, after which the ears should be packed 
with iodoform or bichloride gauze, and some absorbent cotton plugs 
placed in the nose.” 
1 Deutsche Chirurgie, Lieferung, 30. 
2 International Encyclopaedia of Surgery, vol. v. 
3 Handbook of Medical Science, vol. viii. p. 226. 
4 The Medical Record, November 23, 1889. WARREN, FRACTURE OF TEMPORAL BONE. 
9 
In the case reported here every effort was made to prevent infection 
through the Eustachian tube. The epistaxis and hematemesis in this case 
may have been due, in part, to the flow of blood from this canal. It 
was, in any event, important to keep the inner opening to the middle 
ear in as aseptic a condition as possible. 
This can hardly be accomplished by gauze or cotton plugs in the nose 
unless they are brought in direct contact with the mouth of the Eusta- 
chian tube. 
Rosenbach has shown that the pharynx is a not infrequent seat of the 
pyogenic cocci, and the antisepsis of this region must, consequently, also 
be carefully attended to. 
Frequent douching of the naso-pharynx and mouth with antiseptic 
sprays is perhaps as efficient and safe a method as any. At the Boston 
City Hospital diphtheria patients are sprayed hourly in this way with a 
1:1000 solution of sublimate given with an insufflator, and often without 
waking the patient. A little iodoform powder dusted once a day on to 
the membrane near the Eustachian opening may aid in preserving the 
region in an antiseptic condition. Should a more extensive fracture, 
such as one crossing the vault of the pharynx, exist, it might be advis- 
able to plug the pharynx and posterior nares with antiseptic gauze. 
Such a dressing would be no annoyance to a comatose patient, and it is 
difficult to see how a fracture of this region could be dressed antisepti- 
cally in any other way. 
The use of the trephine has been recommended for depressed fractures 
of the base, but has not been frequently employed, and then only in the 
occipital region. Hutchison1 has applied the trephine successfully near 
the foramen magnum for a depressed fracture of that region in a boy 
fourteen years of age; puncture of the membrane was subsequently 
resorted to for a serous effusion, and recovery took place. 
Keen recommends an opening for drainage in the roof of the orbit in 
punctured wounds at that point. Allis (Annals of Surgery, July, 1889) 
drilled through the cribriform plate for drainage of a compound depressed 
fracture of the frontal bone situated an inch above the right eye—a 
drainage tube three-eighths of an inch in diameter was passed through 
the openings. The patient recovered. 
Trephining for drainage in fractures of the base is a device which I 
do not find mentioned in a moderate search through the literature of this 
subject, and its successful application to Dr. Homans’s patient seems to 
me of sufficient importance alone to justify placing the case on record. 
Applied just above the external auditory meatus the instrument makes 
an opening which drains most effectually the middle fossa. This opera- 
tion would, therefore, be applicable not only to fractures of the temporal 
1 Medico-Chirurgical Transactions, vol. ii. p. 105. 10 
WARREN, FRACTURE OF TEMPORAL BONE. 
bone but fractures through the sphenoid, and even those involving the 
anterior fossa. For this latter region, however, it would probably be 
desirable to place the trephine near the pterion, as injuries to the middle 
meningeal artery might thus also be attended to. 
In fractures of the occipital bone the opening should be made below 
the insertion of the tentorium in order to drain the posterior fossa, and 
care should be taken to avoid the lateral and occipital sinuses. The tre- 
phine should, therefore, be placed below the superior curved line, and 
not too near the crest of the occiput. 
Recently I had an opportunity to see two autopsies of cases of fracture 
of the base. In one case there was a partially detached fragment of the 
occiput half-way between the foramen magnum and superior curved 
line. The fragment could not be removed, owing to severe hemorrhage 
from the lateral sinus, and the surgeon had left the parts so as to favor 
drainage. On opening the skull but a small amount of extravasated 
blood was found in the pia mater of the cerebellum and medulla. In a 
second case where the sinuses had also been ruptured and no opening for 
drainage had been made, the entire surface of the brain was covered with 
extravasated blood. 
In a fracture clearly involving the vault of the pharynx, even though 
it were not possible to say that the temporal bone had been injured, the 
trephine might be placed a little anterior to the auriculo-bregmatic line 
and a gauze drain inserted along the floor of the skull in the route of the 
fissured bone. A case can even be imagined where it would be proper 
to place the trephine upon the squamous portion of each temporal bone 
in order that the entire region of the sphenoid bone might thus be con- 
trolled by the drainage gauze. 
The materials used as drains in surgery of the brain should, it seems 
to me, differ essentially from those used ordinarily for this purpose else- 
where. The sharp edges of bone or rubber drains are sources of irrita- 
tion and may even destroy brain substance by pressure. Catgut may 
be absorbed too soon, but otherwise works well. Horse-hair may be 
suited for the scalp, but could not easily be introduced into a lacerated 
wound of the brain-tissue without danger of irritation from the sharp 
points. 
The antiseptic gauze used in my case seemed to meet all requirements. 
It can be easily slipped along the inner surface of the dura and consti- 
tutes not only a drain, but also an antiseptic dressing, which protects 
the cranial contents from invasion from the naso-pharyngeal cavities or 
the ear. It can drain, not only the wound, but may absorb from the 
subdural space fluid which accumulates on either side of the dressing, 
and by capillary attraction aspirate the exudation from different direc- 
tions. 
No better illustration of the advantages of drainage for fractures of WARREN, FRACTURE OF TEMPORAL BONE. 
11 
the base could be given than that afforded by the celebrated tamping 
iron case. (Fig. 4.) Dr. Harlow1 thus describes the opening made through 
the floor of the skull: 
Fig. 4. 
Photograph of the base ol the skull of the tamping iron case, showing the hole made 
by the iron in its passage through the frontal and sphenoid bones. 
“ The missile . . . entered the base of the skull at a point, the centre 
of which is one and one-fourth inches to the left of the median line, in the 
junction of the lesser wing of the sphenoid with the orbital process of the 
frontal bone, comminuting and removing the entire lesser wing with one-half 
of the greater wing of the sphenoid bone; also fracturing and carrying away 
a large portion of the orbital process of the frontal bone, leaving an opening 
in the base of the cranium, after the natural efforts at repair by the deposit of 
new bone, of one inch in its lateral by two inches in its antero-posterior 
diameter.” 
In his remarks upon the case he says: 
“ The bolt did little injury until it reached the floor of the cranium, when, 
at the same time that it did irreparable mischief, it opened up its way of 
escape, as without this opening in the base of the skull, for drainage, recovery 
would have been impossible.” 
1 Passage of an iron bar through the head. Read before the Massachusetts Medical 
Society, June 31,1868. John M. Harlow, M.D. THE AMERICAN JOURNA 
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