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The Transorbital Intracranial Penetrating Injury
  1. PETER M KYLE

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    The Transorbital Intracranial Penetrating Injury. By Martin Th A van Duinen. Pp 176; £58. Dordrecht: Kluwer Academic Publishers, 1999. ISBN 0-7923-5915-1.

    Many of us, although not quite there yet, dream of retirement and specifically what we will do with all the time. Doctor van Duinen came with up with an interesting solution—to review a relatively rare condition of relevance to neurosurgeons but also of interest to ophthalmologists. The topic he selected was that of the transorbital intracranial penetrating injury (TIPI). He reviewed all the cases in the literature including two dissertations and came up with 347 cases.

    The rarity of the condition is supported by the author conceding that in his 35 years of clinical practice as a neurosurgeon, he did not see a single case. Interest was stimulated by an intriguing press report of an accident or attempted murder in which the necropsy revealed an intracranially positioned ballpoint pen, the pen having entered through the orbit. (For “attempted” read “suspected” and this highlights one of the problems with the text.) An attempt is made to divide the monograph into chapters. Credulity is frequently stretched—for example, in the chapter on the “History of the condition”, it is given that David slew Goliath with a stone that penetrated the brain stem having passed through the orbit. Henry II of France sustained a similar injury while jousting. The various classic causes of the injury are umbrellas, pencils, knives, and chopsticks. There are other collectors' items like a kangaroo tooth and a needlefish. Most have in common a sharp tip with a fairly thin piece thereafter. Certain points recur; that this is an easy injury to miss even with appropriate imaging; the history is not uncommonly unreliable; fragments of wood entering intracranially often have a bad prognosis. Other chapters deal with antibiotic therapy, complications, and the role of imaging.

    This is a flawed book. It is extraordinary that a publisher allowed it to slip through what must be a very wide meshed net. The translation does not help. While the general text is acceptable, the more complex medical matters are in many instances rendered incomprehensible—for example, “acute blindness after orbital penetration has an unfavourable prognosis for vision”. There is a lack of uniformity throughout the text in the style of presentation, the photographs, and indeed the topic covered; at various points transoral and transnasal injuries feature in the text. Ultimately this leads to confusion.

    Unfortunately, the main conclusion is that the pursuit of academia in retirement is best avoided.

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