“The pen is mightier than the sword” – suicidal trans-orbital intracranial penetrating injury from a pencil

Abstract

A 40-year-old drug addict, who was being treated with methadone and occupational therapy, committed suicide by striking a wooden pencil into his right eye socket. While still conscious, he hit his head hard against a table, jamming the pencil even deeper into his head. The autopsy showed that the pencil missed the globe and lodged in the inner part of the right eye socket. It pierced the orbital part of the right ethmoid bone, the right ethmoid cells, and the right superior nasal concha, then passed through the body of the sphenoid bone and the clivus of the occipital bone before stopping in the brain tissue. The basilar artery was transected at the pontomedullary junction, where the tip of the pencil had lodged. Also, at the pontomedullary junction, an approximately 3 mm deep laceration of the brainstem was evident together with flecks of green paint. Histological examination revealed that laceration at the pontomedullary junction was even deeper than the macroscopic appearance had suggested, with several small lateral cracks, focal deep hemorrhage, and disruption of both gray and white matter of the brainstem. Fragments of cellulose originating from the wooden pencil could also be clearly distinguished. Toxicological analysis was performed using liquid chromatography with mass spectrometry, and it showed traces of methadone in the blood and humor vitreous samples. The cause of death was damage to the vital structures in the brainstem, resulting from a penetrating injury to the head by a pencil. Herein, we present a self-inflicted trans-orbital penetrating injury by a non-missile, low-velocity object – a pencil, with a rather unusual, immediately incapacitating outcome.