Self-inflicted gunshot wounds are a common cause of death in forensic pathology practice.1 There are cases described in the literature in which self-inflicted gunshot wounds have suggested a criminal offense or homicide.2,3 The circumstances preceding death, the deceased's medical history, scene findings, and features of the gunshot injury and associated findings at autopsy assist in differentiating self-inflicted gunshot wounds from those caused by other individuals.
Defensive wounds are often seen in the context of homicidal sharp-force wounds in which the deceased can have superficial wounds on the hands or forearms from attempts at blocking incoming attacks from a sharp object.4–6 Defensive entry wounds from gunshots are less common but have been reported to involve a hand of the victim who tries to block or move a gun fired by the perpetrator.4 If fired at close range, the entry wound on the hand can show soot deposition or stippling with or without soot deposition from the muzzle discharge.
We report a case with a unique hand injury associated with a self-inflicted gunshot wound.
The deceased was a 72-year-old man who had a recent diagnosis of metastatic lung cancer. He lived alone. His wife had died 8 years previously. A neighbor became concerned about his welfare and alerted the deceased's brother. He found him dead fully clothed in an empty bathtub (Fig. 1A). There was a bloody towel folded on his groin. The towel was not available for examination at the time of the autopsy. There were no photographs of the towel taken by the police when it was removed from the deceased's body. The police investigators did note that there was a circumscribed blood stain around a hole in the towel. It showed no soot deposition. When the outer fold of the towel was lifted, the deceased's left hand was seen on the rest of the towel, which was on his left thigh. His right hand was between his thighs near a .38 special revolver, which was on the floor of the tub (Fig. 1B).
The revolver was loaded with 6 cartridges. A single fired cartridge was aligned with the barrel. A bullet was found beside the tub (Fig. 1A, arrow). There was an indentation in the upper wall near a mirror opposite the bathtub (Fig. 1C, arrow). There was a note found on the kitchen table stating that he was ending his life because he did not want people to see him suffer. The residence was observed by the police to be tidy.
The postmortem examination confirmed that the deceased died of a contact gunshot wound that entered the right temple (Fig. 2A). The entry was 8 cm from the top of the head, 7 cm from the midline, and 1.3 cm above the right ear. It was oval and 1.1 × 0.5 cm. There was an eccentric abrasion ring that was up to 0.7 cm on the inferior edge of the wound. Soot deposition was seen particularly at the 3 o'clock (anterior) and 6 o'clock (inferior) sides of the wound. The wound track passed through the right temporal bone and exited the left lateral parietal scalp. The exit was 4.5 cm from the top of the head and 7 cm from the midline. The wound was irregular, and its edges were not abraded to suggest shoring (Fig. 2B). The direction of the wound track, in relation to the deceased, was left, up and back.
The right (firing) hand did not show any blood spatter in the photograph taken of the body at the scene. Wounds were noted on the nonfiring hand. There was an irregular hole, 1.5 × 0.4 cm, on the left palm and a 3.5 × 1.0-cm hole on the dorsum of the hand (Fig. 2, C and D). Neither of these wounds showed soot deposition or stippling. Photographs of the left hand at the scene showed blood staining limited to the wound on the palm.
The deceased had metastatic adenocarcinoma originating in the right upper lobe of the lung (Figs. 1, 2).
To our knowledge, this is the first report of a perforating wound through a hand placed over the exit site in a case of a self-inflicted gunshot wound.
The deceased had terminal lung cancer. He left a note indicating his intent to kill himself. The entry wound was contact range and on the temple, a common site for self-infliction.5,6 The upward trajectory was consistent with the deceased seated in the bathtub. There were no other signs of trauma on the body.
There was no soot deposition or stippling on the hand wounds indicating that the deceased interposed his hand between the muzzle of the revolver and his temple. On occasion, the nonfiring hand will be inadvertently positioned over the muzzle and result in a perforating wound to the hand and re-entry into the head.5 In this case, the injuries on the left hand were caused by the deceased placing his palm over the left side of his scalp where he anticipated the bullet exiting. How the deceased positioned the towel at the time of shooting cannot be definitively determined because it was not available at the time of the postmortem examination; however, it was likely held by his left hand because it was seen inside the folded towel resting on his left thigh. After the bullet perforated the hand, it traveled up to hit the opposite wall from where it bounced to the floor landing beside the bathtub.
In conclusion, this case report describes a rare hand injury associated with a self-inflicted gunshot wound to the head. The perforating wounds through the nonfiring hand raised the possibility of a defensive type wound. The circumstances, scene, and autopsy findings are consistent with an injury pattern arising from the victim placing his nonfiring hand over the exit site on his head.
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