ORIGINAL ARTICLE
Forensic Issues in Suicidal Single Gunshot Injuries to the Chest
An Autopsy Study
Veljko Strajina, MD, Vladimir Zivkovi(, MD, PhD, and Slobodan Nikoli(, MD, PhD
Abstract: This study presents a case series of suicides carried out
by self-inflicted gunshot wounds to the chestVa relatively uncommon
means of suicide. The retrospective autopsy study performed included
all cases of single suicidal gunshot injuries to the chest during a 20-year
period and which were committed by the use of a handgun. The sample
included 67 deceased persons that were an average of 44.4 T 19.1 years
old (range, 12Y89 years; 58 men and 9 women). The most common region
of the entrance wound was the left side of the chest (54/67), followed by
the sternum (10/67), and the right side of the chest (3/67). For 9 subjects,
the range of fire could not be determined, as well as whether the shot
went through their clothing. In the remaining 58 subjects, only contact
or near-contact wounds were found. Of the 58, only 3 subjects had their
clothing removed between the chest wall and the muzzle. Three direc-
tions of the internal bullet paths were those most frequently found:
downward right-to-left (27/67), downward left-to-right (20/67), and
downward parallel (10/67) (W2 = 101.045, P = 0.000). Also, most bullet
paths were directed downward (57/67, W2 = 32.970, P = 0.000). The most
frequently injured organ was the heart (47/67), and the immediate causes
of death were exsanguination (49/67), heart disruption (14/67), and
tamponade (4/67).
Key Words: forensic pathology, suicide, gunshot wounds, firearms,
penetrating thoracic trauma
(Am J Forensic Med Pathol 2012;33: 373Y376)
S uicide by means of firearms is the most common method of
suicide in the United States, whereas in Europe, it comprises
a much lower proportion of suicide.1 For such a type of sui-
cide, the most common site of the entrance wound is the head,
followed by the chest in a much lower proportion.2
A case series describing this relatively uncommon means
of suicide is presented here. Characteristics commonly reported
in autopsy series involving firearm suicides are addressed here
as well, but several additional findingsVwhich are otherwise
rarely includedVare also discussed. The aim of this study has
been to determine whether there is a pattern of gunshot wounds
to the chest typical of a suicide victim.
MATERIALS AND METHODS
The retrospective autopsy study was performed for a 20-year
period (from January 1990 to March 2011), and it included se-
Manuscript received April 25, 2011; accepted July 11, 2011.
From the Institute of Forensic Medicine, University of Belgrade Y School of
Medicine, Belgrade, Serbia.
This study was supported by the Ministry of Science of the Republic of
Serbia, Grant No. 45005.
The authors report no conflicts of interest.
Reprints: Slobodan Nikoli(, MD, PhD, Institute of Forensic Medicine,
University of Belgrade Y School of Medicine, 31a Deligradska str.,
11000 Belgrade, Serbia. E-mail: bobanvladislav@yahoo.com;
slobodan.nikolic@mfub.bg.ac.rs.
Copyright * 2012 by Lippincott Williams & Wilkins
ISSN: 0195-7910/12/3304Y0373
DOI: 10.1097/PAF.0b013e31824a4797
Am J Forensic Med Pathol & Volume 33, Number 4, December 2012
Copyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
lected cases of single suicidal gunshot injuries to the chest, in-
flicted by the use of handguns.
Cases were determined to be suicides through police in-
vestigations, specific circumstances of death, suicide notes, pre-
vious suicide attempts, heteroanamnestic or medical data about
the presence of mental disorders, and other various medical con-
ditions as a motivation to commit suicide. There was no question
of foul play in any case used in the study.
The starting assumption was that certain anatomical sites
of a gunshot entrance wound to the chest and the directions
of the bullet path may be significantly more common and may
typically occur in subjects who commit suicide by a single gun-
shot injury to the chest. Also, internal organ injury and the im-
mediate cause of death were registered. The common assumption
that those victims who commit suicide by a gunshot wound to
the chest frequently remove clothing between their chest wall
and the muzzle was also explored.
Three regions of the chest, as sites of a gunshot entrance
wound, were established in this study: the right and left sides of
the chest, whereas wounds involving the sternum were classified
in a separate group.
The exact locations of the entry and exit gunshot wound in
the observed anatomical sites were determined by measuring the
distance of the wounds in relation to at least two fixed ana-
tomical lines in two planes: the distance of the wounds were
measured from the anterior middle sagittal line (the distance on
the right or left side from this line) and the distance from the
footplate. This is part of the standard autopsy technique for
cases of gunshot injuries to the chest in the institution where
the autopsies were performed. In this manner, an internal 3-
dimensional direction of the bullet path could be established
precisely in relation to three planes: horizontal (upward, paral-
lel, and downward) and sagittal (right-to-left, parallel, and left-
to-right). Because all of the entrance wounds were at the front
of the body, the direction in the frontal plane was constant (front-
to-back). In cases where there was no exit wound, a precise
direction of the bullet path was established according to mac-
roscopically detectable primary tissue damage to soft tissues,
organs, or bone established through an autopsy. All cases where
the direction of the wound track was not clearly documented in
the autopsy record have been excluded from this study.
Owing to any possible misinterpretation of the gunshot
entrance or exit wounds by medical personnel, or its alteration
during a patients hospitalization (surgical debridement of the
wounds, the removal of bone fragments, infection or healing,
etc), all cases where the site of the gunshot entrance and/or exit
wound was not certain to have been according to the autopsys
finding have been excluded from the study. Thus, all cases where
patients survived for more than 72 hours have also been excluded.
Multiple entrance wounds were found in 12 subjects who
have also been excluded from further analysisV10 of them with
an additional wound to the head, as well as 2 subjects with a
wound to the head and neck.
Handguns were the most commonly used weapon, per-
taining to 67 cases, and a shotgun or a rifle were used in 12 cases
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Strajina et al Am J Forensic Med Pathol & Volume 33, Number 4, December 2012

(6 for each). These latter cases have been excluded owing to their
small number, which would prevent any meaningful statisti- TABLE 1. Frequencies of Internal Organ Involvement With
cal comparison from taking place. Different Bullet Path Directions
The data obtained were analyzed using Pearson W2 test and Heart Lungs Liver Spleen Aorta
t test for estimating differences. P G 0.05 was considered sig-
nificant, and P G 0.01 was considered highly significant. Direction PP 1 0 0 0 0
UP 0 1 0 0 1
UR 0 1 0 0 0
RESULTS PR 1 0 0 0 0
A sample including 67 deceased subjects who fulfilled the DR 14 17 2 3 1
criteria had a mean age of 44.4 T 19.1 years (range, 12Y89 years);
DP 6 5 1 0 2
the sample consisted of 58 men (46.1 T 16.4 years) and 9 women
(33.0 T 11.9 years). In this sample, the male-to-female ratio was DL 21 16 2 3 8
6.4:1 (W2 = 35.836, P = 0.000). Women were statistically PL 3 2 0 0 2
younger than men at a significant rate (t = 2.309, P = 0.024). UL 1 3 0 0 1
The most common region of the entrance wound was the Total 47 45 5 6 15
left side of the chest (54 subjects), followed by entrance wounds DL indicates downward, right-to-left; DP, downward, parallel; DR,
involving the sternum in 10 subjects, and the right side of the downward, left-to-right; PL, parallel, right-to-left; PP indicates parallel,
chest in 3 subjects. parallel; PR, parallel, left-to-right; UL, upward, right-to-left; UP, up-
For 9 subjects who survived the initial injury and were ward, parallel; UR, upward, left-to-right.
treated, but died within the next 72 hours, their clothes had been
removed and their wound area was frequently altered in some
way. For this reason, a range of fire could not be reliably de- P = 0.000). Also, most bullet paths were directed downward
termined for them. In the remaining 58 subjects, only contact or (57/67, W2 = 32.970, P = 0.000). The frequencies of internal
near-contact wounds were found. Also, among these 58 subjects, organ involvement with different bullet path directions are
any removal of clothing between the chest wall and the muzzle shown in Table 1.
was only found in 3 subjects, whereas others had shot through The most common immediate cause of death was exsan-
their clothing. guination (49 subjects), followed by heart disruption (14 sub-
All the entry wounds were located on the front of the jects), and tamponade (4 subjects).
chest, and therefore, all bullet paths were directed backward. Data about the handedness of each of the deceased were
The frequencies of the different internal directions of the bullet derived from heteroanamnestic data but were not found in 25 of
path are shown in Figure 1. Three pathways were most 67 subjects. Among the remaining subjects, only 2 were left-
frequently found: downward right-to-left, downward left-to- handed, which prevented any statistical analysis of the bullet
right, and downward parallel, in this respective order. The path direction about this factor from occurring.
difference in frequencies is statistically significant (W2 = 101.045, Exit wounds were present in 55 subjects, whereas bullets
were found embedded in the tissue in the remaining 12 subjects.
Ethanol was detected in femoral blood in 13 of 67 sam-
ples taken (range, 0.23Y3.7 g/L; mean, 1.51 g/L).

FIGURE 1. The frequencies of specific internal bullet path
directions: DL indicates downward, right-to-left; DP, downward,
parallel; DR, downward, left-to-right; PL, parallel, right-to-left;
PP indicates parallel, parallel; PR, parallel, left-to-right; UL, upward,
right-to-left; UP, upward, parallel; UR, upward, left-to-right.
One wound with a path direction parallel to both planes was
found but not demonstrated in this graph.
DISCUSSION
The previously raised question on gunshot wound char-
acteristics about determining suicide as a manner of death is
further explored in this study. Many of these variables, which
are not in themselves specific only to homicide or suicide, could
be combined into a model that would be able to discriminate be-
tween homicidal and suicidal deaths.3 Thus, if an additional vari-
able were taken into consideration, it could potentially enhance
predictions regarding the manner of death that was carried out.
Characteristics commonly reported in autopsy series in-
volving firearm suicides include the age and sex of the deceased,
the type of weapon used, the number of entry wounds, the entry
wound location, and the range of fire. These are addressed in
this study, but several additional findings that are rarely included
are also discussed: canal direction, internal organ involvement,
the immediate cause of death, and the removal of clothing.
The subjects in this sample were younger than those in
other studies, which could be attributed to the socioeconomic
circumstances in our country.
A significantly lower proportion of women (female-to-male
ratio, 1:6.4) observed in this study corresponds to the findings of
Karger et al1 who have recapitulated the results of other authors
and quoted that females constitute only from 1Y3% to 5Y7% of
all firearm suicides in European studies and approximately
20% to 30% in American studies. In our country, firearms are
relatively easily accessible to both males and females, and the

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Am J Forensic Med Pathol & Volume 33, Number 4, December 2012
finding that women still use them significantly less frequently
could be due to a number of causes: complex cultural issues,
knowledge that a firearm injury is potentially disfiguring, or that
men are by far more familiar with firearms than are women in
our country.
Concerning differences between the sexes, it has also been
reported that a smaller percentage of women shoot themselves
in the head than men do.4
Handguns are the most commonly used type of weapon
across different continents and cultures, as is demonstrated by
this study and has been demonstrated by other studies from
Finland, Italy, Turkey, and the United States.4Y7 Most likely,
availability is the primary factor for this. Some authors have
found a correlation between the type of weapon and the site of
the entrance wound, whereas when a shotgun is used, entrance
wounds are found in the chest, abdomen, and head, often in the
mouth.5 The results presented here are not able to support this
finding.
Although the location of a self-inflicted wound varies
depending on the type of weapon used and the sex of the victim,
when handguns are used, the most common site of the entrance
wound is the head, followed by the chest in a significantly lower
proportion.2 In comparison, another study carried out during a
10-year period identified 479 subjects who had committed sui-
cide by gunshot to the head.8
It is somewhat surprising that such a small number of vic-
tims choose a less disfiguring area so infrequently. The possible
explanations of this are numerous, and some shall be elaborated
on here. The lethality of self-inflicted gunshot injuries in those
who survive the initial injury is reported to be significantly lower
for chest entrance wounds than for entrance wounds located in
the head (the overall mortality of self-inflicted gunshot wounds
was 66.7%, whereas in those patients with a gunshot wounds to
the head, mortality was measured at up to 80.0%).9 It is probably
safe to presume that suicide victims are not aware of a series like
the one carried out here in this study but are well aware of both
the lethality of a direct injury to the heart and the rough pro-
jection of the heart in the chest wall. It might be speculated that
some could have even used the apical impulse to locate the heart.
One possible explanation is that, when individuals shoot
themselves in the chest, they probably are not capable of hold-
ing the weapon in the same manner as they would if they were
firing the weapon at a target. Most probably, they will hold a
handgun with their fingers wrapped around the back of the butt,
using the thumb to depress the trigger, firing the weapon. Some
individuals will even steady a gun against the body by grasping
the barrel with the nonfiring hand.7 This might explain whyV
when handguns are concernedVthe most common site of the
entrance wound is the head because the weapon is able to be held
in the same way when it would be firing at a target, whereupon a
steadier firing position could be achieved with the head as the
target. When the chest is chosen, however, a steady firing po-
sition could be achieved in a limited number of positions, which
may be able to explain why some directions are more frequent
than others are.
Another aspect in which this studys results deviate from
most other studies is that a small proportion of entrance wounds
involving the sternum or the right part of the thoracic wall have
been identified. It seems that the left side of the chest is uni-
versally quoted as an exclusive site of suicidal gunshot wounds
to the chest. However, the study presented here questions this
finding.
Additional information that certainly could be of value is
if there are internal bullet path directions that typically occur
in suicides. Surprisingly, although many authors did state that
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Suicidal Single Gunshot Injuries to the Chest
this is a potentially fruitful idea, it has been studied in just a
small number of articles.1
The rationale for the assumption that a particular pattern
of suicidal gunshot wounds to the chest exists is based on the
presumed intention to shoot at the heart and the limitations on
the part of both human anatomy and weapon construction that
limit the number of positions in which this can be performed,
as has already been explained.
The three most common directions in the series were
downward to the left, downward to the right, and downward
parallel to the sagittal plane. This corresponds to the findings of
Druid,10 although he had a smaller, less homogenous series and
did not perform a statistical analysis. Of special note is that the
most commonly used weapon for both chest and all other
locations in his series was the shotgun, therefore these data
should be compared cautiously.
Another study analyzing the direction of internal bullet
paths found that suicides commonly fire from right-to-left or
parallel, whereas homicidal bullet paths frequently run from left-
to-right. Although more pathways were directed leftward, the
direction reported by that study to be indicative of homicide was
found in a fairly large proportion of suicides in the study pre-
sented here. Handguns were the most commonly used suicide
weapon in that study, yet it is not reported as to whether this was
the case for chest wounds specifically.1 Although the right-to-
left direction was the most common in the present study (27/67),
in a significant number of subjects (20/67), a left-to-right di-
rection was found as well. Also, most of the paths were directed
downward.
Although certain directions are significantly more com-
mon, Figure 1 illustrates that any direction is possible.
Descriptions of injuries to internal organs and immediate
causes of death are scarce for this kind of autopsy series. In this
study, the most frequently injured organ was the heart, followed
by the lungs, the aorta, the spleen, and the liver. Exsanguination
by far exceeded all other causes of death. Direct injury to the
heart was common, and the wound was more frequently a source
of bleeding, suggesting that the heart continued to effectively
pump blood. Although this might seem unusual considering the
direct hit to the heart and close range of fire, it could be attri-
buted to the fact that the weapon used is a low-velocity hand-
gun, thus making the heart only leaky, while not transferring
enough energy to cause disruption, which would severely com-
promise its pumping function or even its rhythm.
This may be important in the light of a recently published
series of severe chest gunshot wound treatments and subsequent
survival. Although heart disruption cannot be effectively treated,
bleeding, tamponade, and rhythm disturbances are potentially
treatable under certain circumstances, as long as appropriately
organized by a medical team. In any case, the lethality of chest
wounds reported in these series still remains high but much
lower than in those wounds inflicted to the head.8,11
Another issue addressed recently by Hejna and Safr12 is the
long-standing empirical rule stating that suicide victims remove
their clothing and shoot directly into their exposed skin. The
study has found that the tendency of suicide victims to expose
the site of the future bullet entry is small and that shooting
through garments in no way precludes suicide. The findings in
the series of the study presented here have been very similar,
with clothes being removed in only 3 subjects, although this was
not determined for 9 subjects.
Gunshot wounds to the chest are less common means of
committing suicide; but, when in question, handguns are the
most commonly used type of weapon, and females constitute
a significantly lower proportion among the victims of suicide
www.amjforensicmedicine.com 375
Strajina et al
committed in this manner. The range of handgun fire was either
contact or near contact. Certain internal bullet path directions are
more common in suicidal gunshot wounds to the chest. Most
paths were directed downward. The most frequently injured organ
was the heart, with exsanguination being the most frequent cause
of death. Only a marginal number of the deceased had removed
their clothing and shot directly into their exposed skin.
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