T H E AMERICAN JOURNAL OF CLINICAL PATHOLOGY

Vol. 35, No. 5, pp. 393-402 May, 1961

Copyright © 1961 by The Williams & Wilkins Co.
Printed in U.S.A.

A MICROSCOPIC STUDY OF DERMAL GUNSHOT WOUNDS

LESTER ADELSON, M.D.
Laboratory, Cuyahoga County Coroner's Office, and the Institute of Pathology, Western Reserve University
School of Medicine, Cleveland, Ohio

The medicolegal importance of evidence fatal episode and discloses the finer details
that may be obtained by careful examination of this unique variety of injury.
of wounds produced by bullets has long Rationale of the study. The firing of a
been recognized. In view of this, it is sur- bullet involves a chain of explosive chemical
prising that virtually nothing with regard reactions. Flame, hot gases, fragments of
to the microscopic characteristics of bullet burned, burning, and unburned powder,
wounds is to be observed in the English or and perhaps small particles of metal shaved
American literature. This paper deals with off of the bullet, precede and follow the
descriptions of the histologic features of rapidly moving pellet (ball, missile) from
entrance and exit wounds produced by a the muzzle. Any or all of these substances
variety of weapons at different ranges of may be present in or on the target, human
fire. or otherwise, depending on the distance
An autopsy is the most reliable key to the between target and muzzle, type of am-
correct solution in fatal gunshot incidents munition, variety of weapon, and so on.
in which the sole witnesses were the assailant It may be accepted as a truism that all
and the (dead) victim, or where several cartridges of modern firearms are loaded
witnesses offer conflicting and contra- with some type of smokeless powder.
dictory information. The classic anatomic The products of the muzzle blast are
approach to the gunshot fatality involves responsible for the zone of charring and the
meticulous description and accurate localiza- fouling and stippling ("soiling"), popularly
tion of the external wound or wounds, miscalled "powder burns," which are
followed by complete autopsy with explora- invariably present on the skin, or clothing,
tion of the entire bullet tract, visualization or both, of the victim with contact or near
of all injuries, and recovery of all bullets wounds. The flame of the muzzle blast
and bullet fragments in the body. Pains- produces surface burns if the skin is within
taking study of the victim's clothing, range. The bullet, heated by the friction
together with such ancillary technics as resulting from its passage through a tightly
photography, x-ray, and chemical studies fitting barrel and the explosion within the
(Walker test), is an essential corollary of the chamber, creates thermal injury in the
anatomic examination. deeper areas, as well. The blast may become
Bullet injuries are among the most a factor in the production of skin damage
complex lesions encountered in forensic with contact and close wounds.
pathologic practice. Careful scrutiny of the
wounds is essential for correct reconstruction METHOD
of the shooting incident. Microscopic
study of surface and deeper gunshot wounds Microscopic sections stained with hema-
provides yet an additional avenue for toxylin and eosin were made from entrance
exploration to aid in the recreation of the and exit gunshot wounds excised from
victims of fatal shootings as part of routine
anatomic examination. Police reports were
Received, July 22, 1960; revision received, Aug- consulted for the circumstances surrounding
ust 12; accepted for publication January 13, 1961.
the fatal episode, including facts revealed
Dr. Adelson is Pathologist and Chief Deputy
Coroner, Cuyahoga County Coroner's Office, and by investigation of the scene, interrogation
Assistant Professor of Forensic Pathology, De- of witnesses and suspects (when available),
partment of Pathology, Western Reserve Uni- type of weapon, and other pertinent data.
versity School of Medicine, Cleveland, Ohio. Inasmuch as the presence of clothing (light
393

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 394
or heavy, single or multiple layers, type of
fabric) at the site of bullet entry may
significantly alter the dermal characteristics
of an entrance gunshot wound, special
attention was directed to the effects pro-
duced by the victim's garments.
W O U N D S OF ENTRANCE
Entrance gunshot wounds are usually
round or elliptical perforations with an
areola of abrasion where the pellet has
rubbed off the epithelium. When the pellet
strikes the skin, it first indents and then
stretches the surface so that perforation
occurs through a taut area. After the pellet
has completed its passage through the skin,
the resiliency of the tissues restores the
previous state of turgor, and the defect
contracts. As the skin is being stretched
over the nose of the missile, it is burned,
abraded, and soiled over an area larger
than the opening itself. Marginal abrasion
and soiling are the hallmarks of entrance
of gunshot wounds and are observed at all
ranges.1-3
Thus, an entrance wound is usually
smaller in diameter than the bullet which
made it, and one can not establish with any
degree of accuracy the caliber (diameter)
of the bullet from the dimensions of the
skin perforation. Moreover, the missile may
"tumble" and strike the target in profile
or at some irregular angle ("key hole").
This is likely to happen if the victim is
struck by a ricochet. In such instances the
skin perforation may be greater than the
diameter of the bullet.
A halo of oil or grease is occasionally
present at the edges of the perforation,
representing material wiped from the
bullet during its passage through the skin.
The amount of this type of marginal soiling
varies with the nature of the projectile.
Lubricated lead bullets cause more soiling
than nonlubricated jacketed missiles.
For purposes of the present discussion
and descriptions, entrance wounds were
classified on the basis of naked eye appear-
ances into the following 3 types:
1. Contact. The margins of the perforation
are charred with occasional fouling of the
abraded border, and there is no grossly
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ADELSON Vol. 35
visible soiling of the intact skin. Powder
residue is always present in the subcutaneous
and deeper areas.
2. Close or near. The skin adjacent to the
bullet perforation and its areola of abrasion
is fouled and sometimes stippled ("soiled").
Powder residue is almost always present on
the surface and within the defect, in the
subdermal areas, and occasionally in the
more deeply situated regions.
3. Distant. All tissue damage results
solely from the missile.
Observations
The histologic findings will be grouped
according to the type of wound, i.e., contact,
near or close, and distant, and the changes
classified as epithelial, collagenous, and
powder residue.
Contact Type
1. Epithelial changes. Epithelial damage
in tight contact and loose contact wounds
results from a combination of mechanical
and thermal trauma, the former produced
by the impact of the rapidly moving pellet,
and the latter from a combination of muzzle
flame and hot missile. A distinctive feature
of all entrance wounds, regardless of the
range of fire, is a more or less orderly series
of changes in the epidermis, ranging from
little or no alteration at the periphery,
through varying degrees of cellular dis-
tortion and disruption, to total epithelial
destruction and absence at the center
(Fig. 1). As the perforation is approached,
the first significant cytologic evidence of
injury is provided by a region of compressed
and distorted epithelial cells, many revealing
"streaming" of the nuclei (Fig. 2). This
area is succeeded by a region in which the
more superficial epithelial layers are absent.
Only the deeper extensions of the rete pegs
remain in situ at the edge of the perforation
(Fig. 3). In the defect, all epithelial elements
are absent. If contact between muzzle and
skin was not tight (especially when one or
more layers of clothing are interposed),
there may be scattered foci of epithelial
damage surrounded by essentially normal
tissue. This pattern probably results from
 May 1961 GUNSHOT WOUNDS 395

PIG. 1 (upper). Entrance wound at contact range. Intact skin at left (periphery)
with compression, distortion, and loss of epithelium at right (perforation). Promi-
nent collagenous changes in dermis. Minimal powder residue (PR). Weapon was a
23-20 Marlin rifle. Hematoxylin and eosin. X 35.
FIG. 2 (lower). Elongation and "streaming" of epithelial nuclei on surface of
entrance wound. Prominent perinuclear halos. Focus of PR on surface. Weapon was
a P 38 automatic. Hematoxylin and eosin. X 440.

deflection and spread of the muzzle blast
by the clothing (Fig. 4).
A distinction should be made between 2
varieties of heat injury which may be
present in the epithelium. One is produced
by the hot missile, and the other results
from the burning gases expelled from the
muzzle. The latter may be sufficiently hot
to carbonize the epidermis. This is partic-
ularly true in the case of muzzle blast from
shotguns and large-caliber or high-velocity
sporting rifles with their relatively massive
heat production. The hot bullet is more
likely to produce a coagulative type of

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 396
necrosis rather than carbonization.4 The
basal epithelial cells frequently manifest
nuclear swelling and vacuolization, indicat-
ing this latter type of thermal injury (Fig.
2). Blast may partially separate the entire
thickness of the epithelium from the corium.
2. Collagenous changes. Thermally induced
changes in the dermal collagen are observed
in all entrance wounds. In sections stained
with hematoxylin and eosin 2 striking
collagenous characteristics are present. The
first one involves the tinctorial properties
and is manifested by amphophilia, basophilia,
or chromophobia. With the first 2 types of
changes, the affected fibers stain variously
from a deep blue-red through a variety of
colors to a mottled gray-blue. These changes
result from heat coagulation. If the temper-
ature has been sufficiently high to car-
bonize the tissue, chromophobia ensues.
The spectrum of staining of the altered
collagen stands in sharp contrast to the
usual uniform, rather soft pastel, orchid-
pink fibers seen in undamaged skin. Con-
comitant with the color change is fusion and
homogenization (coagulation) of the collagen
fibers so that the damaged site may present
itself as an almost solid sheet of rather
hyaline material (Fig. 1). Occasionally the
collagen may swell to the extent that it
protrudes through the skin defect above the
level of the adjacent epithelium.
That the collagen changes are caused by
heat and not merely by perforation or
drying is established by the absence of these
findings in perforating injuries produced by
cold objects such as knives, ice picks, or
scissors. In this respect it is also significant
that such coagulative change is usually
much less pronounced at the site of exit
if the bullet tract is entirely through soft
tissue (see below).
Skin appendages and cellular elements in
the corium also reveal evidence of thermal
trauma as indicated by nuclear pyknosis
and vacuolization and cellular shrinkage.
The alterations in the epithelium and
dermal collagen brought about by the heat
which the products of discharge of firearms
and pellet have created are comparable to
those in other types of thermal injury.6
3. Powder residue. Powder residue (PR)
occurs as black amorphous clumps or as
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ADELSON Vol. 85
scattered collections of brown-yellow
needles. Abundant PR is usually seen on
the surface of the epithelial defect (Fig. 3)
and in the subcutaneous tissue of a contact
entrance wound. PR is frequently observed
grossly and microscopically in the deeper
areas (muscle and bone) and even in the
underlying viscera, having been carried to
these relatively remote sites through several
layers of soft and osseous tissues by a
combination of blast and bullet soiling. It is
not unusual to find PR in the brain beneath
contact or near wounds of the head or in
the thoracic organs with similar wounds of
the chest (Fig. 5).
Relatively little PR is observed on the
skin surface immediately adjacent to the
defect if contact was tight between muzzle
and skin. With loose contact there may be
moderate quantities on the abraded border
and even inside the epithelial cells as well
as scattered collections on the neighboring
undamaged skin (Fig. 6). This is particularly
true in shotgun wounds, especially if a
layer or two of clothing was present between
muzzle and skin.
Near Wounds
When the weapon is sufficiently close to
the human target to produce grossly visible
fouling and stippling, the microscopic
features are in some respects similar to
those previously noted, with the differences
being quantitative rather than qualitative.
The pattern of epithelial cellular damage
and alteration is essentially the same as
that observed in contact wounds, i.e.,
gradually increasing damage as one passes
from outer edge to center. However, there
is usually a heavy deposit of PR on the
intact skin surface, frequently mingled with
the overlying keratin. The deposit is spotty
rather than uniform with areas of relatively
heavy soiling alternating with zones of
comparatively sparse or no fouling. Intra-
epithelial PR is abundant. The amount of
foreign material on the epithelial defect and
in the subcutaneous tract varies but is
often abundant. It is noteworthy that PR
may be observed within viscera located at
considerable distances from near entrance
wounds, having been deposited in these
sites by a combination of blast and bullet
 May 1961 GUNSHOT WOUNDS 397

I"'M...'•$^upper). Close-up of edge of entrance wound. Progressively increasing

damage and distortion from periphery (left) to perforation (right). Rete pegs
preserved. Moderate quantity of PR present. Collagenous changes slight in this
area. Grossly skin perforation was surrounded by area of soiling 1}4 in. by % in.
Weapon was a .32 caliber revolver. Hematoxylin and eosin. X 120.
FIG. 4 (lower). Area adjacent to loose contact entrance wound. Solitary focus of
epithelial destruction with abundant intra-epithelial PR. Neighboring skin intact.
Edges of perforation were blackened and adjacent surface fouled. Victim was shot
through underwear which revealed perforation surrounded by zone of soiling and
burning. Weapon was a .22 caliber rifle. Hematoxylin and eosin. X 120.

soiling. Figure 7 reveals large quantities of Hair at the target site will be singed if
characteristic black material in the cere- it is within range of muzzle flame (Fig. 6).
bellum resulting from a near entrance wound Thermal collagenous injury is comparable to
on the side of the nose. that seen in contact wounds, indicating

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 398 ADELSON Vol. 35

rft£ t*

Jliti.«*P''.

F I G . 5 (upper). P R in myocardium. Deceased was wearing woolen sweater and

heavy winter underwear when shot a t contact range through precordium. Skin
perforation bordered by areola of black abrasion % t o Vg in. No gross fouling or
stippling of intact skin or clothing. Weapon was a .22 caliber Springfield rifle.
Hematoxylin and eosin. X 120.
F I G . 6 (lower). Contact wound with abundant P R on abraded epithelium, in
corium and extending laterally over undamaged skin. Grossly t h e skin perforation
was surrounded by a rim of charring measuring up to Ys in. without peripheral
soiling. Hair singed. Weapon was a .22 caliber target pistol. Hematoxylin and eosin.
X 35.

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 May 1961 GUNSHOT WOUNDS 399

FIG. 7 (upper). PR in right cerebellar hemisphere. Entrance wound on left side

of nose surrounded by area of soiling measuring up to % in. in diameter. Bullet
perforated nose, sphenoid sinus, dorsum sellae, pons, and cerebellum. Weapon was
a .32 caliber automatic. Hematoxylin and eosin. X 120.
FIG. 8 (lower). Exit wound with essentially intact epithelium extending to
margin of defect. Cellular distortion and compression absent. PR absent. Minimal
thermal collagenous changes. Bullet passed through trunk. Weapon was a .45 caliber
automatic. Hematoxylin and eosin. X 35.

that this portion of injury probably results
from heat imparted by the bullet as well as
from direct muzzle flame.
Distant Wounds
The pattern of epithelial damage and
defect in distant gunshot wounds is similar
to that noted in the contact and near
varieties. Dermal collagenous polychromato-
philia and fusion are consistently present,
comparable to that previously described.
T h e m a j o r di ff er ences between this group
of gunshot injuries and the other 2 reside
mainly in the quantity of and distribution

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 400
of the PR. The foreign material derived from
the muzzle blast is sparse or absent in
distant gunshot entry wounds. The only
exception is the shotgun injury in which
wads may constitute secondary missiles.
Inasmuch as a distant gunshot wound is
denned as one in which the target is beyond
the range of flash and smoke of the muzzle
blast, any PR on the surface or in the
tract of such an injury must originate from
surface debris on the missile. The small
quantities of residue wiped off of the pellet
as it penetrates the skin and subcutaneous
tissues are usually located in the epithelium
and superficial zone of the corium. PR is
rarely, if ever, observed in the viscera in
distant gunshot wounds.
The skin changes in re-entrance wounds
are similar to those of a distant wound,
regardless of the nature of the original
wound. Little or no PR is present, the
bullet having cleansed itself during its initial
passage through the body, and the muzzle
blast, if any, having been absorbed at the
primary site. The dermal collagen reveals
the tinctorial changes and fusion previously
described.
Effect of clothing on entrance wounds. The
patterns of epithelial damage and col-
lagenous amphophilia and fusion are not
significantly altered by the interposition of
one or several layers of cloth or fabric
between muzzle and skin; however, the
deposition and introduction of PR may be
seriously altered in such instances. The
extent of the alteration produced by the
clothing depends on the number of layers
of fabric, the type of fabric, and whether
it is tightly woven or loose-mesh. Frag-
ments of fabric may be seen occasionally
in the subcutaneous area, blown in by
muzzle blast, or carried in by the missile.
Contact or near gunshot wounds sus-
tained through loosely woven clothing, even
when several layers are present, can result
in the deposition of PR on and in the skin,
and in the deeper areas in quantities com-
parable to those seen with similar wounds
received in an unclothed area (Figs. 4 and
5). Distant gunshot wounds sustained
through clothed areas are essentially similar
to those in which no clothing is present at
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ADELSON Vol. 85
the site of entry. PR is either sparse or
absent.
The intervention of one or several thick-
nesses of clothing between muzzle and skin,
even when the muzzle is pressed firmly
against the outer fabric, converts the wound
from "contact" to "near," and tends to
impart the characteristics of the latter type
to the dermal injury.
W O U N D S OF E X I T
Exit wounds result from a stretching
force applied to the skin from its under-
surface with perforation as the limits of
skin elasticity are exceeded. They vary in
size, shape, and configuration and may be
stellate, cruciate, triangular, or crescentic.
They may even resemble stab wounds. The
skin edges are frequently everted, and the
characteristic collar of abrasion, fouling,
stippling, and burning is never seen.
Exit wounds are usually larger than the
corresponding entrance wound if the latter
has not been affected by expanding muzzle
blast, or if the missile did not strike the
skin in profile or at an angle.
Observations
The major difference between exit wound
and entrance wound is the nature of the
epithelial damage and defect. The epithelial
defect of an exit wound is almost always
sharply demarcated from the adjoining
surface covering with the latter demon-
strating relatively little or no evidence of
damage except immediately adjacent to
the edge of the perforation (Fig. 8). This
contrasts conspicuously with the transi-
tional changes and progressive increase in
damage observed as one approaches an
entrance defect. The epithelium may be
partially stripped from the underlying
tissue as seen in contact entrance wounds.
The marginal zone of epithelial abrasion, so
characteristic of entrance wounds, is con-
stantly absent (Fig. 9).
Powder residue in exit wounds is usually
sparse or absent. PR may be abundant in
an exit wound only when entrance and exit
are quite close to each other, and when the
entrance wound is of such nature as to
result in the abundant deposition of PR
 May 1961 GUNSHOT WOUNDS 401

FIG. 9 (upper). Edge of exit wound. Epithelium essentially undamaged except

immediately adjacent to defect. The keratin has been elevated by the departing
bullet. Weapon was a .25 caliber Colt automatic. Hematoxylin and eosin. X 120.
FIG. 10 (lower). Overall appearance of exit wound. Skin edges sharply margi-
nated. Adjacent epithelium reveals no distortion. PR absent. Conspicuous
collagenous heat changes. Bullet entered posterior wall of thorax, traversed thorax,
and perforated sternum. Exit wound in presternal area. Weapon was a P 38 auto-
matic. Hematoxylin and eosin. X 25.

in the skin and subcutaneous tissues. When
PR is present, it tends to localize in the
deeper regions, and is less conspicuous in
the more superficial areas, a distribution
opposite to that seen in entrance wounds.
The best explanation for the presence of
PR in the depths of an exit wound located
at a considerable distance from the cor-
responding entrance injury is the deposition
in this site of surface debris carried by the
pellet.
Dermal collagenous changes are frequent
in exit wounds, indicating the presence of
residual heat in the missile to which heat
created by friction may have been added
as the missile passed through the tissues.

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 402
This is likely to be prominent if it has
passed through bone (Fig. 10). Occasionally
the dermis of the exit wound may reveal
little or no evidence of thermal injury.
Histologic evidence of hemorrhage and
acute inflammatory response are observed
both in entrance and exit wounds and serve
no useful purpose in distinguishing between
the two. Granulocytic infiltration and
fibroblastic proliferation are indications of
vital response to trauma and furnish valu-
able concrete evidence of survival for shorter
or longer intervals after injury.
SUMMARY
Bullet wounds represent a unique combi-
nation of mechanical, thermal, and blast
injury.
Microscopic examination of entrance and
exit gunshot wounds disclosed several
histologic features (1) that clearly dis-
tinguish these 2 types of injury and (2)
that are often useful in establishing the
range of fire.
Bullets produce more or less specific
types of epithelial damage and derangement
at the sites of entry and exit.
The quantity and distribution of powder
residue on and in the epithelium and in the
deeper areas are important diagnostic
features.
Thermal changes in the dermal collagen
are present in all types of entrance wounds
and in some exit wounds. The degree of
change tends to be more conspicuous in
the entrance injury, but occasionally it may
be equally prominent in both sites.
All of the histologic changes should be
taken into consideration in the study of
the nature of the wound, and the micro-
scopic appearance should be correlated with
the gross character of the injury.
SUMMARIO I N I N T E R L I N G U A
Vulneres de balla representa un combina-
tion unic de injuria mechanic, thermic, e
explosive.
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ADELSON Vol. 36
Le examine histologic del vulneres de
entrata e de exito facite per ballas de fusil
revelava plure aspectos histologic le quales
(1) establi le nette differentiation inter iste
duo typos de injuria e (2) es frequentemente
de valor in determinar le distantia del foco.
Ballas produce plus o minus specific typos
de lesion epithelial e de disrangiamento al
sito de lor entrata e al sito de lor exito.
Le quantitate e le distribution del residuo
de pulvere super e in le epithelio e in le areas
plus profunde es importante aspectos diag-
nostic.
Alterationes thermic in le collageno dermal
es presente in omne typos de vulnere de
entrata e in certe vulneres de exito. Le grado
de alteration tende a esser plus conspicue in
le caso del vulnere de entrata, sed occasional-
mente illo es equalmente prominente in le un
e le altere sito.
Omne le alterationes histologic deberea
esser prendite in consideration in le studio del
natura de tal vulneres, e le apparentia micro-
scopic debe esser correlationate con le
character macroscopic del injuria.
Acknowledgments. T h e author acknowledges
with deep gratitude t h e valuable advice and sug-
gestions of D r . Alan R. Moritz, Director of the
I n s t i t u t e of Pathology, in t h e preparation of this
manuscript. The photomicrographs were made by
Mr. Sid Pancner, Chief Photographer of t h e
Cuyahoga County Coroner's Office.
REFERENCES
1. ADELSON, L.: Medical evidence in fatal gunshot
injuries. Am. J . Clin. P a t h . , 23: 758-767,
1953.
2. F I S H E R , R. S., AND F R E I M U T H , H . C : Gunshot
wounds. Postgrad. Med., 16: A 68-72,1954.
3. M O R I T Z , A. R., AND D U T R A , F . R . : Scientific
evidence in cases of injury b y gunfire. A.
M. A. Arch. P a t h . , 37: 340-349, 1944.
4. MORITZ, A. R.: Personal communication.
5. MORITZ, A. R . : Studies of thermal injury. I I I .
Pathology and pathogenesis of cutaneous
burns. An experimental study. Am. J .
P a t h . , 23: 915-941, 1947.