Where’s the Bullet?
1967, Parkland Hospital, Dallas
One of the most important things a pathologist does in the autopsy of a gunshot victim is to map the course of the bullet from entry wound to exit and, if the bullet is still in the body, to recover it.
Forensic pathologists perform these autopsies in the course of their duty as official medical examiners. But it was far different in the 1960s when I was a pathology resident at Dallas’ Parkland Hospital. Back then Dallas had but a single forensic pathologist, Earl Rose, MD, JD, who was greatly over-worked and underpaid. The “Saturday night knife and gun club,” as we called it, provided a steady stream of corpses, sometimes a three or four per day. Most had to be autopsied, wounds described, entrance and exit points mapped precisely, bullets retrieved, and so on. If Earl wasn’t around, residents (me, doctors in training after getting their MD) were eager to do them for the $35 fee, which covered the autopsy and one court appearance, if necessary. And we were especially eager for gunshot victims because the task was straightforward. But if a “floater” came along—a decomposing body fetched from the Trinity River, for example—and it was your turn, you were stuck.
One of the first tricks I learned about gunshots with no exit wound was to feel for the bullet beneath the skin at a point directly opposite the entry wound. This owes to the fact that skin is the toughest thing a bullet has to penetrate. Think about it. Skin is, literally, tough as leather; bullets do not have a sharp tip; and they are generally made of lead and brass, relatively soft metals. Knuckling through skin sucks a lot of energy out of a bullet, which spends further energy barging through internal organs or bone before fisting its way through skin on the other side. Sometimes it runs out of gas trying to penetrate the second layer of skin, which catches the bullet like a ball in a net. In those cases all the pathologist has to do isfeel for and find the bullet, nick the skin and squeeze it out. Easy pickings—thirty-five bucks.
But sometimes bullets are hard to find. They hide in muscle, bone and other tissues, and finding them is confounded by gouts of clotted blood. On one occasion I scooped out a big clot, plopped it into the sink, and heard the clink of metal. It was a close call.
Bullets can do strange things. My first such experience came in the case of a man shot multiple times with a small caliber (.22) pistol. There were clear and matching entry and exit wounds, and I easily found all of the bullets but one, which seemed to have disappeared after passing through the front of his chest wall and aorta. Massive hemorrhage was present throughout the chest; the heart and big blood vessels was a mass of mangled tissue and gouts of blood. There was no exit wound on the back. The bullet had to be in there somewhere.
It was frustrating—clotted blood obscured and distorted the anatomy. I poked here and cut there, but try as I might, I could not find the bullet and concluded it must have come to rest in the bone and muscle of the spine. Following standard practice for these mysteries, I called radiology and asked for a tech and portable x-ray machine to take some chest x-rays. They did. The tech shot a chest image and went back to radiology to process the film. I got out of my gown and gloves and went to radiology to have a look. Bullets are very easy to see on x-rays; a child could do it. No bullet was visible. I asked the tech to come back to the morgue with me to take two more shots, one of the upper chest and neck, and another of the pelvis. Bullets can do crazy things.
This did not sit well with the tech, who didn’t want to be in the morgue in the first place. Few but pathologists feel at home in a morgue. The sights and smells are disquieting to most—stay a while and the odor gets in your shoes and clothes—people want to get out as quickly as they can. What’s more, taking an x-ray involves maneuvering the corpse to insert a film cassette beneath—a cumbersome, messy task that requires a lot of effort. Now I was asking the tech for a more exposures. It was clear he thought I needed his help to make up for my lack of skill, a conclusion surely reinforced when no bullet was present in either of the two additional shots.
Confidence, usually one of my long suits, was failing. What could have happened! Had I mismatched some of the entry and exit wounds and I was searching for a bullet that was not present? Then it dawned on me: maybe the bullet entered the aorta—a big, heavy-duty, rubbery blood vessel—but didn’t have enough residual energy to exit. Maybe it got trapped in the flood of blood from the still-beating heart and got washed downward with the flow. I made the mistake of explaining this rationale to the X-ray tech. He brusquely pointed out that the body had so many bullet holes that maybe I had mixed up entrance and exit wounds and there was no bullet to be found. But to his credit he agreed to another picture.
I asked him for one more of the thighs and knees. And with that we found it. There it was, in the hollow of the left knee. It had been swept downstream and stopped when it got to a tributary too small for it to travel further.
Improbable as the behavior of that bullet was, it was not the oddest. I had two other unusual gunshot cases.
In each instance the patient was dead on arrival in the emergency room and the corpse was rolled into the morgue in street clothes. Morgue attendants (dieners, from German for waiter) were trained to inventory personal items such as rings and watches, clothing, and so on. In each of these cases the diener found a bullet loose in the clothing. In one case it was loose beneath a thin cotton T-shirt. The bullet had passed through the skin of the back, tore through heart and lungs with fatal effect, and forced its way through the skin of the front of the chest—but did not have enough residual energy to tear through the flimsy material of a T-shirt. The evidence was plain: a bullet hole in the back of the T-shirt, the skin of the back and the skin of the front, but no exit hole in the front of the t-shirt.