DLDrINSTITUTE REPORT NO. 239

WIAT' S MRONG W: TH THE WOUND BALL I ST I CS L I TERATURE,

AND VW.iY

DTICL0 ELECTE

N M.L. FACKLER, M.D. D

DIVISION OF MILITARY TRAUMA RESEARCH

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Dm-E-hU'ON ST.TiApproved, fom public reb-e4.- -.

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JULY 1981 "

LETTERMAN ARMY INSTITUTE OF RESEARCHPRESIDIO OF SAN FRANCISCO, CALIFORNIA 94129

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Division of Military Traumua Research, LAIRPresidio of San Francisco, CA 94129-6800 Fort Detrick, Frederick, MD 21701

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]a 2A84 AC 10911. TITLE (include Security CIassilcation)-Institute Report No. 239, What's Wrong with the Wound Ballistics Literature, and Why

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M.L. Fackler, M.D.13a. TYPE OF REPORT I3b. TIME COVERED 14. DA~TE OF REPORT (Year, Month, Day) 15S PAGE COUNT

Institute Report FROM I1R6TO ... R7L 1987 jl 3316. SUPPLEMENTARY NOTATION

17. COSATI CODES It.-SSUBJECT TERMS (Continue on reverse sf neceszary and identify by block number)

-- FELD GROUP SUB-GROU Wound Ballistics; Gunshot Wounds: High Velocity;

k -4 - I Kinetic Energy.ý-ý

19. A§`TRACT (Continue on reverse if necessary and identify by block number)"&Attempts to explain wound ballistics (the st..dy of effects on the body

produced by penetrating projectiles) have succeeded in mystifying it.Fallacious research by those with little grasp of the fundamentals has been rperpetuated by editors, reviewers, and other investigator-s with no bettergrasp of the subject. This report explains the projectile-tisst'einteraction and presents data showing the location' ý-f tissue disrupted byvarious projectiles. These tissve diaruption data are presented in theform of wound profiles. The major misconceptions perpetuated in the fieldare listed, analyzed, and their errors exposed using wound profiles andother known data. The more serious consequences of these rniscianceptions

are discussed. Failure in adhering to the basic precepts of scienit-kficmethod is the common denominator in all of the listed misconceptions..

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ABSTRACT

Attempts to explain wound ballistic3 (the study ofeffects on the body produced by penetrating projctiles)have succeeded in mystifying it. Fallacious recearch bythose with little grasp of the fundamentals has beenperpetuated by editors, reviewers, and other' investigatorswith no better grasp of the subject. This report explainsthe projectile-tissue interaction and presents datashowing the location of tissue disrupted by variousproj&ctiles. These tissue disruption data are prasentedin the form of wound profiles. The major misconceptionsperpetuated in the field are listed, analyzed, and theirerrors exposed using wound profiles and other known data.The more serious consequences of thesa misconceptions arediscussed. Vailure in adhering to the basic precepts ofscient'.fic method is the common denominator in all of the1 ieted misconcept ions

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Gunshot wounds are a fact of life in our society.The coammon assumption is that military conflicts, woundballistics research, and a steady stream of dailyexperience in our larger cities have provided theknowledge and skill to assure uniform excellence intreatment of these injuries. Sadly, this assumption iswrong.

Probably no scientific field contains moremisinfoi'mation than vound ballistics. In a 1980 JournalIof Trauma editorial entitled "The Idolatry of Velocity, orLies, Damn Lies, and Ba115.stics,w Lindsey identified manyof the misconceptions and half-truths distorting theliterature (1). Despite his cogent revelation3, the

errors he attempted to rectify are still being repeated inthe literature (2-7), often embellished with unprovenIassumption and uninformed speculation. The body ofliterature generated at the wound ballistics laboratory ofthe Letterman Army Institute of Research over the past sixyears (8-14) strongly supports the points made byProfessor Lindsey. The author of this paper has chosen tocorrect errors, as they appeared, with letters to journaleditors (15-22), a time-consuming endeavor of questionableIeffectiveness. This critical review calls attention tothe problem, corrects the most widespread and damagingmisinterpretations, and lays the groundwork for improvedresearch, understanding and clinical treatment.

Between 1875 and 1900, the study of gunshot effectshad reached a high level of sophistication, thanks mainlyI to Theodor Kocher, whose work was the epitome of soundscientific method (23-27). However, with the advent ofthe high-speed movie camera in the present century,emphasis in wound ballistics shifted from sound scientificmethod to spectacular cinematography--a triumph of highItechnology over common sense. Unfortunately, a sideshowmentality seized upon the technology of the twentiethcentury. Flamboyance attractod more attention than soundscience. Wound ballistics research was reduced to taking

movies of shots into everything imaginable, and the focusof understanding narrowed to exclude every variable exceptIprojectile velocity. The exaggeration inherent in thesemethods so distorted the concept of temporary cavitationthat, to some, it came to represent the entirety of theprojectile-tissue interaction (28, 29). Rarely does the

viewer find a measuring scale included in reproductions ofthese dramatic cinematographic frames (30). Undoubtedly,Imany readers have seen the Swedish film of an anesthetized

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pip being shot through the abdomen vlth an M-16 rifle that"made the rounds' about fifteen years ago. No scale orany other item was included to provide size orientation.How large was the pig? Most would assume the animal to bein the 100- to 150-kg range. It was actually a mini-pig,weighing about one tenth that much. The exaggeration ofeffects so introduced is obvious.

THE WOUND PROFILE - UNDERSTANDING THE PROJECTIILB-TISSUEINTERACTION

A projectile crushes the tissue it strikes duringpenetration, and it may impel the surrounding tissueoutward (centrifugally) away from the missile path.Tissue crush is responsible for what is commonly calledthe permanent cavity and tissue stretch is responsible forthe so-called temporary cavity. These are the solewounding mechanisms. In addition, a sonic pressure waveis 9ýnerated by projectiles traveling faster than thespeed of sound. In air this wave trails the projectilelike the wake of a ship. The sonic boom experienced afterpassage of a supersonic airplane is an example of a sonicpressure wave. This pressure wave travels at the speed ofsound in the mudium through which it passes, and soundtravels four times as fast through tissue as it doesthrough air. Thus the sonic wave pr.cedes the projectilein tissue. Contrary to popular opinion (3, 30), thiswave does not move or iniure tissue. Harvey's exhaustiveexperiments during WW I: showed clearly the benignity ofthe sonic pressure wave :31). The lithotripter, a recentinvention that uses this sonic pressure wave to break upkidney stones, generates a wave five times the amplitudeof the one from a penetrating small arms projectile. Upto 2,000 of these waves are used in a single treatmentsession, with no damage to soft tissue surrounding thestone (32,33). It would be difficult to imagine moreconvincing confirmation of Harvey's conclusions.

The wound produced by a particular penetratingprojectile is characterized by the amount and location oftissue crush and stretch. In our laboratory, we measurethe amount and location of crush (permanent cavity) andstretch (temporary cavity) on the basis of shots firedinto gelatin tissue simulant. Since we have calibratedthis simulant to reproduce the projectile characteristics(penetration depth, deformation, fragmentation, yaw)equivalent to those observed in living animal tissue,

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measurements from these shots can be used to predictapproximate animal tissue disruption (8-10). These dataare presented in the form of Wound Profiles (Fig 1-8),which illustrate the amount, type, and location of tissuedisruption, projectile mass, velocity, construction, andshape (before and after the shot), as veil as projectiledeformation and projectile fragmentation pattern whenapplicable. The scale on each profile permits quickdetermination of tissue disruption dimension at any pointalong the penetration path for comparison with otherprofiles, other experimental results, or with measurementsfrom actual wounds in a clinical settin g or at autopsy.Wound profile date will be used to rectify the fallacieslisted below.

MAJOR MISCONCEPTIONS

1. Idolatry of Velocity:

A widespread dogma claims that wounds caused by"high-v'locity" projectiles must be treated by extensiveexcision of tissue around the missile path (34-40),whereas those caused by 'low-velocity" missiles needlittle or no treatment (41, 42). Two half-truths nurturethis error. The first of these, *Cavitation is aLallistic phenomenon associated with very high velocityvissiles" (7), is easily disproved. The wound profile inFig 1 shows a very substantial temporary cavity producedby a "low-velocity" bullet. This bullet, fired from theVetterli rifle at 1357 ft/s (414 m/s), has ballisticcharacteristics typical of those used by military forcesin the latter half of the nineteenth century. It is thesame bullet used by Theodor Kocher for most of his woundballistics studies (23-27). It is obvious from this woundprofile that temporary cavitation is not, as popularlybelivved, a modern phenomenon associated exclusively withprojectiles of "high velocity.'

The adjunct half-truth, 'Cavitation requiresextensive debridement of tissues... (7), lacks validscientific support. Cavitation is nothing more than atransient displacement of tissue, a stretch, a localized"blunt trauma." It is not surprising that elastic tissuessuch as bowel wall, lung, and muscle are relativelyresistant to being damaged by this stretch, while solidorgans such as liver are not (9). Most of the musclesubjected to temporary cavity stretch survives; tissuesurvival has been verified in every case in which muscle

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was allowed to remain in situ and healing was followed tocompletion (43-48).

Misinterpretation of the mechanism by which the M-16rifle causes tissue disruption perpetuated the foregoingmisconceptions. The M-16 (Fig 2) van introduced inVietnam, and many compared the increased tissue disruptionit produced (12-14, 49, 50) with that caused by previousmilitary rifles. In the Vietnam era, the major roleplayed by bullet fragmentation in tissue disruption wasnot recognized (8). It is nov appreciated (12-14) anddocumented (Fig 3) that bullet fragmentation is thepredominant reason underlying the M-16's inc-reased tissue m

disruption. Despite this recent evidence, a generation ofsurgeons and weapon developers (28) has been confused andprejudiced by the assumption that "high velocity" andwtemporary cavitationw were the sole causes of tissuedisruption.

It is indeed surprising that only Lindsey questionedthe attribution of the marked increase in tissuedisruption to a rather modest 10% increase in velocity.Surely, someone should have noticed that the largestincrease of projectile velocity in the history of small-arms development (a 50% increase--made possible by theinvention of the copper-jacketed bullet near the end ofthe nineteenth century) was accompanied by a markeddereas in soft tissue disruption (51, 52). Thisdecrease was predicted by Kocher, whose work had taughthim the importance of projectile deformation (26, 27); newsmaller-caliber bullets did not deform upon strikingtissue as did previous large caliber soft lead bullets(Fig 1).

2. Exaggeration of Temporary Cavity Size, Pressure, andEffect,-

In 1971, Amato et al (53) wrote that the temporarycavity 'can approximate 30 times the size of the missileo"They showed the temporary cavity caused by a 0.25-in.(6.4-mm) steel sphere shot at 3,000 ft/s (914 m/s) throughthe hind leg of an anesthetized dog. Although no scalewas included on the high-speed roentgenograms, the readercan use dividers to determine the sphere diameter and willfind that the largest temporary cavity shown is 11 spherediameters--not 30 diameters. Wound profile data obtainedin our laboratory gave comparable results; a 6-mm steelsphere at slightly over 1000 m/s produced a maximum

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temporary cavity of only 12.5 sphere diameters (Fig 4)Other authors, citing no data, Jescribe the temporarycavity as 0...30 times the diameter of the projectile...(35), 0...30 times or more...0(54), and 30. to 40 times themissile diameter (36, 40)--all sizable exa•oeratlons.

To further confuse the issue, pressures of up to lu0atmospheres are incorrectly attributed to temporarycavitation by many authors (39, 40, 55-57). These authorsappear to have confused the sonic pressure wave with thepressure generated in tissues by temporary cavitation.Temporary cavity tissue displacement can cause pressures

of only about 4 atmospheres (31). A careful reading ofHarvey's paper (31) should correct this confusion.

Probably the most exaggerated account of temporarycavity effect in the literature appears in High locity I

.i.S Wo.nd&by Oven-Smith (36). His Fig 2.20 on page35 shows a lesion in a pig's colon caused by a 'standardbullet fired at 770 m/s (2500 ft/s)." Concerning thiswound, he states t there are microscopic changes of celldeath extending 20 cm from the edge of the hole in thecolon; this is why such an area must be resected if it hasbean damaged b a rifle bullet." Perusal of the sourcedocument of th picture (58), however, reveals that Adeforming soft-:oint hunting bullet was used for thisjhot. In describing the effect of this shot, the sourcedocument states, I...haemorrhage extended macroscopicailyto a dialter (my emphasis) of 20 cm.0 When the 8-cm holediameter is subtracted, a 6-cm distance (rather than the20 cm reported by Oven-Smith) from the edge of the hole oneach side adds up to the 9diameter of 20 cm" reported byScott in the source document. Furthermore, photographs ofbowel defects caused by bullets must be viewed withcaution. Folding back the bowel wall around the edges ofthe hole can make tissue defits appear larger. If colontissue at a distance of 20 cm from the bullet hole iskilled, as asserted by Owen-Smith, what happens to theloops of small bowel and other organs that are within 20cm of the bullet hole? Are they killed too? if so, thiswould equate to destruction of most of the abdominalcontents by every penetratin *high-velocity" bullet.Clearly, this conclusion is inconsistent with wellestablished available facts. A study done in ourlaboratory (9), for example, showed damage to a pig coloncaused by a nondeforming military bullet traveling at 911m/s (2989 ft/s) that was only slightly larger than thedimensions of the bullet that had caused it.

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It should be noted, however, that stretch fromtemporary cavity tissue displacement can disrupt bloodvessels or break bones et some distance from therojectile path (40), just as they can be disrupted bylunt trauma. We can produce this in the laboratory Dy

careful choice of projectile and projectile trajectory intissue (48), but in practice this happens only veryrarely. Date from the Vietnau conflict show thet thegreat majority of torso and *xtramity wounds wereattributable to the damage due to the permanent cavityalone (59).

3. Asaumption of Bullet Tumbling" in Flight:

The notion that a comaon cause of increased woundingis the bullet's striking at large yaw angles (anglebetween the bullet's long axis and line of flight), oreven sideways due to utumbling* in flight (37, 40), isclearly fallacious. Anyone who has ever shot a rifle andobserved the holes made by the bullet recognixes that theyare round, not oblong, as would be the case if they yawedor tumbled in flight. This misconception seemsattributable in large measure to misinterpretation of areport publiahed, in 1067, by Hopkinson and Marshall.These authors presented diagrams of the yaw angles andpatterns made by the bullet tip in flight (60). Theangles on cheir drawings were exaggerated for clarity,showing 25 to 30 degrees rather than the 1 to 3 degreasthat actually occur for properly designed bullets of smallarms (61). In 1972, Amato and Rich reproduced thesediagrams and added one for 'tumbling" T62). In 1975 thesediagrams reappeared in the N= Handbook-Emeraency War•Lu (40), where the text described them as resulting

from aerodynamic forces acting upon the spin-stabilizedbullet during flight. In 1980, Swan and Swan (37)reproduced these diagrams, but for the yawing bulletshowed he impossible situation of rotation around thebullet tip rather than its center of mass. They alsoadded a unique opinion (unsupported) that "yaw" and"tumble' are special ballistic properties associated withmissiles or "vmry high velocities (c [sic] 3000 ft/s).*

Data from ballistics studies (10, 13, 14) show quiteclearly that:

*Bullets fired from a properl; designed rifle yaw nomore than a few degrees in flight, regardless ofvelocity.

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ein the:r path through tissue, all nondeformingpointed bullets, and some round-nosed ones, yaw toISO degroes, ending their path traveling base forward(Pigs aend 5).

Thus bullet yaw in tissue, an importantconsideration, has been confused with bullet yaw inflight, which is, in moat cases, of negligibleconsequence,

4. Presumption of "Kinetic Energy Deposit" to Be aM4echaniam of Wounding:

Serious misunderstanding has been generated bylooking upon *kinetic energy transfer* from projectile totissue as a mechanism of injury. In spite of data to thecontrary (1, 63), many assume that the amount of "kinetic.energy deposit" in the body by a projectile is a measureof damage (2-5. 36, 37., 40). Such opinions ignore thedirect interaction of projectile and tissue that is thecrux of wound ballistics. Wounds that result in a givenamount of 'kinetic energy deposit* may differ widely. Thenondeforming rifle bullet of the AX-74 (Fig 6) causes alarge temporary cavity which can cause marked disruptionin some tissue (liver), but has far less effect in others(muscle, lung, bowel wall) (9). A similar temporarycavity such as that produced by the M-16 (Fig 2),stretching tissue that has been riddled by bulletfragments, causes a much larger permanent cavity bydetaching tissue segments between the fragment paths.Thus projectile fragmentation can turn the energy used intemporary cavitation into e truly destructive forcebecause it is focused on areas weakened by fragment pathsrather than being absorbed evenly by the tissue mtass. Thesynergy between projectile fragmentation and cavitationcan greatly increase the damage done by a given amount ofkinetic energy.

A large slow projectile (Fig 7) will crush (permanentcavity) a large amount of tissue, whereas a small fastmissile with the same kinetic energy (Fig 4) will stretchmore tissue (temporary cavity) but crush little. If thetissue crushed by a projectile includes the wall of theaorta, far more damaging consequences are likely to resultthan if thts same projectile "deposits" the same amount ofenergy beside this vessel.

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Many body tissues (muscle, skin, bowel wall, lung)

are soft and flexible--the physical characteristics of agood shock absorbtr. Drop a raw egg onto a cement floorram a height of 2 ma then drop a ruktber ball of the same

mas from the aam* height. The kinetic energy exchange inboth dropped objects was the same at the moment of impact.Compare the difference in effect; the egg breaks while theball rebounds undamaged. Most living n imal soft tissuehas a consistency much closer to that of the rubber ballthan to that of the brittle egg shell. This simpleexperiment demonstrates the fallacy in the commonassumption that all kinetic energy "deposited" in the bodydoes damage.

The assumption that "kinetic energy deposit" isdirectly proportional to damage done to tissues also failsto recognize the components of the projectile-tissuecollision that use energy but do not cause tissuedisruption. They are 1) sonic pressure wave, 2) heatingof the tissue, 3) heating of the projectile, 4)deformation of the projectile, and 5) motion imparted tothe tissue (gelatin block displacement for example).

The popular format for determination of "kineticenergy deposit' uses a chronograph to determine strikingvelocity and another to determine exit velocity. A 15-cm-thick block of tissue simulant (gelatin or soap) is thetarget most often used. This method has one big factor inits favor; it is simple and easy to do. As for itsvalidity, the interested reader is referred to woundprofiles shown in Figs 1-7. Comparing only the first 15cm of the missile path with the entire missile path asshown on the profiles shows the severe limitation of the15-cm block format. The assumption by weapons developersthat only the first 15 cm of the penetrating proj ectilet spath through tissue is of clinical significance (64) maysimplify their job, but fails to provide sufficientinformation for valid prediction of the projectile'swounding potential. The length of bullet trajectoriesthrough the human torso can be up to four times as long asthose in these small blocks. Even if this method werescientifically valid, its use has been further flawed bynearly all investigators who have included the M-16 riflebullet in those projectiles tested. This method assumesthat the projectile's mass remains constant through bothchronographs. The 4-16 routinely loses one third of itsmass in the form of fragments which may remain in thetarget (see Fig 2). The part of the bullet that passes

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through the second chronograph screens weighs only abouttwo-thirds as much as the intact bullet that passedthrough the first met of screens. No provision is madefor catching and weighing the projectile to correct forbullet fragmentation when it occurs. The failure tocorrect for loss of bullet mass can cause large errors in"energy deposit" data (8).

Surgeons sometimes excise tissue from experimentalmissile wounds that is, in their judgment, nonviable andcompare the weight of tissue excised with the "kineticenergy depositeA" (65). A surgeon's judgment and histechnique of tissue excision is very subjective, as shownby Berlin et al (66), who found in a comparison that "Onesurgeon excised less tissue at low energy transfers andrather more at high energy transfers than the othersurgeon, although both surgeons used the same criteriawhen judging the tissues." None of these experimentsincluded control animals to verify that tissue the surgeonhad declared "nonviable" actually became necrotic if leftin place. Interestingly, all studies in which animalswere kept alive for objective observations of woundhealing report less lastina tissue damaqe than estimatedfrom observation of the wound in the first few hours afterit was inflicted (43-47, 67, 68). In a study of over4,000 wounded in WW II it was remarked, "It is surprisingto see how much apparently nonvital tissue recovered"(69).

Anyone yet unconvinced of the fallacy in usingkinetic energy alone to measure wounding capacity mightwish to consider the example of a modern broadhead huntingarrow. It is used to kill all species of big game, yetits striking energy is only about 50 ft-lb (68 Joules)--less than that of the .22 Short bullet. Energy is usedefficiently by the sharp blade of the broadhead arrow.Cutting tissue is far more efficient than crushing it, andcrushing it is far more efficient than tearing it apart bystretch (as in temporary cavitation).

5. Excision of the Wound as Not Only the Most Crucial butto Many the Sole Treatment for Gunshot Wounds:

"Debridement of missile injuries is essential toprevent clostrid'.um myositis..." (7) is the often repeated,iilitary dogma. In many papers, administration ofLystemic antibiotics for the treatment of penetratingprojectile wounds has been described as "only an ancillary

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measure" (40), "an issue of debate" (41), or not mentionedat all (7). However, this dogma apparently overlooks thehistorical fact that the most important cause of deathfrom missile wounds on the battlefield in the pre-antibiotic era was streptococcal bacteremia (70). Deathsfrom streotococcal bacteremia have been essentiallyeliminated from the battlefield by systemic antibiotics.A precipitous decline in the incidence of clostridiummyositis, from 5% of those wounded in World War I to 0.7%in World War II and 0.08% in the Korean conflict (71),correlates very closely with the increasing use ofantibiotics on the battlefield, yet debridement techniqueremained essentially unchanged during that time period.Thus, it appears that benefits of systentic antibioticusage have been incorrectly attributed to wounddebridement.

6. Spheres Assumed to Be a Valid Model for AllProjectiles:

This misconception ignores the important variable ofprojectile shape. Comparing the wound profile produced bya sphere (Fig 4) with that produced by a military bullet(Fig 3) shows a basic difference in tissue disruptionmorphology. The meximum disruption produced by the sphereis always near the entrance hole, since projectilevelocity is highest there. A pointed nondeforming bulletcauses its maximum disruption not at the point of highestvelocity, but where yaw increases the bullet's surfacearea striking the tissue (bullet shape becomesnonaerodynamic), causing increased tissue disruption.Although spheres may be useful in studying the effects ofblunt fragments (like those from explosive devices),conclusions drawn from these studies are not valid whenapplied to bullet wounds.7. Animals of 10 to 20 kg Falsely Assumed to Be a ValidModel for Human Wounds:

Temporary cavitation is no more than the pushingaside of tissue. The distance the tissue is displaceddepends, among other things, on its weight. As might beexpected, a given projectile will cause a temporary cavityof smalle- diameter in a larger limb because of theincrease'l weight of the mass being moved. This has beenproved experimentally (72) and points out the misleadinginformation that might be obtained through the use ofthese small animals. Bullet size cannot be reduced

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without changing its characteristics, so there is nochoice but to increase the size of the test animal toapproximate the dimensions of adult humans if scientificvalidity is to be maintained.

8. Use of Tissue Simulants with Unproved Equivalence toLiving Animal Tissue:

Fundamental to the use of tissue simulants, in lieuof animals, in wound ballistics is the establishment oftheir equivalence to animal tissue. For validity thesimulant must reproduce the physical effects of the

projectile-tissue interaction on the projectile(deformation, fragmentation), and in the simulant theprojectile must stop at the same penetration depth as itdoes in living animal tissue. This requirement isfrequently ignored by wound ballistics investigators (2,28-30, 38T thus compromising, if not eliminating, theapplicability of data so obtained to better understand thewounding process.

Duct-sealing compound '73), clay (2,74), soap (66,72), gelatin (28-30, 38), and water-soaked phone books ornewspapers (74) are commonly used tissue simulants.Information from each has been presented in the literaturewith the implication that it yields valid predictiveinformation about wounding effects in living animals.Contrary to the assumptions that these materials areequivalent to animal tissue, bullet deformation caused byimpact with them can vary widely. Recently, for example,we tested a 9-mm soft point pistol bullet that showed nodeformationi at all when shot into fresh swine cadaver legmuscle or into our 10% gelatin (shot at 4 degrees C), butexpanded to a diameter of 15 mm when shot into duct-sealing compound (75).

Nonelastic tissue simulants (duct-sealing compound,clay, soap) can also mislead by their dramaticpreservation of the maximum temporary cavity. Suchdemonstrations give a false impression that these cavitiesrepresent the potential for tissue destruction rather thanthe potential for tissue stretch. The latter may beabsorbed by most living tissues with little or no lastingdamage.

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CONSEQUE.NCES OF THESF MISCONCEPTIONS

1. Inappropriate Treat..-:nt of Gunshot Wounds:

Sacrifice of viable tissue on the altar of "highvelocity"--treatment more disruptive than the malady--isthe most obvious consequence of the postulate that assumesthat manifest tissue damage must accompany passage of a"high-velocity" missile. Surgical removal of excesstissue, based solely on a tenuous history of supposedprojectile velocity, is practiced widely (34-40). Inaddition to the risk of permanent disability fromexcessive removal of muscle, such surgery takes longerwith an attendant increase in surgical and anestheticcomplications, and is more likely to require bloodreplacement.

In the battlefield setting the surgeon cannot know,with certainty, all the properties of the woundingprojectile (shape, mas3, construction type, strikingvelocity). In a majority of civilian cases informationabout the wounding weapon is not available (76).Fortunately, such information is not necessary for theproper treatment of gunshot wounds. In fact, it is theauthor's opinion that the patient will be better off ifhis medical care provider doesn't know anything about thewounding weapon at all. The provider might then, withoutbias, use objective data from his physical examination androentgenographic studies to make more valid treatmentdecisions.

When a penetrating projectile does cause significanttissue disruption, that disruption is usually veryobvious. For example, in an uncomplicated extremity woundcaused by the M-16 rifle (Fig 2), if the bullet yawssignificantly and fragments, this will be evident in theform of a large exit hole. If no significant yaw occurs,the exit will closely resemble the entrance hole, andlittle or no functional disturbance will be evidentbecause of minimal tissue disruption. If, on the otherhand, the bullet breaks up very early in its path throughthe tissue, it is possible that the entrance and exitholes could be small despite marked tissue disruptionw4 thin the limb (such a pattern is typical of a soft pointbullet (Fig 7); occasionally this pattern may also beproduced by the M-16 bullet. The situation should pose nodiagnostic problem; marked functional disturbance withswelling will be obvious on physical examination, and the

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bullet fragmentation with soft tissue disruption will beobvious on biplanar x-rays. As in the therapy of anyother form of trauma, objective data should guidetreatment decisions.

The corollary postulate, "low-velocity projectilescause insignificant damage," can also lead to disaster.The author was consulted recently about a case in whichgas gangrene had developed in a leg wound caused by a .38

Special pistol (a "low-velocity" projectile). Surgicalexploration of the wound had been delayed until 40 hoursafter the injury, and the first antibiotic had beenadministered four hours after the operation. It was the

author's opinion that treatment had been inappropriate,but could net be considered.negligent, since theliterature contains many recommendations such as "...themajority of low velocity gunshot wounds of the extremitiesmay be safely treated without recourse to the operatingroom" (41), and "Debridement is unnecessary for woundscaused by bullets whose muzzle energy is less than 400foot pounds" (42). If antibiotic coverage had beenstarted soon after the wound occurred, and if the biasobtained from the literature had not misled the surgeon todelay surgical exploration of the wound, this lethalinfection most certainly wiuld have been avoided.

2. Misguided Weapon Testing and Development:

A heavier bullet of lower initial velocity wasrecently adopted, by US military forces, to overcemedeficiencies in the M-16 rifle's long-range performance.To stabilize this longer bullet the rifle's barrel had tobe replaced by one with a faster ritling twist (causingthe bullet to spin more rapidly). Not only was thischange costly but it has produced a unique "error waitingto happen" situation. The new bullet is loaded in thesame cartridge as the previous one. Thus it can be firedfrom the older M-16 rifles with the slower twist barrels.When this is done, the bullet is inadequately stabilized,resulting in extremely poor accuracy and yaw angles of upto 70 degrees in flight (77), possibly endangering thelives of soldiers who depend on it for protection on thefield of battle. When fired from the new faster-twistbarrel, it produces a wound profile similar to that of theolder M-16 bullet, but when fired from the old barrel itcauses marked tissue disruption at a shallower penetrationdepth (Fackler, M.L., unpublished data, 1984) much like asoft point bullet (Fig 8) (78).

Fackler--14

Light iulleta of high velocity lose velocity rapidlyin flight--a basic physical phenomenon (11). Perhaps theaforementio,,eC weapon problems could have been avoided ifweapons designers had been less inflnenced by the mystiqueof 'high velocity" and more influenced by basic physics ofprojectiles in flight. They might hev6 realizod that theolder M-16 bullt-ý. was too 1 ght to be effective at longerranges and used a heavier bullet in the first piace. Itis difficult tu be optimistic for the future when theseweapons developers still use the scientificallydiscredited "kinetic energy deposit" method to estimatewounding effects.

An extensive body of misinformation has beenpromulgated (28,29), based on the assumption that thetemporary cavity produced by a handgun bullet is the solefactor determining its "incapacitation" effect on thehuman target. These studies were done to aid lawenforcement agencies in their choice of weapons. Theinvestigators superimposed temporary cavity measurements,derived from shots into gelatin blocks, on a "computerman" diagram of the human body. They judged relativedamage by the anatomic regions "included" in the cavity."A "Relative Incapacitation Index" for each bullet was thencalculated from these data. The superimposition of thetemporary cavity on a region to determine the anatomicstructures it encompasses reveals a seriousmisunderstanding of wounding mechanisms. Bv definition.,no tissue is included "in" the temporary cavity: tissueis• ushed aside by it. Using the permanenlt cavity in thisfashion would make sense, but the permanent cavity istotally ignored in the calculation of the RelativeIncapacitation Index. Not svrprisingly, this RelativeIncapacit3tion Index bas bten criticized (17, 79, 80), b1treliance on its supposed validity continues to endangerthe lives of those who must depend or the reliableperformance of their weapon. These RelativeIncapacitation Index studies were supported by the USGovernment (Dept. of Justice), causing many to assumetheir validity, and compounding the detrimental effects ofthe misinformation.

Fackler--15

DISCUSSION

Violation of simple, fundamental scientific method

aTppears to be the common thread that runs through themisconceptions dealt with in this review. The author hasfound verifiable validity in only a small percentage ofthe material in print. The field of wound ballistics ispart physics and part biological science. Considering thelarge proportion of "exact* science in wound ballistics,we should expect to produce a literature with morevalidity and reproducibility than other medical or"inexact" fields. Quite the opposite appears to havetaken place. Failure to consider all the variables in themissile-tissue interaction, failure to use a controlanimal, failure to calibrate tissue simulants, failure torequire data to support assumptions, etc.--these were thebasic errors responsible fcr the miaconceptions listed inIthe foregoing pages. The reader will probably agree thatnone of them involve a high degree of complexity.

Misinterpretation of war trauma experience has misledmany writers. Such experience is anecdotal. Rarely ifever is the weapon, type of bullet, distance from muzzleto target, and absence of intermediate targets known withcertainty on the battlefield as it is in the woundballistics laboratory. Memory mixes all types of warwrounds together, assumptions on treatment efficacy arema'de despite lack of follow-up information, and statementsfrom higher headquarters concerning treatment rendered inthe field of action are frequently based on inaccuratedata and incorrect assumptions. In sum, a lot of error isreported as fact.

Physicians writing in the field of wound ballisticsneed to acquire sufficient expertise in weapon technologyso that they are not completely dependent on ballisticsengineers or other "experts" for information. Ballisticsengineers writing in the field must acquire sufficientexpertise about the living animal so that they at leastknow the pertinent questions to ask. Unless the"knowledge gap" between the physical and biologicalsciences is bridged at least partially by those who workin this field, an enormous potential for inaccuracy is

likely to continue.

Recognizing the projectile-tissue interaction as asimple mechanical collision and comprehending how tissueis disrupted (crush and stretch) in this collision,

Facklor--16

coupled with Wound profiles illust~rating how much crushand stretch occurs at any depth of projectile penetration,should give the reader sufficient background to recognizeany perpetuation of past errors or creation of new ones inthe future. It is not surprising that attempts to teachwound ballistics using formulae or tables of velocity andkinetic energy have been counterproductive. These methodshave diverted attention from the actual tissue disruptionand made the subject appear unnecessarily complicated.

An intelligent surgeon, knowing nothing about gunshotwounds except that they are contaminated, would mostlikely treat them quite appropriately. He would base histreatment decisions on objective data from the physicalexamination and x-ray studies, as he would in treating anyother form of trauma. The surgeon who has read andaccepted what is written in the wound ballisticsliterature could become a menace, doing more harm with histreatment than was done by the bullet. it is encouragingto note from the author's own experience as a combatsurgeon and contacts with others that most treatment ofpenetrating injuries rendered on the field of battle wasgoverned more by the common sense and good training of thesurgeon than by what is written in the wound ballisticsliterature.

Fackler--17

A•K.OWLEDGDM4NTS The author wishes tc acknowledge theadvice and assistance of John D. O'Benar, PhD, and CharlesZ. Wade, PhD, of the Military Trauma Research Division,and John P. Hannon, PhD, Scientific Advisor of theLetterman Army Institute of Research, in arranging thedata and expressing the thoughts contained in this paper.He also wishes to express appreciation to Paul J.Dougherty, Senior Medical Student at the UniformedServices University of the Health Sciences Medical School,for his contribution of valuable literature referencespreviously unknown to the author.

II"I

Fackler--18

RIFERUNCES

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4. Russotti GM, Sim FH: Missile wounds of theextremities: A current concepts review. Orthopedics1985;8:1106-1116.

5. Barach E, Tomlanovich M, Novak R: Ballistics: Apathophysiologic examination of the woundingmechanisms of firearms, Part I. J Trauma 1986;26:225-235. Part TI. J Trauma 1986;26:374-383.

6. Newman D, Yardley M: New generation small armsammunition. Int Def Rev 1986;19:921-925.

7. Swan KG: Missile injuries: Wound ballistics andprinciples of management. Mili Ned 1987;152:29-34.

8. Fackler ML, Surinchak JS, Malinowski JA, Bowen RE:Bullet fragmentation: A major cause of tissuedisruption. JTrauma 1984;24:35-39.

9. Fackler ML, Surinchak 3S, Malinowski JA, Bowen RE:Wounding potential of the Russian AK-74 assault rifle.J Trauma 1984:24:263-266.

10. Fackler ML, Malinowski JA% The wound profile: Avisual method for quantifying gunshot woundcomponents. 3 Trauma 1985;25:522-529.

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12. Fackler ML: Ballistic injury. Ann Emerq Med1986;15:1451-1455.

13. Fackler ML: Wound ballistics, in Trunkey DD, Lewis FR(eds.): Current Therapy of Trauma - 2,

- ~ ~ ~ ~ 5 -~~jm ýZ N J O A' , A~ U W .R M~kJR-A K I &AL A IL SA..2U h.A "I .2¶0[A .AA.- . J '.J t1&!~

Fackler- -19

Toronto, SC Decker Inc, 1986, pp 94-101.

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Fackler--20

Stangpunktt der umainitaet. llth internationalNedicsi Congress, Roe. 29 March-5 April, 1891; 1Parts GJenerale 32C-32b.

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Fackler--21

1980, pp 7-15.

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39. Litvin NS: Trauma: Management of the acutelyinjured tient, in Sabiston DC Jr (ed): •TLY.UChristoe Tetboo~kof Sugalrv. 24 12. Philadelphia,

D Sa lera Co, 1981, chap 19. l

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43. Harvey ZX: Studies on wound ballistics, inAndrus CE, Bronk DW, Corden GA Jr, et al (eds):Advances in Military Medicine. Boston, Little, Br.wn,1948, chap 18.

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48. Breteau JPL, Fackler ML, Taxit R, Courbil LJ: Trajet

tN

?ackler--22

lesionnel ou 'Wound Profileset vasomotricite cutanee.in yravguz asientifioues dep Chercheurs ft S 1 A"1 n X 1" 8. Direction Central* de Ser*vice de

Sante deo Armee, Paris, Republique Francaise Ministrede la Defense, 1987.

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Fackler--23

60. Hopkinson DAW, Marshall TK: Firearm injuries. DrJbra 1967;540344-352.

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---------

Fackler--24

71. Hardaway RM ITI: Vietnam wound analysis. J Trauma1978;18:635-643.

72. Janzon B: Hioh energy missile trauma. Department ofSurgery II, University of Goteborg, Sweden, 1983.

73. Grennell DA: Favorite loads for favorite guns. GunWorld 1987;27:46-49,62.

74. Matunas EA: Rating handgun power, in Warner K (ed):Gun Digest. Northbrook, Ill, DBI Books Inc, 1984.

75. Fackler ML: Tissue simulants: Use and misuse. IntPef Rev (in press).

76. Dugas R, D'Ambrosia R: Civilian gunshot wounds.Orthopedics 1985;8:1121-1125.

77. Humphreville M: US Customs Service Armam, t R&DCenter, Glynco, GA. personal communication, 1984.

78. Albreht MA: Data presented at the 5th InternationalWound Ballistics Symposium, Goteborg, 3weden, 1985, JTrauma (in press).

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80. Fackler ML: Letter to the editor. Int Def Rev (inpress March 1987).

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