DLDr

INSTITUTE REPORT NO. 239

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

AND VW.iY

DTIC
L0 ELECTE
N M.L. FACKLER, M.D. D

DIVISION OF MILITARY TRAUMA RESEARCH

"-.' ,. ,

Dm-E-hU'ON ST.Ti
Approved, fom public reb-e4.- -.
~~s~bitiflUnlimited

JULY 1981 "

LETTERMAN ARMY INSTITUTE OF RESEARCH

PRESIDIO OF SAN FRANCISCO, CALIFORNIA 94129
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11.TITLE (include Security CIassilcation)-
Institute Report No. 239, What's Wrong with the Wound Ballistics Literature, and Why

12.PERSONAL AUTHOR(S)
M.L. Fackler, M.D.
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Institute Report FROM I1R6TO ... R7L 1987 jl 33
16. 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 r
perpetuated by editors, reviewers, and other investigator-s with no better
grasp of the subject. This report explains the projectile-tisst'e
interaction and presents data showing the location' ý-f tissue disrupted by
various projectiles. These tissve diaruption data are presented in the
form of wound profiles. The major misconceptions perpetuated in the field
are listed, analyzed, and their errors exposed using wound profiles and
other known data. The more serious consequences of these rniscianceptions
are discussed. Failure in adhering to the basic precepts of scienit-kfic
method is the common denominator in all of the listed misconceptions..
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Martin L. Fackler (415) 561-5817 ISGRD-UL-MT
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 ABSTRACT

Attempts to explain wound ballistic3 (the study of

effects on the body produced by penetrating projctiles)
have succeeded in mystifying it. Fallacious recearch by
those with little grasp of the fundamentals has been
perpetuated by editors, reviewers, and other' investigators
with no better grasp of the subject. This report explains
the projectile-tissue interaction and presents data
showing the location of tissue disrupted by various
proj&ctiles. These tissue disruption data are prasented
in the form of wound profiles. The major misconceptions
perpetuated in the field are listed, analyzed, and their
errors exposed using wound profiles and other known data.
The more serious consequences of thesa misconceptions are
discussed. Vailure in adhering to the basic precepts of
scient'.fic method is the common denominator in all of the
1ieted misconcept ions

Aes;0O'ý For

NTIS CRAWI
OTIC TAB
Ulannouriced [I
oJustificatton .f.. ...

By......................

Di-AIItbutor I
Availablity Codes
Avail Ind Ior
Dl-t Special

INSPEC°EI
 Fackler--l

Gunshot wounds are a fact of life in our society.

The coammon assumption is that military conflicts, wound
ballistics research, and a steady stream of daily
experience in our larger cities have provided the
knowledge and skill to assure uniform excellence in
treatment of these injuries. Sadly, this assumption is
wrong.
Probably no scientific field contains more
misinfoi'mation than vound ballistics. In a 1980 JournalI
of Trauma editorial entitled "The Idolatry of Velocity, or
Lies, Damn Lies, and Ba115.stics,w Lindsey identified many
of the misconceptions and half-truths distorting the
literature (1). Despite his cogent revelation3, the
errors he attempted to rectify are still being repeated in
the literature (2-7), often embellished with unprovenI
assumption and uninformed speculation. The body of
literature generated at the wound ballistics laboratory of
the Letterman Army Institute of Research over the past six
years (8-14) strongly supports the points made by
Professor Lindsey. The author of this paper has chosen to
correct errors, as they appeared, with letters to journal
editors (15-22), a time-consuming endeavor of questionableI
effectiveness. This critical review calls attention to
the problem, corrects the most widespread and damaging
misinterpretations, and lays the groundwork for improved
research, understanding and clinical treatment.
Between 1875 and 1900, the study of gunshot effects

I had reached a high level of sophistication, thanks mainly

to Theodor Kocher, whose work was the epitome of sound
scientific method (23-27). However, with the advent of
the high-speed movie camera in the present century,
emphasis in wound ballistics shifted from sound scientific
method to spectacular cinematography--a triumph of highI
technology over common sense. Unfortunately, a sideshow
mentality seized upon the technology of the twentieth
century. Flamboyance attractod more attention than sound
science. Wound ballistics research was reduced to taking
movies of shots into everything imaginable, and the focus
of understanding narrowed to exclude every variable exceptI
projectile velocity. The exaggeration inherent in these
methods so distorted the concept of temporary cavitation
that, to some, it came to represent the entirety of the
projectile-tissue interaction (28, 29). Rarely does the
viewer find a measuring scale included in reproductions of
these dramatic cinematographic frames (30). Undoubtedly,I
many readers have seen the Swedish film of an anesthetized

h~~maIv aia-V
rackler--2

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

THE WOUND PROFILE - UNDERSTANDING THE PROJECTIILB-TISSUE

INTERACTION
A projectile crushes the tissue it strikes during
penetration, and it may impel the surrounding tissue
outward (centrifugally) away from the missile path.
Tissue crush is responsible for what is commonly called
the permanent cavity and tissue stretch is responsible for
the so-called temporary cavity. These are the sole
wounding mechanisms. In addition, a sonic pressure wave
is 9ýnerated by projectiles traveling faster than the
speed of sound. In air this wave trails the projectile
like the wake of a ship. The sonic boom experienced after
passage of a supersonic airplane is an example of a sonic
pressure wave. This pressure wave travels at the speed of
sound in the mudium through which it passes, and sound
travels four times as fast through tissue as it does
through air. Thus the sonic wave pr.cedes the projectile
in tissue. Contrary to popular opinion (3, 30), this
wave does not move or iniure tissue. Harvey's exhaustive
experiments during WW I: showed clearly the benignity of
the sonic pressure wave :31). The lithotripter, a recent
invention that uses this sonic pressure wave to break up
kidney stones, generates a wave five times the amplitude
of the one from a penetrating small arms projectile. Up
to 2,000 of these waves are used in a single treatment
session, with no damage to soft tissue surrounding the
stone (32,33). It would be difficult to imagine more
convincing confirmation of Harvey's conclusions.
The wound produced by a particular penetrating
projectile is characterized by the amount and location of
tissue crush and stretch. In our laboratory, we measure
the amount and location of crush (permanent cavity) and
stretch (temporary cavity) on the basis of shots fired
into gelatin tissue simulant. Since we have calibrated
this simulant to reproduce the projectile characteristics
(penetration depth, deformation, fragmentation, yaw)
equivalent to those observed in living animal tissue,
 F•nkler--3

measurements from these shots can be used to predict

approximate animal tissue disruption (8-10). These data
are presented in the form of Wound Profiles (Fig 1-8),
which illustrate the amount, type, and location of tissue
disruption, projectile mass, velocity, construction, and
shape (before and after the shot), as veil as projectile
deformation and projectile fragmentation pattern when
applicable. The scale on each profile permits quick
determination of tissue disruption dimension at any point
along the penetration path for comparison with other
profiles, other experimental results, or with measurements
from actual wounds in a clinical settin g or at autopsy.
Wound profile date will be used to rectify the fallacies
listed below.

MAJOR MISCONCEPTIONS

1. Idolatry of Velocity:

A widespread dogma claims that wounds caused by

"high-v'locity" projectiles must be treated by extensive
excision of tissue around the missile path (34-40),
whereas those caused by 'low-velocity" missiles need
little or no treatment (41, 42). Two half-truths nurture
this error. The first of these, *Cavitation is a
Lallistic phenomenon associated with very high velocity
vissiles" (7), is easily disproved. The wound profile in
Fig 1 shows a very substantial temporary cavity produced
by a "low-velocity" bullet. This bullet, fired from the
Vetterli rifle at 1357 ft/s (414 m/s), has ballistic
characteristics typical of those used by military forces
in the latter half of the nineteenth century. It is the
same bullet used by Theodor Kocher for most of his wound
ballistics studies (23-27). It is obvious from this wound
profile that temporary cavitation is not, as popularly
belivved, a modern phenomenon associated exclusively with
projectiles of "high velocity.'

The adjunct half-truth, 'Cavitation requires

extensive debridement of tissues... (7), lacks valid
scientific support. Cavitation is nothing more than a
transient displacement of tissue, a stretch, a localized
"blunt trauma." It is not surprising that elastic tissues
such as bowel wall, lung, and muscle are relatively
resistant to being damaged by this stretch, while solid
organs such as liver are not (9). Most of the muscle
subjected to temporary cavity stretch survives; tissue
survival has been verified in every case in which muscle

S-V"
Fackler--4

was allowed to remain in situ and healing was followed to

completion (43-48).
Misinterpretation of the mechanism by which the M-16
rifle causes tissue disruption perpetuated the foregoing
misconceptions. The M-16 (Fig 2) van introduced in
Vietnam, and many compared the increased tissue disruption
it produced (12-14, 49, 50) with that caused by previous
military rifles. In the Vietnam era, the major role
played by bullet fragmentation in tissue disruption was
not recognized (8). It is nov appreciated (12-14) and
documented (Fig 3) that bullet fragmentation is the
predominant reason underlying the M-16's inc-reased tissue m

disruption. Despite this recent evidence, a generation of

surgeons and weapon developers (28) has been confused and
prejudiced by the assumption that "high velocity" and
wtemporary cavitationw were the sole causes of tissue
disruption.
It is indeed surprising that only Lindsey questioned
the attribution of the marked increase in tissue
disruption to a rather modest 10% increase in velocity.
Surely, someone should have noticed that the largest
increase of projectile velocity in the history of small-
arms development (a 50% increase--made possible by the
invention of the copper-jacketed bullet near the end of
the nineteenth century) was accompanied by a marked
dereas in soft tissue disruption (51, 52). This
decrease was predicted by Kocher, whose work had taught
him the importance of projectile deformation (26, 27); new
smaller-caliber bullets did not deform upon striking
tissue as did previous large caliber soft lead bullets
(Fig 1).

2. Exaggeration of Temporary Cavity Size, Pressure, and

Effect,-

In 1971, Amato et al (53) wrote that the temporary

cavity '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) through
the hind leg of an anesthetized dog. Although no scale
was included on the high-speed roentgenograms, the reader
can use dividers to determine the sphere diameter and will
find that the largest temporary cavity shown is 11 sphere
diameters--not 30 diameters. Wound profile data obtained
in our laboratory gave comparable results; a 6-mm steel
sphere at slightly over 1000 m/s produced a maximum
 Fackler--5

temporary cavity of only 12.5 sphere diameters (Fig 4)

Other authors, citing no data, Jescribe the temporary
cavity as 0...30 times the diameter of the projectile...
(35), 0...30 times or more...0(54), and 30. to 40 times the
missile diameter (36, 40)--all sizable exa•oeratlons.
To further confuse the issue, pressures of up to lu0
atmospheres are incorrectly attributed to temporary
cavitation by many authors (39, 40, 55-57). These authors
appear to have confused the sonic pressure wave with the
pressure
Temporary generated in tissues by temporary cavitation.
cavity tissue displacement can cause pressures
of only about 4 atmospheres (31). A careful reading of

I
Harvey's paper (31) should correct this confusion.

Probably the most exaggerated account of temporary

cavity effect in the literature appears in High locity
.i.S Wo.nd&by Oven-Smith (36). His Fig 2.20 on page
35 shows a lesion in a pig's colon caused by a 'standard
bullet fired at 770 m/s (2500 ft/s)." Concerning this
wound, he states t there are microscopic changes of cell
death extending 20 cm from the edge of the hole in the
colon; this is why such an area must be resected if it has
bean damaged b a rifle bullet." Perusal of the source
document of th picture (58), however, reveals that A
deforming soft-:oint hunting bullet was used for this
jhot. In describing the effect of this shot, the source
document states, I...haemorrhage extended macroscopicaily
to a dialter (my emphasis) of 20 cm.0 When the 8-cm hole
diameter is subtracted, a 6-cm distance (rather than the
20 cm reported by Oven-Smith) from the edge of the hole on
each side adds up to the 9diameter of 20 cm" reported by
Scott in the source document. Furthermore, photographs of
bowel defects caused by bullets must be viewed with
caution. Folding back the bowel wall around the edges of
the hole can make tissue defits appear larger. If colon
tissue at a distance of 20 cm from the bullet hole is
killed, as asserted by Owen-Smith, what happens to the
loops of small bowel and other organs that are within 20
cm of the bullet hole? Are they killed too? if so, this
would equate to destruction of most of the abdominal
contents by every penetratin *high-velocity" bullet.
Clearly, this conclusion is inconsistent with well
established available facts. A study done in our
laboratory (9), for example, showed damage to a pig colon
caused by a nondeforming military bullet traveling at 911
m/s (2989 ft/s) that was only slightly larger than the
dimensions of the bullet that had caused it.
Fackler--6

It should be noted, however, that stretch from

temporary cavity tissue displacement can disrupt blood
vessels or break bones et some distance from the
rojectile path (40), just as they can be disrupted by
lunt trauma. We can produce this in the laboratory Dy
careful choice of projectile and projectile trajectory in
tissue (48), but in practice this happens only very
rarely. Date from the Vietnau conflict show thet the
great majority of torso and *xtramity wounds were
attributable to the damage due to the permanent cavity
alone (59).
3. Asaumption of Bullet Tumbling" in Flight:
The notion that a comaon cause of increased wounding
is the bullet's striking at large yaw angles (angle
between the bullet's long axis and line of flight), or
even sideways due to utumbling* in flight (37, 40), is
clearly fallacious. Anyone who has ever shot a rifle and
observed the holes made by the bullet recognixes that they
are round, not oblong, as would be the case if they yawed
or tumbled in flight. This misconception seems
attributable in large measure to misinterpretation of a
report publiahed, in 1067, by Hopkinson and Marshall.
These authors presented diagrams of the yaw angles and
patterns made by the bullet tip in flight (60). The
angles on cheir drawings were exaggerated for clarity,
showing 25 to 30 degrees rather than the 1 to 3 degreas
that actually occur for properly designed bullets of small
arms (61). In 1972, Amato and Rich reproduced these
diagrams and added one for 'tumbling" T62). In 1975 these
diagrams reappeared in the N= Handbook-Emeraency War
•Lu (40), where the text described them as resulting
from aerodynamic forces acting upon the spin-stabilized
bullet during flight. In 1980, Swan and Swan (37)
reproduced these diagrams, but for the yawing bullet
showed he impossible situation of rotation around the
bullet tip rather than its center of mass. They also
added a unique opinion (unsupported) that "yaw" and
"tumble' are special ballistic properties associated with
missiles or "vmry high velocities (c [sic] 3000 ft/s).*

Data from ballistics studies (10, 13, 14) show quite

clearly that:
*Bullets fired from a properl; designed rifle yaw no
more than a few degrees in flight, regardless of
velocity.
 Fackler--7

ein the:r path through tissue, all nondeforming

pointed bullets, and some round-nosed ones, yaw to
ISO degroes, ending their path traveling base forward
(Pigs aend 5).

Thus bullet yaw in tissue, an important

consideration, has been confused with bullet yaw in
flight, which is, in moat cases, of negligible
consequence,

4. Presumption of "Kinetic Energy Deposit" to Be a

M4echaniam of Wounding:

Serious misunderstanding has been generated by

looking upon *kinetic energy transfer* from projectile to
tissue as a mechanism of injury. In spite of data to the
contrary (1, 63), many assume that the amount of "kinetic.
energy deposit" in the body by a projectile is a measure
of damage (2-5. 36, 37., 40). Such opinions ignore the
direct interaction of projectile and tissue that is the
crux of wound ballistics. Wounds that result in a given
amount of 'kinetic energy deposit* may differ widely. The
nondeforming rifle bullet of the AX-74 (Fig 6) causes a
large temporary cavity which can cause marked disruption
in some tissue (liver), but has far less effect in others
(muscle, lung, bowel wall) (9). A similar temporary
cavity such as that produced by the M-16 (Fig 2),
stretching tissue that has been riddled by bullet
fragments, causes a much larger permanent cavity by
detaching tissue segments between the fragment paths.
Thus projectile fragmentation can turn the energy used in
temporary cavitation into e truly destructive force
because it is focused on areas weakened by fragment paths
rather than being absorbed evenly by the tissue mtass. The
synergy between projectile fragmentation and cavitation
can greatly increase the damage done by a given amount of
kinetic energy.
A large slow projectile (Fig 7) will crush (permanent
cavity) a large amount of tissue, whereas a small fast
missile with the same kinetic energy (Fig 4) will stretch
more tissue (temporary cavity) but crush little. If the
tissue crushed by a projectile includes the wall of the
aorta, far more damaging consequences are likely to result
than if thts same projectile "deposits" the same amount of
energy beside this vessel.

,I

~1
Vackler--S

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

are soft and flexible--the physical characteristics of a
good shock absorbtr. Drop a raw egg onto a cement floor
ram a height of 2 ma then drop a ruktber ball of the same
mas from the aam* height. The kinetic energy exchange in
both dropped objects was the same at the moment of impact.
Compare the difference in effect; the egg breaks while the
ball rebounds undamaged. Most living n imal soft tissue
has a consistency much closer to that of the rubber ball
than to that of the brittle egg shell. This simple
experiment demonstrates the fallacy in the common
assumption that all kinetic energy "deposited" in the body
does damage.
The assumption that "kinetic energy deposit" is
directly proportional to damage done to tissues also fails
to recognize the components of the projectile-tissue
collision that use energy but do not cause tissue
disruption. They are 1) sonic pressure wave, 2) heating
of the tissue, 3) heating of the projectile, 4)
deformation of the projectile, and 5) motion imparted to
the tissue (gelatin block displacement for example).
The popular format for determination of "kinetic
energy deposit' uses a chronograph to determine striking
velocity and another to determine exit velocity. A 15-cm-
thick block of tissue simulant (gelatin or soap) is the
target most often used. This method has one big factor in
its favor; it is simple and easy to do. As for its
validity, the interested reader is referred to wound
profiles shown in Figs 1-7. Comparing only the first 15
cm of the missile path with the entire missile path as
shown on the profiles shows the severe limitation of the
15-cm block format. The assumption by weapons developers
that only the first 15 cm of the penetrating proj ectilet s
path through tissue is of clinical significance (64) may
simplify their job, but fails to provide sufficient
information for valid prediction of the projectile's
wounding potential. The length of bullet trajectories
through the human torso can be up to four times as long as
those in these small blocks. Even if this method were
scientifically valid, its use has been further flawed by
nearly all investigators who have included the M-16 rifle
bullet in those projectiles tested. This method assumes
that the projectile's mass remains constant through both
chronographs. The 4-16 routinely loses one third of its
mass in the form of fragments which may remain in the
target (see Fig 2). The part of the bullet that passes
 Fackler--9

through the second chronograph screens weighs only about

two-thirds as much as the intact bullet that passed
through the first met of screens. No provision is made
for catching and weighing the projectile to correct for
bullet fragmentation when it occurs. The failure to
correct for loss of bullet mass can cause large errors in
"energy deposit" data (8).

Surgeons sometimes excise tissue from experimental

missile wounds that is, in their judgment, nonviable and
compare the weight of tissue excised with the "kinetic
energy depositeA" (65). A surgeon's judgment and his
technique of tissue excision is very subjective, as shown
by Berlin et al (66), who found in a comparison that "One
surgeon excised less tissue at low energy transfers and
rather more at high energy transfers than the other
surgeon, although both surgeons used the same criteria
when judging the tissues." None of these experiments
included control animals to verify that tissue the surgeon
had declared "nonviable" actually became necrotic if left
in place. Interestingly, all studies in which animals
were kept alive for objective observations of wound
healing report less lastina tissue damaqe than estimated
from observation of the wound in the first few hours after
it was inflicted (43-47, 67, 68). In a study of over
4,000 wounded in WW II it was remarked, "It is surprising
to see how much apparently nonvital tissue recovered"
(69).
Anyone yet unconvinced of the fallacy in using
kinetic energy alone to measure wounding capacity might
wish to consider the example of a modern broadhead hunting
arrow. It is used to kill all species of big game, yet
its striking energy is only about 50 ft-lb (68 Joules)--
less than that of the .22 Short bullet. Energy is used
efficiently by the sharp blade of the broadhead arrow.
Cutting tissue is far more efficient than crushing it, and
crushing it is far more efficient than tearing it apart by
stretch (as in temporary cavitation).
5. Excision of the Wound as Not Only the Most Crucial but
to Many the Sole Treatment for Gunshot Wounds:

"Debridement of missile injuries is essential to

prevent clostrid'.um myositis..." (7) is the often repeated
,iilitary dogma. In many papers, administration of
Lystemic antibiotics for the treatment of penetrating
projectile wounds has been described as "only an ancillary
Fackler--10

measure" (40), "an issue of debate" (41), or not mentioned

at all (7). However, this dogma apparently overlooks the
historical fact that the most important cause of death
from missile wounds on the battlefield in the pre-
antibiotic era was streptococcal bacteremia (70). Deaths
from streotococcal bacteremia have been essentially
eliminated from the battlefield by systemic antibiotics.
A precipitous decline in the incidence of clostridium
myositis, 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 of
antibiotics on the battlefield, yet debridement technique
remained essentially unchanged during that time period.
Thus, it appears that benefits of systentic antibiotic
usage have been incorrectly attributed to wound
debridement.

6. Spheres Assumed to Be a Valid Model for All

Projectiles:

This misconception ignores the important variable of

projectile shape. Comparing the wound profile produced by
a sphere (Fig 4) with that produced by a military bullet
(Fig 3) shows a basic difference in tissue disruption
morphology. The meximum disruption produced by the sphere
is always near the entrance hole, since projectile
velocity is highest there. A pointed nondeforming bullet
causes its maximum disruption not at the point of highest
velocity, but where yaw increases the bullet's surface
area striking the tissue (bullet shape becomes
nonaerodynamic), causing increased tissue disruption.
Although spheres may be useful in studying the effects of
blunt fragments (like those from explosive devices),
conclusions drawn from these studies are not valid when
applied to bullet wounds.
7. Animals of 10 to 20 kg Falsely Assumed to Be a Valid
Model for Human Wounds:

Temporary cavitation is no more than the pushing

aside of tissue. The distance the tissue is displaced
depends, among other things, on its weight. As might be
expected, a given projectile will cause a temporary cavity
of smalle- diameter in a larger limb because of the
increase'l weight of the mass being moved. This has been
proved experimentally (72) and points out the misleading
information that might be obtained through the use of
these small animals. Bullet size cannot be reduced
 Fackler--ll

without changing its characteristics, so there is no

choice but to increase the size of the test animal to
approximate the dimensions of adult humans if scientific
validity is to be maintained.

8. Use of Tissue Simulants with Unproved Equivalence to

Living Animal Tissue:

Fundamental to the use of tissue simulants, in lieu

of animals, in wound ballistics is the establishment of
their must reproduce the physical For
equivalence
simulant to animal tissue. validity
effects the
of the
projectile-tissue interaction on the projectile
(deformation, fragmentation), and in the simulant the
projectile must stop at the same penetration depth as it
does in living animal tissue. This requirement is
frequently ignored by wound ballistics investigators (2,
28-30, 38T thus compromising, if not eliminating, the
applicability of data so obtained to better understand the
wounding process.

Duct-sealing compound '73), clay (2,74), soap (66,

72), gelatin (28-30, 38), and water-soaked phone books or
newspapers (74) are commonly used tissue simulants.
Information from each has been presented in the literature
with the implication that it yields valid predictive
information about wounding effects in living animals.
Contrary to the assumptions that these materials are
equivalent to animal tissue, bullet deformation caused by
impact with them can vary widely. Recently, for example,
we tested a 9-mm soft point pistol bullet that showed no
deformationi at all when shot into fresh swine cadaver leg
muscle or into our 10% gelatin (shot at 4 degrees C), but
expanded 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 dramatic
preservation of the maximum temporary cavity. Such
demonstrations give a false impression that these cavities
represent the potential for tissue destruction rather than
the potential for tissue stretch. The latter may be
absorbed by most living tissues with little or no lasting
damage.
Fackler--12

CONSEQUE.NCES OF THESF MISCONCEPTIONS

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

Sacrifice of viable tissue on the altar of "high

velocity"--treatment more disruptive than the malady--is
the most obvious consequence of the postulate that assumes
that manifest tissue damage must accompany passage of a
"high-velocity" missile. Surgical removal of excess
tissue, based solely on a tenuous history of supposed
projectile velocity, is practiced widely (34-40). In
addition to the risk of permanent disability from
excessive removal of muscle, such surgery takes longer
with an attendant increase in surgical and anesthetic
complications, and is more likely to require blood
replacement.

In the battlefield setting the surgeon cannot know,

with certainty, all the properties of the wounding
projectile (shape, mas3, construction type, striking
velocity). In a majority of civilian cases information
about the wounding weapon is not available (76).
Fortunately, such information is not necessary for the
proper treatment of gunshot wounds. In fact, it is the
author's opinion that the patient will be better off if
his medical care provider doesn't know anything about the
wounding weapon at all. The provider might then, without
bias, use objective data from his physical examination and
roentgenographic studies to make more valid treatment
decisions.

When a penetrating projectile does cause significant

tissue disruption, that disruption is usually very
obvious. For example, in an uncomplicated extremity wound
caused by the M-16 rifle (Fig 2), if the bullet yaws
significantly and fragments, this will be evident in the
form of a large exit hole. If no significant yaw occurs,
the exit will closely resemble the entrance hole, and
little or no functional disturbance will be evident
because of minimal tissue disruption. If, on the other
hand, the bullet breaks up very early in its path through
the tissue, it is possible that the entrance and exit
holes could be small despite marked tissue disruption
w4 thin the limb (such a pattern is typical of a soft point
bullet (Fig 7); occasionally this pattern may also be
produced by the M-16 bullet. The situation should pose no
diagnostic problem; marked functional disturbance with
swelling will be obvious on physical examination, and the
 Fackler--13

bullet fragmentation with soft tissue disruption will be

obvious on biplanar x-rays. As in the therapy of any
other form of trauma, objective data should guide
treatment decisions.

The corollary postulate, "low-velocity projectiles

cause insignificant damage," can also lead to disaster.
The author was consulted recently about a case in which
gas gangrene had developed in a leg wound caused by a .38
Special pistol (a "low-velocity" projectile). Surgical
exploration of the wound had been delayed until been
40 hours
after the injury, and the first antibiotic had
administered four hours after the operation. It was the

author's opinion that treatment had been inappropriate,

but could net be considered.negligent, since the
literature contains many recommendations such as "...the
majority of low velocity gunshot wounds of the extremities
may be safely treated without recourse to the operating
room" (41), and "Debridement is unnecessary for wounds
caused by bullets whose muzzle energy is less than 400
foot pounds" (42). If antibiotic coverage had been
started soon after the wound occurred, and if the bias
obtained from the literature had not misled the surgeon to
delay surgical exploration of the wound, this lethal
infection most certainly wiuld have been avoided.
2. Misguided Weapon Testing and Development:

A heavier bullet of lower initial velocity was

recently adopted, by US military forces, to overceme
deficiencies in the M-16 rifle's long-range performance.
To stabilize this longer bullet the rifle's barrel had to
be replaced by one with a faster ritling twist (causing
the bullet to spin more rapidly). Not only was this
change costly but it has produced a unique "error waiting
to happen" situation. The new bullet is loaded in the
same cartridge as the previous one. Thus it can be fired
from 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 up
to 70 degrees in flight (77), possibly endangering the
lives of soldiers who depend on it for protection on the
field of battle. When fired from the new faster-twist
barrel, it produces a wound profile similar to that of the
older M-16 bullet, but when fired from the old barrel it
causes marked tissue disruption at a shallower penetration
depth (Fackler, M.L., unpublished data, 1984) much like a
soft point bullet (Fig 8) (78).
Fackler--14

Light iulleta of high velocity lose velocity rapidly

in flight--a basic physical phenomenon (11). Perhaps the
aforementio,,eC weapon problems could have been avoided if
weapons designers had been less inflnenced by the mystique
of 'high velocity" and more influenced by basic physics of
projectiles in flight. They might hev6 realizod that the
older M-16 bullt-ý. was too 1 ght to be effective at longer
ranges and used a heavier bullet in the first piace. It
is difficult tu be optimistic for the future when these
weapons developers still use the scientifically
discredited "kinetic energy deposit" method to estimate
wounding effects.

An extensive body of misinformation has been

promulgated (28,29), based on the assumption that the
temporary cavity produced by a handgun bullet is the sole
factor determining its "incapacitation" effect on the
human target. These studies were done to aid law
enforcement agencies in their choice of weapons. The
investigators superimposed temporary cavity measurements,
derived from shots into gelatin blocks, on a "computer
man" diagram of the human body. They judged relative
damage by the anatomic regions "included" in the cavity.
"A "Relative Incapacitation Index" for each bullet was then
calculated from these data. The superimposition of the
temporary cavity on a region to determine the anatomic
structures it encompasses reveals a serious
misunderstanding of wounding mechanisms. Bv definition.,
no tissue is included "in" the temporary cavity: tissue
is• ushed aside by it. Using the permanenlt cavity in this
fashion would make sense, but the permanent cavity is
totally ignored in the calculation of the Relative
Incapacitation Index. Not svrprisingly, this Relative
Incapacit3tion Index bas bten criticized (17, 79, 80), b1t
reliance on its supposed validity continues to endanger
the lives of those who must depend or the reliable
performance of their weapon. These Relative
Incapacitation Index studies were supported by the US
Government (Dept. of Justice), causing many to assume
their validity, and compounding the detrimental effects of
the misinformation.
 Fackler--15

DISCUSSION
Violation of simple, fundamental scientific method
aTppears to be the common thread that runs through the
misconceptions dealt with in this review. The author has
found verifiable validity in only a small percentage of
the material in print. The field of wound ballistics is
part physics and part biological science. Considering the
large proportion of "exact* science in wound ballistics,
we should expect to produce a literature with more
validity and reproducibility than other medical or
"inexact" fields. Quite the opposite appears to have
taken place. Failure to consider all the variables in the
missile-tissue interaction, failure to use a control
animal, failure to calibrate tissue simulants, failure to
require data to support assumptions, etc.--these were the
basic errors responsible fcr the miaconceptions listed inI
the foregoing pages. The reader will probably agree that
none of them involve a high degree of complexity.
Misinterpretation of war trauma experience has misled
many writers. Such experience is anecdotal. Rarely if
ever is the weapon, type of bullet, distance from muzzle
to target, and absence of intermediate targets known with
certainty on the battlefield as it is in the wound
ballistics laboratory. Memory mixes all types of war
wrounds together, assumptions on treatment efficacy are
ma'de despite lack of follow-up information, and statements
from higher headquarters concerning treatment rendered in
the field of action are frequently based on inaccurate
data and incorrect assumptions. In sum, a lot of error is
reported as fact.
Physicians writing in the field of wound ballistics
need to acquire sufficient expertise in weapon technology
so that they are not completely dependent on ballistics
engineers or other "experts" for information. Ballistics
engineers writing in the field must acquire sufficient
expertise about the living animal so that they at least
know the pertinent questions to ask. Unless the
"knowledge gap" between the physical and biological
sciences is bridged at least partially by those who work
in this field, an enormous potential for inaccuracy is
likely to continue.
Recognizing the projectile-tissue interaction as a
simple mechanical collision and comprehending how tissue
is disrupted (crush and stretch) in this collision,
Facklor--16

coupled with Wound profiles illust~rating how much crush

and stretch occurs at any depth of projectile penetration,
should give the reader sufficient background to recognize
any perpetuation of past errors or creation of new ones in
the future. It is not surprising that attempts to teach
wound ballistics using formulae or tables of velocity and
kinetic energy have been counterproductive. These methods
have diverted attention from the actual tissue disruption
and made the subject appear unnecessarily complicated.
An intelligent surgeon, knowing nothing about gunshot
wounds except that they are contaminated, would most
likely treat them quite appropriately. He would base his
treatment decisions on objective data from the physical
examination and x-ray studies, as he would in treating any
other form of trauma. The surgeon who has read and
accepted what is written in the wound ballistics
literature could become a menace, doing more harm with his
treatment than was done by the bullet. it is encouraging
to note from the author's own experience as a combat
surgeon and contacts with others that most treatment of
penetrating injuries rendered on the field of battle was
governed more by the common sense and good training of the
surgeon than by what is written in the wound ballistics
literature.
 Fackler--17

A•K.OWLEDGDM4NTS The author wishes tc acknowledge the

advice and assistance of John D. O'Benar, PhD, and Charles
Z. Wade, PhD, of the Military Trauma Research Division,
and John P. Hannon, PhD, Scientific Advisor of the
Letterman Army Institute of Research, in arranging the
data and expressing the thoughts contained in this paper.
He also wishes to express appreciation to Paul J.
Dougherty, Senior Medical Student at the Uniformed
Services University of the Health Sciences Medical School,
for his contribution of valuable literature references
previously unknown to the author.

I
I

"I
Fackler--18

RIFERUNCES

1. Lindsey D: The idolatry of velocity, or lies, damn

lies, and ballistics. JTa 1980;20:1068-1069.
2. Swan KG, Swan RC, Levine MG, Rocko 3M: The US M-16
rifle versus the Russian AK-47 rifle. ?.J Sura
1983;49:472-479.
3. Ordog GJ, Wasserberger J, Balasubramanium S: Ann
Emera KO• 1964;13:1113-1122.

4. Russotti GM, Sim FH: Missile wounds of the

extremities: A current concepts review. Orthopedics
1985;8:1106-1116.
5. Barach E, Tomlanovich M, Novak R: Ballistics: A
pathophysiologic examination of the wounding
mechanisms 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 arms
ammunition. Int Def Rev 1986;19:921-925.
7. Swan KG: Missile injuries: Wound ballistics and
principles of management. Mili Ned 1987;152:29-34.
8. Fackler ML, Surinchak JS, Malinowski JA, Bowen RE:
Bullet fragmentation: A major cause of tissue
disruption. 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: A
visual method for quantifying gunshot wound
components. 3 Trauma 1985;25:522-529.
11. Fackler ML, Bellamy RF, Halinowski JA: Wounding
mechanism of projectiles striking at over 1.5 km/sec.
J Trauma 1986;26:350-354.
12. Fackler ML: Ballistic injury. Ann Emerq Med
1986;15:1451-1455.
13. Fackler ML: Wound ballistics, in Trunkey DD, Lewis FR
(eds.): Current Therapy of Trauma - 2,

- ~~ ~ ~ 5 -~~jm
N J
ýZ U
O A', A~WR
. M~kJR-A K I &ALILA SA..2Uh.A "I .2¶0[A.AA.-
'.J
t1&!~ . J
 Fackler- -19

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

14. Fackler MW: Physics Of pnetrating trauma,

In McSvain NE Jr. Kerstern MD (eds.)s Ra 1uiiatjops2An
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16. Fackler MLs Letter to the editor. Ann 3nmerq Mod

1985;l4t936-938.
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21. Fackler ML: Letter to the editor. 1npt_ DefZgv (in

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Untersuchungen ueber ale Wirkun(3sseise der Modernen
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Fackler--20

Stangpunktt der umainitaet. llth international

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"c nAnShsyns
S. Ceasel, .G. Fisher & Co,
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Surgery 1946;21:218-239.

32. Kahnoski RJ, Lingemen JE, Coury TA, Steele RA,

Mosbaugh PG: Combined percutaneous and extracorporeal
shock wave lithotripsy for staghorn calculi: An
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33. Kuvahara M, Kambe K, Kurosu S, Orikasa S, Takayama K:

Extracorporeal stone disintegration using chemical
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34. Gill W, Long WB III: Shock Trauma Manual. Baltimore,

Williams & Wilkins, 1978, p 35.

35. Rybeck B: Missile wounding and hemodynamic effects of

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36. Owen-Smith MS: High Velocity Missile Wounds. London,

Edward Arnold, 1981, pp 21-32.

37. Swan KG, Swan RC: Gunshot Wounds: Pathophvsiologv

and Management. Littleton, Mass, PSG Publishing Co
 Fackler--21

1980, pp 7-15.
38. Orlowski T, Piecuch T, Domani~cki J, badowski A:
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40. Whelan TJ Jr: Missile-caused wounds, in Emeroency War
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Washington, DC, Government Printing Office, 1975,
chap 2.

41. Marcus MA, Blair WF, Shuck JM, Omer GE: Lov-velocity
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1064.

42. Morgan M4, Spencer AD,, Hershey FB: Debridement of

civilian gunshot wounds of soft tissue. Trauma
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43. Harvey ZX: Studies on wound ballistics, in
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44. Dziemian AJ, Mendelson JA, Lindsey D: Comparison of
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45. Mendelson JA, Glover JL: Sphere and shell fragment

wounds of soft tissues: Experimental study. J Trauma
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46. Hopkinson DAW, Watts
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47. Fackler ML, Breteau JPL, Courbil LJ, Taxit R, Glas J,

Fievet JPt Open wound drainage versus wound excision
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48. Breteau JPL, Fackler ML, Taxit R, Courbil LJ: Trajet

tN
?ackler--22

lesionnel
in yravguz ouasientifioues
'Wound Profileset vasomotricite cutanee.
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5?. Borden NC% Military surqery. Proc Miit Sure

190009:3-68.

53. Amato JJ, Rich NX, Billy LJ, Gruber RP, Lawson NS:
High-velocity arterial injury: A study of the
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54. Belkin M: Wound ballistics. PrJ Sura 1978;16:7-24.
55. Rich NN, Spencer F: Experimental arterial
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56. Herget 04: Wound ballistics, in Bowers WB:

Surqerv of Trauma. Philadelphia, JB Lippincott Co,
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57. Pavletic 1M4: Gunshot wounds in veterinary medicine:
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58. Scott R: Projectile Trayma an ncnuirv into Bullet
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59. Bellamy RF: Department of Military Medicine,
Uniformed Services University of the Health Sciences
Medical School, Bethesda, Md, personal communication,
1986.
 Fackler--23

60. Hopkinson DAW, Marshall TK: Firearm injuries. DrJ

bra 1967;540344-352.
61. French Rw, Callender GOz Ballistic characteristics of
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62. Amato JJ, Rich NM: Temporary cavity effects in blood

vessel injury by high velocity missiles. CardiovLsc
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64. Kokinakis W, Neades D, Piddington H, Roecker E: A

gelatin energy methodology for estimating
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65. Janzon B, Seeman T: Muscle devitalization in high-

energy missile wounds, and its dependence on energy
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67. Wang ZG, Qian CU, Zhan DC, Shi TZ, Tang CG:
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68. Ziervogel 3F: A study of muscle damage caused by the

7.62 NATO rifle. Acta Chir Scand 1979;Suppl 489:131-
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69. Ferguson LK, Brown RB, Nicholson JT, Stedman HE:
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70. Ireland MW, Callender GR, Coupal JF: The Medical

Department of the US Army in World War I.
Washington, DC, US Government Printing Office, 1929,
vol 12.

---------
Fackler--24

71. Hardaway RM ITI: Vietnam wound analysis. J Trauma

1978;18:635-643.
72. Janzon B: Hioh energy missile trauma. Department of
Surgery II, University of Goteborg, Sweden, 1983.
73. Grennell DA: Favorite loads for favorite guns. Gun
World 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. Int
Pef 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&D
Center, Glynco, GA. personal communication, 1984.
78. Albreht MA: Data presented at the 5th International
Wound Ballistics Symposium, Goteborg, 3weden, 1985, J
Trauma (in press).
79. Stolinski DC: Stopping power--a physician's report,
in Bell EG (ed): Guns and Ammo Annual, Los Angeles,
Peterson Pub Co, 1986.
80. Fackler ML: Letter to the editor. Int Def Rev (in
press March 1987).
 Fackler--k5

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of Health Sciences Commander
Office of Grants Management US Army Aeromedcal Research Laboratory
4301 Jones Bridge Road Fort Rucker, AL 36362.5000
Bethesda, MD 20814.4799
AIR FORCE Office of Scien~tific
US Army Research Office Research (NL)
ATTN: Chemical and Biological Building 410, Room A217
Sciences Division Boiling Air Force Base, DC 20332-6448
PO Box 12211
Research Triangle Park, NC 27709-2211 Commander
USAFSAM/TSZ
Director Brooks Air Force Base, TX 78235-5000
ATTN: SGRD-UWZ-L
Walter Reed Army Institute Head, Biological Sciences Division
of Research OFFICE OF NAVAL RESEARCH
Washington, DC 20307.5100 800 North Quincy Street
22217-5000
Arlington, VA
CommanderI
US Army Medical Research Institute
of lnfe,-tious Diseases
ATTN: SGRD-ULZ.. A
Fort Detrick, MD 21701-5011