Journal of Trauma (China), 6(2) Supplomant: 32-37; 1990. APPLIED WOUND BALLISTICS: WHAT’S NEW AND WHAT’S TRUE Martin L. Fackler, M.D. and Beat P. Kneubuehl*, M. of Math. Letterman Army Institute of Research, Presidio of San Francisco, California, US.A.; Defense Procurement Group 2, Ballistics Division, Ministry of Defense, Thun, ‘Switzerland* APPLICATION ‘The widespread misconception that projectiles possessing “*high-velocity”” or "high-energy" in- variably cause extensive damage” has been addres- sed recently**, The critical reviews that have que- stioned this concept in the past have gone relatively unheeded", Interestingly, those who have que- stioned the *high-velocity/high-energy"” conceptof ‘wounding (Lindsey, Hampton, Fackler) have all had extensive combat surgery experience. Let us consider the most common penetrating injuries of the battlefield. Multiple penetrations fragments from explosive devices are probebly the most common injury seen in most armed conflicts. Figure I shows the trunk of a soldier who has suffered multiple fragment wounds from anexplosivedevice. ‘These fragments generally penetrate no more than 15 cm in human soft-tissue; they cause a punctate en- profile in Figure 2 can be used to demonstrate this Ussve disruption in i Som ofproicct tation where there is no significant temporary cavi- tation, Military rifle bullets cause the same type of wound with negligible cavitation, ‘ion in the first part of produced by projectiles of lesser velocity. Note that Fig. 1. All of the fragments that caused thtse ‘entrance wounds remained in the body. sluced by the far lower velocity bullets. Thousands of these simple perforations of the extremity (Figure 4) are seen each year in our larger city civilian hospitals; the great majority of these wounds are treated with systemic antibiotics but no surgery — they heal well" ‘Before the frenzy of wound ballistics "'research’” that followed the Vietnam conflict, uncomplicated wounds caused by the military rifle (and small frag- ment wounds for the most part) were also treated with little orno surgery — they healed well. Compa- re Stevenson's advice in 1897” against surgical inter- ference with the bullet path in uncomplicated rifle wounds, with Theodor Kocher’s observations from -32-Fig.2. Observe that litle or nocavitation occurs in the last 15 cm of penetration. This last part of the sphere’s path corresponds to what is observed in battlefield casualties, yet most wound ballistics re- searchers who use this projectile concentrate exclu- sively on the initial part of the path. We admit, the first partis more drathatic, but it is not a valid model for application to the wounded combat casualty. World War I; that the minimal damage produced by the rifle bullet allowed the wounds ("..wie Verlet- zungen ohne hautwunde ausheilten."") to heal so well that it appeared as if they had no skin wounds. Jolly, in 1941, noted that '"Many high-velocity builet wounds of soft parts have small punctured wounds of entrance andexit. Often such wounds do not require operation; and if operation is performed, nothing more than excision of the orifices of the track to provide better drainage need be undertaken. Such wounds usually heal spontaneously within ten days. The high velocity bullet, unlike other projectiles, does not usually carry foreign matter into the tissues and tends to leave an aseptic track."” * Bailey, in 1942!, advised that the "’.. .seton wound is innocuous, it should be left alone.”” Fergu- sonetal"®, Slesinger”, Crile*, and Cope’ made similar Fig. 3. Comparison of the first 12 cm of the projectile path in the five wound profiles pictured shows why the wounds from "'high-velocity” rifle bullets may be no more disruptive or dramatic than many simple extremity wounds caused by lowest velocity handgun bullet. observations, and Ogilvie, consultant surgeon to British forces in World War Il, listed as his first sin" of war surgery the unnecessary operations on through and through bullet wounds of the soft parts, stating that '"The majority of these with rest and sulfonamide heal rapidly and leave no disability; ‘operation means loss of time and loss of function.’ King®, reporting on war wounds from South Vietnam, wrote that ""Uncomplicated perforating soft-tissue wounds were the most common bullet ‘wounds of the extremities; they showed small entry and exit wounds and a clean soft-tissue track with little or no devitalisation of tissue. They usually healed if left alone.” ‘The first author ofthis paper served in one of the busiest US Military hospitals in South Vietnam (Naval Support Activity Hospital, DaNang) duringFig. 4. This through and through wound of the plantar surface of the foot was caused by an’M-6 rifle bullet at close range. The tissue disruption was ne the most active period of the Viemam .conflict (December 1967 to December 1968). Immediately thereafter he served three years at the US Naval Hospital, Yokosuka, Japan, caring for the combat casualties from South Vietnam who were transpor- ted there by air as soon as they could be moved after their primary surgery. He was also a delegate to the lasttwo Tri-Service War Surgery Conferences (1970, 1971. The amount, type, and location of tissue disruption, determined objectively by physical exa- mination and appropriate roentgenographic studies was the information on which this author and his colleagues based their treatment of penetrating war ‘wounds?, Should not the battlefield experience guide wound ballistics research? The Viemam war surge- ry conferences did not identify any special problems associated with "high-velocity" projectile wounds. ‘The last conference listed **Topics suggested for farther study”, but no need to study penetrating projectiles (wound ballistics) was mentioned. Despite this, extensive wound ballistics study pro- ‘grams were inaugurated, including the six Interna- tional Wound Ballistics Symposia. Itappears thatthe motivation for these studies was something other than improving the care of the battlefield wounded. Speculating on motives at this point is probably not fruitful, but the applications of the resulting stu- dies— the effects of this research — need no specu- lation, They are clear. Most wounds seen on the battlefield are simple and have been treated by simp- Je means with good results for the past hundred unnecessarily projectile wounds, and assuming that all battlefield wounds fall into this category the overall effectof the past twenty years of wound ballistics research can only be considered a giant step backwards. ‘WHAT'S NEW Many suppose that one must have expensive and sophisticated equipment to do useful and valid work in wound ballistics. We suggest that a chrono- graph, available for just a few hundred dollars, and some tissue simulant in which bullet deformation and penetration depth reflect that observed in living animal tissue, are all that is really needed to determi- ne the wounding potential of penetrating projectiles. Ordnance gelatin, provided itis made and stored properly’, and shot while at a constant and uniform known temperature, gives the most information. Projectile penetration depth, projectile deformation, ‘Projectile fragmentation pattern, and temporary cavity configuration can be determined for each shot’. Soap can be used to determine all of these except fragmen- tation patter; the partial persistence of the tempors- ry cavity distorts the pattern of fragments as compa- Ted to that seen in animal tissue. ‘Tissue simulants such as clay and ductseal should be avoided because they cause far greater projectile deformation’ and much less penetration depth than seen in animal tissue (Figure 5). Water can be usedFig. 5. Shots from a 45 ACP handgun with ‘Winchester Silvertip bullets are shown in three materials. The top block is clay and was shot at 20 degrees C; the bullet expanded to a diameter of 22 mm and penetrated 8.6 cm. The center block is ‘Swedish soap and was shot at 20 degrees C; the bullet expanded to a diameter of 20 mm andpenetrated 20 cm. The bottom block is 10% ordnance gelatin and ‘was shot at 4 degrees C; the bullet expanded to a diameter of 20mm and penetrated toadepthof 26cm as a tissue simulant and causes just slightly more bullet deformation than gelatin or soap; the Firearms Training Unit of US Federal Bureau of Investigation usesitasascreening medium to decide which bullets expand well enough to merit further scrutiny’. Penetration calibration studies, done recently at the Letterman Army Institute of Research, in which 43 mm (0.17 inch) copper-plated steel spheres, weighing 0.34 gm (5.3 grains), were shot at 593 +13 fs (81 + 4 mys), gave the following penetration ‘As can be seen from these results, ordnance -35- gelatin changes its characteristics considerably with temperature; penetration depth increases 82% as the ‘block temperature increases from 4 to 20 degrees C. Soap also changes with temperature; penetration depth increases 38% over this same 4 to 20 degree temperature range. It is mandatory to report the block temperature in’ any study using gelatin and strongly recommended when using soap. We must not forget that the purpose of scientific communica- tion is to learn from the comparison of data; suffi- cient detail must be given so that others can accura- tely reproduce the experiment in order to have valid comparisons. Currently, at the Letterman Army Institute of Research, we are using a one-half mi duration flash system to study bullet yaw behavior in ordnance gelatin. This equipment also allows us to visualize temporary cavitation (Figure 6). Advanta- ges of this system over high-speed cine include its cost (each flash apparatus costs only about $3500) and the time saved in its use. By exposing a polaroid camera simultaneously with a standard film camera itis possible to find out in just a minute if the desired result has been obtained from a shot. With cine ‘equipment one must wait for the film to be developed and then retum another day for additional shots if the result is not ideal. The one-half microsecond flash also allows us to freeze rifle bullet images of shots in 88416 em 8.5+0.4cm 4.4+0.2cm 8.0+0.2cm 4.203cm $.8+0.4cm air. This most useful feature permits the use of thisFig. 6. A45 ACP Winchester Siivertip bullet fired into 10% ordnance gelatin at 4 degrees C is shown with the maximum temporary cavity captured witha one-half microsecond flash. Thebulletexpan- ded to 20 mm, Using acalipers the maximum tempo- rary cavity diameter (11.9cm) can be measured from this film by using the bullet as a scale. There should be no parallax error since the bullet is the same distance from the film plane as the cavity. equipment to study bullet yaw in air whereas during the longer exposure time of the high-speed cine most rifle bullets move 5 to 10 cm in air and appear on the film only as a blur. WHAT'S TRUE We suggest that the interested reader doesn’t need us to tell him "what's true’ (and what's not) in wound ballistics. We suggest that he take a long, hard, and critical look at the literature himself. Compare results. Hard physical data measured from shots into suitable tissue simulants and photos of shots into animals (including battlefield and civilian ‘wounded) will provide a sound basis for validating findings or detecting inconsistencies. The historical and critical review papers given as references will provide a further resource and a basis to compare from a historical perspective. The reader who takes this suggestion will be well prepared torecognize error when itis published. Only if sufficient numbers of interested and infor- med readers let journal and book editors know that continued publication of blatant error presented as unqualified fact will no longer be tolerated can the field of wound ballistics evolve into a respected and uly scientific discipline. SUMMARY There comes a time of reckoning, when overail effects of research results must be evaluated. In our view, wound ballistics researchis supposed to.id the surgeon in providing optimal care for the wounded. Unfortunately, in the past twenty vears, most of the work in this field has deen counterproductive to this objective. As a result, today -nany surgeons are likely to do unnecessarily radical or crippling 2xci- sions of tissue if the word ""high-velocity”” is men- tioned in connection with the wound they are trea- ting. ‘Themostcommon battlefield voundhasasimrle unciate entrance with dssue disruption limited toa diameterno larger than the wounding projectile, The rifle wound of the extremity, in which the tissue path is limited to that initial portion of zhe wound profile where the bullet has not yet yawed, and virtually all individual wounds from explosive device fragments fall into this category. The tissue disruption observed with this kind of wound is no greater than that seen in most handgun wounds. Viewed rom the histori- cal perspective, this type of rifle wound as een singled out inthe literature because of its propensity to heal well despite litle or no treatment — even in preantibiotic days. ‘The amount, type, and location of tissue disrup- tion, determined objectively by physical examina- tion and appropriate roentgenographic studies, ze- ‘mains today, as it has throughout history, the critical information that should be used by she battlefield surgeon to determine treatment, -36-REFERENCES L Bailey H: (ed) Surgery of Modem Warfare. 2aded, Vol I. Baltimore, Williams & Wilkins. 1942: 6. . 2. Commander in Chief Pacific (CINCPAC). ‘War Surgery. (Proceedings of the Commander in Chief Pacific Fifth Conference on War Surgery, 29 March - 2 April 1971, Fokyo, Japan). 1971, p. 33. (Available from CINCPAC, Attn: Surgeon, FPO San Francisco, California 96610, U.S.A.) . 3.CopeZ: (ed) Surgery. London, Her Majesty's Stationery Office. 1953: 29. 4. 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