CONTEMPORARY ISSUES IN TRAUMA 0733-8627/98 $8.00 + .

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CIVILIAN GUNSHOT WOUNDS

AND BALLISTICS: DISPELLING
THE MYTHS
Martin L. Fackler, MD, FACS

Few fields of endeavor have such solid exact science underpinnings

as wound ballistics, yet, despite this well-established capacity to define
and clarify bullet effects on the body, the understanding of wound
ballistics among health care providers continues to be plagued by igno-
rance about firearms. Misinformation in the medical literature can ad-
versely affect the care of those wounded by gunfire and also undermine
effective measures aimed at preventing future firearm-related violence.
This review attempts to dispel1 the myths that have arisen concern-
ing wound ballistics and to suggest a role that emergency physicians
can play to improve the situation for those wounded by gunfire.

BASIC WOUND BALLISTICS: SCIENTIFIC

UNDERPINNINGS

Wound ballistics is the study of the interaction of penetrating

projectiles with living body tissue. It is supported by a solid foundation
of exact science, beginning with Newton’s Laws of Motion.24Several
centuries of observations of wounds and treatment from the battlefield
and recorded by military surgeons have reinforced this f~undation.~-~, IR,

19, 21, 26, 29 The high-speed imaging and measurement techniques of the
present century have defined and clarified the mechanisms by which
penetrating projectiles disrupt tissue.15 The bullet crushes sufficient tis-
sue to make a hole (the permanent cavity) through which it penetrates,

From the International Wound Ballistics Association, Hawthorne, Florida

EMERGENCY MEDICINE CLINICS OF NORTH AMERICA

-
VOLUME 16 * NUMBER 1 FEBRUARY 1998 17
18 FACKLER

and, if traveling at sufficient speed, it impels the walls of the permanent

cavity radially outward to form a temporary cavity. The temporary cavity
is comparable to the splash formed by throwing a stone into a pool of
water-it is nothing more than a ”tissue splash.” A third mechanism,
the forcing aside of tissue by the powder gases that follow the bullet
out of the barrel, occurs only in wounds in which the gun‘s muzzle is
in contact, or nearly in contact, with the skin at the time of firing. Any
damage to tissue, other than that caused by crushing from direct impact
of the penetrating missile, is due to the stresses caused by tissue being
displaced by the temporary cavity or by powder gases.5, The interaction
of penetrating projectiles with tissue is purely mechanical and not diffi-
cult to understand.
For more than a century, shots have been fired experimentally into
various materials to study and illustrate projectile effects, but it has been
for only the past 12 years that we have had a scientifically valid tissue
simulant, calibrated for penetration depth against living animal tissue.6
Using this calibrated tissue simulant (i.e., 10% ordnance gelatin), we
have developed a standardized method for measuring and illustrating
both the permanent and temporary cavities produced by a given
projectile. The projectile is shot into the gelatin, with blocks large enough
to catch the entire projectile path being used, and measurements taken
from the gelatin are provided as illustrations with a measuring scale so
that any dimension of the temporary or permanent cavity can be deter-
mined at any penetration depth. The validity of these illustrations, called
wound profiles (Figs. 14), has been verified by comparing them with
measurements taken from human a u t ~ p s i e sThese.~ profiles have given
a valid method for comparing the effects of different projectiles, have
been a useful aid in teaching the principles of wound ballistics, and
have provided a useful method for predicting the disruption potential
of various projectiles, of which the mass, speed, and type are known.
MacPherson has collected much of the information outlined above,
added data from his own experiments, and published a unified pre-
dictive mathematical model of bullet p e n e t r a t i ~ n . ~ ~

THE HIGH-VELOCITY MYTH

The false belief that a bullet damages tissue in direct proportion to

its velocity is widespread. In the trauma surgery literature is found such
irrational and unsupported advice as ”aggressive resection is particu-
larly indicated for high-velocity* weapon injuries in which tissue dam-
age is usually more extensive than can be visually appre~iated.”~~ This

*In British usage high velocity means 1100 ft/sec (the speed of sound in air or higher).
Some American authors use 2000 ft/sec, some 2500 ft/sec, and some 3000 ft/sec as the
lower limit for high velocity, but most writers simply use the term without defining its
meaning. The precision needed for scientific communication can be attained only by
defining bullet velocity using exact numbers or numeric velocity ranges.
 CIVILIAN GUNSHOT WOUNDS AND BALLISTICS: DISPELLING THE MYTHS 19

assertion maintains that even though the tissue around the path of what
we have been told is a ”high-velocity” projectile might appear normal,
it has been irreversibly damaged and must be excised. Physicians misled
by such information may feel justified in excising large amounts of
normal tissue because of the presumed high velocity of the bullet.
The history of small arms development, the physics of penetrating
projectiles, bullet testing, and even a thoughtful consideration of present-
day emergency department experience combine to disprove the high-
velocity myth.
The last two decades of the 19th century saw the largest velocity
increase in the history of bullet development. It was made possible by
the inventions of the jacketed bullet (in which the bullet’s soft lead core
was covered with a layer of harder metal) and smokeless gunpowder. If
the high-velocity myth were true, these new bullets should have in-
creased wound severity dramatically. In fact, a striking decrease in
wound severity was reported from all battlefields where these new high-
velocity bullets were used.17,22, 23, 32 This apparent incongruity illustrates
a point crucial to the understanding of wound ballistics: the tissue
disruption produced by a projectile depends as much on its shape,
construction, and mass, as on its ~elocity.~, The decreased tissue disrup-
tion produced by the first jacketed bullets, compared with their prede-
cessors, illustrates this point well and can be explained by comparing
respective wound profiles (Fig. 1). The behavior of the 6.5-mmn Mann-
licher-Carcano bullet (Fig. 1, bottom) is typical of the first generation of
jacketed bullets (or full-metal-jacketed [FMJ] bullets). The diameter of
these bullets was smaller (25 to 30 caliber compared with 40 to 45
caliber), and their mass about one half that of the previous lead bullets.
This decrease in mass was needed to keep rifle recoil manageable at the
greatly increased velocity. The long, round-nosed, small-caliber bullets
tended to remain stable and travel point forward in body soft tissue
until they had penetrated 2 ft or more. Being considerably harder than
lead, the jacketed bullets did not flatten or deform in human soft tissue.
They made small punctate holes with minimal tissue disruption, unless
they struck bone, which could cause them to deform or yuw (a yawing
bullet is not pointing in the exact direction of its path). Yawing bullets
strike more tissue and produce a larger temporary cavity (note the last
half of the projectile path in Fig. 1, bottom).
Figure 1 also shows the wound profile of the Vetterli bullet, typical
of the conoid solid-lead bullets that preceded the jacketed bullets. Al-
though the velocity of these lead bullets approximated that of some
present-day 22-caliber rimfire bullets, their diameters were large (41 to
45 caliber), and they weighed from 300 gr to 500 gr. The tips of these
large soft-lead bullets flattened on striking the body, causing them to
assume a mushroom shape and double their diameters. The blunted
shape of the flattened bullets, in addition to making a larger hole, caused
them to produce temporary cavities as large as those made by a modern
M-16 rifle bullet (Fig. 2).
Military FMJ bullets produce minimal tissue disruption at the begin-
20

1
FACKLER

Temporary Cavity
-
VETTERLI 1 0 4 rnm LRN
Vel-1357 lis (414 mis)
WI-30C gr (19.4 gm)

Ocm 5 10 15 20 25 30 35 40 45 50

Permanent Cavity
-
6 5 mm Mannlicher-Carcano
(635 m/s)
Vel-2085 I/$

--.__.I.
8
* ~ -

Temporary Cavity A+.

0 cm 25 50 75 100 106

Figure 1. The wound profile at top was produced by the Vetterli bullet. Typical of bullets
used by military forces in the latter half of the 19th century, this large lead bullet flattens
on striking living animal soft tissue. This expands its diameter and also gives it a blunt
(nonaerodynamic) shape that, despite the bullet‘s “low” velocity, produces a substantial
temporary cavity. The 44 magnum hollow-point bullet, shot from a rifle (most commonly
used in handguns), is a modern bullet that produces a wound profile similar to that of the
Vetterli bullet. All modern expanding handgun bullets (hollow-point or soft-point) produce a
wound profile similar to that of the Vetterli bullet. The maximal diameter of the temporary
cavity increases with both bullet velocity and mass, and the depth of penetration increases
mostly with bullet mass. An expanding handgun bullet that does not mushroom (many do
not) penetrates to about twice the depth of one that doubles its diameter, and makes a
much smaller temporary cavity.
The wound profile at bottom was produced by the 6.5 Mannlicher-Carcano FMJ bullet.
This bullet penetrates animal soft tissue without deforming, usually to an average of 61 cm
before beginning to yaw, accounting for its deep total penetration. When a bullet’s tissue
disruption potential is spread over a long penetration depth, the disruption caused per
centimeter of travel is small. This is the caliber and bullet type that was used in the
assassination of President Kennedy. If the wound profile illustrating the deep penetration
potential of this type of bullet had been available at the time of the investigation into this
murder, it would have allayed any doubt about the capacity of a single 6.5-mm bullet to
pass through the base of President Kennedy’s neck, continue through the chest of Governor
Connally, and then pass through his wrist (including the distal radius) before penetrating
the thigh.

ning of their tissue path, where their velocity is the highest; this fact
alone provides sufficient refutation of the high-velocity myth. The dis-
tance these bullets travel before they yaw-rather than their velocity-is
the major determinant of the tissue disruption they cause. In the civilian
equivalent of the modern military rifle bullet (Fig. 3), however, the bullet
begins to deform in the first inch or so of its tissue path and does not
have the inherent variation in the distance of penetration before yaw
 CIVILIAN GUNSHOT WOUNDS AND BALLISTICS: DISPELLING THE MYTHS 21

-.----.-

I Detached Muscles

Permanent Cavity

IT=:;
ce--L
70%
*---

Temporary Cavity
Bullet Fragments -.__.._--’
I
5 10 15 20 25 30 36 40 45

Figure 2. Variations in the wound profile produced by the M-16A1 FMJ bullet, illustrating
the variation in wound profile inherent in the FMJ-type military bullet. In seven of ten cases
the distance before yaw in the M-16A1 FMJ bullet will be within f 25% of that shown on
the middle profile. The middle profile is the average seen in about 70% of cases, the top
and the bottom profiles will occur in about 15% of cases (each). There may be some cases
in which yaw occurs earlier or later than shown. Some observers in Vietnam thought the
M16 was “terribly destructive”; others found it minimally disruptive. Most of the observers
had seen few if any gunshot wounds before, and their knowledge of the circumstances
surrounding the shootings was incomplete at best. Add to this the inherent variation
illustrated, and it is easy to see why there was confusion. As shown, the variations in
wounding pattern depend on the variable distance before yaw.

that makes the effects of the military type bullet somewhat unpredict-
able. In the civilian hunting bullet (of hollow-point or soft-point design)
the hard jacket does not cover the bullet’s tip. This weakens the tip and
ensures consistent expansion of the bullet (with concomitant increased
tissue disruption) early in its tissue path. These so-called expanding or
mushrooming bullets are mandated by law for hunting because they
consistently cause the increased tissue damage needed to kill the animal
hunted, whereas the military type bullets (Fig. 4) are far more likely
merely to wound the animal.
Failure to understand this basic difference in bullet type and the
inherent variation in the damage profile caused by the military type
bullet may cause confusion among clinicians. Even many of those with
considerable experience treating gunshot wounds would deny that it is
22 FACKLER

Bullet Fragments
Detached Muscl

Vel-2923 fis (891 mis)

Wt-150 gr (9 7 gm)
Final w1-99.7 gr ( 6 46 gm)
33.4% Fragmentation

ocm 5 10 15 20 25 30 35 42

Figure 3. Wound profile produced by the 7.62 NATO cartridge loaded with a soft-point
hunting bullet, more commonly known as the 308 Winchester to civilians. This bullet
expands to more than double its original diameter, within an inch or two of striking tissue,
and loses about one third of its weight in fragments. These fragments cause multiple
perforations of the tissue surrounding the bullet path-penetrating up to 9 cm radially. Then
the large temporary cavity violently displaces this tissue, which has been weakened by
multiple perforations by fragments. The synergy between fragmentation and cavitation
results in detachment of pieces of muscle and adds to the permanent cavity dimensions.

7 62 mm NATO
Vel-2830 fis (862 mis)
Wt-150 gr (9 7 gm) FMC

, Permanent Cavity

Ocm 5 10
,

15
v,
20 25 30 35 40
Temporary Cavity

45 50 55 60 64

Figure 4. Wound profile of the military 7.62 NATO rifle bullet. The wounding potential of
this bullet is the same as the bullet shown in Fig. 3 (masses and velocities are similar). It
penetrates to about 15 cm before yawing, however, (the yaw pattern is subject to the same
variations shown in Fig. 2) and does not deform or fragment. The wound it produces in
most parts of the body therefore is likely to be far less disruptive than that produced by the
soft-point bullet with the same wounding potential (Fig. 3). If the FMJ bullet hits bone,
however, the bullet can deform and fragment. The wound it then produces can approach
those produced by the soft-point bullet in severity.
 CIVILIAN GUNSHOT WOUNDS AND BALLISTICS DISPELLING THE MYTHS 23

possible for a military M-16 bullet, traveling at 3100 ft/sec (see Fig. 2),
to perforate a 12-cm thick human thigh and cause no more damage than
a 22 long rifle bullet traveling at 1200 ft/sec; or for an AK-47 military
bullet, traveling at 2300 ft/sec, to perforate a human torso and cause no
greater damage than a 38 Special handgun bullet traveling at 800 ft/
s ~ c . ~Both
, are common occurrences, however. A bullet’s potential for
disrupting tissue depends on its mass and its velocity: the realization of
this potential, however, is determined largely by the bullet’s construc-
tion.
Those with experience in urban emergency departments need pon-
der only their own observations to reject the high-velocity myth. One
need only compare the tissue disruption caused by a 22-caliber rimfire
bullet with that caused by a 44-Magnum hollow-point bullet and then
compare both to the disruption caused by a load of 00 buckshot fired
from a 12-gauge shotgun-all three fired from a distance of about 15 ft.
In shotgun wounds at distances < 20 ft the pellets hit so close together
that they shred the tissue for a diameter of up to 10 cm; no other small
arm causes such extensive tissue disruption. It is clear that the shotgun
causes far more disruption than does the 44 Magnum, and the 44
Magnum causes far more disruption than does the 22. The projectile
velocity in all three cases, however, is about the same.
Other assertions, such as the ”kinetic energy deposit” from a bullet
acting as a mechanism of injury, have been disproved el~ewhere.~, y, l 1

The high-velocity myth, however, is the one most likely to mislead

health care providers confronted with victims of urban violence.

“FIREARM ILLITERACY”: CAUSES AND

CONSEQUENCES

An ignorance about firearms-a kind of ”firearm illiteracy’’-is

increasing in the United States. Mistaken ideas about bullet effects
dominate the public’s perceptions, including health care providers.1h
Some of the factors causing or contributing to this are listed here.

Exaggeration and Sensationalization of Gunshot

Effects by the Entertainment Industry

American history has provided a never-ending source of material

for the entertainment industry. Western movies invariably show persons
being shot. These shootings are almost always sensationalized; the per-
son struck is shown being driven backward by the bullet, usually
knocked off his feet. In fact, bullets do not possess enough momentum
to move a human body p e r c e p t i b l ~ This
. ~ ~ can be verified by anyone
curious enough to study a few documented shooting incidents, or one
can compare the results of bullets striking human-sized animals (e.g.,
deer). Actors also usually show an immediate reaction to being shot:
24 FACKLER

spurting blood or collapsing. The most common reaction to being struck

in the torso by a bullet is to show no immediate sign of being hit.
Debriefings of law enforcement officers who have been in gunfights
reveal their surprise at the lack of any immediate outward sign that the
bullets had struck their adversaries (Personal communication: Horn JM
SSA, FBI; Chief, Critical Incidents Unit, Quantico, VA, 1992). They often
became confused and sometimes terrified because the person shot con-
tinued shooting back at them.

Exaggeration and Sensationalization of Gunshot

Effects by the News Media

“Black Talon” Bullet

In November, 1994, a major TV network ran a program, ”Deadly
Bullets,” about the Black Talon, a hollow-point handgun bullet devel-
oped by Winchester. Program participants claimed that this bullet causes
such ”carnage” that it ”should not exist in a civilized society.’’ An
animation of the human torso showed what purportedly differentiates
the Black Talon from less destructive ammunition. A conventional bullet
bored a hole straight through the body, but the Black Talon penetrated
through the torso, and, instead of exiting when it reached the opposite
abdominal wall, it turned sharply about 120 degrees, penetrated down-
ward for 6 or 7 inches, then turned sharply again, forming a triangle by
going back across the first leg of its path. The Black Talon was shown
producing a path of destruction about 3 inches in diameter. No penetrat-
ing projectile can produce a path in the body with angles that even
remotely resemble those depicted for the Black Talon. The 9-mm Black
Talon’s expanded diameter is about one half-inch; a one half-inch diame-
ter handgun bullet cannot destroy a cylinder of tissue 3 inches in
diameter.
Actually, the sharp edges of the folded-back jacket of the Black
Talon provide a cutting mechanism, which makes up for the decrease
in the tissue crush mechanism as the bullet slows during tissue penetra-
tion. This gives the bullet a more even and reliable tissue disruption
throughout its penetration than do other expanding bullets (that lose
effectiveness as their velocity decreases during the latter part of tissue
penetration).

Gun Prohibitionist Political Propaganda

No honest review can ignore the contamination from this distasteful
source: increasing in the past decade, it has recently found its way
even into ”respectable” medical journals. How much advese effect this
misinformation is having on patient care is, as yet, unknown. This
problem is well described in the comprehensive review by Kates et a1.16
 CIVILIAN GUNSHOT WOUNDS AND BALLISTICS DISPELLING THE MYTHS 25

GUIDELINES FOR THE EMERGENCY CARE OF THE

GUNSHOT WOUND PATIENT

Attain an Adequate Circulation Blood Level of a

Penicillin Penicillin-Spectrum Antibiotic on All
Gunshot Wound Patients as Soon as Possible.

Health care providers need not understand the intricacies of wound

ballistics to treat gunshot wound victims properly. What they must
know, however, is that penetrating projectiles invariably carry bacteria
into the wound; a bullet is not sterilized by being fired.2",33 Group A
beta-hemolytic streptococcus bacteria, because of its capacity break
down the body's fibrin barriers and spread by enzymatic action, has
throughout history been the major cause of mortality in battlefield-
wounded patients.'2, 31 Since World War 11, however, beta-hemolytic
streptococcus bacteria has nearly disappeared from battlefields because
antibiotics have been used in treating virtually all of those wounded by
projectiles. Fortunately, streptococcus has remained sensitive to penicil-
lin penicillin-spectrum antibiotics, which are also effective against Clos-
tridia spp., which cause gas gangrene.', 28, 3(1

Resuscitate and Treat the Patient Wounded by

Penetrating Projectiles the Same as the Victim of Any
Other Trauma.

Determine the location, type, and amount of the tissue disruption

using a physical examination and appropriate radiographic studies.
Then "treat' the wound, not the weapon." Even were the high-velocity
myth true, it would be of little use in practice. Outside of the wound
ballistics laboratory there are few situations in which the health care
provider has any reliable indication of the bullet's velocity and type.
Victims of gunshot wounds are often likely to misrepresent the events
surrounding shooting, including the weapon type and distance of fire.
Determining which radiographic studies are needed requires coop-
eration with the trauma surgeon, but clinicians should be aware of
excellent studies that have shown that a good physical examination
can reduce the number of unnecessary angiograms for penetrating or
perforating wounds of the e~tremities.'~, l4
The chief cause of confusion in wound ballistics is how to treat the
least serious wounds-uncomplicated (e.g., no artery or bone disruption)
gunshot perforations of the extremities. A simple punctate perforation,
with no indication of significant tissue disruption surrounding the
bullet's path, can be produced by nearly any handgun bullet or a
military FMJ rifle bullet (see Figs. 1, 2, and 4), or a single pellet from a
load of buckshot from a shotgun. This type of wound is treated conser-
vatively (i.e., without surgery), with good results in most civilian hospi-
tals. These injuries are mostly caused by handguns. This type of injury
26 FACKLER

has also been treated conservatively and with excellent results on most
military battlefields of the past century, where it was most often caused
by a rifle bullet.lO,18, 23, 32 A wound of this type may cause trauma
surgeons misled by the high-velocity myth to open the whole wound
and potentially do more harm with the treatment than was done by the
bullet, particularly if they suspect that the wound was produced by an
"assault rifle" bullet (or any other high-velocity projectile).
This is not to say, however, that a bullet could not cause consider-
able disruption in the muscles of the extremity and still have a small
punctate entrance and exit wound. Such a wound of the extremity
should be easily diagnosed by a careful physical examination and roent-
genographic evaluation, however. If there is significant buried tissue
disruption, the patient should have the wound opened widely, have
obviously nonvital or seriously disrupted tissue excised, and then the
wound left open to be observed in 2 days. If at that time no more tissue
has become nonvital, it should then be left open for another few days
and then closed with micropore paper tape (after tincture of benzoin
has been applied and allowed to dry thoroughly on the cleaned and
defatted skin edges) rather than sutures being used.
Marginal cases should be watched closely and opened for decom-
pression if there is any indication of a compartment syndrome. Although
prioritization of treatment in civilian hospitals is not as vital as in the
military setting, the emergency physician should be aware that when an
extremity wound is well decompressed (either by surgery or by the
tearing of constraining tissues by the temporary cavity produced by the
bullet itself), and the patient is on an adequate dose of a penicillin
spectrum antibiotic, the actual removal of severely disrupted tissue
appears to be done as well by the body's own defense mechanisms as
by scalpel.1o

Record the Location (Measured from Appropriate

Landmarks), Size, and Shape of Each Aperture Made
by a Penetrating Projectile.

One should look for and describe any soot deposits or punctate
marks on the skin made by powder particles associated with any of the
projectile-produced wounds. The best way to avoid having to appear in
court to testify about the appearance of a gunshot wound is to record
these data, and not to theorize about the direction of fire. Direction of
fire is a forensic opinion, and clinicians untrained in that field should
concentrate on recording accurate physical findings.

CONCLUSION

This purpose of review is to help clinicians handle some practical

and difficult problems not been previously addressed effectively in the
 CIVILIAN GUNSHOT WOUNDS AND BALLISTICS DISPELLING THE MYTHS 27

medical literature. To shrink from discussion of such problems because

they are unpleasant and difficult is to encourage their persistence and
unnecessarily endanger the lives of those wounded by gunfire.
Ideally, the solid science supporting wound ballistics should be
translated into improved care of those wounded by gunfire. Practically,
however, serious impediments to this goal exist: increasing ”firearm
illiteracy,” and inaccuracies in both the medical literature and lay press
that have combined to confuse and mislead clinicians and degrade their
ability to provide acceptable care to gunfire victims.
The emergency physician, understanding the information provided
herein, can play an increasingly critical role in helping to improve the
care of the gunshot wound patient.

References

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668-680, 1947
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21. Larrey Baron JD: Memoires de Chirurgie Militaire et Campagnes. Paris, Chez J
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Martin L. Fackler, MD, FACS
211 Star Lake Drive
Hawthorne, FL 32640