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JR Army Med Corps 1988; 134: 119-125

Wound Ballistics: Contemporary and Future Research

• Lieutenant Colonel J M Ryan*t
FRCS,RAMC
Senior Lecturer in Military Surgery

eGraham J Cooper*
PhD
Senior Lecturer in Trauma Science and Head of Trauma Section

• Dr Robert L Maynard*
BSc, MB, BCh
Senior Lecturer in Clinical Pharmacology and Superintendent Medical Division

* The Ministry of Defence, Chemical Defence Establishment, Porton Down, Salisbury, Wilts. SP40JQ

•• t Also Consultant Surgeon - Princess Alexandra Hospital, RAF Wroughton, Swindon, Wilts.

SUMMARY: Wound ballistics research has contributed much to the understanding of the pathophysiology of missile
injury that now exists. From this store of knowledge treatment regimes have evolved which have greatly improved the lot
of the soldier wounded in war. However, research must keep pace with changes that are taking place in weapons research
• and development so that the particular needs of the Army Medical Services on a future battlefield can be met. The
.. differing needs of civilian and military medical services are highlighted. The marked differences that exist between the
missile wound seen and treated in a late twentieth century hospital and the wounds likely to be encountered on the modern
battlefield are enumerated and discussed.

a.. Introduction century, penetrating bullet wounds became a common

... A Medical Officer attempting to review the wound feature of European battlefields and became the object
ballistics literature which has appeared over the last 10 of study by the military surgeons of the day. These early
years would be faced with a bewildering mountain of pioneers have left us a rich written legacy, much of it still
papers from a large number of research centres. Much relevant. Ambroise Pare spent over 30 years in the
of the research has been conducted by non-medical French Army and wrote extensively on the subject of
l, scientists, including engineers, physicists, biochemists wounds caused by firearms, His works, translated into
"and weapon technologists. The consequence of this is English by Thomas Johnson, remained a standard
that many papers are unfamiliar in presentation and reference work on treatment for a century following his
technical content to medical readers. This has led to death 6 , In Great Britain, over a century later, John
misunderstanding and misinterpretation by some, Hunter published his celebrated treatise on gunshot
Lt particularly surgeons, as a critical review of ballistics wounds 7 . Like Pare's work it became a bench mark for
-..articles in the surgical journals reveals 1,2, military surgeons.
The aim of this paper is to review the more important
and controversial papers and to explore, examine and Research in the nineteenth century:
explain, in context, the views stated and conclusions Modern ballistics came into being in the middle of the
drawn. This would seem to be of particular importance nineteenth century with the recognition of wounds
• at the present time in view of some recent publications caused by high velocity bullets from rifled muskets. The
in the world literature. These, at first sight at least, pattern of injury in such wounds was widely reported in
appear to contest the orthodox in the wound ballistics many countries8 ,9,1O,1l,12.
area that finds acceptance in this country and in the There followed the first controlled experiments on
Army Medical Services in particular3 ,4,5, injuries produced by high-velocity projectiles l3 . In the
In addition the opportunity is taken to suggest where United Kingdom a series of experiments by Horsley
• future ballistics research pertinent to the requirements using clay, soap and anaesthetised dogs demonstrated
of the Army Medical Services should be directed. lateral disturbance of tissues following the passage of
high-velocity missiles l4 , He concluded that wounding
Historical power was a consequence of energy transfer to the
Early Observations particles of tissue which are "hurried forward" enlarging
~ Wound ballistics research is not new. With the advent the wound track, In 1897 Stevenson, the Professor of
• of an efficient handgun in the middle of the sixteenth Military Surgery at Netley conducted a series of
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120 Wound Ballistics: Contemporary and Future Research

experiments firing high-velocity missiles through open gangrene in high velocity bullet wounds of
and closed lead cans filled with water. He demonstrated muscle 22 .That contamination, studied experimentally.
for the first time that the lateral displacement of tissue, by Owen-Smith and Matheson, occurs in practice has
in this case water, followed the passage of the missile 15. been confirmed by numerous workers20.23.R25.26. It has
This phenomenon of energy transfer associated with been shown that muscle damage beyond the limits of the
displacement of tissue was also noted during permanent wound track favours the growth of numerous
experiments conducted in the United States and was organisms, particularly Cl tetani and Cl welchii. The
called cavitation by Woodruffl6. pathol03~ of wounds other than in muscle was studied.
by Scott . Although macroscopic chan~es in brain and
The Twentieth Century: liver had been described as early as 1957 8 it was not until
Little further progress was made until, using clay 1976, following Scott's experiments on liver and brain,
models, Callender and French clearly demonstrated the that there was much understanding of the cavitation
cavitation process and showed the importance of effect on these organs.
retardation in the energy transfer/wound severity His conclusions were that Hopkinson's earlier.
equation. They examined the effects of velocity, missile histological description of the muscle wound was
geometry, mass and stability and they propounded applicable to the liver. He noted also that altered cell
certain definitions and formulae in an attempt to make viability beyond the area of cavitation could extend to
the subject understandable to the Military Surgeon 17. the liver capsule. Skull injury following the passage of a
U sing spark photography, Zuckerman and his high-velocity missile was studied using dried human:
colleagues showed that cavitation would also occur in an skulls (some of which were empty and some of which'
elastic tissue simulant l8 . With the advent of high-speed were filled with 20% gelatin and covered either with
cinematrography Zuckerman's work was carried further chamois leather or a helmet). Scott clearly
by Harvey and his colleagues at Princeton. They demonstrated the marked increase in severity of fracture
confirmed the relationship of cavitation effect to missile in the skulls filled with gelatin. Using anaesthetised _
velocity and reiterated the kinetic energy equations animals he went on to demonstrate macroscopically and:#..
propounded by Callender and French l9 . histologically the damage presumably caused by
cavitation in the mammalian brain 27.
Contemporary Research In a further series of experiments Scott looked at the
Experimental work using cadavers, clay and elastic effect of altering impact velocity in wounds to pig colon. _:A
tissue simulants such as 20% gelatin are limited in their Using a deformable soft pointed hunting bullet (Hornet .-
scope. It was not until 1963 that the detailed 0.22") and by varying the charge he showed the possible
'pathophysiology of missile wounds was studied using a increase in severity of injury that may occur as the
standardised penetrating thigh wound model in impact velocity changes from low to high-velocity. His
anaesthetised sheep2o. This work demonstrated a experiments on the effect of striking bone using Soviet,
relationship between the extent of muscle damage and American and NATO assault rifle bullets demonstrated •
cavitation, a phenomenon already known to be related the great increase in wound severity that occurs. Slivers"-
to velocity. Three distinct areas in a penetrating missile of bone, behaving as secondary missiles, are accelerated
wound of muscle were defined; there was a central non- through surrounding tissues. A complimentary study
viable area of tissue directly in the path of the missile looked at the effect of bullet break up or fragmentation
which was lacerated and crushed, an adjoining area of on wounding, and again he clearly demonstrated an
damaged tissues as demonstrated by abnormal increase in wound severity, increasing with bulle~
histological staining, and, surrounding this, was an area mass27 .
where there was lack of filling of small blood vessels and Concurrent with Scott's work in the United Kingdom,
extravasation of blood. Berlin and his colleagues in Sweden were carrying out
The liability of these damaged areas to infection by extensive experiments aimed at the question of
anaerobic organisms was recognised. Owen-Smith and correlating damage done at time of injury to the transfer .
Matheson went further and demonstrated of kinetic energl9 .30 . Using pigs of Swedish landrace-
experimentally that contamination of damaged muscle stock and carefully standardised methods, they
with spores of Clostridium welchii inevitably led to gas produced a large series of experimental wounds
gangrene 21 • produced by high velocity missiles. Seven weapon types
They showed that the development of gas gangrene were used giving a wide variation in bullet calibre
could be prevented by early excision of the damaged (5.56mm up to 9.00mm) and velocity (607m/s up to.
muscle but not by fasciotomy alone. Owen-Smith went 911m/s). The results of their work were in keeping with
on later to demonstrate the beneficial effect of the work being done in the United Kingdom.
antibiotics in preventing such infection even when They considered that most of the destructive effects
surgery was delayed. He found that intramuscular of high-velocity assault rifle bullets are due to the high
penicillin and high dose oral tetracycline, administered velocity of the projectiles, the inherent instability of
early, were completely effective in the prophylaxis of gas these missiles in tissue, and to the deformation and-
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J M Ryan, G J Cooper and R L Maynard 121
break up of these missiles in tissue. When a bullet now a better understanding of the pathophysiology of
entered a medium of higher density than air, changes in wounding, particularly so called high-velocity
• effect occurred. Firstly, spin stabilisation was wounding. A new and more descriptive term entered the
overwhelmed in a high density material allowing the language of wound ballistics, "high-energy transfer
missile to commence tumbling and thus to increase its wounding", recognising that the cavitation produced by
transfer energy to the tissues. Then a temporary cavity a missile is more a feature of its energy transfer than of
was formed behind the projectile because of the its impact velocity. This more accurate term reflected
• deposition of energy. The rate of energy transfer was the better understanding of these wounds that now
viewed as an intergral of the retarding forces at work existed. High-velocity missiles, it was realised, given
over the missile's length of travel. certain circumstances would produce a high-energy
Comments were made on shock waves. It was pointed wound. It was equally realised that under different
out that strong shock waves occur in air when the circumstances they might not. Although the importance
velocity of the missile reaches supersonic speed and that of velocity is not in question, other factors also play a
• these increase in amplitude with increasing velocity. vital role in energy transfer and therefore in wounding
However, acoustic or stress waves did not cause power - orientation of the missile, fragmentation and
appreciable movement of tissue and they therefore deformation, tissue track characteristics and, not least,
concluded that these waves play only a minor role in the mass of the missile 17 ,23,27,29.
wounding by penetrating missiles. Their comments on A number of problems remained, There was as yet no
• fragmentation were in agreement with Scott's findings. clear and accurate guide for distinguishing with certainty
• It was noted that retarding forces are greatly increased damaged but recoverable muscle from non-viable
(up to 20 times) when a missile tumbles as compared to muscle and this still meant that surgeons might excise
when it retains nose-on stability. These forces were viable muscle. Although the problems of tetanus and gas
further increased if the missile fragmented because the gangrene had been extensively studied, there was
" fragments usually stopped in the tissue thus yielding all little understanding of the interaction between damaged
4. their available kinetic energy. muscle and bacterial contaminants, Owen-Smith
Berlin and his colleagues produced a large number of showed clearly the beneficial effects of antibiotics in
wounds caused by a range of weapons and ammunition. prophylaxis of gas gangrene 22 , but their role in general
The wounds produced were excised and a correlation contamination and infection had not been established,
was demonstrated between the amount of debrided Dahlgren, working with Berlin, Rybeck and others
4t, tissue (MD) and the energy transferred (6E). It is studied the bacteriological findings in standardised
important to point out that this correlation is accurate wounds at one hour, six hours and twelve hours after
only for injuries to soft tissues in limbs using non- wounding31 . No al)tibiotics were used, They identified
fragmenting, non-yawing spheres. Calculations were reversibly damaged cells in the border zone between
improved by including a track length term in the obviously dead tissue and obviously healthy tissue, as
• equation. MD could then be expressed as amounts of had already been reported by Hopkinson and Scott 23 ,27,
.. debrided tissue per millimetre of track length. It was and they were able to demonstrate that these cells were
found that the pattern of energy deposition along the adversely affected by even small amounts of mixed
wound track, expressed in percentage terms, differed bacteria, including strains not normally considered
from projectile to projectile. Conclusions from Berlin's pathogenic.
second study29 published in 1977 elaborated on their These sparse mixed contaminants, it was felt, seemed
... earlier findings, and it was stated that energy transfer to be able to create conditions necessary for the
decides the character and severity of missile damage. development of clinical infection if treatment was
Energy transfer from a missile was principally delayed. They noted that the extent of non-viable
governed by changes in its orientation along the wound muscle increased with time, particularly within the first
track. It was further influenced by deformation and six hours after wounding, and concluded that, using
fragmentation of the missile. From the foregoing it was current operative technique, it would be possible to
• concluded that, although velocity is important as a prevent, or at \east control, infection if surgery was
determinant of available energy, tumbling and undertaken within six hours, Beyond that time bacteria
fragmentation determine the transfer to the tissues. It would have entered the phase of rapid growth and
was felt that the current criteria for determining the non- invasion, and surgery alone would be insufficient. They
viability of muscle were crude and inexact and might also concluded that current debridement techniques
• lead to the excision of potentially viable tissue. It was would appear to leave contaminated tissues in situ.
also felt that no one has yet been able to pinpoint the Positive cultures were found in 99% (66% infection,
ideal time interval between wounding and 33% contaminants) of swabs taken from post excision,
commencement of surgical excision 29 . apparently healthy margins in the 12 hour group.
At the time of the reporting of these experiments by Caution is necessary in interpreting the work of
Scott in the United Kingdom and Berlin in Sweden, a Dahlgren and his colleagues, A semiquantitative
.. clearer picture of wound ballistics emerged. There was evaluation of the total number of bacteria was done and
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122 Wound Ballistics: Contemporary and Future Research

terms such as "small", "moderate" and "heavy" were and that there is no indication to debride a temporary
used to describe bacterial growth. The finding of a cavity is, however, much more contentious. In the first
"heavy" growth of a single strain was taken to indicate place, few surgeons speak of debriding a temporary.
infection. "Small" or "moderate" growth of one or more cavity. A temporary cavity is a space, created transiently
strains was assumed to indicate that growth in situ had by the movement of tissue; the cavity exists for only a
not taken place and a diagnosis of contamination was very short time and, after its collapse, a permanent
made. There is no universal definition of these terms and wound track remains. It is this wound track and the
this makes clear deductions from this work difficult. surrounding tissues that concern the surgeon, and these •
There followed a trial attempting to determine the may certainly require excision depending on
influence of earli antibiotic administration coupled to circumstances as discussed earlier in this review.
delayed surgerl . The aim of early antibiotic therapy Fackler's major review paper3, recently published, is,
was to destroy the mixed contaminating flora seen early on the surface, equally contentious. He argues strongly
following wounding, and assumed to be the precursor of that sonic pressure waves do not cause injury, and cites
a later significant infection by a single pathogenic strain. evidence from papers by Harvey and, more recently, •
As they had earlier identified these mixed sparse from lithotripsy centres in support of this view. Most
organisms as being sensitive to benzyl penicIllin, this was workers in Europe, such as Scott and Berlin, are largely
the antibiotic of choice. Their results indicated that the in agreement with this and have stated that stress or
expected growth of a pathogenic strain (itself usually sonic waves are not clinically important in injury
penicillin resistant) following a twelve hour delay, was produced by penetrating missiles. They do, however, •
inhibited by giving penicillin one hour after wounding. have a significant role in non-penetrating impact 33 . With •
Indeed, giving antibiotics early seemed to produce a regard to his discussion on cavitation he is right to point
similar result to that seen' in the group operated on out the error of stating that "cavitation requires
within six hours. It was also noted that, in addition to extensive debridement of tissue 34 . It would be more
this treatment preventing infection in the delayed appropriate to say that cavitation may produce tissue. ~
surgery group, the amount of tissue judged to be non-
viable was markedly reduced compared to that in the
damage which may require wound excision. Like
Lindsey he perhaps understates the possible importance
*
delayed group in the previous study. This finding of cavitation when he describes it as "stretch" or
obviously raised the question of whether penicillin itself "localised blunt trauma". Research shows that, given
had a direct effect on injured cells or whether it was its the right conditions, it may be devastating27. The role of
effect on bacterial contaminants that allowed injured cavitation in the destruction of tissue is determined'
cells to reCover. principally by the characteristics of the organ in which
An important concluding point made in this paper was the cavitation occurs. He is also of the view that the role
that these early trials and results should not lead to the of fragmentation is underestimated, although Scott,
suggestion that treatment protocols should be altered. It Berlin and others had recognised and reported on
was emphasised that devitalised tissue must always be fragmentation in the 1970's. •
removed before healing can take place. At best, the Fackler points out certain fallacies and misunder- ..
available evidence indicated that early antibiotic standings that appear to exist as evidenced by some
treatment may buy time and reduce the quantity of papers that have been publishedl.2. Cavitation, he points
devitalised tissue which would usually be found after a out, is not exclusive to very high-velocity missiles, and
delay in surgical treatment. both he and Scott have demonstrated cavitation with
In the United States these studies have been critically low-velocity missiles 3 .27 . He makes it clear that bullets. .
appraised in various journals. Some of these critical do not tumble in flight unless they have struck obstacles; .
papers appear, at first glance, to comment adversely on drawings with exaggerated angles of yaw produced for
certain aspects of the experimental design and on the clarity have been misinterpreted 3s • He points out the
conclusions drawn. Two of these require close scrutinl. fallacy of using the kinetic energy deposition alone as an
Lindsey's dramatic editorialS entitled "The Idolatry of index of wound severity. This would be wrong because,
Velocity, or Lies, Damn Lies, and Ballistics" is within particular tissues and at particular sites along the.
interesting in that he reiterates much of what is already wound track, the extent of cavitation can be correlated
agreed, certainly in the United Kingdom and Sweden. with the kinetic energy deposition at that site. The
He reminds readers that KE = '/2 MV2 is the "kinetic degree of cavitation, however, does not necessarily
energy formula" and not the formula for wounding. He determine the severity of injury, and one cannot state
argues that velocity receives too much attention in therefore, that kinetic energy deposition alone is an •
energy equations and he reminds us of the importance index of wound severity. Clearly various tissues will
of mass. Few would disagree. Most experimental and differ in their responses to given quantities of kinetic
field surgical evidence clearly indicates that velocity has energy and some will be more resistant to injury than
an important but not exclusive role in the determining of others.
wound severity. Lindsey's statement that cavitation is His view that the assessment of what constitutes non-
nothing more than mechanical displacement of tissue viable tissue by general surgeons is very crude would be.
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J M Ryan, G J Cooper and R L Maynard 123
accepted. Equally accepted is his view that surgical six hour target for the commencement of surgery is an
excision alone is not the best treatment of missile ideal that is unlikely to be attained for most Priority 2
• wounds, but the corollary equally holds true, and few and 3 casualties. Many may have to wait for up to 12-18
would relegate surgery to a place of minor importance in hours (or even longer) for surgery because of delays in
management. He points out the danger of drawing evacuation to the Forward Surgical Complexes or
incorrect conclusions from experiments carried out on because of a decision to evacuate the Priority 2s and 3s
tissue simulants. Although the phenomena seen in to rear hospitals.
• gelatin blocks may well represent the physical events Thirdly, the workload in resuscitation and in the
produced in living tissue, it is not correct to assume that operating theatre may well be heavy, and the surgery of
all tissues affected in this way will be injured, either penetrating wounds may be carried out by overworked,
reversibly or irreversibly. He goes on to express concern tired and inexperienced surgeons who may not always
that surgeons having read some ballistics literature, will be thorough.
overestimate the effects of injury by high-velocity And lastly, there may be extended lines of evacuation
• missiles and may embark on treatment which is worse causing inevitable delays.
than the malady. It is hoped that this is an ill-founded
worry, and that most surgeons will study the literature Missile Fragmentation
intelligently and will understand what may ensue It is important to recognise that most of the
following high-energy wounding, rather than what will penetrating missile wounds seen in war will be produced
• follow. by fully jacketed bullets and by anti-personnel
.. It would be quite wrong, therefore, to be alarmed at fragments.
apparent disagreements in recent ballistics literature. As The wound ballistics literature is dominated by work
with most medical disciplines, controversy will continue on bullets, perhaps, in part, because of the startling and
to exist, and such controversy points to a healthy visually impressive effects seen within gelatin and soap
atmosphere in which further research will flourish. blocks when hit by these high velocity missiles.
~: Representatives of law enforcement agencies and their
Future Research experts may debate the relative merits of penetration or
A major proportion of the wound ballistics literature fragmentation in this role. These questions are
is concerned with the terminal ballistics of bullets important for these agencies but they are not important
encountered in civilian medical practice and the for the AMS. The wounds seen by the AMS in war will
~ management of penetrating missile wounds in modern not be produced by fragmenting bullets; the AK74 bullet
hospital facilities. Few papers address the problems of is very strong and will not fragment. Indeed, very few
surgery in war, where not only is the nature of wounds small calibre bullets will fragment although some might
different, but also where the management of casualties extrude lead from their bases. (The M113 from the MI6
will be significantly influenced by the conditions rifle is often described as fragmenting in tissue but, in
• prevailing in the field 36 • In any attempt to review briefly fact, it will only disrupt at close range when it impacts at
.. the contemporary wound ballistics research in support a relatively high yaw of 3-5 degrees) .
of the Army Medical Services (AMS), attention should Anti-personnel fragments will, therefore, account for
be directed towards the management of casualties in war the majority of penetrating missile injuries. The size of
and away from rather unproductive arguments on, for these fragments can vary considerably, but weapon
example, the role of "shock" waves in wounding and the designers expend considerable effort to produce a
. . relative merits of soap and gelatin as tissue simulants. It consistent fragment size that offers the best compromise
. is conditions in war, not those of downtown New York between range, velocity, probability of a hit, and
that must be considered. Efforts in trauma research, terminal effectiveness. Modern pre-formed fragments
must therefore be directed towards the specific surgical weigh about O.2g with a diameter of about 2-3mm. Initial
issues that will improve the treatment of casualties under velocities exceed 1500m/s but decline rapidly with range.
these difficult conditions, and towards the best Large calibre HE shells and mortars of older design
• allocation of stretched resources to provide the greatest fragment into rather more variably sized missiles. The
benefit to the largest number of casualties under the general pattern of injury in a large proportion of
special conditions of surgery in war. fragment casualties, wearing body armour and surviving
Some of these "special conditions" which make the to reach definitive surgery, will be mUltiple wounds to
management of penetrating missile wounds different in-- the peripheral limbs. Most wounds will be non-
• wartime can be indicated. Firstly, most war wounds will perforating with injury largely confined to the wound
be severely contaminated by foreign bodies, such as track.
filthy uniform, and by bacteria. An important feature of fragment wounds is their
Secondly, there may be considerable delay from the degree of contamination by foreign bodies principally
time of wounding to the time of treatment, including clothing and skin fragments. The jagged fragment is
early treatment, such as commencement of antibiotics adept at cutting uniform and transporting parts of it into
• and resuscitation at the RAP, and primary surgery. The wounds; the bigger the fragment, the greater the
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124 Wound Ballistics: Contemporary and Future Research

contamination. With low energy fragments, the that may be produced by some modern anti-personnel
contamination is confined to the wound track and is weapons such as bomblets. Wide debridement or wound
usually found as a discrete plug of material. With high excision may not be required for some of these latter •
energy fragments wounds, typified by "large" fragments types of wounds.
striking at or near the velocity of bullets, this pattern of Surgical debridement (laying open) of wounds is
contamination changes. undertaken for three reasons - to reduce tissue tension,
These large fragments are likely to lead to a greater to allow the removal of contamination associated with
degree of contamination because of the increase in their the wound track and more distant sites such as fascial •
potential cutting area, and cloth shredded by such planes, and to permit adequate wound excision.
fragments is dispersed as small fibres which are very It is the degree of wound excision that is the principal
difficult to detect at surgery. Also, although the role of target for Fackler's comments on the surgery of
the temporary cavity in devitalisation or destruction of penetrating missile wounds 3. Fackler emphasises that
soft tissue may be contentious, an underestimated and the formation of the temporary cavity does not
generally overlooked consequence of the temporary necessary injure tissue adjacent to the wound track - •
cavity is the widespread dispersion of wound quite true, of course, for muscle - and that surgeons who
contaminants. The shredded contamina.nt may be operate upon such wounds with preconceived ideas of
widely dispersed along the wound track and may also be the role of the cavitation effect may well be too radical in
found some distance from the track, either in fissures wound excision and may remove recoverable and viable
within the tissue peripheral to the track or between tissue. ••
fascial planes which may be separated by the formation Now, if the sole purpose of wound excision was to
of the temporary cavity. In this manner, contamination remove dead tissue and non-viable tissue, then Fackler
may be transported to distant sites showing no overt would be right to debate the viability of "stretched"
signs of injury. If the fragment should perforate the tissue and to question the criteria for wound excision.
limb, the reduced pressure within the temporary cavity The authors, however, believe that excision of war
is also capable of indrawing clothing shreds from the exit wounds has an additional purpose, namely the removal ~,
wound and depositing them between fascial planes; we of the contamination, and if potentially viable tissue has
have demonstrated this phenomenon in our studies of to be sacrificed to achieve this, then such a sacrifice is
wound contamination. The same principles of course, justified. In this context, questions on the critical
apply to bullet wounds but because of their pointed delineation of viable and non-viable tissue become
shape, bullets carry relatively little contamination into academic. ,
wounds. Those working in the field of wound ballistics, and
For those suffering penetrating missile wounds to who are primarily interested in the management of war
limbs, antibiotic therapy will commence at RAP or Field wounds should study the relative importance of
Ambulance. The Casualty Treatment Regimes (CTRs) antibiotics, debridement and wound excision on the
specify benzyl penicillin, but for severe wound onset of wound sepsis and systemic infection over the
contamination, ampicillin and cloxacillin are also time scales realistically likely to be encountered in war. The 11·
recommended. Priority 1 (PI) casualties will be object of this research should be to minimise the surgical
operated upon at Forward Surgical Complexes (FSCs) load involved in the treatment of large numbers of P2
but P2 and P3 casualties will normally be evacuated to and P3 casualties without increasing the number of
Rear Surgical Complexes (RSCs) or Base Hospitals for wounds which become infected, or reducing the
surgery. numbers of wounds which heal well.
Many of the penetrating wounds in these latter groups
will be multiple, low energy, small fragment wounds Conclusion
reminiscent of shot-gun pellet injuries. It is apparent, Future study should address specific pertinent
therefore, that many P2 and P3 casualties with questions.
penetrating missile wounds will not receive surgical The benefits which would accrue from the use of
treatment for many hours or perhaps days. The role antibiotics forward of the RAP must be assessed, and it •
of the antibiotic regimes must be to delay the onset of must be determined if these would outweigh the cost and
wound infection during this inevitable delay before logistic problems of such use.
definitive surgery may be carried out. An important area It must be established for how long the current
of research is the assessment of the ability of currently antibiotic policy will delay the onset of serious wound
recommended antibiotic therapy to meet this infection in the different patterns of wound
requirement. The relative roles of antibiotic therapy, contamination described in this article. •
debridement and wound excision in the controlling of The necessity for time-intensive procedures, such as
different types of contamination also need to be defined. formal wound excision for all wounds must be studied to
The degree and extent of contamination may vary find out if adequate debridement and mechanical
from that described for large high energy fragment irrigation (using for example, hydrogen peroxide,
injuries to the "peppering" low energy type of injuries povidone iodine or eusoI) will control contamination i n .
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J M Ryan, G J Cooper and R L Maynard 125

selected wounds. Indeed, an attempt should be made to 14. HORSLEY V. The Destructive Effects of Projectiles.
identify any type of penetrating missile wounds where Proceedings of the Royal Institution of Great Britain 1894;
• management by antibiotics and dressings alone might XIV: 228-238.
suffice. 15. STEVENSON W F. Wounds in War: The Mechanism of
Their Production and Their Treatment. London 1897:
The wound infection experiments by Dahlgren et al
Longmans, Green, and Co.
represent a beginning in this field 31.32. Wound infection
16. WOODRUFF C E. The causes of the explosive effects of
has been the principal adversary of Military Surgeons modern small calibre bullets. New York Medical Journal
• for generations. Much more needs to be done so that 1898;67:593-601.
Military Surgeons will be ready, should the need arise, 17. CALLENDER GRand FRENCH R W. Wound ballistics-
to provide the best possible care for the soldier Studies in the Mechanism of Wound Production by Rifle
wounded on the modern battlefield. Bullets. The Military Surgeon 1935; 77: 177-201.
18. BLACK A N, BURNS B D and ZUCKERMAN S. An
Acknowledgement Experimental study of the Wounding Mechanism of High
Velocity Missiles. Lancet 1941; 2: 872-874.
• The authors wish to express their thanks to Mr Leslie 19. HARVEY E N, et al. Mechanism of Wounding. War
Payne, Honorary Ballistics Archivist to the Royal Army Medicine 1945; 8:91-104.
Medical Corps, for his invaluable help in tracing source 20. HOPKINSON D A W. and WATTS J C. Studies in
material and for access to his Ballistics library. Experimental Missile Injuries of Skeletal Muscle. Proc R

•• 21.
Soc Med 1963; 56: 461-468.
OWEN-SMITH M Sand MATHESON J M. Successful
Prophylaxis of Gas Gangrene in the High Velocity Wound
in Sheep. Br J Surg 1968; 5: 36-39.

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Wound Ballistics:
Contemporary and Future
Research
J M Ryan, Graham J Cooper and Robert L
Maynard

J R Army Med Corps 1988 134: 119-125

doi: 10.1136/jramc-134-03-02

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