Clinical and legal significance of fragmentation of bullets in relation to size of wounds: retrospective analysis

British Medical Journal, August 14, 1999 by Robin Coupland

Abstract

Objective To examine the relation between fragmentation of bullets and size of wounds clinically and in the context of the Hague Declaration of 1899.

Design Retrospective analysis of prospectively collected data on hospital admissions.

Setting Hospitals of the International Committee of the Red Cross.

Subjects 5215 people wounded by bullets in armed conflicts (5933 wounds).

Main outcome measures Grade of wound computed from the Red Cross wound classification and presence of bullet fragments on radiography.

Results Of the 347 wounds with fragmentation of bullets, 251 (72%) were large wounds (grade 2 or 3)--that is, those with a clinically detectable cavity. Of the 5586 wounds without fragmentation of bullets, 2915 (52.1%) were large wounds. Only 7.9% (251/3166) of large wounds were associated with fragmentation of bullets.

Conclusions Fragmentation of bullets is associated with large wounds, but most large wounds do not contain bullet fragments. In addition, bullet fragments may occur in wounds that are not defined as large. Fragmentation of bullets is neither a necessary nor sufficient cause of large wounds, and surgeons should not diagnose extensive tissue damage because of the presence of fragments on radiography. Such findings also do not necessarily represent the use of bullets which contravene the law of war. Future legislation should take into account not only the construction of bullets but also their potential to transfer energy to the human body.

Introduction

The St Petersburg Declaration of 1868 banned the use of bullets that explode on impact with the human body, and this was the basis of the legal notion of "superfluous injury or unnecessary suffering."[1] In the 1890s concern mounted about the effects on human beings of other bullets, including British dumdum bullets. This concern opened a debate about, on the one hand, the effectiveness of bullets or their stopping power and, on the other hand, how much injury civilised nations should inflict on their enemies.[2-5] As a result, in the Hague Declaration of 1899, the contracting parties agreed "to abstain from the use of bullets which expand or flatten easily in the human body, such as bullets with a hard envelope which does not entirely cover the core or is pierced with incisions." (Such bullets now have various names such as expanding, soft-point, and hunting; they are best referred to collectively as semi-jacket bullets.) Since then, all military bullets have been covered by a full metal jacket, an example of successful international legislation.

Wounds are caused by transfer of kinetic energy from projectiles to tissues of the body: the greater the transfer of energy the larger the wounds. The nature of the bullets' jackets is only one of the factors determining how much energy is transferred; other factors are velocity, mass, stability in flight, and the length of the track in the body.[6 7] Therefore, if bullets with full metal jackets cause large wounds their use in armed conflict may comply with the word of the law but not with the spirit of the law. In other words, legislation about the jacket of bullets may not prevent the effect that gave rise to the concern that prompted the legislation. The issue has been further confused by the different focus of the disciplines concerned. While surgeons have invoked bullets' velocity or kinetic energy as the cause of large wounds,[8 9] lawyers and technicians have remained focused on the construction of bullets.

The physical basis of wound ballistics and the causation of large wounds were understood as early as 1908.[10] However, many wound ballistic experiments have been performed this century with a view to establishing whether certain bullets comply with the Hague Declaration of 1899. The detection of fragments of bullets either on radiography or by shooting a given bullet into simulated soft tissue is assumed to show non-compliance with the treaty or the use of bullets that have not been designed for military use.[11-15] This assumption is based on another: that the process of fragmentation of bullets is a necessary and sufficient cause of large wounds. Questioning these assumptions and so questioning the clinical and legal significance of fragmentation of bullets requires critical examination of the occurrence of large wounds and the extent to which this is associated with the fragmentation of bullets.

I used the Red Cross wound classification to examine the relation between fragmentation of bullets as detected on clinical radiography and the size of wounds sustained in the field.

Methods

Red Cross wound classification

The Red Cross wound classification permits documentation of the effects of missiles and explosions on people.[16-19] It is an anatomical classification alone and does not include a physiological variable. In a clinical setting this classification has been used to document the incidence of bullet disruption in armed conflict[14] and the categories of wounds caused to civilians by hand grenades[20] and to establish the size of wounds inflicted by conventional weapons.[1]