Introduction

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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

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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 conflict¹⁴ and the categories of wounds caused to civilians by hand grenades²⁰ and to establish the size of wounds inflicted by conventional weapons.¹

View larger version (8564K): [in this window] [in a new window]   Fig 1.    Bullet wound of left thigh. Top: Entry wound is indicated by pen and measured <1 cm. Exit wound on lateral side of thigh is large and obvious. Bottom: Radiograph shows comminution of femur with one large and several small metallic bullet fragments. Wound is grade 2 (scores: E=1, X=8, C=1, F=2, V=0, M=2)

Wound database
The wound database of the International Committee of the Red Cross originates from a system of data collection which was established in the organisation's independent hospitals in 1991. Included in the information recorded for each of the 26 636 patients are the cause of injury and the Red Cross wound classification.

	Results

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A total of 5215 patients had scores for their bullet wounds. Of these 718 had two scored wounds. Thus, there were a total of 5933 scored wounds from which the grade could be computed. The table shows the grade of wound by M score.

Of the 347 wounds associated with fragmentation of bullets (total of M2 wounds), 251 (72%) were large wounds (grade 2 or grade 3). Of the 5586 wounds not associated with fragmentation of bullets (total of M0 plus M1 wounds), 2915 (52.1%) were large wounds. Fragmentation of bullets (M2 wounds only) was associated with 96 (3.5%) of the 2767 grade 1 wounds and with 251 (7.9%) of the 3166 large wounds. Fragmentation of bullets was associated with large wounds (Pearson's ²= 53.3, P<0.0001).

View larger version (7465K): [in this window] [in a new window]   Fig 2.    Bullet wound of left arm. Top: Entry wound is just proximal to elbow joint and is indicated by forceps in surgeon's hand. Exit wound in forearm is large and obvious. Bottom: Radiograph shows comminution of forearm bones and no metallic bullet fragments. Wound is grade 3 (scores: E=1, X=11, C=1, F=2, V=0, M=0)

	Discussion

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These results show that fragmentation of bullets and large wounds is associated with large wounds, but fragmentation does not necessarily cause large wounds. Previous assumptions about the significance of fragmentation of bullets are misguided; this conclusion is supported by the fact that 82.1% of the large wounds occurred without fragmentation of bullets.

Limitations of the study
This study has several limitations related to the conditions under which the data were collected. A plain radiograph of the wounded part is taken routinely in Red Cross hospitals. A few may not have had this investigation either because the wounds were so serious that the person was taken directly to the operating theatre or because the wound did not require surgical intervention; in such cases the M score would be recorded as zero.

Conclusions
None of these limitations refute the conclusion that fragmentation of bullets is an unreliable indicator of large wounds. Disproving the assumptions about the association between bullet fragmentation and large wounds has important implications. In a clinical setting surgeons should not diagnose extensive tissue damage because of the presence of bullet fragments on radiography. Likewise, lawyers should not claim that fragmentation of bullets as seen on clinical radiographs or in wound ballistic studies implies contravention of the Hague Declaration of 1899.