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Trauma Care Manual
Trauma Care
Manual

Third Edition

Edited by

Ian Greaves FRCP, FRCEM, FRCSEd, FIMC, DTM&H, DMCC,

DipMedEd, FRSA
Visiting Professor,
University of Teesside
and
Consultant in Emergency Medicine,
James Cook University Hospital, Major Trauma Centre, Middlesbrough UK; Chairman of Trauma Care (UK)

Keith Porter Kt, FRCSEng, FRCSEd, FIMCRCSEd, FSEM, FRCEM,

FRCGP, FRSA
Professor of Clinical Traumatology, Queen Elizabeth Hospital Birmingham; Formerly Chairman of
Trauma Care (UK)

Jeff Garner MD FRCSEd (Gen Surg)

Consultant Colorectal Surgeon, The Rotherham NHS Foundation Trust and Major Trauma Consultant,
Sheffeld Major Trauma Centre
Third edition published 2022
by CRC Press
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN

and by CRC Press

6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487–2742

© 2022 Taylor & Francis Group, LLC

First edition published by Arnold, A member of the Hodder Headline Group Publisher 2001

Second edition published by Hodder Arnold, Part of Hachette UK 2009

CRC Press is an imprint of Informa UK Limited

This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts
have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal
responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any
views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not
necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended
for use by medical, scientific or healthcare professionals and is provided strictly as a supplement to the medical or other
professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and
the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on
dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant
national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their
websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book does
not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole
responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients
appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced
in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any
copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic,
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Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for
identification and explanation without intent to infringe.

British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging-in-Publication Data

A catalog record for this book has been requested

ISBN: 978-1-032-05435-3 (hbk)

ISBN: 978-1-498-78884-7 (pbk)
ISBN: 978-1-003-19756-0 (ebk)

DOI: 10.1201/9781003197560

Typeset in Minion
by Apex CoVantage, LLC
Contents

Preface to the Third Edition vii

List of Contributors ix
Glossary xiv
Acknowledgements xix

1. The Trauma Epidemic 1

2. Mechanism of Injury 11
3. Triage 23
4. Pre-Hospital Care 33
5. Trauma Systems, Centres and Teams 47
6. Patient Assessment 63
7. Trauma Physiology and Metabolism 78
8. Catastrophic Haemorrhage 92
9. Airway Management 100
10. Thoracic Trauma 119
11. Shock Management 149
12. Damage Control Surgery 169
13. Head Injury 179
14. Maxillofacial Trauma 199
15. Ophthalmic Injuries 211
16. Spinal Injuries 228
17. Abdominal and Genitourinary Trauma 246
18. Vascular Trauma 259
19. Musculoskeletal Trauma 277
20. Radiology 296
21. Infection in Trauma 307
22. Injuries in Children 315
23. Trauma in Women 349
24. Trauma in the Elderly 361
25. Firearms, Ballistics and Gunshot Wounds 372
26. Blast Injuries 386
27. Injuries Due to Burns and Cold 396
28. CBRN and the Trauma Victim 412
29. Care of the Obese Trauma Patient 430
30. Analgesia and Anaesthesia 438
31. Intensive Care Management of Major Trauma 457
32. Patient Transfer 474
vi Contents

33. Psychological Aspects of Trauma 489

34. Rehabilitation after Trauma 505
35. Trauma Scoring Systems and Their Application 521
36. Transplantation and Organ Donation 528

Appendix A: Viscoelastic Haemostatic Assays 546

Index 550
Preface to the Third Edition
The first edition of the Trauma Care Manual
was published in 2000 in order to ‘begin the
process of establishing United Kingdom guide-
lines for best practice in the management of
major trauma’. At the time we recognized both
that this was an ambitious project and that
further editions would be needed to ensure
that the manual continued to reflect best prac-
tice in a UK context. The second edition was
issued in 2009, completely revised and with
a number of new chapters. Perhaps, the most
notable changes in the second edition were
the adoption of the <C>ABCDE resuscitation
sequence and of hypotensive resuscitation in
uncontrolled haemorrhage. At this time, we
were increasingly aware of the divergent paths
of trauma resuscitation in the US and in the UK
and wished also to reflect the developments
which had resulted from clinical practice dur-
ing the wars in Iraq and Afghanistan.
In 2019, Trauma Care issued the first edi-
tion of the Trauma Care Pre-hospital Manual,
believing that pre-hospital care was a sufficiently
different specialty to require its own specifically
tailored guidelines reflecting the particular chal-
lenges of this area of practice. As a consequence,
further editions of the Trauma Care Manual
would concentrate entirely on hospital practice.
This third edition of the Trauma Care Manual
has, once again, been completely revised and a
further nine chapters introduced. New chapters
include Infection in Trauma, Damage Control
Surgery, Trauma Systems, Centres and Teams,
CBRN and the Trauma Victim and Care of the
Obese Trauma Patient. We have continued to offer
didactic guidelines for clinical practice and each
chapter is, wherever possible, extensively refer-
enced. The features of earlier editions—tables,
information boxes, clinical tips and illustra-
tions—have been retained and expanded.
Again, since the second edition, we have
changed our guidelines regarding fluid resus-
citation: reflecting the currently available
evidence in recommending, with certain spe-
cific caveats, the use of hybrid resuscitation in
uncontrolled haemorrhage, and we believe that
the guidelines we offer are as up to date and
evidence based as we can make them.
The production of a manual such as this
requires a great deal of hard work and the edi-
tors are grateful to all the contributors to this
and to previous editions.
Trauma Care’s (and our) dear friend Prof.
David Alexander died shortly after completing,
with his colleague Prof. Susan Klein, the chap-
ter on psychological responses to trauma. On
re-reading this chapter during the final edit-
ing, we can hear his voice of calm common
sense and kindness expressed in prose which
could only be his. Trauma Care has established
the David Alexander Memorial Lecture in his
memory to be given annually on a subject
related to the mental health aspects of trauma.
The editorial team at Trauma Care has now
embarked on the final one of our intended trio
of manuals, the Trauma Care Paediatric Manual
which will be published in the near future. We
hope that the three manuals between them will
make a significant contribution to the care of
the trauma victim and to the confidence of
those called upon to treat them.
Ian Greaves
Keith Porter
Jeff Garner
Teesside, 2022
Professor David Alexander, 1943–2020
Contributors

Surg Lt Cdr Steve Adshead BSc (Hons), MRCEM RN Surg Lt Cdr Philippa M Bennett, MRCS, PhD, PG Dip Med
Specialist Trainee in Anaesthetics Ed MRCS, PhD, PG Dip Med Ed RN
University Hospitals Bristol NHS Foundation Trust Trauma and Orthopaedic Specialist Registrar
Bristol, UK Defence Medical Services
Defence Medical Services UK Ministry of Defence
UK Ministry of Defence Firearms, Ballistics and Gunshot Wounds, Blast Injury
Blast injury
Lt Col Richard Blanch BSc (Hons), MBChB (Hons), PhD, MRCS
The late Emeritus Professor David A Alexander (Edin) FRCOphth

MA [Hons], PhD, [Hon] DSc, FBPS, FRSM, [Hon] FRCPsych Consultant Ophthalmologist
Consultant Trauma Specialist British Army and Royal Centre for Defence Medicine
Principal Advisor Birmingham, UK
UK Police Services Ophthalmological Trauma
Psychological Aspects of Trauma
Surg Cdr S Bland MSc (MedTox), FRCEM RN
Lt Col S Bahadur RAMC, MRCGP, MRCP (Rheum), MSc (SEM), Consultant in Emergency Medicine
MSc (Rheumatology), Dip Occ Med, MPhil Medical Law, PG Cert MSK US Royal Navy and Queen Alexandra Hospital
Consultant Rheumatology and Rehabilitation Portsmouth Hospitals NHS Trust
Medicine Portsmouth, UK
Defence Medical Rehabilitation Centre, CBRN and the Trauma Victim
Stanford Hall
Loughborough, UK Prof Stephen Bonner FRCA
Trauma Rehabilitation Clinical Director Critical Care
The James Cook University Hospital
Lt Col Tom Barker DMCC, MD, FRCS, RAMC Middlesbrough, UK
Consultant Vascular Surgeon Intensive Care Management, Organ Donation and
British Army Transplantation
Vascular Trauma
Lt Col Johno Breeze RAMC
Mr Emir Battaloglu MSc, MRCS, DIMC Consultant in Maxillofacial Surgery
Specialty Training Registrar in Trauma & British Army, University Hospitals Birmingham NHS
Orthopaedic Surgery Foundation Trust and Royal Centre for Defence
Royal Orthopaedic Hospital Medicine
Birmingham, UK Birmingham, UK
Mechanism of Injury Maxillofacial Trauma
x Contributors

Prof Derek Burke FRCSEd, FRCEM, FRCPCH Mr Jeff Garner MD FRCSEd (Gen Surg)
Formerly Medical Director and Consultant in Consultant Colorectal Surgeon, The Rotherham NHS
Paediatric Emergency Medicine Foundation Trust and Major Trauma Consultant
Sheffield Children’s NHS Foundation Trust Sheffield Major Trauma Centre
Sheffield, UK Editor
Now Head of Clinical Governance
Gibraltar Health Authority Dr WG Gensheimer MD
Gibraltar, UK Department of Oral and Maxillofacial Surgery
Injuries in Children Warfighter Eye Center, Malcolm Grow Medical
Clinics and Surgery Center
Surg Cdr Philip JB Coates MRCS, FRCR RN Joint Base Andrews, Maryland, USA
Consultant Radiologist Department of Surgery, Division of Ophthalmology
Defence Medical Services Uniformed Services University
UK Ministry of Defence Bethesda, Maryland, USA
Derriford Hospital Ophthalmological Trauma
Plymouth, UK
Trauma Radiology Prof Ian Greaves FRCP, FRCEM, FRCSEd, FIMC, DipMedEd,
DTM&H, DMCC
Lt Col David Cooper FRCEM, RAMC Visiting Professor
Consultant in Emergency Medicine and Pre-Hospital University of Teesside and Consultant in Emergency
Emergency Medicine Medicine
British Army and Royal Stoke University Hospital James Cook University Hospital
Stoke-on-Trent, UK Middlesbrough, UK
Shock Management Chairman of Trauma Care UK
Editor, Thoracic Trauma
Dr Nick Crombie BMedSci (Hons), FRCA, FIMC
Consultant Trauma Anaesthetist, Associate Medical Mr Liviu Hanu-Cernat DM, FDSRCS, FRCS (OMFS), Cert Med Ed
Director and Clinical Lead Resuscitation Services Consultant Oral and Maxillofacial Surgeon
University Hospital Birmingham University Hospitals Coventry and Warwickshire NHS
Birmingham, UK Trust
Airway Management, Analgesia and Coventry, UK
Anaesthesia Maxillofacial Injuries

Miss Antoinette Edwards BA Surg Lt Kieran M Heil PG Cert Clin Ed, BEng, RN
Executive Director Medical Officer 3 Command Brigadel
UK Trauma Audit and Research Network Defence Medical Services
Trauma Scoring UK Ministry of Defence
Firearms, Ballistics and Gunshot Wounds
Dr Chris Fitzsimmons FRCEM, FRCSEd (A&E)
Consultant in Paediatric Emergency Medicine Lt Col (Rtd) Andrew Jacks OstJ, BSc, FRCOpth
Sheffield Children’s Hospital NHS Trust Consultant Ophthalmologist
Sheffield, UK University Hospitals Birmingham NHS
Injuries in Children Foundation Trust
Birmingham, UK
Mr Navin Furtado BSc, MBBS, MSc (Eng), FRCS (Neuro Surg) Ophthalmological Trauma
Consultant Neurosurgeon and Spinal Surgeon
University Hospital NHS Trust Prof Steven Jeffrey FRCS, EBOPRAS, FRCS (Plast)
Birmingham, UK Consultant Plastic Surgeon
Spinal Injuries Queen Elizabeth Hospital
 Contributors xi

Birmingham Salford Royal Hospital

Birmingham Children’s Hospital Salford, UK
Birmingham, UK Honorary Professor and Research Director of the
Injury Due to Burns, Electrocution and Cold Trauma Audit and Research Network (TARN)
Leicester, England, UK
Lt Col Andy Johnson FRCA, RAMC Trauma Scoring
Consultant in Respiratory Medicine and Critical Care
Medicine Mr. Jack Lewis FdSc, PGcert, MSci (Hons), MSc, MCPara
Defence Lecturer in Critical Care Critical Care Paramedic
Royal Centre for Defence Medicine Midlands Air Ambulance
Birmingham, UK UK West Midlands Ambulance Service
British Army Mechanism of Injury
Trauma Physiology and Metabolism
Surg Cdr Richard Miles MRCP, FRCR, RN
Lt Col Damian Keene FRCA, FIMC Consultant Interventional Radiologist
Consultant in Anaesthesia and Pre-Hospital Defence Medical Services
Emergency Medicine Queen Elizabeth Hospital UK Ministry of Defence
Birmingham, UK Derriford Hospital
Midlands Air Ambulance Plymouth, UK
British Army Trauma Radiology
Clinical Lecturer in Department of Military
Anaesthesia and Critical Care Dr Debbie Mortiboy MBChB, MRCP(UK), FRCPath, PGcert
Royal Centre for Defence Medicine Consultant Microbiologist
Birmingham, UK University Hospital
Patient Transfer Birmingham, UK
Associate Post Graduate Dean
Prof Mansoor Ali Khan MBBS, PhD, PGDip, FRCS, FEBS, FACS, Health Education England (West Midlands)
CMgr, FCMI Birmingham, UK
Consultant Oesophagogastric, General and Trauma Infection in Trauma
Surgeon
Honorary Clinical Professor of Trauma Surgery Lt Col Ross Moy FRCEM, FIMC
Brighton, UK Consultant in Emergency Medicine and Pre-Hospital
Sussex University Hospital Care
Brighton, UK John Radcliffe Hospital
Damage Control Surgery, Abdominal and Oxford, England
Genitourinary Trauma Defence Medical Services
UK Ministry of Defence
Prof Susan Klein MA (Hons), Cert COSCA, PhD Trauma in the Elderly
Professor of Health and Social Care, Strategic
Research Advisor to the Veterans and Families Surg Cdr Nick Newton MD, FRCS
Institute for Military Social Research Veterans and Consultant General and Military Surgeon University
Families Institute for Military Social Research Hospitals Birmingham NHS Trust
Chelmsford Campus, Anglia Ruskin University Birmingham, UK
Chelmsford, Essex, UK Abdominal and Genitourinary Trauma
Psychological Aspects of Trauma
Dr James O’Connor MD, FACS
Prof Fiona Lecky FRCS (A&E), DA, MSc, PhD, FRCEM Professor of Surgery
Clinical Professor of Emergency Medicine University of Maryland School of Medicine
Honorary Consultant in Emergency Medicine Baltimore, MD, USA
xii Contributors

Chief Prof Julian Redhead FRCP, FRCEM, MFSEM, Dip SEM

Thoracic and Vascular Trauma R Adams Cowley Medical Director and Consultant in Emergency
Shock Trauma Center Medicine
Baltimore, MD, USA Imperial College London
Thoracic Trauma London, UK
The Trauma Epidemic
Maj Oliver LP O’Sullivan RAMC, BSc (Hons), MBChB (Hons),
MRCP (UK), DMCC, DipIMC, PGCertMedEd Mr Steven Robinson MD, FRCS
Specialty Registrar Consultant General
Rehabilitation and Rheumatology Weight Loss and Bariatric Surgeon
Defence Medical Services Worcester Acute Hospital NHS Trust
UK Ministry of Defence Worcester, UK
Trauma Rehabilitation Care of the Obese Trauma Patient

Prof Ian Pallister MD, FRCS Dr Karen Selby FRCOG

Consultant Trauma Surgeon Morriston Hospital Consultant in Obstetrics and Gynaecology
Swansea, UK Sheffield Teaching Hospital NHS Foundation Trust
Professor of Trauma and Orthopaedics Sheffield, UK
Swansea University Trauma in Women
Wales, UK
Musculoskeletal Trauma Lt Col Danny Sharpe FRCEM, RAMC
Consultant in Emergency Medicine and Pre-Hospital
Col Paul Parker FRCSEd, FRCS (Orth), FIMC, L/RAMC Emergency Medicine
Consultant Orthopaedic Surgeon St Mary’s Hospital
University Hospitals Birmingham NHS Foundation London, UK
Trust and Royal Centre for Defence Medicine British Army
Birmingham, UK Patient Assessment
Catastrophic Haemorrhage
Dr Peter Shirley FRCA
Surg Cdr Jowan G Penn-Barwell MSc, PhD, FRCS (Tr & Orth) Consultant in Intensive Care and Anaesthesia
Consultant Orthopaedic Trauma Surgeon Adult Critical Care Unit
Oxford Major Trauma Centre Royal London Hospital
Defence Medical Services London, UK
UK Ministry of Defence Intensive Care Management
Firearms, Ballistics and Gunshot Wounds
Sqn Ldr Sam Todd FIMC (RCSEd), FRCEM, RAF
Prof Sir Keith Porter FRCS, Eng, FRCSEd, FIMC, FSEM, FRCEM Specialist Trainee in Emergency Medicine
Professor of Clinical Traumatology Royal Air Force
University Hospitals Birmingham St Mary’s Hospital
Birmingham, UK Imperial College Healthcare NHS Trust
Former Chairman of Trauma Care UK London, UK
Editor CBRN and the Trauma Victim

Dr Michael Prosser FRCEM, FIMC Surg Lt Cdr Jamie Vassallo MRCEM, PhD, RN
Emergency Medicine and Major Trauma Consultant Specialist Registrar in Emergency Medicine
Royal Cornwall Hospital Royal Navy
Truro, UK Triage
Critical Care Doctor
WNDLR Air Ambulance Charity (Helimed 53) Dr Angus Vincent FRCA, FFICM
Pre-Hospital Care Consultant Critical Care and Clinical Lead for
 Contributors xiii

Organ Donation North East England Royal Victoria Welsh Institute for Health and Social Care
Infirmary University of South Wales
Newcastle upon Tyne, UK Pontypridd, Wales, UK
Intensive Care Management Injuries in Children

Laura White Prof Mark Wilson PhD, FRCS (SN), FIMC, MRCA
Operations Director Consultant in Neurosurgery and Pre-Hospital Care
UK Trauma Audit and Research Network Specialist
Trauma Scoring Imperial Hospitals NHS Trust
London
Flt Lt Owen Williams Professor of Brain Injury
Academic Fellow in Emergency Medicine Imperial College London
Royal Air Force Gibson Chair of Pre-Hospital Care
Thoracic Trauma, Trauma Systems, Centres and Royal College of Surgeons of Edinburgh
Teams, Thromboelastography (Appendix A) Edinburgh, UK
Head Injuries
Prof Richard Williams OBE, TD, FRCPsych
Emeritus Professor of Mental Health Strategy
Glossary

AAAM American Association for ARS-G Acute radiation syndrome-

Automotive Medicine gastrointestinal
AAJT Abdominal Aortic & Junctional ARS-H Acute radiation
Tourniquet syndrome-haematopoietic
AAP Associate ambulance practitioner ARS-N Acute radiation
AAST American Association for the syndrome-neurovascular
Surgery of Trauma ASAP As soon as possible
ABPI Ankle brachial pressure index ASCOT A Severity Characterization of
ACOT Acute coagulopathy of trauma Trauma
ACS Abdominal compartment ASIA American Spinal Injuries
syndrome Association
ACSCOT American College of Surgeons ASIS Anterior superior iliac spine
Committee on Trauma ATLS Advanced Trauma Life Support®
ADH Antidiuretic hormone ATMIST Age, time, mechanism, injuries,
AED Automatic external defibrillator signs, treatment
AEP Attenuating energy projectile ATP Adenosine triphosphate
AIS Abbreviated Injury Scale/Score AVPU Alert, responds to voice, responds
AKI Acute kidney injury to pain, unresponsive
AKIN International AKI Network BASICS British Association for Immediate
ALARA As low as reasonably achievable Care
ALI Acute lung injury BETTS Birmingham Eye Trauma
ALS Advanced life support Terminology System
AMPDS Advanced Medical Priority BLS Basic life support
Dispatch System BMI Body mass index
AMPLE Allergies, medicines, past medical BOAST British Orthopaedic Association
history, last meal, events Standards for Trauma
AP Antero-posterior BSA Body surface area
APACHE Acute Physiology and Chronic BTAI Blunt thoracic aortic injury
Health Evaluation BURP Backward-upward-rightward-
APP Abdominal perfusion pressure pressure
aPTT Activated partial thromboplastin BVM Bag-valve-mask ventilation
time β-HCG β human chorionic gonadotrophin
APVR Airway pressure release C Cervical (spine)
ventilation CaO2 Oxygen content of arterial blood
ARDS Adult respiratory distress CAP Community acquired pneumonia
syndrome CAT Combat Application Tourniquet®
CBD Criteria-based dispatch
 Glossary xv

CBF Cerebral blood flow DCD Donation after circulatory death

CBRN Chemical, biological, radiological DCR Damage control resuscitation
and nuclear DCS Damage control surgery
CBT Cognitive behavioural therapy DDAVP Desmopressin
CCA Common carotid artery DI Diabetes insipidus
CCI Charlson Comorbidity Index DIC Disseminated intravascular
CCP Critical care paramedic coagulation
CCR Canadian C spine rules DM Diabetes mellitus
CCT Certificate of completion of DNA Deoxy ribose nucleic acid
(specialty) training DO2 Tissue oxygen delivery
CDL Clean-dirty line DRESS Drug reaction with eosinophilia
CG Clinical guideline and systemic symptoms
CIRCE Cardiovascular and Interventional DSM-V Diagnostic and Statistical Manual
Radiological Society of Europe of the American Psychiatric
CISD Critical incident stress debriefing Association
CISM Critical incident stress DTI Department of Trade and Industry
management DVT Deep venous thrombosis
CJD Creutzfeldt–Jakob disease EAST Eastern Association for the
CK Creatinine kinase Surgery of Trauma
CK-MB Creatine phosphokinase ECA External carotid artery
myocardial band isoenzyme ECG Electrocardiogram
cmH2O Centimetres of water (unit of ED Emergency department
pressure measurement) EDH Extradural haematoma
CMRO2 Cerebral metabolic rate of oxygen EDV End-diastolic volume
CNS Central nervous system eFAST Extended focused abdominal
CO Cardiac output sonography for trauma
CO Carbon monoxide EM Emergency medicine
COBR(A) Cabinet Office Briefing Room (A) EMDR Eye movement desensitization and
COPD Chronic obstructive pulmonary reprocessing therapy
disease EMLA Eutectic mixture of local
CO2 Carbon dioxide anaesthetic
COVID-19 Coronavirus Disease-19 EMP Electromagnetic pulse
COX Cyclo-oxygenase EN Enteral nutrition
CPAP Continuous positive airways ENT Ear nose and throat
pressure ERN Enteral nutrition
CPK Creatine phosphokinase ETHANE Exact location, type, hazards,
CPP Cerebral perfusion pressure access, numbers, emergency
CPR Cardio pulmonary resuscitation services
CQC Care Quality Commission ET(T) Endotracheal (tube)
CRP C-reactive protein ETCO2 End-tidal carbon dioxide
CSF Cerebrospinal fluid EVAR Endovascular aortic repair
CT Computed tomography EVD External ventricular drain
CTA CT angiography EWA Early walking aids
CXR Chest radiograph FAST Focused abdominal (or
DAI Diffuse axonal injury assessment) sonography for
DALY Disability-adjusted life year trauma
DAMPs Damage-associated molecular FES Fat embolism syndrome
patterns FFP Fresh frozen plasma
DBD Donation after brainstem death FFP Filtering facepiece
xvi Glossary

FGM Female genital mutilation ITU Intensive therapy unit

FIB Fascia iliaca block IV Intravenous
FIM Functional Independence IVRA Intravenous regional anaesthesia
Measure IVUS Intravascular ultrasound
FMJ Full metal jacket JRCALC Joint Royal Colleges Ambulance
FRC Functional respiratory capacity Liaison Committee
GA Tabun (nerve agent) KE Kinetic energy
GABA Gamma-aminobutyric acid kPa Kilopascal
GB Sarin (nerve agent) L Lumbar (spine)
GBD Global Burden of Disease LASIK Laser in situ keratomileusis
GCS Glasgow Coma Score LAT Lidocaine, Adrenaline, Tetracaine
GD Soman (nerve agent) LEH Local emergency hospital
GMC General medical council LMA Laryngeal mask airway
GOS(E) Glasgow Outcome Scale LP Light perception
(extended) LSA Long saphenous vein
GSW Gunshot wound LSD Lysergic acid diethylamide
GTN Glyceryl trinitrate LTH Life-threatening haemorrhage
Gy Gray LVEDV Left ventricular end-diastolic volume
HAP Hospital acquired pneumonia MAC Multi-lumen access catheter
HART Hazardous area response team MAP Mean arterial pressure
HAZMAT Hazardous material MBRRACE-UK Mothers and Babies
Hb Haemoglobin Reducing Risk Through Audit and
HCO3 Bicarbonate Confidential Enquiries
HCPC Health Care Professions Council mCCI Modified Charlson Comorbidity
Hct Haematocrit Index
HEMS Helicopter emergency medical MDT Multi-disciplinary team
service MHP Major haemorrhage protocol
HGV Heavy goods vehicle MILS Manual inline stabilization (of the
HIV Human immunodeficiency virus cervical spine)
HMO Hand movements only MIO Mechanism of injury
HR Heart rate MIST Mechanism, injuries, signs,
H2S Hydrogen sulphide treatment
IAP Intra-abdominal pressure mmHg Millimetres of mercury (blood
ICA Internal carotid artery pressure unit)
ICD Intercostal drain MODS Multi-organ distress syndrome
ICD-10 International Classification of MOF Multiple organ failure
Mental and Behavioural Disorders MPTT-24 Modified Physiological Triage
ICP Intracranial pressure Tool-24
ICRC International Committee of the MRA Magnetic resonance angiography
Red Cross MRI Magnetic resonance imaging
ICU Intensive care unit MSCT Multi-slice computed tomography
IED Improvised explosive device mTBI Mild traumatic brain injury
ILO International Labour Office MTC Major trauma centre
IL-6 Interleukin-6 MTTT Major Trauma Triage Tool
INR International normalized ratio NAC N-Acetyl cysteine
IO Intraosseous NAI Non-accidental injury
IOFB Intraocular foreign body NAO National Audit Office
IR Interventional radiology NASCIS National Acute Spinal Cord Injury
ISS Injury severity score Study
 Glossary xvii

NATO North Atlantic Treaty PFA Psychological first aid

Organization PGD Patient group directive
NAVY Nerve, artery, vein, Y fronts PHEA Pre-hospital emergency
NCEPOD National Confidential Enquiry anaesthesia
into Patient Outcome and Death PHEM Pre-hospital emergency medicine
NCTH Non-compressible torso PLC Posterior ligamentous complex
haemorrhage Plt Platelet
NDMA N-Nitrosodimethylamine pmp Per million population
NEXUS National Emergency POCT Point of care testing
X-Radiography Utilization Study PPE Personal protective equipment
NG Nasogastric PPRB Packed red blood cells
NHBOD Non-heart-beating organ donor PRC Packed red cells
NHS National Health Service PRK Photorefractive keratectomy
NHSBT NHS Blood and Transplant PROM Patient reported outcome
NIBP Non-invasive blood pressure measure
NICE National Institute for Health and PROMMTT Prospective Observational
Clinical Excellence Multicenter [sic] Major
NIJ National Institute of Justice Trauma Transfusion Study
NIPPV Non-invasive positive pressure PROPPR Pragmatic, Randomized
ventilation Optimal Platelet and Plasma
NISS New Injury Severity Score Ratios Study
NLP No light perception PT Prothrombin time
NO Nitric oxide PTA Post-traumatic amnesia
NOAC New generation oral anticoagulant PTSD Post-traumatic stress disorder
NP Nasopharyngeal (airway) PVD Peripheral vascular disease
NRP Normothermic regional perfusion PVR Pulmonary vascular resistance
NSAID Non-steroidal anti-inflammatory RAPD Relative afferent pupillary defect
drug RBC Red blood cell
OECD Organization for Economic RCA Riot control agent
Cooperation and Development RCR Royal College of Radiologists
OMFS Oral and maxillofacial surgery RCT Randomized controlled trial
ONS Office of National Statistics (UK) REACT/TS Radiation Emergency
OP Oropharyngeal (airway) Assistance Centre/Training Site
OR Operating room REBOA Retrograde Endoscopic
ORCHIDS Optimisation through Balloon Occlusion of the Aorta
Research of Chemical Incident REBOA-SAAP REBOA-Selective Aortic Arch
Decontamination Systems Perfusion
OSA Obstructive sleep apnoea REE Resting energy expenditure
OTS Ocular trauma score RIC Rapid Infusion Catheter
P Priority RIFLE Risk, injury, failure, loss of
PaO2 Partial pressure of oxygen in kidney function, end stage
arterial blood renal disease
PCA Patient-controlled analgesia RNLI Royal National Lifeboat
PCCU Paediatric critical care unit Institution
PCR Polymerase chain reaction ROSC Return of spontaneous
PDA Potential donor audit circulation
PDT Percutaneous dilation tracheotomy ROTEM Rotational thromboelastometry
PE Pulmonary embolism RRT Renal replacement therapy
PEEP Positive end-expiratory pressure RRV Rapid response vehicle
xviii Glossary

RSI Rapid sequence induction TARN Trauma Audit & Research Network
(of anaesthesia) TBI Traumatic brain injury
RTC Road traffic collision TBSA Total body surface area
RTS Revised Trauma Score TEG Thromboelastography
RV Right ventricle TEN Toxic epidermal necrolysis
SAD Supraglottic airway device TEVAR Thoracic endovascular aortic repair
SAH Subarachnoid haemorrhage tfCBT Trauma-focused cognitive
SALT Sort, Assess, Life-saving behavioural therapy
interventions, Treatment and THOR Trauma Hemostasis [sic] and
Transfer Oxygenation Research Network
SaO2 Arterial oxygen saturation TLC Total lung capacity
SBP Systolic blood pressure TMT Tactical Mechanical Tourniquet®
SCI Spinal cord injury TNP Topical negative pressure (dressing)
SCIWORA Spinal cord injury without TNT Trinitrotoluene
radiological abnormality TOE Transoesophageal
ScvO2 Central venous oxygen saturation echocardiography
SDG Sustainable development goal TPN Total parenteral nutrition
SDH Subdural haematoma TRALI Transfusion-related acute lung
SH Salter–Harris (classification of injury
fractures) TRiM Trauma risk management
SI Sagittal index TRISS Trauma and Injury Severity Score
SIC Self-intermittent catheterization TS Tertiary survey
SIRS Systemic inflammatory response TSH Thyroid-stimulating hormone
syndrome TTL Trauma team leader
SMA Superior mesenteric artery TU Trauma unit
SNOD Specialist nurse in donation TV Tidal volume
SNOM Selective non-operative TXA Tranexamic acid
management (of solid organ injury) UNHCR United Nations High
SOF Single organ failure Commissioner for Refugees
SOFA Sequential organ failure assessment UNICEF United Nations Children’s
SPC Suprapubic catheter (Emergency) Fund
SpO2 Oxygen saturation USAISR United States Army Institute of
SSTI Skin and soft tissue infection Surgical Research
START Simple Triage and Rapid Treatment USS Ultrasound
STIR Short tau inversion recovery VAP Ventilator associated pneumonia
(images) VATS Video-assisted thoracoscopy
SV Stroke volume VC Vital capacity
SVR Systemic vascular resistance V/Q Ventilation/perfusion
T Thoracic (spine) VTE Venous thromboembolism
T3 Triiodothyronine WB Whole blood
T4 Thyroxine WBCT Whole-body CT
TACO Transfusion-related circulatory WCC White (blood) cell count
overload WHO World Health Organization
Acknowledgements
The editors would like to express their thanks
to the authors of the chapters and sections of
this book. We are also grateful to all those who
contributed to previous editions of the Trauma
Care Manual. Without the support and flair
of Domini Lawson and Andrew Ormerod, the
day-to-day administration and development of
Trauma Care would have taken a great deal
more of the editors’ time, and we are more than
aware of how much we owe them. Our families,
as ever, have put up with the preparation of this
volume and this time we won’t even pretend
that it is the last we will do. Miranda Bromwich
and Sam Cooke of Taylor & Francis Group have
made the preparation of this volume, as they
have with our earlier books, a pleasure rather
than a chore.
We are grateful to the copyright holders of
the following illustrations for allowing us to
reproduce them:
●● Figure 13.8 Reproduced with permission
from the Oxford Handbook of Pre-Hospital
Care.
●● Figure13.9 Wikimedia Commons
●● Figure15.2 Wikimedia Commons
●● Figure 17.1 Reproduced with permission
from the Oxford Handbook of Pre-Hospital
Care.

The Trauma Epidemic
OBJECTIVES
After completing this chapter, the reader will:
• Understand the scale of the global burden of
trauma
• Understand the differences in impact of this
burden of trauma between developed and non-
developed countries
INTRODUCTION
Epidemic—affecting many persons at the same
time and extremely prevalent or widespread.
Global estimates suggest that the lives of
between 14,000 and 16,000 people are lost each
day as a result of trauma. This accounts for 5
million annual deaths, equating to 9% of the
worldwide burden of mortality. However, these
figures hide much larger physical and mental
effects for survivors of trauma and their fami-
lies and associated communities. They also
hide the reality that trauma remains the lead-
ing cause of death in young people, where it
accounts for over 25% of all deaths.1
The mortality and morbidity associated with
trauma are largely predictable and preventable.
There is evidence that injury rates have fallen
worldwide and that we could consequently
conclude that the world is becoming a safer
place to live; however, the patterns of injury
1
• Understand the strategies for prevention and
better care of the victim of trauma
vary widely by cause, age, sex, region and
time and conflicting predictions suggest that
the burden of trauma will rise over the next
20 years, mainly due to the increasing world
population.2
In 2015, the United Nations adopted the
ambitious Sustainable Development Goals
(SDGs), which set out ambitious targets to be
achieved by 2030. Improvements in the defined
areas are monitored annually by the World
Health Organization (WHO). For trauma the
SDGs are related to suicide, road traffic col-
lisions, disasters, homicide and conflicts. By
2018 there had been areas of improvement
within individual populations and countries,
but new risks had also been highlighted: lat-
est estimates suggest that 23% of adults suf-
fered physical abuse as a child and that 35% of
women experience either physical and/or sex-
ual intimate partner violence or non-partner
sexual violence at some point in their lives.
Violence against children not only has life-
long impacts on individual health, but also has
impacts on communities and nations. Violence
DOI: 10.1201/9781003197560-1
2 Trauma Care Manual
against women results in both short-term and
long-term effects on physical, mental, sexual
and reproductive health, leading to high social
and economic costs for women, families and
societies.3
Both the cause and effects of traumatic injury
differ depending on the population concerned;
injuries differ between males and females,
between geographical areas, and between low-,
middle- and high-income countries. Thus,
although injury remains the leading cause of
death for those aged between 15 and 44, indi-
vidual mortality and morbidity may be higher
in the elderly.4 To add to the complexity of
understanding the problems caused by trauma,
countries with unequal income levels suffer
diverse burdens of disability due to injury;
levels of disability due to extremity injury are
very high in the developing world, but a greater
proportion of disability due to head and spinal
cord injuries occurs in high-income countries,
suggesting that some types of trauma and their
resultant morbidity may be amenable to rela-
tively simple interventions such as improved
orthopaedic care and rehabilitation, especially
in the developing world.5
Deaths due to injury are devastating for fam-
ilies, communities and societies; however, for
every death many more are left disabled. The
1990 Global Burden of Disease (GBD) study
developed the concept of disability-adjusted
life years (DALYs). This concept expresses not
only years of life lost to premature death, but
also years lived with a disability of a specified
severity and duration. One DALY is one lost
year of healthy life. It was calculated in 1990
that injuries caused 10% of worldwide mortal-
ity but 15% of DALYs.6 The effect of changing
living patterns, especially increased mobility
and expenditure on motor vehicles, particu-
larly in the developing world, has contributed
to a dynamic picture of injury and its effects on
populations. A World Bank report projected
that the global road death toll will rise by 66%
over the next 20 years due to increasing car
ownership. Importantly, this value incorpo-
rates a greater divergence between rich and
poor nations in the future. An approximate
28% reduction in fatalities is anticipated in
high-income countries, but rises of 92% and
147% in fatalities are expected in China and
India, respectively.7
Gender has a great impact on traumatic
injury incidence and mechanism. Mortality
from road traffic collisions (RTCs) and inter-
personal violence is almost three times higher
in males than in females. Globally, injury mor-
tality in males is twice that among women, with
the highest rates in Africa and Europe; how-
ever, in some regions, particularly South-East
Asia and the eastern Mediterranean, females
have the highest burn-related deaths at all
ages. This distribution is particularly apparent
in elderly people in both areas, especially the
Eastern Mediterranean, where the risk of burn-
related death is seven times higher for females
than for males.8 Age itself has a marked influ-
ence on incidence, mechanism and mortality
from injury. It is well established that young
people between ages of 15 and 44 account for
approximately 50% of global mortality due to
trauma.9
Trauma in elderly patients (so-called sil-
ver trauma) is being increasingly recognized
as a significant challenge to healthcare sys-
tems—in the United Kingdom (UK) in 2018
the average age of all major trauma cases was
60 years. There is thus a growing demand for
clinical trauma services amongst the elderly,
with some evidence suggesting a doubling of
absolute numbers between 2007 and 2016 and
an associated increase in the proportion of
patients with major trauma from 25% to 37%.
In addition, almost 40% of older patients will
die within 1 year of the event and over 50%
will be incapable of living independently. In the
UK, the predominant mechanism of injury in
this population is not road traffic accidents but
falls and again in the majority of cases simple
interventions may lead to a reduction in this
burden.10,11
Injuries have traditionally been looked upon
as the result of ‘accidents’ or random events,
but in recent years this view has changed, and
most injuries can now be viewed as poten-
tially preventable. This important area is now
widely studied, leading to the implementation
of interventions to lessen the related burden of

disease in areas from handgun control initia-
tives to road and water safety education. Other
potentially modifiable factors implicated in
trauma are the use of drugs and alcohol. Drug
intoxication has been associated with inter-
personal violence, self-directed violence and
vehicular trauma,12 and alcohol has a signifi-
cant role to play in many areas of traumatic
injury, including interpersonal violence,
youth violence, child and sexual abuse, elder
abuse and vehicular accidents.13 The impacts
of disasters, however, both natural and man-
made, are often profound and far-reaching
and generally less amenable to prevention. The
effects of the 2004 Indian Ocean earthquake
and the resultant tsunami spread over an
immense geographical area from the east coast
of Africa to Alaska and caused approximately
230,000 deaths.14 However, with improved
disaster planning and early warning systems,
the associated mortality and morbidity from a
similar event in the future could undoubtedly
be reduced.
It is pertinent to remember, however, that
trauma data are often complete only for high-
income, developed nations, with only poor and
incomplete data collection in the developing
world, where the greatest increase in traumatic
injury is occurring. The GBD project found
that, although vital registration systems cap-
ture about 17 million deaths annually, this is
probably only about 75% of the total, as in
some regions data are incomplete. For example,
in Africa data are available for only approxi-
mately 19% of countries. The true mortality
and morbidity due to injury may therefore be
much greater than we imagine.
In the UK, the agenda for health is chang-
ing with greater emphasis on and invest-
ment in prevention. Historically, prevention
campaigns have been successful in reducing
the burden of injury from road traffic colli-
sions and in workplaces—featuring a blend
of education, engineering and enforcement.
However, home and leisure accidents, as
well as injuries from violence have not ben-
efitted from these rigorous and enduring
national strategic approaches. In 2018, the
Royal Society for the Prevention of Accidents
The Trauma Epidemic 3
in association with members of the National
Accident Prevention Strategy Advisory Group
and a number of partners set out a national
strategy to prevent serious accidental inju-
ries,15 and local initiatives have found evi-
dence of reducing rates of violent injuries
from identification of hotspots, data sharing
between organizations and targeted cam-
paigns to at-risk groups.
INTENTIONAL INJURIES
The WHO divides injuries into intentional and
unintentional injuries.
Interpersonal Violence
In 2000, intentional injuries accounted for
49% of the annual mortality from injury, one-
quarter of all deaths being due to interpersonal
violence and suicide.8 By 2013, the WHO and
the United Nations were able to demonstrate that
the overall trend in the global homicide rate is
a decrease—globally by 17%. However, regional
trends are diverse so that in Europe and Asia
rates are decreasing, but in the Americas and
parts of Africa, homicide rates have remained
high and in some countries they have increased.
This is particularly evident in low- and middle-
income countries. An estimated 477,000 mur-
ders occurred globally in 2016, with 4 out of 5
victims being males and the Americas suffering
the highest rates of homicide death at 31.8% per
100,000 population.2,3
Half of homicides are committed with a
firearm, but methods vary markedly by region
with firearm injuries accounting for 75% of
all homicides in the low- and middle-income
countries of the Americas but only 23% in
the low- and middle-income countries of the
Western Pacific Region.3
The SDG target is to eliminate certain forms
of violence in the next 15 years, but targets have
also been set for violence reduction. In 2014,
the World Health Assembly asked for more
work to be done in addressing world violence
and in particular where it affects women, girls
and children.3
4 Trauma Care Manual
Self-Inflicted Injury
In 2013, self-harm was the leading cause of
death from injury and was the main contribu-
tor to injury DALYs. There is evidence of world
events such as the financial crisis of 2007/2008
adversely affecting suicide rates; however,
the overall trend is a decline in self-inflected
fatalities. Again, there are regional variations
in this trend. More than half of all self-harm
DALYs occur in East and South-East Asia, and
although there has been a significant decline in
South-East Asia, rates have risen in South Asia.
Economic factors appear to be only part of
the cause, with distribution of wealth, cultural
shifts, ease of access to mental health services
and ease of access to the differing means of self-
harm also being potentially important.3
War-Related Injuries
Between 1990 and 2011, there was a decline in
the number and intensity of wars and conflicts.
The WHO estimates a 2% reduction of deaths
each year—although this excludes the Rwandan
genocide in 1994. However, since 2011 there
has been an increase in deaths. In 2014, there
were at least 17 conflicts killing more than 1,000
people each, compared to 15 in 2013. In 2016,
180,000 people were killed in wars and conflicts,
with the average death rate due to conflicts dou-
bling to 2.5/100,000 population in 2012–2016
when compared to 2007–2011.3
These death rates hide the long-term effects
of conflict on injuries and displacement of
populations, with resulting mortality, mor-
bidity and social upheaval. According to the
United Nations High Commissioner for Refugees
(UNHCR), 20.5 million people were refu-
gees by 2005; although data were available on
only about a quarter of these people, approxi-
mately 44% were estimated to be under 18.
United Nations Children’s (Emergency) Fund
(UNICEF) data suggest that in the 1990s about
2 million children died as a result of war, and
4–5 million were injured or disabled.16
The aim of modern war is to destabilize the
political, social, cultural and psychological
foundation of one’s opponent, with torture,
execution and rape being used routinely as
methods of social intimidation. Weapons
designed to maim rather than kill are used
against civilians as well as combatants, extend-
ing the battlefield to the entire society.
Fewer troops are now directly exposed
to combat, in contrast to the massed battles
of previous wars, but those who are face an
increased risk of injury. Penetrating injuries,
such as those caused by small arms or explod-
ing munitions, cause 90% of combat trauma,
and the advent of effective personal ballistic
protection has skewed the distribution of pene-
trating injuries to involve the limbs rather than
the trunk. Improved evacuation times and bet-
ter medical care have generally contributed to
decreased mortality.
The pattern of warfare continues to change,
with large battles fought between standing
armies becoming a rarity, largely replaced by
urban combat involving vaguely identified
combatants, including sympathetic civilians.
This represents the ‘asymmetric’ battlefield of
the future. Approximately 50% of the casualties
in the Second World War were civilians; this
figure increased to ~80% in the Vietnam War
and is ~90% in current wars. Changes in the
conduct of war have meant that vulnerable
areas such as shelters and hospitals are delib-
erately targeted, with health workers being
interned or executed.
The deliberate involvement and targeting of
civilian populations have profound effects, with
grave economic and social implications for the
victims and their countries. In 1994, 14% of the
population of Rwanda was slaughtered within
the space of 3 months, leaving nearly 1 million
dead. Landmines continue to exact a huge toll,
often on the poorest of the world’s inhabitants,
despite a ban on their use, largely due to the
250 million stockpiled munitions, including
70 million still deployed in over 60 countries.
Antipersonnel mines and unexploded ord-
nance are the best-known weapons that cause
superfluous injury or unnecessary suffering.16
Terrorism can be defined as the ‘systematic
use of violence to create a general climate of fear
in a population and thereby to bring about a

particular political objective’. The apparent ran-
domness of an attack together with the prob-
ability of non-combatants being targeted make
terrorism an effective weapon, as it engenders
fear and dread often out of all proportion to
the actual mortality it causes. Global deaths
due to terrorism rose to a peak in the late 1980s
and then slowly diminished until the attack on
the USA on 11 September 2001 (9/11), which
killed 2,973 people.17
Western Europe benefitted from a simi-
lar decrease in terrorist attacks from the late
1980s onwards but also experienced renewed
activity in the new millennium, typified by the
Madrid bombings in 2004, in which 191 peo-
ple were killed and over 1,700 injured and the
London bombings of 2005, which killed 52 and
injured over 700.17 More recently, new methods
of terrorism, such as the use of vehicles and
coordinated attacks, have emerged, making
prevention more difficult and the requirement
to focus on the root cause of the issues more
apparent.
Factors Contributing to
Intentional Injury
Alcohol use is linked to several forms of inten-
tional injury. Self-inflicted injury, particularly
suicide, is common in alcohol-dependent indi-
viduals, and alcohol dependence is known to
increase the risk for suicidal ideation, attempts
and completed suicides.18 People who attempt
suicide are often young, single or separated,
are likely to have made previous attempts and
have higher levels of substance abuse than
those who have not made a suicide attempt.19
Teenagers who drink are five times as likely to
be injured in a fight and six times as likely to
carry weapons as non-drinkers.20 Young adult
males in England and Wales who binge drink
are twice as likely, and similar females four
times as likely, to be involved in a fight as are
non-binge drinkers.21 Although males are more
likely than females to be both perpetrators and
victims of alcohol-related violence, there is evi-
dence of disproportionate increases in violent
behaviour among girls in some countries.22 In
The Trauma Epidemic 5
addition, alcohol-related violence may be more
likely to result in physical injury to victims and
also in more severe injury.
Illicit drugs have had an enormous effect
on the incidence, epidemiology and severity
of major trauma. Demetriades et al.23 found an
association between a high rate of alcohol and
illicit drug use and patients dying from pen-
etrating trauma, particularly males aged 15–50
and those of Hispanic or African American
origin. In a UK study of trauma patients, the
prevalence of positive toxicology screens,
including cannabinoids, cocaine, amphetamine
and methadone, was 35%.24 In a Belgian drug
screening study, illicit drugs were detected in
the urine of 19% of drivers admitted to hospital
after a road traffic collision.25
It has been suggested that violence and drugs
are related in three ways: first, the pharma-
cological effects of a drug may result in vio-
lent behaviour by the user; second, users may
commit violent crime to obtain the money to
purchase drugs; and, third, systemic violence
is a common feature of the drug distribution
system, a finding confirmed by a study show-
ing that violent crime is significantly related
to involvement in drug sales and that most
crimes are directly related to the business of
drug selling.26 This violence is compounded
by the efforts of the three-quarters of a million
street gang members in the USA who routinely
use firearms in pursuit of both gang discipline
and criminal activity.27
UNINTENTIONAL INJURIES
Road Trauma Deaths
In 2012 road traffic injuries were the ninth lead-
ing cause of death, although this is estimated to
rise by 2030 to become the seventh most com-
mon cause of death. In children aged between
5 and 14 years it remains the leading cause of
death.1 However, the global status report on road
safety in 2015,28 reflecting information from
180 countries, suggested that the total number
of global deaths has plateaued at 1.25 million
per year, with the highest fatalities occurring in
6 Trauma Care Manual
low-income countries. Over 90% of all road traf-
fic collisions occur in low- or middle-income
and non-OECD high-income countries, which
account for 85% of the world’s population but
only 56% of the world’s registered vehicles.
There are a number of important factors at work
including poor or poorly implemented legisla-
tion, inadequate road and vehicle quality and
maintenance, a higher proportion of vulnerable
road users and increasing numbers of vehicles.
There has been progress in making vehicles
safer and in establishing legislation to improve
road safety. Seventeen countries have aligned at
least one of their laws with best practice on seat
belts, drink-driving, speed, motorcycle helmets
or child restraints. Such progress is clearly too
slow. The SDG called for a halving of deaths and
injuries from road traffic collisions by 2020. This
target was missed. However, 76 countries reduced
the number of deaths on their roads between 2000
and 2013, demonstrating that change is possible.3
Poisoning
According to WHO data, in 2012, 193,460
people died as a result of unintentional poi-
soning, with over 10.7 million years of DALYs
lost. Of these deaths, 84% occurred in low- and
middle-income countries.3
The WHO estimates that approximately
2,500,000 people are envenomated in snake
attacks each year, posing significant challenges
for medical management and resulting in an
estimated 125,000 deaths. Deaths due to enven-
omation depend not only on the lethality of the
venom but also on the interaction between the
local environment and available medical services.
The inland taipan has the world’s most toxic
venom, but it lives in the desert of eastern central
Australia and has never caused a recorded fatality.
There are approximately 100 adder bites per year
in the UK, but there have been only 10 recorded
deaths, the last of which was 30 years ago.
FALLS
Falls are now the second leading cause of
accidental or unintentional death worldwide.
A total of 646,000 deaths were attributable
to falls, with over 80% occurring in low- and
middle-income countries. 37.3 million falls are
severe enough to require hospital attention.
Adults over 65 years suffer the greatest num-
bers of falls and this proportion is predicted to
increase.3 Children are also a high-risk group
accounting for 40% of the 17 million total
DALYs lost each year. Childhood falls occur
as a result of evolving developmental stages
resulting in ‘risk taking’, with lack of parental
supervision often being cited as the root cause,
although this should always be interpreted in
the light of the complex interactions of poverty,
sole parenthood, poor education and hazard-
ous environments, particularly in the home.
Home is a major site of unintentional injury
and death, with poisoning, falls and fires being
the commonest causes. Poor architecture and
overcrowding have been suggested to contrib-
ute to 11% of injuries among children,29 and in
the UK, about 2.6 million accidents occurring
in the home are treated in emergency depart-
ments each year. In the UK, 4,000 people are
killed annually as a result of accidents at home,
and the total cost has been estimated to be
around £30 million a year.30 Non-fatal home
accidents in the UK were projected to increase
from 2.5 to 3 million per year by 2010, but
accompanied by a fall in deaths from 3,400 to
2,40030; however, this prediction has not been
fulfilled—there are now 6,000 annual deaths
from home accidents. A Department of Trade
and Industry (DTI) report30 in 1999 concluded
that:
Most home accidents happen when people
are doing ordinary, everyday things such
as going up or down stairs, cooking, and
gardening or when children are playing. Only
a small proportion of accidents occur when
doing obviously hazardous things such as
climbing ladders.
The report also suggested that, although
accidents usually happen as a result of com-
plex interactions between many factors, such
as social and economic circumstances, alco-
hol, tiredness and safety awareness, human

behaviour appears to be the most common
cause of home accidents in the UK.31 More
research and prevention strategies need to be
established between industry and education to
reduce this burden of injury.
In 2005, the WHO and the International
Labour Office (ILO) estimated that although
the work-related injury toll had reached
2,000,000 cases annually, it continued to rise
because of rapid industrialization in develop-
ing countries.32 They also suggested that the
risk of occupational disease had become the
most prevalent danger faced by people at their
jobs, with disease accounting for 1.7 million
work-related deaths annually, or four times the
rate for fatal accidents. In addition, there were
approximately 268 million non-fatal work-
related accidents each year, on average result-
ing in at least 3 days of sick time for the victims.
The ILO has previously estimated that about
4% of the world’s gross domestic product is lost
each year as a result of workplace accidents and
illnesses.
In many newly industrialized countries,
such as Korea, the rate of workplace accidents
has levelled off once the phase of rapid con-
struction changes to a more mature stage of
development and the workforce takes up less
dangerous service jobs. Where rapid develop-
ment continues, especially in Asia and Latin
America, the death toll is still rising.32 The esti-
mated number of fatal accidents in China rose
from 73,500 in 1998 to 90,500 in 2001, and
Latin American countries, particularly Brazil
and Mexico, have seen fatal accidents in the
construction sector rise from 29,500 to 39,500
over the same period. In 2005, it was estimated
that there was a construction industry death
somewhere in the world every 10 minutes.32
Fires
It is estimated that 322,000 people died from
burns alone, worldwide in 2002, and that they
accounted for 10 million DALYs. Until 2013,
this figure was falling; although it remains a
significant issue in certain regions, 16 out of
21 regions demonstrated a reduction. Burns
The Trauma Epidemic 7
disproportionally affect younger populations,
being the ninth most common cause of death
in children between 5 and 14 years and the 15th
in young adults between 15 and 29 years.1,3 The
impact of physical disfigurement from burns
is far-reaching, as social stigma leads to isola-
tion and resultant mental health problems.33
The overwhelming majority (90%) occur in
low- and middle-income countries and among
the poorest communities. This relationship
between fires and poverty holds true in afflu-
ent countries as well; in the UK a child from the
lowest social class is 16 times more likely to die
in a house fire than one from a wealthy family.3
Drowning
Drowning is the third leading cause of death
worldwide, accounting for 7% of all injury-
related deaths and thus about 360,000 deaths
worldwide. However, global estimates almost
certainly under report the issues due to poor
data.34 Children, males and individuals with
access to open water are most at risk of drown-
ing: children under 5 have the highest drown-
ing mortality rates worldwide. Drowning is the
leading cause of injury death in children in
China, the leading cause of unintentional injury
death in children under 3 in Australia and the
second leading cause of death in US children
under 14. Worldwide, children account for
over half of deaths from drowning.8
Other risk factors for death from drowning
include epilepsy, occupation and alcohol. In
Sweden, drowning is the cause of death in 10%
of epileptics; 90% of occupational mortality
in Alaskan fishermen is due to drowning, and
alcohol is a risk factor for drowning particu-
larly among adolescents and adults. Alcohol
or drug use has been implicated in 14% of
unintentional drowning deaths in Australia, of
which approximately 80% are in males.32
DISASTERS
Natural disasters such as earthquakes, tsu-
namis, hurricanes and cyclones inflict often
incalculable losses on populations, not only
8 Trauma Care Manual

in terms of injury and trauma deaths but also approached 250,000, with an estimated half a
in terms of mortality from subsequent disease million injured. The tsunami also destroyed the
and starvation. infrastructure needed to treat the injured and
Between 2000 and 2014, an average of 86,500 to enable recovery from the disaster, including
people were killed each year by an average of health facilities. A total of over US$7 billion
656 natural disasters.3 Trends were dominated was provided by nations across the world as aid
by major events where more than 50,000 people for damaged regions.37
were killed in single events such as the Indian
Ocean tsunami of 2004 or the Haiti earthquake
CONCLUSION
in 2010.
The risk of disasters is increasing, with data
The available data suggest that the numbers of
showing a significant increase in the frequency
people killed or injured by trauma will continue
of recorded disasters over the past 50 years
to rise over the next 20 years. Injuries already
and over 2 billion people affected in the past
kill 5 million people each year, equating to 9%
10 years.35 Several factors have been cited to
of worldwide deaths, and for every death many
explain this, including global warming, rapid
more are left disabled. Globally, injury mortal-
human population changes and urbanization,
ity in males is twice that among women, with
civil war and conflict, the rise of terrorism,
the highest rates in Africa and Europe. Young
increased technology (with immature safety
people between the ages of 15 and 44 account
systems) and improved data collection.36
for approximately 50% of global mortality due
Approximately 90% of disasters occur in coun-
to trauma and, although injury remains the
tries with a per capita income of less than
leading cause of death for young people, indi-
US$760 per annum, and countries in this posi-
vidual mortality and morbidity may be higher
tion tend to have more disasters but less capac-
in the elderly.
ity to cope, plan and prepare; the frequency of
Intentional injuries account for half of the
disasters often meaning that there is little time
annual trauma mortality, with one-quarter
for recovery between events. In the Western
of all deaths being due to interpersonal vio-
Pacific region alone, there were 127 major nat-
lence and suicides. Falls were the second high-
ural disasters between 1990 and 2000, which
est global injury cause of unintentional death
killed 530 and left over 6 million homeless.36
after road traffic collisions. In 2005, there was
The ability of the populations likely to be
a construction industry death somewhere in
affected by disasters to plan, prepare and
the world every 10 minutes. In 2000, drowning
respond has a great impact on the scale of
was the second leading cause of unintentional
death and injury and is demonstrated by the
injury death.
circumstances surrounding the Asian tsunami
Nevertheless, injuries are preventable, and
of 2004 and Hurricane Katrina in 2005. On 26
there is growing evidence that where countries
December 2004 the second biggest earthquake
take a focused and coordinated approach to
ever recorded, with a score of 9.3 on the Richter
prevention lives are saved and improved.
scale, occurred, with the epicentre close to
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Mechanism of Injury
OBJECTIVES
After completing this chapter, the reader will:
• Understand the relationship between the
mechanism of injury and the patterns of injury
found on patient assessment
• Understand the importance of gaining as much
information as possible about events at the
scene of a traumatic incident
INTRODUCTION
Improvements in trauma care continue to
progress as systems mature, despite increas-
ing patient age and worsening injury com-
plexity.1 The principles and patterns of
injury which most commonly occur, when
considered from the perspective of their
causative mechanisms, continue to fol-
low well-recognized and distinct trends.
Safety measures, particularly with regard
to motor vehicles and domestic regulations,
have altered but not eliminated many of the
common injuries; yet, mechanism of injury
remains a key aspect of understanding both
the individual trauma patient’s injuries
and the global trends in injury types and
incidences. This information also plays a
pivotal role in informing injury prevention
initiatives.
2
• Recognize the importance of not missing injuries
that do not fit with the anticipated injury
pattern
THE IMPORTANCE OF MECHANISM
OF INJURY (MOI)
The mechanism of injury is an indicator of the
level of energy transfer to the body and an infer-
ence of the severity of injury can be made on this
basis. Indeed, it is of more value in determining
the likely severity of a patient’s injuries than their
specific nature. Mechanism of injury has been
shown to be an independent predictor of mortal-
ity and this is true both for adults and paediatric
trauma.2,3 Establishing a mechanism of injury is
clinically relevant for triage decision-making, as
well as being an important criterion for emer-
gency medical service dispatch.4–7 However,
MOI has not been shown to be related to the
development of post-traumatic stress disorder
or major depressive disorder.8,9 The relative fre-
quencies of common injury mechanisms in the
UK are given in Boxes 2.1 and 2.2 and Figure 2.1.
DOI: 10.1201/9781003197560-2
12 Trauma Care Manual
Box 2.1 Common UK Mechanisms
of Injury in Adults (Relative
Frequencies in Brackets)
●● Fall <2m (39%)
●● RTC (29.5%)
●● Fall >2m (18%)
●● Penetrating (2%)
●● Other (11.5%)10
The past 20 years have seen a marked increase
in the older part of the age distribution of adult
major trauma patients, with the over 50 years
old cohort making up just under 56% of cases
on the national trauma registry, doubling from
27% in 1990. This change mirrors the shift in
population demographics in many high- and
middle-income countries.
Box 2.2 Paediatric Mechanism
of Injury in the UK (Relative
Frequencies in Brackets)
●● Fall <2m (42.9%)
●● RTC (29.7%)
●● Assault (Blows, Shooting, Stabbing) (9.7%)
●● Fall >2m (9%)
●● Other (8.7%)11
While road traffic collisions remain the
leading cause of trauma death, especially
from a global perspective, mortality rates by
mechanism of injury have shifted over time.
It has been suggested that this might be due to
improvements in vehicle safety for occupants,
with trauma deaths increasingly related in per-
centage terms to falls and penetrating injury.12
An association of geographic location with
mechanism of injury, as well as mortality rate,
has been demonstrated with increased rates of
blunt trauma (road traffic collisions and falls)
and higher mortality rates in rural environ-
ments.13 Even obesity may have an impact
upon injury incidence relative to mechanism
of injury.14
MECHANISM OF INJURY INCIDENCE -
ADULT
Other
Penetrating
RTC
Fall<2m
Fall<2m
MECHANISM OF INJURY INCIDENCE -
PAEDIATRIC
Other
Assault RTC
Fall<2m
Fall<2m
Figure 2.1 Mechanism of injury, incidence, by
age.10,11
ENERGY TRANSFER
A key aspect of the assessment for mecha-
nism of injury is understanding the transfer
of energy to the body. Estimation of the sever-
ity of the resultant injury(s) may be possible,
depending upon the type of tissue and the
magnitude of the force. Injury can result from
any form of energy, although it is the conse-
quence most frequently of kinetic energy trans-
fer. Other forms of energy which can cause
injury include chemical, electrical, nuclear and
thermal energy. When the energy imparted to
a tissue exceeds the threshold of tolerance for
that tissue, damage will occur. The essential
definitions and principles underlying energy
transfer are given in Box 2.3.

Box 2.3 Definitions and Principles
●● Inertia: resistance of any physical object
to any change in its velocity (v).
●● Force: equal to the product of the mass
(m) and the acceleration of an object.
●● Impulse: the product of force and time or
the change in momentum.
●● Momentum: equal to the product of the
mass and the velocity of an object.
●● For every action (force) there is an equal
and opposite reaction.
●● Conservation of momentum means the
total energy remains the same before and
after the impact.
Kinetic energy (KE) is calculated by:
KE = ½mv2
In trauma, the collisions are frequently
inelastic, thus the kinetic energy performs
work in the form of deformation of material(s),
sound, heat or friction.
Learning to ‘read’ a scene can provide
essential information for first responders and
hospital staff. Many pre-hospital systems now
allow photographs of the scene to be taken
and uploaded to the patient record, providing
a vital link for hospital staff to aid under-
standing of the potential forces involved. For
example, the presence of significant cab-space
intrusion, a ‘bullseye’ pattern on a wind-
screen (much rarer than in previous years)
and patient positioning are all highly relevant
indicators of potential force dispersal and
injury pattern that may inform the presence
of occult injury that may not otherwise be
directly apparent.
AGE-DEPENDENT VARIABLES
When considering the importance of mecha-
nism on potential injury patterns, caution must
be exercised when considering the extremes
of age. A growing body of evidence demon-
strates that the elderly in particular are at risk
Mechanism of Injury 13
of serious injuries despite relatively low energy
mechanism events such as falls from stand-
ing. This so-called Silver Trauma is due to a
combination of physiological factors, includ-
ing reduced bone density, dehydration and
reduced reaction times, as well as the presence
of a range of comorbidities and polypharmacy
blunting the patient’s physiological responses.
Silver trauma triage tools have been created in
an attempt to reflect this, with particular mech-
anisms, such as ‘fall down stairs’ warranting
conveyance to a major trauma centre, regard-
less of other findings. Similarly, infants and
children, as a consequence of their anatomical
variations, are at high risk of injury through
lower force mechanisms. Examples include an
increased risk of head injury in pedestrian ver-
sus car road traffic collisions and a higher risk
of intra-abdominal pathology.
TYPES OF INJURY
Mechanism of injury can be initially catego-
rized into two distinct types; blunt injury or
penetrating injury. The differences in the pat-
tern of injury(s) between the two types are sig-
nificant enough to warrant separate analysis
and comparison. Combined mechanism inju-
ries are also discussed, as well as blast injuries
and burn injury, which all have marked differ-
ences in the clinical correlation of mechanism
to injury assessment and treatment.
Motor Vehicle Collisions
In modern society, motor vehicles are the most
abundant mode of transport and are capable of
generating large amounts of force; as a result,
motor vehicle collisions are the most common
mechanism of injury in trauma. Severity of
injury is directly proportional to vehicle speed,15
seat belt compliance16 and impaired driving sta-
tus (drug/alcohol intoxication or distraction).17
Overall, severe head or chest injuries are the
leading causes of death following motor vehicle
collisions.18 Motor vehicle collisions can be clas-
sified according to the nature of the vehicle and
of the interaction (Box 2.4).
14 Trauma Care Manual
Box 2.4 A Classification of Road
Traffic Collisions
Vehicle
●● Car
●● Light Goods Vehicle
●● Heavy Goods Vehicle
●● Motorcycle/Bicycle
Interaction
●● Vehicle versus static object (central reser-
vation, tree, building or structure)
●● Vehicle versus vehicle
●● Vehicle versus pedestrian
The recommendations of the feld triage of
injured persons guideline identify the follow-
ing categories in relation to vehicle collisions:
●● High-risk vehicle collision
●● Intrusion, including roof: >12 inches
occupant site; >18 inches any site
●● Ejection (partial or complete) from
vehicle
●● Death in same passenger compartment
●● Vehicle telemetry data consistent with
a high risk for injury
●● Vehicle versus pedestrian/bicyclist;
thrown, run over or with signifcant
(>20 mph) impact
●● Motorcycle crash >20 mph
Figure 2.2 Vehicle impact and intrusion.
Occupant entrapment due to deformation of
the vehicle is a poor prognostic sign and should
be recognized as a high-energy mechanism of
injury (Figure 2.2). Reported rates of entrap-
ment vary between 10% and 30% in high-speed
RTCs.19 Significantly higher injury severity is
associated with vehicle entrapment cases, with
a reported mortality rate of 10%, three-quarters
of fatalities occurring during the pre-hospital
phase of care.20,21
Rollover crashes have an increased risk of
severe or fatal injury and frequently cause injury
to the head, neck and spine due to roof intrusion.
In addition, rollover crashes have a higher inci-
dence of occupant ejection from the vehicle.22
INCIDENTS INVOLVING CARS
Over the last two decades, two- and four-seater
commuter vehicles have been a focus of tech-
nological design aimed at increasing occupant
safety. While a plethora of vehicle safety rating
systems exist, lack of seat belt compliance and
the degree of vehicle intrusion are correlated
with injury severity and thus are key factors to
be observed on scene.23 Drivers more frequently
report chest injuries, especially sternal injuries,
due to the collision with the steering wheel. Front
passengers more frequently sustain skull, spine
or pelvic injuries when compared to drivers.24
Impact with the steering wheel or windshield
during a frontal crash can cause characteristic

injuries to the head, neck, torso and distal
upper extremity. Steering wheel deformity is
an independent predictor of serious thoracic
and abdominal injury. Impact of a flexed knee
with the dashboard during a frontal collision
can result in knee, thigh and hip injuries. Distal
lower extremity injuries are encountered when
the floorboard is driven into the foot. Lateral
impact crashes commonly result in traumatic
brain, thoracic, abdominal and pelvic injuries,
which are more often fatal to occupants on
the side of the impact.25 Unrestrained children
sustain high rates of cervical spine injury. Two-
point or three-point seat belt use is associated
with lower rates of cervical spine trauma but
higher rates of thoracic and lumbar trauma, par-
ticularly flexion-distraction injuries, when com-
pared with children’s car seats or booster seats.26
INCIDENTS INVOLVING HEAVY GOODS
VEHICLES (HGVS)
The size and weight of most HGVs result in
large amounts of kinetic force being trans-
ferred during impact, even at very low speeds.
Intrusion into the cab space and consequent
injury to the driver are rare as the latter are
usually well protected by virtue of the height
of their seated position and the use of safety
systems. Where any HGV has collided with
another vehicle or pedestrian, this is almost
always a highly significant mechanism of injury
and there should be a high index of suspicion
for significant injury in those affected.
Figure 2.3 Relative impact sites for pedestrian injuries.
Mechanism of Injury 15
INCIDENTS INVOLVING MOTORCYCLES
Motorcycle riders and pillion passengers remain
a vulnerable group of road users, with limited
protective measures in the event of an accident.
Global kinetics vary depending upon the motor-
cycle’s position in relation to the collision. In par-
ticular, frontal impacts result in the rider’s trunk
impacting the handlebars and the head striking
the obstruction.27 Severe lower extremity injuries,
especially complex or open tibial and femoral
fractures, are common as a result of motorcycle
collisions.28 Another recognized injury pattern is
from the pelvis striking the fuel tank of the motor-
cycle.29 Pillion passengers frequently either strike
the rider’s back or are ejected from the motorcycle
and experience a higher tumbling force following
the impact.30 Helmet use is inversely correlated
with decreased severity of head injury31 as well as a
33% reduction in health economic expenditure.32
INCIDENTS INVOLVING PUSH-BIKES
Cyclists also experience many of the vulner-
abilities of road use. Injury fatality is correlated
with increased speed of collision, heavier weight
of the impacting vehicle and poor weather or
lighting conditions.23 Helmet use produces a
25%–42% reduction in mortality without an
increased incidence of neck injury.33–35
INCIDENTS INVOLVING PEDESTRIANS
Vehicle collisions involving pedestrians are
exceptionally common (Figure 2.3). While vehi-
cle safety features have developed, with ratings
16 Trauma Care Manual
for testing of a pedestrian subset doubling aver-
age scores in the past decade, pedestrians remain
extremely vulnerable to major trauma. Severely
injured pedestrians are more commonly female
than male, as well as either younger than 16
years or older than 60 years in age.
Pedestrians present with higher rates of head
injuries, pelvic injuries and lower extremity
injuries. The nature and severity of pedestrian
injuries is reflected in the higher mortality rate
for such an injury mechanism.36
Falls
Gravity, or the gravitational effect of the mass
of the Earth, exerts a force on all objects caus-
ing attraction towards the centre of the Earth.
Gravity (g) is 9.80665 m/s2. The height or dis-
tance fallen influences the velocity of the falling
body until the terminal velocity is reached by
the patient and thus factors into the energy/
force of impact.37
V = √2gh
where g is gravity and h is height.
High-risk mechanisms of injury from falls
are categorized by height:
●● Adults: >6 m
●● Children: >3 m or twice the child’s height
However, the distance fallen as a sole indepen-
dent variable has been questioned as a predic-
tor of injury severity, and a number of factors
may modulate the severity of injury observed
with falls from height, including38:
●● Context (accidental, improper or failure of
safety equipment, occupational, deliberate
self-harm)
●● Landing surface (solid surface [concrete,
tarmac, rock], particulate [sand, grass,
stones], fuid [water, mud])
●● Impact(s) during fall (tree branches, wires/
cables, gradient of landing surface)
●● Age/frailty
●● Orientation at impact39
LOW HEIGHT
Falls from heights below the critical distances
specified above may result in significant trau-
matic injury, especially when sustained by older
adults or those with medical comorbidities
which put them at risk of frailty. Such popula-
tions require interpretation of the mechanism
of injury and correlation with the index of sus-
picion for major trauma. The effect of medical
comorbidity and the associated influences of
medications must be factored into the assess-
ment of mechanism of injury, in particular the
use of anticoagulants in head injury,40 as well as
in diabetic patients.41
FALLS FROM A SIGNIFICANT HEIGHT
The distance fallen correlates strongly with
death on impact and injury severity.42,43
Injuries resulting from a fall are due to the sud-
den deceleration of the body after it hits a sur-
face. Sudden deceleration results in two types
of injuries: those from direct impact and those
from transmitted force.44 Head injury following
falls demonstrates a bimodal distribution, with
increasing frequencies seen below 7–10 m and
above 25–30 m.43,45 Falls from greater than 15
m are associated with an increased frequency
of multiple body regions injured, especially in
relation to solid organ visceral injuries.42
Deliberate Self-Harm
Suicidal intent is a frequent causative factor in
high height falls and is associated with a greater
distance of fall46,47 and higher rates of unsurviv-
able injuries (AIS 6/ISS 75). Substance misuse
is an associated risk factor for falls from height
and correlates with psychiatric illness.48,49
Crush Injury
As a mechanism of injury, crush is directly
related to the anatomical area of the body
sustaining trauma. While a much higher pro-
portion of injuries may result from crushing
mechanisms in situations of building collapse,
particularly those seen in natural disasters or

earthquakes, the majority of crush injuries are
sustained in the context of motor vehicle colli-
sions or occupational accidents. Crush injury
may also occur in equestrian or agricultural
related incidents, where patients sustain injury
as a result of falling under large animals.50,51
Crush injuries sustained to the torso or head
are frequently fatal due to the magnitude of force,
thus injuries appear to be more common in the
extremities. Extremity crush injury can be fol-
lowed by crush syndrome, a secondary injury
resulting from the development of a combination
including: compartment syndrome, rhabdomy-
olysis, renal failure and reperfusion injury. Crush
syndrome must be considered and mitigated
through prompt recognition and treatment.52
Assault/Non-Accidental Injury
Assaults commonly result in injuries to the head
and maxillofacial region as well as the upper
limbs.53,54 Zygomatic and mandibular fractures,
as well as fractures to the skull or base of skull
are poor prognostic features when associated
with intracranial haemorrhage and are a leading
cause of mortality in blunt trauma assault mech-
anisms. Blunt force injuries sustained through
interpersonal violence, frequently in situations of
domestic abuse or non-accidental injury to chil-
dren or vulnerable persons, should be suspected
wherever appropriate. The patterns of injury
described in earlier literature have been plagued
by poor sensitivity and specificity for identify-
ing this abuse or inflicted injury. However, fatali-
ties resulting from abuse are frequently reported
to be preceded by repeated injury episodes or
attendances at emergency departments. Routine
enquiry should be integrated into normal prac-
tice when dealing with traumatic injury(s) in
order to maximize the potential to detect abuse.
Penetrating Trauma
PATTERNS OF INJURY
Injury patterns from penetrating trauma are
frequently directed towards the thoraco-
abdominal region (57%), as well as to the upper
extremities (32%).55 Major vascular injury
Mechanism of Injury 17
leading to exsanguination is the primary cause
of death following penetrating trauma and
junctional regions, including the neck, axilla
and groin line are vulnerable areas. Penetrating
injury can be crudely divided into stab wounds
and gunshot wounds. Gunshot wounds carry a
significantly higher associated mortality rate,
attributable largely to the higher level of energy
transferred as a consequence of the injuries.56
KNIFE WOUNDS
Penetrating injuries resulting from bladed
weapon assaults are typically of low velocity and
as such the damage is usually limited to the direct
anatomical structures associated with the point
of wounding. Great care should always be taken
to fully assess the patient for additional wounds
in the thoraco-abdominal regions including the
axillae, back, perineum and groin. Importantly,
the diameter of the wound will give little indi-
cation of the length of the weapon, often with
relatively minor wounds resulting in significant
injury to underlying structures, particularly
where improvised weapons such as screwdriv-
ers have been used. Defensive injuries to the
hands and arms are also common and can offer
clues to the nature of the attack. It is essential not
to be distracted by dramatic flesh wounds prior
to the completion of a full trauma assessment.
FIREARMS AND BLAST INJURY
Whilst thankfully rare in most countries,
firearms-related injuries are an increasingly com-
mon occurrence in the UK. The energy from a
ballistic projectile is transferred in a number of
ways, principally as the bullet loses its kinetic
energy as it passes through the victim’s tissues.
Gunshot wounds are discussed in greater detail
in Chapter 25. Blast injuries are covered in greater
detail in Chapter 26.
BURNS
Burns are discussed in detail in Chapter 27.
Here, it is sufficient to note that they can result
from a variety of mechanisms including:
●● Flash
●● Flame
18 Trauma Care Manual

●● Contact of injury. Accurate and adequate informa-

●● Scald tion from the scene of a traumatic event is
●● Cold essential in managing the patient effectively
●● Radiation and promptly. The provision of photographs
●● Electrical by emergency services personnel is a use-
●● Chemical ful part of this component of patient care.
Accurate assessment of the mechanism of
Concomitant thermal and non-thermal injury injury is a vital tool in any judgement regard-
may occur, especially in the context of vehicle ing the seriousness of a patient’s condition
fire entrapment and war-related/blast injury.57,58 and may prompt a search for injuries which
might otherwise have been missed, especially
in the early stages of resuscitation. Conversely,
CONCLUSION it must never result in clinicians ignoring the
possibility of injuries which do not ‘fit’ the
This chapter has provided a brief introduc-
assumed mechanism.
tion to the important subject of mechanism

Clinical Case History

Incident The ambulance crew suspect the patient

A 46-year-old man is working on scaffolding
at a height of 15 m when his safety equip-
ment fails, causing him to fall onto asphalt.
Colleagues immediately call the emergency
services stating that he is conscious and
orientated, but with obvious leg injuries. An
emergency ambulance is dispatched.
On arrival the ambulance crew ensure the
scene is safe, before proceeding to assess
the patient. They fnd the man is responding
normally, has a patent airway, is breathing
at 26 breaths a minute with no signs of
obvious chest injury, has rapid but weak
radial pulses and is pale with abdominal
tenderness, pelvic tenderness and obvious
bilateral femoral open fractures. During their
secondary survey they ascertain that he has
reduced power and sensation from his lower
thoracic region downwards.
●● GCS 15/15
●● Heart rate 127
●● Respiratory rate 26
●● Oxygen saturations 95% on air
●● Blood pressure 95/40
has sustained pelvic and leg fractures with
a high likelihood of thoracic spinal cord
injury. They apply oxygen via a non-
rebreathing mask at 15 L per minute, apply
a pelvic binder and gain IV access. 5 mg
Morphine and 1 g tranexamic acid are
administered for analgesia and clot stabi-
lization. A Kendrick® Traction Device is
placed on each femur to reduce the open
fractures and 1.2 g co-amoxiclav is admin-
istered. The patient is immobilized using a
scoop, head blocks and hard collar, wrapped
in a blizzard blanket and packaged onto the
pre-warmed ambulance. He is then conveyed
to the nearest major trauma centre under
emergency conditions, 30 minutes away.
Enroute a pre-alert is passed using the
ATMIST format.
During transfer the crew note that the
patient’s blood pressure drops to 80/35 and
his heart rate increases to 135. An initial
fuid challenge of 250 mL sodium chloride
is given to no effect. A further 500 mL is
administered with a slight unsustained
response in blood pressure.
 Mechanism of Injury 19

Hospital Management This is followed by damage control surgery

On arrival at the major trauma centre, the
patient is received by a trauma team who
repeat and confrm the primary survey of
the ambulance crew. Blood products are
administered as part of damage control
resuscitation process. The patient undergoes
a whole-body CT. This reveals the severity of
the asymmetrical pelvis with vertical shear
fracture, comminution of open fractures to
both femora, vertebral fracture at T11 and
bilateral calcaneal fractures.
In addition to the musculoskeletal inju-
ries, the trauma scan identifies an injury
to the descending thoracic aorta, along
with multiple rib fractures and pulmonary
contusions. The aortic injury is managed
through the use of an endovascular stent
placed through urgent interventional
radiology.
to stabilize his injuries, including external
fxation of his pelvic and femoral fractures,
wound debridement and topical negative
pressure dressings.
The patient is then transferred to the
intensive care unit (ICU) for ongoing resus-
citation and monitoring. In the following
24 hours, further investigation includes
spinal MRI to delineate the severity of the
spinal cord injury and guide spinal stabi-
lization surgery. Subsequently, during the
next days and weeks the defnitive manage-
ment for his injuries is undertaken by a
multidisciplinary team of surgical and
medical specialties. Once the acute phase
of trauma care is completed, transfer to a
dedicated spinal injury rehabilitation
facility is arranged in order to continue the
recovery continuum.

INTERNATIONAL PERSPECTIVE

While injuries account for around 10% of deaths globally and are the leading cause of
death for those under the age of 45, the patterns of mechanism vary between regions and
nations. Excluding a state of war in a particular location, the prevalence of certain types
of traumatic injury is infuenced by economic, cultural and legislative factors.
The rate and nature of road traffc collisions (RTC) can be understood in relation to access
to motorized vehicles; in particular the percentage of vulnerable road users, as well as the
developmental state of traffc systems. The level of road infrastructure and quality, vehicle
age and safety features, traffc signals, pedestrian safety and road traffc laws will all affect
the incidence and type of injuries. Legislation, especially pertaining to seat belt and helmet
use, and road laws remain a key determinant which can signifcantly alter the kinematics
of injury and the resulting pathology. Similarly, with regard to other types of accidents,
individual nations’ industrial and domestic safety standards, health and safety law and
legislation for safety will all infuence the incidence of injury mechanisms.
Another important determinant of injury mechanism is exemplifed by the prevalence and
legal status of frearms infuencing the rate and severity of penetrating trauma. This may also
be a factor in the method selected in suicides. Furthermore, the cultural practices relating to
civil justice and retribution within a society have a bearing upon the nature of trauma.
The age and medical status of a population underpins the nature of injury mechanism seen
from an international perspective: an increased percentage of frail or chronically ill people
constitutes a group at increased risk of trauma who may suffer trauma from mechanisms not
encountered in healthy individuals.
20 Trauma Care Manual
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 3
Triage

OBJECTIVES

After completing this chapter, the reader will:

• Understand that triage is the process by which • Acknowledge that triage should never be allowed
patients are sorted to ensure optimal care and to delay treatment
use of resources
• Understand that triage is a dynamic process
which must be performed by senior staff and
repeated regularly

INTRODUCTION surgeons as triage officers, finding that experi-

enced doctors produced more accurate triage.
The campaigns of the Napoleonic Wars saw Triage can take many different forms and
battles that resulted in huge numbers of sol- operates at a number of different levels, but at
diers being killed or wounded in a single day.
At Borodino on 7 September 1812, the worst
of these battles resulted in the deaths of 80,000
French and Russian soldiers; in addition, the
Russians inflicted 35,000 wounded on the
French.1 During these campaigns, Baron
Dominique Larrey (1766–1842), Chief Surgeon
to Napoleon Bonaparte, introduced a system of
sorting the patients arriving at his field dress-
ing stations which he termed triage (Figure 3.1).
Triage comes from the French trier, ‘to sort or
to sieve’ and was originally used to describe the
selection of coffee beans. It is the process of sort-
ing patients according to priority in order to
establish an order for treatment and evacuation.
Larrey’s primary objective was the swift return
of fit men to action and minor wounds were
treated early—thereafter his priorities were sim-
ilar to those in use today. He used senior military Figure 3.1 Baron Dominique Larrey.

DOI: 10.1201/9781003197560-3
24 Trauma Care Manual
all times its aim is to give the right patient the
right care at the right time in the right place.
In certain circumstances, this may also mean
‘doing the most for the most’ with the limited
resources available.
Triage must be a simple procedure that is
swift, reliable and reproducible. Many systems
are in use worldwide depending on the sce-
nario and the end-point required. A surgeon
deciding which of three patients to operate on
first will employ a different system from a doc-
tor faced with 80 patients at a major incident.
The condition of any patient is liable to
change because of time or medical interven-
tion, and this is especially true of the seriously
injured. An unconscious patient with a moder-
ate isolated head injury may die if his or her
airway is not supported but once conscious can
be simply observed—this patient’s triage prior-
ity is initially high but becomes low. Triage is
thus a dynamic process and should be repeated
on a regular basis.
WHEN DOES TRIAGE TAKE PLACE?
In pre-hospital medicine, triage is applied
both to the individual patient setting and the
major incident context when there are multiple
patients. It is used not only to assign treatment
and evacuation priorities to patients but also to
determine which hospital the patient is taken
to, the most appropriate means of transport
and the sort of team meeting them on arrival.
Triage of the emergency call in ambulance con-
trol can also determine the type and speed of
the ambulance service response. This is pri-
oritized dispatch and is discussed below. Triage
to assign treatment and evacuation priorities
must take place whenever patients outnumber
the skilled help and other resources available. A
two-person ambulance crew attending a two-
car motor vehicle crash could have six patients
to deal with. Initially, the crew must assess
all those involved, identify those with life-
threatening and serious injuries and develop a
plan of action for treatment and transport both
before and after other help becomes available.
Within an emergency department the same six
trauma patients may arrive in a short period of
time. It is unlikely that the resuscitation room
will have a bay and a full trauma team available
for each patient. Using triage principles will
help the team leader to determine how to allo-
cate staff and decide which patients are seen
in the resuscitation room. Ideally, ambulance
control will have triaged some of the patients to
other local hospitals, but this may not be pos-
sible for geographical reasons. Once the resus-
citation has been completed, patients may need
further triage for transfer to specialist centres
such as neurosurgical or burns units.
WHERE DOES TRIAGE TAKE PLACE?
Before any patient contact, triage at the ambu-
lance control centre may have determined the
type of response dispatched. Once at the scene,
the ambulance crew will triage the patients to
determine both the destination hospital and
the appropriate mode of transport. Following
the introduction of major trauma centres in the
UK, in the event of a patient sustaining major
trauma, paramedics are able to bypass the near-
est emergency department for a major trauma
centre if the situation fulfils certain criteria
(Figure 3.2). During a major incident involv-
ing multiple patients, triage takes place at the
scene in order to determine initial priorities for
treatment and transport to the casualty clear-
ing station. The patients may be re-triaged for
treatment priorities on arrival at the casualty
clearing station and again for transport priori-
ties to hospital after treatment. At the hospital,
another round of triage will take place at the
doors of the emergency department to reassign
treatment priorities.
After initial resuscitation, priorities for sur-
gery and imaging will be determined. Many
UK emergency departments carry out triage
of all patients on arrival. These circumstances
are obviously very different from those in the
pre-hospital or major incident setting, but the
same principles of triage apply—immediately
life-threatening conditions must be treated
without delay; serious problems must be iden-
tified and given a higher priority than minor
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Title: The book of witches

Author: Oliver Madox Hueffer

Release date: June 18, 2022 [eBook #68341]

Language: English

Original publication: United States: The John McBride Co, 1909

Credits: Brian Coe, Graeme Mackreth and the Online

Distributed Proofreading Team at https://www.pgdp.net
(This book was produced from images made available
by the HathiTrust Digital Library.)

*** START OF THE PROJECT GUTENBERG EBOOK THE BOOK

OF WITCHES ***
 THE

BOOK OF WITCHES

BY

OLIVER MADOX HUEFFER

_Author of "In Arcady and Out," &c._

With Frontispiece in Colours by W. Heath Robinson

THE JOHN McBRIDE CO

New York

1909

CONTENTS
CHAPTER I.
ON A POSSIBLE
REVIVAL OF 1
WITCHCRAFT
 CHAPTER II.
A SABBATH-
19
GENERAL
CHAPTER III.
THE ORIGINS OF
45
THE WITCH
CHAPTER IV.
THE HALF-WAY
61
WORLDS
CHAPTER V.
THE WITCH'S
88
ATTRIBUTES
CHAPTER VI.
SOME
REPRESENTATIVE 114
ENGLISH WITCHES
CHAPTER VII.
THE WITCH OF
127
ANTIQUITY
CHAPTER VIII.
THE WITCH IN
141
GREECE AND ROME
CHAPTER IX.
FROM PAGANISM
163
TO CHRISTIANITY
CHAPTER X.
THE WITCH-BULL
188
AND ITS EFFECTS
CHAPTER XI.
THE LATER
PERSECUTIONS IN 206
ENGLAND
CHAPTER XII.
 PERSECUTIONS IN 232
SCOTLAND
CHAPTER XIII.
OTHER
253
PERSECUTIONS
CHAPTER XIV.
PHILTRES, CHARMS
278
AND POTIONS
CHAPTER XV.
THE WITCH IN
298
FICTION
CHAPTER XVI.
SOME WITCHES OF
315
TO-DAY

FOREWORD
Lest any reader should open this volume expecting to read an
exhaustive treatise on witches and witchcraft, treated scientifically,
historically, and so forth, let me disarm him beforehand by telling him
that he will be disappointed. The witch occupies so large a place in
the story of mankind that to include all the detail of her natural history
within the limits of one volume would need the powers of a magician
no less potent than was he who confined the Eastern Djinn in a
bottle. I have attempted nothing so ambitious as a large-scale
Ordnance Map of Witchland; rather I have endeavoured to produce a
picture from which a general impression may be gained. I have
chosen, that is to say, from the enormous mass of material only so
much as seemed necessary for my immediate purpose, and on my
lack of judgment be the blame for any undesirable hiatus. I have
sought, again, to show whence the witch came and why, as well as
what she was and is; to point out, further, how necessary she is and
must be to the happiness of mankind, and how great the
responsibility of those who, disbelieving in her themselves, seek to
infect others with their scepticism. We have few picturesque
excrescences left upon this age of smoothly-running machine-
wheels, certainly we cannot spare one of the most time-honoured
and romantic of any. And if anything I have written about her seem
incompatible with sense or fact, I would plead in extenuation that
neither is essential to the firm believer in witchcraft, and that to be
able to enter thoroughly into the subject it is above all things
necessary to cast aside such nineteenth-century shibboleths.
I would here express my gratitude to the many friends who have
assisted me with material, and especially to Miss Muriel Harris,
whose valuable help has done much to lighten my task.

London, _September, 1908_.

THE BOOK OF WITCHES

CHAPTER I
ON A POSSIBLE REVIVAL OF WITCHCRAFT
To the superficial glance it might seem that he who would urge a
revival of witchcraft is confronted by a task more Herculean than that
of making dry bones live—in that the bones he seeks to revivify have
never existed. The educated class—which, be it remembered,
includes those who have studied in the elementary schools of
whatever nation—is united in declaring that such a person as a witch
never did, never could, and never will exist. It is true that there are
still those—a waning band—who, preserving implicit faith in the
literal exactitude of revealed religion, maintain that witchcraft—along
with Gardens of Eden, giants, and Jewish leaders capable of
influencing the movements of sun and moon—flourished under the
Old Dispensation, even though it has become incredible under the
New. Yet, speaking generally, the witch is as extinct in civilised men's
minds as is the dodo; so that they who accept as gospel the
vaticinations of race-course tipsters or swallow patent medicines with
implicit faith, yet moralise upon the illimitability of human superstition
when they read that witch-doctors still command a following in West
Africa, or that Sicilian peasants are not yet tired of opening their
purses to sham sorcerers.
Were the reality of sorcery dependent upon a referendum of our
universities—or, for that matter, of our elementary school mistresses
—it were at once proclaimed a clamant imposture. Fortunately for
the witch, and incidentally for a picturesque aspect of the human
intellect, the Enlightened, even if we include among them those who
accept their dogma as the New Gospel, are but a small—a
ridiculously small—item of the human race. Compared with the
whole population of the world, their numbers are so insignificant as
to be for all practical purposes nonexistent. There are villages but a
few miles beyond the boundary of the Metropolitan Police District,
where the witch is as firmly enthroned in the imaginations of the
mobility as in those of their ancestors three centuries ago. There are
many British legislators who would refuse to start an electioneering
campaign upon a Friday. I myself have known a man—and know him
still—a Romney Marshlander, who, within the last decade, has
suffered grievously—himself and through his children—at the hands
of witches whose names and whereabout he can detail. And I have
known a woman—she kept a lodging-house in the Kennington Road
—who, if not herself a witch, was yet the daughter of one, and of
acknowledged power. It is true that, if the daughter's tale—told to me
in the small front parlour in intervals between the crashing passage
of electric trams and motor-lorries—may be accepted, her mother's
gifts were put to no worse use than the curing of her Devonshire
neighbours' minor ailments.
There is no need to go fifty, nor five, miles from London to find
material for a revival in Black Magic. Scarcely a week passes but
some old crone is charged before a Metropolitan police magistrate
with having defrauded silly servant-girls on the pretence of telling
them their futures. You cannot pass down Bond Street during the
season without encountering a row of sandwich-men—themselves
preserving very few illusions—earning a meagre wage in the service
of this, that, or the other Society crystal-gazer, palmist, or
clairvoyant. Who has not seen some such advertisement as the
following—quoted from a current journal—proffering information
about the future, "calculated from astrological horoscopes," at the
very moderate charge of half-a-crown. The advertiser—in deference
to modern convention he is described as a "Professor" rather than a
sorcerer—further protests his mastery of Phrenology, Graphology,
Clairvoyance, and Psychometry. And this advertiser is but one of
many, all seeking to gain some humble profit by following in the
footsteps of Diana and Mother Demdyke of Pendle Forest.
Are there not a hundred and one select Societies, each with its band
of earnest adherents—many with official organs, published at more
or less regular intervals and commanding circulations of a sort—
openly furthering "arts" such as would, two centuries ago, have
entailed upon their members the charge of Witchcraft? Is not
spiritualism exalted into an international cult? The very existence of
such a coterie as the "Thirteen Club," with a membership sworn to
exhibit, _hic et ubique_, their contempt of degrading superstitions, is
the strongest testimony to their ubiquitous regard. Most curious fact
of all, it is in America, the New World, home of all that is most
modern and enlightened, that we find superstitions commanding
most implicit faith. It is only necessary to glance through the
advertisement pages of an American popular magazine to realise
how far the New World has outstripped the Old in its blind adherence
to this form of faith. Nowhere has the Hypnotic, the Mesmeric, the
Psychic Quack such unchallenged empire.
In Lady Charlotte Bury's "Memoirs of a Lady in Waiting," we find an
example of the belief in Witchcraft cherished in the most exalted
circle in the nineteenth century. Writing of the unhappy Princess—
later Queen—Caroline, wife of George IV., she says as follows:
—"After dinner her Royal Highness made a wax figure as usual, and
gave it an amiable addition of large horns; then took three pins out of
her garment and stuck them through and through, and put the figure
to roast and melt at the fire.... Lady —— says the Princess indulges
in this amusement whenever there are no strangers at table, and she
thinks her Royal Highness really has a superstitious belief that
destroying the effigy of her husband will bring to pass the destruction
of his Royal Person." We laugh at this instance of Royal credulity;
yet is not the "mascot" a commonplace of our conversation?
Madame de Montespan, it is recorded, had recourse—not without
success—to the Black Mass as a means towards gaining the
affections of Louis XIV. It is but a few years since the attention of the
police was directed towards the practices of those—Society leaders
for the most part—who had revived, in twentieth-century Paris, the
cult of Devil worship. The most widely circulated London newspapers
of the day gravely discuss in "special articles" the respective value of
various mascots for motorists, or insert long descriptive reports of
the vaticinations of this spiritualist or that wise-woman as to the
probable perpetrators of mysterious murders. This is no
exaggeration, as he may prove for himself who has patience to
search the files of the London daily Press for 1907. And, be it
remembered, the self-proclaimed mission of the contemporary Press
is to mirror the public mind as the most obvious way of instructing it.
Under these circumstances it is easy to credit the possibility of a
revival of the belief in witchcraft even in the most civilised countries
of the modern world. What is more, it is far from certain that such a
revival would be altogether deplorable. Granted that oceans of
innocent blood were shed in the name of witchcraft—the same might
be said of Christianity, of patriotism, of liberty, of half a hundred other
altogether unexceptionable ideals. And, as with them, the total
extinction of the witchcraft superstition might, not impossibly, have
results no less disastrous than, for instance, the world-wide adoption
of European fashions in dress. This quite apart from any question of
whether or no witches have ever existed or do still exist. Even if we
grant that superstition is necessarily superstitious in the more
degraded sense of the word, we need not therefore deny it some
share in alleviating the human lot.
A very large—perhaps the greater—share of human happiness is
based upon "make believe."
The world would be dull, miserable, intolerable did we believe only
what our unfeeling stepmother Science would have us believe. It is
already perceptibly less endurable—for those unfortunate enough to
be civilised—since we definitely abandoned judgment by the senses
in favour of algebraical calculations. While it might be too much to
say that the number of suicides has increased in proportion to the
decline of witchcraft, it is at least certain that superstition of whatever
kind has, in the past, played a notable part in making humanity
contented with its lot. The scientist has robbed us of Romance—he
has taken from many of us our hope of Heaven, without giving us
anything to put in its place; he reduces the beauty of Nature to a
formula, so that we may no longer regard a primrose as a primrose
and nothing more; he even denies us the privilege of regarding our
virtues and vices as anything more than the inevitable results of
environment or heredity. Every day he steals away more and more of
our humanity, strips us of yet another of the few poor garments of
phantasy shielding us from the Unbearable. He is indeed the Devil of
modern days, forcing knowledge upon us whether we will or no. And
we, instead of execrating him after the goodly fashion of our
forefathers, offer our happiness upon his altars as though he were
indeed the God he has explained away. And why? Purely on the faith
of his own asseverations.
Why should we accept the scientist more than his grandmother, the
witch? We have no better reason for accepting him than for rejecting
what he tells us are no more than idle dreams. Let him discover what
he will, it does but vouch the more decidedly for the illimitability of
his, and our, ignorance. It is true he can perform apparent miracles;
so could the witch. He pooh-poohs the arts that were so terrible to
former generations; our posterity will laugh at his boasted knowledge
as at a boastful child's. Already there are world-wide signs that
whatever his success in the material world, mankind is ready to
revolt against his tyranny over the Unseen. The innumerable new
religious sects, the thousand and one ethical fads, the renaissance
of so many ancient faiths—the Spiritualist and the Theosophist, the
Christian Scientist and the Cooneyite, the Tolstoyan and the
Salvationist—laugh at them individually who may—are all alike
outward and visible signs of the revolt of man against being
relegated to the insignificance of a scientific incident. And among
such troubled waters witchcraft may well come into its own again.
For it, as much as any, has brought happiness out of misery.
Consider the unsuccessful man. Under the _régime_ of
enlightenment he can find no one to blame for his sorrows, nor
anywhere to look for their solacement. Everything works according to
immutable laws; he is sick, poor, miserable, because the Law of the
Inevitable will have it so; he has no God to whom he can pray for
some capricious alleviation; he cannot buy good fortune from the
Devil even at the price of his soul—there is no God, nor Devil, nor
good fortune nor ill; nothing but the imperturbably grinding cog-
wheels upon whose orbit he is inevitably bound. Were he not a
happier man if he might find an old-time witch whose spells, being
removed, would leave him hope, even though fulfilment never come?
Undoubtedly. We have been told that had there been no God, it
would have been necessary to invent one. Yes, and along with Him a
Devil and good and evil spirits, and good luck and bad, and
superstitions as many as we can cram into our aching pates—
anything, everything that may save us from the horrible conception
of a machine-like Certainty, from which there is no escape, after
which there is no future. Surely it were better that a few thousand old
women be murdered in the name of superstition, a few millions of
human beings butchered in the name of religion, than that all
mankind be doomed to such a fate.
Be it remembered, too, that even the witch has her grievance against
the learned numbskulls who have undone her. For the witch-life was
not without its alleviations. Consider. Without her witchcraft she was
no more than a poor old, starved, shrunken woman, inconsiderable
and unconsidered, ugly, despised, unhappy. With it she became a
Power. She was feared—as all mankind wishes to be—hated
perhaps, but still feared; courted, also, by those who sought her
help. She was again Somebody, a recognisable entity, a human
being distinguished from the common ruck. Surely that more than
outweighed the chances of a fiery death. Nor was the method of her
death without its compensations. Painful indeed it was, though
scarcely more so than slow starvation. But if she knew herself
innocent, she knew as well that her short agony was but the prelude
to the eternal reward of martyrdom. If she believed herself, with that
poor weary brain of hers, sold to the Devil, what a world of
consolation in the thought that he, the Prince of the Powers of
Darkness, scarcely inferior to the Almighty Himself, and to Him
alone, should have singled her out as the one woman whose help he
needed in all the countryside. And this being so, was there not
always the hope that, as he had promised, he might appear even at
the eleventh hour and protect his own. If he failed, the witch had but
little time to realise it and all the Hereafter, full of infinite possibilities,
before her. Few witches, I think, but would have preferred their grim
pre-eminence, with its sporting interest, to being made the butt of
doctors little wiser than themselves in the sight of infinity, held up to
mockery as silly old women, cozening or self-cozened.
If witches do not in fact exist for us, it is because we have killed them
with laughter—as many a good and evil cause has been killed. Had
we laughed at them from the beginning of things it is even possible
that they had never existed. But, as between them and Science, the
whole weight of evidence is in their favour. There is the universal
verdict of history. For untold centuries, as long as mankind has
lorded it over the earth, their active existence was never held in
doubt, down to within the last few generations. The best and wisest
men of their ages have seen them, spoken with them, tested their
powers and suffered under them, tried, sentenced, executed them.
Every nation, every century bears equal testimony to their prowess.
Even to-day, save for a tiny band of over-educated scoffers sprung
for the most part from a race notorious for its wrong-headed
prejudice, the universal world accepts them without any shadow of
doubt. In August of the present year a police-court case was heard
at Witham, an Essex town not fifty miles from London, in which the
defendant stood accused of assaulting another man because his
wife had bewitched him. And it was given in evidence that the
complainant's wife was generally regarded as a witch by the
inhabitants of the Tiptree district. Nor, as I have already pointed out,
does Tiptree stand alone. Dare we, then, accept the opinion of so
few against the experience, the faith, of so many? If so, must we not
throw all history overboard as well? We are told that an Attila, a
Mahomet, an Alexander, or, to come nearer to our own days, a
Napoleon existed and did marvellous deeds impossible to other
men. We read of miracles performed by a Moses, a Saint Peter, a
Buddha. Do we refuse to believe that such persons ever existed
because their recorded deeds are more or less incompatible with the
theories of modern science? The witch carries history and the
supernatural tightly clasped in her skinny arms. Let us beware lest in
turning her from our door she carry them along with her, to leave us
in their place the origin of species, radium, the gramophone, and
some imperfect flying-machines.
Those same flying-machines provide yet another argument in the
witch's favour. Why deny the possibility that she possessed powers
many of which we possess ourselves. The witch flew through the air
upon a broomstick; Mr. Henry Farman and Mr. Wilbur Wright, to
mention two out of many, are doing the same daily as these lines are
written. The vast majority of us have never seen either gentleman;
we take their achievements on trust from the tales told by newspaper
correspondents—a race of men inevitably inclined towards
exaggeration. Yet none of us deny that Mr. Farman exists and can fly
through the air upon a structure only more stable than a broomstick
in degree. Why deny to the witch that faith you extend to the
aeronaut? Or, again, a witch cured diseases, or caused them, by
reciting a charm, compounding a noxious brew in a kettle, making
passes in the air with her hands. A modern physician writes out a
prescription, mixes a few drugs in a bottle—and cures diseases. He
could as easily cause them by letting loose invisible microbes out of
a phial. Is the one feat more credible than the other? The witch sent
murrains upon cattle—and removed them. He were a poor
M.R.C.V.S. who could not do as much. In a story quoted elsewhere
in this volume, a sorcerer of Roman days bewitched his horses and
so won chariot-races. We refuse him the tribute of our belief, but we
none the less warn the modern "doper" off our racecourses. The
witch could cause rain, or stay it. Scarcely a month passes but we
read well attested accounts of how this or that desert has been made
to blossom like the rose by irrigation or other means. But a few
months since we were told that an Italian scientist had discovered a
means whereby London could be relieved of fogs through some
subtle employment of electricity. It is true that since then we have
had our full complement of foggy weather; but does anyone regard
the feat as incredible?
In all the long list of witch-attainments there is not one that would
gain more than a passing newspaper paragraph in the silly season
were it performed in the London of to-day. Why, then, this obstinate
disbelief in the perfectly credible? Largely, perhaps, because the
witch was understood to perform her wonders by the aid of the Devil
rather than of the Dynamo. But must she be therefore branded as an
impostor? Certainly not by those who believe in a personal Spirit of
Evil. I do not know the proportion of professing Christians who to-day
accept the Devil as part of their faith, but it must be considerable;
and the same is the case with many non-Christian beliefs. They who
can swallow a Devil have surely no excuse for refusing a witch. Nor
is the difficulty greater for those who, while rejecting the Devil,
accept the existence of some sort of Evil Principle—recognise, in
fact, that there is such a thing as evil at all. For them the picturesque
incidentals of witch-life, the signing of diabolical contracts, aerial
journeyings to the Sabbath, and so forth, are but allegorical
expression of the fact that the witch did evil and was not ashamed,
are but roundabout ways of expressing a great truth, just as are the
first three chapters of Genesis or the story that Hannibal cut his way
through the Alps by the use of vinegar.
The conscientious agnostic, again, has no greater reason for
disbelieving in witches and all their works than for refusing his belief
to such historical characters as Cleopatra and Joan of Arc—eminent
witches both, if contemporary records may be trusted. I pass over
the great army of heterodox sects, Unitarians, Christian Scientists,
and the like, many of whom unite with the orthodox in accepting the
principle of Evil in some form or other, and with it, as a natural
corollary, the existence of earthly agencies for its better propagation;
while, for the rest, witchcraft stands in no worse position than do the
other portions of revealed religion which they accept or do not
accept, as their inclinations lead them.
It is sometimes held out as an argument for implicit belief in the
Biblical legend of the Deluge that its universality among all races of
mankind from China to Peru can only be accounted for by accepting
Noah and his Ark. How much more forcibly does the same argument
uphold the _bona fides_ of the witch. Not only has she been
accepted by every age and race, but she has everywhere and
always been dowered with the same gifts. We find the witch of
ancient Babylon an adept in the making of those same waxen or clay
images in which, as we have seen, a nineteenth-century Queen of
England placed such fond reliance. Witch-knots, spells, philtres,
divination—the witch has been as conservative as she has been
enduring. Every other profession changes and has changed its
aspects and its methods from century to century. Only the witch has
remained faithful to her original ideals, confident in the perfection of
her art. And for all reward of such unexampled steadfastness we,
creatures of the moment, deny that this one unchanging human type,
this Pyramid of human endeavour, has ever existed at all!
Buttressed, then, upon the Scriptures, to say nothing of the holy
writings of Buddhist, Brahmin, Mahometan, and every other religion
of the first class, countenanced, increasingly though unwittingly, by
the researches of science into the vastness of our ignorance;
acceptable to orthodox and heterodox alike, vouched for by history
and personal testimony of the most convincing, our rejection of the
witch is based but upon the dogmaticisms of one inconsiderable
class, the impenitent atheist, blinded by the imperfection of his
senses into denying everything beyond their feeble comprehension.
To deny our recognition to a long line of women who, however
mistakenly, have yet, in the teeth of prodigious difficulties,
persevered in their self-allotted task with an altruistic enthusiasm
perhaps unrivalled in the history of the world—to relegate those who
have left such enduring marks upon the face of history to an obscure
corner of the nursery, and that upon such feeble and suspect
testimony, were to brand ourselves as materialists indeed. Rather let
us believe—and thus prove our belief in human nature—that long
after the last atheist has departed into the nothingness he claims as
his birthright, the witch, once more raised to her seat of honour, will
continue to regulate the lives and destinies of her devotees as
unquestioned and as unquestionable as she was in the days of Saul
and of Oliver Cromwell. It is to women that we must look chiefly for
the impetus towards this renaissance. Always the more devout, the
more faithful half of humanity, there is yet another peculiar claim
upon her sympathies towards the witch. In days such as ours, when
the whole problem of the rights and wrongs of women is among the
most urgent and immediate with which we have to deal, it were as
anachronistic as unnatural that Woman should allow the high
purpose, the splendid endurance, the noble steadfastness in inquiry,
of a whole great section of her sex—including some of the most
deservedly famous women that ever lived—should allow all this not
only to be forgotten, but to be absolutely discredited and denied.
Persecuted by man-made laws as she has ever been, and as
eternally in revolt against them, there could be no more appropriate
or deserving figure to be chosen as Patroness of the great fight for
freedom than the much-libelled, much-martyrised, long-enduring,
eternally misunderstood Witch.
No. The time has come when we can appreciate the artistic
temperament of Nero; when Bluebeard is revealed to us in the newer
and more kindly aspect of an eccentric Marshal of France; when
many of us are ready to believe that Cæsar Borgia acted from a
mistaken sense of duty; and that Messalina did but display the
qualities natural to a brilliant Society leader. Surely among them all
not one is more deserving of "whitewashing" than that signal
instance of the _femme incomprise_, the Witch. We may not
approve all her actions, we may not accept her as an example to be
generally followed; let us at least so far escape the charge of narrow-
mindedness and lack of imagination as to pay her the tribute, if not of
a tear, at least of respectful credulity.

CHAPTER II
A SABBATH-GENERAL
It is wild weather overhead. All day the wind has been growing more
and more boisterous, blowing up great mountains of grey cloud out
of the East, chasing them helter-skelter across the sky, tearing them
into long ribbons and thrashing them all together into one whirling
tangle, through which the harassed moon can scarcely find her way.
The late traveller has many an airy buffet to withstand ere he can top
the last ascent and see the hamlet outlined in a sudden glint of
watery moonlight at his feet. Those who lie abed are roused by the
moaning in the eaves, to mutter fearfully, "The witches are abroad to-
night!"
The witch lives by herself in a dingle, a hundred yards beyond the
last cottage of the hamlet. The dingle is a wilderness of brush-wood,
through which a twisted pathway leads to the witch's door. Matted
branches overhang her roof-tree, and even when the moon, breaking
for a moment from its net of cloud, sends down a brighter ray than
ordinary, it does but emphasise the secretiveness of the ancient
moss-grown thatch and the ill-omened plants, henbane, purple
nightshade, or white bryony, that cluster round the walls. He were a
bold villager who dared venture anywhere within the Witch's dingle
on such a night as this. The very wind wails among the clashing
branches in a subdued key, very different from its boisterous
carelessness on the open downs beyond.
There is but one room—and that of the barest—in the witch's
cottage. The village children, who whisper of hoarded wealth as old
Mother Hackett passes them in the gloaming, little know how scant is
the fare and small the grace they must look for who have sold
themselves to such a master. She sleeps upon the earthen floor, with
garnered pine-needles for mattress. She has a broken stool to sit on,
and a great iron pot hangs above the slumbering embers on the clay
hearth.
It wants still an hour to midnight, this eve of May Day, when there
comes a stirring among these same embers. They are thrust aside,
and up from beneath them Something heaves its way into the room.
It is the size of a fox, black and hairy, shapeless and with many feet.
From somewhere in its middle two green eyes shed a baleful light
that horribly illuminates the room. It moves across the floor, after the
manner of a great caterpillar, and as it nears her the witch casts a
skinny arm abroad and mutters in her sleep. It reaches the bed, lifts
itself upon it, and mumbles something in her ear. She awakes, rises
upon her elbow, and replies peevishly. She has no fear of the Thing
—it is a familiar visitant. She is angry, and scolds it in a shrill old
voice for disturbing her too soon. Has she not the Devil's marks upon
her—breast and thigh—round, blue marks that are impervious to all
pain from without, but itch and throb when it is time for her to go
about her devilish business? The Thing takes her scoldings lightly,
twitting her with having overslept herself at the last Sabbath—which
she denies. They fall a-jesting; she calls it Tom—Vinegar Tom; and
they laugh together over old exploits and present purposes.
A moonbeam glints through a hole in the thatch. Where the witch
has lain now sits a black cat, larger than any of natural generation—
as large, almost, as a donkey. It talks still with the witch's voice, and
lingers awhile, the two pairs of green eyes watching each other
through the darkness. At last, with a careless greeting, it bounds
across the floor, leaps up the wall to the chimney opening, and is
gone. The shapeless Thing remains upon the bed. Its sides quiver, it
chuckles beneath its breath in a way half-human, yet altogether
inhuman and obscene.
The black cat is hastening towards the hamlet under the shadow of
the brush-wood. When she comes within sight of the end house, she
leaves the path and strikes out into the gorse-clad waste beyond the
pasture, keeping to it until she is opposite the cottage of Dickon the
waggoner. A child has been born, three days back, to Dickon and
Meg his wife. It is not yet baptised, for the priest lives four miles
away, beyond the downs, and Dickon has been too pressed with
work to go for him. To-morrow will be time enough, for it is the
healthiest child, not to say the most beautiful, the gossips have ever
set eyes upon. Perhaps, if Meg had not forgotten in her new-found
happiness how, just after her wedding, when old Mother Hackett
passed her door, she made the sign of the cross and cried out upon
the old dame for a foul witch, she might not be sleeping so easily
now with her first-born on her bosom.
The black cat creeps on under the shadow of a hedge. Old Trusty,
the shepherd's dog, left to guard the flock during the night, sees
where she goes, and, taking her for a lurking fox, charges fiercely
towards the hedge, too eager to give tongue. But at the first flash of
the green eyes as she turns her head, he knows with what he has to
deal, and flies whimpering for shelter in the gorse, his tail between