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TRAUMA CARE
PRE-HOSPITAL MANUAL
http://taylorandfrancis.com
TRAUMA CARE
PRE-HOSPITAL MANUAL
EDITED BY
IAN GREAVES FRCEM FRCP FRCSEd FIMC FASI DTM&H DMCC DipMedEd L/RAMC
Consultant in Emergency Medicine, UK
KEITH PORTER FRCS FRCSEd FRCEM FFSEM FIMC FASI

Professor of Clinical Traumatology, UK
with
CHRIS WRIGHT DIMC FRCEM L/RAMC

Consultant in Emergency Medicine, UK
CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742
© 2019 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Printed on acid-free paper
International Standard Book Number-13: 978-1-138-62684-3 (Paperback)

International Standard Book Number-13: 978-1-138-62457-3 (Hardback)
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
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Library of Congress Cataloging‑in‑Publication Data
Names: Greaves, Ian, editor. | Porter, Keith M., editor.

Title: The trauma care pre-hospital manual / edited by Ian Greaves, Keith Porter.
Description: Boca Raton : CRC Press, 2018. | Includes bibliographical references and index.
Identifiers: LCCN 2018012347| ISBN 9781138626843 (pbk. : alk. paper) | ISBN 9781138624573
(hardback : alk. paper) | ISBN 9781315212821 (ebook)
Subjects: | MESH: Advanced Trauma Life Support Care | Wounds and Injuries--therapy | United Kingdom
Classification: LCC RD93.95 | NLM WB 105 | DDC 617.1--dc23
LC record available at https://lccn.loc.gov/2018012347
Visit the Taylor & Francis Web site at

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This edition is dedicated to Professor David Alexander
Contents
Introductionix
Abbreviations and acronyms xi
Contributorsxvii
1 Trauma: A global perspective 1

2 Safety14
3 The incident scene 31
4 Communication in pre-hospital care 40
5 Mechanism of injury 50
6 The primary survey 61
7 Catastrophic haemorrhage 72
8 Airway management 83
9 Chest injuries 98
10 Shock115
11 Entrapment and extrication 125
12 Head injury 138
13 Spinal injuries 151
14 Musculoskeletal trauma 165
15 Analgesia, sedation and emergency anaesthesia 179
16 The injured child 194
17 Trauma in pregnancy 213
18 Trauma in the elderly 223
19 Burns233
20 Firearms, ballistics and gunshot wounds 243
21 Blast injuries 256
22 Trauma management in the austere pre-hospital environment 264
23 Mass casualty situations 278
24 Retrieval and transport 299
25 Handover and documentation 308
26 Law and ethics in pre-hospital care 322
27 Research and audit in pre-hospital care 330
28 Training in pre-hospital emergency medicine (PHEM) 341
29 Trauma systems 349
Annex A: Practical procedures in thoracic trauma 369

Annex B: Traumatic cardiac arrest 374
Index378
vii
Introduction
When the first edition of the Trauma Care Manual was published in 2001, we wrote that it
had been prepared to ‘begin the process of establishing United Kingdom guidelines for best practice
in the management of major trauma’ and expressed a wish that it and future editions would be
recognised as ‘definitive statements of best practice’. So it has turned out. A second edition of
the Trauma Care Manual appeared in 2009, and a third edition, focused on care of the victim of
trauma in hospital is currently being prepared.
This volume, the Trauma Care Pre-Hospital Manual, builds on the earlier books and, like
them, offers evidence-based guidelines for the management of major trauma, written by clini-
cians with many years of trauma experience, and endorsed as authoritative by Trauma Care
(UK). As its title suggests, it deals with the management of trauma in the pre-hospital environ-
ment and thus complements the upcoming third edition of the Trauma Care Manual.
In 2001, few if any of those most involved in the care of victims of trauma could have antici-
pated the changes and developments that have occurred in the years that followed. The UK
now has functioning (and on the evidence to date) effective trauma systems and networks,
and clinical developments include the introduction of damage control resuscitation, tranexamic
acid, blood product resuscitation, hybrid resuscitation and an emphasis on the control of major
external haemorrhage as part of a new <C>ABCDE approach. As a consequence, more patients
with major trauma are surviving than ever before. Much of this change has been led by experi-
ence from recent conflicts in Iraq and Afghanistan. If this experience has taught one thing more
emphatically than any other, it is that optimal pre-hospital care is essential if survival rates are
to be improved and morbidity reduced.
We are more aware than ever that trauma victims do not, in a sense, die from the trauma,
but from the effects of trauma. These include hypoxia, acidosis, embolism, haemorrhage, abnor-
mal clotting, hypothermia, metabolic and immunological derangement. The sooner these
harmful processes are arrested (or better still prevented), the better outcomes will be. It is the
recognition of this concept as the key to trauma management that underpins these guidelines.
The Trauma Care Pre-Hospital Manual offers clear, didactic, evidence-based guidelines for
the management of major trauma before arrival at hospital. Where it is available, the evidence
base is given, and where it is not, we have indicated a course of action supported by recognised
authorities in the field. Needless to say, we have ensured that all the recent advances in care
of the trauma victim are included, but we have tempered our recommendations with practical
experience of what can realistically be achieved outside hospital. We hope this text will be use-
ful to all practitioners of pre-hospital care whatever their profession or seniority, and we look
forward to future editions incorporating the changes that will undoubtedly occur in the next
few years.
ix
Abbreviations and acronyms
AAA abdominal aortic aneurysm

ac alternating current
ACCOLC access overload control
ACE angiotensin converting enzyme
ACS American College of Surgeons
ACSCT American College of Surgeons Committee on Trauma
ADI acute decompression illness
A&E accident and emergency
AED automated external defibrillator
AEP Attenuating Energy Projectile
AF atrial fibrillation
AIC ambulance incident commander
AIS abbreviated injury scale
ALS advance life support
ALSO advanced life support obstetrics
AMPLE Allergies, Medications, Past Medical History, Last ate or drank, Events
AOC air operations centre
AP anteroposterior
APACHE Acute Physiology and Chronic Health Evaluation
APLS advanced paediatric life support
ARDS acute respiratory distress syndrome
ASHICE Age, Sex, History, Injuries sustained, Condition of patient, Estimated time
of arrival
ATLS Advanced Trauma Life Support®
ATMIST Age, Time of injury, Mechanism of injury, Injuries suspected or known, Signs
as recorded, Treatment provided, and its effect
ATOMFC Airway obstruction, Tension pneumothorax, Open pneumothorax, Massive
haemothorax, Flail chest, Cardiac tamponade
AV atrioventricular
AVLS automatic vehicle location system
AVNRT AV nodal re-entrant tachycardia
AVPU Alert, Voice, Pain, Unresponsive
BA biological agent
BASICS British Association for Immediate Care
BAT burns assessment team
BATLS Battlefield Advanced Trauma Life Support
BLS basic life support
BP blood pressure
BSA body surface area
BTLS basic trauma life support
xi
BURP backward-upward-rightward pressure

BVM bag, valve, mask
CAA Civil Aviation Authority
<C>ABCDE catastrophic external haemorrhage, airway, breathing, circulation, disability, exposure
CAD computer-aided dispatch
CAT Combat Application Tourniquet®
CBRN chemical, biological, radiological, and nuclear
CCA Civil Contingencies Act
CCC Civil Contingencies Committee
CCS casualty clearing station
CH47 Chinook helicopter
CLI caller line Identification
cm centimetre
CMACE Centre for Maternal and Child Enquiries
CNS central nervous system
CO carbon monoxide
COBR Cabinet Office Briefing Room
COPD chronic obstructive pulmonary disease
CPP cerebral perfusion pressure
CPR cardiopulmonary resuscitation
CRM crew resource management
CSCATT Command and control, Safety, Communication, Assessment, Triage, Treatment, Transport
CSF cerebrospinal fluid
CT computerised tomography
CVA cerebrovascular accident
DAI diffuse axonal injury
dc direct current
DCS damage control surgery
DCR damage control resuscitation
DipIMC Diploma in Immediate Medical Care
DKA diabetic ketoacidosis
DNR do not resuscitate
DORA dynamic operation risk assessment
DSTC Definitive Surgical Trauma Care®
DVT deep vein thrombosis
ECG electrocardiogram
ECT enhanced care team
EDH extradural/epidural haematoma
EMD electromechanical association
EMJ Emergency Medicine Journal
EPO emergency planning officer
ePRF electronic patient report form
ERL emergency reference level
ET endotracheal
ETC European Trauma Course
ETCO2 End-tidal CO2
FEMA Federal Emergency Management Agency (US)
FIMC Fellowship in Immediate Medical Care
xii
FMJ Full metal jacket

FPOS first person on scene
GCS Glasgow Coma Scale
GMC General Medical Council
GMP Good Medical Practice
GSW gunshot wound
GTN glyceryl trinitrate
HART hazardous area response team
HAZCHEM hazardous chemical
HAZMAT hazardous material
HCPC Health and Care Professions Council
HEMS helicopter emergency medical service
HGV heavy goods vehicle
HITMAN Hydration, Hygiene, Infection, Tubes, Temperature control, Medication,
Analgesia, Nutrition and notes
HIV human immunodeficiency virus
hr hour
IBTPHEM Intercollegiate Board for Training in Pre-Hospital Emergency Medicine
ICH intracerebral haemorrhage/haematoma
ICP intracranial pressure
ICRC International Committee of the Red Cross
IED improvised explosive device
IHCD Institute for Health Care Development
IHD ischaemic heart disease
ILMA intubating laryngeal mask airway
Im intramuscular
In intranasal
ISS Injury Severity Score
ICU intensive care unit
ITU intensive therapy unit
Iv Intravenous
JESIP Joint Emergency Services Interoperability Programme
JRCALC Joint Royal Colleges Ambulance Liaison Committee
JVP jugular venous pressure
KE kinetic energy
kg kilogram
L litre
LA local anaesthetic
LEDC less economically developed country
LEH local emergency hospital
LMA laryngeal mask airway
LSD lysergic acid diethylamide
m metre
MAC military aid to the civil powers
MAOI monoamine oxidase inhibitor
MAP mean arterial pressure
MCA Maritime and Coastguard Agency
mcg microgram
xiii
MDI metered dose inhaler

MERIT Medical Emergency Response Incident Team
METHANE Major incident declared or stand by; Exact location; Type of incident; Hazards present and potential;
Access, the direction of approach; Numbers of casualties, with nature and type; Emergency services
present and required
mg milligram
MI myocardial infarction
MIA medical incident advisor
MICC major incident coordination centre
MICP mean intracranial pressure
MIMMS Major Incident Medical Management and Support
min minute
mL millilitre
mm millimetre
MMMF man-made material fibre
MRC Medical Research Council
MRCC Maritime Rescue Co-ordination Centres
MRSC Maritime Rescue Sub-Centres
MSK musculo-skeletal
mTBI mild traumatic brain injury
MTC major trauma centre
MTPAS Mobile Telecommunications Privileged Access System
NAI non-accidental injury
NAIR National Arrangements for Incidents involving Radioactivity
NASA National Aeronautics and Space Administration (US)
NATO North Atlantic Treaty Organisation
NCEPOD National Confidential Enquiry into Patient Outcome and Death
NEXUS National Emergency X-Radiography Utilization Study
NIBP non-invasive blood pressure
NICE National Institute for Health and Care Excellence
NIJ National Institute of Justice (US)
NMC Nursing and Midwifery Council
NPA nasopharyngeal airway
NPIS National Poisons Information Service
NRPB National Radiological Protection Board
NRS (verbal) numerical rating scale
NSAID non-steroidal anti-inflammatory drug
OPA oropharyngeal airway
ORCON operational research consultancy
PACS picture archiving and communication system
PASG pneumatic anti-shock garment
PCI percutaneous coronary intervention
PE pulmonary embolism
PEA pulseless electrical activity
PEFR peak expiratory flow rate
PEPP paediatrics for pre-hospital professionals
PHEA pre-hospital emergency anaesthesia
PHEC pre-hospital emergency care
xiv
PHEM pre-hospital emergency medicine

PHPLS pre-hospital paediatric life support
PHTC pre-hospital trauma course
PHTLS pre-hospital trauma life support
PICO Population (participants), Intervention (or exposure for observational studies),
Comparator and Outcomes
PICU paediatric intensive care unit
PPE personal protective equipment
PR per rectum
PRF patient report form
PTS paediatric trauma score
RCSEd Royal College of Surgeons of Edinburgh
REBOA retrograde endoscopic balloon occlusion of the aorta
RED Russell extrication device
RICE rest, ice, compression, and elevation
RNLI Royal National Lifeboat Institution
RSI rapid sequence induction (of anaesthesia)
RTC road traffic collision
RTS revised trauma score
RVS Royal Voluntary Service (formerly Women’s Royal Voluntary Service)
SAD supraglottic airway device
SAH subarachnoid haemorrhage/haematoma
SAMU Service d’Aide Médicale Urgente
sc subcutaneous
SCG Strategic Coordinating Group
SCIWORA spinal cord injury without radiological abnormality
SDH subdural haematoma
sec second
SIDS sudden infant death syndrome
SIRS systemic inflammatory response syndrome
SOAP-ME Suction, Oxygenation, Airway, Pharmacy, Monitoring, Equipment
SOP standard operating procedure
SSRI selective serotonin reuptake inhibitors
START Simple Triage and Rapid Treatment
Stat Immediately
SUFE slipped upper femoral epiphysis
SVT supraventricular tachycardia
TARN Trauma Audit and Research Network
TBI traumatic brain injury
TBSA total burn surface area
TCA tricyclic antidepressant
tds three times daily
TED Telford extrication device
TETRA Terrestrial Trunked Radio
TIA transient ischaemic attack
TRA trauma resuscitation anaesthetist
TREM transport emergency
TRISS trauma score – injury severity score
xv
TRTS Triage Revised Trauma Score

TTL trauma team leader
TU trauma unit
TWELVE Tracheal deviation, Wounds, surgical Emphysema, Larynx, Veins, Exposure
UKIETR UK International Emergency Trauma Register
USS ultrasound scanning
V volts
VAS visual analogue scale
VF ventricular fibrillation
VRS verbal categorical rating scale
VT ventricular tachycardia
WHA World Health Assembly
WHO World Health Organization
xvi
Contributors
Neil Abeysinghe mrcp uk frca fficm dipimc bsc (hons) Paul Dias mrcp frca
pgcertmeded Consultant Neuroanaesthetist
Consultant Critical Care Queen Elizabeth Hospital Birmingham,
Queen Elizabeth Hospital Birmingham, Birmingham, UK
Birmingham, UK
Paul Gates
Colette Augre Consultant Paramedic
Specialist Registrar in Anaesthetics North West Ambulance Service, UK
West Midlands Rotation, UK
Ian Greaves frcem frcp frcsed fimc fasi dtm&h dmcc
David Balthazor dipimc mrcs frca fficm dipmeded l /ramc
Consultant Anaesthetist and Intensivist Consultant in Emergency Medicine
Queen Elizabeth Hospital Birmingham, James Cook University Hospital, Middlesbrough;
Birmingham, UK Defence Medical Services, UK
Jon Barratt mcem dmcc dipimc ramc
Stephen Hearns frcs frcem frcp dipimc diprtm
Specialist Registrar in Emergency Medicine
Consultant in Emergency Medicine
St Mary’s Hospital; London and Defence Medical
Royal Alexandra Hospital; Paisley and Retrieval Doctor
Services, UK
with the Emergency Medical Retrieval Service of
Emir Battaloglu mbchb msc mrcs Scotland
Specialist Registrar in Trauma and Orthopaedic Surgery
Kieran M Heil beng rn
University Hospitals Birmingham NHS Foundation Trust
Institute of Naval Medicin, Portsmouth, UK
Philippa M Bennett mrcs rn
Specialist Registrar in Surgery Simon Horne frcem dipimc ramc
Institute of Naval Medicine, Portsmouth, UK Consultant in Emergency Medicine and Pre-Hospital Care
Derriford Hospital Plymouth; Defence Medical Services UK
Matt Boylan frcem dipimc ramc
Consultant in Emergency Medicine and Pre-Hospital Care Amy Hughes mbe dtm&h (liv) emdm mrcem
Royal Centre for Defence Medicine, Birmingham, UK Lecturer in Emergency Humanitarian Response
and Programme Director (Global Health)
Alasdair Corfield mrcp fcem dipimc Humanitarian and Conflict Response Institute, University
Consultant in Emergency Medicine of Manchester
Royal Alexandra Hospital; Paisley and Retrieval Doctor with
the Emergency Medical Retrieval Service of Scotland Jon Hulme mbchb mrcp dipimc frca fficm
Consultant in Anaesthesia and Intensive Care Medicine
Nick Crombie frca fimc Sandwell and West Birmingham Hospitals NHS Trust
Consultant Trauma Anaesthetist Resuscitation Service
Clinical Lead, Honorary Researcher, NIHR SRMRC Tim Kilner phd dipimc rcsed pgcert bn rn
Queen Elizabeth Hospital Birmingham; Midlands Air Senior Lecturer
Ambulance Service, Birmingham, UK Institute of Health and Society, University of Worcester
xvii
Contributors
Dhushy Surendra Kumar fca rcsi frca ficm Peter Oakley frca
Consultant in Critical Care, Anaesthesia and Pre-Hospital Former Consultant Anaesthetist
Emergency Medicine University Hospitals of the North Midlands,
University Hospital, Conventry, UK Stoke-on-Trent, UK
Graham Lawton bsc dmcc md frcs (plast.) ramc Jowan G Penn-Barwell frcs (tr & orth) rn
Consultant Plastic and Reconstructive Surgeon Specialist Registrar in Trauma and Orthopaedic Surgery
Imperial College Healthcare NHS Trust, London; Medical Institute of Naval Medicine, Portsmouth, UK
Officer, British Army
Professor Sir Keith Porter frcs frcsed frcem ffsem
Caroline Leech frcem fimc rcsed fimc fasi
Consultant in Emergency Medicine Honorary Professor of Clinical Traumatology
University Hospitals Coventry and Warwickshire NHS University of Birmingham
Trust Consultant Trauma Surgeon
Queen Elizabeth Hospital Birmingham, Birmingham, UK
Simon Leigh-Smith mrcgp frcsed (a&e) dipimc frcem rn
Consultant in Emergency Medicine and Pre-Hospital Paul Reavely frcem
Care Consultant in Emergency Medicine
Edinburgh Royal Infirmary; Defence Medical Services, UK Bristol Royal Infirmary and Bristol Royal Hospital for
Children
Ari K Leppäniemi md phd dmcc
Chief of Emergency Surgery Julian Redhead frcp frcem mfsem
Department of Surgery, Meilahti Hospital Consultant in Emergency Medicine and Paediatric
University of Helsinki, Helsinki, Finland Emergency Medicine, Medical Director
Imperial College Healthcare NHS Trust
Rod Mackenzie td phd frcp frcs frcem
Consultant in Emergency Medicine and Pre-Hospital Andy Thurgood msc fimc rcsed diphs rgn sr para
Emergency Care Consultant Nurse in Pre-Hospital Medicine
Addenbrooke’s Hospital, Cambridge, UK Advanced Clinical Practitioner (Emergency Department)
Chairman and Clinical Director
David McConnell mrcem rn Mercia Accident Rescue Service
Specialist Registrar in Emergency Medicine
Defence Medical Services, UK Darren Walter mph frcs(ed) frcem fimc
Consultant in Emergency Medicine
Carl McQueen mb chb (hons) mcem mmed sci (dist) dipimc University Hospital of South, Manchester, UK
rcsed nihr
Doctoral Research Fellow Matt Wordsworth ma dipimc mrcc ramc
Warwick Clinical Trials Unit Warwick Medical School, UK Specialist Registrar in Surgery
Imperial Healthcare NHS Trust; Defence Medical
Robb Moss frca dipimc Services, UK
Consultant Anaesthetist
Queen Elizabeth Hospital Birmingham; Mercia Accident Chris Wright dipimc frcem ramc
Rescue Service, Birmingham, UK Consultant in Emergency Medicine, Defence Consultant
Advisor in Pre-Hospital Emergency Care
Ross Moy frsem dipimc ramc Imperial College Healthcare NHS Trust; Defence Medical
Consultant in Emergency Medicine and Pre-Hospital Care Services, UK
John Radcliffe Hospital Oxford; Defence Medical
Services, UK
xviii
Trauma: A global perspective
OBJECTIVES
After completing this chapter the reader will
▪▪ Comprehend the scale of the challenge presented by trauma across the world
▪▪ Understand the different effects of trauma in developed and less developed societies
▪▪ Understand the importance of prevention in reducing the impact of trauma internationally
INTRODUCTION
All we can do in the face of that ineluctable defeat called life is to try to understand it.
Milan Kundera, The Curtain (1)
The aetiology, pathophysiology and management of trauma are complex and challenging. In
contrast to a disease process, trauma as an aetiological factor involves more or less immediate
external energy transfer into the human body, whether caused by mechanical, thermal or some
other form of energy. In order to better understand the multitude of factors involved in the
process of traumatic injury, a wider perspective encompassing the context in which the trauma
occurs is warranted. When analysing the evolving trends in trauma, a perspective is needed
that goes beyond narrow local and clinically orientated views. This chapter considers trauma in
its widest context, including other causes of mortality and morbidity, with an emphasis on the
causes and manifestations of trauma on a global scale.
THE BIG PICTURE

Many seemingly unrelated events in different parts of the world produce the same end result:
one or more people are severely injured or killed as a result of trauma, whether associated
with a natural or man-made disaster, a single violent act by an individual, organised crime, an
industrial accident, terrorism or warfare. Although easily interpreted as individual and unre-
lated events, there are many trends in the globalised world that offer at least a partial explana-
tion of the root causes of these occurrences.
1
Various combinations of fundamentalism, individual and institutional greed, inequality and

lack of basic human rights and democracy, just to mention the most obvious factors, can lead to
unforeseen consequences. For example, the Arab Spring, which began on December 18, 2010,
in Tunisia as a protest against police corruption and ill treatment, triggered demonstrations,
protests, riots, civil wars and revolutions all over North Africa and the Middle East culminating
in the Syrian civil war that started in 2011. As a consequence of the Syrian civil war, hundreds
of thousands of Syrians have sought to escape their war-torn country creating the worst refu-
gee problem in Europe since the Second World War. After 4½ years of war, more than a quarter
of a million people have died, many whilst trying to cross the Mediterranean or in the hands
of human traffickers. Eleven million have fled their homes (2). In addition to these refugees
from war, many others seek better living conditions by trying to enter the United States or the
European Union illegally, adding to the already explosive refugee problem.
The financial crisis of September 2008 originating in the United States but having economic
consequences throughout the world can be seen just as a temporary setback in continuous
globalisation and the success story of the current consumer- and market-orientated way of life.
However, it could also be a signal that the current culture based on speculation and immedi-
ate reward is no longer sustainable. Immanuel Wallerstein (3) has predicted that after half a
millennium of success, the recognisable capitalist world order is coming to an end and is likely
to bring chaos for the next 50 years. The main reason he gives is a decrease in profits due to
a shortage of cheap labour and natural resources. According to some economists, there are
also fundamental flaws in the global monetary and banking system, where independent coun-
tries have to increasingly rely on financing their budgets with borrowed money (4). It is also
clear that the reactions of individual organisations and states are closely entwined. The current
and ongoing political and economic crisis in Greece, for example, was triggered by the fear of
losses to major German and French banks. The Greek financial crisis demonstrated that the
real global financial (and by extension political) power rests not only in major economies such
as the United States, China or Germany, but in the multinational institutions and corporations
that also have substantial political influence. Inevitably, unrest and a sense of injustice will lead
to changes in the global pattern of trauma.
As stated in a TV interview by Kishore Mahbubai, a leader of the Lee Kuan Yew School of
Public Policy in Singapore, 900 million Westerners, 15% of the world population, can no longer
dictate world opinion. With the increasing economic power of Asia, especially China and India,
it can be expected that their role in the global economy as well as in international organisa-
tions will grow at the expense of a Europe that is suffering from shrinkage of its population.
According to an estimate by the Berlin Institute, the population of Europe will decrease by
8.3% from 2007 until 2050 and that of Russia by 21.1%. In contrast, the population in Africa,
Asia, Latin America (including the Caribbean), the United States and Canada will increase by
105.2%, 30.1%, 37.6% and 30.7%, respectively (5). According to the United Nations Economy
and Social Division (DESA), by the end of the year 2008, half of the 6.7 billion people in the
world were living in cities and the projection for 2050 is 70%. By 2025 there will be 27 mega-
cities, mostly in Asia and Africa (6). The dark side of rapid economic growth was revealed in
one of the fastest growing economies when a huge corruption scandal involving the Brazilian
oil company Petrobras emerged in 2013. Top politicians and businesspeople received bribes
including luxury yachts, cars, art, fine wines and the services of prostitutes (7). It has been
estimated that in 2013 alone the total amount of corruption money was between US$32 billion
and US$53 billion.
Another threat to welfare in rich countries is presented by the so-called frail states. Almost
50 countries, including Afghanistan, Ethiopia, Georgia, Kenya, Nigeria, Somalia, Sudan and
2
Climate change and energy use
South Sudan are listed as frail states: they have a total population of 870 million. Such states are
characterised by the inability or lack of political will of the state to provide basic services critical
to welfare, such as essential social services, security, human rights and the uninterrupted func-
tion of basic economic and social institutions. In a typical frail state, poverty increases bringing
violence, anarchy and crime, producing uncontrollable refugee flows, epidemics and environ-
mental destruction (8). However, a contrasting view has been presented by the researchers of
the World Bank who estimate that the absolute number of the poorest segment of the popula-
tion in developing countries has decreased by 500 million in the last 50 years (9). In some coun-
tries such as Ethiopia, substantial progress has been made in the last decade where the annual
economic growth has been around 10%, millions more people have access to clean water, and
in spite of the population growing from 40 million in 1984 to 95 million in 2014, the mortality
rate among children less than 5 years old has at the same time decreased from 227 to 63 per
thousand births (10). Consequently, the life expectancy has increased from 65.3 years in 1990
to 71.5 in 2013.
CLIMATE CHANGE AND ENERGY USE

Climate change is real and becoming critical. Only a few would now deny the contribution
of human behaviour to its causation. The sea level rises about 1 mm for every 360 gigatons of
water, and during a study period of 1994 to 2013 based on photographs by NASA, the sea level
has risen about 4 mm from the melting of Alaskan glaciers alone. The Alaskan coast no longer
freezes as it has in the past and storms erode the coastline causing houses to fall into the sea
and populations to move inland.
According to the worst-case scenario of the Intergovernmental Panel on Climate Change,
the mean temperature of the Earth will increase from 15 to 20 centigrade by the year 2100.
Even if this is an overestimate, most scientists agree that the current trend in climate change
will bring huge effects including natural disasters and epidemics (11). In the last three decades,
over 1000 extreme weather events hit the World Health Organization (WHO) European region
alone. Climate change increases the frequency and severity of these events, and according to
the latest projections, if global warming is unconstrained (12), the future effects of heatwaves,
floods and droughts, worsening air pollution and changes in vector and plant distribution are
likely to harm the health of millions of people. As stated by the economist Jeffrey Sachs, climate
change is already driving warfare in some Sub-Saharan countries where hungry people clash
over scarce food and water (13). Interestingly, it has been shown that long-term fluctuations in
war frequency and population changes follow the cycles of temperature change and that rela-
tive food scarcity is a fundamental cause of outbreaks of conflict (14).
Besides the long-term effects on climate change through the production of greenhouse gases,
the global dependency on oil, especially in the Western world and growing Asian economies,
will have major effects in the short term. It has been estimated that the world has utilised about
one third of its oil reserves and that the demand for crude oil has permanently surpassed the sup-
ply, which means that the price of oil will not consistently decrease in the future (15). The search
for alternative fuels has in the last few years focused on bio-fuels made of corn, wheat, soybean
or palm oil, for example. This has led to acute food shortages with the risk of food-related unrest
in at least 33 countries, as estimated by the former World Bank President Robert Zoellick (16). In
the United States, one-third of the corn produced is already used for the production of ethanol,
and 75% of the increase in food prices is caused by favouring bio-fuel production (17). Michael
Delgado, an agricultural economist from the World Bank, has estimated that the global food
3
reserves per capita are lower than at any time during the last 35 years (18). In addition to food
shortages caused by diverting arable land from food production to fuel production, droughts
in Australia for example, and speculation in the global food markets have increased the price
of food and led to violent uprisings in numerous countries, including Egypt, the Philippines,
Yemen, Haiti, Cameroon, Mozambique, Morocco and Indonesia (19).
GLOBAL BURDEN OF TRAUMA

According to the Global Burden of Disease project (20), there will be a projected 40% increase
in global deaths due to injury between 2002 and 2030, predominantly due to the increasing
number of road traffic collision deaths that, together with increases in population numbers,
more than offset small declines in age-specific death rates for other causes of injury. Road traffic
collision deaths are projected to increase from 1.2 million in 2002 to 2.1 million in 2030, pri-
marily due to increased motor vehicle fatalities associated with economic growth in low- and
middle-income countries (21). The overall increase in injury-related deaths is projected to be
from about 5 million to about 7 million by 2030. The changes in rankings for causes of deaths
from 2002 to 2030 show an increase in road traffic collisions from 10th to 8th and self-inflicted
injuries from 14th to 12th. In disability adjusted life years (DALYs), the ranking change for road
traffic accidents is from 8th to 4th, violence from 15th to 13th and self-inflicted injuries from
17th to 14th.
NATURAL DISASTERS
During the last few years, dramatic natural disasters have claimed the lives of hundreds of
thousands of people. The 2004 underground earthquake and the following tsunami in South
East Asia killed over 230,000 people in 10 countries and the earthquake in October 2005 in
northern Pakistan killed 78,000. On May 3, 2008, the floods caused by hurricane Nargis killed
85,000 people and 53,000 went missing in southern Myanmar. The Caribbean and the United
States have been hit repeatedly by hurricanes several times a year, with Katrina in 2005 killing
1836 people in New Orleans (22,23).
On March 11, 2011, following a major earthquake, a 15-meter tsunami hit the Japanese
coast and disabled the cooling system of three nuclear reactors leading to melting of all three
cores and radioactive releases into the air and sea. Although there were no immediate deaths
from radiation sickness, over 100,000 people had to be evacuated. The long-term effects on the
population and environment remain to be seen.
In large-scale natural disasters with damage or overwhelming of the local and national
healthcare facilities, rapid and well-coordinated international relief efforts are of the utmost
importance. In some cases, individual countries have opted for evacuating their own citi-
zens from the disaster area (24). In an analysis of the fatalities caused by Hurricane Katrina
in Louisiana, the major causes of death were drowning in 40%, injury and trauma in 25% and
heat-related illness in 11%. People of 75 years old and older formed the most affected popula-
tion cohort. The authors recommended that future disaster preparedness efforts should focus
on evaluating and caring for vulnerable populations, including those in hospitals, long-term
care facilities and their own homes (25).
A new and worrying development in the management of disasters is the increasingly com-
mon privatised disaster response, to the extent that disasters themselves have become major
4
War
new markets, a phenomenon Naomi Klein has called the ‘disaster-capitalism complex’ (26).
Within weeks of hurricane Katrina, several major private companies signed contracts worth
millions of dollars for services that included protection of Federal Emergency Management
Agency (FEMA) operations and providing mobile homes to evacuees. These companies
increasingly regard both the state and non-profit organisations as competitors, while the state
has lost the ability to perform its core functions without the help of external agencies. Also on
the list of privatised services are the global communication networks, emergency health and
electricity services, and the providers of transportation for a global workforce in the midst of a
major disaster.
MAN-MADE DISASTERS
Many mass casualty incidents are man-made (or a combination of a natural disaster with man-
made elements). In many cases the reason is the lack of appropriate supervision of construction
and storage sites by local authorities.
On August 12, 2015, two explosions at a warehouse storing dangerous chemicals devastated
an industrial park in the northeastern port city of Tianjin in China killing at least 121 people,
including 67 firefighters. More than 700 people were injured and thousands were evacuated
because of the risk posed by chemicals stored at the site. On September 11, 2015, at least 87 peo-
ple died and almost 200 were injured in Mecca in Saudi Arabia when a construction crane fell
over the Masjid al-Haram mosque (27). The increasing use of immigrant workforces, especially
in some wealthy oil-producing states in the Middle East, has led to a near epidemic of construc-
tion site accidents due to deficient safety practices. Added to the reckless driving culture in
many of those countries, their trauma centres see many blunt trauma patients every year.
WAR
There were more wars in 2014 than in any other year since 2000. There were 14 conflicts that
killed more than 1000 people. Syria, Iraq and Afghanistan were the three deadliest wars with
Nigeria being the fourth where the number of deaths almost tripled from the previous year due
to the intensification of the conflict with the militant group Boko Haram. While the number of
state-based conflicts has remained stable for the last 10 years, the number of non-state conflicts
increased from 29 in 2004 to 48 in 2013. Using the Global Peace Index ranking of 162 coun-
tries by their relative states of peace, the bottom five countries were Syria, Afghanistan, South
Sudan, Iraq and Somalia. In Europe despite the dense web of legal conventions, political agree-
ments, institutions of different kinds and other security instruments in place, political crisis
escalated into major conflict in Ukraine in the space of only few months. It has been estimated
that by the end of 2014 more than 4300 people had been killed in this conflict and that 500,000
people have been internally displaced. At the time of writing, there appear to be no prospects
of a lasting settlement.
In addition to the geopolitical considerations of destabilising neighbouring countries to pre-
vent them joining the opposite political bloc, the persistence of conventional warfare doctrine
related to ethnic and resource competition is evident, for example in the war in August 2008
between Georgia and Russia where the control of the oil pipelines from the Caspian Sea area
was undoubtedly a major factor. It has been speculated that the vast untapped energy reserves in
the Persian Gulf and the Caspian Sea area could provoke great-power warfare even today (28).
5
An interesting new theory about the causes of conflicts has been presented by the German
population scientist Gunnar Heinsohn. The expansion of men aged 15 to 29 years to comprise
more than 30% of the adult male population, a so-called youth bulge, seems to correlate with the
risk of conflict (29). The size of the youth bulge in some of the recent conflict areas is significant:
53% in the Gaza strip, 52% in Kenya and 49% in Afghanistan.
According to a global report on child soldiers, the use of children in wars has decreased
during the past few years, but they are still present among the fighters in Myanmar, Chad, the
Democratic Republic of Congo, Sudan, Uganda (Lord’s Resistance Army), Yemen and Israel
where the military has used Palestinian children as human shields and the training of those
under the age of 18 is common (30). Another disturbing development is the increasing use
of rape as a method of war, as has been witnessed recently in eastern Congo (31). In modern
conflicts the great majority of victims are civilians, as seen in the conflict in Syria with millions
of civilians fleeing the country and overwhelming neighbouring countries and the whole of
Europe with an unprecedented influx of refugees, not forgetting that of the more than 200,000
deaths and more than 800,000 wounded, a large majority were civilians.
One of the uncertain factors potentially destabilising the Middle East is the nuclear program
in Iran. In spite of the nuclear agreement with Iran and the reactions of its neighbours, particu-
larly Israel, the strategic balance in the region may shift and lead to a regional and potentially
global conflict. The recent decision by the USA to withdraw unilaterally from this agreement
has the potential to destabilise an already difficult situation, not least by rendering the situation
of Iranian modernisers more difficult. A pre-emptive air strike or other form of attack on the
Iranian nuclear facilities would lead to economic and political turmoil which could have world-
wide implications. The closure of the Strait of Hormuz, for example, would severely impair
global oil availability (32,33).
In 2014, world military expenditure was estimated at US$1776 billion, representing 2.3%
of global gross domestic product or US$245 per person. Military spending has continued to
increase rapidly in Africa, Eastern Europe and the Middle East, and the conflicts in Ukraine,
Syria and Iraq are likely to continue to drive military expenditure in many countries in these
regions. Divided by region, military spending in 2014 was largest in North America (US$627 bil-
lion) followed by East Asia (US$309 billion) and Western and Central Europe (US$292 billion).
Civil wars continue in many parts of the world and their relationship with the drug trade
has become increasingly recognised, at least in Colombia and Afghanistan. According to the
United Nations Office on Drugs and Crime (UNODC), the Taliban rebels in Afghanistan
received 64 million euros in 2007 from opium growers. The total yield from opium fields was
8000 tons when the average global consumption is 4000 tons. The rest is in storage in unknown
locations. Conversely, in Colombia real progress in the FARC conflict may be possible with the
release of long term hostages, the death of their leader Manuel Marulanda and the signing of
a political accord with the government (31) A political resolution between FARC and the civil
government was signed in 2016 but may not ensure permanent peace as large numbers of for-
mer FARC members are now leaderless and have lost political and social influence. Illustrative
of the difficulties in nation building after a civil war is the double assassination attempt in 2008
on the president and prime minister of East Timor. President Jose Ramos-Horta suffered two
abdominal gunshot wounds and was operated on in Australia (34).
The most important major new strand in international terorrism of recent years has been
Islamic extremism. The Islamic State of Iraq and Syria (ISIS), or the Islamic State of Iraq and
the Levant (ISIL), now known as Islamic State (IS), expanded very rapidly and by the most
brutal means to control large areas of the Middle East. Although this geographical dominance
is now largely lost, as a result of military intervention by Iraq, Syria and the Western powers,
6
Terrorism
there is no doubt that the spreading of an extremist Islamic ideology will remain prominent in
motivating terrorist activity and it seems likely that a consequence of the loss of territory will be
the export of violence to states perceived to represent most clearly a decadent western lifestyle
and willing to engage militarily with IS. As well as extreme brutality including mass killings,
executions and kidnappings, IS was also responsible for destroying ancient temples in Palmyra,
possibly for manufacturing or capturing chemical weapons, and using videos advertising a
luxury lifestyle to recruit young people to join the five star jihad (35). Another destabilising
factor in the area is the complex relationship between Turkey and the Kurdish areas both inside
and outside Turkey and in northern Iraq and Syria, mostly driven by domestic political struggle
in Turkey between the model of a secular state and an Islamic republic.
TREATMENT OF WAR WOUNDS

In an analysis of 82 US Special Operations Forces fatalities from 2001 to 2004, 19 were non-
combat deaths, while of the combat deaths 43% were caused by explosions, 28% by gunshot
wounds, 23% by aircraft accidents and 6% by blunt trauma (36). Seventy of the deaths were
classified as non-survivable and 12 (15%) as potentially survivable. Of those with potentially
survivable injuries, cause of death was identified in 16 cases: 8 (50%) truncal haemorrhage,
3 (19%) compressible haemorrhage, 2 (13%) haemorrhage amenable to tourniquet, and 1 (6%)
each from tension pneumothorax, airway obstruction, and sepsis. Structured analysis identi-
fied improved methods of truncal haemorrhage control as a principal research requirement.
This data and analysis reflects the findings of the very considerable literature arising from
medical interventions in Iraq and particularly Afghanistan where there have been significant
developments in trauma and particularly shock management which are increasingly being
incorporated into civilian practice.
TERRORISM
Since 2000, there has been a more than fivefold increase in the number of deaths from terror-
ism, rising from 3361 in 2000 to 17,958 in 2013. Over 80% of the lives lost to terrorist activ-
ity in 2013 occurred in only five countries – Iraq, Afghanistan, Pakistan, Nigeria and Syria.
However, another 55 countries recorded one or more deaths from terrorist activity (37). On
July 22, 2011, a deranged Norwegian man exploded a truck bomb adjacent to the govern-
ment building in Oslo and continued by gunning down young people in a summer camp on
a nearby island. Overall, 78 people died and more than 150 were injured. In another incident
in Finland in 2002, a young man detonated a self-made explosive in a shopping centre killing
and injuring 164 people. In 2013, 60% of all attacks involved the use of explosives, 30% used
firearms and 10% used other tactics including incendiary devices, melee attacks and sabotage
of equipment (37).
To increase the fatality rate from terrorist attacks some innovative methods have recently been
used including spherical metal pellets propelled by the explosion increasing the severity of injuries
and adding a penetrating component to the blast injury and blunt trauma. Potential transmission
of infection by body fragments in suicide bombings is also a concern. Medical teams assessing
and treating terrorist bomb victims should be trained to recognise these injuries (38).
A dirty bomb is a mix of a conventional explosive with radioactive material resulting in dis-
persion of radioactive material. Although the major medical risk associated with a dirty bomb is
7
blast injury caused by the conventional charge, the casualty profile of such a bomb will include
a small group of casualties who may also be contaminated with radioactive material and who
may require implementation of decontamination procedures either in the field or at the receiv-
ing hospital (39).
The use of a second hit (a second bomb designed to explode in the vicinity of the first bomb
after a short time period to injure helpers and bystanders) has been recorded in several recent
terrorist attacks. It is imperative that in any current terrorist explosion the risks must be mini-
mised by strict security procedures and scene access control. In two cases recorded from Israel,
the second bombs exploded 10 to 30 minutes after the first detonation (40). In addition, the
discovery in Israel in 2003 of arms and gunmen in some ambulances lead to the practice that all
ambulances, even those conveying critically injured victims had to pause for brief inspection at
the perimeter of the hospital’s grounds (41). Another potential security risk for EMS personnel
entering a ‘hostile’ area is the possibility of a sniper (42).
In addition to the conventional injury pattern associated with explosions (primary, second-
ary, tertiary and associated blast injuries) the possibility of biological foreign body implantation
from the suicide bombers or other victims has been recently reported (43,44).
Despite the death of Osama bin Laden in 2011, al-Qaeda and its associated organisations
are still thought to have cells in 40 to 50 countries and a membership of 200–500 men. The
decentralised structure makes it hard to control and major attacks can be perpetrated with
only a handful of members. The biggest threat, however, is thought to be related to the ability
of the terrorists to obtain weapons of mass destruction (45). Access through the Internet to the
SCADA guidance systems that control many industrial processes and infrastructures could
also be serious by inducing malfunctions in nuclear power plants, mass transport systems, oil
and gas pipes, and electricity networks (46).
In the long run, the key issue in coping with militant Islamic radicalism is to understand the
deep resentment of Western values by the Wahhabist form of Islam that since the 1700s has been
the dominating ideology in Saudi Arabia. Wahhabism was founded by Ibn Abdul Wahhab in
the 18th century and has militantly asserted the monotheistic roots of Islam. According to Dore
Gold, the former Israeli ambassador to the United Nations, the uneasy alliance of the ruling
Saudi family and the Wahhabist ulama (religious leadership), and the Saudi state support for its
ideology of hatred has provided the framework for promoting Wahhabi ideology and financial
support for radical groups in many conflict areas of the world reaching from Bosnia and the
Caucasus through the former Soviet republics in Central Asia and the Taliban in Afghanistan to
the Philippines and Indonesia (47). The only permanent solution seems to be in trying to engage
the rulers of Saudi Arabia in a meaningful dialogue about the peaceful coexistence of different
cultures and ideologies, and minimal standards of acceptable international behaviour.
ORGANISED CRIME AND CIVILIAN VIOLENCE

While the organised crime societies in southern Italy seem to be suffering from severe weaken-
ing thanks to diligent work by the police, the rampant violence and turf wars of the drug cartels
in Mexico seem to be becoming uncontrollable. Since 2006 at least 85,000 people have been
killed, and in 2014 alone there were 19,699 murders in Mexico (48). There are many similarities
between the actions of the Mexican drug cartels and IS; extremely brutal killings, mass graves,
rapes and hangings, with videos distributed through the Internet. Both obtain arms from the
United States: IS by stealing equipment from the Iraqi army and cartels by smuggling illegal
arms across the border, about 250,000 weapons annually.
8
Globalisation, trauma systems and education
School and other mass shootings have occurred with regularity during the last few years.
The highest number of victims in such a shooting (33 dead) was recorded in the Virginia Tech
massacre on April 16, 2007, but even in Finland an 18 year-old high school student killed 9 people
including himself and injured 12 on November 7, 2007. The killer admired school shooters in
other countries and left hints of his plans on the Internet 2 days before the shooting (49). A sim-
ilar incident occurred on September 23, 2008, in the western part of Finland when a 22-year-old
student shot 10 people in a training centre for adults and then killed himself (50). The number
of gunshot wounds in the victims varied from 1 to 20 reflecting the degree of determination and
hatred of the perpetrator. Besides the dangers of marginalisation, alienation and the specific
sub-culture of violence glorification among young men in Western countries, the availability
of, and lax laws governing the purchase of, handguns need to be urgently revised. Most of the
innocent victims of school and other public-place shootings were shot with guns that had been
purchased recently and legally (51).
According to a report from the United States, the number of murders has increased rap-
idly in some of major cities, by 76% in Milwaukee, 60% in St. Louis and 56% in Baltimore
(52). The most popular explanation seems to be that the increased criticism of police actions
(starting from August 2014 when an unarmed black teenager was shot by a white policeman
in Ferguson, Missouri) has resulted in a less aggressive approach by police forces allowing
criminals to have the upper hand. In June 2016, 50 people were shot dead in a bar in Orlando
frequented by the LGBT community, an event which, with more recent mass shootings, has
led to increasing public demands for gun control legislation. To date there seems little political
appetite at a central level for such intervention and the ‘gun lobby’ remains an exceptionally
powerful force in US politics.
GLOBALISATION, TRAUMA SYSTEMS AND EDUCATION

Trauma care practices are becoming increasingly uniform all over the world, not in small
part due to trauma training programmes, such as Advanced Trauma Life Support (ATLS®), the
European Trauma Course (ETC®) and Definitive Surgical Trauma Care (DSTC™). Although some
countries are ahead of others, the principles vary little from continent to continent (53–58).
A landmark event in global trauma care occurred on May 23, 2007, when the World Health
Assembly (WHA) adopted Resolution 60.22, ‘Health Systems: Emergency Care Systems’,
which called on the World Health Organization (WHO) and governments to adopt a variety
of measures to strengthen trauma and emergency care services worldwide (59). This resolution
constitutes the highest level of attention ever devoted to trauma care on a global scale.
There are signs, however, that medical systems have increasing difficulty in providing ade-
quate emergency care to their populations. In the United States some hospitals have had to
close their emergency departments (60). In 2007, the National Academy of Science and Institute
of Medicine published its report ‘Future of Emergency Care for the US Health System’ which
identified the following problems: poorly coordinated and chaotic pre-hospital care ambulances
being regularly turned away from hospital doors; overcrowded emergency departments, long
waiting times, lack of senior decision makers in emergency departments, poor facilities for pae-
diatric patients and lack of space for continuation of patient care. One of the solutions offered
is reorganisation and regionalisation of emergency care along the trauma system model, with
improvement in resourcing, training, leadership and research (61).
In Europe, the WHO has observed that emergency departments are overcrowded with
cases that cannot be considered urgent and has urged the development of daytime emergency
9
services, better coordination and selection of emergency patients, and more training of the
doctors and nurses treating emergency patients (62). In the UK the alleged pressure on the
National Health Service resulting from European Union migration was a major area of contro-
versy in the referendum regarding the EU membership debate and there is an opposite political
lobby demanding, in effect, ever-increasing health spending with no recognised limit.
One key issue is the level of expertise in the emergency department. Experiences from the
United Kingdom and New Zealand show that increasing availability of specialist-level physi-
cians in emergency departments shortens emergency department and hospital lengths of stay,
increases daytime and decreases night-time emergency operations, and decreases costs (63,64).
In the United States the combination of trauma surgery, emergency general surgery and
surgical critical care into one acute care surgery model and curriculum has progressed rapidly
(65). Initial experiences show that the acute care surgery model does not compromise the care
of the injured patients, and improves the care of some emergency surgery patient groups, such
as acute appendicitis or ruptured abdominal aortic aneurysms (66–68). This new paradigm is
also having an influence on clinical practice, for example by extending the concept of damage
control surgery to emergency general surgery (69,70). Based on a report from various hospitals
with similar complication rates but highly variable mortality rates, the concept of failure to res-
cue has been introduced, and surgical rescue has been included as the fifth pillar of acute care
surgery (in the United States) or emergency surgery (in Europe) alongside trauma, critical care,
emergency surgery and elective general surgery (71,72).
Finally, the paradigm change will also affect patient care on a system level. A message from
the president, Timothy Fabian, in the American Association for the Surgery of Trauma newsletter
stated: ‘For delivery of Emergency Surgical Services, it is time to ‘circle the wagons’ and regionalize
care in the same fashion as healthcare is being regionalized for many disease processes. The future will
hold Regional Emergency Surgery Hospitals’ (73).
SUMMARY
In spite of significant advances in clinical practice, economical, educational and organisational
limitations prevent us from providing the best available care for many of our patients, at least on
a global scale. Fresh solutions and new paradigms are needed in order to approach the key issues
successfully. Trauma and emergency clinicians can and should play a key role in identifying the
problems and challenges in providing adequate trauma care to the population. To do it, however,
requires a view encompassing the wider trends and challenges of the world we live and work in.
REFERENCES
1. Kundera M. The Curtain. New York: Harper Collins Publishers, 2005.
2. Huusko J. Pakolaiskriisin jäljet johtavat Syyriaan. Helsingin Sanomat, August 22, 2015.
3. Nieminen T. 2008a. Tohtori Wallersteinin hirviö. Helsingin Sanomat, March 9, 2008.
4. Immonen P. 2015. Tsunami avasi silmät. Raha-aktivisti Ville Iivarinen kertoo ihmisille
rahajärjestelmän ongelmista. Helsingin Sanomat, September 2, 2015.
5. Ahtiainen I. 2008. Euroopan väestökehitys maahanmuuton varassa. Helsingin Sanomat,
August 22, 2008.
6. Sillanpää S. Kaupungistumisesta tulee kiivainta Aasiassa ja Afrikassa. Helsingin
Sanomat, June 29, 2008.
10
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Glenquhargen. They were all nimble-footed, and the panic with
which they were now actually seized gave wings to their speed, and
rendered a matter of no regard the rocks and other impediments
over which they were flying. Their pursuer was not more speedy, but
much longer winded, and the rage which then impelled him was not
less potent than their terror. He possessed a fund of physical ability
which was almost inexhaustible, and he had sworn not to drop the
pursuit till he had “smashed the hale set,” so that from the length of
the race the poor wights had but a small chance of safety. At length
the top of Glenquhargen, then Cairnkinnow, and next Gowkthorn,
were reached, without any loss or advantage to either party. From
the latter of these places, the ground declines nearly the whole way to
Drumlanrig, and the soldiers, with the start in their favour, flew on
with a glimmering of hope that now they could scarcely be overtaken.
Their hope was realised, but not without such overstraining as had
nearly proved equally fatal with the vengeance from which they fled.
Leaning forward almost to the ground, and staggering like drunkards
from excess of fatigue, they at last reached the western staircase
which leads into the court of the castle. Behind them Glenmannow
rushed on also with abated speed, but with indignation as hot as
ever. He still bore upon his shoulder the ponderous car limb; his face
was literally bathed in perspiration; and the wild expression of his
eyes, and the foam which was beginning to appear at each corner of
his mouth, rendered him a true personification of Giant Madness
broken from his chains.
The two dukes, who had been informed of their approach by some
servants who observed them descending the opposite heights, were
waiting to receive them within the balustrade which runs along that
side of the castle; but on marking the fury of Glenmannow, Duke
James deemed it prudent to retire with the exhausted soldiers until
the storm should be passed; for while his tenant remained in that
mood of mind, he dared not, absolute as was his authority, to come
into his presence. His brother of Buccleuch was therefore left to bear
the first brunt of the salutation, who, on Glenmannow’s approach,
called out, “What is the matter? What is to do?” Glenmannow,
without regarding this interrogatory further than by darting upon
him a wild and fierce look, sprang up stairs, and rushed past him into
the court of the castle. But here his progress was stopped; for among
the several doors which lead from thence to every part of the castle,
he knew not by which his enemies had entered. One, however, was
known to him, and along that passage he rapidly hastened, until he
at length arrived in the kitchen. There he was equally at fault, and
there his pursuit was ended; for the smiles of the sonsy cook, and the
fondlements of the various servants who thronged around him,
succeeded in restoring his mind to a degree of calmness and repose.
The cook eased his shoulder of the car limb, with the intention of
repaying herself for the trouble by using it as fuel; others divested
him of his bonnet; and all, with many words, prevailed upon him at
last to assume a chair. After a moment’s silence, in which he seemed
to be lost in reflection, “Ay, ay,” said he, “I see through a’ this noo. It
has been a trick o’ the juke’s makin’ up.” Then, with a serious air, he
added, “But it was dangerous though; for if I had gotten a haud o’
thae chaps, wha kens what I might hae done!”
The duke, on being informed of this change wrought upon his
tenant, and having learnt from the soldiers the way in which he had
been deprived of his breakfast, ordered him a plentiful refreshment,
and afterwards sent for him into the presence of himself and of
Buccleuch. The breach between them was speedily healed; and
Glenmannow, nothing poorer for his race, returned shortly
afterwards with a servant on horseback, who was dispatched to
convey to headquarters the poor grenadier who had been so roughly
handled in the affray.
Mally, with a humanity and forgiveness which the soldier had little
right to expect, had succeeded in removing him from the spot where
he was cast down, into the house, and having there laid him upon a
bed, tended him with such kindness and care, that, by the time of
Glenmannow’s return, he was so far recovered as to be able to sit
upon the horse sent to remove him. Glenmannow, after Mally had
wrapped round him a pair of blankets, bore him out in his arms, and
placed him behind the servant, who in this manner conducted him in
safety to Drumlanrig.
This is the last exploit of a remarkable kind which I have been able
to glean respecting Glenmannow. He lived to a pretty long age, yet
his life was abridged within its natural period by imprudently taxing
his great strength beyond its actual capability. A high dyke was in the
course of being built, from the heights on the left of the Nith into the
channel of the river, about four miles above Drumlanrig, on the way
to Sanquhar, and in order to resist the force of the current, the
largest stones that could be moved were built into the dyke at its
termination. One in particular, which lay near the place, was deemed
excellently fitted for that purpose, but its weight rendered it
unmanageable. Glenmannow undertook to lift it into its place, and in
reality did so; but in the effort he injured his breast and spine, and
brought on a lingering disorder, of which he died in less than a
twelvemonth afterwards, in the year 1705. I am not aware of his
having left any descendants to perpetuate and spread his name; one
thing at least is certain, that in the present day none such are to be
found in that district which was the principal scene of his exploits,
and where still is cherished to such a degree his singular yet honest
renown.—Traits of Scottish Life, and Pictures of Scenes and
Character.
MY GRANDMOTHER’S PORTRAIT.
By Daniel Gorrie.
In picture galleries, or in private apartments, portraits seldom

receive much attention from visitors, unless they happen to have
known the originals, or to be aware that the pictures are the
productions of distinguished artists. And yet, whether we have
known the originals or not, and apart altogether from the general
artistic merit of the works, there are many portraits which have a
wonderful effect in giving the mind a reflective and inquisitive turn.
Portraits of this description may occasionally be seen in retired
country houses of modest dimensions, where one need scarcely
expect to find specimens of the highest class of art. Faces we may
there observe, silently depending from the walls, on which strongly-
pronounced character is depicted in spite of every artistic defect, and
through the deep lines of which the record of a stirring or painful life
seems to struggle earnestly for utterance. People are too much in the
habit of regarding every person as commonplace and uninteresting
who has not managed somehow to make a noise in the world; but in
these “counterfeit presentments” of men and women who have died
in comparative obscurity, known only to their own circle of friends,
we may see much that strangely moves our hearts, and makes us long
to learn what their history has been.
Let the reader look in fancy on that old portrait hanging before me
there on the wall. To me it is no dead picture, but rather does it seem
the living embodiment of a maternal grandmother—a heroic old
dame, who never lost heart whatever might betide, and of whom that
image is now almost the sole remaining relic. Even a stranger could
scarcely fail to note with curious interest that small round face with
nose and chin attenuated by years—those peering eyes, where a
twinkle of youth yet breaks through the dim of eld—that wrinkled
brow, shaded with a brown frontage-braid of borrowed hair—and
that compact little head, encased in a snow-white cap with its broad
band of black ribbon. The least skilful artist could hardly have failed
in depicting the features; but the old familiar expression is also there,
preserved as in amber, and the aged face is pleasantly blended in my
mind with memories of early days. Detached incidents in her life,
which she was fond of frequently relating to her grandchildren, who
eagerly clustered around her, listening to the oft-told tale, recur to
me with considerable freshness after the lapse of many years.
At the time when that portrait was taken, Mrs Moffat—as I shall
name her—was well-nigh eighty years of age. For about the half of
that period she had led a widowed life. Her husband, who witnessed
many stirring scenes on sea and shore, had been a surgeon in the
Royal Navy, and she was left “passing rich with forty pounds a year”
of government pension.
There was one remarkable incident in his history to which she
frequently recurred. Samuel Moffat obtained an appointment as
surgeon on board the ill-fated Royal George; but before the time set
apart for her leaving port, he found that the smell of the fresh paint
of the new vessel created a feeling of nausea, which would have
rendered him unfit for duty; and by his good fortune in getting
transferred, on this account, to another man-of-war, he escaped the
sad fate that befell so many hapless victims—
When Kempenfelt went down
With twice four hundred men.
A striking incident of this kind naturally made a deep impression on

his own mind, and it also formed a prominent reminiscence in the
memory of his faithful partner during the long remainder of her life.
The earlier period of Mrs Moffat’s widowhood was passed in
Edinburgh; but when death and marriage had scattered her family,
she followed one of her married daughters to the country, and took
up her abode in a neat poplar-shaded cottage on the outskirts of a
quiet village, situated in a fertile and beautiful valley of the county
that lies cradled in the twining arms of the Forth and the Tay. That
cottage, with its garden behind, and pretty flower-borders in front,
and with its row of poplar and rowan-trees, through which the
summer breeze murmured so pleasantly, comes up vividly before my
mind’s eye at this moment. Beautiful as of yore the valley smiles
around, with its girdling ridges belted with woods, and dotted with
pleasant dwellings; and away to westward, shutting in the peaceful
scene from the tumult of the great world, rise the twin Lomond hills,
glorious at morn and eve, when bathed in the beams of the rising and
setting sun. The good old lady, who had spent a large portion of her
life in “Auld Reekie,” when narrow Bristo Street and Potterrow and
the adjoining courts were inhabited by the better class of citizens,
took kindly to the country cottage, and she was fond of the garden
and flowers. With a basket on her arm, she trotted about the garden,
apparently very busy, but doing little after all. In autumn, after a
gusty night, one of her first morning occupations was to gather up
the fallen ruddy apples, which she preserved for the special
gratification of her grandchildren. Many a time and oft were they
debarred from touching the red berries of the rowan-trees, which
look as tempting in children’s eyes as did the forbidden fruit in those
of Mother Eve. The girls were even enjoined not to make necklaces of
these clustering red deceivers.
In that retired village there were, in those days, a good many well-
to-do people, who had not found it very difficult to make money out
of a generous soil. The different families lived on very sociable terms,
and during the winter season there were rounds of tea-parties,
winding up with cold suppers and hot toddy. Teetotalism was a thing
unknown in that district and in those days, though I shall do the
good folks the justice of saying that they knew the virtues of
moderation. To all those winter gatherings of the local gentry, Mrs
Moffat invariably received an invitation. They could not do without
her, relishing as they did her ready wit and hearty good-humour. She
was, in sooth, the life of every party. On such occasions she displayed
all the artless buoyancy of youth, as if she had never endured the
agonies of bereavement, or borne the burdens of life. She was then
the very image of “Old Delight,” and her aged face renewed its youth
in the sunshine of joy. Some of the knowing lairds tried by bantering
and otherwise to draw her out, and her quick cutting repartees were
followed by explosions of mirth. It seemed marvellous that such a
well of sunny mirth should be encased in that tiny frame. Indeed, it
was nothing unusual for the hearty old lady to treat the company to a
“canty” song at these village parties, and touches of melody still
lingered about the cracks of her voice. When bothered overmuch to
sing another song after she had already done enough, she generally
met the request with a solitary stanza to this effect:—
There was a wee mannie an’ a wee wifie,
And they lived in a vinegar bottle;
“And O,” says the wee mannie to the wee wifie,
“Wow, but oor warld is little, is little!
Wow, but oor warld is little!”
Rare encounters of wit and amusing banter occasionally took place

between her and a strange eccentric humorist of a lawyer of the old
school, who frequently visited the village from a neighbouring
country town. Old Bonthron was the name by which he was
familiarly known.
It may readily be imagined that, when old Mr Bonthron and Mrs
Moffat met in the same company, the fun would grow “fast and
furious,” and such certainly was the case. I have seen the hearty old
humorist take the equally hearty old lady on his knee, and dandle her
there like a child, greatly to their own delight and to the infinite
amusement of the company. There will be less genial and boisterous
mirth now-a-days, I should imagine, in that sequestered village.
Such was Mrs Moffat in her lightsome hours, when friends met
friends; but her grandchildren were as much delighted with her
when, in graver mood, she recalled early recollections, told them
pleasant little stories, and narrated graphically what to her were
eventful incidents in her life.
I can still remember some of the pleasant pictures she gave us of
her early days. She was born in the town of Dalkeith, which is
beautiful for situation, being planted in the midst of the richest
woodland scenery, and she imprinted in our hearts vivid impressions
of the delighted feelings with which, in the days of her girlhood, she
looked through the gate of the Duke’s great park, and saw the long
winding avenue and the greensward traversed by nibbling sheep, and
the magnificent trees whose “shadowing shroud” might cover a
goodly company at their rural feast in the noontide of a summer’s
day. She described the rustic seats and summer-houses on the banks
of a brook, that wandered at its own sweet will through the wooded
grounds—regions and resorts of joyance, where the children of the
town, through the kindness of the then reigning Duke of Buccleuch,
were permitted to spend the livelong summer’s day, thus enabling
them to store their memories with pleasing recollections, which
might come back upon them in their declining days, like visions of
beauty from lands of old romance. There was a pathetic story about a
family of larks that had their nest in the Duke’s Park, which she
recited to us over and over again, by way of inculcating the virtue of
treating kindly all the creatures of God. Her story was, that some of
the young rascals of Dalkeith had caught the mother-bird in the nest,
and had carried off her and the whole family of young ones at one fell
swoop. The male bird, thus deprived at once of mate and family, took
up his melancholy station near the nest, and mourned his loss with
plaintive pipe for two days, at the end of which time the broken-
hearted warbler died. This affecting incident, told with much
seriousness and feeling, was not unproductive of good effect upon
the young listeners. Cities and towns being still to us mysteries of
which we had only a vague conception, it pleased us much to hear
her tell how the bells of Dalkeith tolled children to bed, and how little
boys walked through the streets at night, calling “Hot pies for
supper!” It struck us that at whatever hour the bell tolled, we should
have liked to remain out of bed till the pies went round.
On winter evenings, beside the good old lady’s cottage fire, she was
often constrained to recount her famous voyage to London, in which
she wellnigh suffered shipwreck. The war-vessel on board of which
her husband acted as surgeon had arrived in the Thames. He could
not then obtain leave of absence, and as they had not met for many
long months, she determined—protracted as the passage then was
from Leith to London—to make an effort to see her husband, and to
visit the great metropolis. Steamers had not, at that period, come
into existence, and the clipper-smacks that traded between Leith and
London, and took a few venturesome passengers on their trips,
dodged along the Scotch and English coasts for days and weeks, thus
making a lengthened voyage of what is now a brief and pleasant sail.
It was considered a bold and hazardous undertaking, in those days,
for any lady to proceed alone on such a voyage. This, however, she
did, as she was gifted with a wonderful amount of pluck, leaving her
family in the charge of some friends till she returned.
The vessel had scarcely left the Firth of Forth, and got out into the
open sea, when the weather underwent a bad turn, and soon they
had to encounter all the fury of a severe storm, which caused many
shipwrecks along the whole eastern seaboard. With a kind of placid
contentment—nay, even with occasional glee—would she describe
the protracted miseries and hardships they endured, having run
short of supplies, and every hour expecting the vessel to founder. It
was three weeks after leaving Leith until the smack was, as she
described it, towed up the Thames like a dead dog, without either
mast or bowsprit—a hapless and helpless hulk. However, she
managed to see her husband, and the happiness of the meeting
would be considered a good equivalent for the mishaps of the voyage.
She saw, in the great metropolis, the then Prince of Wales—the “First
Gentleman in Europe,” and used to relate, with considerable gusto
(old ladies being more rough-and-ready then than now), how the
Prince, as he was riding in St James’s Park, overheard a hussar in the
crowd exclaiming, “He’s a d——d handsome fellow!” and
immediately lifting his hat, his Royal Highness replied, “Thank you,
my lad; but you put too much spice in your compliments!” That
London expedition was a red-letter leaf in Mrs Moffat’s biography,
and it was well thumbed by us juveniles. Her return voyage was
comparatively comfortable, and much more rapid; but she never saw
her husband again, as he died at sea, and was consigned to the deep.
Even more interesting than the London trip were all the stories
and incidents connected with her only son—our uncle who ought to
have been, but who was dead before any of us were born. Through
the kindness and influence of Admiral Greig of the Russian navy, he
obtained a commission in the Russian service at an unusually early
age—Russia and Britain being at that time in close alliance. Neither
the Russian navy nor army was in the best condition, and the
Emperor was very desirous to obtain the services of British officers,
Scotsmen being preferred. Mrs Moffat loved her son with all the
warmth of her kindly nature, and when he had been about a year or
two in the Russian service, the news spread through Edinburgh one
day, that a Russian man-of-war was coming up the Firth to Leith
roads. I have heard the good lady relate the eventful incidents of that
day with glistening eyes and tremulous voice.
The tidings were conveyed to her by friends who knew that she had
some reason to be interested in the news. She had received no
communication from her son for some time, as the mails were then
very irregular, and letters often went amissing; and, filled with the
hope that he might be on board the Russian vessel that was
approaching the roads, she immediately hurried off for Leith,
whither crowds of people were already repairing, as a Russian war-
vessel in the Forth was as great a rarity then as it is now. Before she
arrived at the pier, the vessel had anchored in the roads, and the
pier, neither so long nor so commodious as it is now, was thronged
with people pressing onwards to get a sight of the stranger ship.
Nothing daunted by the crowd, Mrs Moffat squeezed herself forward,
at the imminent risk of being seriously crushed. A gentleman who
occupied a “coigne of vantage,” out of the stream of the crowd,
observed this slight-looking lady pressing forward with great
eagerness. He immediately hailed her, and asked, as she appeared
very much interested, if she expected any one, or had any friends on
board. She replied that she half expected her son to be with the
vessel. The gentleman, who was to her a total stranger, but who must
have been a gentleman every inch, immediately took her under his
protection, and having a telescope in his hand, he made
observations, and reported progress.
One of the ship’s boats had been let down, and he told her that he
observed officers in white uniform rapidly descending. Mrs Moffat’s
eagerness and anxiety were now on the increase. The boat put off
from the ship, propelled by sturdy and regular strokes, cutting the
water into foam, which sparkled in the sunshine. When the boat had
approached midway between the ship and the shore, Mrs Moffat
asked her protector if he could distinguish one officer apparently
younger than the others.
“Yes,” he replied; “there is one who seems scarcely to have passed
from boyhood to manhood.”
Her eager impatience, with hope and fear alternating in her heart,
seemed now to agitate her whole frame, and the bystanders, seeing
her anxiety, appeared also to share in her interest.
At last the boat, well filled with officers, shot alongside the pier,
the crowd rushing and cheering, as it sped onward to the upper
landing-place. It was with great difficulty that the gentleman could
restrain the anxious mother from dashing into the rushing stream of
people. When the crowd had thinned off a little, they made their way
up the pier, and found that the officers had all left the boat and gone
into the Old Ship Inn—probably because they had no desire of being
mobbed. Mrs Moffat immediately went to the inn, and requested an
attendant to ask if one of the officers belonged to Scotland, and if so,
to be good enough to mention his name.
“Yes—Moffat!” was the cheery response, and in a short time
mother and son were locked in each other’s arms in the doorway of
the Old Ship.
With a glee, not unmingled with tender regrets, she used to tell
how, when she and the spruce young officer were proceeding up
Leith Walk together to Edinburgh, an old woman stopped them, and,
clapping him kindly on the shoulder, said—“Ay, my mannie, ye’ll be a
captain yet!” This prophecy of the old woman certainly met its
fulfilment.
After staying a few days in the old home near the Meadows, young
Moffat again took his departure, never more to see his affectionate
mother, or the bald crown of Arthur Seat rising by the side of the
familiar Firth. He joined the army (changes of officers from the navy
to the army being then frequent in the Russian service), and
reenacted his part honourably in many memorable scenes. Still do I
remember the tender and tearful care with which his old mother
opened up the yellow letters, with their faded ink-tracings, which
contained descriptions of the part he played in harassing the French,
during their disastrous retreat after the burning of Moscow. One of
these letters, I recollect, commenced thus—“Here we are, driving the
French before us like a flock of sheep;” and in others he gave painful
descriptions of their coming up to small parties of French soldiers
who were literally glued by the extreme frost to the ground—quite
stiff and dead, but still in a standing attitude, and leaning on their
muskets. Poor wretches! that was their sole reward for helping to
whet the appetite of an insatiable ambition. In those warlike times,
young Moffat grew into favour, and gained promotion. He received a
gold-hilted sword from the Emperor for distinguished service, but he
succumbed to fatigue, and died on foreign soil. The gold-headed
sword and his epaulets, which he had bequeathed to a favourite
sister, fell into the hands of harpies in London, and to this day have
never reached Scotland.
In the quiet village Mrs Moffat spent her declining days in peace
and sweet content, and she now sleeps in the village churchyard, till
the last spring that visits the world shall waken inanimate dust to
immortal life.
THE BAPTISM.
By Professor Wilson.
It is a pleasant and impressive time, when, at the close of divine

service, in some small country church, there takes place the gentle
stir and preparation for a baptism. A sudden air of cheerfulness
spreads over the whole congregation; the more solemn expression of
all countenances fades away; and it is at once felt that a rite is about
to be performed which, although of a sacred and awful kind, is yet
connected with a thousand delightful associations of purity, beauty,
and innocence. Then there is an eager bending of smiling faces over
the humble galleries—an unconscious rising up in affectionate
curiosity—and a slight murmuring sound, in which is no violation of
the Sabbath sanctity of God’s house, when, in the middle passage of
the church, the party of women is seen, matrons and maids, who
bear in their bosoms, or in their arms, the helpless beings about to be
made members of the Christian communion.
There sit, all dressed becomingly in white, the fond and happy
baptismal group. The babies have been intrusted, for a precious
hour, to the bosoms of young maidens, who tenderly fold them to
their yearning hearts, and with endearments taught by nature, are
stilling, not always successfully, their plaintive cries. Then the proud
and delighted girls rise up, one after the other, in sight of the whole
congregation, and hold up the infants, arrayed in neat caps and long
flowing linen, into their fathers’ hands. For the poorest of the poor, if
he has a heart at all, will have his infant well dressed on such a day,
even although it should scant his meal for weeks to come, and force
him to spare fuel to his winter fire.
And now the fathers were all standing below the pulpit, with grave
and thoughtful faces. Each has tenderly taken his infant into his toil-
hardened hands, and supports it in gentle and steadfast affection.
They are all the children of poverty, and if they live, are destined to a
life of toil. But now poverty puts on its most pleasant aspect, for it is
beheld standing before the altar of religion with contentment and
faith. This is a time when the better and deeper nature of every man
must rise up within him, and when he must feel, more especially,
that he is a spiritual and immortal being making covenant with God.
He is about to take upon himself a holy charge; to promise to look
after his child’s immortal soul; and to keep its little feet from the
paths of evil, and in those of innocence and peace. Such a thought
elevates the lowest mind above itself, diffuses additional tenderness
over the domestic relations, and makes them who hold up their
infants to the baptismal font, better fathers, husbands, and sons, by
the deeper insight which they then possess into their nature and
their life.
The minister consecrates the water; and, as it falls on his infant’s
face, the father feels the great oath in his soul. As the poor helpless
creature is wailing in his arms, he thinks how needful indeed to
human infancy is the love of Providence! And when, after delivering
each his child into the arms of the smiling maiden from whom he
had received it, he again takes his place for admonition and advice
before the pulpit, his mind is well disposed to think on the perfect
beauty of that religion of which the Divine Founder said, “Suffer little
children to be brought unto me, for of such is the kingdom of
heaven!”
The rite of baptism had not thus been performed for several
months in the kirk of Lanark. It was now the hottest time of
persecution; and the inhabitants of that parish found other places in
which to worship God and celebrate the ordinances of religion. It was
now the Sabbath-day, and a small congregation of about a hundred
souls had met for divine service in a place of worship more
magnificent than any temple that human hands had ever built to
Deity. Here, too, were three children about to be baptised. The
congregation had not assembled to the toll of the bell, but each heart
knew the hour and observed it; for there are a hundred sun-dials
among the hills, woods, moors, and fields, and the shepherd and the
peasant see the hours passing by them in sunshine and shadow.
The church in which they were assembled was hewn by God’s hand
out of the eternal rocks. A river rolled its way through a mighty
chasm of cliffs, several hundred feet high, of which the one side
presented enormous masses, and the other corresponding recesses,
as if the great stone girdle had been rent by a convulsion. The
channel was overspread with prodigious fragments of rock or large
loose stones, some of them smooth and bare, others containing soil
and verdure in their rents and fissures, and here and there crowned
with shrubs and trees. The eye could at once command a long
stretching vista, seemingly closed and shut up at both extremities by
the coalescing cliffs. This majestic reach of river contained pools,
streams, rushing shelves, and waterfalls innumerable; and when the
water was low, which it now was in the common drought, it was easy
to walk up this scene, with the calm blue sky overhead, an utter and
sublime solitude. On looking up, the soul was bowed down by the
feeling of that prodigious height of unscaleable and often
overhanging cliff. Between the channel and the summit of the far-
extended precipices were perpetually flying rooks and wood-pigeons,
and now and then a hawk, filling the profound abyss with their wild
cawing, deep murmur, or shrilly shriek. Sometimes a heron would
stand erect and still on some little stone island, or rise up like a white
cloud along the black wall of the chasm and disappear. Winged
creatures alone could inhabit this region. The fox and wild-cat chose
more accessible haunts. Yet there came the persecuted Christians
and worshipped God, whose hand hung over their heads those
magnificent pillars and arches, scooped out those galleries from the
solid rock, and laid at their feet the calm water in its transparent
beauty, in which they could see themselves sitting in reflected
groups, with their Bibles in their hands.
Here, upon a semicircular ledge of rocks, over a narrow chasm, of
which the tiny stream played in a murmuring waterfall, and divided
the congregation into two equal parts, sat about a hundred persons,
all devoutly listening to their minister, who stood before them on
what might well be called a small natural pulpit of living stone. Up to
it there led a short flight of steps, and over it waved the canopy of a
tall graceful birch-tree. This pulpit stood in the middle of the
channel, directly facing that congregation, and separated from them
by the clear deep sparkling pool into which the scarce-heard water
poured over the blackened rock. The water, as it left the pool,
separated into two streams, and flowed on each side of that altar,
thus placing it on an island, whose large mossy stones were richly
embowered under the golden blossoms and green tresses of the
broom. Divine service was closed, and a row of maidens, all clothed
in purest white, came gliding off from the congregation, and crossing
the stream on some stepping-stones, arranged themselves at the foot
of the pulpit, with the infants about to be baptized. The fathers of the
infants, just as if they had been in their own kirk, had been sitting
there during worship, and now stood up before the minister. The
baptismal water, taken from the pellucid pool, was lying consecrated
in a small hollow of one of the upright stones that formed one side or
pillar of the pulpit, and the holy rite proceeded. Some of the younger
ones in that semicircle kept gazing down into the pool, in which the
whole scene was reflected, and now and then, in spite of the grave
looks or admonishing whispers of their elders, letting a pebble fall
into the water, that they might judge of its depth from the length of
time that elapsed before the clear air-bells lay sparkling on the
agitated surface. The rite was over, and the religious services of the
day closed by a psalm. The mighty rocks hemmed in the holy sound,
and sent it in a more compacted volume, clear, sweet, and strong, up
to heaven. When the psalm ceased, an echo, like a spirit’s voice, was
heard dying away up among the magnificent architecture of the cliffs,
and once more might be noticed in the silence the reviving voice of
the waterfall.
Just then a large stone fell from the top of the cliff into the pool, a
loud voice was heard, and a plaid hung over on the point of a
shepherd’s staff. Their watchful sentinel had descried danger, and
this was his warning. Forthwith the congregation rose. There were
paths dangerous to unpractised feet, along the ledges of the rocks,
leading up to several caves and places of concealment. The more
active and young assisted the elder—more especially the old pastor,
and the women with the infants; and many minutes had not elapsed,
till not a living creature was visible in the channel of the stream, but
all of them hidden, or nearly so, in the clefts and caverns.
The shepherd who had given the alarm had lain down again in his
plaid instantly on the greensward upon the summit of these
precipices. A party of soldiers were immediately upon him, and
demanded what signals he had been making, and to whom; when
one of them, looking over the edge of the cliff, exclaimed, “See, see,
Humphrey! we have caught the whole tabernacle of the Lord in a net
at last. There they are, praising God among the stones of the river
Mouss. These are the Cartland Craigs. By my soul’s salvation, a noble
cathedral!” “Fling the lying sentinel over the cliffs. Here is a canting
Covenanter for you, deceiving honest soldiers on the very Sabbath-
day. Over with him, over with him—out of the gallery into the pit.”
But the shepherd had vanished like a shadow; and, mixing with the
tall green broom and brushes, was making his unseen way towards
the wood. “Satan has saved his servant. But come, my lads, follow
me; I know the way down into the bed of the stream, and the steps
up to Wallace’s Cave. They are called the ‘Kittle Nine Stanes.’ The
hunt’s up—we’ll be all in at the death. Halloo, my boys, halloo!”
The soldiers dashed down a less precipitous part of the wooded
banks, a little below the “Craigs,” and hurried up the channel. But
when they reached the altar where the old grayhaired minister had
been seen standing, and the rocks that had been covered with people,
all was silent and solitary—not a creature to be seen.
“Here is a Bible dropped by some of them,” cried a soldier; and
with his foot spun it away into the pool.
“A bonnet! a bonnet!” cried another. “Now for the pretty sanctified
face that rolled its demure eyes below it.”
But after a few jests and oaths the soldiers stood still, eyeing with a
kind of mysterious dread the black and silent walls of the rock that
hemmed them in, and hearing only the small voice of the stream that
sent a profounder stillness through the heart of that majestic
solitude. “Curse these cowardly Covenanters! What if they tumble
down upon our heads pieces of rock from their hiding-places?
Advance? Or retreat?”
There was no reply; for a slight fear was upon every man. Musket
or bayonet could be of little use to men obliged to clamber up rocks,
along slender paths, leading they knew not where; and they were
aware that armed men now-a-days worshipped God,—men of iron
hearts, who feared not the glitter of the soldier’s arms, neither barrel
nor bayonet; men of long stride, firm step, and broad breast, who, on
the open field, would have overthrown the marshalled line, and gone
first and foremost if a city had to be taken by storm.
As the soldiers were standing together irresolute, a noise came
upon their ears like distant thunder, but even more appalling; and a
slight current of air, as if propelled by it, passed whispering along the
sweetbriers and the broom, and the tresses of the birch-trees. It came
deepening and rolling, and roaring on, and the very Cartland Craigs
shook to their foundation as if in an earthquake. “The Lord have
mercy upon us!—what is this?” And down fell many of the miserable
wretches on their knees, and some on their faces, upon the sharp-
pointed rocks. Now it was like the sound of many myriad chariots
rolling on their iron axles down the stony channel of the torrent. The
old grayhaired minister issued from the mouth of Wallace’s Cave,
and said, with a loud voice, “The Lord God terrible reigneth!” A
waterspout had burst up among the moorlands, and the river, in its
power, was at hand. There it came—tumbling along into that long
reach of cliffs, and in a moment filled it with one mass of waves.
Huge agitated clouds of foam rode on the surface of a blood-red
torrent. An army must have been swept off by that flood. The soldiers
perished in a moment; but high up in the cliffs, above the sweep of
destruction, were the Covenanters—men, women, and children,
uttering prayers to God, unheard by themselves in that raging
thunder.
THE LAIRD’S WOOING.
By John Galt.
The laird began the record of his eighteenth year in these words:—
There lived at this time, on the farmstead of Broomlands, a person
that was a woman, by calling a widow; and she and her husband,
when he was in this life, had atween them Annie Daisie, a dochter;—
very fair she was to look upon, comely withal, and of a feleecity o’
nature.
This pretty Annie Daisie, I know not hoo, found favour in my eyes,
and I made no scruple of going to the kirk every Sabbath day to see
her, though Mr Glebeantiends was, to a certainty, a vera maksleepie
preacher. When I forgathered with her by accident, I was all in a
confusion; and when I would hae spoken to her wi’ kindly words, I
could but look in her clear een and nicher like Willie Gouk, the
haverel laddie; the which made her jeer me as if I had a want, and
been daft likewise; so that seeing I cam no speed in courting for
myself, I thocht o’ telling my mother; but that was a kittle job,—
howsoever, I took heart, and said—
“Mother!”
“Well, son,” she made answer, “what would ye?”
“I’m going to be marriet,” quo’ I.
“Marriet!” cried she, spreading out her arms wi’ consternation.
“And wha’s the bride?”
I didna like just to gie her an even down answer, but said I thought
myself old enough for a helpmeet to my table, which caused her to
respond with a laugh; whereupon I told her I was thinking of Annie
Daisie.
“Ye’ll surely ne’er marry the like o’ her;—she’s only a gair’ner’s
dochter.”
But I thocht of Adam and Eve, and said—“We’re a’ come of a
gair’ner;”—the which caused her presently to wax vera wroth with
me; and she stampit with her foot, and called me a blot on the
‘scutcheon o’ Auldbiggins; then she sat down, and began to reflec’
with herself; and, after a season, she spoke rawtional about the
connection, saying she had a wife in her mind for me, far more to the
purpose than such a causey-dancer as Annie Daisie.
But I couldna bide to hear Annie Daisie mislikened, and yet I was
feart to commit the sin of disobedience, for my mother had no mercy
when she thought I rebelled against her authority; so I sat down, and
was in a tribulation, and then I speir’t, with a flutter of affliction, who
it was that she had willed to be my wife.
“Miss Betty Græme,” said she; “if she can be persuaded to tak sic a
headowit.”
Now this Miss Betty Græme was the tocherless sixth daughter o’ a
broken Glasgow provost, and made her leevin’ by seamstress-work
and flowering lawn; but she was come of gentle blood, and was
herself a gentle creature, though no sae blithe as bonnie Annie
Daisie; and for that I told my mother I would never take her, though
it should be the death o’ me. Accordingly I ran out of the house, and
took to the hills, and wistna where I was, till I found myself at the
door of the Broomlands, with Annie Daisie before me, singing like a
laverock as she watered the yarn of her ain spinning on the green. On
seeing me, however, she stoppit, and cried—
“Gude keep us a’, laird!—what’s frightened you to flee hither?”
But I was desperate, and I ran till her, and fell on my knees in a
lover-like fashion; but wha would hae thocht it?—she dang me ower
on my back, and as I lay on the ground she watered me with her
watering-can, and was like to dee wi’ laughing: the which sign and
manifestation of hatred on her part quenched the low o’ love on
mine; an’ I raise an’ went hame, drookit and dripping as I was, and
told my mother I would be an obedient and dutiful son.
Soon after this, Annie Daisie was marriet to John Lounlans; and
there was a fulsome phrasing about them when they were kirkit, as
the comeliest couple in the parish. It was castor-oil to hear’t; and I

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Manual of Definitive Surgical Trauma Care, Fifth

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1 Trauma: A global perspective 1

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TRTS Triage Revised Trauma Score

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