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 Table of Contents

SECTION 1 Essential Information ITLS Secondary Survey—Critical Information 54

SAMPLE History 54
CHAPTER 1 Introduction to Traumatic Disease 1
Vital Signs and Repeat Initial Assessment 54
Chapter Overview 2
Neurological Exam 54
Situational Awareness 2
Detailed Exam 56
Case Presentation 3
Ground Rules for Teaching and Evaluation 57
Scene Size-up 4
Standard Precautions 4 CHAPTER 4 Hemorrhage Control and Shock 58
Scene Safety 4 Chapter Overview 59
Total Number of Patients 6 Case Presentation 59
Essential Equipment and Additional Resources 6 Pathophysiology of Shock 60
Mechanism of Injury 7 Evaluation of Tachycardia 61
Blunt Trauma 7 The Shock Syndromes 62
Penetrating Trauma 13 Management 63
Priorities of Trauma Care 16 Special Situations in Hypovolemic Shock 65
Trauma Triage Decisions 17 Obstructive Shock 66
Prevention and Public Education 17 Cardiogenic Shock 68
CHAPTER 2 Trauma Assessment and Management 23 Current Thinking in the Treatment of Shock 70
Chapter Overview 24 CHAPTER 5 Shock and Hemorrhage Control Skills 77
Case Presentation 24 Cannulation of the External Jugular Vein 78
ITLS Primary Survey 26 Intraosseous Infusion 78
Scene Size-up 26 Indications 79
Initial Assessment 29 Contraindications 79
Rapid Trauma Survey or Focused Exam 31 Recommended Sites 79
ITLS Reassessment Exam 35 Potential Complications 79
ITLS Secondary Survey 36 FAST Responder™ Intraosseous Device 84
Adjuncts for Trauma Patient Assessment 39 Length-Based Resuscitation Tapes 86
Transfer of Care 39 Control of Life-Threatening Hemorrhage 87
CHAPTER 3 Assessment Skills 43 Application of Tourniquets 90
ITLS Primary Survey—Critical Information 44 Use of Hemostatic Agents 92
Scene Size-up 44 CHAPTER 6 Airway Management 96
Initial Assessment 44 Chapter Overview 97
Rapid Trauma Survey 49 Case Presentation 97
ITLS Reassessment Exam—Critical Information 52 Anatomy and Physiology 98
Subjective Changes 52 Nasopharynx 98
Mental Status 52 Oropharynx 98
Reassess ABCs 52 Hypopharynx 99

iv
     C o n tr i b u t o r s           xi

Patrick J. Maloney, MD S. Robert Seitz, MEd, RN, NRP

Staff Physician, Denver Health Medical Center and Denver Assistant Professor, School of Health and Rehabilitation
Emergency, Center for Children; Clinical Instructor, Univer- Sciences, Emergency Medicine Program, University of
sity of Colorado School of Medicine, Denver, CO Pittsburgh, Pittsburgh, PA; Assistant Program Director,
Office of Education and International Emergency Medi-
David Manthey, MD, FACEP, FAAEM cine, University of Pittsburgh Center for Emergency Med-
Professor of Emergency Medicine and Vice Chair of icine; Continuing Education Editor, Journal of Emergency
Education, Wake Forest University School of Medicine, Medical Services; Editorial Board, International Trauma Life
Winston-Salem, NC Support
Leslie K. Mihalov, MD
Chief, Emergency Medicine, and Medical Director, Emer- Nicholas Sowers, MD, FRCPC
gency Services, Nationwide Children’s Hospital; Associate Associate Professor of Emergency Medicine, Dalhou-
Professor of Pediatrics at The Ohio State University College sie University School of Medicine, Halifax, Nova Scotia,
of Medicine, Columbus, OH Canada

Richard N. Nelson, MD, FACEP J. T. Stevens, NRP (ret.)

Professor and Vice Chair, Department of Emergency Med- Sun City, SC
icine, The Ohio State University College of Medicine,
Columbus, OH Shin Tsuruoka, MD
Vice Director and Chief of Neurosurgical Department, JA
Jonathan Newman, MD, MMM, FACEP Toride Medical Center, Toride, Japan; ITLS Japan Chapter
Assistant Medical Director, United Hospital Center, Medical Director
Bridgeport, WV
Howard A. Werman, MD, FACEP
Bob Page, MEd, NRP, CCP, NCEE Professor of Clinical Emergency Medicine, The Ohio State
Edutainment Consulting and Seminars, LLC, Spring- University, Columbus, OH; Medical Director, MedFlight of
field, MO Ohio
William Bruce Patterson, Platoon Chief/EMT-P Katherine West, BSN, MSEd, CIC
Strathcona County Emergency Services, Alberta, Canada
Infection Control Consultant, Manassas, VA; Editorial
Andrew B. Peitzman, MD Board, Journal of Emergency Medical Services
Distinguished Professor of Surgery, Mark M. Ravitch Chair
in Surgery, Chief in the Division of General Surgery, and Melissa White, MD, MPH
Vice-President for Trauma and Surgical Services, University Associate Professor and Assistant Residency Director,
of Pittsburgh Medical Center, Pittsburgh, PA Department of Emergency Medicine, Emory University
School of Medicine, Atlanta, GA; Medical Director, John’s
William F. Pfeifer, MD, FACS Creek Fire Department; Medical Director, Emory Emer-
Professor of Surgery, Department of Specialty Medicine, gency Medical Services; Associate Medical Director, AirLife
Rocky Vista University College of Osteopathic Medicine; Georgia
Mile High Surgical Specialists, Littleton, CO; Colonel MC
USAR (ret) Janet M. Williams, MD
Professor of Emergency Medicine, University of Rochester
Art Proust, MD, FACEP Medical Center, Rochester, New York
Associate Medical Director, Southern Fox Valley EMS Sys-
tem, Geneva, IL E. John Wipfler, III, MD, FACEP
Attending Emergency Physician, OSF Saint Francis Med-
Mario Luis Ramirez, MD, MPP ical Center Residency Program; Medical Director, STATT
Tactical and Prehospital EMS Fellow and Clinical Instructor TacMed Unit, Tactical Medicine; Sheriff’s Physician, Peoria
in Emergency Medicine, Department of Emergency Medi- County Sheriff’s Office; Clinical Associate Professor of Sur-
cine, Vanderbilt University Medical Center, Nashville, TN gery, University of Illinois College of Medicine, Peoria, IL
Alexandra Rowe, NRP
CE Solutions, Burnett, TX Arthur H. Yancey II, MD, MPH, FACEP
Medical Director, Grady EMS Emergency Communications
Jonathan M. Rubin, MD, FAAEM Center; Medical Director, College Park Fire Department;
Associate Professor of Emergency Medicine, Medical Associate Professor, Department of Emergency Medicine,
College of Wisconsin, Milwaukee, Wisconsin Emory University School of Medicine, Atlanta, GA
 Organization of This Book

The ninth edition of International Trauma Life Support for Also new to this edition is the editorial assistance of
Emergency Care Providers has been reorganized to reflect a Dr. Kyee Han, Consultant in Accident and Emergency Med-
more functional approach to the assessment and manage- icine, who has joined Dr. Alson as the Associate Editor of
ment of the trauma patient in the prehospital environment. the text. Dr. Han has extensive experience in EMS care and
The book is divided into four sections. education and has been a contributor to the ITLS text and
Section I, “Essential Information,” includes Chapters 1–7. course for over 20 years.
These topics are core to the care of the trauma patient and The text again conforms to the American Heart Associa-
include mechanism of injury, assessment of the trauma tion/International Liaison Committee of Resuscitation
patient, hemorrhage control, and shock and airway man- (AHA/ILCOR) guidelines, as well as those put forth by
agement. Following each didactic chapter on a clinical topic the Committee on Trauma of the American College of Sur-
is a chapter that reviews the essential skills needed to man- geons, as well as position statements from the National
age the clinical situation. Association of EMS Physicians, the Committee for Tactical
Emergency Casualty Care, the American College of Emer-
Section II, “Foundational Knowledge,” includes Chap-
gency Physicians, and other international advisory groups.
ters 8–16. Topics include assessment and management
of injuries to specific body areas: chest trauma, abdomi- Some of the chapter-by-chapter key components and
nal trauma, spinal injuries and spinal motion restriction, changes are:
extremity trauma, and traumatic cardiac arrest. Chapters • The Introduction explains the concept of the “Golden
covering specific skills follow the didactic material. Period” and why it remains important to what we do as
The chapters in Section III, “Special Populations,” include emergency care providers.
burn patients, older adults, pediatric and pregnant patients, • Chapter 1 continues to emphasize scene safety and the
and patients under the influence of intoxicating substances. concept that trauma care as a team effort involving
The final section, available online or in text, covers other many disciplines as central components. The chapter
important areas: standard precautions, pain control, multi- now includes a discussion of the changes in response
casualty triage, trauma scoring, air medical, drowning, heat put forth by the Hartford Consensus.
and cold injuries, advanced skills, and overview of tactical • Chapter 2 includes minor changes in the assessment
medical care. sequence based on feedback from ITLS instructors and
providers. It also reinforces the importance of identify-
ing and controlling hemorrhage at the start of the assess-
What’s New in This Edition ment. As the leader performs the assessment, he or she
will delegate responses to abnormalities found in the
The ninth edition of International Trauma Life Support for initial assessment. This is to reinforce the rule that the
Emergency Care Providers has been updated to provide the leader must not interrupt the assessment to deal with
emergency care provider with information on the latest and problems but must delegate the needed actions to team
most effective approaches in the care of the trauma patient. members. This emphasizes the team concept and keeps
The science of trauma is constantly evolving, and the on-scene time at a minimum. The order of presentation of
authors, in collaboration with the research working group the three assessments (ITLS–Primary Survey, ITLS Reas-
at ITLS, have updated the text with the latest information sessment Exam, and ITLS Secondary Survey) has been
that is pertinent to the initial care of the trauma patient. changed. The ITLS Reassessment Exam is performed
This is the first edition without the presence of Dr. John before the ITLS Secondary Survey, a more common situ-
Campbell, FACEP, the founder of ITLS and the first Editor ation, and may replace it. The chapter also mentions the
in Chief. Dr. Campbell passed away in 2018 after a long and use of fingerstick serum lactate levels and prehospital
valiant battle with cancer. This text strives to continue his abdominal ultrasound exams as ways to better identify
focus on providing the emergency care provider with the patients who may be in early shock.
knowledge and skills to render to trauma patients the best • The assessment skills in Chapter 3 reflect the changes in
possible care. Chapter 2.

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     Org a n i z at i o n o f T h i s B o o k           xiii

• Chapter 4 includes an updated discussion of hemorrhagic reviews indications for termination of resuscitation for
shock to once again reflect the latest experience of the the trauma patient in the prehospital setting.
military during recent conflicts. A discussion of the role • Chapter 19 now includes a discussion of the ways in
of tranexamic acid (TXA) in the management of hemor- which advancing age increases mortality and identifies
rhage has been added as well as the need to limit crystal- it as an independent risk factor for needing trauma cen-
loid infusion to prevent hemodilution of clotting factors. ter care.
Emphasis on fluid resuscitation in the field is to restore • Appendices: Online at Student Resources Page (www
perfusion, not normalize vital signs. .pearsonhighered.com/bradyresources) and/or in-text
• Chapter 5 covers the skills associated with hemorrhage ——Added a section on pain control in the prehospital
control including wound packing, use of hemostatic setting
agents, and early application of tourniquets. It also
—Updated
— section on drowning and hypothermia (online)
reviews intraosseous access.
—Bloodborne
— pathogens has been moved to online
• Chapter 6 again stresses capnography as the standard for
confirming and monitoring the position of the endotracheal —Tactical
— EMS has been revised to reflect current think-
tube as well as the best way to assess for hyperventilation ing within the Hartford Consensus (online)
or hypoventilation. The volume of air delivered with each —Additional
— skills includes surgical cricothyrotomy
ventilation now emphasizes the response of the patient (rise (online)
and fall of the chest), rather than a fixed volume amount. —Videos
— (online) demonstrating
• Chapter 7 discusses the importance of properly position- ∘∘ Cricothyrotomy: needle and surgical
ing the patient to improve successful airway manage-
ment and reinforces the key role of supraglottic airways ∘∘ Wound packing
(SGAs) in basic airway management. The chapter also ∘∘ Tourniquet application
includes a discussion of video intubation as a tool for
difficult airways and reviews drug-assisted intubation.
∘∘ Chest seal application
• Chapter 8 reviews the indications for needle decompression ∘∘ IO insertion—electric and manual
of tension pneumothorax and pericardiocentesis when ∘∘ Needle decompression of tension pneumothorax
such procedures are in the emergency care provider’s
scope of practice. It also discusses the use of ultrasound to
∘∘ Supraglottic airway insertion
identify such injuries and also to identify a pneumothorax. ∘∘ Log roll
• Chapter 9 covers needle decompression of the chest for a ∘∘ Scoop stretcher
tension pneumothorax, reflecting challenges faced by tac-
tical EMS providers, as well as the use of chest seals. Three-
sided taping of field-expedient chest seals is replaced with
Note on Skills and
four-sided taping and use of needle decompression. Terminology
• Chapters 11 and 12 now reflect current science and evolu- Prehospital personnel around the world vary in their per-
tion of when to apply spinal motion restriction based on mitted scope of practice, based on local regulations. This
published guidelines. Emphasis is on the use of the back- textbook may at times describe procedures that are out-
board as a transfer device and the transport of a patient side the permitted scope of practice. Completion of an
on a backboard is now discouraged. These chapters also ITLS course should not be construed as permission for an
include how to remove the patient from the backboard emergency care provider to exceed their permitted scope
once placed on a transport stretcher. of practice. Ultimately, the final arbiter of what the emer-
• Chapter 13 now includes pelvic fractures, reflecting the gency care provider is permitted to do is determined by the
association of these injuries with concurrent abdominal physician medical director (advisor) for the EMS system.
injuries. The chapter also discusses application of pelvic The text has attempted to be gender neutral in describing
binders and reviews the use of fingerstick serum lactate lev- personnel. In places where it is not, it should not be con-
els and the use of prehospital abdominal ultrasound exams. strued as diminishing the ability of any one person to per-
• Chapter 14 reviews the management of bleeding from form the skills needed to provide emergency care.
extremity injuries, including a discussion of hemostatic Throughout the world, there are many terms used to describe
agents. those who provide emergency care to the victims of injury and
• Chapter 15 reviews procedures for use of a tourniquet illness. In this text, we use emergency care provider to describe
and use of hemostatic agents and includes a discussion such individuals. When used, the terms “first responder” and
of pelvic binders for pelvic fractures. “emergency medical technician (EMT)” refer to personnel
• Chapter 16 now includes an algorithm for management trained at a basic life support level, while “paramedic” refers
of traumatic cardiac arrest. Again, the chapter also to personnel trained at an advanced life support level.
xiv          Org a n i z at i o n o f T h i s B o o k

As has been said before, EMS constantly undergoes endovascular balloon occlusion of the aorta (REBOA),
changes. Things that were only ideas a couple of years ago which acts like cross clamping of the aorta during a thora-
are now in common use. This change in technology and cotomy, is showing promise as an intervention for patients
resources will only continue to grow. As this book goes with massive internal hemorrhage. At this point however,
to press, we note the markedly increasing use of point-of- civilian field use is limited to those systems where there
care ultrasound to help identify life threatening injuries and is an EMS physician on scene who is trained in use of the
help with determination of destination for trauma patients. device. At this time, ITLS has not included discussion of
EMS agencies and helicopter emergency medical services REBOA in the text due to the limited availability of this
are beginning to carry blood for transfusion when deal- device to EMS personnel.
ing with a patient in shock due to blood loss. Retrograde
Acknowledgments

The creation of a text and course is a major undertaking and could not be done without the effort of many. For many of
those involved, this is a true labor of love. We want to give special thanks to the following friends of ITLS who provided
invaluable assistance with ideas, reviews, and corrections of the text. This was such a big job, and there were so many
people who contributed that we are sure we have left someone out. Please accept our apologies in advance.
We wish to thank the following EMS professionals who reviewed material especially for this ninth edition of International
Trauma Life Support for Emergency Care Providers. Their assistance is appreciated.
Jacky Chan, DN, MSc, BN, RN Walt Stoy, PhD, EMT-P
Advanced Practice Nurse, Hospital Authority, Hong Kong Professor, Emergency Medicine Program, School of Health
and Rehabilitation Sciences and Director Emeritus, Center
Juan Chessa, EMT-P Professor
for Emergency Medicine, Office of Education, University of
International Medical Academy, Lima, Peru
Pittsburgh, Pittsburgh, PA
Barbara Sauter, RN, BSN
Keith Wesley, MD FACEP FAEMS
City of Frankfort Fire and EMS, Frankfort, KY
HealthEast Medical Transportation, Saint Paul, MN
We wish to thank Jill Rembetski, our development editor, for her patience and for “herding the cats.”
Another special thanks goes to the following photographers who donated their work to help illustrate the text:
Roy Alson, PhD, MD, FACEP, FAEMS Pamela Drexel, Brain Trauma Lewis B. Mallory, MBA, REMT-P
Jennifer Achay, Centre for Emergency Foundation Masimo Corporation
Health Sciences Ferno Washington, Inc. Bonnie Meneely, EMT-P
Sabina Braithwaite, MD, FACEP Peter Gianas, MD Nonin Medical, Inc.
James Broselow, MD Peter Goth, MD North American Rescue
Brant Burden, EMT-P KING Airway Systems Bob Page, MEd, NRP, CCP, NCEE
Anthony Cellitti, NRP Kyee H. Han, MD, FRCS, FRCEM William Pfeifer, MD, FACS
Alexandra Charpentier, EM-P Michal Heron Robert S. Porter
Leon Charpentier, EMT-P Eduardo Romero Hicks, MD Don Resch
Stanley Cooper, EMT-P Jeff Hinshaw, MS, PA-C, NRP SAM Medical
Delphi Medical Kelly Kirk, EMT-P

xv
 Introduction to the
ITLS Course
Trauma, the medical term for injury, has become the most The Golden Period begins at the moment the patient is
expensive health problem in the United States and most injured, not at the time you arrive at the scene. Much of
other countries. In the United States, trauma is the fourth this period has already passed when you begin your assess-
leading cause of death for all ages and the leading cause of ment, so you must be well organized in what you do. In
death for children and adults under the age of 45. Trauma the prehospital setting it is better to think of the Golden
causes 73% of all deaths in the 15- to 24-year-old age group. Period for on-scene care as being 10 minutes. In those
For every fatality, there are 10 more patients admitted to 10 minutes, you must identify live patients, make treatment
hospitals and hundreds more treated in emergency depart- decisions, and begin to move patients to the appropriate
ments. The price of trauma, in both physical and fiscal medical facility. This means that every action must have
resources, mandates that all emergency medical services a lifesaving purpose. Any action that increases scene time
(EMS) personnel learn more about this disease to treat its but is not potentially lifesaving must be omitted. Not only
effects and decrease its incidence. must you reduce evaluation and resuscitation to the most
Because the survival of trauma patients is often determined efficient and critical steps, but you also must develop the
by how quickly they get definitive care in the operating habit of assessing and treating every trauma patient in a
room, it is crucial that you know how to assess and manage planned logical and sequential manner so you do not forget
the critical trauma patient in the most efficient way. The critical actions.
purpose of the ITLS course is to teach you the most rapid When performing patient assessment, it is best to proceed
and practical method to assess and manage critical trauma in a “head-to-toe” manner so that nothing is missed. If you
patients. The course is a combination of written chapters to jump around during your assessment, you will inevitably
give you the “why” and the “how” and practical exercises forget to evaluate something crucial. Working as a team
to practice your knowledge and skills on simulated patients with your partner is also important because many actions
so that at the end of the course you feel confident in your must be done at the same time.
ability to provide rapid lifesaving trauma care. It has been said that medicine is a profession that was
created for obsessive–compulsive people. Nowhere is
this truer than in the care of the trauma patient. Often the
Philosophy of Assessment patient’s life depends on how well you manage the details.
It is very important to remember that many of the details
and Management of the necessary to save the patient occur before you even arrive
Trauma Patient at the scene of the injury.
Severe trauma, along with acute coronary syndrome and You or a member of your team must:
stroke, is a time-dependent disease. The direct relation- • Know how to maintain your ambulance or rescue vehicle
ship between the timing of definitive (surgical) treatment so that it is serviced and ready to respond when needed.
and the survival of trauma patients was first described by • Know the quickest way to the scene of an injury. Use
Dr. R. Adams Cowley of the famous Shock-Trauma Center of global positioning satellite (GPS) navigation has been
in Baltimore, Maryland. He discovered that when patients shown to decrease not only the time to respond but also
with serious multiple injuries were able to gain access to the time of transport.
the operating room within an hour of the time of injury,
• Know how to size up a scene to recognize dangers and
the highest survival rate was achieved. He referred to
identify mechanisms of injury.
this as the “Golden Hour.” Over the years we have found
that some patients (such as penetrating trauma to trunk) • Know which scenes are safe and, if not safe, what to do
do not have a golden hour but rather a shorter period of about them.
minutes, whereas many patients with blunt trauma may • Know when you can handle a situation and when to call
have a golden period longer than an hour. It has been sug- for help.
gested that we now call the prehospital period the “Golden • Work effectively as a team so the care provided is appro-
Period” because it may be longer or shorter than an hour. priate and effective.

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     A b o u t I T LS           xvii

• Know when to approach the patient and when to leave patients that we might have saved if we had been a little
with the patient. smarter, a little faster, or a little better organized. Make no
• Know your equipment, and maintain it in working order. mistake, there is no “high” like saving a life, but we carry
• Know the most appropriate hospital and the fastest way the scars of our failures all our lives.
to get there. (Organized trauma systems and transfer/ Your mindset and attitude are very important. You must be
bypass guidelines can shorten the time it takes to get a concerned but not emotional, alert but not excited, quick
trauma patient to definitive care.) but not hasty. Above all, you must continuously strive
for what is best for your patient. When your training has
As if all that were not enough, you also have to: not prepared you for a situation, always fall back on the
question, What is best for my patient? When you no longer
• Know where to put your hands, which questions to ask,
care, burnout has set in and your effectiveness is severely
what interventions to perform, when to perform them,
limited. When this happens, seek help. (Yes, all of us need
and how to perform critical procedures quickly and
help when the stress overcomes us.) Or seek an alternative
correctly.
profession.
If you think the details are not important, then leave the Since 1982, the International Trauma Life Support (ITLS,
profession now. Our job is saving lives, a most ancient and formerly BTLS) organization has been identifying the best
honorable profession. If we have a bad day, someone will methods to get the most out of those few minutes that pre-
pay for our mistakes with suffering or even death. Since the hospital EMS providers have to save the patient’s life. Not
early beginnings of emergency medical services, patients all patients can be saved, but our goal is never to lose a life
and even rescuers have lost their lives because attention that could have been saved. The knowledge in this book
was not paid to the details listed here. Many of us can recall can help you make a difference. Learn it well.

About ITLS
International Trauma Life Support is a global not-for-profit • Flexible. ITLS courses are taught through a strong net-
organization dedicated to preventing death and disability work of chapters and training centers that customize
from trauma through education and emergency trauma care. content to reflect local needs and priorities.
• Team centered. ITLS emphasizes a cohesive team approach
that works in the real world and recognizes the impor-
The Smart Choice for tance of your role.
Trauma Training • Grounded in emergency medicine. Practicing emergency
physicians—medicine’s frontline responders—lead
Train with the best. Train with ITLS. Together, we are ITLS efforts to deliver stimulating content based on solid
improving trauma care worldwide. International Trauma emergency medicine.
Life Support—a not-for-profit organization dedicated to
• Challenging. ITLS course content raises the bar on perfor-
excellence in trauma education and response—coordi-
mance in the field by integrating classroom knowledge
nates ITLS education and training worldwide. Founded in
with practical application of skills.
1985 as Basic Trauma Life Support, ITLS adopted a new
name in 2005 to better reflect its global role and impact.
Today, ITLS has more than 80 chapters and training centers Focused Content That
around the world. Through ITLS, hundreds of thousands
of trauma care professionals have learned proven tech- Delivers
niques endorsed by the American College of Emergency ITLS empowers you with the knowledge and skill to pro-
Physicians. vide optimal care in the prehospital setting. It offers a
ITLS is the smart choice for your trauma training because variety of training options for all levels and backgrounds
it is: of emergency personnel around the world. ITLS courses
combine classroom learning, hands-on skills stations,
• Practical. ITLS trains you in a realistic, hands-on and assessment stations that put your learning to work in
approach proven to work in the field—from scene to simulated trauma situations. Not only are courses taught
surgery. as a continuing education option, but they are also used
• Dynamic. ITLS content is current, relevant, and respon- as essential curricula in many paramedic, EMT, and first
sive to the latest thinking in trauma management. responder training programs.
 International Trauma Life
Support Courses
ITLS Basic Completer Course
ITLS Basic is designed for the Emergency Medical Tech- The ITLS Completer course is for the learner who has suc-
nician (EMT-Basic) and the emergency care responder. cessfully completed eTrauma and wishes to become ITLS
This hands-on training course offers basic EMS providers certified. The Completer course covers 8 hours of skills
complete training in the skills necessary for rapid assess- learning and assessment as well as the ITLS written post
ment, resuscitation, stabilization, and transportation of the course exam.
trauma patient. The course provides education in the initial
evaluation and stabilization of the trauma patient.
Provider Recertification
This course provides continuing education in ITLS for the
ITLS Advanced experienced provider who has already completed the Basic
ITLS Advanced is a comprehensive course covering the or Advanced course. Sample course agendas are available
skills necessary for rapid assessment, resuscitation, sta- in the eighth edition ITLS Coordinator and Instructor
bilization, and transportation of the trauma patient for Guide or from the International Office.
advanced EMTs, paramedics, and trauma nurses. The
course teaches the correct sequence of evaluation and the
techniques of critical intervention, resuscitation, and pack- ITLS Instructor Bridge
aging of a patient. Course
The ITLS Instructor Bridge Course is designed for the
ITLS Combined instructor who has successfully completed an Advanced
Trauma Life Support (ATLS) or Pre-hospital Trauma Life
Many ITLS courses choose to train both Advanced- and Support (PHTLS) instructor course and wishes to transition
Basic-level providers. In the ITLS Combined courses, the to the ITLS program. The course typically runs 8 hours, and
Basic-level providers partake of all didactic sessions and a sample course agenda is available in the eighth edition
observe the advanced skill stations. ITLS Coordinator and Instructor Guide or from the Inter-
national Office. Following completion of an ITLS Bridge
course, a candidate must be monitored teaching an ITLS
ITLS Military provider course to complete the steps to become an ITLS
The ITLS Military Provider course combines the funda- instructor.
mentals of ITLS trauma assessment and treatment with
recent military innovations utilized in the world’s current
war zones. The course adapts proven techniques taught in ITLS Provider Bridge Course
the civilian ITLS course to the military environment, where The ITLS Provider Bridge Course is designed for the pro-
limited resources are the rule, not the exception. vider who has successfully completed a PHTLS, ATT, or
TNCC course and wishes to transition to the ITLS program.
The course typically runs 8 hours. A sample course agenda
eTrauma is available in the eighth edition ITLS Coordinator and
ITLS eTrauma covers the 8 hours of ITLS Provider class- Instructor Guide or from the International Office.
room instruction providing online training on the core
principles of rapid assessment, resuscitation, stabilization,
and transportation of trauma patients. ITLS eTrauma is ITLS Access
offered at both the Basic and Advanced levels. At the com- This ITLS Access course provides EMS crews and first
pletion of eTrauma, the learner receives 8 hours of CEUs responders with training to utilize the tools commonly
from CECBEMS and is qualified to take the ITLS Completer carried on an ambulance or first responder unit to reach
course that will lead to ITLS certification. entrapped patients and begin stabilization and extrication.
xviii
     I n t e r n at i o n a l T r a u m a L i f e S u pp o rt C o u r s e s           xix

ITLS Pediatric Enrolling in an ITLS Course

ITLS Pediatric concentrates on the care of injured children. ITLS provides its courses through chapters and training
The course is designed to train EMS and nursing person- centers. The ITLS Course Management System makes it
nel in the proper assessment, stabilization, and packag- easy to find a course in your area. Log on to cms.itrauma.
ing of a pediatric trauma patient. The course also covers org to search for courses and contact the course adminis-
communication techniques with pediatric patients and trator to register.
parents. If you need information about your local chapter or training
center, check our list at itrauma.org or call ITLS headquar-
ters at 888-495-ITLS or +1-630-495-6442 (for international
ITLS Instructor Courses callers). We will put you in touch with your local organiza-
ITLS Instructor courses are offered for both ITLS Advanced tion—or help you start a program in your area.
and ITLS Basic courses. Other methods of achieving instruc- International Trauma Life Support
tor status are used for ITLS Pediatric and ITLS Access 3000 Woodcreek Drive, Suite 200
courses. To become an instructor, students must have suc- Downers Grove, IL 60515
cessfully completed the provider-level course with specific Phone: 888-495-ITLS
requirements on both the written and practical exams and +1-630-495-6442 (International)
be monitored teaching the lecture, skills, and testing por- Fax: 630-495-6404
tions of the Provider course. Web: www.itrauma.org
E-mail: [email protected]
ITLS Leadership
Board of Directors
Russell Bieniek, MD, FACEP (USA) Miles Darby, EMT-P (USA)
Richard Bradley, MD, FACEP, EMT-P (USA) Jonathan L. Epstein, MEMS, NRP (USA)
Neil Christen, MD, FACEP (USA) Aaron Jeanette, EMT-P, PI, FF (USA)
Elizabeth Cloughessy, AM, RN, Mast Health Mgt, Peter Macintyre, ACP (Canada)
FAEN (USA), MRCNA (AUS) Eric Roy, MBA-HCM, BMaSc, CD OSJ (Canada)
Tony Connelly, EMT-P, BHSc, PGCEd (Canada) Chen Zhi, MD (China)

ITLS Leadership
Editorial Board
Leaders
Chair: Darby L. Copeland, Ed.D, RN, NRP, NCEE (USA)
Past Chair: Donna Hastings, MA, EMT-P, CPCC
(Canada)
Editor in Chief: Roy Alson, PhD, MD, FACEP, FAEMS
(USA)
Associate Editor: Kyee Han, MBBS, FRCS, FRCEM (UK)

Members
Timothy Ballard, MD, MPH, SFS, Lt Col, USAF, MC, Aurora Lybeck, MD (USA)
DIMO (USA) David Maatman, NRP/IC (USA)
Sabina Braithwaite, MD, MPH, FACEP, NRP (USA) Bob Page, M.Ed, NRP, CCP, NCEE (USA)
Maia Dorsett, MD, PhD (USA) Antonio Requena Lopez, MD (Spain)
Jonathan Epstein, MEMS, NRP* (USA) – Board Liaison S. Robert Seitz, M.Ed., RN, NRP (USA)
Tim Hillier, MA, ACP (Canada) Matt Sztajnkrycer, MD, PhD, FACEP (USA)
xx          I n t e r n at i o n a l T r a u m a L i f e S u pp o rt C o u r s e s

ITLS Editorial Teams

Research Team
Lead: Kyee Han, MBBS, FRCS, FRCEM (UK) David Maatman, NRP/IC (Florida)
Aftab Ahmed, FRCSEd UK, CCRP (Pakistan) Eva Molter, MD (Germany)
Pamela Bertone, EMT-P (Mid-Atlantic) Art Proust, MD, FACEP (Illinois)
Richard Neville Bradley, MD, EMT-P (Texas) Eduardo Romero Hicks, MD (Mexico)
Gregory R. Brown, NRP, EMT-P (Pennsylvania) Robert Sklar, BS, NRP (Pennsylvania)
Liz Cloughessy, AM, RN, MHM, FAEN* (Australia) Hiroyuki Tanaka, MD (Japan)
Sean Davenport, CCEMT, NRP (Kentucky) Brian Therian, NRP, CCP, MICP (Pennsylvania)
Tim Hillier, ACP (Saskatchewan) Brian Weston, EMT-P, CCEMT-P, FP-C (Mid-Atlantic)
Todd Knight, BS, CCEMT-P, FP-C (Tennessee/Alabama) Jennifer Williams, ACP (Saskatchewan)
Ron Kowalik, ACP (Ontario)

Scenario Development Team

Lead: David Maatman, NRP/IC (Florida) Jurij Kryvonos, MD (Poland)
Vice Lead: Terry Hastings, BHSc, ACP (Saskatchewan) Matt McGurk, ACP (Saskatchewan)
Ma. Karbee Alvendia, RN, NRP (Philippines) Nick Montelauro, BS, NRP (Indiana)
Robert Carpenter, NRP (Pennsylvania) George W. Murphy, NRP, I/C (Massachusetts)
Derek Chrisco, RN, EMT-P (North Carolina) Wayne Perry, M.Ed, BS, NRP, EMT-P, NCEE (Mid-Atlantic)
Tony Connelly, EMT-P, BHSc, PGCEd.* (Alberta) Antonio Requena Lopez, MD (Spain)
Qirong Du, MD (China–Shanghai Xin Hua Hospital) J.T. Stevens, EMT-P [Ret.] (Georgia)
Billy Eldridge, EMT-P (North Carolina) Susan Wright, ACP (Alberta)
Ron Kowalik, BPHE, ACP (Ontario)
 1
Introduction to
Traumatic Disease
Maia Dorsett, MD
Sabina Braithwaite, MD, FACEP, FAEMS
James H. Creel, Jr., MD, FACEP

Einführung in die Traumatologie Introduction aux lésions d’origines traumatiques

Introducción al Trauma como Enfermedad Εισαγωγή στο Τραύμα
Introducción a la Enfermedad Traumática Bevezetés a sérült ellátásba
Uvod u traumatsku bolest
Introdução ao Trauma
Pengantar Pada Penyakit Traumatis
Введение Оценка места происшествия Poškodbe

(Top: Jack Dagley Photography/Shutterstock)

Objectives
Key Terms
Upon successful completion of this chapter,
blast injury, p. 15 you should be able to:
blunt trauma, p. 7 1. Identify the most common causes of death due to
committee for tactical emergency ­traumatic injury.
casualty care (C-TECC), p. 6 2. Summarize the components of scene size-up.
disease, p. 7 3. Describe the role of scene size-up in provider safety
essential equipment, p. 6 and anticipation of patient injuries.

focused exam, p. 3 4. Explain the relationship between kinetic injury and

injury severity.
high-energy event, p. 8
5. Identify the three collisions associated with a motor
index of suspicion, p. 8
vehicle collision, and relate potential patient injuries
ITLS Primary Survey, p. 3
to the deformity of the vehicle, interior structures, and
kinetic energy (KE), p. 7 body structures.
mass casualty incident, p. 3 6. Describe how vehicle safety mechanisms affect antici-
mechanism of injury (MOI), p. 7 pated injury patterns.
occupant restraint systems, p. 10 7. List the factors that predict the type and severity of
injury due to fall.
2          C H A P T E R 1      I n troductio n to T rau m atic D i s ea s e

Objectives (continued)
Key Terms (continued)
8. Describe how bullets cause tissue injury and explain
OPIM, p. 4 the relationship between bullet characteristics and
penetrating trauma, p. 13 injury severity.
personal protective equipment (PPE), p. 4 9. Relate the five injury mechanisms involved in blast
preventable death, p. 16 injuries to scene size-up and patient assessment.

rapid trauma survey, p. 3 10. Describe the priorities of prehospital trauma care and
relate them to preventable causes of death.
scene size-up, p. 3
11. Discuss the role of preventative efforts in reducing
secondary collision, p. 10
injury and death due to trauma.
secondary insult, p. 16
standard precautions, p. 2
tactical combat casualty care (TCCC), p. 16
temporary cavity, p. 14
wound ballistics, p. 13
wound track, p. 14

Chapter Overview
Traumatic injury remains a leading cause of death internationally. More than 5 million
people die every year secondary to injury, accounting for 9% of the world’s deaths (World
Health Organization [WHO] 2014). The most common cause of death by injury is road
traffic injury, followed by intentional injury, suicide, and falls (WHO 2014). As a result of
preventative efforts and changing demographics, the epidemiology of trauma is chang-
ing. For example, in developed countries, preventive efforts have reduced death due
to traffic injuries by crash avoidance, car safety, and improved medical care (Sise et al.
2014; WHO 2014). Meanwhile, deaths due to falls continue to rise, in part due to aging of
the population (Alberdi et al. 2014; Sise et al. 2014).
Death is only one consequence of trauma. Injury leads to substantial health care costs
and survivors may have significant physical, psychological, or economic morbidity. This
is particularly true for traumatic injury, as it disproportionately impacts young people who
have many potential life-years left (WHO 2014). Injuries account for 6% of all years lived
standard precautions: steps each with disability (WHO 2014). Therefore, while the ideal intervention is injury prevention,
health care worker takes to protect measures to improve trauma care postinjury can minimize death and disability from those
themselves and their patient from events that do occur.
exposure to infectious agents;
includes treating each patient and
him- or herself as if infectious. At Situational Awareness
a minimum this entails wearing At the scene of an injury, there are certain important steps to perform before you
gloves, frequently requires a face begin care of the patient. Failure to perform a scene size-up will subject you and
shield, and occasionally requires a your patient to danger and may cause you to fail to anticipate serious injuries your
protective gown. patient may have sustained. Take standard precautions and assess the scene for
 C H A P T E R 1     I n troductio n to T rau m atic D i s ea s e           3

rapid trauma survey: a brief

Table 1-1: ITLS Patient Assessment
exam from head to toe performed
ITLS Primary Survey Perform a scene size-up to ­identify life-threatening injuries.
Perform initial assessment focused exam: an exam used
Perform a rapid trauma survey or focused exam when there is a focused
Make critical interventions and transport decision (localized) mechanism of injury
Contact medical direction or an isolated injury. The exam is
ITLS Secondary Survey Repeat initial assessment limited to the area of injury.
Repeat vital signs and consider monitors multiple casualty incident
Perform a neurological exam (MCI): also referred to as a mass
Perform a detailed (head-to-toe) exam casualty incident, is an event that
ITLS Reassessment Exam Repeat initial assessment produces more casualties than the
Repeat vital signs and check monitors responding agency has resources to
Reassess the abdomen manage.
Check injuries and interventions scene size-up: observations
made and actions taken at a trauma
scene before actually approaching
dangers first. Determine the total number of patients. Look for stickers or other the patient. It is the initial step in
markers that may indicate a special needs patient. Determine the need for additional the ITLS Primary Survey.
emergency care providers or special equipment. If there are more patients than you
can manage with available resources, report to dispatch and initiate mass casualty ITLS Primary Survey: a
incident protocols. brief exam to find immediately
Scene size-up is the first step in the ITLS Primary Survey (Table 1-1). It is a critical life-threatening conditions. It is
part of trauma assessment. It begins before you approach the patient, and should made up of the scene size-up, initial
even start before arrival on scene by using dispatch information. Failure to perform assessment, and either the rapid
trauma survey or the focused exam.

Case Presentation
An advanced life support (ALS) ambu- with a starred front windshield. Some
lance is dispatched along with the fire 30 feet (9 meters) behind it, you see a man
service to the scene of a truck rollover. on the ground near a heavily damaged
Dispatch advises responding personnel motorbike, not moving. What are the first
that bystanders report fluid leaking from steps and decisions you need to make?
the truck. Upon arrival, the fire depart-
Before proceeding, consider these
ment establishes command and orders the
questions:
ambulance to stage approximately one-half
mile (800 meters) upwind of the incident. • Is the scene safe?
Two minutes later, Incident Command (IC) • Are responders and/or victims in poten-
advises medical personnel that the minor tial danger?
petroleum spill is controlled and that there • What protective clothing is required?
may be more than one patient: the truck
driver, who is out of his truck, alert, and • Other than the spill, are there other
walking around; and the drivers of a motor potential hazards?
vehicle and a motorcycle, which were dam- • How many patients do you have?
aged in the collision. Command tells them • What additional equipment may be
they should proceed to the site. required?
As you arrive with the ambulance, you Keep these questions in mind as you read
observe fire personnel containing the spill. through the chapter. Then, at the end of the
You smell diesel fuel. You see a four-door chapter, find out how the emergency care
sedan damaged in the front and left fender providers managed this emergency.
4          C H A P T E R 1      I n troductio n to T rau m atic D i s ea s e

Table 1-2: Steps of the Scene Size-up

1. Standard precautions (personal protective equipment)

2. Scene safety
3. Initial triage (total number of patients)
4. Need for more help or equipment
5. Mechanism of injury

the preliminary steps of scene size-up may jeopardize your life as well as the life of
your patient. Scene size-up includes taking standard precautions to prevent expo-
sure to blood and other potentially infectious material, evaluating the scene for
dangers, determining the total number of patients, determining essential equip-
ment needed for the particular scene, and identifying the mechanisms of injury
(Table 1-2).

Scene Size-up
Scene size-up begins at dispatch, when you anticipate what you will find at the scene.
Based on the nature of the event—such as a hazardous material (hazmat) incident or
a scene involving an active shooter—where you stage before you enter the scene can
vary. Agencies and jurisdictions will have protocols to help guide your decision as to
whether to stage, what location to stage, or whether to enter the scene. At that time,
you should think about what equipment you may need and whether other resources
(e.g., more units, special extrication equipment, mass casualty incident [MCI] proto-
cols) may be needed. Although information from dispatch is useful to begin to think
about a plan, do not overrely on this information. Information given to the dispatcher
may not be accurate. Be prepared to change your plan according to your own size-up
of the scene.

Standard Precautions
Emergency care providers are at significant risk of exposure to blood or other poten-
OPIM: short for other potentially tially infectious material (OPIM) when caring for trauma patients. Not only are
infectious material to which an trauma patients often bloody, but they may also require active airway management
emergency care provider may be under adverse conditions. Personal protective equipment (PPE) is necessary at
exposed (other than blood). trauma scenes. Protective gloves are always needed, and many situations will also
require eye and face protection. It is wise for the emergency care provider in charge
personal protective equipment of airway management to don a face shield or eye protection and mask. In highly
(PPE): equipment that an contaminated situations, impervious gowns with mask or face shield may be needed
emergency care provider dons for as well. In a toxic environment, chemical suits and gas masks may be needed. Remem-
protection from various dangers
ber to protect your patients from body fluid contamination by changing your gloves
between patients.
that may be present at a trauma
scene. At a minimum that entails Scene Safety
wearing protective gloves. At a
Begin sizing up the scene for hazards as you approach in your vehicle. Your first
maximum it is a chemical suit and decision is to determine the nearest safe place to park the ambulance or rescue vehi-
self-contained breathing apparatus. cle. You would like the vehicle as close to the scene as possible, and yet it must be far
enough away for you to be safe while you are performing the scene size-up. In some
situations, you should not enter the scene until it has been cleared by fire personnel,
law enforcement, or hazmat technicians. Try to park facing away from the scene, so if
dangers arise, you can load the patient and leave quickly. Next, determine if it is safe
to approach the patient. Perform a “windshield survey” before leaving your response
vehicle. Consider the following:
• Crash/rescue scenes. Is there danger from fire or toxic substances? Is there danger
of electrocution? Are unstable surfaces or structures present such as ice, water,
a slope, or buildings in danger of collapse? Areas with potential for low oxygen
 C H A P T E R 1     I n troductio n to T rau m atic D i s ea s e           5

levels or toxic chemical levels (e.g., sewers, ship holds, silos, etc.) should never be
entered until you have the proper protective equipment and breathing apparatus.
You should never enter such areas without proper training, safety equipment, and
appropriate backup support.
• Hazmat incidents. Presence of hazardous materials is often indicated by placards on
the outside of the vehicle (see Figure 1-1). These will vary depending on the country
in which you work. If you observe such indicators, do not approach without proper
protective equipment and training. Request specialist resources to assist with the
rescue, containment, and possible decontamination.
• Farms. Silos are confined spaces and should not be entered without proper equip-
ment and training. Livestock can also pose hazards to emergency care providers.
Be aware of the machinery present as well as manure pits or ponds.
• Crime scenes. Danger may exist even after a crime has been committed. Be alert for
persons fleeing the scene, for persons attempting to conceal themselves, and for
persons who are armed or who make threatening statements or gestures. Do not
approach a known crime scene if law enforcement personnel are not present. Wait
for law enforcement, not only for your own safety and the safety of victims, but also
to help preserve evidence. Do not approach the scene if you have not been cleared
to enter it by law enforcement.
• Bystanders. You and the victims may be in danger from bystanders. Are bystanders
talking in loud, angry voices? Are people fighting? Are weapons present? Is there
evidence of the use of alcohol or illegal drugs? Is this a domestic-violence scene?
Are dangerous animals present? Request law enforcement personnel at any sign of
danger from violence.
• Blast scene. Explosions are usually associated with industrial accidents, but because
the threat of terrorist activity is both common and worldwide, it should be consid-
ered when approaching the scene of an explosion. Terrorists often place a second
device designed to kill or injure responders. In addition, in some countries

Figure 1-1 Warning placards indicating presence of hazardous material.

6          C H A P T E R 1      I n troductio n to T rau m atic D i s ea s e

the proliferation of illegal methamphetamine labs has been associated with an

increased incidence of chemical explosions.
Whatever the cause of an explosion, if possible, law enforcement personnel, along
with appropriate specially trained personnel (hazmat technician, bomb technician),
should first evaluate the blast scene to make sure it is safe to enter and that no active
chemical, biological, or radiological hazards exist. If possible, park your vehicle
outside the blast zone (the area where glass is broken). If you are not sure of scene
safety, call for ambulatory victims to leave the scene by following a designated
emergency responder to a safe area for triage and decontamination.
• Mass shooting/active shooter events. An active shooter is an individual who is actively
committee for tactical engaged in killing or attempting to kill people in a confined or populated area.
emergency casualty care Unfortunately, the number of active shooter incidents leading to mass casualty
(C-TECC): events has increased in recent years, particularly in the United States. Traditionally,
evidenced-based and best- emergency care providers have not entered the scene until it was secured by law
practice trauma care guidelines enforcement, potentially causing significant delays during which victims may die
of massive hemorrhage. A number of initiatives have recommended revising these
for civilian high-threat prehospital
traditional roles and more fully integrating emergency medical services (EMS) into
environments.
the response to an active shooter in an effort to save as many lives as possible.
essential equipment: equip- Rather than staging and waiting for casualties to be brought to the secure part
of the scene, EMS responders enter the scene with law enforcement protection to
ment that is worn or carried when
provide care in areas where there is no immediate threat. The goal is to provide
the team approaches the trauma
only emergent interventions such as control of life-threatening hemorrhage, then
patient. It includes personal pro- rapidly evacuate victims to a more secure area for further assessment and treatment
tective equipment, long backboard (Jacobs et al. 2013; Joint Committee 2013). This model of rapid assessment medical
and strapping, rigid cervical extri- support, as outlined in the Hartford Consensus, requires cross-disciplinary training
cation collar, oxygen and airway between law enforcement and EMS in which law enforcement receives education
equipment, and trauma box. in hemorrhage control and EMS providers acquire additional operational knowl-
edge of active shooter events and committee for tactical emergency casualty care
(C-TECC) (CTECC 2015; Joint Committee 2013; Mechem, Bossert, and Baldini 2014).

PEARLS Total Number of Patients

MCI Initial Response Next, determine the total number of patients. If there are more patients than your team
ETHANE can effectively handle, call for additional resources. Based on dispatch information
• Exact location of the incident and additional information received en route, you may need to do this while still
• Type: The nature of the
responding to the incident. On arrival, medical command must be established. Use
incident, includes numbers the acronym ETHANE to help guide you through the initial steps after arrival.
of vehicles and types, build- Remember that you usually need one ambulance for each patient who is seriously
ings, aircraft, etc. that are injured. If there are many patients, establish medical command and initiate mass
involved casualty incident (MCI) protocols.
• Hazards: Identified and When determining the total number of patients, consider this question: Are all patients
possible hazards such as fuel accounted for? If a patient is unconscious, and there are no witnesses to the incident,
spills, weather, floods
look for clues that other patients might be present (e.g., schoolbooks or diaper bag,
• Access: How arriving units passenger list in a commercial vehicle). Carefully evaluate the scene for patients. As
should approach and enter you do so, not only look toward the vehicle or the center of the scene, but also look
the scene
outward to see if there are victims behind you. This is especially important at night
• Numbers: Number of casual- or if there is poor visibility.
ties including dead on scene;
triage categories, if known
Essential Equipment and Additional Resources
• Emergency services: Which If possible, carry all essential equipment to the scene. This prevents loss of time
services are already on
returning to the vehicle. The following equipment are often needed for trauma
scene and which others are
required, including special
patients.
resources such as hazmat, • Personal protection equipment: minimum of gloves and goggles
Search and Rescue, etc.
• Patient extrication and transport devices (stretcher, long spine board, vacuum mattress,
scoop stretcher, etc.) with effective strapping and head motion-restriction device
 C H A P T E R 1     I n troductio n to T rau m atic D i s ea s e           7

• Rigid cervical extrication collar of an appropriate size

• Oxygen and airway equipment, which should include suction equipment and a
PEARLS
bag-valve mask (BVM)
Equipment
• Trauma box (bandage material, hemostatic agent, tourniquet, blood pressure cuff,
It is wise to invest in a high-
stethoscope)
intensity tactical flashlight.
It is small enough to carry in
Remember to change gloves between patients.
your shirt pocket but it is many
If special extrication equipment, more ambulances, or additional personnel are needed, times brighter than regular
call as soon as you recognize the need. Be sure to tell additional responders exactly where flashlights.
to respond or stage and of any dangers present on the scene. In larger events, a staging
area for ambulances and other responding units may be established. Use of designated
radio channels for a specific incident, if available, helps in effective communications.

Mechanism of Injury
A disease is an illness that is characterized by specific signs and symptoms. While the disease: A dysfunction in the
term is traditionally applied to afflictions such as infection, cancer, and chronic illness, body usually due to an identifiable
trauma can be considered a disease as well. Much like a virus has a predictable effect cause, producing specific signs and
on the body, with signs and symptoms that often present with characteristic patterns, symptoms.
the effect of trauma on the body follows reproducible patterns that can often be pre-
dicted by mechanism of injury (MOI). mechanism of injury (MOI):
The absorption of kinetic energy (KE) is the major component producing tissue dam- the means by which the patient
age in traumatic injury. The law of conservation of energy states that energy is neither was injured, such as a fall, motor
created nor destroyed, but is only changed in form. Thus, kinetic energy, whether in vehicle collision, or explosion.
the form of a bullet or moving vehicle, must be absorbed. Kinetic energy is propor-
tional to the mass of an object and to the square of the velocity. Therefore, the speed kinetic energy (KE): the energy
at which a vehicle collision occurs or the speed of a bullet has greater impact on the that an object has as a result of
severity of traumatic injury than the size of the object. being in motion.
Broadly speaking, the two major types of traumatic injury due to motion are blunt
and penetrating, though patients can have both at the same time.

Blunt Trauma
Part of the initial assessment of a trauma scene is identification of clues that signal a
high-energy mechanism, as it may help you predict severe injury. To explain the forces
involved, consider Sir Isaac Newton’s first law of motion: A body in motion remains
in motion in a straight line unless acted on by an outside force. Motion is created by force
(energy exchange), and therefore force will stop motion. If this energy exchange occurs
within the body, tissue damage occurs. You should keep in mind that injuries from
blunt trauma occur as separate events: machine collision, body collision, and organ blunt trauma: injury produced
collision, which are described in the next section (Figure 1-2). by application of force to the body.

Motor Vehicle Collisions

With respect to motor vehicle collisions (MVCs), research has demonstrated that
certain features are highly associated with increased injury severity. Some collision
features that are associated with increased risk of death include rollover crashes,
passenger compartment intrusion, death of another occupant in the vehicle, signif-
icant extrication time, ejection from the vehicle, and pedestrian struck (Champion,
Lombardo, and Shair 2009; Evans et al. 2009; Haider et al. 2009; Lerner et al. 2011).
Understanding the association between mechanism of injury and potentially
life-threatening injury is important not just for anticipating the need for prehospital
interventions, but also in assisting in determining patient transport destination in
systems that have designated trauma centers (Sasser et al. 2012).
The patterns of injuries from collisions with automobiles, motorcycles, all-terrain vehicles
(ATVs), personal watercraft, and farm or construction vehicles are varied (Table 1-3).
8          C H A P T E R 1      I n troductio n to T rau m atic D i s ea s e

B C

Figure 1-2 The three collisions of a motor vehicle crash. A. Vehicle collision. B. Body collision.
C. Organ collision. (Photo copyright Mark C. Ide)

Newton’s law is well exemplified in the automobile crash. The kinetic energy of the
vehicle’s forward motion is absorbed as each part of the vehicle is brought to a sudden
halt by the impact. Remember that the body of the occupant is also traveling at the same
speed as the vehicle until impacted by some structure within the car when it stops as a
result of a collision.
For example, consider approaching an MVC in which an automobile has hit a tree
head-on at 40 miles (64 kilometers) per hour. The tree brings the automobile to an
immediate stop by transferring the energy into damage to the tree and the automobile
high-energy event: a mecha- (vehicle collision). The person inside the vehicle is still traveling at 40 miles per hour
nism of injury in which it is likely until he or she strikes something that stops him or her (such as seat belts, steering
that there was a large release of un- wheel, windshield, or dashboard) (body collision). At that point, energy transfers into
controlled kinetic energy transmit- damage to the person and to the surface struck. The organs inside the person are also
ted to the patient, thus increasing traveling at 40 miles per hour until they are stopped by striking a stationary object
the chance for serious injury. (such as inside of skull, sternum, steering wheel, dashboard) or by their ligamentous
attachments (such as the aorta by ligamentum arteriosum) (organ collision). In this
index of suspicion: the medical auto-versus-tree example, appreciation of the rapid forward decelerating mechanism
provider’s estimate of a disease or (high-energy event) coupled with a high index of suspicion should make you con-
injury being present in a patient. cerned that the victim may have life-threatening multisystem trauma.
A high index of suspicion means Utilizing the three-collision concept described previously, check for the presence of
there is a high probability the the following:
injury is present. A low index of • Machine collision. Look for damage to the vehicle at the site of impact, but also
suspicion means there is a low risk in other areas that may indicate rollover or spinning of the vehicle as a result of
of the injury. impact.
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order to make and repair the highways; and by a peculiar irony,
although the great thoroughfares were thus maintained solely at the
peasants' expense, the roads which the peasants really needed, the
cross-roads in agricultural districts, were left to ruin and neglect.
More odious still were the demands of the militia service. Every
unmarried man up to forty years of age could be called upon for this
oppressive duty. No substitution was allowed. Although for the
wealthy the exemptions were innumerable, for the poorest class no
exemption was permitted. Improvident marriages offered the only
means of escape. The approach of the Government's agent was the
signal for panic and disorder, and the miserable villagers fled for
concealment to the woods.
Even more grievous than the Corvée and the militia were the abuses
which pervaded the whole system of taxation. The heaviest of all the
taxes was the terrible burden of the Taille, a direct tax levied
sometimes on property and sometimes on income, falling almost
entirely on the poor—alike on the struggling landowner and on the
landless labourer—assessed without order or method, constantly
varying and constantly increased. Every year in the rural districts
some unfortunate villager was selected to act as collector of the
Taille. He alone had to decide how much each of his neighbours was
worth, and how much he must extort from them to satisfy the
Government, and if his efforts or his calculations failed, his own
property and person were responsible for the amount. The
opportunities for abuse in such a system, for the satisfaction of
personal jealousies and grudges, are as obvious as its unfairness
towards those on whom the office was inflicted. 'The office of
collector,' cried Turgot, 'drives to despair and frequently to ruin all
those on whom it is imposed.' In order to escape the Taille, the
peasant strenuously concealed his savings. If, in spite of his
Government, he prospered, he dared do nothing to give an air of
comfort to his home. We find him in one case entreating his landlord
not to tile the roof of his cottage, because such a sign of prosperity
would mean for him an increase of taxation. It was the object of
every man to seem desperately poor. Then besides the Taille, the
peasant had to pay the accessory taxes, which in process of time
had been assimilated with it; the Poll-tax and the Vingtièmes,
imposts imposed by Louis XIV on all alike, but the weight of which
the powerful classes had contrived to shift on to the shoulders of the
weak; the road-tax, when the Corvées were abolished; the tax of the
franc-fief, whenever he happened to own lands which had once been
the lands of nobles; and always, apart from the demands of the
Exchequer, his seigneur's dues and his pastor's tithe. Statistics may
sometimes be misleading, but an able statistician has calculated,
upon evidence which it is difficult to deny, that, allowing for all these
direct charges, the peasant in many parts of France paid away four-
fifths of his income to the Treasury, the seigneur, and the Church,
and out of every hundred francs he earned, retained little more than
eighteen francs himself[4].
But the record of his troubles did not end there. The Gabelle,
perhaps the most exasperating impost ever devised by an empty
Exchequer, compelled all citizens over seven years of age to
purchase yearly seven pounds of salt from the agents of the State.
But this salt was reserved for cooking and eating alone, and if salt for
any other purpose were needed, the agents of the State had the
right to make its subjects purchase more. The whole system of
indirect taxation was conceived in the same spirit as this monument
of fiscal folly. The face of the country was covered by barriers and
custom-houses, occupied by an army of revenue officers, who
purchased from the Government the right of collecting the customs
and excise. Twelve hundred leagues of artificial frontiers separated
the various provinces of France, impeded trade, and played havoc
with prices. The small vine-growers were almost ruined by the excise
levied upon wine, which even in those days was conspicuous for its
severity and for the inquisitorial practices of those who enforced it.
Calonne declared that the salt tax alone produced every year nearly
four thousand sentences, of imprisonment, flogging, exile and the
galleys. Under such auspices smuggling multiplied, and the
Government retorted by heavy punishments. Bodies of armed
banditti were organised in disturbed districts, and carried on for
years together a guerilla war against the forces of the Crown.
Unemployed labourers and ruined peasants found a livelihood in
swelling the ranks of disaffection, and in the absence of any poor-law
administration, mendicancy and vagabondage rapidly increased.
The records of the last years of the Ancien Régime are consequently
full of evidence of alarming and growing disorder. Townspeople
complained that the beggars, driven from the country, flocked into
the cities for shelter. The Intendants reported to the Council that the
chief highways of the kingdom were infested with dangerous
vagrants. In vain the Government multiplied its corn-laws and
arrests, and endeavoured to stifle the clamours of indigence by
feeding some and by punishing others. In 1767, fifty thousand
beggars were arrested; but in 1777, the numbers of that unfortunate
class had risen to nearly a million and a quarter. In Paris the census
of 1791 declared that out of a population of six hundred and fifty
thousand, over one hundred and eighteen thousand were without the
means of regular subsistence. It is easy to understand how, pressed
by hunger, and pursued by a rigorous penal code, many of these
wandering mendicants crossed the thin line which separates
extreme want from crime, and how, when the Old Monarchy
suddenly collapsed, and when in the search for freedom law was for
the moment lost, this large group of miserable beings, armed with
brief power and long-accumulated hatred, exacted a terrible revenge
for the wrongs of the labouring community in France, from whose
ranks they and their ancestors had been driven by a system
politically and socially unjust.
Such, in the eighteenth century, were some of the conditions of life in
France. Each class lived apart, entrenched in its own chilling
traditions. 'Nobody,' cried Turgot, 'cares for any interest but his own.'
Local patriotism, common intercourse, friendly feeling, no longer
drew men of different ranks together. The sense of citizenship had
generally died out. Below the others the peasant stood alone. His
poverty clung to him as a garment of shame. His commonest
impulses were want and fear. His love of legend made him
superstitious. His ignorance made him credulous, bigoted,
suspicious, easily persuaded to believe in evil. Isolated from the
world, conscious of belonging to an inferior caste, encountering on
all sides the privileges of his masters, and yet with no superior to
care for him and no wise counsellor to guide him, blunted in feeling
by long endurance, gentle, submissive, often gay, but more often
brooding on the indignities which he suffered, and resenting the
injustice even more than the hardship of his lot, he heard and
welcomed with passionate illusion the new doctrine of human
dominion, which proclaimed that men were equal, whatever their
station, whatever their distress, and from that moment the attainment
of equality, so easy to imagine, so hard to approach, became the
commanding ideal of the poor.

FOOTNOTES:
[1] It will be understood that in the Pays d'État, the powers of the
Intendants, as regarded taxation and public works, were limited
and controlled by the rights of the local assemblies.
[2] The expenses of the royal table amounted to nearly three
hundred thousand pounds a year.
[3] I have taken all these figures from M. Taine's Ancien Régime,
and have reduced them roughly to their equivalents in English
money of our own day. I have, however, throughout calculated the
livre at 10d., although Arthur Young puts it as high as 10-1/2d.; so
that the amounts in the text are, if anything, understated.
[4] One part of the taille, that which fell upon the cultivator,
reached the privileged orders indirectly through their farmers, but
even then there were certain exemptions in their favour. The
franc-fief was the tax of one year's revenue levied every twenty
years on non-noble holders of noble lands. The calculation of
income given here I take from the note on the subject contained
in the appendix to M. Taine's volume on the Ancien Régime,
which is founded on the procès-verbaux of the provincial
assemblies. On an income of 100 francs, he estimates the taille
(with its accessories), the poll-tax, and the road-tax together, at
42 fr. 15 c.; the two vingtièmes at 11 fr., the tithe at 14 fr. 28 c.,
and the feudal dues at 14 fr. 28 c.; total 81 fr. 71 c.
 CHAPTER II.
The Last Years of the Ancien Régime.
The decay of the old society was accompanied in France by a decay
of the ideas which were inseparably associated with it, and which,
long kept alive by authoritative sanctions, had exacted, not always
without violence, the reverence of men. As the State had usurped
the control of every department of action, so the Roman Catholic
Church had usurped the control of every department of thought.
Resting serenely upon authority and dogma, it had dictated and
circumscribed the knowledge of its subjects, had directed their
intellectual interests, and had aimed at supplying not only a religion
to govern their conduct, but also a complete theory to govern their
lives. Against this monopoly, and the conceptions on which it was
established, the best minds of the eighteenth century rose in revolt,
and their revolt was celebrated by an outbreak of active and intrepid
thought. Beginning in the mysterious domain of physical science,
with great discoveries in astronomy, chemistry, physics, geology and
mathematics, the new spirit of enquiry spread like a flame to illumine
other topics. Its votaries, rejecting ancient tradition and immemorial
habit, turned with sudden enthusiasm to observation and analysis,
and built up for themselves step by step new systems of knowledge,
based, not on what their teachers taught them, but on positive facts
which they had ascertained and tested for themselves. The vivid
curiosity thus aroused woke in them distrust of all preconceived
notions, banished the reverent awe which had restrained earlier
generations, and broke down the old barriers of belief.
Before long the passion for investigation passed beyond the limits of
physical science, and ranging far afield, entered the domain of
theology, of economics, of politics and social laws. In all fields alike
there appeared the same disposition to repudiate opinions previously
held, to examine afresh, under no restrictions, the principles which
lay at the root of religion and government, the general laws which
regulated human institutions, the origin of existing conceptions of
society and property, of justice and right. Tradition was dethroned,
and reason was set up in its seat, as the only test by which opinions
could be determined, without regard to the subordinate place which
reason fills in the conduct of men. The classical spirit, with its finish,
its artificiality, its limitations, already dominant in France, set its
stamp upon the new philosophy, and afforded the vehicle for
conveying it to the world. In successive generations of polished
intercourse, the French language had acquired extreme nicety and
clearness of expression; it was admirably fitted for criticism, analysis,
argument, definition; and it thus rendered the new ideas at once
popular and lucid. A passion for philosophical discussion took hold of
the educated world, and carried them past the facts which they ought
to have noticed, to theories which seemed more distant and
consequently more profound. All alike began to speculate, to
generalise, to enquire into the meaning of many things, the current
interpretation of which they had determined no longer to accept;
while the necessity, from which all Frenchmen suffer, of never being
dull, encouraged superficiality in the new search for truth, and
checked the close study of history, which alone could have avoided
error.
As the secrets of the universe unfolded, and as men learned how
clear and simple were the laws of physical nature, they determined
that there must be other laws of nature, equally clear and simple, to
explain society and politics; and finding this theory lamentably
contradicted by the confusion of institutions and abuses round them,
they began to assail those institutions and abuses with the audacity
which science gives. Law and religion in their actual forms were so
corrupt that the shocked imagination of these dreamers fell back
upon ideals of natural religion and natural law. Far aloof themselves
from actual politics, untrained by that wisdom of many voices which
free political discussion bestows, dissatisfied with their own political
customs, but disdaining to study thoroughly the political customs of
others and the origin of all, they proceeded to formulate, by the aid of
pure reason, theories which would satisfy their newly roused
emotions, and fit in with some apparently more simple and scientific
formula of life. All those for whom politics in practice were a sealed
book, took refuge in these politics of the imagination, and the political
world in France found itself presently divided into two camps, one
consisting of those who governed, the other of those who
discoursed, the latter perpetually establishing principles, which the
former perpetually broke. A society devoted to letters and to
conversation embraced and disseminated the speculative literature
of the age, and thus the great literary men of the eighteenth century
became in France what politicians sometimes strive to be in happier
lands, the fountains of political inspiration, and the real leaders of
public thought.
Among the pioneers of the new doctrines two men stand out
conspicuously in each half of the century,—Montesquieu and Voltaire
in the first half, Diderot and Rousseau in the second. Montesquieu,
the earliest of the philosophers, was a polished and eminent lawyer,
well versed in history, serious, acute, a profound student of human
institutions, and the master of a terse and pointed style. His writings,
generally speaking, were no mere flights of pert fancy, but the result
of systematised and careful thought, weighty, luminous, moderate in
tone, and scientifically sane. It was Montesquieu, who, in his Lettres
Persanes, initiated the philosophic movement, and unmasked the
batteries of criticism and satire, which for two generations were to
play so effectively upon the foundations of the old monarchy in
France. It was Montesquieu, who, twenty seven years later, when he
produced the great work of his life, the Esprit des Lois, analysed with
clear and wide sagacity the laws which regulate human governments
and customs, and thus destroyed the mysterious prestige which had
never till then been stripped from the ancient institutions of France. It
was Montesquieu, who first exposed those institutions to a ruthless
analysis which they could not stand. But the slow and careful
method, which was Montesquieu's distinction, was less popular with
his successors. It involved too much trouble. It ran the risk, except in
a master's hands, of being dull. The classical spirit, the French
temperament, the love of amusement combined to guide criticism
into an easier groove, and the philosophic movement, without
altogether deserting the studious atmosphere of facts, adopted a
more becoming garment in the exquisite raillery of Voltaire.
Voltaire's life extended long past the middle of the century, and its
closing years were the years of its greatest triumphs. But he yet
belongs to the generation of Montesquieu rather than to that of
Rousseau. Under him, the tone of the new movement altered. It
became lighter, and bolder too. Its reserve vanished. Its intrepidity
increased. It entered every field. It illumined every subject. In verse,
in prose, in history, in drama, in romance, Voltaire assailed traditions,
beliefs, abuses, exposing mercilessly their shortcomings and shifts,
laughing aloud over their absurdities, denying the pretensions which
they boasted, denouncing the iniquities to which they led. Voltaire's
rare and versatile wit, his light touch, his unabashed scepticism, his
brilliant common-sense, appealed irresistibly to the minds of his
countrymen. He made the philosophic movement popular. He
identified it with many errors, and with the gravest faults of taste. But
with it all he taught men to despise many follies and to impeach
many wrongs.
It was Voltaire who gave to the literary movement that decisive tone
of irreligion, which it so long retained. The Church stood in the van of
the opponents whom the philosophers had to encounter, and to
attack the Church, her practice and her creeds, was to Voltaire an
intellectual delight. More than any other institution the Church in
France represented the spirit of tradition, of authority, of submission
to formulas, of reverence for the past. As such, she was certain to
view with alarm the new spirit of independent enquiry. Of all forms of
political power, the political power of the Church was the most
unpopular. She stepped in to support with mysterious sanctions the
civil institutions which many felt were unjust. As the censor of the
Press, she represented the Government at the very point where the
Government and the philosophers came into conflict. Of all the
supports of the old order, she was in many ways the most open to
attack. Consequently, the philosophic movement from the first
brought its forces to bear upon the Church, and Voltaire led the
onslaught with the irreverent vivacity of his nature, and the rich
splendour of his information and literary resource.
In the middle of the eighteenth century, however, the conduct of the
philosophic movement passed to a large extent into younger hands.
In 1751, the first volume of the celebrated Encyclopaedia
concentrated public attention on a group of writers of no common
range and understanding, all inspired with the new spirit, and
combined to carry it into every field of economic, political, and social
action. The Encyclopaedists numbered among them many
distinguished men. On the roll of their contributors we find the names
of Turgot, Rousseau, Buffon, Marmontel. D'Alembert, the
accomplished mathematician, brought to the work his trained
abilities, his admirable style, and the wisdom acquired by a student
during a life spent in frugality and independence. But the greatest of
the staff, the most original in genius, the most reckless in expression,
and the most intense and imaginative in thought, was the brilliant,
perverse, impetuous Diderot, with his extraordinary, magnetic
conversation, his indomitable perseverance, his genuine
consciousness of his own shortcomings, his ardent desire for the
improvement of mankind. It is significant that nearly all the prominent
members of the Enyclopaedic party had been brought up as pupils of
the Jesuits, and unquestionably, as a party, they associated
themselves with a pronounced attack upon the chief tenets of the
Catholic Church. But it is difficult and not very profitable to attempt to
assign definite names of obloquy to the varieties of disbelief within
their ranks, and it is a grave mistake to regard that aspect of their
writings as the most characteristic or important. What gave to the
enterprise its force and success was the fact that it travelled far
beyond the barren conflicts of theology, and brought the new ideas,
the new habit of enquiry and analysis, the new fearlessness of social
comment, and the new humanitarian zeal, to investigating political
and economic phenomena, to preparing the way for practical reform.
The glory of the Encyclopaedists lies not in their contempt for things
holy, but in their hatred of things unjust, in their denunciation of the
trade in slaves, of the inequalities of taxation, of the corruption of
justice, of the wastefulness of wars, in their dreams of social
progress, in their sympathy with the rising empire of industry, which
was beginning to transform the world.
Posterity is more familiar with the defects than with the virtues of this
strange episode in human thought. Its ideals were disfigured by
many faults—by unreality, political ignorance, dangerous license,
violent extremes. In its anxiety to escape from conventions, it relaxed
necessary codes. It made impiety obstreperous. It hastily adopted a
belief in the perfectibility of man, to fill the niche where once had
rested a belief in the perfection of God. In place of the traditions and
systems which it uprooted, it taught its followers to look for guidance
to their own instincts, and to vague aspirations after imaginary
systems of natural law. It planted in the French people an
inextinguishable desire to abolish everything which reminded it of the
past, however much they might suffer in the attempt. Its teaching
seemed to discourage the impulses of virtue, and to offer no
satisfaction for the spiritual needs of man. Helvetius' famous treatise
De l'Esprit laid down, amid much shallow commonplace, the
depressing doctrine that self-interest dictates both the conduct and
the views of men, and that the attainment of pleasure is their only
final aim. Holbach's not less famous Système de la Nature touched
the climax of a century of philosophical commotion, in its passionate
indictment of the vices of kings and the slavery of men, in its direct
demand for revolution, in its remorseless rejection of every form of
faith, in its insistence upon atheism and materialism as the only true
philosophy of life. 'Religious and political errors,' cried Holbach, 'have
changed the universe into a valley of tears.'
Beside the contributors to the Encyclopaedia, and sometimes among
them, were men of different schools of thought, allied with them in
advocating change. Quesnai and Turgot were conspicuous in the
ranks of an eminent sect termed by some Economists, by others
Physiocrats. The Economists shared with Diderot and his colleagues
the zeal for reform, the contempt for the past, the democratic temper
of the times. They were prepared to enforce equality even at the cost
of despotism. They insisted on the subordination of all private rights
to the public interest. They preached the necessity of national
education as the first essential of national prosperity, and urged that
the burden of taxation should be thrown upon the land, which they
regarded as the sole source of wealth. They advocated free trade,
free agriculture, free industry, while they cared little for freedom itself.
Others like Morelly, the author of the Code de la Nature, accepted
the Economist theory of the omnipotence of the State, but added
other theories of their own. Morelly proposed to establish community
of goods and uniformity of all conditions. He denounced the
institution of private property, and he shadowed forth in their earliest
shape many of those suggestions for the readjustment of the world,
which have since assumed the name of Socialism and acquired the
dimensions of a spectre in minds intolerant of change.
But far above the sound of other voices rose the lofty tones and the
sonorous rhetoric of Rousseau. Rousseau disdained the study and
analysis of the past, in which Montesquieu had sought laborious
wisdom. He cared nothing for the diffusion of knowledge and art, of
which Voltaire was the brilliant representative. He hardly understood
the wide, ambitious projects, by which Diderot and Turgot hoped to
benefit humanity. He resented the utilitarian theories of Helvetius. He
hotly denied the material philosophy of the school of Holbach. To
Rousseau's angry discontent with life, study, knowledge, cultivation,
seemed to be only steps in the degradation of man. To his inflamed
vision all society was artificial, all accepted forms of political
organisation were tyranny and abuse. Man, he protested, was
naturally good and just and loving, created by a just and loving God,
until art, the bane of life, invaded his simplicity, tainted his virtue, and
brought him face to face with suffering and sin. Sweep away
therefore, he exhorted his hearers, all the false fabric of society, the
world of ugly want and insolent riches miscalled civilization, the
oppression miscalled order, the error miscalled knowledge! Level its
inequalities, repudiate its learning, break its conventions, shatter its
chains! Let men return to the simplicity of ancient days, to the idyllic
state, when uncorrupted instinct only ruled them, and there once
again, innocent and ignorant, as Nature made them, and guided only
by the 'immortal and celestial voice' of reason, seek the high paths of
felicity of life.
In a generation full of privilege and hardship, and weary of its own
artificial ways, such teaching as this struck a resounding chord. It did
not matter that the teacher reconciled a rather sordid practice with a
gorgeous theory, and was himself too often morbid, egotistical,
unmanly, mean. The disciples, who drank in his doctrines, did not
enquire critically into his motives. They did not ask—and possibly we
have not the right to speculate—whether he assailed society,
because he failed to shine in it, or whether he inveighed against
riches, because he lacked the patient industry to earn them for
himself. They did not know or care whether his quarrel with the
world, his indictment of its usages and laws, his eloquent defence of
human instinct, and his sensuous love for Nature, were or were not
dictated by the feverish longing which possessed the man to follow
every impulse of his mind, and to submit his impulses to no control.
They did not see that the example of a master, who, whatever
shameful faults he might commit, could still maintain that civilization,
and not he, deserved the blame, and could still gravely describe
himself to his friends as one of the best men that he had ever known,
was only too well calculated to enable his disciples to persuade
themselves that they were instruments of virtue, purity and justice,
while they were permitting iniquity and palliating crime. They knew
that his denunciation of oppression coincided with the bitter lessons
which their experience taught. They found that his eloquent words
renewed their self-respect, and raised their ideal of the dignity of
man. They felt that he pleaded the cause of the unfortunate in tones
and with a genius which made the fortunate attend, and that he
brought to that exalted service the widest compassion, the readiest
sympathy, and the most majestic language which the eighteenth
century had heard.
In 1762, Rousseau published one of the most famous, and, in its
consequences, probably one of the most important books ever
written. 'Man was born free,' ran the prologue to the Contrat Social,
—'man was born free, and is everywhere in chains.' In the Contrat
Social Rousseau rejected altogether the historic method—that wise
process of political philosophy, which patiently studies the
circumstances of the past, in order, by the experience so obtained, to
modify and to improve the present. Relying on the unsafe methods
of abstract, a priori speculation, he proceeded to develop, out of his
ardent and imaginative brain, an ideal theory of society, which should
establish by logical and conclusive argument the opinions which his
sentiments had already espoused. The result of the enterprise was
the celebrated doctrine of the Sovereignty of Peoples. The origin of
every human society, argued Rousseau, was this:—At some remote
epoch in the dawn of days, men, living in a state of nature, virtuous,
rational, equal and free, had resolved to enter into an association to
defend the persons and property of all, while every individual in it
remained free. Accordingly, they had formed a Social Compact,
under which each individual had submitted himself to the direction of
the general will, and had been received as an inseparable part of the
whole. The body formed by this Social Compact was the Sovereign.
All citizens who belonged to it—and all did—had an equal share in
the common sovereignty, and were bound to one another by a
fraternal tie. Its sovereignty consisted in the exercise of the general
will, and that sovereignty could not be alienated to any individual or
group, nor could it be divided up into different parts and distributed
among different officials. The will of the sovereign body was
expressed in laws, and every member of it must take his part
personally, and not by delegation, in the making of those laws. If he
delegated that right to representatives, he surrendered his share of
sovereign power. For the sake of convenience, the sovereign body
might delegate to governments certain executive powers for a limited
time; but the sovereign body still retained the right of resuming or
modifying those powers at will, and must from time to time assemble,
in order to enforce its right. When the whole sovereign people was
thus assembled, the power of governments ceased, and all
executive authority was suspended. If any government usurped the
sovereignty, the Social Compact was thereby broken; all citizens
resumed their liberty to act, and might rise in rebellion to assert it.
Lastly, in religion, the sovereign body was entitled to impose a civil
profession of faith, and to compel all its citizens, under penalties of
banishment and death, to believe in the existence of a beneficent
God, in an immortal life, in the reward of the just and the
chastisement of the wicked, in the obligation of the Social Contract
and of the laws.
It is easy in these days to criticise the Contrat Social. The mistaken
idea of compact as the basis of society; the rejection of
representative legislatures, and the insistence on a principle which
could only apply in a miniature State—the personal participation of
every citizen in the making of the laws; the sanction given to the right
of insurrection, when the imaginary compact was broken; the
absence of any method of ascertaining whether the compact were
broken or not;—these are flaws in its argument which will readily
occur. It is easy also to point to certain characteristics which disfigure
it throughout—to its disregard of facts, to its sophistry and
inconsistencies, to the narrow intolerance of its sentimental theology,
to its aloofness from the region of practice, to its reliance on dogma
and on the logic of words. But it is not so easy to appreciate the
extraordinary impression which in those days it produced, or the
enthusiasm aroused in all who looked for liberty, by the fearless
splendour of its phrases, by the fused argument and passion of its
style, by its generous democratic temper, by the spiritual
earnestness which inspired it, by its fine exaltation of patriotism and
freedom. The Contrat Social supplied the text and lit the fire of
revolution. It became the gospel of the Jacobin party, and of that
party Robespierre constituted himself high-priest.
The seed sown by these remarkable writers fell upon fruitful soil. The
years which immediately preceded the outbreak of the Revolution in
France were years of vague but widespread agitation. An
enthusiasm for the natural greatness of man, and a boundless
contempt for the age and society in which he lived, pervaded the
thought of the time. In almost every European country, observers
noticed the same presentiment of impending change, and of a
change which, on behalf of humanity, most people were prepared to
welcome. Thinkers and talkers alike were full of illusions, full of
curiosity, full of unselfishness, full of hope. Outside France, as within
it, everyone plunged into philosophical debate. In the trading cities of
Germany, merchants and manufacturers would gather, after the
day's work, to discuss the condition of the human race. Sovereigns
like Frederick, Catherine, and Joseph affected the secure radicalism
of despots. In Spain, in Portugal, in Tuscany, as well as in England
and France, statesmen echoed the new humanitarian maxims.
Aranda, Pombal and Manfredini exhibited the spirit, and emulated
the reforms, of Turgot and Necker, of Fox and Pitt. The outbreak of
the American Revolution roused the deepest interest in Europe.
Volunteers from France poured over to America, to fight for the
political ideals, about which they had for so long been dreaming, and
the realisation of which in the New World seemed to bring home
conviction to the Old. The tidings of the triumph of the American
colonists were received with acclamation in the roadsteads of
Elsinore. Strangely enough, the feverish unrest of the time produced,
in an age which professed to have undertaken a war against
superstition, a revival of the mysticism of an earlier day. On the eve
of the French Revolution, the best educated classes in Europe were
engrossed by secret societies and brotherhoods, like the Illuminati,
the Swedenborgians, the Mesmerists, the Rosicrucians, dabbling on
all sides in necromancy and occult science, and frequently the dupes
of ridiculous impostors, who, catching the temper of the times,
proposed to effect by charlatanism the regeneration of the world.
This vague perturbation of spirit did not, it is true, penetrate to the
lowest or unlettered class. But in all above that rank it was
conspicuous. The years of the reign of Louis XVI were in France, as
in nearly all parts of Europe, years of national expansion. The trade
of the country was advancing by leaps and bounds, and the
commerce of Bordeaux already exceeded, in the sober judgment of
Arthur Young, that of any English port save London. At the same
time the wealth of the middle classes was increasing with similar
rapidity. Year after year they lent more money to the Government;
and year after year, as they saw the Government wasting it with
reckless profusion, and falling steadily deeper into debt, they ranged
themselves more decidedly in the ranks of opposition, and became
more emphatic in their discontent. The gross mismanagement of the
finances became a matter in which they felt they had a right to
interfere. Their stake in the game of politics made them politicians,
and not only that—it made them reformers too. And thus the growing
wealth of the country tended indirectly to multiply the enemies of the
Court, and to throw on to the side of revolution that important
financial interest, which is generally a stable, sometimes an
obstructive, element in a State.
In other ways also, by the end of the century, in their style of living, in
their education, in their enlightenment, the middle classes had
become the equals of the nobles. They had imbibed the same
philosophy; they had cultivated the same tastes; they contemplated
with the same sublime ignorance of history and politics the
philanthropic ideas of the age; and they resented, even more bitterly
than before, the exclusive and exacting privileges of caste. At the
same time, the nobles, on their side, were losing, under the benign
influence of philosophy, a great deal of the apathetic insolence,
which had made their privileges hateful. The Court of Louis XVI was
very different from that of his predecessors. It was less pompous,
less artificial. The rules of etiquette were relaxed. A better tone
prevailed in its society. The haughtiest nobles opened their doors
freely to lowborn genius. They debated republican theories in their
drawing-rooms. They applauded republican sentiments in the
theatres. They began dimly to realise their public duties, and in a
tentative way to perform them. They awoke to the distress of the
poor about them, and endeavoured to alleviate it with a generous
hand. Some of the nobility proposed to surrender their immunity from
taxation. Others, headed by the King, emancipated the serfs who still
remained on their estates. The Marquis de Mirabeau established a
gratuitous office for the settlement of law-suits. The Duchesse de
Bourbon rose early in the morning, to visit with alms the garrets of
the poor. The Queen laid out a village at the Trianon, where, attired
in a muslin gown and a straw hat, she could fish in the lake and see
her cows milked. The King multiplied his private charities, and, one
severe winter, commanded that all the poor, who came, should be
fed daily in the royal kitchens. On all sides, among the upper classes
of society, the same symptoms showed themselves. Extravagant but
kindhearted sensibility became the mainspring of their actions;
reform was their passion, limitless, radiant hope their creed. 'With no
regret for the past,' says one of their number, looking back from the
sere contemplation of later years on that entrancing morning of his
life,—'with no regret for the past and no apprehensions for the future,
we danced gaily along a carpet of flowers stretched over an abyss.'
The same spirit animated the Government of the time. In spite of his
want of strength, his lamentable irresolution, and his well-intentioned
lethargy of mind, Louis XVI possessed not a few of the qualities in
which good kings excel—a high standard of morality and duty, a
large fund of quiet simplicity and courage, a readiness to listen to the
advice of wiser men, a marked sensitiveness to public opinion, and a
genuine desire to serve his people. Louis had not been long upon
the throne before he gave proof of his benevolent intentions by
appointing to the office of Comptroller-General the greatest practical
reformer of the day. Under Turgot the new spirit penetrated rapidly
into every department. The extravagances of the Court were cut
down. Useful changes were introduced into the system of farming
and collecting the taxes. The Corvées were converted into a regular
impost, from which the privileged classes were not exempt. The
guilds, which monopolised and fettered trade, were suppressed.
Fresh encouragement was offered to agriculture and commerce.
Free trade in corn was established within the kingdom. The minister
talked of commuting feudal dues, and dreamed of abolishing the
inequalities of taxation. A spirit of gentleness and consideration
came over the administration. The Government not only introduced
reforms; it condescended to recommend them to the public, to point
out their necessity, to explain their intention. 'The burden of this
charge,' said the Royal edict which abolished the Corvées, 'falls
solely upon those who possess nothing but the right to toil.' 'The right
to work,' ran the preamble to the edict which suppressed the guilds,
'is the most sacred of all possessions, and every institution which
infringes it, violates the natural rights of man.'
In the same way, Necker, when he succeeded Turgot, appealed for
support to public opinion. He recognised the 'invisible power which
commanded obedience even in the King's palace,' and endeavoured
to justify his policy by publishing an account of the state of the
finances. In the same way, though Turgot and Necker fell, and their
schemes perished with them, the reforming spirit continued to affect
the Government all through Louis' reign. Change after change,
experiment after experiment, attested the readiness of the Crown to
bend before the forces of the time. The measures taken, first of all to
suppress, and afterwards partly to restore the guilds, destroyed the
old relations between employers and workmen, while they did little to
establish a more complete or satisfactory system in their place. And
thus, when the Revolution came, there reigned generally among the
artisans of the great towns a sense of uncertainty and discontent,
which rendered discipline impossible and mischief easy.
Again, only a year before the Revolution, one royal decree
transformed the administration of justice in France; while a year
earlier, in 1787, another bold and memorable measure completed
the reform begun as an experiment some years before, and
established provincial assemblies in all the Pays d'Élection. The
importance of this step, which has been sometimes overlooked
among the graver changes of a later day, can hardly be
exaggerated; for it introduced, almost without warning, a new
principle into the government of the country. By the side of the
autocratic Intendants, new provincial assemblies were created,
which stripped the Intendants of most of their powers, or, if they
resisted, entered into active competition with them. By the side of the
autocratic Sub-Delegates, new district assemblies were formed, to
pursue a similar course of action in a smaller sphere. In place of the
ancient parochial assemblies, and in the midst of the inequalities and
privileges, of which French villages were the familiar scene, and
which in themselves remained unaltered, new, elective, municipal
bodies sprang up to assert democratic methods, among conditions
wholly irreconcilable with democratic ideas. When one considers the
scope of these important changes, their novelty, their
inconsistencies, and the suddenness with which they were made,
one realises something of the confusion and paralysis which they
must have produced in the public service, and one begins to
understand why the agents of the Government proved so powerless,
in spite of their prestige, when they had to face the crisis in 1789. On
the very eve of the Revolution, Louis and his advisers, forgetful of
the salutary maxim that the most dangerous moment for a bad
Government is the moment when it meddles with reform, had
deliberately destroyed the old, despotic, administrative system,
which, at the end of the eighteenth century, formed the only certain
mainstay of the throne.
It is not necessary to linger here over the episodes of Louis' reign.
Turgot and Necker fell in turn; but Necker carried with him from office
a reputation for sound finance, for disinterestedness, and for honest
liberality of opinion, which won for him a name out of all proportion to
his powers. He left behind him a problem of ever-increasing difficulty,
and a deficit alarmingly enlarged by the intervention of France in the
American war. For a time, after the overthrow of Necker, reactionary
influences had their way. The wastefulness of the Treasury
continued. The spectre of reform was for the moment laid. And at the
head of that splendid and light-hearted Court, which combined the
profuse traditions of the Grand Monarque with the gay philanthropy
that was the fashion of the day, and resented all economies as
mean, and radical innovations as thoroughly ill-bred, there stood,
conspicuous in brilliancy and beauty, the figure of the Queen. Wilful
and proud, unthinking and extravagant, intolerant of disagreeable
facts, because she was wholly ignorant of their truth, already widely
calumniated and misjudged, but destined to face far worse
calumnies, which partisanship, in the mask of history, has repeated
since, Marie Antoinette has never ceased to command the interest
and attention of posterity, as her tragic story, and the fall to which her
errors partly led, have never ceased to move its pity and respect. In
1783, Calonne took office as Comptroller-General, and for four
years, encouraged by the favour of the Queen and Court, and
helped by his own surprising agility and resource, Calonne
maintained his place. Money was found at ruinous expense to supply
the necessities of the Government and the rapacious claims of
courtiers. Every day bankruptcy came more distinctly into view. At
last Calonne, unable to carry on his system any longer, fell back
upon a desperate expedient. He summoned, in February, 1787, an
extraordinary assembly of Notables, consisting of nobles, bishops,
magistrates and officials, laid before them frankly the situation of
affairs, and gaily informed them that within the last ten years the
Government had borrowed no less than fifty millions sterling.
It is curious to notice the attitude of this assembly, and the way in
which its action was received by the country. As might be expected,
the Notables, consisting almost entirely of members of the privileged
orders, were not prepared to make large personal sacrifices to save
the state. When Calonne audaciously proposed to them the abolition
of privileges and exemptions, and asked them to submit to a heavy
tax, he fell, amid a storm of reproaches from the courtiers, who
regarded him as a deserter from their ranks. But instead of carrying
popular sympathy with him, Calonne found that his opponents,
although they were resisting reform, had usurped the popularity of
reformers. The Notables adroitly shifted the ground of attack to the
conduct of the Government. They demanded the public accounts.
They censured the acts of the Administration. And simply because
they assailed the Government, and ventured to criticise and oppose
the Crown, they suddenly found themselves, to their own surprise,
transformed into popular heroes, and their conduct and courage
applauded all over the kingdom. The same thing happened after
Calonne's fall. Loménie de Brienne, the Archbishop of Toulouse,
succeeded to Calonne's office, and found himself compelled to take
up many of Calonne's plans. Thereupon the Parlement of Paris
stepped to the front, and following the example of the Notables,
accepted some of the Minister's reforms, and particularly the edict
for the establishment of provincial assemblies, while they rejected
the new taxes, which were an inseparable part of the Government's
scheme. In vain the King threatened and punished the members of
the Parlement. The Parlement, borrowing the language of the times,
and forgetting that they themselves were only a privileged and
exclusive corporation, posed as the representatives of the nation,
and demanded that the States-General should be summoned to
express the national will.
The Government attempted to carry its schemes through with a high
hand. All over the kingdom, the local Parlements, the judicial
magistracy of France, took up the cause of the exiled Parlement of
Paris, echoed its tones, and even threatened dangerous rebellion. In
Dauphiné, in particular, the clergy, nobles, and commons of the
province, gathering at Vizille, and led by the courageous eloquence
of Mounier, protested against the policy of the Minister, and defied
the Crown. The nation, caring little for the rights or wrongs of the
quarrel, but delighted to see the all-powerful Government baffled and
assailed, welcomed the Parlements as national deliverers, and
proclaimed them the champions of popular freedom. For a moment
the strange spectacle offered of the privileged orders in France
defending their privileges, with the enthusiastic support of the nation,
against the Government, which wished to destroy them in the
interests of all. In face of this extraordinary union, the Government
recoiled. Alarmed by the increase of riots and disorder, by the high
price of food, by the disaffection in the army, by the Ministry's total
loss of credit, and by the prospect of bankruptcy in the immediate
future, the King decided to consult the nation. He announced that the
States-General, the ancient, representative Parliament of France,
would again, after the lapse of a century and three-quarters,
assemble to debate the destinies of the kingdom. Then the
popularity of the privileged bodies died as suddenly as it had begun.
In August, 1788, Necker was recalled to office, and a general
outburst of rejoicing celebrated the astonishing surrender of the
Crown.
A wise minister would have endeavoured by prompt and decisive
action to allay the vague excitement of the time. Every day the
feeling of restlessness was spreading in the country. Paris had
become a great debating club. The tension in the public mind was
already extreme. Instead, however, of hurrying on the elections,
instead of showing a resolution to face the crisis with enlightenment
and calmness, the Government hesitated, procrastinated, wavered,
and allowed all the world to see that it had formed no policy, and
hardly knew what its intentions were. The meeting of the States-
General was delayed until the following spring, and in the meantime
the Government stimulated the fever of opinion. All through the
winter of 1788-9, France was flooded with political addresses and
with democratic pamphlets—among which the audacious pamphlet
of the Abbé Sieyès excited general remark—calculated to raise as
high as possible the hopes and pride of the Tiers-État. To add to the
war of words, the Government invited all classes to draw up Cahiers
or petitions of grievances, to be laid before the States-General, when
they met, and thus, by its own action, it focussed the attention of its
subjects on the many abuses which had been borne silently so long.
Moreover, when the important question of the constitution of the new
States-General arose, the Government found it impossible to make
up its mind. In the electoral arrangements, as might be expected
from the innumerable local and personal rights still existing in the
country, there was very great complexity and confusion. But the
general principle, at any rate in the Pays d'Élection, was this. The
nobles and clergy of each Bailliage, as a rule, elected their
representatives directly, though the rule was subject to a good many
exceptions. In the election of the commons, on the other hand, the
voting was in no case direct, but had two, or even three or four
degrees. All Frenchmen over twenty-five, who had paid even the
smallest amount of direct taxes, had votes. They might vote for any
representatives they pleased, for there was no property qualification
for candidates. But they could not vote for them directly. The
electoral assembly of each Bailliage thus consisted of the nobles and
clergy of the Bailliage, and of a number of representatives of the
commons, who had been previously elected by primary assemblies
of voters in the different towns and villages of the Bailliage. When
the electoral assembly of the Bailliage had been formed, the nobles,
the clergy, and the electors of the Tiers-État, who composed it,
separated into three distinct bodies[5], and each order chose a
certain number of deputies to represent it in the States-General at
Versailles. The number of deputies allowed to each Bailliage varied
according to circumstances, but was mainly determined by its
population and wealth.
It was arranged without opposition that the nobles and the clergy in
the States-General should have, according to usage, three hundred
representatives each; but then the difficult question arose, how many
deputies were the Tiers-État to elect. The advocates of democracy
urged, amid enthusiastic applause from the public, that the commons
infinitely out-numbered the other two orders, and ought therefore to
have at least double the number of representatives. On this point
Louis and Necker alike wavered undecided, besieged by the
importunities of the democratic feeling which they had let loose in
France. In vain Necker, in November, 1788, gathered another
assembly of Notables, and tried to shift his responsibility on to them.
The Government at last made up its mind to concession, and
announced that the commons were to have 'the double
representation'—six hundred representatives in the new Parliament.
But the genius of irresolution still dogged its steps. It could not even
then bring itself to decide whether the three orders should sit and
vote in separate Houses, or whether they should all sit in one
Chamber and vote together. The timidest intelligence must have
perceived that, unless the three orders were to vote in one body, the
numerical superiority which the commons had obtained would be
without significance, and the Government's concession to popular
feeling would be merely a delusion. And yet to the last this important
question was left undecided by the Crown, as a fruitful source of
quarrel out of which the troubles of the Revolution might begin. So,
with a Government perplexed by fears, with a local administration
paralysed by a variety of recent changes, with signs of disorder
multiplying upon every side, with innumerable difficulties requiring
settlement, and with the fixed spirit of old traditions vainly attempting
to assimilate the new, the monarchy prepared to meet the
representatives of the nation, who, already flushed with triumph, and
intoxicated with self-confidence and hope, advanced to realise their
long-delayed millennium, and with the aid of freedom and philosophy
to readjust the destinies of France.

FOOTNOTES:
[5] In three cases only, in Langres, Péronne, and Montfort
l'Amaury, the three orders sat and voted together in the electoral
assembly.

CHAPTER III.
The Early Days of the Revolution.
On the 5th May, 1789, the States-General were opened by Louis at
Versailles. From the first the Government betrayed its helplessness,
and its total inability to appreciate the situation. The Commons'
deputies had come to Versailles for the most part with the largest
expectations. They were fully alive to existing evils. They were full of
schemes and ideals of reform. They foresaw, and were willing to
foresee, no obstacles. They were prepared to transform the country;
and they confidently expected, under the guidance of a benevolent
King and of a liberal and experienced Minister, to begin without delay
the work of national regeneration. But from the outset they
encountered a series of checks and disillusionments, which
increased in gravity as time went on. They found that the
Government, instead of taking the lead with vigour, met them with no
definite proposals for reform, and with little but vague philanthropic
intentions over and above its desire to restore the finances. They
found that the King and his advisers had not even made up their
minds as to the constitution of the new Parliament, and could not
bring themselves to decide whether the three orders were to sit and
vote together or apart. They found themselves in an atmosphere
new to most of them, set to do work new to all, conscious in their
own minds that a new era had begun and that they must assert
themselves to mark it, but yet accustomed from immemorial habit to
regard the nobles as their superiors, the King as their master, and
the Government as irresistibly strong.
Accordingly, at first, the attitude of the Commons was one of great
embarrassment. They had as yet no recognised leaders of their own,
and the Ministers, to whom they looked for leadership, were silent
and appeared to be as much perplexed as themselves. On one point
only they were clearly resolved and determined to yield to no
pressure. They insisted that the deputies of the nobles and clergy
should join them, and should form one chamber with themselves. On
their side, the nobles and clergy refused to listen to this innovation.
The Commons steadily rejected a compromise, and on that point the
deadlock arose. Instead of the States-General setting to work to
repair the finances and to carry reforms, six weeks went by,
occupied only with this preliminary quarrel, while all the time the
excitement in Paris and in the country deepened, the conflict of class
interests became more apparent and acute, and the reactionary
courtiers rejoiced at the fiasco and used their influence to widen the
breach. The Commons, growing more confident as they felt their
strength, and as they realised the power of the forces behind them,
held their ground, disregarded the pressure and the innumerable,
little, social slights, to which they were daily exposed at Versailles,
and became more and more pronounced in their policy of self-
assertion; and the Government revealed more strikingly than ever,
alike to the States-General and to the public, its entire lack of
purpose and resolve.
At last, after six weeks of waiting, the Commons took matters into
their own hands, and from that moment events moved fast. On the
17th June, the deputies of the Tiers-État resolved on a momentous
step, and on the motion of Sieyès, constituted themselves alone the
National Assembly of France. The Government, alarmed at this
usurpation of power, determined to reassert its authority and, while
offering a large programme of reform, to insist on the separation of
the three orders. On the 20th, the Commons found themselves
excluded from their hall, and their sittings consequently interrupted;
but they persevered in the policy which they had adopted, and
adjourning simultaneously to the Tennis Court, swore solemnly never
to separate till they had given a constitution to France. On the 23rd,
the King came down in state to the Assembly Hall, and while offering
large concessions, annulled the resolutions of the Commons. But the
Commons, inspired by the courageous words of Mirabeau, rejected
the programme which Louis had laid before them, adhered to their
resolutions, and defied the Crown. Within a few days, the nobles and
the clergy were requested by Louis to abandon the struggle, and the
union of the three orders was complete.
But the Court party bitterly resented the usurpation of the Commons.
The disorder in Paris was increasing fast. Necker held ostentatiously
aloof from his colleagues. The King, distressed and embarrassed,
suffered himself to be persuaded by the haughtier spirits at Court,
helped by the direct influence of the Queen, to make an attempt to
recover the authority which he had allowed to slip from his grasp.
The old Maréchal de Broglie, a veteran of the Seven Years' War, was
summoned to the royal counsels. Great masses of troops, composed
chiefly of Swiss and German regiments in the service of France,
were concentrated, in spite of the protests of the Assembly, around
Paris and Versailles. On the 11th July, Necker and three other
Ministers were dismissed, and their places in the Government filled
by decided adherents of the reactionary party. On the 12th, the news
reached Paris, and the people, scared, famished and indignant,
burst into revolt. On the 14th, that revolt culminated in the decisive
movement which destroyed the Bastille, which shattered the plans of
the Court party, and which completed the triumph of the Revolution
and the humiliation of the Crown.
'With the 14th July,' said a wise and enlightened witness of the time,
'the terror began.' The rising in Paris was the signal for the first
general outbreak of violent disorder in France, which proved that the
distressed classes had taken the law into their own hands, and that
the Government was utterly unable to cope with or control them. The
strongest motive for disorder was unquestionably material want. For
many years past, the condition of the poorer peasants and labourers,
both in the towns and in the country side, had been almost
intolerable, and in 1789, the chronic distress of this large class
reached an acute stage. In 1788, a severe drought had been
followed, on the eve of the harvest, by a hail-storm of extraordinary
violence and extent, which had destroyed the crops for sixty leagues
round Paris. That, in turn, had been followed by the severest winter
known for eighty years, which had completed the ruin which the
drought and the storm had begun. The consequence was that, in the
spring and summer of 1789, the price of bread rose as in a siege,
and on all sides the cry of famine spread. From all parts of France, in
the spring of 1789, came the same alarming rumours of scarcity and
distress. From all parts of France, in the months preceding the
capture of the Bastille, came the same reports of disturbances and
riots occasioned by the want of food. Discontented peasants,
unemployed labourers, rapidly reduced to criminals by hunger,
passed from patient misery to despair, and broke out into resistance.
Compromised or defeated in the country, they took refuge in the
towns; and thus, in April and May, observers noticed that 'frightful
numbers of ill-clad men of sinister appearance,' many of them
foreigners, all more or less destitute and dangerous, were pouring
into Paris, where already bread was exorbitantly dear, and where
already the number of unemployed and paupers bore a dangerous
proportion to the population of the city.
The trouble caused by the scarcity of food was stimulated by another
motive second to it only in importance—the feverish excitement of
political hope. Depressed and ignorant as they were, the labouring
class in France had, nevertheless, grasped the idea that in some
vague way the meeting of the States-General marked an era in their
lives, and was somehow or other destined to ease the intolerable
burden of their lot. With them political freedom and constitutional
reform took the immediate shape of food, work, and relief from
feudalism and taxation. Once the idea had been implanted in them,
their restless anticipations rapidly increased. Every week of delay
rendered them less manageable. Every check experienced by the
Assembly was a spur to their impatience. Every step taken by the
Government to assert its authority or to overawe the reformers filled
them with indignation, suspicion and panic. In the poorer districts of
Paris, and especially in the gardens of the Palais Royal—the
headquarters of Bohemians, idlers, mischief-makers, crowds—the
political excitement of the time found expression in perpetual
demonstrations, not unmixed with rioting and outbreaks. The regular
authorities of the city, unused to the spectacle, looked on, unable to
control it. The police force of Paris under the Ancien Régime was so
small as to be practically useless. The garrison, formed of the
Gardes Françaises, who were responsible for the maintenance of
order, sympathised with the citizens, who spared no hospitality or
flatteries to gain them, and finally, mutinying against their officers,
went over to the popular side. The other regiments in the
neighbourhood showed a marked inclination to follow the example of
the Gardes Françaises. The Government, deserted by its own
agents, drew back; and the spirit of disorder, produced by the desire
for food and the desire for freedom, obtained the mastery of Paris,
and took command of the Revolution too.
The example set by Paris was immediately followed in the provinces.
At Strasbourg, Lyons, Dijon, Troyes, Besançon, Rouen, Caen, all
over the country, spontaneous risings occurred, directed against the
authorities or practices of the Ancien Régime, and often
accompanied by violence and bloodshed. The people, stimulated by
the pressure of famine and by the feverish excitement of the time,
and believing that the hour of their deliverance had come,
determined to deliver themselves. In different places the outbreak
took a hundred different forms. In garrison cities the people, imitating
the Parisians, attacked the nearest fortress or castle, and, as in
Paris, the troops generally fraternised with the assailants. In some
quarters popular indignation was directed against the tax-offices and
custom-houses, in some against the local magistrates, in some
against the tithes, in some against the newly-introduced machinery,
in some against the Jews, in most against corn-dealers and all
concerned in trafficking in grain. In the towns the distressed
workmen rose against the bourgeois, and against the unjust
economic system, which had long rendered their condition
unbearable. In the country districts the peasants rose against the
iniquities of feudalism, and burned the monasteries and châteaux,
where the court-rolls, the records of their hated liabilities, were kept.
No doubt, with the desire to redress abuses there mingled, in the
minds of an ignorant and embittered peasantry, a great deal of
ferocity and crime. In many places indiscriminate war was declared
against all kinds of property, and the outbreak took the form of a
struggle between rich and poor. But the most notable features of the
revolutionary movement were, first, its universality, and secondly, the
powerlessness of the authorities to confront or to suppress it.
Everywhere the agents of the administration collapsed. The
Intendants, the law-courts, the police, completely paralysed,
abdicated or disappeared, and the inhabitants of town and country
alike, recognising the helplessness of the Government, gave way to
an inevitable panic.
The consequence was that the months of July and August were
signalised by a sense of insecurity amounting to terror. The wildest
rumours pervaded the country, and the most extraordinary instances
are found of places where the people, panic-stricken by some vague,
unfounded report of the approach of brigands, who had no existence
out of their imagination, rushed to arms or fled into concealment to
protect themselves against their own alarm. One result of the 'great
fear' was that volunteer forces of citizens, interested in restoring
order, sprang up on all sides, in imitation of the National Guard just
organised in Paris, to which they were destined before long to be
assimilated; and these volunteer forces, though sometimes used by
the bourgeois to repress the movements and to maintain the
subjection of the labouring class, were still invaluable in restoring
peace. Moreover, in place of the authorities of the Ancien Régime,
there sprang up, to exercise the duties of administration, informal
municipal committees composed of electors, which, usurping the
powers abdicated by the Government, rapidly organised themselves,
secured the obedience of their fellow-citizens, and set to work, as
best they could, to reconstruct the administration of the country. The
rapidity and skill with which these municipal committees and their
volunteer forces organised themselves, clearly illustrate the
readiness of the provinces to act on their own initiative and to take
over the responsibilities of the Revolution, and show how completely
the people of France at first kept pace with, if they did not outstrip,
their leaders in Paris and Versailles.
The most obvious and the wisest course for the National Assembly
to adopt, would have been to legalise as rapidly as possible the
changes so suddenly effected, and to set to work without delay to
organise the new administrative system. After the 14th July, the King
had completely surrendered, and the Assembly had only to act in
order to be obeyed. The task before it was, it is true, difficult and
almost endless. It was imperatively necessary to restore order. But it
was also imperatively necessary—and this the Assembly did not see
—to construct, as quickly as it could be done, some form of local
government, to replace the old order which had disappeared. It was
imperative to provide by some means for the necessities of the
revenue, until a permanent financial system could be organised, in
place of the old taxes which people would no longer pay. It was
imperative to take steps to convince, not only the bourgeois and the
peasants, but the distressed artisans in the towns as well, that the
Assembly was alive to the urgent necessities of the moment, had a
real grasp of the situation of affairs, and would do all that could be
done to protect their interests, and to save them from the starvation
which they imminently feared. These were the measures which
Mirabeau urged upon his colleagues, but unfortunately, there were
few men in the Assembly who possessed the gift of practical
statesmanship, which genius, lit by experience, had conferred on
Mirabeau.
The character of that famous Assembly, read in its own day by the
critical but far-seeing eyes of Burke, has excited the wonder of
posterity. Its most notable feature was its want of practical
experience. Among the upper clergy and the nobles, there were, it is
true, certain deputies, who from their position had obtained some
knowledge of affairs, but these men were liable to be distrusted by
their colleagues, because the moderation which their experience
taught them, obviously coincided with their interests. Among the
Commons there were not a dozen men who had held important
administrative posts. There was only one deputy, Malouet, who had
held the great office of Intendant, and was in consequence really
familiar with the working of the old administrative system. The great
majority of the deputies of the Commons consisted of lawyers of little
celebrity, who brought to the Assembly all the facility of expression,
but little of the utilitarian caution, which in England is associated with
their profession. The place of experience, in the case of most
members of the Assembly, was taken by a large imagination, a
boundless optimism, a vast store of philosophic tags and democratic
phrases, a fatal fluency of speech, a fine belief in logic, an academic
disregard of the rude facts of practical existence. Never was any
body of men so much inspired by hope and confidence, so full of
honourable enthusiasm, so convinced of its own ability, or so fixed in
its honest desire, to regenerate the world.
Accordingly, the early history of the Assembly is marked by a series
of strange scenes, only possible in a nation with whom extreme
versatility of temperament takes the place of humour, illustrating the
susceptibility, the emotion, the feverish excitement, the liability of the
whole body to act on the impulse of the moment, regardless of what
the consequences might be. A happy phrase, a witty saying, a burst
of declamation, would carry it off its feet, and settle the fate of a
division. The prodigious quantity of written rhetoric declaimed from
the tribune wasted a prodigious quantity of time, but there was
always an audience ready to applaud it. The debates were
conducted with very little order. The entire absence of method in the
Chamber often frustrated the business-like work done by its
committees. In vain Mirabeau urged his colleagues to adopt the
procedure of the English House of Commons. The French people,
newly emancipated, disdained the example of any other nation. In
the great halls at Paris and Versailles, where the Assembly
successively sat, the process of legislation continued to be attended
by a constant clatter of talk and movement, interrupted by noisy
shouts and gestures, by obstruction and personal abuse, and
aggravated by the presence in the galleries of large numbers of
strangers, whom at first the Assembly welcomed, and whose
turbulence it afterwards vainly attempted to control. The noisy