Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
- Trealment The severity of an injury depends on the amount and distribution of the energy absorbed by the body. A major injury to the respiratory system, to the cardiovascular system, to the brain (which controls both), or to the upper spinal cord (which controls respiration) results in early death. A patient with a less severe injury enters the medical care system, but a cascade of events has been set in motion by the primary damage; unless this can be interrupted, death or disability can ensue. If the patient survives, the intensity of this cascade and the skill with which it is managed will play a major role in determining the degree of functional recovery. Problems lie in resuscitation and transportation of the injured patient, In immediate care in an emergency department, and in the speed with which diagnosis and surgical care become available. Control of continuing hemorrhage from any site, establishment of an adequate airway, and removal of blood clots from the brain are the immediate surgical tasks, and they require a wide range of advanced surgical expertise. PRE8OSPITAL CARE Prehospital care of the injured has been improved over the last few years. Rapid evacuation of the injured was stressed during our recent military conflicts. The use of helicopters in Vietnam saved many lives by getting severely injured patients to definitive care in a minimum of time.' In civilian life, the system is varied and unstructured, but good ambulance standards have beep set in some areas, and helicopter services are available in 65
66 others. 3 6 The civilian use of local military heli copters has also improved the transport system. The development of the teas ic emergency medical tech- n ician and paramedic systems has provided professional care at the scene. Well-trained paramedics are able to attend to airways, treat shock with the administration of fluids, and monitor a patient's condition.8 7 In addi- tion, they can notify a receiving institution with an estimate of that condition and an estimated time of arrival. A need for intensive study of what should be done at the scene of an injury event under different geographic circumstances remains. For example, patients in some urban areas might benefit from a system of Scoop and run,. in which the emphasis is on speedy transport to a nearby injury center. In such a case, the need is for an effective transportation system. In other urban areas, a lack of municipal organization still constitutes a major problem, and patients might be taken to inadequately staffed and poorly equipped facilities. If an injury occurs in a rural area miles from a major center, it might be better for treatment to begin at the scene. If so, major questions must be answered. For example, should paramedics be trained to intubate a patient, start intravenous f luids, and give medications? What is the best method of getting a patient to a major center--by air or ground transports' Between the extremes of urban and rural, consideration should be given to a system of movement to the nearest hospital, where resuscitation can be initiated, the severity of the injury assessed, and arrangements made for transfer to center. We need to knaw whether and under what circus stances patient care is improved by providing emergency surgery at ~ local hospital and then transferring a patient to a center immediately for continuing support. Each of these possible approaches to treatment has advocates, but little information is available to suppor t any one approach over another. Assessment based on an injury severity score needs to be implemented at all levels of care, including prehos- pital care. This allows a receiving unit to have some idea of what is coming and to be prepared. It is of particular value in a small hospital, where a physician is not even called until a patient arrives; that can impose a delay before definitive medical attention is available. The use of a graded system of evaluation is essential for measuring results. One example is the
67 Glasgow Coma Scale for head injury, which is now inter- nationally accepted. ~ ~ ~ 9 A reasonable immediate goal might be to document more fully the extent of national failure in transportation, in emergency room equipping and staffing, in provision of diagnostic equipment (e.g., a computed tomographic scanner is essential in head injury, and an ultrasonic scanner and a computed tomographic scanner are necessary in torso injury), and in immediate availability of diversified surgical help. ~ The presence of differences in geo- graphic distance, in type of in jury (e.g., automobile, gunshot, or fire), in site of in jury (e.g., head or chest), and in age and general health of the injured all Comparisons - call for an extensive and versatile survey. with the few centers where optimal treatment appears to be available and with foreign centers where alternative models are available (e.g., the West Germany helicopter service and the southern Sweden community hospital system) are essential. For our several population patterns, we might require some combination of the above. Continued review and updating of systems will be needed as we strive toward the optimal system for delivery of care. At the moment, neither the small community hospital nor the hospital devoted exclusively to injury (as in Birmingham, England) appears to be the perfect means for providing adequate care in all instances. 2 ~ S One thing is known: optimal care is not universally available, and this lack results in otherwise avoidable mortality and morbidity. HOSPITAL CARE Shock One major result of injury is bleeding, either internally or externally. There can also be major shifts Of fluid in the body, which has three fluid compartments-- intravascular, interstitial, and intracellular . The resulting reduction in vascular blood volume (shock) leads to a reduction in cardiac output (blood pumped by the heart) and affects most organs and their cells. Another effect of the decrease in circulating blood is a reduction in blood pressure. Thus, the entire system is · ~ ~ ~ ~ 76 compromised by this phenomenon.7 As blood pressure decreases, baroreceptors (pressure- sensitive areas) in the heart and great blood vessels
68 detect the loss of blood volume and-in turn stimulate various neuroendocrine responses. Neuroendocrine receptors (see below) in turn trigger many responses that are believed to compensate for, or protect against, the decrease in blood pressure. 6 2 A reduction in circulating blood volume can be assessed by measuring various functions, such as blood pressure, central venous pressure, and urinary output. The problem can be corrected in a crude way by adding to blood volume with whole blood, blood substitutes, and electrolyte solutions intravenously.2 B ~ ~ 9 ~ 74 But there is a need for a better understanding of the response and the factors that serve as mediators of the response (such as kinins, prostaglandins, and myocardial depres- sant factor). What stimulates these mediators? Should we interfere with them? Are they all protective, or might they at times be destructive7 Further information on the internal shifts of fluid is also needed. Until these are fully elucidated, optimal treatment will not be possible. Neuroendocr ine Response The brain and its closely associated neuroendocrine system are the controllers of heart and lung function, of water and electrolyte dynamics, of temperature regula- tion, of hormone regulation, and of the compensatory and reparative responses of the body to stress. Injury tuba coos not involve the brain directly can nevertheless lead to myriad changes in function of the neuroendocr ine system. The precise mechanisms by which changed hormonal function leads to changed metabolism have not been defined. Some metabolic changes lead to increased availability of glucose to the wound and to some critical tissues, such as the heart and brain, and also support the restitution of lost blood volume. How- ever, as injury becomes more severe, the compensatory mechanisms tend to fail. The mechanisms underlying such failure await def inition. Some hormonal and metabolic responses to injury can be detrimental--e.g., loss of protein, retention of salt and water, and the loss of immune competence, which predis- poses an injury victim to infection. Consequently, the elucidation of the mechanisms of these responses is important in providing opportunities to limit or prevent them. Studies are needed to determine the degree to
69 which therapy, such as the administration of fluids, improves a patient's response. The best therapeutic approach might bypass the neuroendocrine response and consist of substitution therapy. When the brain is injured, it loses the ability to control its own metabolism and the metabolism of the body as a whole. This loss of control leads eventually to a total collapse of the respiratory and cardiovascular systems. Infection It was recognized years ago that most exposures of most people to bacteria did not result in infection, because of natural resistance. Eventually, this resistance was demonstrated to be due to the immune system of the body, but how this works and how to alter it (if we should) are still under investigation. 3 In more recent years, it has been found that viral and fungal agents play a role in in jury . Control and treatment of fungal disease have been learned to some extent, but there is almost no information on the effects of viral agents in injury. Sepsis is a major cause of death among injury patients who survive beyond the first 6 or 12 hours after injury. There is no way to predict which patients will become septic. A morphologic change in the white blood cells (part of the immune system) can often be identified within 60 minutes; after injury, but whether and how it should be altered are not known. An extensive inves- tigation of what this response means and whether it is helpful or harmful is needed. CHARACTERISTICS OF INJURIES THAT REQUIRE TREATMENT Options for treatment are vast, because treatment can involve every organ and its cellular components and every type of injury. It seems prudent to classify injury into several broad categories and discuss specific examples of them, rather than dealing with each specific organ system. Three broad categories can be considered: injuries in which cellular changes alter function; injuries in which deformation of a physical structure produces major prob- lemfi; and injuries that lead to loss of an organ.
70 Cellular Changes That Alter Function Bruised, burned, or otherwise damaged tissue undergoes a local reaction of which swelling, or the accumulation of fluid, is a prominent part. In some regions of the body, such as; the ankle, this reaction can be incidental . In others, such as the intestine, it can seriously compli- cate fluid and nutritional regulation. In the inexpansile skull, brain swelling results in high intracranial pres- sure and brain displacement within the skull, in failure of blood to reach the brain, and finally in loss of ability of the brain to regulate body function. Brain swelling is commonly the major factor that determines survival, death, or disability and the degree of dis- ability--physical, intellectual, behavioral, and epileptic . We do not know what happens in the brain cells and in their immediate surroundings to interrupt their function and cause them to swell. This problem will be the central theme of basic research in head injury during the next few decades. Lack of cerebral oxygen (anoxia ) or lack of available glucose impairs cellular metabolism and function. Potas- sium, sodium, calcium, and water concentrations change, and a disadvantageous acidity develop';. Calcium-activated proteases affect the basic structure of the brain. Blood vessels become distended, and intracranial blood volume increases. As vascular function fails, the bare ier between blood and brain becomes impaired, and fluid leaks from the bloodstream into the brain tissue. Brain cells, with impaired energy, suffer further as fluid separates them from their blood supply. Brain cell failure results in disturbance of the brain 's regulating hormones and cbemicale. Lack of blood to the cells results in libera . . . tion of free fatty acids that are toxic. A small amount of work at this cellular laurel is being undertaken in this country and abroad by basic biochemists, membrane physiologists, cell biologists, pathologists, and surgeons. This work needs to be greatly expanded and intensified, because it is from such labors that future progress will emerge. Physical Alterations That Produce Major Problems Injury to a Major blood vessel or nerve or fracture of a major bone are examples of physical alterations that
71 produce major problems. When a blood vessel is divided or becomes obstructed as a result of an injury, movement of nutrients to tissues beyond the point of injury ceases, and organ and cellular dysfunction--including cellular deatb--occurs. For each tissue of the body , there is a small period during which circulation can be diminished or absent without preventing partial or complete recovery. For example, injury to a major vessel to the brain can produce a stroke within a matter of minutes; an extremity can withstand up to about 8 or 12 hours of diminished circulation and yet recover completely when circulation is restored. Most other organs and tissues are between those extremes. Most tissues can recover if repair is accomplished and the blood supply is restored. There will be a scar at the site of repair, but normal or almost normal function will still be possible. Nervous tissue presents a special case. Even if damaged brain heals, function might not return. Damage to the brain can result in epilepsy, owing to the scar in the healing process. The spinal cord does not heal to the extent that func- tion returns if it has been cut or severely contused. Hemorrhage or inappropriate movement of the body (the so-called second injury) can destroy function that had been spared by the initial injury; bedsores, lung and urinary infections, and skeletal contractures are all too frequently the affliction of the inadequately treated paraplegic. Peripheral nerves might regenerate if they are care- fully repaired, but the process is extremely slow, often requiring 1-2 years for regrowth. In the meantime, tis- sues distal to the point of injury are paralyzed and undergo severe atrophy. Frequent physical therapy might prevent some of the atrophy and has led to major improve- ment in patients with injured nerves. The whole class of skeletal injury comes under the . . . . heading of physical alterations that cause major prob- lems--from milder injuries that cause a greenstick angulation or accentuate intervertebral disk degenera- tion, through hip fractures and band injuries, to major injuries that dislocate the spine or sever a limb. The optimal management of all these involves research into microsurgical methods of repair, the use of synthetic prosthetic materials, and the introduction of melody that not only restore function early, but prevent late degenerative changes.
72 Loss of an Organ Obviously, some organs can be lost without killing a per son, including limbs, spleen, a k idney, over ies, and testes . But the loss of others cannot be survived, such as the brain, heart, and liver . Sometimes, an organ is damaged severely enough to suggest that its function will be temporarily lost, but physical repair is possible. Examples are a smashed liver, kidney, pancreas, and lung. In such a case, we need to tide the patient over for a few days or a few weeks, until repair has occurred; e.g., if a damaged kidney Is in failure, dialysis allows survival of the patient until renal function is restored. CONCLUSIONS Injury can be superficial or deep, and it can affect one organ or area of the body or several organs or areas Acute treatment of the injured demands a special approach. It requires a team effort, often involving several specialists who lend their expertise in particular organ systems. In jury is a time-demanding phenomenon whose peak incidence is late in the day and on weekends, when hospital staffing is minimal. There is a need for designated centers for the manage- ment of the severely injured. Many hospitals and many physicians cannot manage the complexities of the severely injured, nor should they be able to. As important as knowledge are the backup facilities, including well- stocked blood banks, computed tomographic scanners, and capacity for cardiopulmonary bypass and renal dialysis. We have come a long way in the last 40 years in the management of injury, but muab remains to be learned.47 Table 5-1, at the end of this chapter, summarizes what we know in a broad, general way and what we need to learn. Not every known or needed item is listed; the intent is to present rather broad categories, to demonstrate the desperate need for research in a variety of problems that affect the care of injury victims. We have tried in this brief chapter to show where we are and to suggest some of the things that need to be done. Only through continued research will these prob- lems be solved. We must recognize that injury is an epidemic. The same effort and funding for research should be applied to it that we would apply to any other
73 health problem that is attended by similar morbidity and mar tal ity . RECOMMErNDATIONS 1. Long-term collaborative studies should be insti- tuted by epidemiologists, statisticians, biomedical engineers, trauma physicians, rehabilitation physi- cians, behavioral scientists, and health economists, to identify and evaluate factors that produce optimal results, to identify factors that result in less than optimal results, and to institute programs for promulgating optimal management techniques. 2. Programs in basic research should be instituted and supported, in collaboration with morphologists, biochemists, membrane physiologists, pharmacologists, neurobiologists, bacteriologists, virologists, and others, to study shock, infection, tissue responses and healing, and brain and spinal cord swelling. 3. Biomedical and biomechanical programs should be instituted and supported in relation to injury mechanism and prevention and the development and evaluation of biomedical materials, including prostheses and artif icial organs. 4. Clinical studies should be instituted and supported in development and evaluation of pharmacologic options, surgical techniques, and management options. 5." Programs designed to train professionals in the research and care of injury should be instituted and supported .
74 h :' h - . ~ 8 - v o 0 At I: TIC C o o o ~t, _~ 0 aS~ ~A: o oV ~ ~ o U) 0 1 Us TIC of= o EN CQ ~ , _ _ O a, _ ~ o 0 om a_ I: a: h ~ ~ O O - 1 ,C TIC c' ~ al I: A_ 0 `: ~ O O 0 0= A: ~ ~ t) A: _ O ~ O~ - 0 0 , in `: h ~ · o~ a MY3 O a S.C ~ 0 :~ - 0 . C `: O C O_ V ~ ' 0 0 ~ 0m c: ~ aQ (L _ 0 ~ 0 ~ ~ V I: ~ CI- 0 ~ V ".O ~ 60 ~ 0 eo 0 0 - C ~ `: 0 ~ S m~ ov . 0 ~ 0 ~ ~ ~ ~ :' .c 0 0 0 U ~ ~ P4_ _ 0 0 tU 0 0 0 ~ O ~ ~-Q 0 ~ ° ~ . ~ ~ ta _1 3 ~ ~1 ~J ~ O ~ ~ 0 O ~: 3 0 `: ~: C S 0 ~JJ O ~ E - ~ ' O 0 - ~ 0 ~E 0 ~ e4 0 ~ ~ ~ ~ O O :' O ~: _ eC ~ ^ ~ ~ e~ V ~ V ~- ~ - V 0 0 C ~ 0 ~ - CR~ ~= ~ ~ ~ V _ 0- V 0 0 18 Q ~ 3 ~ ~ 81 "C ~ ~ S O c) ~ ~- ~ ~ d-~ ~ · c ~I ~ v ~ D 0 0 ~ ~ ~ ~ ~ 0 0 ~ - 0 ~o ~ O O ~ ~ E 0 a ~ ~ · ~ c: ~ ~ ~ C ~c .) 3 ~ ~ 64 IU 0 ~ ~ O ~O ~ 0 ~ O OD O-I ~ · ~ ~J ~ 3 0 ~5: ,1 ~'6 ~ ~ ~ 3 0 :- ~ ~ ~ 0 0 ~ 3 ~ ~ ~ C ~ ~_~ C ~ C O O ~- 0 0 ~ - 0 ~ · 0 8) ~ - C ~ O ~ ~ h -~ ~ :, ~ ~ 0 ~ ~ 0 C ' aQ ~ ~ 0 ~ 0 O ~ ~ 04 ~ a~ "~~ ~ ~ ~ :^ _I _~ ~: ~ ~ ~ 3 0 0 ' O ~ 0_ 0 ~ 0 O ~-~ ~ 0 3 ~ v - 1 0 ~ 0S ~ ~ - _~ _ ~ 0 ~ ~ O ~ ' g~ ~0e D 0 ~ _ 0 0 _1 ' :> O _ 0 ~ 0 ~ ~ to ~ C O C ~ ~ O C ~ 0 0 ~ O O- ~O ~ `5. 0 0 ~ t) 0 ~ 3 0 a ~ v D 0 m~: m 0 e ~ ~ E! ~ ~ 0 ~ ~ 0 ~ ~ ~ C ,~ ,~ _ D ~ ~ ~ O O ~ ~, ~ ~, _ 3 x: O Ll ~ ~ ~ 3 S c: ~ g Q 0 · OS Ll 0 `: ~ ~ _ 0 - C ~ _ ~ 0 0 m m~ c 0 0 m =-Q a _ C) 0 C 0 3 _ _ _ ~Q O m :, - O~ ~ ~ ~c o ~: ~a C ~ cs 0 , ~ ~ m o~ ~ _ _ _' ~ ~ C 0 0 0 V 0 _ ~ ~ =,,~ 0 0 t) v a, ~ ~ 0 O ~ C: 0 0 0 D D O ~ O 3 _ 0 _ - O O ~ O 3 :~ oo 0 0 ~ :~: 3 ~u ~O _ ~ ~ 0 0 0 ~ 0 ~ a, O `: 0 S 0 U),Q 0 0 0 O O ^ 0 S: O `: ~ _ ~ ~ 0 ~ 0 0 .: :> 0 e ~o ~ - ~ o ~ J 0 - ~ 0 ~ - - ~ 0 ~ c, ~ ~ ~ v e 0 =~ 0 C, 0 ~ ~ 0 0 0 C 0 ~ 10 - 53 _ ?. O 0 0 ~ ~ 0~ ~ ~s~ O ~ ~= al O ~ - - _ ~ ~ ~ 0 - C O 0 0 ~ a 0 0 ~ V t: ~ ~C m0 0 O c: 0 ~ - ~ _ ~ _ ~ ~ 0 _' _ a~ ee ~:0 ~ ~ ~ ~ O O ~ |: 0 ~ O ~ `: C ~ 0 O ~ E~4 m_~= C _ ~ ~ ~ ~ ~ O 0- V ~ oo ~ ~ 0 _ ~ C C O O Pd ~ ~ ~ ~ 0- 64 C ~ lS;
75 I ~ ~ _ 0 ~ 1 ~ 0 ~ - o C _ - - o_ o ~ ~ _~ 0 ~ 0 ~ O ~ ~0 0 `: ~ ~ e v _ c ~ as O C 1 ~ ~ :' ~ 0 _ ~ 0 0 ~ eC O ~ 0 ~ID ~ ~ al ~ m~ ~ ~ _ ~ 0 a ~ ~ ~ 0 ~ ~ " - 0 ~ 0 ~ 0 - ~ ~ ~ = - ~ L. ~ ~ V tic ~ ~ ~0 ~ 0 ~ lo- e ', v 0 ~ 3 ^- :~= ~ ~ 0 ~ ~ · 3 ~ ~ 0 ~e ~ 0 0 - ~ `: a ~ ~ 0 ~ 0 _ ~ v 0 V 0 JJ ~ ~ ~ ~ _ ~ ~ ~ 0 I#-C 0 ~ ~ ~ ~ ~ 0 0 0 ~ ~ O ~ ~ 3 0 ~ 0 0 0 ~ 0 -- ~ ~ 0 O P4~ 0 ~ 0 0 ~ ~ ~ C) ~ ~ ~ _ JJ ~ ~ _ 0 ~ ~ ~ ~ ~ ~ 3 ~ Q ~ ~ v ~ Us 0 ~ ~ ~ ~ ~ O ~ `: o ~ O- m ~ ~ ~ t - `: -.~: · JJ ~ ~ · n oaf_ ~ ~ ~ ~ ~ ~- 0 ~ ~ ~- m~ - 0 ~ ~ · ~ 0 ~ ~ ~ ~ ~ V ~ ~0 10 ~ 0 ~ 0- ~ 0 £ 0 - O tJ, D ~ ~ ~ ~ ~ ~ ~ ~ ~ v o S C: O ~ ' · _' ~) O ~ D 0 0 0 V _ 0 ~ 0 ~ 0 C O ~ ~ 0 ~ O ~ 0 ~ - ~ 0 0 0 ~ ~ - ~ ~ 0 ' 0 ~: ~ ~ 0 ~ _ ~ _ ~ 0 C ~ 0 ~ C) t: ~ 0 ~ ~ 0 ~ · C ~- 0 ~ 0 ..C O 3 ~ I ~ v ~ · ~- ~ a 0 x - ~ 0 ~ ~ ~ C U] ~ ~ ~ 0 V O ~ ~ ~ ~O O ~ 3 ~ ~- 0 ~ O ~ O ~5 0 C: ~ ~ _' V 3 ~ · t~ - ~ V, ~ ~ V ~ ~ 0 - ~ ~ ~ 00 ~: ~o oo ~: ~ 0 0 V ~ ~ ~ 0 O ~ ~ _- ·e ~ ~ "= v_ ~ ~ 0 0 3 0 0 0 ~ ~0 ~ V 0 V ~ ~ ~ o ~ ~ ~ 0 _ :, ~ ~ ~ V ~ ~ ~ ~ ~ 0 3 O X 0 ~0 ~ 0 V O O O ~ 0 0 0 ~ C: 40 to 3 0 .C J:: ~ O ~ O ~ ~ V O ~ V ~ ~ _ 0 U) 1 0 1 41 .C ~- ~ c `: 0 : c: '0 ~ - ~ ~ v o ~ ~ ~ 0 ~ ~ ~ ev ~ ~ ~ 0 ~ ) ~ ov ~ ~ ~ 0 ~ m~ - o e~ ma: o v 3 C U 0~4 ~ 0 = - ·-Q 0 0 0 ~ 0S ~= ~ 0V `: · ~ ~ 0 0 ~ C~ ~ 0 ~ C a~ ~: £: O _ ~ 0 O ~ ~ 0 ~ ~C C _ C- 0 0 0 0 O 10 tY 0 3 V 0-~ ~ C 0m C C: ~ 0 ~ 0 ~ ~ ~ 0 O ~ 1 ~ ~ 1 - ~ ~ 0 0 0 ~ ~ _ _ a" _ ~ ~ ~ _. ^m ~ 0 C >, - ~ a_ t~ V Q aC ~ P' ~ ~ ~B ~ ~ C O ~ ~ ~ :' ~ =- ~_ ~ maQ ~ 0 ~ O ~ C~ ~ _1 ~ V ~ _- O' _' I,, _ ~ ~ ~ V O ~ ~_ ~ ¢: O ~ =' V · C 0 -~ O ~ ~ ~ 0- ~ ~ ~ 0 a - ~: 0 C a~ ~ ~ ~ .~~ t~0 ae o V V ~ ~ 0 0 _ C, ~ cC C ~ ~ ~ 0 C 0 r: 0 0 ~ _ 0 ~:D ~ l: 0 - - " - V ~ ~ 0 ~ ~ ~ C o" v ~ 0 JJ ~r~ 0 ~ _· `: 0 V = - · 0 ~ =- - ~ ~ cr C ~ c ~ ~ 0 0 ~~ C o~ ~ a" 0 ~ ~ ~ a_ ~ ~ ~ _ U ~ ~ ~ 0 ~ ~ ~= 0 0 ~ ~ V 0 U ~ V. 0 ~ ~ ~ ~ C ~ _ ~ ~ - - 0 ~o ~ ~ 0 ~ ~ 0 ~ ~ _ ~ 0 0 a. dV £ 0 ~ 43 _~ ~ ~ ~ 0 ~ ~ ~ ~ ~ O U Pt" - 0 :, ~ ~ _ ~ ~ · _ Z ~ `: ~ ~ ~ 0 ~ · ~ ~ ~ ~ 0 - ~ :^ ~ c:e. v ~ _ ~ ~ m0 00- ~_ 0 _ 0 c, C ~ _. _ 0 0 ~V t: 0 C - ~ . - C 0 :' O a 0 D ~- 0 0 v ~ u ~ ~ v ~ ~ ~ 0 m cn ~o ~; :' ~ ~ V 0 0 0 ~ o |: ~ ~ 0 aC 0 0 N _ _ X 0 m w o 0 E _ t ~ m~ 0 0 O ~ ~ C ~ 0 0 "e ~ 0 0 ~- ~0= ~= O ~ ~ :' 0 U ~ ~ 1 V ' ~ ~-- 64 '0 0 0 .eC~ O 0 ~ ~ ~ ~ a~ o ~, V 0 0 ~-~ V O 0 _ _ ~ _' ~, &- D, ~ _. ' & m0 0 0 0 ~ :' O ~ ~ ~ V~ _~ 0 _~ O 0 0 _1 0 0 40 0--~ 0 0 ~ ~ 0 ~ ~ ~ 0 ~ ~ 0 C ~ ^0 ~ L1 ~ 0 0 = ~ ~ 0 0 O O ~ ~U Q C £ 0 ~ ~ 0 ~:- 0 C- ~ ~ ~ ~ e h ~ tD ~ ~ - ~ ~ ~ C · ~ ~ ~ ~ ~ 0 ~ ~ I m 0 -a ~ ~: r~ ~ ~.c Iy o~ ~ 0 C 0 "_ _ C: 0 ~ ~ 0 ~ 0 - - ~ ~ 0 0 - 0 U _ U 0- 0 0 ~ v ~ v ~ ~ m ~ c ~ ~ ~ ~ 0 _ 0 0 >, 0- ~ C) _ ~ ~ C ~ C V O _- ~ 0 0- ~- 3 C ~ ~ 0 ~ o~ ~ ~ E 0 ~ ~ ~ S ~- ~ O ~ C ~ m ~ ~ c~ Ei ~ ~ c~ ~ ~
76 0 3 :D _ O C C - U. E" ' 0 O ~ . _. 1 0 0mm ~ 0 ~ _ · _ 0 _ ~0 C: of c'~ 0- ~ ~ ~ ~ O e ~ _ ~ ~ ~ ~ ~ ~ ~ ~ ~ O O ~ 0 _ ~ ~ c co ~ ~ ~ · 5: ~ s ~ e ~ ~ ~ ~ It) ~ 0 v u t" ~ ~ ~ ~ ~ c' ~-u ~ ~ ~ ~ e ~ ~ ~ 0 In ~-~ 0 ~ :~ ~ ~5 ~ D E! 0 0 a~ m 0 0 :> 0 0 ~ ~ ~ `: - v -~ ~ O. o. ~ ~- ~ s I) on 0- c ~ c m 0 ~ 0 - ~ D ~ ~ ~ O ~ ~ O ~- 0 _ ~O ~ ~~ " - ~ ~ ~ ~- ~ E ~ ~ - ~ ~ 0 - ~ C ~ V ~ ~ ~ a~ "= C ~ ~- ~ ~- o ~ ~ ~ o e `: ~- :: o. c ~ ~ :~ ~ t~ ~ C 0 ~ ~0 :~ 0- O 3 0 _ _I ~V ~ ~ ~ 0 0 V h O ~ ~ ~ ~ V ~ ~ ~ 0 0 ~ ~ ~ - ~ D ~ ~ 0 U - 0 ~ 0 C ~ O 0 ~ ~O C ~ 30 ~ ~ ~ ~ ~ ~ ~ ~- ~, ~ c, , ~ ~ _ ~ ~ ~ ~ 0 O 0 ~ ~ ~ 0 o2 ~ :- C ~ ~ ~ ~ ~ ~ 0- ~ ~ ~ ~ ~ ~ ~ O· O O ~ C O ~ ~ ~ ~ ~- O ~ = - ~_ 0 c: ~ m :- oo ~ ~ ~ I ~Q O O c: ~ ~ a, ~ O tQ ~ ~ ~ ~ O ~ 1 - 0 C ~ 0 0_ O :5 u: #¢ u ~ 0 ~ ~ ~ ~ ~ ~ ~ m~ ~ 0 c ~ ~ v ~ ~ ~ ~ ~ ~ -' . ~ O 0 ~ ~ ~ ~ O c ~ ~ :~ :> c C: ~ ~c - 0 ~ ~ ~ ~ _ ~ .c d\~ ~ ~ ~ ~ · ~ _ _ ~ O ~ ~ ~ ~ C- O P~ ~ ~ ~ O O ^ C C ~ aC JJ L~ O O ~ ~ ~1 ~ ~ aQ ~ ~ ~ ~ ~ ~ c: ~ O ~ ~ O V ~ C c ~ s ~ O ~ ~ ~ ~ ~ ~ ~ ~ ~ O 0 ~ aQ ~ ~ 0 ~ 0 · ~ ~ O o~ ~ ~ ~ ~ 0 m=_ ~ ~ ~ ~ ~ ~ v ~ ~ ~ ~ ~ ~ ~ _ ~_ 0 ~ 3 ~ 4) _ ~ ~ _ V ~ ~ ~ ~ W ~ 3 a a ~- ~ - o=~ - ~ ~ vv ~o 0 ~ C ~ O ~ _ ~ _ ~ ~ ~ 0 ~ ~ ~ ~ ~ ~ ~ eq C- V S ~ D ~ ~ ~ `: es ~ O .. ~. ~ ~ v ~ ~ ~ >' ~ O ~ O ~Q ~ ~ 0 ~ ~ `: ~ ~ ~ c c ~ ~ ~ == " - "s _ t, O ~~ ~ ~ m a~ ~ ~: ~ tn ~ ~ :~: ~ CL ~ C: f: D C _1 £ C~ 0 "Q 0 14 :, ~ ~ O 0 C 0 ~ C 0 ~ ~c :' v ~c t) ~: ~ c~ ~ - o ~ 0 ' ~ c) ~ ~ o e oo ~ e. _ ~ 0- 0 0 ~ o4" 0 x 0 ~ ~ £ o 0 - - ~Q 0 0 0^ o a 0 c' t) C) c: 0 C O ~ o~ ~ _~0 e _ 0 cs 0 ~ ~ c: 0 u 0 _ ~ ~ ~ ~ ~ ~r c., mv 0 0 ~ 0 0 ~ 0 et - Q e O ~ ~ 0 c ~ ii a~ ~ 0 ~ ~0 £ ~ _ ~ x: O u, _ c 0 _ _~~ c c ~ ~ ~ ~: s 0 0 0 0 0 |: 0 0 O c) _ ~ v s~ ~ . q 0 c~ 0 0 0~ ~ 0= 0 IC ~ - _ ~ 0 m0 0 t) 0 ~ ~ 0 _ ~ D ~ 0 m O ~ ~~ ~ ~ "c v - ~ s ~c ~ ~ O t) O' ~: o ~4 v 0 0 0 0 o e
77 - C 1 ~ _- dV ~ 34 = - U C o o ~ ~_ m~ o ~ 0 ~ ~ ~U ~ ~ 0 - 0 N t) O _ mt a~ ~ O ~ O C ~ 0 V 14 ~ C ~ ~ O JJ V m~ ~ ~ tn X ~ ~ v ~_ ~ O C ~.o ~ ~ O ~ C~ :> O- C Q. ~ O ~ ~oO 5: ~ ~O V ~ ~ V ~ O ~ C ~ ~ ~C V C tO ~ ~ ~ ~ C 0 C P. ~ - C- ~ O tn ~ O ·~ a~ ~o _ C 3 V O m ~ u a u ~ ,Q t, ~C 3 ~ ~: _ o5 00 ~ ~ O 1 ~S ~ ~ aC O ~ ~ ~- O ~ ~ V O ~J 0 C O O ~ 411 ~) ~ O ~ ~1 P. ~ _' -I ~ C C O O V~ - O O '= · 0 0 ~ _ m ~ OQ 0 ~ ~ ~ v ~ ~ 0 0 ~ 0 0 0 · 0 C ~ ~ = ~== U- ~ C V _ ~ i4 ~ V _ 8 ~ ~ ~ e &= 0 ~ c c s ~ om _ ~ V C ~ 00 O ~ V >1 0 ~ ~ ~ c ~ ~ ~ ~ ~ ~= c - ~ Cl, ~ ~ ~ 0 0 ~ ~ m ~ 3 ~ ~ >_ m_ ~ O ~ ~ _ _ ~ ~ _ V C 0 ~ · ~ _ 00 ~ 00 ~ ~ ~- C C ~ ~ C ~ C ~ - m~ ~ ~ ~ ~_ C: O ~ m0 C {V O h ~ D C _ 0 - 0 ~ ~ ~ O ~ ~ ~- C _ ~ ~ ~ ~ ~ ~_ ~ ~ ~ 3 A5 ~S tt ~ _1 81 ~ ~ C V & ~ t~ ~ ~ ~, C V _ ~ ~ ~ X ~ ~ ~ ~ ~ ~ ~ ~ ~ P' O :~ :>' ~ 1 ~ L1 1 ~ · h 3 0 ~ ~ dJ ~·4 1 & ~ ~ _ _ ~ OQ ~a4 _ e · ~ Ld ~: 0 tV ~0- ~ ~ ~ ~ 0 C ~ 0 ~ ~:D O ~' 0 O -~ - ~· 0 · ~ ~ eC u ~ c c ~ _ e ~ V v 0 0 0 ~ 0 0 ~ ~ 0 `: 0 ~ ~ e ~ c ~ ~ ~ ~ ~ - U ~ :, U 0 ~ 0 ~ ., 0~ ~ ~0 ~ ~ =~_- m~ EE ~ Ll~ "= ~ ~ ~ C ~ ~ ~ 0 ~ 0 U ~ ~ _ ~ ~ 0 ~ ~ - ~ ~ ~0 0 0 ~ 0 C a~~. 0 ~ ~ ~ ~ ~ ~ - C: - ~ ~ C ~ ~0 ~ ~ 0 ~ ~ 0 ~ 0 "- ~ ~ "_ Z: ~ ~ 0 `: ~ 0 ~ 0 ~ 0 · ~ ~ 0 0 _ eo ~ ~V ~ ~ ~ 0 4~O.~ _ 0 3 U ~ 0 ° ~ 0 . ~ V .~: O O O _' ~0 ~1 :> C O 0 tY ~0 ~ C,) ~ ~ ~ · 0 eC O 0 -eC :~ Q 0 C 0 N 0 ~1 C~ ~) 3 ~0 0 0 0 0 ~ ~ ,,' 0 0 0 ° _ 8 ~ ~ a' - ~s 0 a ~c . - 0 m 0 0 ~ ~ ~ ~ ~ 14 ~ 0 ~c 0 ~ 0 P ~ O oo O ~ O ~ ~ O ~ Ll V 0 _ ~a ~ ~ h ~ .C ~ C .C C 0 0 ~ ~ 0 0 - ~ ~ ~ 0 ~ 0 ~ ~ 0 ~ 40 a0 ~0 ~ 0 ~ 0 ~ m ~ 0 ~ c ~c r . _ ~ :~ - ~ ~ ~ ~C)~ e "~- ~ ~ ~ ~ ~ 0 ~ 0 0 ~ 0 ~ _ ~ ~ . m ~ 0 0 ~ 0 0 ~ ~ ~ ~d ~ ~ "c ~ O :^ E m ~. ~ ~ ~v ~ ~L ~: ~ :~ ~ ~4 e ~ c ~ 0m 0 0 0 m ~ c)~ ~ O Cho 0 ~ c :, ~ 0 ~ 0 ~ ~ ~ ~ ~ t: ~ C E! ~ ~ O "c 0 ~ o" c ~ O 0 0 ~ 0 0 ~ O ~ ~ - - c: o - .e a;~ - ~= e~ - D ~ ~ u 0 ~ o= - £ a
78 0 0 z c y 0 ~o C ~ _ o C) In 0 ~ ~1 C ~ ~ Uo o ~ ~ ~ ~_ _ o C0 0 ~ ~ 0 0 ~0 ~ ~D U ~ 0_1 C ~ a, ~ ~ Al ~ 14 - ~ ~ ~ ~ ~ O ~ ~ ~ V ~ U 0 0 0 0 - ~ ~ _ O ~ _ JEW ~ C Y · ~ O - ~ h ~ A e~ · :~ I: ~ ~o~ ~ me c 0~~ 0 ~ 0 0 ~ ~ 0 ~ 0 eC ~ c: ~ ~ ~ ~ ~ ~ · 0 ~ ~ ~ ~ ~ 0 ~ 0 0~ ~ Vie ~ ~ _ "= ~ ~ 0 ~ C C 0 ~ P ·_ ~ a ~of · O _~ - ~ ~ 0 0 ~ · ~ ~" - ~ ~ U Y ~ ~ ~ ~V V 0 ~ ~ ~ ~ U C U ~ a~ 0 ~ 0 ~ ~ 0 a_ ~ l:: ~ ~ ~ ~ ~ X~ ~ · ~ ~ ~ ~- - a~ ~ ~ ~ ~ 0= ~ 0 ~ 0 0 3 ~ ~S O ~ ~ ~ - U ~ ~ - ~ U ~ ~ ~ ~ ~ ~ ~ 0 '0 ~ `: O ~ m_ U ~ ~ ~ ~ ~ ~ ~ 0 ~ O O =. ~ ~ - 0 = - ~ ~O ~ O ~ O 41~ _1 ~ - ~ ~' ~ O ~ ~ ~ ~ ~ ~ ~ V S 0 ~ ~ ~ ~ ~ ~ ~mm ~ ~= · 0 - ~ ~ O - _ ~ 0 em ~= ~ 0 :' m~ ~ ~ O ~ 0 u, e ~c ~ ~ _ · ~ ,~: 0 0 ~a ~ ~- ~ ~. - ~ ~ ~ P4 ~ ~ ~ ~ O P. ~ ~ t:: Ei to ~ ~ 64 . ~ ~ ~ ~ ~ ~ ~ ~ 0 ~ ~ ~ ~ · Ei Ck 0 ~ O ~O ~ 0 Q' ~ ~ ~ ~ ~ O 0 m ~ U u, ~ - ~ - - ~ e ~ ~ ~ ~: t) {: ~: ~ ~ ~ ~ 0 0 ~ 0 ~ ~ C ~ · V =~ - 0 · ~ 0 ~`: ~ ~ ~ =_ ~ ~ ~ ~ 0 ~ 0 ~ at ~ 0 · ~ ~0 ~ ~ m_ ~ ~ ~ `: 0 0 ~ ~ ~ ~ ~ ~ ~ ~~ ~- ~ ~ ~ O ~ 3 ~ e 0 ~ C~ ~ ~ ~ :> ~ u 0 ~ O ~ ~ ~ ~ ~ ~ cr _ ~ ~ ~ ~ ~ ' ~ ~a 0 ~ ~ ~ 0 ~ ~ ~ ~ {: m= - 0 ~m ~~ a~ ~ ~ ~ ~ 0 ~ _ - ~ ~0 0~ G~ ~ ~ ~ ~ ~_ 0 ~0 m ~x: ID c: C: · 0 . ~ _ o.c ~ _I ~_ ~3 0 D U D ~ ~0 ~ `: ~ ~ ~ ~ ~: _1 3 ~-~ ,C- - _1 ~0 a a ~·e _ c~ C ~0 ~ :. - ~ 0 0 ~ 0 aC ~ ~ ~ C, `: ~:' O 0 ~0 0 ~ `: _ ~0 C: ~ `: :>, ~ 0 C ~ - - C .c ~ ~- ~: E 0 ~ t u 0 ~u ~a 0 ~ ~ O ~0 ~ ~ - 0 , ~ ~ ~t: ~ 1 ~ ~ - ~ ~ 0 0 ~U _ a,= 0 _ L. a" ~ ~m m 0 · h4 P 0 0 0 C~ O 0 |: =: ~ ~ £: ~ · 3 0 ~ ~ ~ . ~ 0 `: 0 0 ~ ~ 0 ~ E · ~ am - - 0 0 - - ~ _ ~- 0 ~ ~4 0 ~ 0 ~ ~ m ~ O _ ~ .~' 3 ~ f~ ~ ~ ~ ~s p4 a0 0 ~ 0 ~ m~ ~ ~ ~ ~= ~ g ~ 0 ~o ~ ~ ~_
79 o ~ c ~ ~ I: · Cal ~ ~ ~ o ~ _I ~a] ~E ~ ~ ~ - to 81 I ~ :~ O~ ty ~ ~ ~ O ~ ~- O O ~ ~ C ~ ~ O- - ~ ~ ~ ~ :5 ~ ~ ~ ~ ~ A: ~ ~ C: - ~Oto ~5 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~- ~ ~= - C:- h _' ~ e ~ ~ ~ c 0c, ~ ~ of Q ~ £ ~O ~ ~ t ~h ~ ~ ~ ~ ~ 4.~ ET ~V ~ ~ ~ c o ~ 0 ~ ~ _ :. ~ ~ · ~ ~P. 0 co 0 3 0 ~ ~ ~ 0 ~ ~ · ~ ~-3 _ Em ~ c lam c c Pro 0 - a= - ,E Ial tr~ (U _1 dI~ ,,y ~- ~ ~eC O ~ - 10 ~ U O ~ ~2, ~ aY _d ~ ~ h ~ ~0 5: ~ · ~ O · 0 ~ V ~ ~ O. ~ ~ O O Ll ~ ' ~ 0 ~ ~ 0 ~1 _' V ~ O ~ ~ D _ 0 ~ ~ C ~ ~ C ~ O O ~ ~ C ~ ~ ~ ~ ~ ~ ~ C C ~4 C) ~ _I ~ 1D 0 3 C 3 _' _ ~ E aQ ~ C C C ~ 0 E - ~ C ~ Y · _l OS ~ ~ ~ 3 O 3 ~ _ C: ~ 0 ~ ~ ~ C ~ ~ ~ O - ~ - O ~ ~ ~ C O O ~ ~ 0 ~ C 3 ~ ~ ~ C C ~ ~ ~ C _ ~ ~ 3 V a~ ~ ~ ~ ~ C ~ ~ ~ O ~ ~ ~ ~ v c, a~ ~o 3- V ~4 o _1 t) ~aC ~ ~- V C O - ~ m 3 · G) O ~ ~-~ O 0 ~ ~O C ~ " - - = S ~ ~ ~ ~ ~ ~ ~ ~ 0 V ~: ~ - 11) CV 3~ ~ m c v ~ N C Q) L) ~C ~ ~ ~ ~ C ~- · ~ ~- ~ ~ 3 U) · `: ~O ~ ~ l::- O ~ V O O ~ ~ O O o) C ~ V ~ O _' C _ ~ O ~ · · ~ t) ~- `: ~ ~-~ O C _ O C O C tO G) O ~ od ~ O C Q`~ ~0 e ~ " - ~ Q, ~0 ~ s v 0 0 _ 0 3 · O - O C ~ ~ E -~ O 0- 60 O e ~ ~ ~ · c =_ ~ `: ~ ~ ~ ~ c ~ ~ 0 EE `: e ~ 0 a' ~ _ 3 ~ "= ~ ~ ~ ~ O ~ O ~ =~ __ ~ ~ ~ C ~ 3 ~ ~ ~ e ~ :> D ~ tV S {V ~3 _d ~J :> ~ O Q. ~ 0 Ll Q, 10 _~ ~ O ~ c) J~ ~ o2 ~ ~ _1 ~ ~ 0 th =m E ~ 0 O : - ~ 4\ i4 ~ O ~ ~ C 0 ~ e ~ N ~ ~ E ~ C E ~ L' ~ ~ 0 ~ ~ ~ ~ ~ E _ ~ ~ ~ - ~4 3 8 0 c _ o 0 ~ 0 C ~ ~ .C _ _ .c ~, ~ _ 0 ~ r: ~ C D4 ~: O ~a ~ O"= ~0 o 8 8 c ~ ~ ~ ~ 0 ~, ~ ~ 0 to ~ -.C E ~ 0 ~c c: ~ c ~ ~ ~ ~ O ~ 3 O _ 45 ~ ~ ~ ~ ~ __ ~ 0 0 L. ~ ~ V U - - 0 m 0 :' 0 aS ~ ~ ~ 5: 0 ~ :, ~ ~ c: ~ 0 c 0 · 0 0 ~ c ~ ~ ~ ~ '0 0 _ ~ ~ ~ ~ ~ v O ~ ~ s c: ~ ~ o. O ~ r. ~ . =~ 0_ c'_ a ~ :, c ~ JJ :. ~a ~ c "~ e ~ ~_ ~ ~ ~ 0 - ~ ~ 0 0 U] 0 ~ ~ ~ _ 0 C: _' V ~ ~ '0 0O E ~ O 0 ~ ~ O ~ = - = ~0 ~ ~ ~ ~ ~ a ~ ~ _ ~ s s e ~s: E ~E~ :) 0 D O 11J C: _ l: a a tQ 0 - ~: |: D O 0 ~ c: ~ J: _ V ~ O O I 0 d = - C O C~ S O _1 0 =_ a C 0 3= 0 - n `: O ~ O
