Pain and stress in the human fetus

1. Article Lead Author: Smith, Richard Date: 2000
Article: Pain and stress in the human fetus
NOTE: when there are multiple columns on a page, add column reference to page reference.
1. Pain felt at:
a. If the article specifically asserts unborn children feel pain, at what post­
fertilization age?
b. Page: 162, Left Column, Second Paragraph. "Neonates also have behavioral
responses to pain, for example, by facial expression or by crying."
2. Nociceptors:
a. Ifthe article states nociceptors are present, at what post-fertilization age?
b. Page:
3. Thalamus link:
a. If the article states nerves link nociceptors to the thalamus, at what post­
fertilization age?
b. Page:
4. Subcortical plate link:
a. If the article states nerves link to the subcortical plate, at what post-fertilization
age?
b. Page: 161, Right Column, First Paragraph; "However, between 20 and 26 weeks
the subplate zone of the cortex contains an abundant mixture of cholinergic,
thalamo-cortical and corticocortical waiting neurons..."
S. Noxious stimuli reaction:
a. Does the article refer to reaction to noxious stimuli? At what post-fertilization
age?
b. Page:
6. Stress hormones:
a. Does the article refer to increase in stress hormones with noxious stimuli? At
w hat post-fertilization age?
b. Page: 162, Left Column, First Paragraph. "However, studies showed that
neonates, even when preterm, mounted a sizeable stress response to cardiac
surgery."
Page: 162, Right Column, Third Paragraph. " ...piercing the fetal abdomen to
access the IHV for transfusion is associated with substantial rises in these
hormones from as early as 18 weeks gestation."
7. Long-term effects:
a. Does the article describe long term harmful effects from exposure to noxious
stimuli?

2. b. Page:
8. Fetal anesthesia:
a. Does the article refer to use of fetal anesthesia and its effect? At what post­
fertilization age?
b. Page:
9. Cortex:
a. Does the article relate to the asserted need for cortical involvement to
experience pain? How?
b. Page:

3. OBSHTRICS &
GYNf ,OLOGY
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ELSEVlER R ~-nd Yt.'i't.! 0 .."".;,: ·I~ L!(nl) Itl IfI<'
Pain and stress in the human fetus.g,
Richard p, Smith ' , R. Oitau, V, (Hover, Nicholas M. f''isk
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Pe.tJ:><:'d to de<::itie' at what
g(.
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r~ 'Qhe-d
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fl'O.o ,e.et'lt:lIIetll,. in ill, - ~i'e pnx-WUf~ S. io m:<fer·
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lil~ ""jiphCT~ ijnd 'piu,d (.lTd h~ ~e hegl{" bf S we<:h, ""lIlt ('
su[[u:!i",o( r,,'al palh"rh ~,iv lon. a!!d inl6>hlli",,1 .ukuu:.." ill thr~ ~()"(Ilg. into tho: spine <u a", .ul HI "('el" lllt . '< ",brat
i'llallill¥ Tbt>e pl'(_ '·"llu...~. r~l(ing (<<lin ttllla -OUIl<l-l:"ilJ(d <m.:~ ~rl' ." form ~t Ini. Maltt', "ilh dilrt' r~l"i;l.Ii<'1 inlt.
,
nudr~ .upir.lliO!). Uuou-lI lt I" (JflC1l feLl! sOXXet), lII't ill";.';'''. n.el{r'u~s.. Ilb,,,,., ~tia ;,n" ht<l<Jd '~ ~ " qa(ling a • ."h.·UI I r
'
IQding 1 he tlb vil)Ul' qllt~iQn; 11~ l~ felus f~el pain'!
0 "'~k' .. aru:1 cl'nlirruill£ "'ng (tfler birth . Pain lillres p~s'
The ~0t1(ep1 II ,iflt- I ~ t.s i~ a·patient in i« ow,~ risht hlb thf)uSIt lite en muk I,. lhe CN'.,-X . Th~ tinlinl~
IlYAlill'HiS.
lcod '0 illO'tllS"5 iultmS1 in lhe iuhjeel of 1,,1:11 p~ill _ A of ,,~S¢ tJt.u:Ull.)-<"",i",,1 C"UI;u'(;li"n~ l' ..:md al itt dcci<Jing
j ll>litiClllion rnr providing reUl! anuJ.ge<ld 8M .o~"h<:,i; when Ihe ret"~ tiN b.!(,'t)mes C"1"'bl-e or l'e<!ling (Xli" ; llti. is
1.1..< lIti~1 POt only :Ic.::ru'~o( a tlIDtlll. obIi~alion to I'r~v-~nl C')fl>itef-.dIle c(Jnt{mel1'l', ~~p,d (Jotsi- :'/nini(~
lItI ,u'.. a or
'uiTeri l~, 001 alllU hcc~l';e paii~ "I~;~ may affect aN! l~chni'I""~ Ii:"", sbo11 th~ Hrgr_·I/! L1[ Jl¥er~nt lil:>re, inln
~at,; i vQ! and have kjjl!!-~ ~ ulXfe'.·elopnl~lItal M!>4ucl.le. lite ,.)(il:~1 ptalt' netweto 26-·'111(1 ;1,1 ,,~b oll!.e~atitll1 rIj,
1 ".-cr. Ih.: evideuct ' e
·ltt.... Ih.i_ is limited, lIrgl' l ~
r"f which loa, ·t'd ",un~ 10 ",,,,"dude the few;; i, irn:ap,,>lc
i
t)c!l;ilU~ R:~e,m,h in hunHtti (tJ u,,"-, js It"mr""'''''/ by «'Ilucal "f r~elin~ p,iill prior to 26 "'ee~' i ~1 . H,,,, "we, ~lwecn
<'O<IstlllUTts. 1'1,,1 ~t:'(l due 1(. probl~n< iSelining "1Ii,(ul'101)' 20 ami 26 ..·eeL, Iltt< ubplate t('M' "r ,"" ,'One, <'()main.'
oUh,:<,lIDt' lite utes . an abondanl mi.lllI'C' of .. hotiner~i'" d",I",fIl"-ctlrucal and
·
('.)ni.;"",,,rti.::(1 ""iting fll!:uroOC' , and Ihere art Iro.ns'efll
le.;ll ,,·n3p<i. "'"",,it, bel"-een Ib~ , ubplal': and ,m1ical
2, F~lalllJl ilt pl:l~ nfu/t'Ili:- f-' f .w h r~lIe~' of !"lin h ,'on,idtf(d 10
require CHIl""'U('" , ~I",~en Ille nlfte:<. ;<Ild peol'hery,
111.:", b llel ohj~c li .. mcasurerntnl of 'pain-; il I' " ,,"hough, Ihi ' rtt',~,,"pl i(}ll "·"uld fender animal- IJclJn!
'uhj~l i ' C' e,pcrien.:~ T!I~ (el,,·. is unahle 11 Iell 11, i·f il it ,,'(ne ";Itch a n~prL1e" in(~ar;)bk ot fJtr('t~idl :~ pall. It I"
11()t .k.n l~n at whl.ll 1.!Ic 1 10l in, the o'ta{Ut;n il,11l h f,W lt3:'t"L-coie'"nl.
Rcn.."" I ~ !.be J~~'1I 1 h'Yfrt.}f "f Oh"'tcll'l( '<: t tt).~",.~. I ""i3 .Jlltf (""'Ihl), 1Il~k!. con:lC(ltlI11'" to I>enn. ult.. . nt multiple L(nnL.~~ ·
'h,1Y'"j",,~ .. c Ul4'~ P" .. ..t1'lkci a.t ' Inu."h..:: F..:' l.lI fh' iiJUC;'I" ;rod n w:I".ll'" li.lIh the f(ttl "'; rna)' b<-,'''nw ""p'lhk .")f' fedil')~ p.:lin. ;(.nJ It
II) Ih.: T l1.;:1J 1.' ' U('-IO'-:101 ,I 1~)uV 1 f1(;.(tfU,,':,:nior..J hh""'''' '" Cht'" Hl a ~ ~.J ~~(;:ih •.jl !'Jther tha n MIJlkn l(au·.. i ll, '! I. I.u ~urtlltJ.ry.
lh.·~t;t; •.
lHd It~ l flt''' tI'lr('IInrnI, 'lin '
pritn Id .:1 I.' t~~k. li w felll'- <1('< , tH.... h,nc tt,,· rlefJrH~lnalll '
( QfT"nr"'''WIi.l)C .JUU"'''- T.. t · +J 1 (1k . ~ ' 1 1'H)
I.:&.'t ·.l..l..~"'''''I( '' 11 Uli l~~t t p;t',h, .,):.. '" rb...-c to fed p~i " . ~ ''-'~~n ]? ~nd ~()
r .... r' : ••• ~fu .. · r r ~'~'uh~ I..: .k.' I:( .1< l r Smill•• " ~c L " 1 h.II J llh'·L'c)fti~f 1 ~' onnl',,~ lIrm " ..tfl! fpftH mg. ami ~I t(~l
II ~ ; t ~ll'; (I.. ...." _..: . 1" 1'11 ,11,." ,',
I'll , rr " I ! .:. i I ~ I II tI 1 111 J. ;. ~
Unfiled Notes Page I

4. 1(1 Io:te-i. .. I"..~ fi;hl' h.t... " le. n~·l.:~!'Io.j1) c o no ~ll"ln", l( htt l tC:~l~,)fh . i:: t~ . J.C :.... utlic:t.I fc(u"(~ (HKk' rgt.!ing I1HI~H;ucuta r
(';li n hl,l<',d INtblllSion, "ht II .11",>< collecli llin of <;erial bl<.","
'_lm rk" JI tl>.. 1>C;;~lInirll! .111" <nd {'( I~ pn~cdlJrc. I'n..·,·
<Jure' at Iht, r/:O';Cf1(;.1 o:or" inSL'rti.,n 0>('/ I. .... hid, j. ",,'
inne"~I~<I. , ..0 be ,' otllf"lrcd "ilh Il';In..(,,,j,,,,, al lhe inlf.·
hCf).•tti( ""111 (fUV,- whidl il.;.,lv~:. 'ron ,Srt:". ing rhe fetal
i:lUd the la,1 ,e<.'lIde• .he ""'IIlGt<: """ IfNlt<I a';( it ere (rulll (Flg. I,. 10 O{1f unil~ the ~ilc or ~['f'NllJC h h b<><cll ""
illC'l'ahl~ <>f (e",inv pain . HI'l ncf. ludi", ~b()", ed II"" ICl: hn. c lil a;:ctt" depcrlllcnl ,m rCla l " nd rlace m~1 P'"itiOll
i
11C<' u;&!'" <'7~ 11 ""h",l prolcrm.. fll(UllIed a ;il.eahlc ;Ift" .. ilh """h ,If" u>~ oJ dPp'fI~im .. "'[ ~ .~O'l "r
Ihe time. While
r0l'net.... u cardia, ''''11~ry 1-11. willt ri'«" in "1ln: 1l~ "nc. the IHV ~l'rro;J..·h may I"..e" k ",cr ri,' oC<:l'01(1lil'JI ....n <III"
nor(.dntrl.dinc . (Uld corti,,)I . Some ,,[ h".c <: IJ~~~ .... ~re fI' cord l am l'Qn ~<le' a!d al1c''Nl1 "pa<lll. the:' P<:1 apl'w;Kh i~
reduc"d hy o(i, •.id PMI &~,,~ 141 In one f1llld'l",,~d Mud). l"dinit:~l1y e"" cr.
opin .u",.~ihe~b It,.,
('~!l<li:l:u...t ~ilb. it rmu"Ii!l(l it! peri.
"lltW~I I ' C: mq rtalil} r:u.
Si[ll.~e !tlep.. ~ of.eualglj 'ia dunng / .1. /lum"",ui IlrsPfHtW
nto"'111i1 tl)l'!iy b ~ !ltcnr~ th." ~tJ.l.ltdifttl o( care.
Nt'(lu~ (e f,;o h.we be:h;~i(.UJral ~PO"~ 10 pail. (or A'~ li'~li"n 01' Ih.:: Ji!I<Il hH)(illr~la.mo·pihJil'4rl' 'OOleflal ~xi~
e~aR)plo. by foci;tllpr,,'~."n. or by cry;I>1:' 1lK r""",'''-~ II' can t-< iJ:.,e,,,,cod h~" ltIe~,~ufin)§ ~t(e,~ hurm<lO,,·1o 'll<--i'l .J~
,
hrell;l~inlt by facial Klio" ,.~~ d;:.po:udlns Q{l .(~ sleep! !l({;'llreruthn<" c(l"isvl. and 1'·l'od"'1lhiu . Siudying "'tllple.,
"'lIle s~ ,11' the llc'!uat.e, "Illgc~tiilg lhill the be"'lI'(lu r~1 nbl.qill<"<1 III kl,., blood (r~I"f",i,m allo",", cOnpiIJ'iwll nr
~'(IlU I of pnin ~ rrn't;; l>el1a""lUr.ll e:'Xf.'rc~itlft,· C~~Jl befole kvel,; of Ill... ,,, h(.rntu.w, t.;(OI'e l(a~f...,i"n ti.nlmedi8Iel)
the IlPflOfIlJUily 'rr>( leamr<1 re'poll~ (":clJr. tnt. ~l~f a,e ';' 1(' If.t~ l'ollll df:'lll ~tl<l!J i.. t,lahli:lh_d •. ,,(Ill
1(.v~L' al Ihe (nd ..,1' Ir,lflsfusi4l11 (illS! bel~>re Ihe no:tJle i~
1'1:"1(,·• • (1). Afu:r Ir-.tn!ffusion at Ih" PCI (her" i., lillie ch~nge .
in felM '1<1f;((It~line. conN.,!. or Il·e.ndorpitin I7,SI ·
I
H""I)·et. JI> inu~rr,,~d 'ilt 'IS>2, pjerciIt~ tht felal ~b</o ­
Becau~ of th~ otw iou difticlIlic-, ill swdyillg (eldl men: [0 acces..~ lh~ tHY fur .r~n...fusion .~ ,'~Sl:S<l·i at~d with
betlavlour. <lCfi~·ali'm l,r the b>'Jl()ll't.abfll.).-p1lUfI~r): -adren al .u lanlial f~~ In ttl~ e hOfJl)()ne~ rrom a' early ~;; 13 w<i<;k,
R'I L' (0 'SI~~ re,;p<.1Il1<e 'j h;l$ been pto(>{)~ I ~urt(g;tt .. fO~'lil)rl. Til.: median i1cr~~e ill fl~l1d.lI·phin Ic,d~ "a~
iniIkal(Jrof fd:l1 pain. Thi h~ Ilmfitii<l"; : !IIR:»' i1: ~pomes 90 . in ,ol1i~d l .I.e.·d , WIIS 183c~, lfP<J III norkl1'e,)atine
db 1 I <:etiJ 'Idly iillflly ~in ( I' ){' i:untpl~, dUfin£! ne~hel.
101 I~'~h ~'" I %'.i P."]. 5hlll1er flI'(~III't' [,ucn a5 ~I""d
aqd st~ ""$f.'<I~"'" d.) 11111 in',olv~ Ihe c('rt,a, . HQ,,~er~ lhe MU'ttpitni) Wi.h(lut trau ... rlL'iJCJ· l ,,:ero nnl a~'~x'ialcd with ti~.,
,
con,e".e i Ill.. liilllllyp<:>I.heSl . iob. in lbe abse.tlct tlf d ,ile" in cOllij(,1 'f/UI I ~·cndt>fpJ.jIJ. IlIlt then-. '" a.s • "MI."I.· d" j1)
r~po n:se the (elus I, ulllile ly 10 CI)(fRl.riell<:e (/:lin. Also. l'll<." (lie tll•.1(C f~pl(j ll<rrHdn:II~line uSl'onse.
,'(1<1ld ~ue 11"'111" stress r",pon't;> is ll1'~ rcle~':Itlt in '''fIll;;
of imm~llIll; a.nd l"nS'«:rm ~lucl~ ... hetbl'f or 1101 ,,,..,0-­
ci. tetl wilh ""in in Ih~ retu, .
,
Slud i"" I" IuiJmm~ iU~ liruil<,<l by (tie n.,..." rOTan elhi'"l1.lI y· TIle ietu< ro "L(C ~,o! . lali<Ju ha., Ii ""l1ar. ~.oh[l' Cap".., il} to
''''':''l'lllble lJIod,,1. nam.dy tho", fdu..~·; u'l<k'1:o;II!,! dini· 1(' lHOl)Q Ao.....· in re'p<ltl'-C III 'tr~,,'r., [c. prUItt'l
r~tJj~!ribu(~
all~ ·irtdiealed pro,:~dore~ for ili:lgflOo;( k- Of U lCl'apeutk ." mo,~ "jul Ort!""s. ".K:n ;1< I:>rJin and m}n<:arll'um. a.! rh~
C<>rd - - -­
S'1<t 01' tHV n=JHng
[In file:ci Nnt .. ~ P~P" ?

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r~ 11'.QiIl, ~
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"-...
j ~ J ~ ltTn :t'j~ IS] ~id M(", 1 lt to Hf ' U=-t::!i f.,.., ktu TrWn; "':.... no ~.i,.wm·1lD(
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'''peI,s;e I ot1~r ori':M<; "",It ~~ {lUt- ~Jdtie -{ ':uW I~ iIcafiou in hehlwj<out::ll ;'Ir~,,' res(J<.ln",.;s rfiJI · Rat< , Ifl" . .,d
,
"'~tr"'Ulit j~ [91 . N,ullerouo< exp<. nrnenta' ' lJJdic . h~v,,· "') !1­
- perinmaUy ~ ~et e' more c(t(l icu!itc.T(1Ht.' Jnd ~h~'t" iol. sh.1'A'l!r
fi.rIt1CiJ <Ie! fe~I"lJI ~ IlO :.elt~ /lyp''' ..elllia -r m.lI I. Iwe' return I<Y basal levels in ~tre",rlJl ,;illlali"n, 1201.
nl!1rrn8'~ 112.1. and fttllk:e<l 411<'rill" hrfltld n.)W I L~J. Tht primill~ lUlm', h~ ~l"", beell u ~<!d t<> "''''' )' the e'fe~h
Similar'>-, Dowler slud;",; "I' hUIII"" klu,",,, ."t ilh inwwler' uf slrcs" h6nJlon~! .:lntl ~f,~ :'o'" Aumini s-fralKw of dt: ~ arr.lCI1w ·
.
ill/: growtIl =triO:I10II (IUOR I h;,.""
fnund d«rMSc.1 r~..L';' ,(me t.O pr,,~anl thesu, mon~e~"S in lhelal1e~ Ihird 'of
I ind i~'Q ill cerehr~ 1 I H I and adrenul (l51 bk'l)d .10' pregllMlC~ al ~ ,tH:.<' ,1mHac to Ihat. u;.:u ill humans i,
"ch>e'!), 'l'Ocj()f!'n < (FVW, Clln· i.' I¢RI witll Hai;lIi. lrI .
< ,.,,"'11 a"",x:im~'Il .... iU, clcg.:oer." i"" ,hM lIe$ in II~. f~lal hif1l">cam ·
~ tld il1m~5e(1 ltldi:e~ in FVW ftolll ~i·i~J:t~ .. al o~~ hQlh rjl~ fl ll. !iJll". Slre h' a 2·w«k ~lwd 1 e ;. us;e!1oli~ ACf H
l '1'
~ ud1 ' ,he renal 11 61
. nmood If7 1 aAd ('ullnt'IIMY Itlll i~ 3K ;;')CiaIW with illjlaired 111(l(Or <:(llrdi'iarlol llud tlW .,d~
ntctic ~-oi,'J ~enl w.III ,·.. WO'IOslrk ik.n. 1" " iCily. reducat allenl;(,.. "",/11. iUld gf"nlcr irritatiility P21 ·
~Io$ norfl(er' "llrIL'iO' md. our 'gtl<l(l h",.. itIlwn lI ·faU of
. . poDlre I~ '-I=~ in the lallcr lhiro of (X'Clln",ncyis 1 '-''''-''
l-l.5 slllildar~ dO"[1II;v : UI . mjdt.l~ C"~rellr,ll itMI:;r pl/ls;.­ t!.u.!d ..1,11 hiShu ~,~'-' 0( AcrH and ,ooi~ol in Ille
.
(iIi! indl: , o"'I'( lli " ilh lliis re(;JI hruill~I1' j ng f~(l!L¢. ~e'q MI" wh~n ~rr,."S~o!d nJj. _,(,("ure 1 , ire,;, in ut.:m .
0
~ ~, ~~.II!I'" rrw()h- t1l.~ Irai)' II"-,,,. iN ll>( IJie . felilI1noll.~,
(rom ead~ liS 16 wtels_ TI,e lUc:c ~ni !iJtl fo.( thi ~ nol
e'llec iilll), dUril'fl lit", Ii..,.l third nf preg""'l"Y ;" ~"tI
.
l,ialc<i ",1m tower .n're. or alte",;,," and II.<'UmmOll.... matur­
";".­
,
~kaf. bm. " C Olllplilible, with. ' m increnM' III L'(reht-al 1,,,,_ ilv ilfle.r birth 1~41
T ll¢rt' ~Iw an "wrt",;! i II retial and remora I ancr) re~i ",­ • 1.1 huma n~. 1lM",.(,,1 .:in:l.IlllCi,inn ",ithl'U' analgesia I"l'
lanc~ ind'"., an""
rro.; edurc~ iihl1l vin!llr~ n ,gress i(}n the (lr been ~fmwn 10 tncn:ttsc ubse(lU!'" llaln hchor,,"
IH io"llr (mea ­
feM u!lld. ~imililrl y '(!II1I'~li"'e "ilh fewl llr<l,n, paring ~u~d ,'lttjt':Ij,tl} fnlrl1 vi,leo(Jpe by M ind"pe~<knl (lh~er'
imanll....::ri1'1 in 1lt,1'lIrilliunl. TI,csc ':Od"g'" are I!<)( setl)
. "~"" kllli)V.ing ·...:cinalion 4~ -6 Olonths I.(er·wltcn C()lDpd ....d
afterr pn_d",es HI Ill" PCL n,;.'
redhtnhuljul1 in bU<><1 f1m.
_
, 10 llncir~lIlIlci,,,,<1 ""olrols [25 _Tlth SUSS'",, ilial • stQgle
may tl<" ~U;I~-<J hy Ih" '~Ul'ath"I.k sy:"tem. {lr 1>, 'l>ther SUl:~ ';flil eVCflt ¢ .arly ill 'ir~_ "n.:n 11t<' n~'ou~ ~} stem i, .till
u.nd¢~l1lliI¢ lI)~ani"t'-'_ . (teVf:lo-pfu&, Can innui!lIc" llt'.UCI;>L.k:y"klpcIll:1If and m.. y hJj,e
~ lif"llllli eft",-"! on ~I~" ""P<)~~_ F"l1hern1Urc. >rwpeI"d­
li..~ ~jQ1tlenl with Ilx:al ;u~"'I~tic cr~alll 1I1t~nua1edlbe
~PO"~ 10 a.:c;n~ljlln , "'I;&.. "iog t./ta! "ncl g~<ia c"n~lt~r
tilt' tn"~c t uf Sire.., (.n neurode>elopm;'lll I '~; I
There is inc~a5 i(); e"iMItI:(' Ihat ~acl)- p~inrul or sire ,,)".. , [n re51'OOse 10 vlI<:cinali<'n in illfau~y. we h3'" found Ih,'l
eertl~ CiI.I ..:n"-itis.: "n itt<.li,' idual III l.1t~ r~ill or sires,. b;lbie< "')m hy j'I 'I!Jlne nt;>! ddivc:r) have a gre~lu ri,;c tr.
Evi""nce from i'.rerlllal 'Iudies indk~le- Ilq'l A ; tr"sshd salh'lry Nl1i>nl and cl)- for I,," g~r Ih:m lh",e hOnl oormally.
perina OJ I ~'' en~ c,;m kn~ k,"g ~ I'-'fn elfe<:ll' on hiPfXW: m1pal whHc thn..~ born h) el~cti"C' Cae~.ut.' an "o,:rlou hl:"1."t: J.
dc elupmcm ,,"ott ;tI~;.,~ ~hil: i()UL In roJt~. which :ttt: bum al ,rnatl/!l' n'(' .. oJ cry I;;,;, Ihan .he n(Jrm;.1 group l2til
It Ia c ~!(.u'!II-e ,1t in •k'''I''fI1~nt to rhe I;l~ l1unl<ln fClu,.
. Whcth<!f fI'l itl '" ~Ire~~ til Ul~nl h.~, ("nl;-ICnn implio;;d!ion,
earl y pllslnoU.1l hJ11dJi"S ~LL'':' all i(l~TO:""e in !!1W:OC:< !f!,<:uid l.". ItOt ku o "n~ illtt..l ~ttldle.) are hWLlc-U by the t!lbknl nt'ed ( 0
R-..:"p tnr lknsrl." in 11 ••ipI'ocarnp'" and" ,ifdonlt mod - cl)nfifl(! 11l~" ~i,e r,.",;cdure, to lh (J >C li>l .. hieb thcti: i, ,
Unfiled Notes Page 3