Epitaph William Allen Pusey John Thorne Crissey, M.D. Los Angeles, CA William Allen Pusey, who for many years was known quite properly as the dean of American dermatology, was born in Elizabethtown, KY, on Dec. 1, 1865. A descendant of Quaker immigrants who had come to America with William Penn and the son of a much loved and respected Eliza- bethtown general practitioner, he received his un- dergraduate education at Vanderbilt University, from which institution he was graduated in 1885, valedictorian of his class. He received his M.D. degree in 1888 from the Medical College of New York University. Tenth in a class of 200, he was unhappy with the didacticism, lack of student in- put, and failure to instruct on a practical level that characterized the curriculum of this and many other American medical schools at the time--his lifelong interest in educational matters took its origin in these years of student discomfort. His very first scientific publication, Medical Educa- tion From the Student' s Point o[" View ( 1891) 1 was in fact a stinging indictment of the system which, in the manner of most youthful productions, was long on criticism and short on practical sugges- tions for reform. Pusey's interest in dermatology came early. Immediately after graduation he spent 2 years working with George Elliott at the Skin and Cancer Hospital in New York, following which, with a new bride, he sailed for Europe for the tour of the clinics that was then de rigueur for phy- sicians interested in specialization. Within a few months his father died and the young physician returned to Elizabethtown for a year to settle the family affairs. He returned to Europe in 1891 and spent the next 2 years at the dermatology clinics in From the Department of Dermatology and Syphilology, University of Southern California, School of Medicine. Reprint requests to: Dr. John T. Crissey, 960 East Green St., Pasadena, CA 91106. 702 London, Paris, Vienna, and Berlin, never staying long enough in any one place, however, to be identified with a particular European school. Nothing in Pusey's life was allowed to happen by chance or without preparation, if he could help it. After thoroughly canvassing the geographic possibilities, he settled in Chicago in 1893, at the age of 29, and without any influential medical connections, opened an office. The "cold turkey" approach was as painful then as now, and to sup- plement his income he took a job as examiner for the New York Life Insurance Company. It is en- tirely characteristic of Pusey's remarkable ability to organize and influence others that he was soon made local medical director of the company. In 1896 Pusey resigned from his insurance company post to devote his time entirely to der- matologic practice, and he also accepted a teach- ing position at the College of Physicians and Surgeons in Chicago. Appointed professor of dermatology a year later, he continued in this ca- pacity for the next 20 years, during which time he also served as secretary of the institution and used his position with great felicity to upgrade the cur- riculum and secure the integration of the school into the University of Illinois system. The diplo- matic expertise developed in that difficult task was an essential adjunct to his later successes in the world of medical politics, but the immediate key to the elevation of Pusey from an obscure figure in the lower echelons of midwestern dermatology to a physician of national prominence is to be found in his early recognition of the significance and usefulness of the turn of the century's most excit- ing therapeutic innovation, x-ray. The 1895 publi- cation of Roentgen's remarkable discovery was followed immediately by a period of feverish ac- tivity in which investigators around the world applied the new technics to medical diagnostic problems. With the appearance of the first x-ray
Transcript
Epitaph
William Allen Pusey John Thorne Crissey, M.D. Los Angeles, CA
William Allen Pusey, who for many years was known quite properly as the dean of American dermatology, was born in Elizabethtown, KY, on Dec. 1, 1865. A descendant of Quaker immigrants who had come to America with William Penn and the son of a much loved and respected Eliza- bethtown general practitioner, he received his un- dergraduate education at Vanderbilt University, from which institution he was graduated in 1885, valedictorian of his class. He received his M.D. degree in 1888 from the Medical College of New York University. Tenth in a class of 200, he was unhappy with the didacticism, lack of student in- put, and failure to instruct on a practical level that characterized the curriculum of this and many other American medical schools at the t ime--his lifelong interest in educational matters took its origin in these years of student discomfort. His very first scientific publication, Medical Educa- tion From the Student' s Point o[" View ( 1891) 1 was in fact a stinging indictment of the system which, in the manner of most youthful productions, was long on criticism and short on practical sugges- tions for reform.
Pusey's interest in dermatology came early. Immediately after graduation he spent 2 years working with George Elliott at the Skin and Cancer Hospital in New York, following which, with a new bride, he sailed for Europe for the tour of the clinics that was then de rigueur for phy- sicians interested in specialization. Within a few months his father died and the young physician returned to Elizabethtown for a year to settle the family affairs. He returned to Europe in 1891 and spent the next 2 years at the dermatology clinics in
From the Department of Dermatology and Syphilology, University of Southern California, School of Medicine.
Reprint requests to: Dr. John T. Crissey, 960 East Green St., Pasadena, CA 91106.
702
London, Paris, Vienna, and Berlin, never staying long enough in any one place, however, to be identified with a particular European school.
Nothing in Pusey's life was allowed to happen by chance or without preparation, if he could help it. After thoroughly canvassing the geographic possibilities, he settled in Chicago in 1893, at the age of 29, and without any influential medical connections, opened an office. The "cold turkey" approach was as painful then as now, and to sup- plement his income he took a job as examiner for the New York Life Insurance Company. It is en- tirely characteristic of Pusey's remarkable ability to organize and influence others that he was soon made local medical director of the company.
In 1896 Pusey resigned from his insurance company post to devote his time entirely to der- matologic practice, and he also accepted a teach- ing position at the College of Physicians and Surgeons in Chicago. Appointed professor of dermatology a year later, he continued in this ca- pacity for the next 20 years, during which time he also served as secretary of the institution and used his position with great felicity to upgrade the cur- riculum and secure the integration of the school into the University of Illinois system. The diplo- matic expertise developed in that difficult task was an essential adjunct to his later successes in the world of medical politics, but the immediate key to the elevation of Pusey from an obscure figure in the lower echelons of midwestern dermatology to a physician of national prominence is to be found in his early recognition of the significance and usefulness of the turn of the century's most excit- ing therapeutic innovation, x-ray. The 1895 publi- cation of Roentgen's remarkable discovery was followed immediately by a period of feverish ac- tivity in which investigators around the world applied the new technics to medical diagnostic problems. With the appearance of the first x-ray
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Fig. 1. Wllham Allen Pusey, as he looked in 1899 when, at the age of 33, he hurried off to Vzenna to collect the parts needed to construct one of America's first x-ray machines
burn, which followed close on the heels of the development of the first x-ray machine, it became evident that radmtion exerted profound effects on the skin It was inevitable that these cutaneous effects would be investigated and exploited In- deed, by 1899 SchIff and Freund m Vienna had already reported the use of x-ray in the epflatlon of a large ha~ry nevus, and the hterature was soon flooded wtth other uses and recommendations, a number of which are qmte capable of generating unpleasant visceral autonomic sensations in the modern phys~clan who reviews them
Pusey was fascinated by the Viennese reports In 1899 he hurried to the Austrian capital, spent a single evening with Freund, acquired an exact duphcate of the apparatus used by Freund, and returned at once to Chicago, where he hired an electrician to assemble the parts and proceeded to put it Into action on patients w~thout ever having
THE
CHICAOO / ~ E D I C A L
R E C O R D E R A P R I L . 1902,
@riO/hal ~Irtlc[@.
REPOET OF CAriES TREATED WI'I2K ~OENTGEN EAY8,
BY WM ALLEN PUSEY. A. M ~ M, D, PItOFI~$OR OF DIt-RM&TOL~Y L~ THB U N | Y ] ~ ' OF II .~IMOI~
Case I l~eferred to me by l~of. H ~ Favill' of ~ush Me&eal College. Woman, age 38, ~',fh ~ t ~ ¢ 0 lupua revolving the d u ~ cheeks and fleck, o f / o u r years' duration H~led wl~ heslthy~ safe, white scars after five months Thls pahent haa be~n well now a year and a half and ~hows no ~tgn of reearrence. ~ ~.e~t ~ reported an detafi m the Journal of the Aratmea~ Medmtd ) ~ [ a a hen, of Dee 8, 1900 (thg 1 and F ig liL}
Case I I Pder red to me by P ~ f A. 3". 0dasher of the Unlver~Ry of n h n m s Lupus of the no~e an a girl s ~ yearn old, of two )ears' duration Healea wlth healthy scars after five mouths. laeally no deformity Thls pahent has been ~11 fo~ a year and t ! l t~
n . evldence of remrcenc~ The ease was reported m dehR mthO Journal o f the Amenean Medleal Aasoclat,o~' Sept, 28~ 1901 (1~
Y , Y /~ , any sorl of skan eruplaon, except the one on her chin Her hmb~ry ~nves ~o eaep~eton ofsyphhs She has four healthy children Ivnng and has had one m~searnage of a healthy fetus between tim tined and fourth months He r family hetory ~a without atgmflcance, ex~lft that he r ~ather &ed a t the age of forLy nine of ohronte lung "trouble. The pahent aa ~at~ befit and not very v~gomus looMng, hut lhora m n o o r g a l l l e dlBeal~
When she came to me m March, 1901~ there we, re two ~hyper- Read wkh climeal and stereoptlcoa demoal~Watlon he.lore the C h l ~
M,nllusl .~a~l~tF. Feb ~16, 19~ For d,scmmtus see March gecmd~r
F,g. 2. Title page to Pusey's 1902 paper, "Report of Cases Treated With Roentgen Rays " The deep im- pression made on colleagues when Pusey presented this paper, along with case demonstrations, before the Chicago Medical Society and the excitement created by the newspaper accounts of the proceedings assured Pusey of future success (From Pusey WA Med Rec- ord 22:251-261, 1902 )
seen the machine in actual operation (Fig 1) Perhaps because the output of his machine was comparatively low, or his efforts were tempered by the caution engendered by his total unfamiliar- ity with the new device, Pusey's results were ap- parently better and less destructive than those achieved by the majority of his contemporaries Over the next 2 years he pubhshed a number of reports on h~s findings, including the first ever uses of x-ray in the treatment o f leukemia and Hodgkln's disease
In February 1902, he presented a paper entitled "Report of Cases Treated by X-rays' '~- before an
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Fig. 3. Case 1. Lupus vulgaris, before and after roentgen-ray treatment, from Pusey's 1902 "Report of Cases Treated With Roentgen Rays." The thirty-six cases presented included numerous "rodent ulcers," carcinoma of the breast, keloid, sarcoma, and a number of other conditions. (From Pusey WA: Med Record 22:251-261, 1902.)
SRO meeting of the Chicago Medical Society. The oral presentation was accompanied by thirty- six case demonstrations, many of them impressive results in the treatment of ' 'rodent u lcers" that had gotten completely out of hand, disastrous exam- ples of lupus vulgaris, and similar cases (Figs. 2 and 3). It was one of the most exciting and dra- matic convocations in the history of that society, matched only by the earlier meeting at which John B. Murphy presented his first report on the surgi- cal treatment of acute appendicitis, and when it was over, Pusey was famous. Arriving at his office the day after the newspaper accounts of the event, he was astonished to find a long line of patients in advanced stages of various forms of dermatologic disrepair, eager to benefit from the new technology. His single machine soon grew to four, and in the heyday of his practice, all of them were busy the whole day long.
The culmination of this work was a magisterial textbook, Roentgen Rays #~ Therapeutics and Di- agnosis, a published by Pusey in 1903 in collab- oration with Eugene Caldwell of the Gibbs X-ray Laboratory in New York. The work was an im- mediate and outstanding success and remained the standard American reference work on the subject for many years.
Despite the efforts of a hardy few, x-ray, espe- cially in the treatment of nonmalignant cutaneous
disease, has largely passed from the dermatologic scene in North America. It is the victim to some extent of the Hiroshima syndrome, that often irra- tional attitude shared by many, in which radiation in any form, from dental x-rays to nuclear power plants, has been pronounced anathema. But x-ray treatment has also succumbed in the natural way to the advent of improved surgical technics, effective antibiotics, topical steroids, and other modalities far less controversial than electromagnetic radia- tion. Because the method is no longer highly visi- ble, younger physicians may have difficulty ap- preciating the impact of Pusey's x-ray reports and textbook and the ease with which he rode this vehicle to national prominence. From 1900 through the 1940s, the x-ray machine was an in- dispensable tool in the treatment of skin diseases, and when George Miller MacKee continued as late as 1947 to insist in his own textbook on radiation therapy that x-ray was "the most useful and im- portant single agent in the armamentarium of der- matology,"4 he expressed accurately the consen- sus of the era.
In addition to the identification of his name with a treatment modality no longer popular, another factor that works to reduce Pusey's apparent rele- vance to current dermatology, and somehow makes him seem a figure more remote in time than he actually was, is his close association with
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syphilology. His bibliography provides ample evidence of a lifelong preoccupation with trepo- nemal problems.'~ His essay, Syphilis as a Modern Problem, 6 which appeared in a volume partially aimed at the general public and published in asso- ciation with the Panama-Pacific exposition pro- ceedings of the American Medical Association (AMA) held in San Francisco in 1915, presented the clinical and social parameters of the disease in a forthright manner that was unusual for the time, and exerted perhaps more influence on the at- titudes of the nonmedical intellectuals and the politically powerful classes of North America to- ward venereal disease than any other contempo- rary work. It was not surprising, then, that follow- ing the entrance of the United States into World War I in 1917, Pusey was invited by the Surgeon General to become his advisor on venereal mat- ters. As an anomalous major, without uniform and unrestricted in his activities, he worked indefa- tigably to outline a complete and remarkably ef- fective program for the identification and man- agement of the enormous problems generated by venereal disease in the rapidly expanding military establishments. As the chairman of a committee of five (the others being men of his own choosing), he put together the standard venereal disease treatment manual used by the armed services throughout the conflict and by many of the state boards of health well into the 1920s.
The decline in the incidence of syphilis in the years following World War II and the decision on the part of dermatologic leaders a generation ago to divorce the specialty from its long association with syphilology have combined to diminish the recognition once accorded to Pusey for his ac- complishments. That the decision to divest der- matology of its venereologic holdings was ill con- sidered is evident in our loss of influence on the national scene, now that these diseases are once more in the public eye, and it is particularly dis- turbing when representatives from other medical disciplines are called upon by the news media to perform as experts on problems that are in fact dealt with with equal skill and often with greater frequency by dermatologists. And more than that, the elimination of the venereologic limb precludes the development within our ranks of those special
masters with the added dimension who contributed so much to the reputation of the specialty in for- mer times, John Stokes, or Udo Wile, or Herman Beerman, for example, and, of course, William Allen Pusey.
Pusey's practical bent and abiding interest in therapeutic matters were illustrated again in his introduction in 1905 of carbon dioxide snow as an agent in the treatment of skin lesions. 7 He was familiar with the earlier work of White 8 and others who had employed liquid air for the same purpose, and he noted that the difficulties in supply and maintenance of the latter effectively prevented its routine use, while liquid carbon dioxide was available wherever soda fountain supplies were sold. In his initial report he stressed the usefulness of carbon dioxide in the treatment of large nevi, but mentioned also that solar keratoses, warts, and other lesions could be treated successfully with the material when it is compressed into solid form in a chamois skin and cut to size with a pocket knife. The technic caught on immediately, and another increment of recognition was added to the inven- tor's already impressive list.
in 1907 Pusey completed a large and very suc- cessful textbook, The Principles and Practice of Dermatology, 9 a task that occupied most of his spare time for more than 3 years. He himself took most of the clinical photographs used in the book and often worked far into the night in his basement hideaway, where he had also set up an apparatus for taking photomicrographs. This book is an example of the new genre, the new style in der- matologic textbook construction pioneered by Louis Dub.ring and Henry Stelwagon, in which the authoritative approach of the nineteenth century was replaced by a conscious attempt at personal detachment on the part of the author and by a text supported with numerous references, photo- graphs, photomicrographs, and a detailed index, to achieve the twentieth century tone and format taken for granted now. The Principles and Prac- tice of Dermatology is less scholarly than Stel- wagon's magnificent treatise, which belongs to the same era, but it benefits greatly from the author's lucid prose style, on which he prided himself, and it can still be read for both profit and pleasure.
The detailed knowledge of the literature ab-
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Fig. 4. William Allen Pusey: mature configuration-- dean of American dermatology, past president of the American Medical Association, editor of Archives of Dermatology and Syphilology, and much, much more.
sorbed by Pusey in preparing his textbook and the literary skills and discipline acquired perforce by anyone who successfully completes a project of this magnitude served him well in carrying out another job of great importance to the specialty. From 1883 through 1919, the most important American literary vehicle devoted to dermatology was the Journal of Cutaneous Diseases. It was a lively publication, but a money-losing proposi- tion, supported by private donors who grew more restive and disenchanted with every passing fiscal year. Pusey, who was himself on the list of those called upon to contribute, succeeded in 1920 in convincing his friends in the hierarchy of the AMA to take over the journal and develop it as a scientific periodical, as that organization had al- ready seen fit to do with a number of other spe- cialty journals. The new version, Archives of Der- matology and Syphilology, was born in 1920 and of course is still in existence. Pusey was selected as chief editor, a post which he held until 1937,
and it is uniformly agreed that no one ever carried out that impossible task with greater proficiency and devotion. 10
Pusey was at one time or another the president of numerous dermatologic, general medical, and paramedical organizations. But it was the know- how developed as treasurer of the AMA from 1911 to 1922, and especially as president and official peacemaker of the faction-ridden Chicago Medical Society during the same period, that pre- pared him for election in 1923 to what was then indisputably the most prestigious political position in American medicine, president of the AMA. Nor was he merely a figurehead. He plunged into the work with customary vigor, concerning himself particularly with the subject of his very first publi- cation, medical education, putting forth proposals designed to strike a balance between the theoreti- cal and the practical, concerns that are with us still. A lifelong conservative, Pusey was also a vigorous advocate of measures to forestall the forces of socialized medicine, forces that, in the aftermath of the Bolshevik revolution of 1917 and the perceived trends in Western Europe, seemed perhaps stronger than they actually were. 11'1~
A nationally known figure by this time (Fig. 4), and accepted as an articulate spokesman for mainstream American medicine, Pusey became even more famous through his efforts as a member of the executive committee of the National Re- search Council to enlist support of that powerful organization in the preparation and presentation of the superb medical exhibits at the Chicago World's Fair of 1933, "A Century of Progress." All agree that this constituted a contribution of great significance in educating the North Ameri- can public on the exciting new directions in mod- em medicine, la
The importance to dermatology of these politi- cal positions and triumphs should not be underesti- mated. Although Pusey belonged, properly speak- ing, to the third generation of the North American version of the specialty, there were still at the time a great many physiciains in and out of academic medicine who were not at all certain that the prac- tice of dermatology was a suitable way for a pro- fessional man to earn his daily bread. The acces- sion to the really prestigious jobs of a man so thoroughly identified with the field helped to sup-
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ply the final imprimatur of legitimacy, and all of us have benefited from it ever since.
Pusey's life was not free, of course, from the rainstorms that dampen the spirits of even the most fortunate from time to time. One such episode that can be appreciated readily by the dermatologists of today who are exposed to similar temptations is the miniflap generated in the early 1930s by the Chicago sage's dealings with that portion of the commercial world concerned with the marketing of soap. Procter & Gamble approached Pusey for advice on how best to advertise honestly to the public a new soap, Camay, which they were about to introduce. "They suggested," Pusey said, "that I get a group of dermatologists of my selec- tion to examine the soap and prepare instructions for bathing and the use of soap and, if they found this soap was of high quality, to certify to that effect."14 When the work was finished, Pusey al- lowed his name to be used in Camay advertise- ments to validate the results. He was roundly criticized for this, even by his own associate in practice, but he justified his position by pointing out that Procter & Gamble had tried to do what the medical profession routinely criticized commer- cial firms for failing to do, namely, seek advice from physicians on the medical aspects of their products.
Could the profession hope to have any influence with business concerns, he asked, if it was always eager to condemn bad commercial practices but never willing to support good ones? Certainly, Pusey's approach was infinitely preferable to the mindless testimonials of show business celebrities with which the public was constantly bombarded, just as it is today. It was also a long way up the ethical ladder from the crass endorsements of tur- tle oil soap made in the previous century by Erasmus Wilson, who was at the time the best- known dermatologist in the English-speaking world. Nevertheless, one suspects that had he known the ultimate reaction, Pusey might have concluded that the rewards, whatever they were, were hardly worth the trouble.
A discussion of Pusey would be shamefully in- complete without some mention of his contribu- tions to medical history. 15 His History of Der- matology, which appeared in 1932,1~ is the first treatise on the subject in English. Coveted now by
collectors, it is a free-flowing commentary, infor- mative, smoothly written, and satisfying to read, and Pusey followed it up a year later with a smaller but equally polished volume on the history of syphilis. 17 No American dermatologist of the first rank excelled Pusey in combining a mastery of the hard facts developed in the scientific labora- tory with the practical, personal, and business skills essential to success in practice, and yet he devoted thousands of hours to these antiquarian pursuits. He was firmly convinced that those who ignore their intellectual antecedents, who fail to appreciate and memorialize in some way the ef- forts of the individuals who traveled the same road in earlier times, are, in the words of Edmund Burke, "no better than the flies of summer." On a more pragmatic level, he was also fully aware of an obvious fact sometimes overlooked by the spe- cialty's educators, that one of the easiest and most effective means available to acquire an under- standing of a complex and current medical prob- lem is to examine in orderly sequence the ideas, observations, and events leading up to it.
Dr. Pusey was fortunate indeed in having a biographer as talented as his associate, Herbert Rattner, who at the time of his chief's retirement wrote him up with the sort of wit, charm, and sympathy we would all be gratified to see em- ployed on our behalf when the moment finally arrives. 14 This pleasing glimpse of Pusey the man appeared in Rattner's account:
The question I am asked most frequently by medical acquaintances is "What is Pusey really like'?." He has been a big name in medicine for so long that most younger men think h!m beyond approach. In fact he is cordiality itself, although there is about him a certain restraint that does not encourage familiarity. Pusey can be taken at face value. He is a man of temperament with occasionally a bilious mood, but there is nothing artificial or insincere about him. I have never known him to curry favor with anybody. Above all he is fair, and his fairness makes its impression on all who have contact with him. He has his foibles, even as do all mortals, and some of his idiosyncrasies are ludicrous. He is slow to shake hands, and if he can avoid it he never touches doorknobs or dirty money. He wears gloves summer and winter, and he always carries a cane. On the golf course he carries an umbrella to shade him from the sun, yet he prefers to ride in his open car. He has a certain degree of vanity, and he is not obtuse
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tO flattery, but he recognizes these weaknesses. He en- joys his ease and requires a great deal o f service, which he accepts graciously. These are all perhaps traits of lesser importance that, if anything, make his personal- ity the more interesting. His presence carries digni ty-- in looks, in manner and in charm and conversation. He would have succeeded equally in any vocation he might have pursued. His career though full and interesting has been one of achievement rather than of adventure. Pusey has remarked that the nearest thing to a real adventure that he has had was that a few years ago he lost his pants in a Pullman car.*
Success had little e f fec t on P us ey ' s smal l town approach to pr iva te p rac t i ce . In his offices in the heart o f down t own Ch icago , he main ta ined a
h o m e s p u n a tmosphe re and an eccentr ic and stub- b o m l y o ld - fa sh ioned decor . " T h e wel l k n o w n count ry doc tor of 7 W e s t M ad i s on S t r e e t , " one obse rve r cal led him, and on another occas ion a V . I .P . pa t ient , p e r c h e d p reca r ious ly for examina- t ion on an article of fu rn i tu re that had seen better days , w a s heard to e x c l a i m , " B y George , Dr. Pusey, y o u m u s t be a d a m n e d g o o d doctor to put patients on a cha i r l ike t h i s . "
Desp i t e his in t imate associa t ion with the power centers o f the genera l med ica l wor ld , Pusey re- ma ined a de rma to log i s t to the end. In one o f his very last pub l ica t ions , TM a su rvey o f de rma to logy that is r edo len t wi th the sweet scent o f benign chauv in i sm , all pe r fec t ly just i f ied of course , he r e v i e w e d the re la t ionsh ip o f the spec ia l ty with the other med ica l fields tha t imp inge upon it. His final printed words addressed to his col leagues were
these:
Dermatology has a field. It has its borderlines, which are not at all points distinct and may merge into other fields. Along these there are likely to be friction, as this also occurs on the ill defined borders between nations. But its great area is well defined, and we possess it not by right of possession but by right of discovery and useful occupation. As long as we hold it by that right it will remain ours. We need have no particular anxiety about the inroads to the highlanders who come down and raid our borders. "The good old rule, the simple plan, that he shall take who has the power and he shall keep who can" is sound ethics when it is applied to the rights o f knowledge. As long as dermatologists justify
the possession of their field by superior usefulness and scientific achievement they can hold it. And no one would wish that they hold it longer.*
In declining health the last few years of his life,
Pusey never theless cont inued to take an active part in his m a n y organizat ional activities a lmost to the end. 19,2° H e died at his h o m e in Chicago on Aug. 29, 1940, at the age of 74.
