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THE NEGLECTFUL PARENT
59 castration than by oestrogen therapy. With either method it was not uncommon for symptoms to return after an interval of about 7 or 8 months ; and when this happened neither castration nor treatment with oestrogen brought any further improvement. However, such relapse was not invariable, and some- of the patients remained free from symptoms for two years or longer. Such an extended arrest of cancer was seen more often in patients treated with stilbcestrol than in those-who had been castrated, and the former method has therefore been now selected by the authors for routine use.
about
more
quickly by
FEVERS
IN
EVERY TONGUE
be considered glasses unnecessary, in fact harmful : ’* If the patient does not go on to cataract, glaucoma, or inflammation of the retina he may consider himself fortunate." Bates ignored, of course, much established clinical and experimental work. In denying the role of the lens in accommodation he harked back a hundred years or more, supporting his thesis by some rather crude demonstrations on the eye of a fish ; though it had already been shown that the mechanism of accommodation in fishes differs from that of mammals. He also denied the action of atropine on the unstriped ciliary muscle, and ascribed its action to an effect on the external muscles though these are striated. Since
atropine acts by paralysing parasympathetic
nerve-
find difficulty in interpreting the exact of endings, it is hard to see how he justified this opinion. of in foreign languages we know fairly writers meaning Nor is it easy to accept an experiment in which he well, when it comes to descriptions of communicable claimed to show that accommodation resulted from diseases like measles, typhoid, or anthrax. English words stimulating the external rectus with an electric current. identical with, or very similar to, the French, Spanish, or This effect was abolished when the muscle was cut, but German terms often connote quite different ideas. One immediately reappeared when the muscle was tied up has only to look at the word anthrax, which in the oriagain, without any interval for regeneration of the ginal Greek &ngr;&thgr;&rgr;&agr;&xgr; means charcoal, but in English-11 injured muscle and nerve. He regarded refractive disease due to B. anthracis, and in France and Spain a errors as an expression of mental restlessness, and his carbuncle or conglomeration of boils. Typhus in France remarkably rapid retinoscopies convinced him that the and England stands for exanthematic typhus, while in refraction of an eye may vary from emmetropia to Germany it means typhoid or enteric fever, sometimes 20 D myopia within a second. But if Bates’s physiology and clinical observations qualified by the adjective " abdominalis." Belgians and French-speaking Swiss also call enteric or typhoid are unsatisfactory, his work and that of his followers typhus." Even when Latin terminology is employed contains an important lesson. Ophthalmologists have the fog is no less dense, for Latin names of communicable not been sufficiently conscious of the truism that there diseases are subject to different interpretations in differare none so blind as those who won’t see : by confusing ent countries. Rubeola at times means measles (Latin, the process of seeing with the act of seeing they have morbilli), at others rubella, rotein or German measles. been apt to overlook a strong subjective element in their From this may arise serious complications-a telegram patients’ sight. Bates and his followers do not make to the Red Cross at Geneva for typhus vaccine, for this particular mistake. example, may result in the despatch, of typhoid vaccine. THE NEGLECTFUL PARENT Errors in death certification are almost unavoidable. are punished by imprisonment for WHEN parents of of Dr. Yves Biraud, head the League Nations service neglect of their children two problems are at once created of epidemiological intelligence, has compiled a volume to send the children while the parents are serving giving all known terms for communicable diseases in Latin -where their and how to prevent them from neglecting the term, and 23 modern European languages. Dr. Biraud is careful children again when they are released. Imprisonment to explain that Gaelic disease-names have not been of parents is no doubt an out-of-date method of treatment included because he considers, and justly, that English for this disorder, and any measure that would teach them is still " one of the national languages of Eire." He does to look after children properly would be more satisfacnot claim that it is a complete list, and with a wise eye to tory. In the Manchester Guardian of Jan. 1, Miss M. future editions, invites the collaboration of the reader Artemus-Jones suggests the establishment of small in supplying names which may have escaped the observacottage institutions, run on the simplest possible lines, he due But to whom credit. his tion of assistants, gives where mothers, taking their children with them, could be it is the work of an extraordinaxily patient and industritaught child care by matrons with practical experience. ous compiler, whose perspicacity and discernment are Neglect, as she points out, is often rooted in mere inefficievident in every page, and with its copious indices will be ency : but the mother who is incompetent to carry out a godsend to the serious student, however expert a her tasks of cleaning and cooking, and lets things drift, linguist he may be. could hardly fail to benefit by simple training in method. THE BATES METHOD The father would be required to contribute to the upkeep FEW of us would wear spectacles if we could find a, of the family while in the training home, and perhaps to clean up the house against their return. way to improve bad sight without them ; hence the The proposal is attractive, though the cost of the attraction of the method devised by the late t)r. W. H. scheme might be substantial. A more serious difficulty Bates is perfectly understandable. The assumptions on which he based his system were set out in a book would perhaps be to keep the mother in the trainingMANY
us
"
published in 1920 (Perfect Sight without Glasses),
and
edition containing fewer technicalities has now appeared under the less ambitious title Good Sight without Glasses Bates held that the lens plays no part in accommodation, which he thought was achieved by a shortening of the globe produced by the action of the extra-ocular muscles. Refraction, he held, is constantly changing and errors of refraction are induced by restlessness or strain." He considered, moreover, that cataract, glaucoma, and optic atrophy are also produced by strain, though of a different type. It followed that
a new
"
of Communicable Diseases: Contribution to the International Nomenclature of Diseases. By Yves Biraud. London: Allen and Unwin. Pp. 556. 4s. MD. 2. The Bates Method of Good Sight without Glasses. William H.
1.
Polyglot Glossary
Bates, MD.
(Faber.
Pp. 159.
10s. 6d.)
home without some prison-like restrictions, or the threat of prison; and this would mean associating the children with the penal aspect of their case. They could hardly fail to acquire some stigma with their contemporaries. Moreover, during the training period, those of -school age would presumably have to go to the school nearest the trainingshome, thus interrupting their attendance at their usual school. Finally the mother-might feel that the father was getting off too lightly. She is to be uprooted from her home and taught her business by a stranger, for which her neighbours will later laugh at her ; whereas he gets offwith cleaning the house-once.
A start might perhaps be made by giving courses in household management to mothers serving terms of
60
imprisonment for neglect ; and if these proved successful, continuation courses mfght be offered for the mothers to attend after discharge. Possibly home helps with some training in social work might, go for a time to the homes of the discharged women, for a couple of hours daily, to help and teach at the same time. The fathers are a tougher proposition. CHEMOTHERAPY OF TYPHUS FEVER only five months since the treatment of typhus
IT is
.
The same paper mentions the use of penicillin in 4 of typhus, and though no conclusions are drawn as to whether this agent modifies the course of typhus itself, it is considered of value in treating secondary bacterial infections. Penicillin has been shown to be of value in experimental murine typhus in mice, but relatively enormous doses were required to affect the outcome of the infection.4 The value of non-specific supportive therapeutic measures in human typhus is stressed in a paper by Woodward and Bland which deals largely with the cardiovascular system in typhus. The circulatory failure, which is so prominent a feature of the disease, is thought to be due predominantly to peripheral vascular rather than to myocardial failure. Adequate fluid intake, parenteral fluids by subcutaneous or intravenous routes, and even human plasma are all regarded as essential in the treatment of typhus, and these, unlike specific remedies such as paba, can be applied even after the first week of the disease at a time when many patients first arrive at the hospital. Their relative impotence in the face of grave typhus is, however, clear from the figures for patients treated symptomatically in the Typhus Commission’s ward in Cairo. cases
discussed in these columns,l but already there is more Members of the American Typhus Commission from Cairo2 record a therapeutic trial of a hitherto unused chemotherapeutic substance, para-aminobenzoic acid (paba). Justification for this trial lay in the fact that large amounts of the substance were found to have a therapeutic effect in experimental murine typhus infection in mice, and a definite inhibitory effect’ on typhusrickettsiæ was also observed in yolk-sac cultures. Furthermore, sulphonamide drugs were thought to have a deleterious action in experimental typhus and it was therefore reasonable to expect that paba, which counteracts the inhibitory action of sulphonamides on ’bacteria,3 would exert an effect opposite to that of the sulphonamides. The American report describes the effect of EFFORT SYNDROME AND GRAVES’S DISEASE 2-hourly dosage with paba by mouth on the course of INTEREST In tne enort synarome, or va uosua-s s louse-borne typhus in 20 Egyptians between the ages has fallen off since 1941, judging by the syndrome, of 18 and 48.The total dose of drug varied from 70 numbers of papers published on it. We are still in the to over 200 grammes in individual’ cases ; all but 2 dark as to its aetiology, however, and Moschcowitz and patients began treatment before the end of the seventh Bernsteinwould like to identify it with what they and 9 of them treated were before or on the fourth day, describe as the larval, or constitutional, phas of Graves’s day of disease. No harmful effect of these massive disease. Superficially their case is convincing, provided doses of paba was observed, the mortality in the 20 that the biological concept of Graves’s disease is valid. treated patients was 10% and the average duration of consider that Graves’s disease " is not a nosological They fever was 12’5 days. Argument is brought forward that in the sense that it has a,well-defined group of entity the drug exerted an ameliorating influence on the course and symptoms and a constant background in signs of the disease, reduced complications, prevented nitrogen morbid anatomy," but rather a series of diseases ranging retention, and caused an earlier defervescence. Cessation from a larval stage to the final classical picture as deof therapy was sometimes followed by a reappearance of scribed in the textbooks. This thesis is not new-it was fever though this was not accompanied by other manithe last war-but added knowledge has festations of typhus infection. Two patients developed’ mooted during the case. strengthened Symptoms and signs in effort a typhus rash while receiving paba, though treated from syndrome are identical in many respects with those of the second and third days of disease.. The observed Graves’s disease, and differences are only noteworthy therapeutic effects were studied against a control back- inthe florid stage. The basal metabolic rate is ground of 44 other patients of similar age-distribution usually said to be normal in effort syndrome, and this is admitted before the end of the first week of the disease often as an important point in the differential accepted to the Commission’s wards in the fever hospital, and diagnosis. But in the larval stage of Graves’s disease too treated symptomatically.These patients, who were the BMR is usually normal; and if a patient suspected selected for study from the general hospital population, of having effort syndrome is found to have a raised experienced severe attacks of typhus with an average BMR the diagnosis is usually changed to Graves’s duration of fever of 18.5 days and had a mortality disease. Again, enlargement of the thyroid gland of 18%. Nine of them, of whom 4 died, were admitted is not uncommon in effort syndrome ; whereas in the. to the hospital in alternate fashion to the patients treated early stages of Graves’s disease, and even sometimes in with paba, but the remainder were admitted at various cases, the gland may not be appreciably well-developed times during the epidemics of typhus in 1943 and 1944. few records exist of florid Graves’s disease True, enlarged. No fewer than 44% of these patients exhibited nitrogen in patients known to have effort developed having retention. the in only follow-up of any size that has syndrome The evidence presented is of the kind most difficult no case of Graves’s disease was found been reported, to assess in the whole complex realm of human therain the 665 patients investigated.7 It might be argued,. peutics. The results are undoubtedly encouraging, yet however, that a man boarded out of ,the forces loses the possibility remains, as in any group of patients much of his cause for anxiety and hence is likely to artificially selected from a series, that the control and improve; Cohn,8 inspecting base hospitals a week after treated groups were not strictly comparable and therethe armistice of 1918, found only a few cases of the fore that chance distribution of mild illnesses may have was
to
report.
It is clear that, at the very early stage of disease when treatment was began, prognosis was impossible. However, all who consult the original paper will agree that unless the Cairo workers were unlucky enough to have selected for treatment patients in whom the prognosis was actually. better than the average, their results should lead to further trials, though probably not to orders for paba by the ton. favoured the
drug therapy.
1. Lancet,1944,ii, 214. 2. Yeomans, A., Snyder, J. C., Murray, E. S., Zarafonetis, C. J. Ecke, R. S. J. Amer. med. Ass. 1944, 126, 349. 3. Woods, D. D. Brit. J. exp. Path. 1940, 21, 74.
D.,
effort syndrome where previously they had been numerous. Moschcowitz and Bernstein give records of 11 cases inwhich the transition from effort syndrome to florid Graves’s disease seems to be well established. While their case cannot be accepted as proved, its further study may provide a means of reconciling the conflicting views of psychologists and physicians.
4. 5. 6. 7. 8.
Moragues, V., Pinkerton. H., Greiff, D. J. exp. Med. 1944, 79, 431. Woodward, T. E., Bland, E. F. J. Amer. med. Ass. 1944, 126, 287. Moschcowitz, E., Bernstein, S. S. Amer. Heart J. 1944, 28, 177. Grant, R. T. Heart, 1925, 12, 121. Cohn, A. E.Amer.J.med.Sci.1919,163,453.
about
more
quickly by
FEVERS
IN
EVERY TONGUE
be considered glasses unnecessary, in fact harmful : ’* If the patient does not go on to cataract, glaucoma, or inflammation of the retina he may consider himself fortunate." Bates ignored, of course, much established clinical and experimental work. In denying the role of the lens in accommodation he harked back a hundred years or more, supporting his thesis by some rather crude demonstrations on the eye of a fish ; though it had already been shown that the mechanism of accommodation in fishes differs from that of mammals. He also denied the action of atropine on the unstriped ciliary muscle, and ascribed its action to an effect on the external muscles though these are striated. Since
atropine acts by paralysing parasympathetic
nerve-
find difficulty in interpreting the exact of endings, it is hard to see how he justified this opinion. of in foreign languages we know fairly writers meaning Nor is it easy to accept an experiment in which he well, when it comes to descriptions of communicable claimed to show that accommodation resulted from diseases like measles, typhoid, or anthrax. English words stimulating the external rectus with an electric current. identical with, or very similar to, the French, Spanish, or This effect was abolished when the muscle was cut, but German terms often connote quite different ideas. One immediately reappeared when the muscle was tied up has only to look at the word anthrax, which in the oriagain, without any interval for regeneration of the ginal Greek &ngr;&thgr;&rgr;&agr;&xgr; means charcoal, but in English-11 injured muscle and nerve. He regarded refractive disease due to B. anthracis, and in France and Spain a errors as an expression of mental restlessness, and his carbuncle or conglomeration of boils. Typhus in France remarkably rapid retinoscopies convinced him that the and England stands for exanthematic typhus, while in refraction of an eye may vary from emmetropia to Germany it means typhoid or enteric fever, sometimes 20 D myopia within a second. But if Bates’s physiology and clinical observations qualified by the adjective " abdominalis." Belgians and French-speaking Swiss also call enteric or typhoid are unsatisfactory, his work and that of his followers typhus." Even when Latin terminology is employed contains an important lesson. Ophthalmologists have the fog is no less dense, for Latin names of communicable not been sufficiently conscious of the truism that there diseases are subject to different interpretations in differare none so blind as those who won’t see : by confusing ent countries. Rubeola at times means measles (Latin, the process of seeing with the act of seeing they have morbilli), at others rubella, rotein or German measles. been apt to overlook a strong subjective element in their From this may arise serious complications-a telegram patients’ sight. Bates and his followers do not make to the Red Cross at Geneva for typhus vaccine, for this particular mistake. example, may result in the despatch, of typhoid vaccine. THE NEGLECTFUL PARENT Errors in death certification are almost unavoidable. are punished by imprisonment for WHEN parents of of Dr. Yves Biraud, head the League Nations service neglect of their children two problems are at once created of epidemiological intelligence, has compiled a volume to send the children while the parents are serving giving all known terms for communicable diseases in Latin -where their and how to prevent them from neglecting the term, and 23 modern European languages. Dr. Biraud is careful children again when they are released. Imprisonment to explain that Gaelic disease-names have not been of parents is no doubt an out-of-date method of treatment included because he considers, and justly, that English for this disorder, and any measure that would teach them is still " one of the national languages of Eire." He does to look after children properly would be more satisfacnot claim that it is a complete list, and with a wise eye to tory. In the Manchester Guardian of Jan. 1, Miss M. future editions, invites the collaboration of the reader Artemus-Jones suggests the establishment of small in supplying names which may have escaped the observacottage institutions, run on the simplest possible lines, he due But to whom credit. his tion of assistants, gives where mothers, taking their children with them, could be it is the work of an extraordinaxily patient and industritaught child care by matrons with practical experience. ous compiler, whose perspicacity and discernment are Neglect, as she points out, is often rooted in mere inefficievident in every page, and with its copious indices will be ency : but the mother who is incompetent to carry out a godsend to the serious student, however expert a her tasks of cleaning and cooking, and lets things drift, linguist he may be. could hardly fail to benefit by simple training in method. THE BATES METHOD The father would be required to contribute to the upkeep FEW of us would wear spectacles if we could find a, of the family while in the training home, and perhaps to clean up the house against their return. way to improve bad sight without them ; hence the The proposal is attractive, though the cost of the attraction of the method devised by the late t)r. W. H. scheme might be substantial. A more serious difficulty Bates is perfectly understandable. The assumptions on which he based his system were set out in a book would perhaps be to keep the mother in the trainingMANY
us
"
published in 1920 (Perfect Sight without Glasses),
and
edition containing fewer technicalities has now appeared under the less ambitious title Good Sight without Glasses Bates held that the lens plays no part in accommodation, which he thought was achieved by a shortening of the globe produced by the action of the extra-ocular muscles. Refraction, he held, is constantly changing and errors of refraction are induced by restlessness or strain." He considered, moreover, that cataract, glaucoma, and optic atrophy are also produced by strain, though of a different type. It followed that
a new
"
of Communicable Diseases: Contribution to the International Nomenclature of Diseases. By Yves Biraud. London: Allen and Unwin. Pp. 556. 4s. MD. 2. The Bates Method of Good Sight without Glasses. William H.
1.
Polyglot Glossary
Bates, MD.
(Faber.
Pp. 159.
10s. 6d.)
home without some prison-like restrictions, or the threat of prison; and this would mean associating the children with the penal aspect of their case. They could hardly fail to acquire some stigma with their contemporaries. Moreover, during the training period, those of -school age would presumably have to go to the school nearest the trainingshome, thus interrupting their attendance at their usual school. Finally the mother-might feel that the father was getting off too lightly. She is to be uprooted from her home and taught her business by a stranger, for which her neighbours will later laugh at her ; whereas he gets offwith cleaning the house-once.
A start might perhaps be made by giving courses in household management to mothers serving terms of
60
imprisonment for neglect ; and if these proved successful, continuation courses mfght be offered for the mothers to attend after discharge. Possibly home helps with some training in social work might, go for a time to the homes of the discharged women, for a couple of hours daily, to help and teach at the same time. The fathers are a tougher proposition. CHEMOTHERAPY OF TYPHUS FEVER only five months since the treatment of typhus
IT is
.
The same paper mentions the use of penicillin in 4 of typhus, and though no conclusions are drawn as to whether this agent modifies the course of typhus itself, it is considered of value in treating secondary bacterial infections. Penicillin has been shown to be of value in experimental murine typhus in mice, but relatively enormous doses were required to affect the outcome of the infection.4 The value of non-specific supportive therapeutic measures in human typhus is stressed in a paper by Woodward and Bland which deals largely with the cardiovascular system in typhus. The circulatory failure, which is so prominent a feature of the disease, is thought to be due predominantly to peripheral vascular rather than to myocardial failure. Adequate fluid intake, parenteral fluids by subcutaneous or intravenous routes, and even human plasma are all regarded as essential in the treatment of typhus, and these, unlike specific remedies such as paba, can be applied even after the first week of the disease at a time when many patients first arrive at the hospital. Their relative impotence in the face of grave typhus is, however, clear from the figures for patients treated symptomatically in the Typhus Commission’s ward in Cairo. cases
discussed in these columns,l but already there is more Members of the American Typhus Commission from Cairo2 record a therapeutic trial of a hitherto unused chemotherapeutic substance, para-aminobenzoic acid (paba). Justification for this trial lay in the fact that large amounts of the substance were found to have a therapeutic effect in experimental murine typhus infection in mice, and a definite inhibitory effect’ on typhusrickettsiæ was also observed in yolk-sac cultures. Furthermore, sulphonamide drugs were thought to have a deleterious action in experimental typhus and it was therefore reasonable to expect that paba, which counteracts the inhibitory action of sulphonamides on ’bacteria,3 would exert an effect opposite to that of the sulphonamides. The American report describes the effect of EFFORT SYNDROME AND GRAVES’S DISEASE 2-hourly dosage with paba by mouth on the course of INTEREST In tne enort synarome, or va uosua-s s louse-borne typhus in 20 Egyptians between the ages has fallen off since 1941, judging by the syndrome, of 18 and 48.The total dose of drug varied from 70 numbers of papers published on it. We are still in the to over 200 grammes in individual’ cases ; all but 2 dark as to its aetiology, however, and Moschcowitz and patients began treatment before the end of the seventh Bernsteinwould like to identify it with what they and 9 of them treated were before or on the fourth day, describe as the larval, or constitutional, phas of Graves’s day of disease. No harmful effect of these massive disease. Superficially their case is convincing, provided doses of paba was observed, the mortality in the 20 that the biological concept of Graves’s disease is valid. treated patients was 10% and the average duration of consider that Graves’s disease " is not a nosological They fever was 12’5 days. Argument is brought forward that in the sense that it has a,well-defined group of entity the drug exerted an ameliorating influence on the course and symptoms and a constant background in signs of the disease, reduced complications, prevented nitrogen morbid anatomy," but rather a series of diseases ranging retention, and caused an earlier defervescence. Cessation from a larval stage to the final classical picture as deof therapy was sometimes followed by a reappearance of scribed in the textbooks. This thesis is not new-it was fever though this was not accompanied by other manithe last war-but added knowledge has festations of typhus infection. Two patients developed’ mooted during the case. strengthened Symptoms and signs in effort a typhus rash while receiving paba, though treated from syndrome are identical in many respects with those of the second and third days of disease.. The observed Graves’s disease, and differences are only noteworthy therapeutic effects were studied against a control back- inthe florid stage. The basal metabolic rate is ground of 44 other patients of similar age-distribution usually said to be normal in effort syndrome, and this is admitted before the end of the first week of the disease often as an important point in the differential accepted to the Commission’s wards in the fever hospital, and diagnosis. But in the larval stage of Graves’s disease too treated symptomatically.These patients, who were the BMR is usually normal; and if a patient suspected selected for study from the general hospital population, of having effort syndrome is found to have a raised experienced severe attacks of typhus with an average BMR the diagnosis is usually changed to Graves’s duration of fever of 18.5 days and had a mortality disease. Again, enlargement of the thyroid gland of 18%. Nine of them, of whom 4 died, were admitted is not uncommon in effort syndrome ; whereas in the. to the hospital in alternate fashion to the patients treated early stages of Graves’s disease, and even sometimes in with paba, but the remainder were admitted at various cases, the gland may not be appreciably well-developed times during the epidemics of typhus in 1943 and 1944. few records exist of florid Graves’s disease True, enlarged. No fewer than 44% of these patients exhibited nitrogen in patients known to have effort developed having retention. the in only follow-up of any size that has syndrome The evidence presented is of the kind most difficult no case of Graves’s disease was found been reported, to assess in the whole complex realm of human therain the 665 patients investigated.7 It might be argued,. peutics. The results are undoubtedly encouraging, yet however, that a man boarded out of ,the forces loses the possibility remains, as in any group of patients much of his cause for anxiety and hence is likely to artificially selected from a series, that the control and improve; Cohn,8 inspecting base hospitals a week after treated groups were not strictly comparable and therethe armistice of 1918, found only a few cases of the fore that chance distribution of mild illnesses may have was
to
report.
It is clear that, at the very early stage of disease when treatment was began, prognosis was impossible. However, all who consult the original paper will agree that unless the Cairo workers were unlucky enough to have selected for treatment patients in whom the prognosis was actually. better than the average, their results should lead to further trials, though probably not to orders for paba by the ton. favoured the
drug therapy.
1. Lancet,1944,ii, 214. 2. Yeomans, A., Snyder, J. C., Murray, E. S., Zarafonetis, C. J. Ecke, R. S. J. Amer. med. Ass. 1944, 126, 349. 3. Woods, D. D. Brit. J. exp. Path. 1940, 21, 74.
D.,
effort syndrome where previously they had been numerous. Moschcowitz and Bernstein give records of 11 cases inwhich the transition from effort syndrome to florid Graves’s disease seems to be well established. While their case cannot be accepted as proved, its further study may provide a means of reconciling the conflicting views of psychologists and physicians.
4. 5. 6. 7. 8.
Moragues, V., Pinkerton. H., Greiff, D. J. exp. Med. 1944, 79, 431. Woodward, T. E., Bland, E. F. J. Amer. med. Ass. 1944, 126, 287. Moschcowitz, E., Bernstein, S. S. Amer. Heart J. 1944, 28, 177. Grant, R. T. Heart, 1925, 12, 121. Cohn, A. E.Amer.J.med.Sci.1919,163,453.