Cullen

The Consultation Letters of Dr William Cullen (1710-1790) at the Royal College of Physicians of Edinburgh

 

[ID:2898] From: Dr Ralph Irving / To: Dr William Cullen (Professor Cullen) / Regarding: Governor George Johnstone (Johnston) (Patient) / 5 October 1786 / (Incoming)

Letter from Ralph Irving, concerning the case of Governor George Johnstone, who has had a swollen testicle and also a tumour of the jaw. His tongue and tonsils are also affected, and it affects speech and swallowing. Irving believes the disease to have a venereal origin, but now to have a cancerous diathesis. He has a history of syphilis (and has bony excrescences on his shins), and has been heavily treated with mercury in the past. He has also taken the waters in Caldas (Caldas da Rainha, Portugal – here misspelled as 'Calas') and at Malvern, and is currently in Bristol. Irving encloses a case note that he wrote at Malvern, with annotations and corrections by the patient himself. Irving also asks Cullen's advice on going to India.

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Metadata

FieldData
DOC ID 2898
RCPE Catalogue Number CUL/1/2/1931
Main Language English
Document Direction Incoming
Date5 October 1786
Annotation None
TypeAuthorial original
Enclosure(s) Enclosure(s) present
Autopsy No
Recipe No
Regimen No
Letter of Introduction No
Case Note No
Summary Letter from Ralph Irving, concerning the case of Governor George Johnstone, who has had a swollen testicle and also a tumour of the jaw. His tongue and tonsils are also affected, and it affects speech and swallowing. Irving believes the disease to have a venereal origin, but now to have a cancerous diathesis. He has a history of syphilis (and has bony excrescences on his shins), and has been heavily treated with mercury in the past. He has also taken the waters in Caldas (Caldas da Rainha, Portugal – here misspelled as 'Calas') and at Malvern, and is currently in Bristol. Irving encloses a case note that he wrote at Malvern, with annotations and corrections by the patient himself. Irving also asks Cullen's advice on going to India.
Manuscript Incomplete? No
Evidence of Commercial Posting Yes

Case

Cases that this document belongs to:

Case ID Description Num Docs
[Case ID:1930]
Case of Governor George Johnstone (Johnston) who has a maxillary gland tumour and diseased tongue, which prove fatal.
3


People linked to this document

Person IDRole in documentPerson
[PERS ID:5446]AuthorDr Ralph Irving
[PERS ID:1]AddresseeDr William Cullen (Professor Cullen)
[PERS ID:99]PatientGovernor George Johnstone (Johnston)
[PERS ID:610]Patient's Physician / Surgeon / ApothecaryDr Richard Huck Saunders (Huck)
[PERS ID:5446]Patient's Physician / Surgeon / ApothecaryDr Ralph Irving
[PERS ID:1]Patient's Physician / Surgeon / ApothecaryDr William Cullen (Professor Cullen)
[PERS ID:714]Other Physician / SurgeonBaron Gerard van Swieten (Van Sweten)
[PERS ID:2872]Other Physician / SurgeonDr Friedrich Hoffmann (Hoffman)
[PERS ID:4018]Other Physician / SurgeonMr Percival Pott
[PERS ID:5448]Other Physician / SurgeonDr Martin Wall
[PERS ID:5447]Patient's Relative / Spouse / FriendMrs Deborah Charlotte Johnstone (Charlotte; later Lady Nugent)

Places linked to this document

Role in document Specific Place Settlements / Areas Region Country Global Region Confidence
Place of Writing Malvern Midlands England Europe certain
Place of Writing New Burlington Street London London and South-East England Europe certain
Destination of Letter Edinburgh Edinburgh and East Scotland Europe certain
Mentioned / Other India Asia certain
Mentioned / Other Bristol South-West England Europe certain
Mentioned / Other Caldas aka Caldas da Rainha Estremadura Portugal Europe certain
Mentioned / Other Malvern Midlands England Europe certain

Normalized Text

[Page 1]
London 5th. Septtr (↑Octr.↑) 1786
at Governor Johnstone's
New Burlington Street –
Sir


Inclosed you have the history of Governor
Johnstone's case which I wrote out at Malvern
It would have been little trouble to me to have
made out a transcript more clear & seemly for
your perusal –– but by sending the original as
corrected by his own hand, you will not only
learn all the facts which were thought necessary
to be mentioned, but also the circumstances of
distress to which his own anxiety is more especially
directed –– I have only one thing to correct or
rather to add viz. that the two ulcers are now
run into one
, but that the circumference of this
ulcerous part is already somewhat less than the
circumference of the two original ulcers separately
taken –– for my own part I think that the bottom
of the ulcers
seems raw & firm –– nor do I hear
than any person suspects it to be [serious?] –– the
pus, indeed, seems to be of excellent quality


Whether or not a Venereal Affection still remains
in the Governor's constitution is a question that
has been much agitated by the Governor's Physicians
No one doubts that the Governor has had his full
share of that Disease
–– nor do I think it less certain
that the swelling of the Testicle was venereal & the
consequence of what is commonly called Hernia
Humoralis
–– Whether the Disease of the Testicle
was in some sort determined to the Throat, as
the swelling in Cynanche Parotidœa is sometimes
to the Testicle, is a question which I have been
fond of studying, but which would no doubt
require a great number of facts to ascertain –-
The interval between the disappearing of the one &
the beginning of the other cannot be easily marked ––
for a degree of hardness & pain might subsist in
the Epididyme for some time, though the [notion?] of
a disease was not attached to it –– Upon the



[Page 2]

whole, I apprehend that there is little doubt that
the Governor's present disorder was ushered in
by a Venereal Affection –– But from the total absence
of the more obvious symptoms of Lues & from the
great quantities of Mercury
which he has taken
I am inclined to believe that Lues makes at this
time no part of the Disorder –– In this opinion
I am seconded, or rather I follow Mr. Pott –– But
on the presumption that the disease was originally
ushered in by a venereal affection, I am disposed to
think that the disorder as it now subsists is not
a primary disease, that it proceeds not from
what has been called a cancerous Diathesis of the
System
, & that therefore we ought to be encouraged
to attempt & hope for a cure –– I have been
the more free in laying my sentiments before you
that they have been misrepresented by others,
who thinking, perhaps with good reason, that they
were not worthy of accurate examination, have
notwithstanding, thought it worth their while to
contradict them by guessing at them in the Lump ––
Should they appear agreeable to facts & good reasoning
I well know that my great master well confirm
them, though their Author had been a score years
younger than he is –––– I have sent Mr. Johnstone's
Letter as it contains several particulars to which
I could not give due force in an extract, yet they
may be well worth attending to – But I have to
qualify two things in this Letter before you can per¬
use it with safety –– Malvern Waters are a mere
whimsie of this worthy man's & in these medical
trifles he is sometimes equally obstinate as in the
noble sincerities of his Heart –– During the fortnight
which I spent with the Governor at Malvern
I do not suppose that he drank more than
twice or thrice of this chimerical panacea
–– It has
indeed, no title to the panacea of Hoffman – for it does
appear to contain a very minute proportion of a
neutral salt
made up of Muriatic acid & Magnesia
but from the white tinge of corks the former seems predominant


[Page 3]

I am certain that it neither contains Iron either in
the state of Vitriol or combined with fixed air or
indeed with any other acid –– nor does it hold
copper as Martin Wall suspects – for the greenish
tinge on adding caustic Sal Ammo Volatile Alkali
proceeds entirely from the separation of a most
minute quantity of particles of magnesia & the
liquor is not greener than soap curdles produced
by hard water –– With respect to the operations
which Mr. Johnstone mentions – I had wrote him
that on an obvious & general melioration of the
disease, the adhesion of the tonsil to the tongue might
perhaps be removed by the knife –– I suspect that
he has transferred my real meaning to the Tumor
itself – to extirpate which (↑this↑) would be an operation
which may God grant me grace never to attempt in
any case whatever –– it's base is quite [fixed?] & no one
knows it's farthest borders


The Governor has been on no course of medicines
for some time except a quack thing called Vegetable
Syrup
which seems to be quite harmless –– I have
my suspicions that the differences of opinion among
his Physicians may have introduced a species of re¬
signation which is neither the duty of a Christian
nor a Physician –– it has one effect of gi[ving]
him to beleive that his case is irremediable {illeg}
allowing it to be so, it would surely be better that
he should moderately think otherwise –– but as his
strength is at present rather improving than otherwise
as neither the tumor nor ulcer have the appearance
or produce the pain & other symptoms of confirmed
cancer
, there is it sur↑e↑ly argues no modesty in the
Physician, nor can operate any advantage to the
patient to give up such a case as incurable
I have already risqued the above opinion to the
Governor & shall be happy indeed should you be
able from your own conviction to support me ––
I had proposed the use of Decoctions of Mezereon
and Sarsaparilla –– the last is a fashionable remedy
here, & from the farinaceous matter it contains, I
thought it might answer the purpose of sheathing



[Page 4]

the acrimony of the Mezereon –– I am, however,
informed by Mrs. Johnstone, that this proposal
was condemned as a very improper one –– I cannot
understand for what reason & indeed I am told of it
more in the light of a laughable story than a thing
that ought to mortify me –– The Governor is now
at Bristol & in a letter I had from him t'other day
he is very anxious to have your opinion as early
as possible –– I have to request that your Letter
may be so worded that I can shew it without
reserve to the Governor –– & though I desire you to
return Mrs. Johnstone's Letter that you need not announce
having done so in your Letter –– In my next I shall
acquant you with my views on going to India – I am
with all possible esteem

Sir your most obliged
Ralph Irving

Doctor Cullen Senr
Edinburgh


Govr. Johnston
October 1786
and Advice


[Page 5]
Sir


In relating the circumstances in the
case of Governor Johnstone I shall in the
first place describe as clearly as I can the
appearances which the tumor in the Throat
& affection of the neighbouring parts do at
present put on –– The Tumor is situated about
half way between the chin and the condyle
of the lower jaw
& is of an oblong shape
The superficial veins are considerably
enlarged & full
as if they were somewhat
varicose
–– the tumor is very hard but
remarkably even on its surface –– the
enlargement
of the corresponding part in
the fauces
is very inconsiderable but the
inflammation
seems to have been more
considerable in the earlier periods of the
disease than at present as there is now
a pretty firm adhesion of the tonsil to the
tongue
–– immediately below this adhesion
are two small ulcers sufficient to admit
of a crow's quill –– the mouths of these
ulcers
are not tucked in nor unequal in
their edges –– their borders appear to be
a very little callous but are parallel with
the surrounding parts which have a
raw moist appearance
–– the matter
discharged from
these ulcers is in small
quantity, but of a thick consistence & yellow
colour
–– I once observed a small quantity
of florid blood upon it's surface
–– In exa¬
mining the mouth I could not be sensible
of the smallest degree of fœtor –– nor can
I discover that there is any swelling in
the glands between these ulcers & the Heart



[Page 6]

About nine months ago the tumor, or rather
it's interior surface
burst of its own
accord & the tum & discharged
an inconsi¬
derable quantity of blood and pus
– the
two openings then produced from the
ulcers
above mentioned –– There are no
diseased
teeth corresponding to the Volume
of the Antium Maxillare nor is there
any pain in the region of that cavity
The Velum pendulum palate is perfectly
sound & were the tongue disengaged from
the tonsil there would probably remain
no impediment either to deglutition or
speech and the latter is more evidently
interrupted
than the former –– There is an
almost incessant & copious flow of Saliva
a prodigious quantity of a thick tenacious
mucus is sometimes also discharged
from
the Lungs and fauces but I have never
been able to discover the smallest appearance
of purulent expectoration –– I am still
more convinced of the absence of an exqui¬
sitely formed Hectic
–– The Governor com¬
plains of much pain along about the Spine
of the neck & over the head –– but the part
where he especially points at is on the
parietal bone near to the verge of the
Lambdoid suture
& I think I can here
perceive a small inequality which ap¬
pears to belong either to the Bone or it's
membrane
–– the pain in his neck &
head seems more distressing than the pain
either of the tumor or the ulcers & cannot
therefore in my opinion be propogated from these


[Page 7]

It may be proper to observe that the
Governor seems to be liable to glandular
swellings –– some time (↑✍five years↑) ✍before the appear¬
ance of the above tumor he had a
swelling of
the Testicle which was sus¬
pected to be schirr scirrhous
but ↑✍gradually↑ ✍dis¬
appeared {illeg} before the coming (↑✍upon bathing in the waters of the [Calas?] in↑)✍
of this tumor (↑✍Portugal & drinking them which are gratly purgative) ✍–– The new tumor on his
Throat
was first discerned about ✍August 1780✍
years ago about the size of a kidney
bean but gave no uneasiness till about (↑✍It came with excruciating pain & was accompanyed↑) ✍
↑✍with a small {illeg} excoriation on the side of the Tongue↑✍ ago –– it↓it↓ seems at present to
be quite stationary & has been so these
↑Two Years↑ months –– The Governor has taken
considerable quantities of Mercury in the
form of ↑the↑ pills of the London Pharmacopœia
& also by fumigating the throat with
Cinnabar but has never used the
Sublimate Corrosive
–– he also employed
a ✍↑quack↑✍ remedy of Dr. ✍↑Huck↑ ✍Saunders which from what (↑✍he had from Vanswaiten↑)✍
I can learn is a combination of Mercury (↑✍and in the winter 1780 he received great benefit from it↑)
and Antimony joined to the use of some¬
thing similar to the Lotion {illeg}

Hemlock has been ✍↑in large dose↑ ✍also used with the (↑✍out↑) ✍
same want of success as those above (↑✍it always communicating head achs &↑)✍
mentioned (↑✍total loss of appetite) ✍–– The remedy he chiefly
relied on at present is Opium↑of which he takes in 24 hours 160 drops↑ ✍–– The
Governor is very much reduced in
flesh
and strength↑& has hardly any appetite ✍–– It is worth
adverting to that there are (↑✍is one↑) ✍small
protuberances perceived about
the middle
of the shins
which seem to belong to
the Tibia or pericostium & appear to be
akin to the affection of the parietal Bone




[Page 8]


The difficulty at Present is how to obtain a
natural discharge being constantly obliged to use
Clysters
nor has any medium proved effectual
Castor oil always purges, but leaves the Patient
quite exhausted & low. The other is to be able
to take food equall to the [want?]. The third is
the means of obtaining sleep

Diplomatic Text

[Page 1]
London 5th. Septtr (↑Octr.↑) 1786
at Governor Johnstone's
New Burlington Street –
Sir


Inclosed you have the history of Governor
Johnstone's case which I wrote out at Malvern
It would have been little trouble to me to have
made out a transcript more clear & seemly for
your perusal –– but by sending the original as
corrected by his own hand, you will not only
learn all the facts which were thought necessary
to be mentioned, but also the circumstances of
distress to which his own anxiety is more especially
directed –– I have only one thing to correct or
rather to add viz. that the two ulcers are now
run into one
, but that the circumference of this
ulcerous part is already somewhat less than the
circumference of the two original ulcers separately
taken –– for my own part I think that the bottom
of the ulcers
seems raw & firm –– nor do I hear
than any person suspects it to be [serious?] –– the
pus, indeed, seems to be of excellent quality


Whether or not a Venereal Affection still remains
in the Governor's constitution is a question that
has been much agitated by the Governor's Physicians
No one doubts that the Governor has had his full
share of that Disease
–– nor do I think it less certain
that the swelling of the Testicle was venereal & the
consequence of what is commonly called Hernia
Humoralis
–– Whether the Disease of the Testicle
was in some sort determined to the Throat, as
the swelling in Cynanche Parotidœa is sometimes
to the Testicle, is a question which I have been
fond of studying, but which would no doubt
require a great number of facts to ascertain –-
The interval between the disappearing of the one &
the beginning of the other cannot be easily marked ––
for a degree of hardness & pain might subsist in
the Epididyme for some time, though the [notion?] of
a disease was not attached to it –– Upon the



[Page 2]

whole, I apprehend that there is little doubt that
the Governor's present disorder was ushered in
by a Venereal Affection –– But from the total absence
of the more obvious symptoms of Lues & from the
great quantities of Mercury
which he has taken
I am inclined to believe that Lues makes at this
time no part of the Disorder –– In this opinion
I am seconded, or rather I follow Mr. Pott –– But
on the presumption that the disease was originally
ushered in by a venereal affection, I am disposed to
think that the disorder as it now subsists is not
a primary disease, that it proceeds not from
what has been called a cancerous Diathesis of the
System
, & that therefore we ought to be encouraged
to attempt & hope for a cure –– I have been
the more free in laying my sentiments before you
that they have been misrepresented by others,
who thinking, perhaps with good reason, that they
were not worthy of accurate examination, have
notwithstanding, thought it worth their while to
contradict them by guessing at them in the Lump ––
Should they appear agreeable to facts & good reasoning
I well know that my great master well confirm
them, though their Author had been a score years
younger than he is –––– I have sent Mr. Johnstone's
Letter as it contains several particulars to which
I could not give due force in an extract, yet they
may be well worth attending to – But I have to
qualify two things in this Letter before you can per¬
use it with safety –– Malvern Waters are a mere
whimsie of this worthy man's & in these medical
trifles he is sometimes equally obstinate as in the
noble sincerities of his Heart –– During the fortnight
which I spent with the Governor at Malvern
I do not suppose that he drank more than
twice or thrice of this chimerical panacea
–– It has
indeed, no title to the panacea of Hoffman – for it does
appear to contain a very minute proportion of a
neutral salt
made up of Muriatic acid & Magnesia
but from the white tinge of corks the former seems predominant


[Page 3]

I am certain that it neither contains Iron either in
the state of Vitriol or combined with fixed air or
indeed with any other acid –– nor does it hold
copper as Martin Wall suspects – for the greenish
tinge on adding caustic Sal Ammo Volatile Alkali
proceeds entirely from the separation of a most
minute quantity of particles of magnesia & the
liquor is not greener than soap curdles produced
by hard water –– With respect to the operations
which Mr. Johnstone mentions – I had wrote him
that on an obvious & general melioration of the
disease, the adhesion of the tonsil to the tongue might
perhaps be removed by the knife –– I suspect that
he has transferred my real meaning to the Tumor
itself – to extirpate which (↑this↑) would be an operation
which may God grant me grace never to attempt in
any case whatever –– it's base is quite [fixed?] & no one
knows it's farthest borders


The Governor has been on no course of medicines
for some time except a quack thing called Vegetable
Syrup
which seems to be quite harmless –– I have
my suspicions that the differences of opinion among
his Physicians may have introduced a species of re¬
signation which is neither the duty of a Christian
nor a Physician –– it has one effect of gi[ving]
him to beleive that his case is irremediable {illeg}
allowing it to be so, it would surely be better that
he should moderately think otherwise –– but as his
strength is at present rather improving than otherwise
as neither the tumor nor ulcer have the appearance
or produce the pain & other symptoms of confirmed
cancer
, there is it sur↑e↑ly argues no modesty in the
Physician, nor can operate any advantage to the
patient to give up such a case as incurable
I have already risqued the above opinion to the
Governor & shall be happy indeed should you be
able from your own conviction to support me ––
I had proposed the use of Decoctions of Mezereon
and Sarsaparilla –– the last is a fashionable remedy
here, & from the farinaceous matter it contains, I
thought it might answer the purpose of sheathing



[Page 4]

the acrimony of the Mezereon –– I am, however,
informed by Mrs. Johnstone, that this proposal
was condemned as a very improper one –– I cannot
understand for what reason & indeed I am told of it
more in the light of a laughable story than a thing
that ought to mortify me –– The Governor is now
at Bristol & in a letter I had from him t'other day
he is very anxious to have your opinion as early
as possible –– I have to request that your Letter
may be so worded that I can shew it without
reserve to the Governor –– & though I desire you to
return Mrs. Johnstone's Letter that you need not announce
having done so in your Letter –– In my next I shall
acquant you with my views on going to India – I am
with all possible esteem

Sir your most obliged
Ralph Irving

Doctor Cullen Senr
Edinburgh


Govr. Johnston
Octr. 1786
and Advice


[Page 5]
Sir


In relating the circumstances in the
case of Governor Johnstone I shall in the
first place describe as clearly as I can the
appearances which the tumor in the Throat
& affection of the neighbouring parts do at
present put on –– The Tumor is situated about
half way between the chin and the condyle
of the lower jaw
& is of an oblong shape
The superficial veins are considerably
enlarged & full
as if they were somewhat
varicose
–– the tumor is very hard but
remarkably even on its surface –– the
enlargement
of the corresponding part in
the fauces
is very inconsiderable but the
inflammation
seems to have been more
considerable in the earlier periods of the
disease than at present as there is now
a pretty firm adhesion of the tonsil to the
tongue
–– immediately below this adhesion
are two small ulcers sufficient to admit
of a crow's quill –– the mouths of these
ulcers
are not tucked in nor unequal in
their edges –– their borders appear to be
a very little callous but are parallel with
the surrounding parts which have a
raw moist appearance
–– the matter
discharged from
these ulcers is in small
quantity, but of a thick consistence & yellow
colour
–– I once observed a small quantity
of florid blood upon it's surface
–– In exa¬
mining the mouth I could not be sensible
of the smallest degree of fœtor –– nor can
I discover that there is any swelling in
the glands between these ulcers & the Heart



[Page 6]

About nine months ago the tumor, or rather
it's interior surface
burst of its own
accord & the tum & discharged
an inconsi¬
derable quantity of blood and pus
– the
two openings then produced from the
ulcers
above mentioned –– There are no
diseased
teeth corresponding to the Volume
of the Antium Maxillare nor is there
any pain in the region of that cavity
The Velum pendulum palate is perfectly
sound & were the tongue disengaged from
the tonsil there would probably remain
no impediment either to deglutition or
speech and the latter is more evidently
interrupted
than the former –– There is an
almost incessant & copious flow of Saliva
a prodigious quantity of a thick tenacious
mucus is sometimes also discharged
from
the Lungs and fauces but I have never
been able to discover the smallest appearance
of purulent expectoration –– I am still
more convinced of the absence of an exqui¬
sitely formed Hectic
–– The Governor com¬
plains of much pain along about the Spine
of the neck & over the head –– but the part
where he especially points at is on the
parietal bone near to the verge of the
Lambdoid suture
& I think I can here
perceive a small inequality which ap¬
pears to belong either to the Bone or it's
membrane
–– the pain in his neck &
head seems more distressing than the pain
either of the tumor or the ulcers & cannot
therefore in my opinion be propogated from these


[Page 7]

It may be proper to observe that the
Governor seems to be liable to glandular
swellings –– some time (↑✍five years↑) ✍before the appear¬
ance of the above tumor he had a
swelling of
the Testicle which was sus¬
pected to be schirr scirrhous
but ↑✍gradually↑ ✍dis¬
appeared {illeg} before the coming (↑✍upon bathing in the waters of the [Calas?] in↑)✍
of this tumor (↑✍Portugal & drinking them wch are gratly purgative) ✍–– The new tumor on his
Throat
was first discerned about ✍Augt. 1780✍
years ago about the size of a kidney
bean but gave no uneasiness till about (↑✍It came with excruciating pain & was accompanyed↑) ✍
↑✍with a small {illeg} excoriation on the side of ye Tongue↑✍ ago –– it↓it↓ seems at present to
be quite stationary & has been so these
↑Two Years↑ months –– The Governor has taken
considerable quantities of Mercury in the
form of ↑the↑ pills of the London Pharmacopœia
& also by fumigating the throat with
Cinnabar but has never used the
Sublimate Corrosive
–– he also employed
a ✍↑quack↑✍ remedy of Dr. ✍↑Huck↑ ✍Saunders which from what (↑✍he had from Vanswaiten↑)✍
I can learn is a combination of Mercury (↑✍and in the winter 1780 he received great benefit from it↑)
and Antimony joined to the use of some¬
thing similar to the Lotion {illeg}

Hemlock has been ✍↑in large dose↑ ✍also used with the (↑✍out↑) ✍
same want of success as those above (↑✍it always communicating head achs &↑)✍
mentioned (↑✍total loss of appetite) ✍–– The remedy he chiefly
relied on at present is Opium↑of wch. he takes in 24 hours 160 drops↑ ✍–– The
Governor is very much reduced in
flesh
and strength↑& has hardly any appetite ✍–– It is worth
adverting to that there are (↑✍is one↑) ✍small
protuberances perceived about
the middle
of the shins
which seem to belong to
the Tibia or pericostium & appear to be
akin to the affection of the parietal Bone




[Page 8]


The difficulty at Present is how to obtain a
natural discharge being constantly obliged to use
Clysters
nor has any medium proved effectual
Castor oil always purges, but leaves the Patient
quite exhausted & low. The other is to be able
to take food equall to the [want?]. The third is
the means of obtaining sleep

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