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13 Articles in Volume 12, Issue #11
“Doc” Holliday: A Story of Tuberculosis, Pain, and Self-medication in the Wild West
"Doc's" Woman: Doc Holliday's Wife
Activation of Latent Lyme Disease Following Epidural Steroid Injection: Case Challenge
An Overview of Complex Regional Pain Syndrome and its Management
Extracorporeal Shock Wave Therapy: Applications in Tendon-related Injuries
Mission Impossible—Developing a Program to Help Chronic Pain Patients
New Ideas for Helping Difficult Pain Patients
Postoperative Pain Relief After Knee and Hip Replacement: A Review
Using Dynamic MRI to Diagnose Neck Pain: The Importance of Positional Cervical Cord Compression (PC3)
December 2012 Pain Research Updates
Best Practices For High-dose Opioid Prescribing
Does Sulindac Affect Renal Function Less Than Other NSAIDs?
The Bewildering Terminology of Genetic Testing

“Doc” Holliday: A Story of Tuberculosis, Pain, and Self-medication in the Wild West

As many of our readers know, “Doc” Holliday was a professional gambler who worked the saloon and gambling halls of the cattle and mining towns of the Western Frontier between 1873 and 1887.1 What readers might not know was that Holliday also suffered from debilitating pain caused by chronic tuberculosis (TB) infection.1-8 Doc Holliday arguably was the most intriguing and colorful characters of the “Wild West” era, and a review of his life, health, and pain problems provides a unique educational opportunity. It might surprise you, but this icon teaches us a great deal about pain. He could be the poster child of the prototype patient who has a chronic disease, eventually develops intractable pain, and knows he has a short time to live. It’s rare that we have the opportunity to dissect and study the history of a pain patient from birth to death—Doc Holliday left us this gift.

To be a better pain practitioner, read about the instructive case of Doc Holliday. After studying his case, you will never approach a chronic pain patient quite the same way.

Just Who Was “Doc” Holliday?
John Henry Holliday was born August 14, 1851 into an aristocratic southern family in the tiny town of Griffin, Georgia.2 Holliday had a classical upbringing and was educated at the Valdosta Institute, a school for sons of southern gentlemen, in Valdosta, Georgia.2 Besides math and science, he was taught Greek, Latin, and French. When Holliday was a boy, his uncle John Stiles Holliday, MD, who was a physician, gave him an 1851 Colt revolver, which he learned to use expertly. When he was a teenager, Holliday moved into his uncle’s house, where a young Mulatto servant named Sophie Walton taught him and his brother how to play cards. She taught them games called “Up and Down the River” and “Put and Take,” which were similar to the card game Faro. She taught them how to count the cards in the deadwood (discard) pile and to remember which cards were yet unplayed. Holliday had an intensive competitive spirit, as well as a remarkable memory and mathematical ability.

Holliday attended the Pennsylvania College of Dental Surgery in his late teens, earning his degree on March 1, 1872.2 He practiced dentistry in Georgia before moving, in 1873, to Dallas, where he became a dental partner with Dr. John A. Seegar. Within his first year of dental practice, Holliday started frequenting gambling establishments and found that gambling was more profitable and exciting than dentistry. Holliday got the nickname “Doc” from his friends and acquaintances in the gambling saloons, who preferred to call him “Doc” rather than Dr. John Holliday.

Life as a Gambler
The life of a professional gambler in the Western Frontier was dangerous—losing players were often inebriated, took umbrage, and were ready to fight. Along the way, Holliday had developed a reputation as a deadly gunfighter. His long-term notoriety primarily stems from his participation in the gunfight at the OK Corral, which took place in Tombstone, Arizona, on October 26, 1881.1,5 Had it not been for this singular event, which lasted all of 30 seconds, Doc Holliday and Wyatt Earp likely would have died in obscurity. As it turned out, this gunfight has long captured the intrigue and fascination of the American public.1-8 Countless movies, books, articles, and songs have been written about it, which often makes telling fact from fiction difficult (see Fact from Fiction at the end of this article).1-12

Because so much has been written about Doc Holliday, much of it conflicting, it often is difficult to get a clear picture of his personal appearance, demeanor, and behavior.1-8 In his memoirs, Wyatt Earp described Holliday this way: “He was a dentist whom necessity had made a gambler, a gentleman whom disease had made a frontier vagabond, a philosopher whom life had made a caustic wit, a long, lean, ash-blond fellow nearly dead with consumption and at the same time the most skillful gambler and the nerviest, speediest, deadliest man with a six-gun I ever knew.”7

There is disagreement over which photos of “Doc” are legitimate.7 His true image has been dramatically altered in the many movies about him, so I have included a number of quotes by various persons in an attempt to capture the truth. Perhaps the best quote to separate fact from fiction is one by W.B. (Bat) Masterson, sheriff of Dodge City and Pueblo, Colorado, who personally knew Holliday. Considering Doc’s TB, Masterson described him as a physical “weakling who could not have whipped a healthy 15-year-old boy in a go-as-you-please fist fight.” Contrast this with the number of robust actors Hollywood chose to play Doc including Kirk Douglas, Jason Robards, Victor Mature, Caesar Romero, and Stacy Keach.

Just how much his pain and health problems influenced his temperament and behavior will always be a matter of debate, but it appeared to this author to be paramount in shaping his short life. There is remarkable consistency among “Doc’s” serious biographies regarding his health problems, which have allowed this author to medically analyze and report his case from a pain practice perspective.1-8

Doc’s Health and Pain History
Holliday’s health problems began at birth—he was born with a cleft lip and possibly a cleft palate.2 His lip was surgically repaired and the Holliday family took the time and effort to teach him to speak properly. Whether there was a genetic aspect to his birth defect will never be known, but it is commonly believed that genes and the environment play a role in the development of these orofascial clefts.

Figure 1. Image depicts two smooth, chromogenic colonies of Mycobacteria

The second major, but critical, event in Holliday’s life was the death of his mother Alice from TB in 1866 when he was 15.2 He had been very close to his mother, because during many of his formative years his father was away fighting for the South in the Civil War. At the age of 21, while practicing dentistry in Georgia, Holliday started to lose weight. He initially attributed this to his active schedule. About 6 months later in the summer of 1873, he developed a nagging cough that forced him to take some time off from his dental practice. When the cough did not subside, he sought out his uncle, Dr. John Stiles Holliday. Using a stethoscope and a bronchoscope he diagnosed Holliday with pulmonary TB,2 which at the time was commonly called “consumption” or “phthisis pulmonales.”13,14

Although the science of contagion was poorly understood at the time, the Holliday family believed his problems were somehow related to the TB that killed his mother. It was not until 1882 that Robert Koch, who already had identified the bacterial cause for anthrax, identified the tubercle bacillus (Mycobacterium tuberculosis) as the agent responsible for TB (Figure 1).14 The treatment recommended by Holliday’s uncle was that proffered by Dr. George Bodington (1799-1882) and the renowned Dr. Benjamin Rush of Philadelphia.13,14 It consisted of a climate of warm, dry air combined with a nutritious diet, a moderate amount of wine, and prolonged rest during convalescence. Of course, Doc did not follow this advice completely considering that he spent a great deal of his life staying up late and living in smoke-filled rooms. Of extreme importance is that Holliday was told if he remained in Georgia’s hot and humid climate he would live about 6 months, but he could extend this time to 2 years if he moved west to a drier, arid location. In other words—his hand was forced; he had no other choice but to move.

On a hot and humid Atlanta day in September 1873, he boarded the Western and Atlantic Railroad; destination—Dallas, Texas.2 There was no return ticket. He was met at the Dallas train depot by his dental partner Dr. Seegar. Due to his consumption condition, which often brought about coughing episodes, as well as a long depression, he couldn’t build much of a dental practice. Thus, he turned to the “sporting life.”

About TB
According to the Centers for Disease Control and Prevention (CDC), a total of 10,528 TB cases (a rate of 3.4 cases per 100,000 persons) were reported in the United States in 2011.15 Both the number of TB cases reported and the case rate decreased compared to 2010, representing a decline of 5.8% and 6.4%, respectively. This is the lowest recorded number since 1992, when the resurgence of TB peaked in the United States. The increase of TB predominantly has been seen among the foreign-born US population. The CDC reports that 62% of TB cases reported in 2011 occurred in foreign-born persons. The TB rate among foreign-born persons (17.2 cases per 100,000) was approximately 11.5 times higher than among US-born persons (1.5 cases per 100,000).

Although less common today than during the mid-to-late 19th century, TB remains a horrible, painful disease. The disease may be acute or chronic and generally attacks the respiratory tract, although other parts of the body, such as the brain, the kidneys, and the spine, may be affected. The symptoms (fever, loss of weight, etc) are caused by the toxins produced by the infecting organism, which also cause the formation of characteristic nodes consisting of a packed mass of cells and dead tissue.

In most cases today, TB is treatable and curable. Despite improvement in medical management, however, TB remains a deadly infectious disease. The CDC reported that there were 529 deaths from TB in 2009, the most recent year for which these data are available; this represented a 10% decline compared to 2008.15 Another confounding factor today is the emergence of multidrug-resistant TB and extensively drug-resistant TB, which leaves the weakest patients with very few treatment options.

Pain from the disease comes as the tubercle bacilli invade nerve tissue; additionally, incessant coughing may cause fractured ribs, ruptured lung tissue, and irritation of the phrenic, vagus, and intercostal nerves. The noted Western writer and historian, Bob Boze Bell, gives a description of “consumption” in his 1994 book, The Illustrated Life and Times of “Doc” Holliday.5 It would be difficult to better describe untreated TB, so it is given here verbatim:

“Consumption can go undetected for some good time, especially if the tendency towards denial is followed. Fatigue is more and more pronounced as one’s appetite seems to disappear. One feels ‘out of sorts’ and clammy. Periods of fever come and go. One wakes up in the dead of night drenched in sweat. In the morning, choking, coughing, and spitting up, at first watery fluid, later blood and chunks of lung tissue, rack the sufferer. The chest feels as if it were imploding and the pain of it all leads many to alcohol for temporary respite. To crown it all, many thought the illness a result of moral laxity. Compounded with terror of contagion, the consumptive becomes something of a pariah—a ‘lunger’ despised in and for his infirmity.”

As has been reported, Holliday was physically impaired by his consumption disease throughout his 14 years as a professional gambler on the Western Frontier. He could hardly fight with fisticuffs, so he apparently became the most deadly and feared gunman of the era. John C. Jacobs, a fellow gambler and casino operator said of Doc: “This fellow Holliday was a consumptive and a hard drinker, but neither liquor nor the bugs seemed to faze him. He could at times be the most genteel, affable chap you ever saw, and at other times he was sour and surly, and would just as soon cut your throat with a villainous-looking knife he always carried, or shoot you with a 41-caliber double-barreled derringer he always kept in his vest pocket.”3 Jacobs describes a volatile man who has exacerbations of intolerable pain as well as mood swings and hostility.

“Doc” Holliday lived until age 36, some 14 years longer than he was predicted to live. His major medicinal treatments were alcohol and opium. Additionally, he likely took “bugleweed,” a standard treatment for TB in the 1800s.14 For the cough and pain of TB, which is a disease of exacerbations and remissions, alcohol and opium were the only potent available treatments at the time.13,14 Much has been written about “Doc’s” alcohol intake including references to his being intoxicated at times and drinking up to 4 quarts of whiskey per day.1,3,4 He is called an alcoholic by several writers. There is another side, however, to their claims. His common-law companion, Kate Elder, reportedly said this about his alcohol intake: “He was not a drunkard. He always had a bottle of whiskey but never drank habitually. When he needed a drink, he would take only a small one.”5 Considering that he had to be alert to count cards, professionally gamble, accurately wield a gun and knife, and ride a horse, it is difficult to believe that Doc spent much time being inebriated. It is quite likely that Holliday suppressed his coughing and pain with a daily maintenance dose of alcohol. For example, he likely knew that a certain daily dosage taken on a regular interval schedule kept him stable. Unfortunately, alcohol is difficult to manage as a medicine because it is a volatile compound and Doc, like other pain patients who use it therapeutically, overdosed on occasion.

Historians agree that Doc’s health began to dramatically fail in about 1884.1-5 While working as a Faro dealer in Leadville, Colorado, he began to deteriorate into what is called stage 2 TB. This stage is characterized by severe weight loss, mental confusion, extreme fatigue, and weakness. It was later discovered that tubercle bacilli like to invade the adrenal glands and produce symptoms of Addison’s disease or adrenal failure. At one point in history, TB was the most common cause of adrenal failure.16 It was most likely the cause of Holliday’s severe late-stage debilitation and his death. Today, with the waning of TB, autoimmune disease and iatrogenic corticoid administration are the major causes of adrenal insufficiency.

Sidebar:  Separating Fact From Fiction

A major problem in researching the pain and health problems of “Doc” Holliday is all the sensational biographies, semi-fiction books, and movies regarding the “Wild West.” They have distorted the image and behavior of Holliday and others. There have been, however, several serious attempts to write factual bibliographies about Holliday, and these serve as the primary basis for this treatise.1-8 One bibliography, “Doc” Holliday, a Family Portrait, is written by Karen Holliday Tanner, who was a distant cousin of Holliday and had access to many family records.2 Another, “Doc” Holliday, the Life and Legend, by Gary L. Roberts, was written with direct communication and advice from Holliday family descendants.3 Other bibliographies have been written by serious and renowned Western historians and academics.4-6 These authors have researched newspapers, court records, census rolls, and interviewed numerous people, leaving no stone unturned to piece together the history of the events and happenings of the 14 years that Holliday roamed the Western Frontier. There are two excellent historical summaries of Doc Holliday, as well as some on Kate Elder, that now are available online.7,8,10,11

Perhaps the best first-person account was written by W.B. (Bat) Masterson, who wrote a series of articles on the gunman he knew when he was Sheriff of Dodge City and Pueblo.12 In his later years, he retired from the Western Frontier and moved to the East to become a journalist and newspaper man. He published his articles in Human Life Magazine in 1907. His collection of articles was republished in book form in 1957 and again in 2009 under the title, Famous Gunfighters of the Western Frontier.12

 

When Doc started to severely deteriorate, he began the regular use of the opium formulation called laudanum.17 Nearly all consumptives used some form of opium to quiet their cough, control diarrhea, reduce stress, and relieve the pain of TB.13,14,18 As he deteriorated, observers could see that Doc could no longer deal cards or work as a gambler. Consequently, he was unable to make much of a living and lived on odd jobs in Denver, Leadville, and Trinidad, Colorado. When Doc was really sinking, Leadville druggist Jay Miller provided Doc with laudanum at no charge. With his health failing, he checked himself into the Glenwood Hotel in Glenwood Springs, Colorado. He had heard that the sulfur springs in the town might bring relief. This was not to be. He became bedridden, lapsed into a coma typical of TB patients, and died within a few weeks, on November 8, 1887.

“Doc’s” Self-help Program
As noted, Doc used alcohol and opium to treat his symptoms of TB. Before you think this was a ridiculous notion, be aware that Dr. John Fothergill, regarded by many to be the world’s most prominent physician in the late 1700s, recommended alcohol and opium for the management of TB. He wrote: “Fresh white poppy [opium] seeds, in the proportions of half an ounce to a pint of Bristol [alcohol], make an excellent emulsion. The cough will abate and gradually cease entirely.”18 In today’s world of high-powered pharmacology, it seems almost ludicrous to think of these two chemicals as a treatment. Be clearly advised, however, that Holliday didn’t have any choice. Aspirin wasn’t even invented until about 1895, some 8 years after Doc died. There were no such things as antibiotics or neuropathic agents or antidepressants. The point to be made, particularly to those who believe pain is just a nuisance to endure, is that patients who have severe pain assuredly will take whatever medicinal agent is available—including alcohol and illicit drugs.19 Furthermore, they will incessantly harangue the medical system and even commit unsavory acts to obtain pain relief. In summary, it is pure ignorance and foolishness for any physician, regulator, and insurance payer to withhold adequate pain treatment with a cavalier, naive attitude that the patient should “tough it out” or “its only psychological.” Colonel John T. Devers reportedly asked Holliday about his life: “Doctor, don’t your conscience even trouble you?” Doc replied, “I coughed that up with my lungs long ago.”

Here are some historical and scientific notes about Doc’s self-help medications.

Alcohol
Alcohol has been used for centuries as a pain reliever. During both the American Revolution in the 1700s and the Civil War in the 1800s, a soldier with an arm or leg that had to be amputated was given alcohol before the surgeon sawed off the appendage. Surveys today indicate that as many as 28% of people with chronic pain use alcohol as a pain management strategy.20 Out of a series of 401,512 urine specimens collected from pain patients throughout the United States, 28,086 (6.9%) contained ethyl sulfate, an alcohol metabolite, with levels indicating they had consumed more than 24 grams of alcohol (equivalent to at least two to three glasses of whiskey) the previous night.21

Doc’s behavior indicates that he primarily used alcohol as a maintenance drug. Please recall, he was an accomplished gambler, gunfighter, and horseman. These feats are not compatible with intoxication. He likely kept alcohol in his blood pretty much throughout the 24-hour cycle to suppress his cough and pain. Holliday undoubtedly exceeded his alcohol maintenance blood level at times due to accident or intent, and, consequently, became intoxicated at times. Such is the problem when alcohol is used as a chronic pain treatment agent. The lesson here for pain practitioners is simple. If alternate, safer pain treatments are not provided, the pain patient may well resort to alcohol. The author once asked two Alcoholics Anonymous members who were patients in his pain clinic to survey their local support groups and find out how many drank to relieve their pain because they couldn’t get adequate pain relief. The answer they gave—about 30%.

Opium
Opium preparations for medicinal use date back 2,500 years. Various formulations, including a poppy head soaked in water, have gone under the names meconium, theriac, diascordium, mithridate, philonium, and diacodium. Laudanum is known today as “tincture of opium.” The laudanum formulation used in the 1800s contained not only opium but also wine, and was flavored with cinnamon or saffron.17 It was primarily used in Doc’s time as a pain killer, sleep aid, and tranquilizer—just like modern-day prescription opioid preparations. Because laudanum could be taken orally, it was easily administered. Essentially no other pain medication was available because morphine only was available as an injectable compound. Other opioids were not developed for oral pain treatment until some years after Doc’s death. Opium was sold without a prescription, and it was a primary ingredient in the so-called “patent” medicines sold in the 19th century. Opium preparations contain small amounts of codeine, morphine, and other opioids. Regardless of what it is called or which formulation has been historically used, opium has, in the words of the 16th century physician George Wolfgang Wedel, been a “heaven-born gift.”17 Opium was the standard treatment for TB throughout the 1800s.

Unfortunately, we do not know the dosages and frequencies of alcohol and opium used by Doc Holliday. This is unfortunate, because he managed to live a considerable time, despite spending his days in smoke-filled rooms. There is some new evidence that opioids may suppress some infections and increase immunity in some patients.22 If this is the case, Doc Holliday may have extended his life with opium.

Figure 2. Nerves in the lung cage

Bugleweed
Although the botanical name is Lycopus virginicus, bugleweed is known by many names including Virginia horehound, archangel, green wolf’s foot, and gypsy wort. It is a very common weed in North merica, growing in low, damp, shady ground and flowering from July to September. The whole herb was used to make extracts and tinctures. It has sedative, astringent, and mild narcotic properties. In particular, it was used if a patient had a blood vessel rupture with bleeding into the lung. The patient was put to bed and given this herb around the clock. This botanical was routinely used for hemoptysis by consumption patients in the 19th century.14

Lung and Chest Wall Pain
Pain emanating from the lung and/or chest wall can be severe and difficult to manage, because the nerve connections in the lung and its cage are complex and quite different from the more common pain sources that originate in the extremities (Figure 2).

For example, pain signals from the wrist, knee, foot, and spine are transmitted to the brain by peripheral nerves and the spinal cord. Although chest wall nerves, the intercostals, use this same pathway, the visceral pleural and lung parenchyma are innervated by the vagus and phrenic nerves. The phrenic nerve transmits noxious stimuli from the mediastinum, pericardium, and diaphragm. A patient with a lung condition may, therefore, transmit noxious pain stimuli through the intercostal and spinal cord as well as through the autonomic system (vagus and phrenic nerves) directly to the brain, bypassing the spinal cord.

The pain associated with lung conditions has been described by patients as deep, visceral, and agonizing. Recently, Slater and Frost described the problem of post-thoracotomy pain in the pain newsletter, Topics in Pain Management.23 They point out that pain in the postoperative period is notable for its intensity and duration. Chronic lung and chest wall pain can be difficult to treat and may require a high opioid dosage as well as a variety of neuropathic agents and local measures such as administration of electromagnetic energy. The fact that the patient must constantly breathe in and out irritates a pain focus and makes it difficult to find relief.

Although not as prevalent as arthritis and other extremity problems, lung and chest wall pain are problems in every pain practice. Lung and chest wall pain can occur due to TB (sarcoid) and trauma as well as after surgery, radiation, and infections (Table 1).

Fortunately, TB in America today is a more treatable disease. This contrasts with the form that produced the horrendous, unstoppable coughing spells tinged with blood that plagued Doc Holliday. I recall from my early career TB patients who would present with broken ribs, ruptured blood vessels, and exhaustion. Opioids always have been the standard for cough and pain. The brain centers that control cough and pain apparently are one and the same. Severe cough from tumors or infections still occasionally can be seen in clinical practice. Just remember that opioids may be needed because they directly and effectively suppress the cough centers.

“Doc” Found Some Happiness
When “Doc” was dying in Glenwood Springs, he asked Kate to come see him. It is not known, however, for how long she stayed or whether she was at his bedside when he died. Prior to this, they had split over her false accusations about the stagecoach robbery in Tombstone (see Doc’s Woman). In the end, however, they were reunited. She claims that among Doc’s last words were: “Well, I’m going just as I told them—the bugs would get me before the worms did.”5 On the day of his death, his nursing attendant stated he woke up for a moment and asked for a drink of whiskey.2 He looked at his bare feet and said, “This is funny.” Apparently, he expected to lose a gunfight somewhere along the way and die with his boots on.

Table 1. Today's Common Causes of Chronic Lung and Chest Wall Pain

Mary Dorian Russell is an anthropologist who has written a semi-fiction book simply called Doc about Holliday and Kate in Dodge City.24 She theorizes that one reason gamblers love to gamble is that the split-second throw of a card or roll of the dice provides an anticipation that removes the individual from the toils and fears of life. Maybe the thousands of “life exits” of Doc Holliday is a major reason he lived beyond his doctor’s predictions.

Chronically Ill Patients
An increasing number of chronically ill and palliative care patients are seeking treatment in pain practices. Rather than TB, patients have a variety of genetic, infectious, and autoimmune diseases that, in their late stages, produce pain and cause premature death (Table 2). Pain practitioners who deal with intractable pain patients with a short life span must encourage them to find some “happiness” and “quality of life” in the time they have left. The other options are hopeless remorse and depression, which only worsen the pain. The hostility, remorse, and fear that pain patients develop often get in their way and bar them from making the critical decision to find some happiness (Table 3). There is no question that Holliday found some happiness and quality of life. He lived about 14 years longer than his doctor predicted. In contemporary terms, he carried out his “bucket list.” He loved to gamble and found a woman he could love and with whom he could travel. She was someone who participated in and accepted his lifestyle and risky existence. May we practitioners help all our patients achieve the happiness and satisfaction I believe “Doc” found.

What can the pain practitioner do to help patients find happiness? How should patients be approached? First and foremost, let patients know you are with them all the way—through thick and thin. Get to know the patients’ families and friends. I have a page in my office visit form that an intractable pain patient must complete at every visit. I review this form with the patient and demand they find activities to keep their mind and body active and develop social interactions. Patients are told that pain medications don’t work very well if the patients are just lying around the house.

Table 2. Some Common Disease with late-stage Pain and Early Death

Table 3. Some Common Beliefs, Perceptions, and Characteristics of Pain Patients With a Short Life Span

Summary
Pain practitioners seldom get to know a patient’s history from birth to death. Doc Holliday gives us a most insightful opportunity to perform a “pain history autopsy.” Although death from TB has essentially disappeared from the American scene, we now have other chronic illnesses that may produce severe pain when the disease enters its late stages. When patients with these underlying diseases develop severe pain, they instinctively know that they may have a shortened life span. These patients now are prevalent in pain practices, and they need aggressive medical treatment lest they self-medicate with whatever agent they can grab, including alcohol and illegal drugs. Besides medication, these patients need our caring and counseling to find some happiness, contentment, and quality of life in whatever time they have left. Doc Holliday started his life as an accomplished health professional. I suspect he would be tickled to know that the study of his life, pain, and illness will help us to help other persons who now face the same challenges he faced.

Last updated on: April 15, 2015
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