THE ANATOMICAL RECORD 298:1036–1046 (2015)
The Orthopedic Diseases of Ancient Egypt KLAUS O FRITSCH,1 HESHEM HAMOUD,2 ADEL H. ALLAM,2 ALEXANDER GROSSMANN,3 ABDEL-HALIM NUR EL-DIN,4 GOMAA ABDEL-MAKSOUD,5 MUHAMMAD AL-TOHAMY SOLIMAN,6 IBRAHIM BADR,7 JAMES D SUTHERLAND,8 M. LINDA SUTHERLAND,9 MAHMOUD AKL,5 CALEB E FINCH,10 GREGORY S. THOMAS,11 L. SAMUEL WANN,12 AND RANDALL C THOMPSON13,14* 1 Orthop€ adische Chirurgie Bayreuth, Parsifalstr.5, Bayreuth, Germany 2 Al-Azhar University School of Medicine, Naser City, Cairo, Egypt 3 Radiologie Im Duererhof, Bayreuth, Germany 4 Faculty of Archaeology and Tourism Guidance, Misr University for Science and Technology, Misr University for Science & Technology, Al-Motamayez District, 6th of October City, Egypt 5 Conservation Centre for Archaeological and Historical Buildings and Museum Artifacts, Conservation Department, Faculty of Archaeology, Cairo University Giza, Egypt 6 Biological Anthropology Dept., Medical Research Division, NRC, El-Behooth St. Dokki, Giza, Egypt 7 High Institute for Tourism & Hotels Alexandria Abu Qir, Egypt 8 South Coast Radiologic Medical Group, Laguna Hills, California 9 Newport Diagnostic Center, Newport Beach, California 10 Davis School of Gerontology, University of Southern California, Los Angeles, California 11 Memorial Care Heart & Vascular Institute, Long Beach Memorial, Long Beach, California 12 Columbia St. Mary’s Healthcare, Milwaukee, Wisconsin 13 Saint Luke’s Mid America Heart Institute, Kansas City, Missouri 14 University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
ABSTRACT Background: CT scanning of ancient human remains has the potential to provide insights into health and diseases. While Egyptian mummies have undergone CT scans in prior studies, a systematic survey of the orthopedic conditions afflicting a group of these ancient individuals has never been carried out. Methods: We performed whole body CT scanning on 52 ancient Egyptian mummies using technique comparable to that of medical imaging. All of the large joints and the spine were systematically examined and osteoarthritic (OA) changes were scored 0-4 using Kellgren and Lawrence classification. Results: The cruciate ligaments and menisci could be identified frequently. There were much more frequent OA changes in the spine (25 mummies) than in the large joints (15 cases of acromioclavicular and/or glenohumeral joint OA changes, five involvement of the ankle, one in the elbow, four in the knee, and one in the hip). There were six cases of scoliosis. Individual mummies had the following conditions: juvenile aseptic necrosis of the hip (Perthes disease), stage 4 osteochondritis dissecans of the knee, vertebral compression frac-
Abbreviation used: OA 5 osteoarthritic Grant Sponsorship, National Endowment for the Humanities (#HJ-50069-12) Grant sponsor: Paleocardiology Foundation, from various individual donors. Grant sponsorship Siemens; Grant sponsor: National Bank of Egypt; Saint Luke’s Hospital Foundation of Kansas City.
C 2015 WILEY PERIODICALS, INC. V
*Correspondence to: Randall C. Thompson, Saint Luke’s Mid America Heart Institute, Kansas City, Missouri. Fax: 816.931.6362. E-mail:
[email protected] Received 16 January 2015; Accepted 30 January 2015. DOI 10.1002/ar.23136 Published online in Wiley Online Library (wileyonlinelibrary. com).
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ORTHOPEDIC DISEASES OF ANCIENT EGYPT
ture, lateral patella-femoral joint hyper-compression syndrome, severe rotator cuff arthropathy, rotator cuff impingement, hip pincer impingement, and combined fracture of the greater trochantor and vertebral bodies indicating obvious traumatic injury. This report includes the most ancient discovery of several of these syndromes. Conclusions: Ancient Egyptians often suffered painful orthopedic conditions. The high frequency of scoliosis merits further study. The pattern of degenerative changes in the spine and joints may offer insights into activity levels of these people. Anat Rec, C 2015 Wiley Periodicals, Inc. 298:1036–1046, 2015. V
Key words: orthopedic conditions; ancient Egypt mummies; CT scanning
X-ray computed tomographic imaging of ancient human’s remains has the potential to provide important insights into health and diseases of both ancient and modern peoples. The mummification process in ancient Egypt, in particular, was quite advanced, and remarkable preservation of the body was sometimes achieved. The bones and cartilage are significantly more durable than soft tissue, and even very ancient skeletal remains can frequently be imaged with remarkable clarity. While plain film X-rays and CT scanning have been applied to Egyptian and other mummies for many years, almost all reports have been small series or case reports and have not had the ability to survey the extent of specific medical issues (Lewin, 1977; Harwood, 1979; Notman, 1986; Mininberg, 2001; Hoffman, 2002; Jackowski, 2002; Zweifel, 2009). Thus, important potential insights from this type of investigation into orthopedic diseases remain unachieved. For the current study, we performed whole body CT scans of 52 ancient Egyptian mummies and systematically reviewed the images of their large joints and spine to determine the nature and severity of orthopedic diseases in ancient Egyptians.
METHODS The HORUS Study is an ongoing investigation into the health of ancient Egyptians using CT scanning as the principle tool. The details of mummy selection and CT scan approach have been described elsewhere (Allam, 2009, 2010, 2011; Thompson, 2013). In brief, the study and its continuation were approved on three occasions by vote of the Egyptian Supreme Council of Antiquities. Mummies at the Museum of Antiquities in Cairo were selected for CT scanning by Egyptologists/preservationists based on their likely good state of preservation. An attempt was made to include mummies of both sexes, a variety of ages at time of death, and from various eras, but the mummies were not randomly selected. Whole body CT scanning was obtained on 45 mummies using a six slice multislice CT scanner (Siemens Somatom, Forchheim, Germany). Imaging of the thorax, abdomen, pelvis, and extremities was performed at 130 kv with 1.25 mm collimation and 50% overlap. The head was imaged at 130 kv with 0.6 mm collimation and 50% overlap. In addition, seven other mummies from British and American museums which had been CT scanned using a similar approach were included in the study (Allam,
2011). The images of the large joints and spine were reviewed and scored according to consensus by a team of physicians. All pathologic findings were reviewed by an orthopedic surgeon (KOF), three radiologists (AG, JDS, MLS), and a rheumatologist (HM). Specifically, OA changes of the large joints and the spine were scored using the classification of Kellgren and Lawrence (Kellgren, 1957). Glenohumeral joint dysplasia was scored using the classification of Walsh (Walch, 1998). Acromioclavicular instability was assessed according to Rockwood (Rockwood, 1996). Hip dysplasia was assessed according to the Crowe classification (Crowe, 1979). Osteochondritis dissecans was assessed according to description of Clanton and DeLee (Clanton, 1982). Scoliosis, when the spine was intact and not disrupted was evaluated according to the description of King (King, 1983). Demographic information was obtained by a team of experienced Egyptologists and preservationists (AG, IB, AN). Records of the Egyptian National Museum of Antiquities were used to determine the historical time period in which each ancient Egyptian lived. Biologic anthropological measures were used to estimate age (femur, clavicle and skull sutures) and gender (pelvis, skull and presence of genitalia) at the time of death by an expert biologic anthropologist (MTS).
RESULTS The estimated mean age of the mummies at the time of death was 38 6 12 years, range 10 to 601. Six mummies were 50 years (13%). There were 33 males and 17 females. Sex could not be definitively determined in two adolescents. Post mortem destruction of body parts is not uncommon in ancient mummies, but all studies in this series were interpretable for the vast majority of joints and the spine. The complete skeleton was interpretable in 46 mummies and 49 mummies had a complete and interpretable skeleton except for the ankles or one arm. In cases of postmortem disruption of the spine, the vertebral bodies were assessed for OA changes, although scoliosis could not be evaluated in four. The cruciate ligaments and menisci of the knee could be identified in the majority of mummies. These structures were often radiographically dense (and probably
Name
Shtwsk
Unknown
Unknown
Unknown
Rai
Tauhert
Unknown
Unknown
Tarepet
Wedjarenes
Nesmin
Djeher
Nesitanebetawy
Tjanefer
Nesimut
Paduimen
Nesinebtawy
Esankh
Amanit
Unknown
Anonymous
Anonymous
Hatiay
Mummy #/Gender/ Age (yrs)
1/F/45-50
2/F/601
3/M/501
4/F/25-30
5/F/30-40
6/M/30-35
7/M/30-35
8/F/25-30
9/F/25-30
10/M/50-60
11/M/50-60
12/M/50-60
13/M/45-50
14/M/30-35
15/M/25-30
16/M/25-30
17/M/30-35
18/M/30-35
19/F/25-30
20/M/30-35
21/M/50-60
22/F/50-60
23/M/45
King’s Minister Wife of King’s Minister Scribe
Unknown
Priest of Amun Priest of Amun Priest of Amun Priest of Amun Priest of Amun Priest of Amun Priestess of Hathor
Unknown
Son of Irheru
Daughter of Nestefet Unknown
Unknown
Unknown
Nurse of Queen Unknown
Unknown
Unknown
Unknown
Unknown
Social position/ Occupation
New Kingdom, 18th Dynasty New Kingdom, 18th Dynasty
3rd Intermediate 3rd Intermediate 3rd Intermediate 3rd Intermediate 3rd Intermediate 3rd Intermediate Middle Kingdom, 11th Dynasty Ptolemaic
Ptolemaic
Ptolemaic
Late
Late
Late
New Kingdom, 18th Dynasty 3rd Intermediate Ptolemaic
Greco-Roman
Greco-Roman
Ptolemaic
Greco-Roman
Period
304–30 BCE 1550–1295 BCE 1550–1295 BCE
332 BCE–364 CE 304–30 BCE 332 BCE–364 CE 332 BCE–364 CE 1570–1530 BCE 1070–712 BCE 304–30 BCE 712–343 BCE 712–343 BCE 712–343 BCE 304–30 BCE 304–30 BCE 1070–712 BCE 1070–712 BCE 1070–712 BCE 1070–712 BCE 1070–712 BCE 1070–712 BCE 1981–1802 BCE
Period years
Thebes
Thebes
Thebes
Unknown
Deir el-Bahri Deir el-Bahri Deir el-Bahri Deir el-Bahri Deir el-Bahri Deir el-Bahri Deir el-Bahri
Akhmim
Akhmim
Akhmim
Unknown
Unknown
Deir el-Bahri Deir el-Bahri Akhmim
Edfu
Edfu
Akhmim
Dahshur
Place of excavation
䊊
$
$
$
Hip OA
~
~
~
~
Knee OA
~
~
~
~
Ankle OA
OA spine
~
~
~
~
~
~
~
~
~
~
~
Elbow OA
Rotator cuff pathology ($ =Yes)
~
GH OA (= Grade 2; 䊊= Grade 3)
AC joint OA ( 5 Grade 2; 䊊= Grade 3)
TABLE 1. Mummy demographic data and orthopedic findings
$
$
$
Scoliosis ($ 5 Yes)
䊏
䊏
䊏
䊏
䊏
䊏
䊏
䊏
䊏
䊏
䊏
Other
Maiherpri
Isis
Unknown
Unknown
Unknown
Unknown
Unknown
Djedhor, Son of Nesihor Unknown
Unknown
AhmoseHenttamehu
Unknown
AhmoseHenutempet
Unknown
Unknown Unknown Nebsy
Djedhor Taditbastet
Shauenimes
Unknown
24/M/25-30
25/F/40-45
26/M/50-55
27/M/25-30
28/M/40-45
29/M/45-50
30/M/45-50
31/M/45-50
33/F/40-50
34/F/40-45
35/F/40-45
36/F/20-25
37/F/19
38/F/45-50 39/M/35-40 40/M/45-50
41/M/35-40 42/F/45-50
43/F/20-25
44/M/25-30
32/M/30
Name
Mummy #/Gender/ Age (yrs)
Unknown
Unknown
Unknown Unknown
Unknown Unknown Unknown
Unknown
Princess
Princess
Queen
Queen
Unknown 3rd Intermediate, 25th Dynasty 3rd Intermediate, 22nd Dynasty Late
Unknown Unknown New Kingdom
2nd Intermediate, 17th Dynasty 2nd Intermediate, 17th Dynasty 2nd Intermediate, 17th Dynasty Roman
New Kingdom, 18th Dynasty
Greco-Roman
Late
King
Unknown
Late
Late
New Kingdom, 18th Dynasty New Kingdom, 18th Dynasty New Kingdom, 19th Dynasty New Kingdom, 18th Dynasty New Kingdom, 18th Dynasty Late
Period
Unknown
Unknown
Unknown
Unknown
Unknown
Nubian Prince Singer
Social position/ Occupation
945–710 BCE
30 BCE–364 CE Unknown Unknown ca. 1550-1070 BC Unknown ca. 700 BCE
1580–1550 BCE
1580–1550 BCE
1580–1550 BCE
332 BCE–364 CE 1550–1295 BCE
1550–1295 BCE 1550–1295 BCE 1295–1186 BCE 1550–1295 BCE 1550–1295 BCE ca. 688–332 BCE ca. 688–332 BCE ca. 688–332 BCE 380–343 BCE
Period years
Unknown
Akhmim Unknown
Fayoum Fayoum Thebes
Thebes, Deir el-Bahri Thebes, Deir el-Bahri Thebes, Deir el-Bahri Thebes, Deir el-Bahri Saqqara
Unknown
Unknown
Asyut
Asyut
Asyut
Thebes
Thebes
Thebes
Thebes
Place of excavation
~
Hip OA
Knee OA
~
Ankle OA
~
~
~
OA spine
~
~ ~ ~
~
~
~
~
Elbow OA
Rotator cuff pathology ($ =Yes)
~
GH OA (= Grade 2; 䊊= Grade 3)
䊊
AC joint OA ( 5 Grade 2; 䊊= Grade 3)
TABLE 1. (continued).
$
$
$
Scoliosis ($ 5 Yes)
䊏
䊏
䊏
Other
Tjayasetimu
Padiametet
Shepenmehyt
Irthorru
Child EA 21809 Unknown
Unknown
Gitbetah
45/?/12
46/M/45-50
47/M/40-45
48/M/40-50
49/?/10
50/M/20-25
51/M/45-55
52/M/25-30
~= Positive for OA.
Name
Mummy #/Gender/ Age (yrs)
High Priest of Amun
Unknown
Unknown
Singer of Interior of Amun Door Keeper of Re, Thebes Sistrum Player Temple of Amun Re Priest of Akhmim Unknown
Social position/ Occupation
Late Intermediate 3rd Intermediate, 23rd Dynasty
Roman
Saite, 26th Dynasty Roman
3rd Intermediate, 22nd Dynasty 3rd Intermediate, 25th Dynasty Saite, 26th Dynasty
Period
Thebes, Deir el-Bahri Thebes
ca. 688–332 CE
828–725 BCE
Unknown
Unknown
Fayoum (Hawara) Thebes
Akhmim
Thebes
ca. 600 BCE ca. 600 BCE ca. 40–55 CE ca. 140–180 CE 500 BCE
Thebes
ca. 700 BCE
ca. 900 BCE
Place of excavation
Period years
AC joint OA ( 5 Grade 2; 䊊= Grade 3)
TABLE 1. (continued). GH OA (= Grade 2; 䊊= Grade 3) Rotator cuff pathology ($ =Yes) Elbow OA
Hip OA
Knee OA
Ankle OA
~
OA spine
Scoliosis ($ 5 Yes)
䊏
Other
Fig. 1. A perthes disease mummy 8.
Fig. 3. Thoraco-Lumbar scoliosis with secondary changes (arrows) mummy 2.
Fig. 4. Hyper-compression of the lateral patella-femoral joint phenomenon both knees. Mummy 7. Fig. 2. Grade 4 osteochodritis dissecans of the right knee—mummy 1.
calcified)—changes we believe are most likely from the mummification process. Several mummies had interruption of the menisci which could be consistent with tears, but the appearances could not be distinguished from post mortem changes.
Osteoarthritic Changes Table 1 lists the mummies studied in the order in which they were CT scanned. The table lists the social position if known, estimated age at death, the era in
which they lived, and the frequency and severity grade of OA changes of the spine, the shoulders, elbows, knees, hips and ankles. Degenerative changes in the spine were common. We did not find cases suggestive of tuberculosis or other osteomyelitis of the spine. One mummy had a cystic lesion in the distal tibia with mild surrounding sclerosis ipsilateral to a missing great toe. The pattern was considered suggestive of osteomyelitis with a Brodie’s cyst/Brodie’s abscess. Figures 1–13 show many of the pathologic orthopedic conditions found in the mummies – Perthes disease, osteochondritis dissecans of the knee, scoliosis of the thoracic spine, hyper-compression of lateral patella-
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FRITSCH ET AL.
femoral joint syndrome, rotator cuff arthropathy, dysplasia of the glenohumeral joint, rotator cuff impingement, traumatic axial force fractures, Brodie’s abscess, vertebral hemangioma, torn meniscus, and hip pincer impingement.
DISCUSSION
mummies. While CT scanning has been used on mummies for a number of years, the vast majority of reports has been single case studies or small series and has most frequently described the anthropologic rather than medical findings. Using this systematic approach, we have found a variety of pathologic orthopedic conditions. We believe that our CT scans represent the most ancient
This is the first study to systematically review the orthopedic diseases observed on CT scans of ancient
Fig. 5. Right cuff tear arthropathy of the shoulder (cranialization with new joint under the acromium, (arrow) and severe secondary degenerative changes). Mummy 9.
Fig. 7. Rotator cuff impingement of the right shoulder. A bony prominence of the clavicle is impinging upon and displacing the rotator tendon (arrow). Mummy 14.
Fig. 6. Osteoarthritis of the acromioclavicular joint with cystic changes: (A) Coronal view. (B) Axial view.
ORTHOPEDIC DISEASES OF ANCIENT EGYPT
1043
Fig. 10. Cervical osteoarthritis C4–C6, Mummy 1.
Fig. 8. (A) Fracture of the left major trochantor (arrows). (B) Old compression fracture of L2 with overgrowing bone and intraspongiosus disc herniation of L4 (arrow). Mummy 39, a male aged 35–40 at the time of death.
Fig. 9. Cystic lesion (arrow) in the distal tibia consistent with Brodie’s abscess. This man also has a missing and presumably amputated ipsilateral great toe, suggesting that the infection which caused this abscess may have begun in the toe. Mummy 51.
case ever reported for the following conditions: juvenile aseptic necrosis of the hip (Perthes disease), lateral patella-femoral joint hyper-compression syndrome, severe rotator cuff arthropathy, rotator cuff impinge-
ment, Brodie’s abscess of the distal tibia, os acetabulare leading to pincer impingement of the hip, and hemangioma of the vertebral body. Our results also include some of the earliest reported cases of osteochondritis dissecans of the knee and traumatic fracture of the leg and vertebrae. While it is perhaps not surprising that ancient people suffered painful conditions of the bones and joints, the variety and frequency of these findings is impressive. One of the more striking features of this study is the seemingly high incidence of scoliosis. Out of 52 mummies, 6 (12%) had pathologic curvature of the spine. We believe that it is unlikely that this appearance occurred post mortem since secondary degenerative changes of the spine and trunk torsion are also seen – secondary changes typical of those in modern patients. The incidence of scoliosis in the general modern population is much lower than this. For example, Yawn et al estimated the frequency of adolescent idiopathic scoliosis to be 1.8% in a population-based school screening study (Yawn, 1999). While our mummies were not randomly selected and may not be reflective of the general ancient Egyptian population, this frequency is quite high and raises the question as to whether environmental factors were responsible. Many of the elite ancient Egyptians who were mummified and make up our study population may well have been quite inactive physically (David, 2011). Other genetic and environmental factors for scoliosis such as those recently reviewed by Wang et al. (2011) are also possible. The mummies in our series lived during a variety of eras spanning over 2000 years. Thus, if particular inherited factors are contributing to this seemingly high rate of scoliosis, genetic factors perhaps had a higher frequency in upper class ancient Egyptians.
Osteoarthritic Changes Of our 52 mummies, 25 (48%) had degenerative changes of the spine with osteophytes and other abnormalities typical of spinal osteoarthritis seen in modern patients. Given the fairly young estimated age at death (mean age 38.1 years), this frequency is higher than expected in a modern population. There were also 13 mummies with OA changes in the acromioclavicular
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Fig. 11. Calcification of cruciate ligaments and menisci are visible on CT in numerous mummies. This calcification is thought to be frommummification effect. (A) Visible Posterior Cruciate Ligament (arrow), (B) Visible Medial Meniscus with questionable rupture.
Fig. 12. Os acetabulare that has lead to pincer impingement of the hip. Fig. 13. Hemangioma of thoracic vertebral body.
joint. OA changes were less common in the large joints of the hip (one case, 2%), elbow (one case, 2%), knees (four cases, 8%), ankles (five cases, 10%), and changes suggestive of traumatic injury to the ankles were not seen. Based on World Health Organization survey statistics, symptomatic osteoarthritis of the knees occurs in on the order of 7,500 per 100,000 population for people in
their 40s (8%) (Woolf, 2003). Thus, the incidence of knee OA found on the CT scans of our mummies is comparable to moderns. However, previous studies of the ancient remains of Native Americans have generally shown that the greatest prevalence of degenerative joint disease is
ORTHOPEDIC DISEASES OF ANCIENT EGYPT
in the knee (Jurmain, 1980; Jurmain, 1980). Degenerative joint changes are in large part related to activity, of course. The mummies we studied were almost certainly not common laborers in life. The social position is known for 25 of them and all were of high social status such as priest or members of the king’s household. The high financial cost of mummification suggests that the other mummies were also of high social status. Although there was no motorized transportation in ancient times, the elites in ancient Egypt may have been quite sedentary (David, 2011). They also likely ate a rich diet (David, 2010). Findings by others: One of our mummies had a combination of greater trochanter neck fracture and fracture and herniation of vertebral bodies—convincing evidence of pre-mortem traumatic injury (see Fig. 8). Jackvoski et al. described findings similar to this in a 4,000 year old South American mummy (Jackowski, 2002). On CT scan they found the mummy to have a femoral neck fracture and fracture of the 4th lumbar vertebrae, possibly from a single injury such as a fall. Likewise, the almost certain explanation for the combination of fractures in the mummy in our series is axial force trauma, such as a fall. In this man’s case, the advanced arthritic changes in the right hip indicated that he survived, and undoubtedly suffered from this injury for years. Other mummies in our series had osteochondritis dissecans, a joint condition that appears to affect primarily subchondral bone, with secondary effects on articular cartilage. With progression, this pathology may present clinically with symptoms related to the integrity of the articular cartilage. Incidence of osteochondritis dissecans has been estimated at between 0.02% and 0.03%, based on a survey of knee radiographs, and at 1.2%, based on knee arthroscopy (Linden, 1976; Bradley, 1989). Osteochondritis dissecans was previously described in an ancient mummy from Chile by Kothari et al (Kothari, 2009). To our knowledge, no other investigators have described the other discreet observations we have included in this report.
LIMITATIONS Although this investigation involves the largest collections of CT scans of mummies ever reported, the study population was not a random sample. Rather, mummies were selected for imaging based on expected good state of preservation. For this reason, the orthopedic findings we described are likely most characteristic of wealthy ancient Egyptians—those who could afford high quality mummification—rather than commoners. Also, we used a six-slice CT scanner for most of the studies. CT technology is rapidly improving and the higher spatial resolution offered by the latest generation of CT scanners would likely yield more subtle findings and additional diagnoses beyond those described herein. Also, the focus of this study was the large joints of the body and the spine. We did not review the small joints of the hands and feet in detail, though such a study is anticipated. We also tried to include only changes which were clearly not from the embalming process or post mortem treatment. For example, scoliosis was only diagnosed if clear secondary changes were seen. However, it is possible that post mortem handling nevertheless pro-
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duced at least some artifacts which mimick pathologic conditions.
CONCLUSIONS Ancient Egyptians often suffered painful orthopedic conditions. The high frequency of scoliosis seen in our series merits further study. The pattern of degenerative changes in the spine and joints may offer insights into the level of activity of these people.
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