Introduction to Japanese Abdominal Palpation Diagnosis

Stephen Birch

Introduction
Palpation is a major feature of the practice of acupuncture and moxibustion in Japan [Birch 1989-90,
Birch, Felt, 1999, Birch Ida, 1998, Ido no Nippon 1986, Manaka et al. 1995, Matsumoto, Birch 1988,
Miyawaki 1976, Shudo 1990]. This paper will summarize various methods of palpation, palpatory
findings, diagnostic reflexes, especially abdominal palpation findings. Point location methods and pulse
diagnosis methods are covered in elsewhere. Palpation in Japan is much more than simply pressing to see
if it hurts, palpation typically covers a broader range of approaches [Ido no Nippon 1986], including what
the practitioner feels as well as what the patient feels, and findings from light touch (assessing at the skin
level) to light pressure to heavier pressure (assessing at the muscle level). The historical development and
general uses of palpation methods are discussed elsewhere [Matsumoto, Birch 1988]. Palpation of the
body, especially the abdominal region as a diagnostic method was first clearly articulated in the Nan Jing.
The methods described there remain important in meridian therapy in Japan. It is also important to note
that acupuncture in Japan was and continues to be strongly influenced by the traditions of massage
therapy [Birch 1989-90, Birch, Ida 1998] and blind practitioners [Birch 1989-90, Birch, Ida 1998,
Fukushima 1991, Matsumoto 1994], both of which have helped place a strong emphasis on the role of
palpation and touch in diagnosis. Unlike China, influences from the more intellectually based systems of
herbal therapeutics have not been as strong [Birch 1989-90, Birch, Felt 1999]. Given these factors, we can
see why a much stronger emphasis on less theoretical hands-on approaches developed in Japan [Birch
2000].

For more detailed discussions of palpation the reader is referred to [Matsumoto, Birch 1988 especially
pages 239-267], and [Birch, Ida 1998 chapter 3]. For more detailed description of how palpation is used
in Manaka's yin-yang channel balancing therapy, see [Manaka et al. 1995 especially pages 131-145]. For
more discussion of how palpation is used in Keiraku Chiryo - Meridian Therapy, see [Shudo 1990, pages
44-106], and [Fukushima 1991 pages 91-132].

As is typical in naked-sense observation based methods of practice [Birch, Felt 1999], acupuncture has
evolved a number of methods of palpation. The practitioner who uses wider gauge, deeply inserted
needles with electrical stimulation, looking for a sore point on a tight spasming muscle that corresponds
with the location of a motor point or trigger point, will typically use strong pressure to find and
discriminate the point to be treated; the blind acupuncturist using keiraku chiryo or meridian/channel
therapy who uses super-thin needles that barely, if at all break the skin, will only lightly touch the skin for
diagnosis and point location. Different systems of practice utilize different methods of palpation. Within
specific systems of practice, palpation will also change depending upon the goal of treatment. In channel
therapy, when correcting problems of vacuity of qi, very light touch can be used to help decide the
diagnosis, and still lighter touch for treatment point location [e.g. Fukushima 1991]. However, in meridian
therapy, when treating a point to relieve a specific symptom, pressure is often applied, such that clear
pressure pain and/or tight points (often called indurations) are found for treatment [Fukushima 1991,
Shudo 1990]. While the methods of palpation vary between and within systems, what does not vary is the
underlying basis of these methods: they are all empirically based rather than being theoretically based.
Each system uses what skilled practitioners have found useful and passed on to their students or shared
with colleagues. Differences between approaches typically depend on personal preferences and the
constraints of specific systems of practice (such as the attempt to replicate the results of experienced
practitioners), rather than on any major theoretical explanation.
Methods of palpation
1) Touch palpation - examining the texture and tonus of the skin. In meridian therapy it is believed that
the channels circulate at the skin surface or in the surface layers of the skin, thus to understand the
condition of qi circulation in the channels, light touch is used. This approach evolved out of the direct
observation that sufficient information could be gathered by simple touch alone, and that surface needling
methods were effective. The belief about the relative placement or depth of the channels appears to have
followed these observations. While the early practitioners of the Toyohari system (a specific school of
channel therapy) primarily used inserted needles [still evidenced in Fukushima's first book, Fukushima
1991], over time they evolved techniques where more powerful and precise treatment effects could be
produced without actual insertion of the needles. This was not a theoretically driven change, but a direct
observation based on study and clinical experience. Denmei Shudo has reported the same experiences
[Shudo 1997 + NAJOM]. With touch palpation the emphasis is placed on what the practitioner feels
rather than what the patient feels. Touch palpation is used on the abdomen in specific reflex areas and
along the channels to see if they feel kyo or jitsu, vacuous or replete.

2) Pressure palpation - examining the texture and tonus of the musculature. This approach is important for
both treatment point location and reflex point or area diagnostic assessment. Most schools of acupuncture
and moxibustion in Japan employ palpation methods that seek pressure pain points. It is relatively easy to
find pressure pain on palpation, and the feedback from the patient can be helpful to confirm what one
finds. But in addition to soliciting pressure pain responses the practitioner can feel a number of other
responses such as softness, hardness, jumpiness/spasming of the muscles. The practitioner can also
observe patient reactions, such as facial expression, jump reactions etc. Each of these will be discussed
below. Having observed in many clinics in Japan with experienced practitioners, we have commonly
found that the more experienced the practitioner, the lighter the palpation to elicit reactions. In the
experience of SB this was a process whereby the use of strong pressure not to miss a pressure pain point
was important early on in practice, but over time other accompanying reactions and textures in the skin
and muscles became apparent. After some time palpation was applied with less pressure to find the same
points, reflex areas. This is not to say that always finding pressure pain is a sign of less sophistication in
practice, rather it is not always necessary. There are times where it may be advantageous to use heavier
pressure to elicit clear reactions. Examples will be given below.

Principle uses of palpation in Japanese acupuncture and moxibustion:

1) To assess the overall state of the patient, and help formulate a prognosis [Birch 1997]. Palpation allows
for a direct assessment of the condition of the qi of the patient. Touching the forearm prior to feeling the
pulses allows one to judge the condition of the skin of the forearm and thus immediately start assessing
the overall status of the qi of the patient [this is described in difficulty 13 of the Nan Jing, (Unschuld 1986
pages 70-71)] Similarly, with the first touch of the patient's abdominal region, the assessment of the
condition of the skin and muscles of the region give immediate information about the overall status of the
qi of the patient [this is based in part on the Nan Jing, (Unschuld 1986 pages 130, 219-221 & 499-501),
and is described in detail in (Birch 1997, Matsumoto, Birch 1988)]. In each of these cases, the assessment
is a direct, non-analytic or non-intellectual assessment of the condition of the qi. Other forms of
acupuncture often require a more intellectually-based process of analyzing signs and symptoms to arrive
at a conclusion about the state of the qi of the patient.

2) Through palpation of the abdominal region (reflex areas and points) one can determine what the
primary pattern treatment points and methods should be [see Matsumoto, Birch 1988 for examples].
Manaka’s yin-yang channel balancing therapy is based on this. Palpation of other reflex points or areas on
the body, helps expand the range of possible patterns and treatment options, for example palpating the
calves to discriminate polar channel treatment. Palpation of the radial pulses in combination with
abdominal palpation is very important in meridian therapy diagnosis. All systems usually have patterns of
symptoms that can also occur, but these are not always necessary.

3) Palpation is very important to find the acupuncture points, this is described below in the chapter on
point palpation.

4) Palpation is not only used to find the exact location of the acupuncture point to be treated, but is
important to select among treatment points in the relief of symptoms. Many points that need to be treated
will show pressure pain and other reactions, this is common in the selection of loci for moxibustion
[Birch, Ida 1998, Fukaya 1982, Irie 1980], intradermal needles [Akabane 1986, Birch, Ida 1998], press-
tack needles [Birch, Ida 1998, Shimizu 1986, Shiozawa 1976], chishin-leaving needle techniques [Birch,
Ida 1998, Shimizu 1986], IP cord treatment [Manaka et al. 1995, Matsumoto, Birch 1988], zinc-copper
needling [Fukushima 1991]. When using okyu/direct moxibustion, the primary treatment point will often
be the one with the most pressure pain and a kind of hardness or know in the tissues. Often authors
describe a range of treatment points that can show reaction on palpation in the presence of a specific
symptom or set of symptoms. For example, Shiroda and Manaka list many symptoms and diseases with
treatment points to select from for moxibustion treatment [Manaka et al. pages 206-217], Akabane
describes the use of intradermal needles on the body selecting from among different points for each
condition [Birch, Ida, pages 159-164]. Palpation of points that are to be treated as part of the ‘branch’,
hyochiho, symptom control treatment are discussed further in the chapter on point location and Part 8,
where the treatment of various symptoms and diseases are discussed.

5) Palpation can give immediate or near immediate feedback about the efficacy of the treatment method
just applied. For example, in Manaka's system, once the IP cords have been attached, there should be an
immediate improvement in the abdominal palpatory findings. How the abdominal findings change gives
feedback about how well that step of treatment was administered, whether it was effective, whether there
are problems with accuracy of point location, selection of treatment etc (usually point location).These
things are discussed further in Parts 3 and 4. Palpation of other regions of the body and the radial pulses
can also give feedback to how well treatment was applied. The pulse changes are discussed briefly in the
chapter on pulse diagnosis and Part 5.

Order of palpation methods on the abdominal region

Generally patients will find it more comfortable if one palpates in a downward direction rather than an
upward direction. Depending on what style of treatment one uses, the areas of palpation, methods and
findings from palpation vary, thus one tends to focus on palpating those areas described as having
diagnostic significance in that style of treatment. The sequence or order of palpation thus also varies.

Primary palpatory findings on the abdomen:

1) Pressure pain.
Pressure pain is a useful finding as there is usually a clear response from the patient, which helps to
reduce the subjectivity of palpation assessment. But it is important to distinguish between pressure pain
that shows with light versus heavy pressure, and it is important not to press points too hard, it is easy to
make anything sore if enough pressure is applied. Many reflex areas or points will also show pressure
pain responses thus aiding in diagnosis [Manaka et al. 1995, Matsumoto, Birch 1988, Shudo 1990]. In
Manaka's system of yin-yang channel balancing therapy, the finding of pressure pain in a number of
related acupuncture points is sufficient to determine where and how to apply the IP cords at step one of
the root/general treatment. Pressure pain is important as a diagnostic finding for both Manaka’s yin-yang
channel balancing therapy and meridian therapy.

2) Muscular tension.
Muscular tension often accompanies pressure pain points, and many points that need to be treated will
manifest muscular tension, likewise, many reflex points or areas show muscular tension, thus aiding in
diagnostic assessment. This muscle tension needs to be distinguished from the normal tonus of a healthy
muscle, and the hardness that can accompany tension in a reactive point or area. Clinical experience is the
best method for understanding these differences. When tension is found can be important for both
Manaka’s yin-yang channel balancing therapy and meridian therapy.

3) Muscular hardness.
Muscular hardness occurs when the abnormal tension in a muscle becomes severe and/or chronic. The
hardening of the muscular tissues indicates a generally more progressed condition. Thus if this is found at
one of two possible treatment points, the point that is hard would be chosen over a point that was merely
tense. If it is found in a reflex area, it indicates a possibly more difficult to treat condition.
In Japan there is a lay term for this kind of hardness, that is the term kori. This term is used in
acupuncture when referring to the kind of stiff and sore shoulders commonly found in Japan (kata kori). It
has begun to find its way into more common use in acupuncture, and there are some speculations about
the nature of this stiffness [Matsumoto, Birch 1988], but it should not be confused with the range of
muscle-related palpable findings that can be found.

Manaka discussed relations between pressure pain, and muscle tonus [Manaka et al. 1995]. If the right
subcostal region were a little tense with no pressure pain, that is generally a sign of a pattern that is less
progressed than if the tension also had pressure pain. If there was also hardness in the right subcostal
muscles, this indicates yet further progression. Muscular hardness and the tight bands of muscle that are
found is important for both Manaka’s yin-yang channel balancing therapy and meridian therapy.

4) Induration.
An induration is a hard fibrous point that is typically very painful with pressure. Indurations are clearly
described by Shudo [Shudo 1990], and are probably most frequently found and used in relation to
selecting points for treatment to relieve symptoms. It is for example, a typical feature of reactive points
for okyu/direct moxibustion [Irie 1980]. Indurations tend to show with quite firm pressure, and thus are
not commonly seen in diagnosis for the root treatment, but they can show in relation to both Manaka’s
yin-yang channel balancing therapy system and less often in meridian therapy.

5) Jump-reactions.
Jump reactions can be very helpful to discriminate among a number of reactive points or areas when
selecting the root treatment pattern or symptomatic treatment points. Sometimes the patient does not say
anything about the reactions in words, or says many things about many points or areas. In both cases it
can be more difficult deciding what is important. Often the reactive points or areas also manifest tension
or tightness, which can be discriminated for significance by the practitioner. But again, sometimes many
points or areas are also tight. In cases like this one should try palpating in such a manner as to elicit a
jump reaction. This requires the use of ‘cross-fiber palpation’. This is a simple technique that uses
palpation with firm pressure across the grains or fibers of the muscle bands that one is palpating. If the
areas or points are very significant either in relation to selecting a root treatment or relevant symptom
treatment point, the patient will often jump when this kind of palpation technique is used. The patient may
experience it as very uncomfortable and painful, but often it is experienced as different, weird or ticklish.
The patient will report that they can’t help it but when they are palpated in that area in that manner they
just jump. Others will report that the palpation is very ticklish. Whatever language and words the patient
may attempt to use to describe the experience, the body is not misleading, it jumps and the patient cannot
control it. This involuntary jump reaction is especially important in Manaka’s root treatment pattern
differentiation, for choosing the best treatment points at step two and for symptom treatment point
selection. It is not generally used in meridian therapy as a diagnostic finding.

6) Muscular flaccidity.
When on palpation one finds that the muscle tonus is lax, and that the hand or fingers tend to sink into the
muscles with little or no resistance, this indicates a more progressed condition, and generally a stronger
vacuity condition. This finding on specific regions of the abdomen can alone be sufficient to determine
what treatment pattern to select in meridian therapy [Shudo 1990]. In Manaka’s yin-yang channel
balancing therapy it is generally only relevant when found in the region below the navel or if the whole
abdominal wall is soft and flaccid [Manaka et al. 1995].

7) Pulsation.
The Nan Jing details how pulsations can be felt in different regions of the abdomen, especially in relation
to the five phases and their respective primary organs. Generally the stronger the pulsation this is a sign of
more vacuity. It is not generally used as a finding in Manaka’s yin-yang channel balancing therapy
system.

8) Skin texture.
The skin can manifest multiple textures, each of which can indicate something a little different. There are
findings such as roughness or smoothness, tautness or looseness, thinness or thickness, including a
puffiness, soft emptiness. These textures are best discerned with light touch, as pressure presses through
them to examine the textures of the underlying tissues, muscles. This is used in some forms of meridian
therapy and is not generally used as a finding in Manaka’s yin-yang channel balancing therapy system.

9) Lustre.
It is interesting that blind practitioners, especially in the Toyohari tradition [Fukushima 1991], use a
visual term to describe what they feel with their hands. The lustre is akin to the vitality of the skin, pulse,
muscle that you are palpating. It is hard to clearly describe and is best understood in practice rather than
on paper. If an area has little lustre, it indicates that the qi flow to that region is poor. If an area that had
poor lustre now has good lustre, it indicates a good treatment. This is used in some forms of meridian
therapy and is not generally used as a finding in Manaka’s yin-yang channel balancing therapy system.

Advantages of the use of palpation in diagnostic assessments:

1) Palpation allows for more precise point location. One observation among acupuncturists in Japan, is
that point loactions can vary slightly from patient to patient, and even day to day, thus simply using the
correct anatomical point is not precise enough with the more delicate needling techniques typically
employed. Palpation allows for precise refinements of point location.

2) Palpation can give immediate and direct feedback about the overall condition of the patient.
3) Palpation can give immediate information that alone can allow a choice of primary treatment pattern,
treatment points and methods, for example, in Manaka's system, abdominal palpation alone can allow a
choice of extraordinary vessel treatment points, sides of treatment and methods of treatment [Manaka et
al. 1995].

4) Palpation can give immediate information that can be analysed with other information gathered
through other methods (looking, listening/smelling, and asking) to allow a choice of primary treatment
pattern, treatment points and methods (e.g. Keiraku chiryo / Toyohari). In this context, the weight of the
palpatory findings can vary depending upon the clarity of the findings (if clear they can form the basis of
that decision, if not so clear, they can be put into the overall context).

5) Palpation can give immediate feedback about the effectiveness of the treatment procedure just applied,
allowing for an immediate judgement of whether sufficient and appropriate change has occured or
whether the procedure needs to be redone, modified in some way, augmented in some way or replaced.

Disadvantages in the use of palpation in diagnostic assessments:

1) Palpation tends to yield subjective information, either reported by the patient or by the practitioner or
both. As with any system of therapy that relies on subjective information, it is subject to error. It is
therefore important not to ignore other less subjective information in the decision making processes, so
that decisions arise out of consideration of potentially more reliable information. However, with studies
demonstrating that the palpatory findings are reliable, they can be used with more confidence [Birch
1997-a, chapter 4]. Despite the paucity of scientific studies of these decision making processes around
the subjective data procured through palpation, these methods can be used with some confidence. In the
Toyohari system, the Kozato method is a consensus building exercise that reinforces the principle of
seeking agreement and over time encourages the consensus (inter-rater agreement) of experts in the
system.

2) It is very easy to become too "New Age" with these kinds of approaches, imagining things that have
little basis in clinical reality.

3) It is very easy to fall prey to "Scientificism", the imagined scientific basis of the procedures that one is
applying. For example, one can find "scientific" sounding claims such as: point X reflects problems of the
thyroid, if sore, treat point Y, if the pressure pain at X, the thyroid point improves, it means you have
improved the condition of the thyroid. Without measurable thyroid pathology as demonstrated by
appropriate thyroid tests and an imprvement in those test results, this kind of claim has no scientific
validity.

4) In certain diseases, the palpatory findings can be very confusing as the patient is unable to give clear
feedback, and/or, what the practitioner feels can be contradictory or misleading.

Problem 1) can be addressed with careful repetitive study and through efforts at establishing the reliability
of the findings in carefully structured scientific experiments.
Problems 2) and 3) pervade many "Alternative" or "Complementary" therapies and are not unique to what
is described here. They are best addressed through a healthy dose of critical thinking, and the demand that
academic rigour be required.
Problem 4) can be addressed through careful clinical practice, over time one can learn to identify those
cases that are contradictory and figure out solutions [Birch 1997, Manaka et al. 1995].

Fukushin - Hara diagnosis - abdominal palpation

As we have seen, abdominal palpation can play an important role in the practice of acupuncture in Japan.
The theories and methods of abdominal palpation started in the Nan Jing, (circa 100 AD). Basically the
Nan Jing seemed to suggest that there is a kind of core center to the qi systems in the body located in the
lower abdomen [Unschuld 1986 pages 130 and following]. This center was called the "moving qi
between the kidneys", and was described both as a dynamic center and as "fundamental to the 5 yin and 6
yang organs, the root of the 12 channels, the gate of breathing. It is the source of the triple burner." [these
concepts are discussed at length in (Matsumoto, Birch 1988), see especially chapters five and six]. It has
been suggested that this idea of a core center in the lower abdomen provided the theoretical basis for
palpating on the abdominal region to understand the nature of the primary disruptions in the qi systems of
the patient. Certainly this idea helps us understand how palpation of the abdominal region can give
specific general information about the overall status of the patient (in terms of assessing prognosis). It
has also led to systematic methods of assessing specific problems in the patient. Chapters 16 and 56 of
the Nan Jing then outlined a basic method of abdominal palpation in relation to the five phases and their
primary zang organs [Unschuld 1986 pages 219-221 & 499-501]. This method has become central in the
use of abdominal palpation in Japanese channel therapy. It has also encouraged the development of
numerous other abdominal palpation mappings, including Manaka's extraordinary vessel mappings of
reactions on the abdominal region. In the final segment of this paper, the author will briefly outline the
primary reflex areas and their reactions for the channel therapy approach (five phase) and Manaka's yin
yang channel balancing approach (extraordinary vessels).

Meridian therapy - five phase reflex areas

The Nan Jing described how each of the five phases and their primary zang organs reflected in a pattern
around the navel. The water/kidney area was described as being below the navel, the earth/spleen area as
around and above the navel, the fire/heart area as below the sternum, the wood/liver area as to the left of
the navel and the metal/lung area as to the right of the navel. In modern practice this map has generally
been extended to include the area directly above the navel up to and including CV-12 as being related to
earth/spleen, the area from around CV-7 and below as being water/kidney related, the area from around
right ST-25 to ST-27 as being metal/lung related, and the areas from left ST-25 to ST-27 and in the right
subcostal region as being wood/liver related [see e.g. (Matsumoto, Birch 1988 page 333}), (Shudo 1990
pages 91-93]. Other variations of this have also developed, [see Matsumoto, Birch 1988 pages 334-346,
& Shudo 1990 pages 93-101]. In this model, the findings from abdominal palpation are interpreted
relative to radial pulse palpation (see chapter 1.xx), the remaining four diagnoses and signs and symptoms
to select the "sho" or pattern. Part 5 describes the details of pattern recognition including pulse and
abdominal findings, signs and symptoms.

Primary findings in the meridian therapy model are:

touch: softness of the skin, puffiness of the skin, rough skin, cool to the touch
pressure: stiffness, pressure pain, softness, pulsation
Yin yang channel balancing therapy

In Manaka's system, the extraordinary vessels are understood relative to a geometric symmetrical model
of the qi circulation systems of the body. In this model the extraordinary vessels and twelve channels are
seen in relation to viewing the body mapped onto an octahedron with dividing lines that run along vertical
and horizontal axes that intersect at the navel, around GB-26 and on the spine [see Manaka et al. 1995
pages 41-47]. The fact that these axes intersect through the navel allows for the examination of reaction
patterns either along the primary axes or in the upper and lower quadrants of the abdomen defined by
these axes. These primary reflex areas correlate to pairs of the extraordinary vessels. Reactions found
along the ren mai indicate the yin qiao-ren mai pattern; reactions along the horizontal axis that intersects
the navel indicate the yang wei-dai mai pattern; reactions in the subcostal regions (‘upper right
quadrant’/URQ & ‘upper left quadrant’/ULQ) indicate the yin wei-chong mai pattern; reactions at the
anterior superior iliac spines -ASIS- (‘lower right quadrant’/LRQ & ‘lower left quadrant’/LLQ) indicate
either the yang wei-dai mai or yang qiao-du mai patterns [see Manaka et al. 1995 pages 134-139].
Additionally Manaka mapped out modern "mu" points that allowed a differentiation between left and
right sided manifestations of reaction [see Manaka et al. 1995 pages 74-75 & 134-135]. The following
table shows these relative to the traditional mu points.

Channel traditional mu point modern mu point

Lung LU-1 LU-1 to LU-2
Large Intestine ST-25 ST-27
Stomach CV-12 ST-21 to ST-21, including CV-12
Spleen LV-13 the line from and including SP-21 to GB-26
Heart CV-14 KI-23 + sides CV-14
Small Intestine CV-4 ST-26
Bladder CV-3 KI-11
Kidney GB-25 KI-16
Pericardium CV-17 PC-1 & CV-17
Triple Burner CV-5 ST-25
Gallbladder GB-24 ASIS & GB-24 (and the line between GB-24 and the ASIS)
Liver LV-14 Subcostal region (and the line between LV-14* and GB-26)
* LV-14 is located at the end of the tenth rib, under the costal border, on a line directly below the
nipple.

The patterns of diagnosis in Manaka’s yin-yang channel balancing therapy are detailed in Parts 3
and 4.

Conclusion

Artisans or hands-on doers in any trade or field of endeavour, develop specialized bodies of
information and specialized techniques. In Japan, through the emphasis on palpation in the
practice of acupuncture and moxibustion, quite detailed and specialized information and
techniques have been developed. Within the Japanese methods of acupuncture and moxibustion
such as Manaka's yin-yang channel balancing therapy, and Keiraku chiryo - channel therapy,
these specialized techniques and information are extremely valuable, underpinning clinical
practice. In fact the patterns of reaction found by abdominal palpation are primary in the
selection of which treatment pattern to apply in Manaka's system [Manaka et al. 1995], and play
a primary confirmatory role in channel therapy [Fukushima 1991, Shudo 1990]. But even
outside of these systems, the methods and information can provide a very useful augmentation of
the practice of acupuncture and moxibustion [Matsumoto, Birch 1988]. The ability to
immediately assess a patient's overall condition from simple touch is an invaluable tool in
clinical practice [Birch 1997].

In this brief introduction to the use of palpation methods, and abdominal palpation in particular,
the author has outlined the major points of clinical interest, important in the practice of Japanese
acupuncture.

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