Parasympathetic

nervous system

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The parasympathetic nervous system

(PSNS) is one of the two divisions of the
autonomic nervous system (a division of
the peripheral nervous system (PNS)), the
other being the sympathetic nervous
system.[1][2] The enteric nervous system
(ENS) is now usually referred to as
separate from the autonomic nervous
system since it has its own independent
reflex activity. The autonomic nervous
system is responsible for regulating the
body's unconscious actions. The
parasympathetic system is responsible for
stimulation of "rest-and-digest" or "feed
and breed"[3] activities that occur when the
body is at rest, especially after eating,
including sexual arousal, salivation,
lacrimation (tears), urination, digestion
and defecation. Its action is described as
being complementary to that of the
sympathetic nervous system, which is
responsible for stimulating activities
associated with the fight-or-flight
response.
 Parasympathetic nervous system

Autonomic nervous system innervation, showing

the parasympathetic (craniosacral) systems in
blue.

Details

Identifiers
Latin Pars parasympathica
divisionis autonomici
systematis
Acronym(s) PSNS

MeSH D010275

TA A14.3.02.001

FMA 9907

Anatomical terminology

Nerve fibres of the parasympathetic

nervous system arise from the central
nervous system. Specific nerves include
several cranial nerves, specifically the
oculomotor nerve, facial nerve,
glossopharyngeal nerve, and vagus nerve.
Three spinal nerves in the sacrum (S2-4),
commonly referred to as the pelvic
splanchnic nerves, also act as
parasympathetic nerves.

Owing to its location, the parasympathetic

system is commonly referred to as having
"craniosacral outflow", which stands in
contrast to the sympathetic nervous
system, which is said to have
"thoracolumbar outflow".

Structure
The parasympathetic nerves are
autonomic or visceral [4][5] branches of the
peripheral nervous system (PNS).
Parasympathetic nerve supply arises
through three primary areas:

1. Certain cranial nerves in the cranium,

namely the preganglionic
parasympathetic nerves (CN III, CN
VII, and CN IX) usually arise from
specific nuclei in the central nervous
system (CNS) and synapse at one of
four parasympathetic ganglia: ciliary,
pterygopalatine, otic, or
 submandibular. From these four
ganglia the parasympathetic nerves
complete their journey to target
tissues via trigeminal branches
(ophthalmic nerve, maxillary nerve,
mandibular nerve).
2. The vagus nerve does not participate
in these cranial ganglia as most of its
parasympathetic fibers are destined
for a broad array of ganglia on or near
thoracic viscera (esophagus, trachea,
heart, lungs) and abdominal viscera
(stomach, pancreas, liver, kidneys,
small intestine, and about half of the
 large intestine). The vagus
innervation ends at the junction
between the midgut and hindgut, just
before the splenic flexure of the
transverse colon.
3. The pelvic splanchnic efferent
preganglionic nerve cell bodies reside
in the lateral gray horn of the spinal
cord at the T12-L1 vertebral levels
(the spinal cord terminates at the L1-
L2 vertebrae with the conus
medullaris), and their axons exit the
vertebral column as S2-S4 spinal
nerves through the sacral foramina.[6]
 Their axons continue away from the
CNS to synapse at an autonomic
ganglion. The parasympathetic
ganglion where these preganglionic
neurons synapse will be close to the
organ of innervation. This differs
from the sympathetic nervous
system, where synapses between
pre- and post-ganglionic efferent
nerves in general occur at ganglia
that are farther away from the target
organ.

As in the sympathetic nervous system,

efferent parasympathetic nerve signals are
carried from the central nervous system to
their targets by a system of two neurons.
The first neuron in this pathway is referred
to as the preganglionic or presynaptic
neuron. Its cell body sits in the central
nervous system and its axon usually
extends to synapse with the dendrites of a
postganglionic neuron somewhere else in
the body. The axons of presynaptic
parasympathetic neurons are usually long,
extending from the CNS into a ganglion
that is either very close to or embedded in
their target organ. As a result, the
postsynaptic parasympathetic nerve fibers
are very short.[7]:42

Cranial nerves

The oculomotor nerve is responsible for a

number of parasympathetic functions
related to the eye.[8] The oculomotor PNS
fibers originate in the Edinger-Westphal
nucleus in the central nervous system and
travel through the superior orbital fissure
to synapse in the ciliary ganglion located
just behind the orbit (eye).[9] From the
ciliary ganglion the postganglionic
parasympathetic fibers leave via short
ciliary nerve fibers, a continuation of the
nasociliary nerve (a branch of ophthalmic
division of the trigeminal nerve (CN V1)).
The short ciliary nerves innervate the orbit
to control the ciliary muscle (responsible
for accommodation) and the iris sphincter
muscle, which is responsible for miosis or
constriction of the pupil (in response to
light or accommodation). There are two
motors that are part of the oculomotor
nerve known as the somatic motor and
visceral motor. The somatic motor is
responsible for moving the eye in precise
motions and for keeping the eye fixated on
an object. The visceral motor helps
constrict the pupil.

The parasympathetic aspect of the facial

nerve controls secretion of the sublingual
and submandibular salivary glands, the
lacrimal gland, and the glands associated
with the nasal cavity. The preganglionic
fibers originate within the CNS in the
superior salivatory nucleus and leave as
the intermediate nerve (which some
consider a separate cranial nerve
altogether) to connect with the facial nerve
just distal (further out) to it surfacing the
central nervous system. Just after the
facial nerve geniculate ganglion (general
sensory ganglion) in the temporal bone,
the facial nerve gives off two separate
parasympathetic nerves. The first is the
greater petrosal nerve and the second is
the chorda tympani. The greater petrosal
nerve travels through the middle ear and
eventually combines with the deep
petrosal nerve (sympathetic fibers) to form
the nerve of the pterygoid canal. The
parasympathetic fibers of the nerve of the
pterygoid canal synapse at the
pterygopalatine ganglion, which is closely
associated with the maxillary division of
the trigeminal nerve (CN V2). The
postganglionic parasympathetic fibers
leave the pterygopalatine ganglion in
several directions. One division leaves on
the zygomatic division of CN V2 and
travels on a communicating branch to
unite with the lacrimal nerve (branch of the
ophthalmic nerve of CN V1) before
synapsing at the lacrimal gland. These
parasympathetic to the lacrimal gland
control tear production.
A separate group of parasympathetic
leaving from the pterygopalatine ganglion
are the descending palatine nerves (CN V2
branch), which include the greater and
lesser palatine nerves. The greater
palatine parasympathetic synapse on the
hard palate and regulate mucus glands
located there. The lesser palatine nerve
synapses at the soft palate and controls
sparse taste receptors and mucus glands.
Yet another set of divisions from the
pterygopalatine ganglion are the posterior,
superior, and inferior lateral nasal nerves;
and the nasopalatine nerves (all branches
of CN V2, maxillary division of the
trigeminal nerve) that bring
parasympathetic innervation to glands of
the nasal mucosa. The second
parasympathetic branch that leaves the
facial nerve is the chorda tympani. This
nerve carries secretomotor fibers to the
submandibular and sublingual glands. The
chorda tympani travels through the middle
ear and attaches to the lingual nerve
(mandibular division of trigeminal, CN V3).
After joining the lingual nerve, the
preganglionic fibers synapse at the
submandibular ganglion and send
postganglionic fibers to the sublingual and
submandibular salivary glands.

The glossopharyngeal nerve has

parasympathetic fibers that innervate the
parotid salivary gland. The preganglionic
fibers depart CN IX as the tympanic nerve
and continue to the middle ear where they
make up a tympanic plexus on the
cochlear promontory of the
mesotympanum. The tympanic plexus of
nerves rejoin and form the lesser petrosal
nerve and exit through the foramen ovale
to synapse at the otic ganglion. From the
otic ganglion postganglionic
parasympathetic fibers travel with the
auriculotemporal nerve (mandibular
branch of trigeminal, CN V3) to the parotid
salivary gland.

Vagus nerve

The vagus nerve, named after the Latin

word vagus (because the nerve controls
such a broad range of target tissues –
vagus in Latin literally means "wandering"),
has parasympathetic that originate in the
dorsal nucleus of the vagus nerve and the
nucleus ambiguus in the CNS. The vagus
nerve is an unusual cranial
parasympathetic in that it doesn't join the
trigeminal nerve in order to get to its target
tissues. Another peculiarity is that the
vagus has an autonomic ganglion
associated with it at approximately the
level of C1 vertebra. The vagus gives no
parasympathetic to the cranium. The
vagus nerve is hard to track definitively
due to its ubiquitous nature in the thorax
and abdomen so the major contributions
will be discussed. Several
parasympathetic nerves come off the
vagus nerve as it enters the thorax. One
nerve is the recurrent laryngeal nerve,
which becomes the inferior laryngeal
nerve. From the left vagus nerve the
recurrent laryngeal nerve hooks around the
aorta to travel back up to the larynx and
proximal esophagus while, from the right
vagus nerve, the recurrent laryngeal nerve
hooks around the right subclavian artery to
travel back up to the same location as its
counterpart. These different paths are a
direct result of embryological development
of the circulatory system. Each recurrent
laryngeal nerve supplies the trachea and
the esophagus with parasympathetic
secretomotor innervation for glands
associated with them (and other fibers
that are not PN).

Another nerve that comes off the vagus

nerves approximately at the level of
entering the thorax are the cardiac nerves.
These cardiac nerves go on to form
cardiac and pulmonary plexuses around
the heart and lungs. As the main vagus
nerves continue into the thorax they
become intimately linked with the
esophagus and sympathetic nerves from
the sympathetic trunks to form the
esophageal plexus. This is very efficient as
the major function of the vagus nerve from
there on will be control of the gut smooth
muscles and glands. As the esophageal
plexus enter the abdomen through the
esophageal hiatus anterior and posterior
vagus trunks form. The vagus trunks then
join with preaortic sympathetic ganglion
around the aorta to disperse with the
blood vessels and sympathetic nerves
throughout the abdomen. The extent of
the parasympathetic in the abdomen
include the pancreas, kidneys, liver, gall
bladder, stomach and gut tube. The vagus
contribution of parasympathetic continues
down the gut tube until the end of the
midgut. The midgut ends two thirds of the
way across the transverse colon near the
splenic flexure.[10]

Pelvic splanchnic nerves

The pelvic splanchnic nerves, S2-4, work in

tandem to innervate the pelvic viscera.
Unlike in the cranium, where one
parasympathetic is in charge of one
particular tissue or region, for the most
part the pelvic splanchnics each
contribute fibers to pelvic viscera by
traveling to one or more plexuses before
being dispersed to the target tissue. These
plexuses are composed of mixed
autonomic nerve fibers (parasympathetic
and sympathetic) and include the vesical,
prostatic, rectal, uterovaginal, and inferior
hypogastric plexuses. The preganglionic
neurons in the pathway do not synapse in
a ganglion as in the cranium but rather in
the walls of the tissues or organs that they
innervate. The fiber paths are variable and
each individual's autonomic nervous
system in the pelvis is unique. The visceral
tissues in the pelvis that the
parasympathetic nerve pathway controls
include those of the urinary bladder,
ureters, urinary sphincter, anal sphincter,
uterus, prostate, glands, vagina, and penis.
Unconsciously, the parasympathetic will
cause peristaltic movements of the
ureters and intestines, moving urine from
the kidneys into the bladder and food
down the intestinal tract and, upon
necessity, the parasympathetic will assist
in excreting urine from the bladder or
defecation. Stimulation of the
parasympathetic will cause the detrusor
muscle (urinary bladder wall) to contract
and simultaneously relax the internal
sphincter muscle between the bladder and
the urethra, allowing the bladder to void.
Also, parasympathetic stimulation of the
internal anal sphincter will relax this
muscle to allow defecation. There are
other skeletal muscles involved with these
processes but the parasympathetic plays a
huge role in continence and bowel
retention.
A study published in 2016, suggests that
all sacral autonomic output may be
sympathetic; indicating that the rectum,
bladder and reproductive organs may only
be innervated by the sympathetic nervous
system. This suggestion is based on
detailed analysis of 15 phenotypic and
ontogenetic factors differentiating
sympathetic from parasympathetic
neurons in the mouse. Assuming that the
reported findings most likely applies to
other mammals as well, this perspective
suggests a simplified, bipartite
architecture of the autonomic nervous
system, in which the parasympathetic
nervous system receives input from
cranial nerves exclusively and the
sympathetic nervous system from thoracic
to sacral spinal nerves.[11]
Autonomic nervous supply to organs in the human body
Organ Nerves[12] Spinal column origin[12]

PS: anterior and posterior vagal trunks T5, T6, T7, T8, T9, sometimes
stomach
S: greater splanchnic nerves T10

PS: vagus nerves T5, T6, T7, T8, T9, sometimes

duodenum
S: greater splanchnic nerves T10

jejunum and PS: posterior vagal trunks

T5, T6, T7, T8, T9
ileum S: greater splanchnic nerves

spleen S: greater splanchnic nerves T6, T7, T8

PS: vagus nerve

gallbladder and
S: celiac plexus T6, T7, T8, T9
liver
right phrenic nerve

PS: vagus nerves and pelvic splanchnic T10, T11, T12 (proximal
colon nerves colon)

S: lesser and least splanchnic nerves L1, L2, L3, (distal colon)

PS: vagus nerves

pancreatic head T8, T9
S: thoracic splanchnic nerves

appendix nerves to superior mesenteric plexus T10

kidneys and PS: vagus nerve

T11, T12
ureters S: thoracic and lumbar splanchnic nerves

Emerging evidence in mouse models is

suggesting that the previously held notion
of the sacral spinal nerves being
parasympathetic is incorrect, and that they
may actually be sympathetic.[11]

Function
Sensation

The afferent fibers of the autonomic

nervous system, which transmit sensory
information from the internal organs of the
body back to the central nervous system,
are not divided into parasympathetic and
sympathetic fibers as the efferent fibers
are.[7]:34–35 Instead, autonomic sensory
information is conducted by general
visceral afferent fibers.

General visceral afferent sensations are

mostly unconscious visceral motor reflex
sensations from hollow organs and glands
that are transmitted to the CNS. While the
unconscious reflex arcs normally are
undetectable, in certain instances they
may send pain sensations to the CNS
masked as referred pain. If the peritoneal
cavity becomes inflamed or if the bowel is
suddenly distended, the body will interpret
the afferent pain stimulus as somatic in
origin. This pain is usually non-localized.
The pain is also usually referred to
dermatomes that are at the same spinal
nerve level as the visceral afferent
synapse.

Vascular effects

Heart rate is largely controlled by the

heart's internal pacemaker activity.
Considering a healthy heart, the main
pacemaker is a collection of cells on the
border of the atria and vena cava called
the sinoatrial node. Heart cells exhibit
automaticity which is the ability to
generate electrical activity independent of
external stimulation. As a result, the cells
of the node spontaneously generate
electrical activity that is subsequently
conducted throughout the heart, resulting
in a regular heart rate.

In absence of any external stimuli,

sinoatrial pacing contributes to maintain
the heart rate in the range of 60-100 beats
per minute (bpm).[13] At the same time, the
two branches of the autonomic nervous
system act in a complementary way
increasing or slowing the heart rate. In this
context, the vagus nerve acts on sinoatrial
node slowing its conduction thus actively
modulating vagal tone accordingly. This
modulation is mediated by the
neurotransmitter acetylcholine and
downstream changes to ionic currents and
calcium of heart cells.[14]

The vagus nerve plays a crucial role in

heart rate regulation by modulating the
response of sinoatrial node, vagal tone
can be quantified by investigating heart
rate modulation induced by vagal tone
changes. As a general consideration,
increased vagal tone (and thus vagal
action) is associated with a diminished
and more variable heart rate.[15][16] The
main mechanism by which the
parasympathetic nervous system acts on
vascular and cardiac control is the so
called respiratory sinus arrhythmia (RSA).
RSA is described as the physiological and
rhythmical fluctuation of heart rate at the
respiration frequency, characterized by
heart rate increase during inspiration and
decrease during expiration.
Sexual activity

Another role that the parasympathetic

nervous system plays is in sexual activity.
In males, the cavernous nerves from the
prostatic plexus stimulate smooth
muscles in the fibrous trabeculae of the
coiled helicine arteries of penis to relax
and allow blood to fill the two corpora
cavernosa and the corpus spongiosum of
the penis, making it rigid to prepare for
sexual activity. Upon emission of
ejaculate, the sympathetics participate
and cause peristalsis of the ductus
deferens and closure of the internal
urethral sphincter to prevent semen from
entering the bladder. At the same time,
parasympathetics cause peristalsis of the
urethral muscle, and the pudendal nerve
causes contraction of the
bulbospongiosus (skeletal muscle is not
via PN), to forcibly emit the semen. During
remission the penis becomes flaccid
again. In the female, there is erectile tissue
analogous to the male yet less substantial
that plays a large role in sexual
stimulation. The PN cause release of
secretions in the female that decrease
friction. Also in the female, the
parasympathetics innervate the fallopian
tubes, which helps peristaltic contractions
and movement of the oocyte to the uterus
for implantation. The secretions from the
female genital tract aid in sperm
migration. The PN (and SN to a lesser
extent) play a significant role in
reproduction.[7]

Receptors

The parasympathetic nervous system

uses chiefly acetylcholine (ACh) as its
neurotransmitter, although peptides (such
as cholecystokinin) can be used.[17][18] The
ACh acts on two types of receptors, the
muscarinic and nicotinic cholinergic
receptors. Most transmissions occur in
two stages: When stimulated, the
preganglionic neuron releases ACh at the
ganglion, which acts on nicotinic receptors
of postganglionic neurons. The
postganglionic neuron then releases ACh
to stimulate the muscarinic receptors of
the target organ.

Types of muscarinic receptors

The five main types of muscarinic
receptors:

The M1 muscarinic receptors (CHRM1 )

are located in the neural system.
The M2 muscarinic receptors (CHRM2 )
are located in the heart, and act to bring
the heart back to normal after the
actions of the sympathetic nervous
system: slowing down the heart rate,
reducing contractile forces of the atrial
cardiac muscle, and reducing
conduction velocity of the sinoatrial
node and atrioventricular node. They
have a minimal effect on the contractile
forces of the ventricular muscle due to
sparse innervation of the ventricles from
the parasympathetic nervous system.
The M3 muscarinic receptors (CHRM3 )
are located at many places in the body,
such as the endothelial cells of blood
vessels, as well as the lungs causing
bronchoconstriction. The net effect of
innervated M3 receptors on blood
vessels is vasodilation, as acetylcholine
causes endothelial cells to produce
nitric oxide, which diffuses to smooth
muscle and results in vasodilation. They
are also in the smooth muscles of the
gastrointestinal tract, which help in
increasing intestinal motility and dilating
sphincters. The M3 receptors are also
located in many glands that help to
stimulate secretion in salivary glands
and other glands of the body. They are
also located on the detrusor muscle and
urothelium of the bladder, causing
contraction.[19]
The M4 muscarinic receptors:
Postganglionic cholinergic nerves,
possible CNS effects
 The M5 muscarinic receptors: Possible
effects on the CNS

Types of nicotinic receptors

In vertebrates, nicotinic receptors are

broadly classified into two subtypes based
on their primary sites of expression:
muscle-type nicotinic receptors (N1)
primarily for somatic motor neurons; and
neuronal-type nicotinic receptors (N2)
primarily for autonomic nervous
system.[20]

Relationship to sympathetic
nervous system

Sympathetic and parasympathetic

divisions typically function in opposition to
each other. The sympathetic division
typically functions in actions requiring
quick responses. The parasympathetic
division functions with actions that do not
require immediate reaction. A useful
mnemonic to summarize the functions of
the parasympathetic nervous system is
SSLUDD (sexual arousal, salivation,
lacrimation, urination, digestion and
defecation).
Clinical significance
This section needs expansion.
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The parasympathetic nervous system

promotes digestion and the synthesis of
glycogen, and allows for normal function
and behavior.

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