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saline solution permitted to ow by gravity into the bladder The rise of pressure as 500 mL of uid is allowed to ow gradually into the bladder, the emptying contractions of the detrusor, and the volume at which the patient reports a sensation of bladder fullness can be recorded by a manometer (A detailed account of cystometric techniques can be found in the monograph of Krane and Siroky) A simple way of determining bladder atony (prostatic obstruction and overdistention having been excluded) is to measure the residual urine (by catheterization of the bladder) immediately after voluntary voiding or to estimate its volume by intravenous myelography or ultrasound imaging Disorders of gastrointestinal motility are readily demonstrated radiologically In dysautonomic states, a barium swallow may disclose a number of abnormalities, including atonic dilatation of the esophagus, gastric atony and distention, delayed gastric emptying time, and a characteristic small bowel pattern consisting of an increase in frequency and amplitude of peristaltic waves and rapid intestinal transit A barium enema may demonstrate colonic distention and a decrease in propulsive activity Sophisticated manometric techniques are now available for the measurement of gastrointestinal motility, especially in the esophagus (see Low et al) Nocturnal penile tumescence is recorded in many sleep laboratories and may be used as an ancillary test of sacral autonomic (parasympathetic) innervation Pharmacologic Tests of Autonomic Function The topical application of pharmacologic agents is particularly useful in evaluating pupillary denervation Part of the rationale behind these special tests is Cannon s law, or the phenomenon of denervation hypersensitivity, in which an effector organ, 2 to 3 weeks after denervation, becomes hypersensitive to its particular neurotransmitter substance and related drugs The instillation of a 1:1000 solution of epinephrine into the conjunctival sac has no effect on the normal pupil but will cause the sympathetically denervated pupil to dilate (3 drops instilled three times at 1-min intervals) The pupillary size is checked after 15, 30, and 45 min As a rule, hypersensitivity to epinephrine is greater with lesions of postganglionic bers than of preganglionic bers If denervation is incomplete, the hypersensitivity phenomenon may not be demonstrable Also, in lesions that involve central sympathetic pathways, the pupil rarely reacts to this test More reliable as a test of sympathetic denervation is the topical application into the conjunctival sac of a 4 to 10% cocaine solution that potentiates the effects of NE by preventing its uptake The test should be carried out as described above A normal response to cocaine consists of pupillary dilatation In sympathetic denervation caused by lesions of the post- or preganglionic bers, no change in pupillary size occurs, since no transmitter substance is available The reason for lack of response in chronic preganglionic lesions is presumed to be a depletion of NE in the postganglionic bers In cases of central sympathetic lesions, slight mydriasis occurs These and other pharmacologic methods of evaluating pupillary disturbances are considered more fully in Chap 14 and are outlined in Fig 14-8 Cutaneous Flare Response The intracutaneous injection of 005 mL of 1:1000 histamine phosphate normally causes a 1-cm wheal after 5 to 10 min This is surrounded by a narrow red areola, and it, in turn, by an erythematous are that extends 1 to 3 cm beyond the border of the wheal A similar triple response follows the.

Time 1 Time 06:40:00 No of Batch Processes 25000 Time 2 11:06:40 1000 Time 3 15:33:20 1900 Time 4 20:33:20 15000 Time 5 23:53:20 30000

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