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Urodynamics, Neurourology and Pelvic Floor Dysfunctions
Gianfranco Lamberti
Donatella Giraudo
Stefania Musco Editors
Suprapontine
Lesions and
Neurogenic Pelvic
Dysfunctions
Assessment, Treatment and
Rehabilitation
Urodynamics, Neurourology and Pelvic
Floor Dysfunctions
Series Editor
Marco Soligo
Obstetrics and Gynecology Department
Buzzi Hospital - University of Milan
Milan, Italy
The aim of the book series is to highlight new knowledge on physiopathology,
diagnosis and treatment in the fields of pelvic floor dysfunctions, incontinence and
neurourology for specialists (urologists, gynecologists, neurologists, pediatricians,
physiatrists), nurses, physiotherapists and institutions such as universities and
hospitals.
More information about this series at http://www.springer.com/series/13503

Gianfranco Lamberti • Donatella Giraudo
Stefania Musco
Editors
Suprapontine Lesions
and Neurogenic Pelvic
Dysfunctions
Assessment, Treatment
and Rehabilitation
Editors
Gianfranco Lamberti Donatella Giraudo
Neurorehabilitation Unit and Pelvic Floor Urology Department
Dysfunction Rehabilitation Center San Raffaele Hospital
SS Trinità Hospital Milano
Cuneo Italy
Italy
Stefania Musco
Department of Neurourology
Careggi University Hospital
Florence
Italy
ISSN 2510-4047 ISSN 2510-4055 (electronic)

Urodynamics, Neurourology and Pelvic Floor Dysfunctions
ISBN 978-3-030-29774-9 ISBN 978-3-030-29775-6 (eBook)
https://doi.org/10.1007/978-3-030-29775-6
© Springer Nature Switzerland AG 2020

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims
in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword
Since 2015, Springer has published five volumes on functional pelvic floor hot top-
ics under the auspices of the Italian Society of Urodynamics (SIUD). Our volumes
always try to portray at best functional aspects in different clinical settings: oncol-
ogy, male urology, genital prolapse, paediatrics, giving original and innovative per-
spectives in different backgrounds in an eclectic way.
The present volume fulfils our mission, looking at neurogenic pelvic floor dys-
functions from an original and, at the present time, still poorly investigated point of
view: the suprapontine lesions. Since recent years, neurourologists have been focus-
ing mainly on spinal cord lesions, developing high-level expertise in their under-
standing and management. More recently, also driven by the changing epidemiology
of neurological disorders with an impact on pelvic floor functions, suprapontine
lesions are increasingly becoming a matter of study. This book will offer an in-depth
look on this topic from a multidisciplinary and multi-professional perspective, wid-
ening the scenario of potentially interested readers, spanning from neurourologists
and clinicians devoted to urodynamics, to those operating in stroke units, including
all the rehabilitation professional figures who will find an updated understanding of
the set of problems many of their patients are involved with. The international fac-
ulty further guarantees an appealing experience with this book.
In the major interest of our patients, we do hope this volume will pique your
interest.
Prof. Marco Soligo

Adjunct Professor in Urogynecology - University of Milan
President of the Italian Society of Urodynamics (SIUD)
Milan, Italy
v
Preface
If we wanted to choose an area of rehabilitation, the field in which we can find the
most multicultural and interprofessional evolution, this could be indeed the rehabili-
tation of perineal and pelvic dysfunctions. Despite that, few are known about the
role of pelvic rehabilitation in some specific neurological populations who poten-
tially benefit on that. The purpose of this book is to provide a general introduction
to the knowledge of pelvic disorders in people affected by suprapontine lesion. The
book is addressed to professionals who are dealing with these types of illnesses for
the first time as well as to those who are already experts and want to extend their
knowledge and interests in this field.
The book takes its cue from the literature and gives more in-depth insights on the
diagnosis and treatment of neurogenic urinary and bowel dysfunctions considering
also the evolution of the functional imaging techniques in the last decades which has
helped us to better understand the physiopathological differences and peculiarities
of this subtype of neurological patients having suprapontine lesions and secondary
pelvic dysfunctions. The interdisciplinary and multidisciplinary fields of actions
involving doctors and health professionals (often with profoundly different back-
grounds) are often still uncharted, but surely, it should tend towards an increasingly
holistic view, in which overall components cannot be dissociable from the context.
Furthermore, the relationships and networks between damage, brain function, blad-
der and intestinal behaviour are still poorly understood. Thus, the management of
pelvic floor dysfunctions in such complex patients is a harder challenge to face
compared to non-neurological or even in spinal cord-injured patients.
We hope that this book can open up ways of communication among different
professionals by making this topic more accessible, often inexplicably confined
(concerning the epidemiological impact and quality of life), to few specialized
centres.
In order to make the material more friendly, we have tried to easily explain the
various subtopics to be understandable even by professionals who are not specialists
in neurourology. We hope we have succeeded in giving a reasonably exhaustive
view of this area of its extensive and complex investigations and treatments, in such
a way as to involve professionals of other specialties (e.g. rehabilitation, internal
medicine, neurology) who often are involved in these pathologies.
After a general introduction on the neurophysiopathology of suprapontine
lesions, the book is divided into chapters, each one concerning a specific subtopic
vii
viii Preface
including the diagnosis and treatment of the various pelvic dysfunctions among the
different types of neurological suprapontine lesions. The influence of the clinical
experience in the daily management of these problems is evident in the development
and writing of the authors’ contributions.
The main epidemiological aspects, always in relation to the patient with a supra-
pontine lesion, clinical evaluation of the perineum and the main reflexes, functional
imaging of the central nervous system, urodynamic investigation and chronic pelvic
pain are then taken into consideration. Particular attention has been paid to the reha-
bilitative aspects of bowel dysfunctions, often neglected in these neurological sub-
populations compared to spinal cord injury patients. Again, also, two interesting but
still poorly addressed arguments have been taken into account, namely, pelvic floor
muscle training and sexual dysfunctions. The various chapters necessary for educa-
tional purposes are actually to be understood as inseparable moments of a unitary
and continuous process.
The writing of this book would not have been possible without the tolerance and
goodwill of many of our colleagues to whom we extend our gratitude. Finally, we
are very grateful to our many patients who, despite the personal tragedy of brain
damage, have made the development of our observations possible.
Milano, Italy Donatella Giraudo

Florence, Italy Stefania Musco
Piacenza, Italy Gianfranco Lamberti
Contents
1 The Bladder, the Rectum and the Sphincters: Neural Pathways

and Peripheral Control�� 1
Gianfranco Lamberti and Antonella Biroli
2 Reflex Testing and Pelvic Examination�� 23
Donatella Giraudo and Francesco Verderosa
3 Investigation of the Central Nervous System in Neurogenic Pelvic
Dysfunctions by Imaging�� 35
Achim Herms and Alida M. R. Di Gangi Herms
4 Urodynamic Patterns and Prevalence of N-LUTDs
in Suprapontine Lesions�� 45
Eugenia Fragalà
5 Suprapontine Lesions and Neurogenic Pelvic Dysfunctions�� 53
Julien Renard, Eugenia Fragalà, Gianfranco Lamberti,
Federica Petraglia, Francesco Verderosa, Anna Cassio,
and Giovanni Panariello
6 Management of the Central Nervous System Chronic
Pelvic Pain�� 61
Marilena Gubbiotti and Antonella Giannantoni
7 Management of Bowel Dysfunction in Patients with Central
Nervous System Diseases �� 71
Gabriele Bazzocchi, Mimosa Balloni, Erica Poletti, Roberta Manara,
Paola Mongardi, Marica Vicchi, Eugenia Fragalà, Elena Demertzis,
Antonella Manzan, and Humberto Cerrel Bazo
8 Management of the Suprapontine Neurogenic Lower Urinary
Tract Dysfunction�� 81
Gaetano De Rienzo, Gianfranco Lamberti, Luisa De Palma,
Donatella Giraudo, Elena Bertolucci, Giuseppina Gibertini,
Caterina Gruosso, and Roberta Robol
ix
x Contents
9 Pelvic Floor Muscle Training and Neurogenic Overactive Bladder

in Stroke and Multiple Sclerosis �� 93
Kari Bø
10 Sexual Dysfunction in Suprapontine Lesions�� 107
David B. Vodušek
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The Bladder, the Rectum
and the Sphincters: Neural Pathways 1
and Peripheral Control
Gianfranco Lamberti and Antonella Biroli
1.1 Introduction
Despite the fundamental contribution given by functional imaging in recent years, to

date, the relationships between the different pathways in coordinating the alternation
between the bladder-filling phase and the emptying phase have not yet been clarified
nor, above all, which area should be considered as the “final decision maker” for
activating micturition. The periaqueductal grey (PAG) and the pontine micturition
centre (PMC) (Fig. 1.1), under physiological conditions with mutual influence, under
the voluntary control of the prefrontal cortex (PFC) (Fig. 1.2), control the function.
These three areas, in turn influenced by various afferents, coordinate the synchroni-
sation between recruitment and inhibition of smooth and striated muscles [1–6]
which regulate the behaviour of the bladder (the system’s reservoir), the bladder neck
and the urethra. The neural control is peripherally guaranteed by the parasympathetic
sacral nerve (pelvic nerves), by the sympathetic thoracic lumbar nerve (hypogastric
nerves) and by the sacral somatic nerve [pudendal nerve] [7, 8].
The importance of bladder control in controlling the homeostasis of the organism
is guaranteed by the regular emptying of the bladder itself, which must be both safe
and appropriate.
Processing the sensation of the bladder filling up is a cognitive element for main-
taining equilibrium [9–11] which must determine finalised behaviours and conse-
quent coherent motor activities [12].
The progression of the feeling of fullness begins with nerve signals whose fre-
quency, intensity and unpleasantness increase proportionally to the bladder filling,
G. Lamberti (*)
Neurorehabilitation Unit and Pelvic Floor Dysfunction Rehabilitation Center,
SS Trinità Hospital, Cuneo, Italy
A. Biroli
Neurological and Autonomic Dysfunction Rehabilitation Unit,
S.G. Bosco Hospital, Turin, Italy
© Springer Nature Switzerland AG 2020 1

G. Lamberti et al. (eds.), Suprapontine Lesions and Neurogenic Pelvic
Dysfunctions, Urodynamics, Neurourology and Pelvic Floor Dysfunctions,
https://doi.org/10.1007/978-3-030-29775-6_1
2 G. Lamberti and A. Biroli
Fig. 1.1 Cerebral and

brainstem nuclei and
pathways related to
micturition and defecation. CC FNX
Abbreviations: CC Corpus
callosum, FNX Fornix, HY
Hypothalamus, DLF DLF
Fasciculus longitudinalis HY PAG
dorsalis, PAG
Periaqueductal grey, PBN INF
Parabrachial nucleus, SOL 1
Nucleus solitarius. PBN
1 = Pontine micturition 2
centre (PMC).
2 = Kölliker-Fuse nucleus.
3 = Pontine continence 3
SOL
centre (PCC)
Fig. 1.2 Hippocampus,

amygdala, subregions of
prefrontal cortex and
dorsal anterior cingulate Dorsal anterior
cortex, cerebral areas cingulate cortex
associated with the control
of the temporal and spatial Amygdala
appropriateness of social
continence Ventromedial
prefrontal
cortex
Hippocampus
Orbitofrontal Dorsolateral
prefrontal prefrontal
cortex cortex
until the individual is obliged to urinate: the fullness cannot be maintained indefi-
nitely and at some point the bladder must be emptied.
1.2 The Bladder Function
The filling and the emptying phase:

Urodynamic tests record the perception of the fullness level: the “first filling
sensation” in healthy subjects (a sensation that is often not precisely perceptible,
which often one does not pay attention to) occurs at about 40% of the total capacity
of the detrusor; the International Continence Society (ICS) defines the “first desire
to urinate as the sensation during a flow cystometry, which would lead the patient to
urinate at the first opportune moment, although with the possibility of postponing
further the emptying” [13] and usually refers to approximately 60% of the total
1 The Bladder, the Rectum and the Sphincters: Neural Pathways and Peripheral… 3
Fig. 1.3 Bladder filling,

desire to void and
behaviour
300 - 500 cc
Strong desire
Volume voided
Bladder filling
Achievement
First desire
Orientation
First sensation
Initiation
100 cc
detrusor capacity. The “strong desire” to urinate is defined by ICS as “the persistent
urge to urinate without the fear of the urine escaping” [13] (Fig. 1.3). These three
conditions should be considered normal; the appearance of a “sudden and impelling
desire to empty” (urgency) can instead be considered as a symptom of overactive
bladder syndrome. People who report urinary urgency should, in any case, be con-
sidered in a non-physiological condition concerning the bladder function.
Under normal conditions, continence control allows the accumulation of urine,
preventing emptying until the filling is complete.
The emptying phase only lasts for a short period of the complete behavioural
cycle: considering how long the micturition can last and that it can be done six
or seven times a day, the time dedicated to emptying does not exceed 1% of the
total time [14].
Finally, the emptying occurs only if appropriate and the main criteria are social
(adequate place and adequate time) and behavioural appropriateness (an adequate
situation in order to avoid any embarrassment concerning the gesture) [15]. It is
known that an attentional shift can influence the perception of the bladder-filling
status, similarly to what occurs with the perception of pain, while a state of anxiety
can increase the level of the desire to urinate, which only confirms how many psy-
chological conditions may, in fact, alter the state of perception of the fullness of the
bladder [14].
1.2.1 Spinal Cord Afferents
The afferent pathways reach the lower urinary tract through the pelvic, hypogastric
nerves and the pudendal nerve stem [5, 14, 16, 17]: they are activated by the bladder
distension and inhibit the detrusor parasympathetic system. Thanks to modern
impregnation techniques it is possible to map first-level axons, coming from the

peripheral areas, directed towards the lumbosacral posterior root ganglia (dorsal
root ganglion, DRG) and to the terminations in the spinal cord, in order to then
interpret their hypothetical role. The neurons from the detrusor wall project to the
lumbar (T11–L2) and sacral (S2–S4) tracts and are responsible for controlling spi-
nal reflex activity and for transmitting the perception of the need to urinate through
the ascending pathways to the encephalic regions.
In men, it is possible to identify a dense nervous network (“sensory web”) [4]
widespread in the basal urothelial layer of the bladder [18–20] with some nerve end-
ings projecting as far as the urothelium [21–23]; hence the medullary afferents are
represented by two different types of fibres: myelinated fibres “A-δ” and small non-
myelinated “C” fibres [24–28] (Fig. 1.4).
The lower threshold fibres (“A-δ”) are myelinated (while non-myelinated
fibres—“C” fibres—have higher thresholds) [4] and in most cases are sensi-
tive to mechanical stimulation and respond to the bladder filling with a varying
PGC
1
3
5
ILC
7
IMG Sympathetic T10-L2

HN
PG
PGC
1
PN DRG 3
B 5
ILC
Ad
7
PG
Parasympathetic S2-S4
EUS Somatic S2-S4
PN
Fig. 1.4 Neural control of the lower urinary tract. Abbreviations: PG Pelvic ganglion, IMG
Inferomesenteric ganglion, HN Hypogastric nerve, PN Pelvic nerve, DRG Dorsal root ganglion,
PGC Posterior grey commissure, ILC Intermedio-lateral column: 1, 3, 5, 7 = Rexed laminae I, III,
V, VII. Dotted line = Afferent pathways. Full line = Efferent pathways
volume sensitivity threshold, from normal filling to extreme distension. Both

passive distension and active contraction activate fibres with larger diameters to
convey information related to bladder filling in physiological conditions [16].
The fibres with smaller diameters can normally be called “silent”, since they
do not operate with bladder distension alone, except with large volumes; also
found in the intestine, they are instead able to convey information from intra-
luminal stimuli of a chemoceptive nature such as saline hypertonicity or that
of a thermal nature [29, 30] sensitising themselves in pathological conditions
(neuropathic or inflammatory ones) and determining the sensation of urgency
or visceral pain.
In addition to the intrinsic characteristics of the detrusor smooth muscle, the fill-
ing phase is made possible by the inhibition of the parasympathetic efferent path-
ways [3] and by the sympathetic system with the activation of the sphincter function
[31, 32]. Bladder adaptation allows an intra-bladder pressure with low values with
a volume below the threshold of the desire to urinate.
The afferent bladder fibres project to the posterior horn of the sacral cord [33–37].
These neurons possess two interesting characteristics: they project directly to the
PAG and the Rexed laminae V, VII and X [38, 39], regions containing parasympa-
thetic interneurons and parasympathetic dendrites [38, 39].
This “direct” connection with the PAG [35, 40] (and not with the PMC) is typical
of human, cat and dog and would allow control of the bladder filling without its
perception (the latter guaranteed by the thalamus). Only reaching a certain filling
level would determine the passage of information between the PAG and the PMC
(and therefore its awareness) and the potential choice of voiding [37].
The intraspinal neurons identified as involved in spinal segmental reflexes
[41–47] with excitatory and inhibitory synaptic connections [48–51] are located in
the Rexed laminae I, V and VII and the posterior grey commissure [52–58] (Fig. 1.4).
The afferent pathways of the pelvic area originating from the urethra, the ure-
thral sphincter and the neuromuscular pelvic spindles present an essentially over-
lapping pattern of endings [59] and this arrangement presumably coordinates the
pelvic floor muscles (PFM) and the sphincteric function during micturition and
defecation [60].
The overlap between the dendritic afferents from the detrusor and the urethra on
the posterior horns and on the posterior grey commissure indicates that these regions
are the most important routes for receiving information from the peripheral area:
these are probably essential sites for the visceral-somatic integration which may
represent a fundamental element in coordinating the detrusor function and the
sphincter activity, which in fact have a similar dendritic pattern [33]. In summary,
during the entire filling phase, the sensation of the detrusor being full is conveyed,
thanks to first-order neurons, by the pelvic and hypogastric nerves [5, 16] while the
hypogastric nerves and the pudendal nerve convey the sensory information from the
neck of the bladder and the urethra [4].
Some spinal interneurons connect with the bladder afferents [52, 54, 55], trans-
mitting signals through the ascending sensory pathway and reaching, after a partial
decussation [35], mainly the gracile nucleus (which conveys the nociceptive
sensitivity to the thalamus and the cortex), the PMC and the PAG [10], that is in turn
connected with numerous other brain areas [61–63] through third-order neurons
[63, 64]. There is a second ascending pathway to the gracile nucleus from the pelvic
organs and subsequently to the thalamus for transmitting nociceptive impulses [65].
1.2.2 Spinal Cord Efferents
The sympathetic preganglionic system is located medially and laterally in the lum-
bar spinal cord segments, the external urethral sphincter motor neurons in Onuf’s
nucleus and the parasympathetic preganglionic neurons in the sacral cord
segments.
The preganglionic cholinergic efferent neurons reach the pelvic plexus ganglia
and the detrusor wall. The axons originate from the sacral parasympathetic nucleus
from S2 to S4, and have synaptic connections with the pelvic ganglia as well as with
the small ganglia on the detrusor wall which release acetylcholine. Nicotinic recep-
tors mediate postsynaptic activation: postganglionic axons run for a short distance
in the pelvic nerves and have terminations in the detrusor wall where they release
acetylcholine which induces the contraction of the smooth muscle fibres. Muscarinic
receptors mediate this postganglionic stimulation; there are two subtypes of musca-
rinic receptors, M2 and M3, in the detrusor: although M2 receptors are more numer-
ous, subtype M3 is specific for the contractions of the detrusor [66, 67].
During the filling phase, the whole set of active afferents and efferents, under
physiological conditions, allows continence to be maintained, thanks to the pres-
ence of urethral reflexes known as a whole as “guarding reflex” [4, 10, 14, 68–70].
In the pelvic-hypogastric component of the “guarding reflex”, the parasympathetic
innervation of the detrusor is inhibited while at the same time the smooth (internal
urethral sphincter, through the hypogastric nerve) and striated components (external
urethral sphincter, through the pudendal nerve) are active. The pelvic-pudendal
component of the reflex, similarly active, under normal conditions, in the occasion
of increases in intra-abdominal pressure (cough, laughter and physical activity),
through the action of glutamatergic pathways and N-methyl-d-aspartate receptors
(NMDA) with the release of acetylcholine, is responsible for the anticipatory con-
traction of the external urethral sphincter.
Unlike what occurs in animals, where the sympathetic lumbar nerve contributes
mainly to inhibiting the detrusor’s smooth muscle and to contracting the bladder
neck [71, 72], in man there could be a control exercised specifically during the fill-
ing phase by the activation of the dorsal portion of the anterior cingulate cortex
(dACC) (Fig. 1.2) and of the surrounding sensory-motor areas, together with the
action of the supplementary motor area, which is active when PFM and urethral
striated sphincter contract [73–77].
Similar control is exercised from an area at the dorsal-lateral pontine tegmentum,
known as “pontine continence centre” (PCC) (Fig. 1.1), which facilitates the reflex
activity of the sphincters [7, 10, 64, 78–88]. This area would receive signals directly
from Onuf’s nucleus and its stimulation, activated via the spinal reflex pathway by
sub-threshold afferent impulses coming from the bladder, would contribute to acti-
vating the “guarding reflex” [33].
The contraction of the PFM simultaneously with a strong desire to urinate acti-
vates the PCC, particularly just before beginning the micturition, and its electrical
stimulation activates the motor neurons of the external urethral sphincter (EUS) and
induces its contraction [2, 78, 89].
The contraction of the EUS activates afferent fibres of the pudendal nerve which
suppress the reflex activity of the bladder [90] by inhibiting the parasympathetic
preganglionic neurons and the interneurons which belong to the micturition reflex
pathway [91, 92], promoting urinary continence [78, 93].
Reaching a certain critical level of distension of the detrusor wall provoked by
the mechanoreceptors [42, 84, 92] causes the “switch” from the “off” phase of fill-
ing to the “on” phase of emptying. This process involves a circuit which conveys the
bladder afferents to the midbrain and the pons and is regulated by the spinal-medulla
oblongata emptying reflex [69].
In reality, emptying the bladder, under physiological conditions, involves the
supraspinal centres and pathways [94, 95]: in fact, the presence of an exclusively
“reflex” circuit would cause an “involuntary” emptying, with consequent urinary
incontinence, once it reaches a specific filling volume. This is what happens in the
child; in the adult, under physiological conditions, however, the reflex is strictly
controlled by the pons and by the brain, and the decision to urinate, fundamentally
crucial in human behaviour, is usually taken only at the appropriate time and place.
It is, therefore, the result of a combination of different physiological, emotional and
behavioural factors.
1.2.3 he Periaqueductal Grey and the Pontine Micturition

T
Centre
Several functional brain imaging studies have shown how the PAG is activated dur-
ing the filling phase [61, 63, 64, 96–98] and can, therefore, be considered to all
effects the integrating centre between different afferent and efferent circuits of the
bladder [99, 100], as it is able to excite or inhibit the bladder activity [101–105],
since the GABA is the mediator involved in these inhibitory mechanisms [106].
There is now a broad consensus on the role of the PAG as the structure which
integrates somatic and autonomic sensory afferents with emotional components in
order to coordinate the reaction to stress, reproductive behaviour [107], aggression,
sense of defence, response to visceral pain [108, 109] and maternal behaviour [110],
and this has determined its definition as part of the “emotional motor system” [111].
The afferents from the pelvic organs reach the mesencephalic PAG through the
connections with the pontine centres [112]: reflexively [demonstrated by electri-
cal stimulation] [113] the PAG determines the emptying of the bladder, but under
normal physiological conditions its activity is conditioned by the information that
allows the person to judge whether the micturition is appropriate based on place
and time.
Similar control is also likely for defecation and sexual activity [114].
In the animal it was possible to record single neuronal units of PAG, which
show different activation patterns: “tonic” and “phasic” filling neurons, which are,
respectively, partially or entirely inhibited during detrusor contractions, and “tonic”
and “phasic” neurons which are active exclusively during the detrusor emptying
phase [115].
Neurons also appear to be distributed, according to their activity, in different
areas of the PAG, for that matter connected by interneurons [113].
In addition to the circuits which interface the PAG and the PMC and the spinal
pathways coordinating the detrusor contraction with the relaxation of the sphincter
during the emptying one, another significant element is represented by the fact that
the bladder afferents end in the central portion of the PAG, while the PMC efferents
originate from more lateral portions of the PAG itself: these connections modulate
the “switch” between the emptying and the filling phases to trigger the emptying or
to maintain continence [116].
The numerous connections of the PAG with the superior areas are the neuronal
substrate for the control of the temporal and spatial appropriateness of social conti-
nence from the brain (dorsal anterior cingulate cortex, insula, amygdala and ventro-
medial prefrontal cortex) [117] (Fig. 1.2).
The PAG, in turn, projects caudally to the PMC (also known as Barrington’s
nucleus) (Fig. 1.1) allowing information about the level of fullness of the bladder
and processes the superior influences responsible for the voiding reflex.
The PMC is located in the pontine tegmentum near the locus coeruleus (LC) [4,
37]; the importance of this area located in the pons concerning bladder control was
first demonstrated in the cat [1] and subsequently also confirmed in other species
[118, 119], and finally functional imaging studies have confirmed the activation of
the dorsal pontine regions in humans at the beginning of voluntary micturition
[120–122].
The PMC projects to the parasympathetic bladder motor neurons of the
sacral cord (Onuf’s nucleus): the mutual coordination between sphincter and
detrusor is determined by the fact that the PMC activates not only the gluta-
matergic fibres facilitating the parasympathetic sacral preganglionic nucleus
[123] but also the GABAergic and glycinergic inhibitory interneurons which
reduce the activity of Onuf’s nucleus with the consequent inhibition of the
urethral sphincter when the detrusor contracts. There is also evidence of pro-
jections from the PMC to the locus coeruleus (LC) [124–126]; as the main
noradrenergic centre of the brain, the LC sends collateral projections to the
entire CNS, including the cerebral cortex [127], modulating neuronal activity
[128] and displacement of the focus of attention due to new stimuli in respect
of the ongoing activities: in this case an increase in attention to visceral stimu-
lation is determined, which “would prepare” the organism for an adequate
emptying.
1.2.4 The Cortical Control
The prefrontal cortex is responsible for the programming of the appropriate micturi-
tion behaviour, the expression of the personality of the person and his/her proper
social behaviour.
In modulating these activities, the midbrain parabrachial nucleus [129] (Fig. 1.1),
the ventromedial cord area [130], the midbrain [116] and the pontine tegmentum
[131] would also intervene, by all providing, with different degrees and ways, some
setting level for a correct “switch” to the emptying phase. The midbrain parabra-
chial nucleus would also be responsible for processing abnormal stimuli in case of
hyperactivity of the detrusor.
The insula, considered the seat of the interoception, i.e. the place where the
physiological sensations of the entire organism, including visceral sensitivity, are
processed, also contributes to modulating the responses; in this case the afferents
are conveyed through small-diameter fibres in the spinal cord through the Rexed
lamina I, exactly as occurs for the bladder afferents (Fig. 1.4). The Rexed lamina I
neurons project to the thalamus and the lobe of the insula; processing visceral
afferents is therefore closely associated with and conditioned by affective and
motivational aspects.
The cerebellum [132, 133] and the hypothalamus are also involved in subcortical
modulation patterns. The caudal hypothalamus is activated in relation to the filling-
emptying phases of the bladder [134, 135]; in the animal, the stimulation of its
anterior portion results in the assumption of the typical posture for micturition or
defecation [136]. Together with the PAG, the hypothalamus can activate the PMC,
thus eliciting the voiding reflex [97, 98].
The cortex of the anterior cingulate gyrus (Brodmann area 32), an area associ-
ated with the motivational component of the gesture, that can be considered to all
effects the “limbic” motor cortex, participates in the bladder control. The basal gan-
glia control micturition in a mainly inhibitory role [137] by physiologically activat-
ing the globus pallidus during the bladder filling [96]. Dopamine controls the
urinary reflex (with an inhibitory action through D1 receptors and a facilitating one
through D2 receptors) and by GABA (by inhibitory action) [138]. Dopamine
released by the substantia nigra and by the striatum nucleus activates the
D1-GABAergic dopamine direct pathway which inhibits the globus pallidus and the
substantia nigra reticulata and also inhibits the urinary reflex through the collateral
GABAergic pathways to the PAG [139].
Co-activation of the insular lobe and the cortex of the anterior cingulate gyrus
during the filling phase is frequently detectable in functional imaging studies [140]
and often occurs during activation of the attentional state by the sympathetic sys-
tem. Activation of the right PMC, insular lobe and dorsal portion of the anterior
cingulate gyrus have been correlated in healthy subjects to the degree of bladder
filling and to the desire to urinate normally.
The limbic system as a whole has close connections with the prefrontal cortex, sug-
gesting that emotional behaviour and cognitive processes are closely linked [141].
PET studies demonstrate the deactivation of the medial prefrontal cortex, which
coincides with the bladder-filling phase, while it is activated during the emptying
one. The presence of a “normal” filling sensation, therefore, would ensure conti-
nence, also when not reaching the level of a conscious stimulus.
When the decision to empty the bladder is made, the prefrontal cortex, the insu-
lar lobe, the hypothalamus, the PAG and the PMC are activated: the activation of the
PMC is the final efferent brain effect, and in a healthy subject it determines the
transmission of the information to void the bladder to the spinal cord sacral
segments.
1.3 The Bowel Function
Faecal continence and defecation are intimately connected and dependent on neuro-
logical control.
It is commonly accepted that the “normal” frequency of intestinal emptying var-
ies between a minimum of three bowel movements a week and a maximum of three
times a day [142]. The number of defecations is affected by several factors: psycho-
logical (anxiety) [143–145], organic [pain when defecating] [146], habit or need to
postpone the evacuation, posture taken while defecating, colic transit speed and
stool volume. The food intake increases peristalsis in the transverse and descending
colon, and this occurs with a double-temporal peak, the first at 10–50 min from the
food intake and the second at 70–90 min.
The “motor” activity of the colon is increased upon awakening [147] and after
meals [148, 149].
The study of transit times has shown a duration of the passage in the colon of
about 72 h on average, and the progression occurs thanks to the low-amplitude con-
tractions (low-amplitude propagated contractions: LAPC) which occur 50–100
times a day, and to the high-amplitude ones (HAPC, high-amplitude propagated
contractions) which occur 5–6 times a day in the adult [149, 150].
The arrival of the material (solid, liquid, gaseous) in the rectum activates through
the pressure receptors present in PFM the recto-anal inhibitory reflex (RAIR) and
the sampling of material in the anal canal.
In the case of complete control of the continence mechanisms, which, once
reached, effectively allows to counter the need induced by the arrival of faecal mate-
rial in the rectum, and in case of an inconvenient place or time for defecating or in case
of the desire to postpone the act, PFM contraction allows postponing defecation [151].
At the moment when the decision to defecate is taken, with a correct diaphrag-
matic expiratory thrust, the anorectal angle becomes horizontal and the faecal mate-
rial is expelled [152]. The normal condition is restored with the closing reflex [153].
The gastrointestinal functions are controlled by a neuronal network composed of
about 500,000 neurons, distributed in the myenteric plexus and the submucosal
plexus [154], which together constitute the enteric nervous system (ENS). The ENS
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includes different types of functionally distinct enteric neurons [primary intrinsic

afferents, afferent and efferent interneurons, excitatory and inhibitory motor neu-
rons], all synaptically bound together in neural circuits that regulate all reflexes
occurring in the digestive tract, including those which regulate peristalsis [155].
This highly integrated neural system, located with the two myenteric and submu-
cosal plexus systems in the intestinal tract wall and extended along its entire length,
is considered the “brain in the gut”, i.e. a nervous system able to control the various
functions even when isolated anatomically from the CNS and from the peripheral
nervous system (PNS).
The network that regulates the filling phase and the emptying phase of the distal
colon depends primarily on this, through the proximodistal [but also distoproximal]
propulsion [156] of the colic content and the defecation, thanks to the relaxation of
the anal sphincter system [157].
This neural circuit belongs only and exclusively to the enteric tract, while the
spinal and supraspinal control systems substantially overlap with those of the blad-
der system.
Obviously, in addition to ENS, which should be considered to all intents as the
intrinsic innervation of the gastrointestinal tract, the sympathetic, parasympathetic
and somatic systems regulate the gastrointestinal functions.
The sensory afferents, which activate the inhibition or recruitment of the
smooth or striated muscle of the anal sphincter complex, come mainly from the
rectum that has to guarantee a continuous compliance “reservoir” function and
from the “sampling” area of the anorectal junction, tasked with the recognition of
the faecal material.
The afferents to the sacral metamers are conveyed by sympathetic and parasym-
pathetic nerves (splanchnic nerves, pelvic nerves and vagus nerve) and by somatic
nerves (pudendal nerve) and reach the posterior horns located in the Rexed lamina
I [158] (Fig. 1.4). The convergence of visceral somatic afferents allows explaining
the phenomenon of “referred pain” (pain caused by a viscera section and perceived
in a body area with sensory afferents which reach the same cord levels of the bow-
els) and of “cross sensitisation” between the different pelvic organs [159].
Anal sensitivity is conveyed by the lower rectal branch of the pudendal nerve.
The cranial anal canal is rich in nerve endings (corpuscles of Krause for cold, of
Golgi-Mazzoni for pressure, of Meissner for tactile sensitivity) [160, 161] while
special afferents would transmit the temperature of the rectum.
The somatic spinal pathways (spinothalamic tract) reach the gracile nucleus and
transmit information concerning the tactile sensitivity of the perineal area.
The processing of information following the distension of the rectal wall on
arrival of the faecal bolus and the resulting stretch is allowed by the non-myelinated
“C” fibres present in the rectal wall [162], and the specialised components for
sensory-mechanical transduction (sensitive to the distension and contraction of the
surrounding musculature) are in the myenteric ganglia of the rectum. There are vari-
ous populations of afferent fibres which allow modulating the information about the
distension of the walls: some transmit physiological information which enables the
propulsion of the bolus, others are activated only above a certain threshold and
contribute to inducing the nociceptive stimulus, and some others (usually “silent”)
are triggered exclusively during inflammatory phenomena [159].
Myelinated “Aδ” fibres provide the evocation and control of RAIR and the recto-
anal excitatory reflex (RAER) in the mucosa [163].
The peripheral sympathetic afferents too are conveyed towards the Rexed lamina
I, from which they project mainly non-myelinated “C” fibres towards the sympa-
thetic thoracolumbar system and from here, through the ascending pathways,
towards the centres of the brainstem (PMC, PAG and midbrain parabrachial
nucleus); they subsequently reach different areas of signal processing of the autono-
mous nervous system (ANS), such as the solitary tract nucleus (STN), the hypo-
thalamus and the amygdala [164–166].
The PAG and the STN moreover receive parasympathetic afferents which are also
conveyed to the hypothalamus and amygdala [167], ensuring an optimal integration
between the two systems. Coordination between activities of the proximal and the
distal gastrointestinal tracts, together with the one between the sigmoid-rectal tract
and the bladder, is guaranteed by the PMC, thanks to its relations with the sacral
parasympathetic system and the motor nucleus of the vagus nerve [128, 168]. Its
projections to the locus coeruleus activate neuronal circuits which govern attention
and shifting of the attentional focus towards new stimuli in respect of activities
already in progress [128]: in this case, as occurs with micturition, the perception of
rectal filling leads to an increase in attention towards the visceral stimulus, which
therefore “would prepare” the organism for an adequate rectal emptying [169].
Gastrointestinal motility and gastric secretion can be modulated by the Kölliker-
Fuse (Fig. 1.1) nucleus or pneumotaxic centre and by the paraventricular nucleus
(PVN) through either the cerebellum vestibular or the cerebellum hypothalamic
pathways [170]. These connections would also explain the activation of the alert
status together with the increase of colic transit which occurs in response to stress
[171]: in this case the production of oxytocin and vasopressin (which are released
by the posterior pituitary) and of the corticotropin-releasing hormone (corticotropin-
releasing factor—CRF) by PVN, which also projects to the LC, increases.
The PMC too is involved in colonic function [172], guaranteeing its activity
together with that of the vesicoureteral apparatus, and also ensuring, through the
nucleus of the vagus nerve, the synergic activity of proximal and distal intestinal
segments. Analogously as happens for the bladder the distension of the colon can
activate the PMC, with a consequent increase in the colon’s motility.
In addition to visceral afferents of lumbosacral origin, various encephalic, mes-
encephalic and brainstem projections reach the PMC, thus confirming the neuroana-
tomical integration between the colic function and different emotional and
behavioural components.
Some pathways ascending from the Rexed lamina I directly reach the medial
thalamus and from here the dACC, an area associated with the emotional aspects of
pain perception; moreover, the facilitating and inhibitory pathways reach the Rexed
lamina I neurons directly from the brainstem and from the LC, thus guaranteeing an
even more complex level of processing the visceral afferents.
Vagal, cholinergic preganglionic fibres originate in the brainstem (the dorsal

motor nucleus of the vagus nerve) [162, 173] and control the neurons of the myen-
teric plexus [174].
Preganglionic neurons controlling the parasympathetic innervation of the distal
colon are in the lumbosacral cord (S1–S4 levels in the intermedio-lateral column)
(Fig. 1.4): they are smaller than the preganglionic neurons which innervate the
bladder [16], from which they are separated, and reach the colon with two path-
ways, directly innervating the postganglionic neurons of the myenteric plexus or
innervating the postganglionic neurons in the hypogastric plexus ganglia [175]
which in turn reach the colon through the rectal nerves: this would ensure a double-
parasympathetic control of the colon, given that enteric neurons are present both in
the spinal cord and in the pelvic ganglia. Parasympathetic innervation is funda-
mentally crucial for colon motility, in particular during defecation: any damage
leads to constipation.
Sympathetic preganglionic neurons which innervate the gastrointestinal tract
originate from the thoracic and lumbar spinal cord. In particular, the innervation of
the colon is predominantly ensured by the L2–L5 levels which have an inhibitory
action of the intestinal mobility, mediated by the myenteric plexus, and an excit-
atory one of the sphincter activity [176]. Preganglionic neurons are cholinergic and
activate postganglionic neurons within the superior and the lower mesenteric gan-
glion; sympathetic and parasympathetic postganglionic neurons are both present in
the pelvic ganglia: the crosstalk between the two systems guarantees the perfect
neuronal integration of the system [177, 178].
The sacral plexus innervates the distal colon and the rectum with a network glob-
ally in common with the lower urinary tract [71, 179], which is similar to that guar-
anteed by the vagus nerve on the proximal tract; a substantial difference to bear in
mind is the presence of fibres that carry the nociceptive message in the pelvic affer-
ents (and not in the vagal ones).
The primary motor cortex is connected to the sacral motor nucleus of the pelvic
floor muscles (Onuf’s nucleus, the site of voluntary recruitment control): here, sepa-
rated areas control urethral sphincter and external anal sphincter function.
Finally, defecation is the consequence of a reflex activated by the distension of
the rectum. Emptying, in a substantially similar manner to what occurs for the blad-
der, in the adult is controlled by the spinal and supra-spinal centres.
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There was only one thing, Faunce thought, that would make her
difficult—a genuine attachment to Rannock. If she really loved him,
as such women can love, it might be hard work to induce her to
betray him, even though no fatal consequences to him hung upon
her secrecy. He knew the dogged fidelity which worthless women
sometimes give to worthless men.
The hotel was almost empty, so after a prolonged siesta Mr. Faunce
dined with the manager in the restaurant, which they had to
themselves, while half a dozen tourists made a disconsolate little
group in the desolation of the spacious dining-room.
Faunce did not pursue the subject of the Randalls and their
behaviour during the social meal, for he knew that the manager's
mind having been set going in that direction he would talk about
them of his own accord, a surmise which proved correct, for M. Louis
talked of nothing else; but there were no vital facts elicited over the
bottle of Pommery which Mr. Faunce ordered.
"The lady was something of a slattern, you say?" said Faunce. "In
that case she would be likely to leave things—odd gloves, old letters,
trinkets—behind her. Now, in my work things are often of the last
importance. Trifles light as air, mon ami, are sign-posts and guiding
stars for the detective. You may remember Müller's hat—his
murdered victim's, with the crown cut down—thriftiness that cost the
German youth dear. I could recall innumerable instances. Now, did
not this lady leave some trifling trail, some litter of gloves, fans,
letters, which your gallantry would treasure as a souvenir?"
"If you come to that, her room was a pig-sty."
"To correspond with her pet name."
"But the hotel was full, and I set the chambermaids at work ten
minutes after the Randalls drove to the boat. We had people coming
into the rooms that afternoon."
"And you had neither leisure nor curiosity to seek for relics of the
lovely creature?"
Monsieur Louis shrugged his shoulders.
"Is my room on the same floor?"
"Mais oui."
"And I have the same chambermaid?"
"Yes. She is the oldest servant we have, and she stays in the hotel
all the summer; while most of our staff are in Switzerland."
This was enough for Faunce. He retired to his room early, after
smoking a couple of cigarettes under the palm trees in front of the
hotel, in the sultry hush of the summer night. The scene around him
was all very modern, all very French—a café-concert on the right, a
café-concert on the left—and it needed an occasional Arab stalking
by in a long white mantle to remind him that he was in Africa. He
meant to start on his return journey to London by the next boat. He
was not going to Corsica or Sardinia in search of new facts. He
trusted to his professional acumen to run the lady to ground in
London or Paris.
He shut the window against insect life, lighted his candles, and
seated himself at the table, with his writing-case open before him,
and then rang the dual summons which brings the hotel
chambermaid.
"Be so good as to get me some ink," he said.
The chambermaid, who was elderly and sour-visaged, told him that
ink was the waiter's business, not hers. He should have rung once,
not twice, for ink.
"Never mind the ink, Marie," he said, in French. "I want something
more valuable even than ink. I want information, and I think you can
give it to me. Do you remember Monsieur and Madame Randall, who
had rooms on this floor before Easter?"
Yes, she remembered them; but what then?
"When Madame Randall left she was in a hurry, was she not?"
"She was always in a hurry when she had to go anywhere—unless
she was sulky and would not budge. She would sit like a stone figure
if she had one of her tempers," the chambermaid answered, with
many contemptuous shrugs.
"She left hurriedly, and she left her room in a litter—left all sorts of
things behind her?" suggested Faunce, with an insinuating smile.
The chambermaid's sharp black eyes flashed angrily, and the
chambermaid tossed her head in scorn. And then she held out a
skinny forefinger almost under Faunce's nose.
"She has not left so much as that," she said, striking the finger on the
first joint with the corresponding finger of the other hand. "Not so
much as that!" and from her vehemence Faunce suspected that she
had reaped a harvest of small wares, soiled gloves and lace-
bordered handkerchiefs, silk stockings with ravelled heels.
"What a pity," he said in his quietest voice, "for I should have been
glad to have given you a couple of napoleons for any old letters or
other documents that you might have found among the rubbish when
you swept the rooms."
"For letters, they were all in the fireplace, torn to shreds," said the
chambermaid; "but there was something—something that I picked
up, and kept, in case the lady should come back, when I could return
it to her."
"There is always something," said Faunce. "Well, Marie, what is it?"
"A photograph."
"Of the lady?"
"No, Monsieur, of a young man—pas grand' chose. But if Monsieur
values the portrait at forty francs it is at his disposition, and I will
hazard the anger of Madame should she return and ask me for it."
"Pas de danger! She will not return. She belongs to the wandering
tribes, the people who never come back. Since the portrait is not of
the lady herself, and may be worth nothing to me, we will say twenty
francs, ma belle."
The chambermaid was inclined to haggle, but when Faunce
shrugged his shoulders, laid a twenty-franc piece upon the table, and
declined further argument, she pocketed the coin, and went to fetch
the photograph.
It was the least possible thing in the way of portraits, of the kind
called "midget," a full-length portrait of a young man, faded and dirty,
in a little morocco case that had once been red, but was soiled to
blackness.
"By Jove!" muttered Faunce, "I ought to know that face."
He told himself that he ought to know it, for it was a familiar face, a
face that spoke to him out of the long ago; but he could not place it in
the record of his professional experiences. He took the photo out of
the case, and looked at the back, where he found what he expected.
There is always something written upon that kind of photograph by
that kind of woman.
"San Remo,
"Poor old Tony. November 22th, '88."

The 22th, the uneducated penmanship sprawling over the little card,
alike indicated the style of the writer.
"Poor old Tony!" mused Faunce, slowly puffing his last cigarette, with
the midget stuck up in front of him, between the two candles. "Who
is Tony? A swell, by the cut of his clothes, and that—well, the good-
bred ones have an air of their own, an air that one can no more deny
than one can describe it. Poor old Tony! At San Remo—condemned
by the doctors. There's death in every line of the face and figure. A
consumptive, most likely. The last sentence has been passed on
you, poor beggar! Poor old Tony! And that woman was with you at
San Remo, the companion of a doomed man, dying by inches. And
she must have been in the flower of her beauty then, a splendid
creature. Was she very fond of you, I wonder, honestly, sincerely
attached to you? I think she was, for her hand trembled when she
wrote those words! Poor old Tony! And there is a smudge across the
date, that might indicate a tear. Well, if I fail in running her to earth in
London, I could trace some part of her past life at San Remo, and
get at her that way. But who was Tony? I'm positive I know the face.
Perhaps the reflex action of the brain will help me," concluded
Faunce.
The reflex action did nothing for Mr. Faunce, in the profound slumber
which followed upon the fatigue of a long journey. No suggestion as
to the original of the photograph had occurred to him when he put it
in his letter-case next morning. It was hours afterwards, when he
was lying in his berth in the steamer, "rocked in the cradle of the
deep," wakeful, but with his brain in an idle, unoccupied state, that
Tony's identity flashed upon him.
"Sir Hubert Withernsea," he said to himself, sitting up in his berth,
and clapping his hand upon his forehead. "That's the man! I
remember him about town ten years ago—a Yorkshire baronet with
large estates in the West Riding—a weak-kneed youth with a
passion for the Fancy, always heard of at prize-fights, and
entertaining fighting men, putting up money for private glove-fights; a
poor creature, born to be the prey of swindlers and loose women."
Faunce looked back to that period of ten years ago, which seemed
strangely remote, more by reason of the changes in ideas and
fashions, whim and folly, than by the lapse of time. He searched his
mind for the name of any one woman in particular with whom Sir
Hubert Withernsea had been associated, but here memory failed
him. He had never had business relations with the young man, and
though his ears were always open to the gossip of the town, he kept
no record of trivial things outside the affairs of his clients. One young
fool more or less travelling along the primrose path made no
impression upon him. But with the knowledge of this former episode
in the pseudo-Mrs. Randall's career, it ought to be easy for him to
find out all about her in London, that focus of the world's intelligence,
where he almost invariably searched for information before drawing
any foreign capital.
CHAPTER IX.
"What begins now?"
"Happiness
Such as the world contains not."
Faunce wrote to Lady Perivale on his arrival in town, and told her the
result of his journey briefly, and without detail. She might make her
mind easy. The woman who resembled her would be found. He was
on her track, and success was only a question of time.
Grace read the letter to Susan Rodney, who was dining with her that
evening. She had been in much better spirits of late, and Sue
rejoiced in the change, but did not suspect the cause. She had gone
to her own den at the back of her house when Grace left her, and
had not seen the carriage standing by the park gate, nor had the
interview in the park come to her knowledge. Her friend, who
confided most things to her, was reticent here. She attributed Lady
Perivale's cheerfulness to a blind faith in Faunce the detective.
The season was drawing towards its close. Lady Morningside's white
ball had been a success, all the prettiest people looking their
prettiest in white frocks, and the banks of gloxinias in the hall and
staircase and supper-rooms being a thing to rave about. The London
season was waning. The Homburg people and the Marienbad
people were going or gone. The yachting people were rushing about
buying stores, or smart clothes for Cowes. The shooting people were
beginning to talk about their grouse moors.
"Sue, we must positively go somewhere," Grace said. "Even you
must be able to take a holiday within an hour of London; and you
may be sure I shan't go far while I have this business on hand. You
will come with me, won't you, Sue? I am beginning to sicken of
solitude."
"I shall love to come, if you are near enough for me to run up to town
once or twice a week. I have three or four pig-headed pupils who
won't go away when I want them; but most of my suburbans are
packing their golf clubs for Sandwich, Cromer, or North Berwick."
"You will come! That's capital! I shall take a house on the river
between Windsor and Goring."
"Make it as near London as you can."
"If you are good it shall be below Windsor, even if the river is not so
pretty there as it is at Wargrave or Taplow. I want to be near London,
for Mr. Faunce's convenience. I hope he will have news to bring me.
I wrote to beg him to call to-morrow morning—I want to know what
discoveries he made in Algiers."
People who have twenty thousand a year, more or less, seldom have
to wait for things. Lady Perivale drove to a fashionable agent in
Mount Street next morning, and stated her wishes; and the
appearance of her victoria and servants, and the fact that she made
no mention of price, indicated that she was a client worth having.
The agent knew of a charming house on a lovely reach of the river
near Runnymede—gardens perfection, stables admirable, boat-
house spacious, and well provided with boats at the tenant's
disposal. Unluckily, he had let it the day before; but he hoped that
little difficulty might be got over. He would offer his client a villa
further up the river. He would write to Lady Perivale next morning.
The little difficulty was got over. The client, actual or fictitious, was
mollified, and Lady Perivale took the house for a month at two
hundred guineas, on the strength of a water-colour sketch. She sent
some of her servants to prepare for her coming, and she and Susan
Rodney were installed there at the end of the week.
The house and gardens were almost as pretty as they looked in
water-colour, though the river was not quite so blue, and the roses
were not quite so much like summer cabbages as the artist had
made them. There were a punt and a couple of good skiffs in the
boat-house; and Lady Perivale and her friend, who could both row,
spent half their days on the river, where Grace met some of those
quondam friends whom she had passed so often in the park; met
and passed them with unalterable disdain, though sometimes she
thought she saw a little look of regret, an almost appealing
expression in their faces, as if they were beginning to think they
might have been too hasty in their conclusions about her.
One friend she met on the river whom she did not pretend to scorn.
On the second Saturday afternoon a skiff flashed past her through
the July sunshine, and her eyes were quick to recognize the rower. It
was Arthur Haldane. She gave an involuntary cry of surprise, and he
turned his light craft, and brought it beside the roomy boat in which
she and Sue were sitting, with books and work, and the marron
poodle, as in a floating parlour.
"Are you staying near here, Lady Perivale?" he asked, when
greetings had been exchanged.
"We are living close by, Miss Rodney and I, at Runnymede Grange. I
hope you won't laugh at our rowing. Our idea of a boat is only a
movable summer-house. We dawdle up and down for an hour or
two, and then creep into a backwater, and talk, and work, and read,
all the afternoon, and one of the servants comes to us at five o'clock,
and makes tea on the bank with a gipsy kettle."
"You might ask him to one of our gipsy teas, Grace," suggested
Susan.
"With pleasure. Will you come this afternoon? We shall be in the little
creek—the first you come to after passing Runnymede Grange,
which you will know by the Italian terrace and sundial."
"I shall come and help your footman to boil the kettle."
He looked radiant. He had seen Lady Perivale's happy look when his
boat neared hers, and his heart danced for joy. All the restraint he
had set upon himself was flung to the winds. If she loved him, what
did anything matter? It was not the world's mistrust he dreaded, or
the world's contempt. His only fear had been that she should doubt
him, misread his motives, rank him with the fortune-hunters who had
pursued her.
"Are you staying near here?" asked Susan.
"I come up the river for a day or two now and then. There is a
cottage at Staines kept by a nice old spinster, whose rooms are the
pink of cleanliness, and who can cook a mutton chop. I keep a quire
or two of foolscap in her garden parlour, and go there sometimes to
do my work. Her garden goes down to the water, and there is a
roomy arbour of hops that I share with the caterpillars, a kind of
berceau, from which I can see the river and the boats going by,
through the leafy screen, while nobody can see me. It is the quietest
place I know of near London. The rackety people seldom come
below Maidenhead."
He spent the hours between tea-time and sunset with Grace and her
friend, in a summer idleness, while the poodle, who found himself
receiving less attention from his mistress than usual, roamed up and
down, scratching holes in the bank, and pretending to hunt rats
among the sedges, evidently oppressed with ennui. Of those three
friends there were two who knew not the lapse of time, and were
surprised to see the great golden disc sink below the rosy water
where the river curved westward, and the sombre shadows steal
over keep and battlements yonder where the Royal fortress barred
the evening sky.
"How short the days are getting," Grace said naively.
They two had found so much to talk about after having lived a year
without meeting. All the books they had read, all the plays they had
seen, the music they had heard—everything made a subject for
discussion; and then it was so sweet to be there, in the full
confidence of friendship, spell-bound in a present happiness, and in
vague dreams of the future, sure that nothing could ever again come
between them and their trust in each other.
"The days are shortening by a cock's step or so," said Sue, looking
up from an afternoon tea-cloth, which she was decorating with an
elaborate design in silk and gold thread, and which she had been
seen engaged upon for the last ten years.
It was known as "Sue's work." It went everywhere with her, and was
criticized and admired everywhere, and everybody knew that it would
never be finished.
"The days are shortening, no doubt," repeated Sue; "they must
begin, or we should never get to the long winter evenings, but I
haven't perceived any difference yet, and I don't think there's
anything odd in the sun going down at eight o'clock."
"Eight o'clock! Nonsense, Sue!" cried Lady Perivale, flinging down a
volume of "The Ring and the Book," which she had been nursing all
the afternoon.
"And as we are supposed to dine at eight, I think we ought to go
home and put on our tea-gowns," pursued Sue, sedately.
Can there be such happiness in life; bliss that annihilates thought
and time? Grace blushed crimson, ashamed of having been so
happy.
Mr. Haldane bade them good night at the bottom of the garden
steps, where his outrigger was waiting for him. It would have been so
easy to ask him to dinner, so easy to keep him till midnight, so easy
to prolong the sweetness of golden hours. But Grace was discreet.
They were not lovers, only friends. She wanted to spin to its finest
thread this season of sweet uncertainty, these exquisite hours on the
threshold of Paradise. And then Sue might think him a bore. Sue
was not overfond of masculine society. She liked to put her feet on a
chair after dinner, and she sometimes liked a cigarette.
"I never smoke before men," she told Grace. "They think we do it to
please, or to shock them."
CHAPTER X.
"True as steel, boys!
That knows all chases, and can watch all hours."
In the course of that summer afternoon's talk with Grace Perivale,
Arthur Haldane had explained the change in his plans since their
meeting in Regent's Park.
The business which would have taken him away from England for
some time had hung fire, and his journey was postponed indefinitely.
He did not tell her that his contemplated journey was solely in her
interests, that he had thought of going to America in quest of Colonel
Rannock, with the idea that he, the man with whose name Lady
Perivale's had been associated, should himself set her right before
that little world which had condemned her. He knew not by what
machinery that rehabilitation could be accomplished; but his first
impulse was to find the man whose acquaintance had brought this
trouble upon her.
Two days after that golden sunset in which he and Lady Perivale had
parted, with clasped hands that vowed life-long fidelity, while yet no
word had been spoken, Mr. Haldane called upon John Faunce at his
pied à terre in Essex Street.
He had written for an appointment on business connected with Lady
Perivale's case, and Faunce had replied asking him to call at his
rooms in Essex Street at ten o'clock next morning. An early hour,
which denoted the man whose every hour was valuable.
He found the house one of the oldest in the old-world street, next
door to a nest of prosperous solicitors, but itself of a somewhat
shabby and retiring aspect. The bell was answered by a bright-eyed
servant girl, clean and fresh looking, but with an accent that
suggested the Irish Town Limerick, rather than a London slum—a
much pleasanter accent to Haldane's ear.
To the inquiry if Mr. Faunce lived there, she answered with a note of
interrogation.
"Mr. Wh-hat?"
"Mr. Faunce."
"Yes, he does. Any message?"
"Is he at home?"
"I don't know. I'll go and see. Wh-hat name?"
A quick-eyed scrutiny of the visitor's spotless holland waistcoat, the
neat dark stripes of the straight-knee'd trousers falling in a graceful
curve over the irreproachable boots, and the sheen of a silk-faced
coat, had assured her of his respectability before she committed
herself even so far as that.
But when this well-groomed gentleman, who was far too quietly
dressed to be a member of the swell-mob, produced an immaculate
card out of a silver case, she grasped it and dashed up the steep
stairs.
"Will I tell 'um you want to see 'um?"
"Thanks."
"I shall!" and she vanished round the first landing.
She was back again and leaning over the same spot on the
bannister rail in half a minute.
"You're to be good enough to step up, if ye plaze, surr."
Mr. Faunce occupied the second floor, front and back, as sitting-
room and bedroom; the busy nature and uncertain hours of his
avocations during the last few years having made his rural retreat at
Putney impossible for him except in the chance intervals of his
serious work, or from Friday to Monday, when that work was slack. It
was not that he loved wife and home less, but that he loved duty
more.
He emerged from the bedroom as Haldane entered the sitting-room,
in the act of fixing a collar to his grey flannel shirt, and welcomed his
visitor cordially, with apologies for not being dressed. He had been
late overnight, and had been slower than usual at his toilet, as he
was suffering from a touch of rheumatism. His profession was
betrayed by a pair of regulation high-waisted trousers of a thick blue-
black material, over Blucher boots, which were also made to the
sealed pattern of the Force. But his costume was rounded off by a
pepper-and-salt Norfolk jacket of workman-like cut.
There was no paltry pride about Mr. Faunce. Although a man of
respectable parentage, good parts, and education, he was not in the
least ashamed of having been for many years a respected member
of the Police. In ordinary life he somewhat affected the get-up of a
country parson with sporting tastes; but here, in his own den, and
quite at his ease, he was nothing more or less than a retired police-
officer.
His rheumatism had taken him in the arm, he explained, or he would
have been at his table there writing up one of his cases.
"There is often as much in one of 'em as would make a three-volume
novel, Mr. Haldane;" and then, with a polite wave of the hand—"in
bulk," he added, disclaiming all literary pretentions, and at the same
time motioning his guest to a chair.
This laborious penwork was perhaps the most remarkable feature in
John Faunce's career. The hours of patient labour this supremely
patient man employed in noting down every detail and every word
concerning the case in hand, which may have come to the notice of
himself or any of his numerous temporary assistants, in and out of
the police-force, stamped him as the detective who is born, not
made, or, in other words, the worker who loves his work.
The room reflected the man's mind. It was a perfectly arranged
receptacle of a wonderful amount of precise information. It was like
the sitting-room of an exceptionally methodical student preparing for
a very stiff examination. The neat dwarf bookcase contained a
goodly number of standard books of reference, and a lesser number
of the most famous examples of modern fiction.
One corner of the room was occupied by a stack of japanned tin
boxes that recalled a solicitor's office; but these boxes had no
lettering upon them. A discreet little numeral was sufficient indication
of their contents for Faunce, who was incapable of forgetting a fact
once registered in the book of his mind.
"You must find papers accumulate rapidly in your work, Mr. Faunce,"
said Haldane.
"They would if I let them, sir; but I don't. When once a case is settled
or withdrawn from my hands, I return all letters and other papers that
may have reached me, and I burn my history of the case."
"You will have nothing left for your Reminiscences, then?"
"They are here, sir," the detective replied sharply, tapping his
massive brow; "and one day—well, sir, one day I may let the reading
world know that truth is stranger—and sometimes even more thrilling
—than fiction. But I must have consummate cheek to talk of fiction to
the author of 'Mary Deane.'"
Haldane started, half inclined to resent an impertinence; but a glance
at the man's fine head and brilliant eye reminded him that the
detective and the novelist might be upon the same intellectual plane,
or that in sheer brain power the man from Scotland Yard might be his
superior.
Faunce had seen the look, and smiled his quiet smile.
"It's one of the penalties of being famous, Mr. Haldane, that your
inferiors may venture to admire you. I have your book among my
favourites."
He pointed to the shelf, where Haldane saw the modest, dark-green
cloth back of his one novel, between "Esmond" and "The Woman in
White."
"And now to business, sir. And first allow me to say that I am glad to
see any friend of Lady Perivale's."
"Thank you, Mr. Faunce. You must not suppose that Lady Perivale
sent me here. She did not even know that I wanted to see you; and I
must ask you not to mention my visit. I heard of what you were doing
from a friend of Lady Perivale's, not from herself, and I am here to
consult you on a matter that only indirectly affects her case."
"Well, sir, I am at your service."
"I shall be perfectly frank with you, Mr. Faunce. I believe a gentleman
of your profession may be considered a kind of father confessor, that
anything I say in this office will be—strictly Masonic."
"That is so."
"Well, then, I may tell you in the first place that Lady Perivale is the
woman whom I admire and respect above all other women, and that
it is my highest ambition to win her for my wife."
"I think that is a very natural ambition, sir, in any gentleman who—
being free to choose—has the honour to know that lady," Faunce
replied, with a touch of enthusiasm.
"I know something of Colonel Rannock's antecedents, and have met
him in society, though he was never a friend of mine; and when I
heard the scandal about Lady Perivale, it occurred to me that the
best thing I could do, in her interest, was to find Rannock and call
upon him to clear her name."
"A difficult thing for him to do, sir, even if he were willing to do it."
"I thought the way might be found, if the man were made to feel that
it must be found. I have the worst possible opinion of Colonel
Rannock; but a man of that character has generally a weak joint in
his harness, and I thought I should be able to bring him to book."
"A very tough customer, I'm afraid, sir. A human armadillo."
"The first matter was to find him. He was said to be in the Rocky
Mountains, and I was prepared to go there after him; only such an
expedition seemed improbable at the time of year. I had heard of him
in chambers in the Albany; but on inquiry there I found he gave up
his chambers last March, sold lease and furniture, and that his
present address, if he had one in London, was unknown."
"Then I take it, sir, not having my professional experience, you were
baffled, and went no further."
"No; I wasn't beaten quite so easily. I think, Faunce, your profession
has a certain fascination for every man. It is the hunter's instinct,
common to mankind, from the Stone Age downwards. After a good
deal of trouble I found Rannock's late body-servant, a shrewd fellow,
now billiard-marker at the Sans-Souci Club; and from him I heard
that Rannock's destination was not the Rockies, but Klondyke. He
left London for New York by the American Line at the end of March,
taking the money he got for his lease and furniture, and he was to
join two other men—whose names his servant gave me—at San
Francisco, on their way to Vancouver. He was to write to his servant
about certain confidential matters as soon as he arrived in New York,
and was to send him money if he prospered in his gold-digging, for
certain special payments, and for wages in arrear. I had no interest
in knowing more of these transactions than the man chose to tell me;
but the one salient fact is that no communication of any kind has
reached the servant since his master left him, and the man feels
considerable anxiety on his account. He has written to an agent in
San Francisco, whose address Rannock had given him, and the
agent replied that no such person as Colonel Rannock had been at
his office or had communicated with him."
"Well, sir, Colonel Rannock changed his mind at the eleventh hour;
or he had a reason for pretending to go to one place and going to
another," said Faunce, quietly, looking up from a writing-pad on
which he had made two or three pencil-notes.
"That might be so. I cabled an inquiry to the agent, whose letter to
the valet was six weeks old, and I asked the whereabouts of the two
friends whose party Rannock was to join. The reply came this
morning. No news of Rannock; the other men started for Vancouver
on April 13th."
"Do you want me to pursue this inquiry further, Mr. Haldane?"
"Yes; I want to find Rannock. It may be a foolish idea on my part. But
Lady Perivale has been cruelly injured by the association of her
name with this man—possibly by no fault of his—possibly by some
devilish device to punish her for having slighted him."
"That hardly seems likely. They may have done such things in the
last century, sir, when duelling was in fashion, and when a fine
gentleman thought it no disgrace to wager a thousand pounds
against a lady's honour, and write his wager in the club books, if she
happened to offend him. But it doesn't seem likely nowadays."
"I want you to find this man," pursued Haldane, surprised, and a little
vexed, at Faunce's dilettante air.
He had not expected to find a detective who talked like an educated
man, and he began to doubt the criminal investigator's professional
skill, in spite of his tin boxes and reference books, and appearance
of mental power.
"In Lady Perivale's interest?"
"Certainly."
"Don't you think, sir, you'd better let me solve the problem on my own
lines? You are asking me to take up a tangled skein at the wrong
end. I am travelling steadily along my own road, and you want me to
go off at a tangent. I dare say I shall come to Colonel Rannock in
good time, working my own way."
"If that is so, I won't interfere," Haldane said, with a troubled look. "All
my anxiety is for Lady Perivale's rehabilitation, and every hour's
delay irritates me."
"You may safely leave the matter to me, sir. Festina lente. These
things can't be hurried. I shall give the case my utmost attention, and
as much time as I can spare, consistently with my duty to other
clients."
"You have other cases on your hands?"
Faunce smiled his grave, benign smile.
"Four years ago, when I retired from the C.I., I thought I was going to
settle down in a cottage at Putney, with my good little wife, and enjoy
my otium cum dignitate for the rest of my days," said Faunce,
confidentially, "but, to tell you the truth, Mr. Haldane, I found the
otium rather boring, and, one or two cases falling in my way,
fortuitously, I took up the old business in a new form, and devoted
myself to those curious cases which are of frequent occurrence in
the best-regulated families, cases requiring very delicate handling,
inexhaustible patience, and a highly-trained skill. Since then I have
had more work brought me than I could possibly undertake; and I
have been, so far, fortunate in giving my clients satisfaction. I hope I
shall satisfy Lady Perivale."
There was a firmness in Faunce's present tone that pleased
Haldane.
"At any rate, it was just as well that you should know the result of my
search for Rannock," he said, taking up his hat and stick.
"Certainly, sir. Any information bearing on the case is of value, and I
thank you for coming to me," answered Faunce, as he rose to escort
his visitor to the door.
He did not attach any significance to the fact that Colonel Rannock
had announced his intention of going to Klondyke, and had not gone
there. He might have twenty reasons for throwing his servant off the
scent; or he might have changed his mind. The new gold region is
too near the North Pole to be attractive to a man of luxurious habits,
accustomed to chambers in the Albany, and the run of half a dozen
rowdy country houses, where the company was mixed and the play
high.
Sport in Scotland and Ireland, sport in Norway, or even in Iceland,
might inure a man to a hard life, but it would not bring him within
measurable distance of the hazards and hardships in that white
world beyond Dawson City.
John Faunce, seated in front of his empty fireplace, listened
mechanically to a barrel-organ playing the "Washington Post," and
meditated upon Arthur Haldane's statement.
He had not been idle since his return to London, and had made
certain inquiries about Colonel Rannock among people who were
likely to know. He had interviewed a fashionable gunmaker with
whom Rannock had dealt for twenty years, and the secretary of a
club which he had frequented for about the same period. The man
was frankly Bohemian in his tastes, but had always kept a certain
footing in society, and, in his own phrase, had never been "bowled
out." He had been banished from no baccarat table, though he was
not untainted with a suspicion of occasionally tampering with his
stake. He played all the fashionable card games, and, like Dudley
Smooth, though he did not cheat, he always won. He had plenty of
followers among the callow youth who laughed at his jokes and
almost died of his cigars; but he had no friends of his own age and
station, and the great ladies of the land never admitted him within
their intimate circle, though they might send him a card once or twice
a year for a big party, out of friendly feeling for his mother—five-and-
twenty years a widow, and for the greater part of her life attached to
the Court.
Would such a man wheel a barrow and tramp the snow-bound
shores of the Yukon River? Unlikely as the thing seemed, Faunce
told himself that it was not impossible. Rannock had fought well in
the Indian hill-country, had never been a feather-bed soldier, and had
never affected the passing fashion of effeminacy. He had loved
music with that inborn love which is like an instinct, and had made
himself a fine player with very little trouble, considering the exacting
nature of the 'cello; but he had never put on dilettante airs, or
pretended that music was the only thing worth living for. He was as
much at home with men who painted pictures as with composers
and fiddlers. Versatility was the chief note in his character. The
Scotch University, the Army school, the mess-room, the continental
wanderings of later years, had made him an expert in most things

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© Springer Nature Switzerland AG 2020

Prof. Marco Soligo

Milano, Italy Donatella Giraudo

1 The Bladder, the Rectum and the Sphincters: Neural Pathways

9 Pelvic Floor Muscle Training and Neurogenic Overactive Bladder

Gianfranco Lamberti and Antonella Biroli

Despite the fundamental contribution given by functional imaging in recent years, to

© Springer Nature Switzerland AG 2020 1

Fig. 1.1 Cerebral and

Fig. 1.2 Hippocampus,

1.2 The Bladder Function

The filling and the emptying phase:

Fig. 1.3 Bladder filling,

1.2.1 Spinal Cord Afferents

impregnation techniques it is possible to map first-level axons, coming from the

IMG Sympathetic T10-L2

volume sensitivity threshold, from normal filling to extreme distension. Both

1.2.2 Spinal Cord Efferents

1.2.3  he Periaqueductal Grey and the Pontine Micturition

1.2.4 The Cortical Control

1.3 The Bowel Function

includes different types of functionally distinct enteric neurons [primary intrinsic

Vagal, cholinergic preganglionic fibres originate in the brainstem (the dorsal

"Poor old Tony. November 22th, '88."

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Milano, Italy Donatella Giraudo

1 The Bladder, the Rectum and the Sphincters: Neural Pathways

9 Pelvic Floor Muscle Training and Neurogenic Overactive Bladder

1.2 The Bladder Function

1.2.1 Spinal Cord Afferents

1.2.2 Spinal Cord Efferents

1.2.3 he Periaqueductal Grey and the Pontine Micturition

1.2.4 The Cortical Control

1.3 The Bowel Function