Williams Obstetrics 25Th Edition F Gary Cunningham Et Al All Chapter

Williams Obstetrics 25th Edition F.
Gary
Cunningham Et Al.
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Williams Obstetrics, 25e >
CHAPTER 2: Maternal Anatomy
As the mechanism of labour is essentially a process of accommodation between the foetus and the passage through which it must pass, it is apparent that
obstetrics lacked a scientific foundation until the anatomy of the bony pelvis and of the so parts connected with it was clearly understood.
—J. Whitridge Williams (1903)
ANTERIOR ABDOMINAL WALL

Skin, Subcutaneous Layer, and Fascia
The anterior abdominal wall confines abdominal viscera, stretches to accommodate the expanding uterus, and provides surgical access to the internal reproductive
organs. Thus, a comprehensive knowledge of its layered structure is required to surgically enter the peritoneal cavity.
Langer lines describe the orientation of dermal fibers within the skin. In the anterior abdominal wall, they are arranged transversely. As a result, vertical skin
incisions sustain greater lateral tension and thus, in general, develop wider scars. In contrast, low transverse incisions, such as the Pfannenstiel, follow Langer lines
and lead to superior cosmetic results.
The subcutaneous layer can be separated into a superficial, predominantly fatty layer—Camper fascia, and a deeper membranous layer—Scarpa fascia. Camper
fascia continues onto the perineum to provide fatty substance to the mons pubis and labia majora and then to blend with the fat of the ischioanal fossa. Scarpa
fascia continues inferiorly onto the perineum as Colles fascia, described in Perineum.
Beneath the subcutaneous layer, the anterior abdominal wall muscles consist of the midline rectus abdominis and pyramidalis muscles as well as the external
oblique, internal oblique, and transversus abdominis muscles, which extend across the entire wall (Fig. 2-1). The fibrous aponeuroses of these three latter muscles
form the primary fascia of the anterior abdominal wall. These fuse in the midline at the linea alba, which normally measures 10 to 15 mm wide below the umbilicus
(Beer, 2009). An abnormally wide separation may reflect diastasis recti or hernia.
FIGURE 2-1
Anterior abdominal wall anatomy. (Modified with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology,
3rd ed. New York, McGraw-Hill Education, 2016.)
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These three aponeuroses also invest the rectus abdominis muscle as the rectus sheath. The construction of this sheath varies above and below a boundary, termed
the arcuate line (see Fig. 2-1). Cephalad to this border, the aponeuroses invest the rectus abdominis bellies on both dorsal and ventral surfaces. Caudal to this line,
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all aponeuroses lie ventral or superficial to the rectus abdominis muscle, and only the thin transversalis fascia and peritoneum lie beneath the rectus (Loukas, 2008).
This transition of rectus sheath composition can be seen best in the upper third of a midline vertical abdominal incision.
The paired small triangular pyramidalis muscles originate from the pubic crest and insert into the linea alba. These muscles lie atop the rectus abdominis muscle but
beneath the anterior rectus sheath.
Blood Supply
The superficial epigastric, superficial circumflex iliac, and superficial external pudendal arteries arise from the femoral artery just below the inguinal ligament within
the femoral triangle (see Fig. 2-1). These vessels supply the skin and subcutaneous layers of the anterior abdominal wall and mons pubis. Of these three, the
superficial epigastric vessels are surgically important to the obstetrician and course diagonally from their origin toward the umbilicus. With a low transverse skin
incision, these vessels can usually be identified at a depth halfway between the skin and the anterior rectus sheath. They lie above Scarpa fascia and several
centimeters from the midline. Ideally, these vessels are identified and surgically occluded.
In contrast, the inferior “deep” epigastric vessels are branches of the external iliac vessels and supply anterior abdominal wall muscles and fascia. Of surgical
relevance, the inferior epigastric vessels initially course lateral to, then posterior to the rectus abdominis muscles, which they supply. Above the arcuate line, these
vessels course ventral to the posterior rectus sheath and lie between this sheath and the posterior surface of the rectus muscles. Near the umbilicus, the inferior
epigastric vessels anastomose with the superior epigastric artery and vein, which are branches of the internal thoracic vessels. Clinically, when a Maylard incision is
used for cesarean delivery, the inferior epigastric vessels may be lacerated lateral to the rectus belly during muscle transection. Preventively, identification and
surgical occlusion are preferable. These vessels rarely may rupture following abdominal trauma and create a rectus sheath hematoma (Tolcher, 2010; Wai, 2015).
On each side of the lower anterior abdominal wall, Hesselbach triangle is the region bounded laterally by the inferior epigastric vessels, inferiorly by the inguinal
ligament, and medially by the lateral border of the rectus abdominis muscle. Hernias that protrude through the abdominal wall in Hesselbach triangle are termed
direct inguinal hernias. In contrast, indirect inguinal hernias do so through the deep inguinal ring, which lies lateral to this triangle, and then may exit out the
superficial inguinal ring.
Innervation
The entire anterior abdominal wall is innervated by intercostal nerves (T7–11), the subcostal nerve (T12), and the iliohypogastric and the ilioinguinal nerves (L1). Of
these, the intercostal and subcostal nerves are anterior rami of the thoracic spinal nerves and run along the lateral and then anterior abdominal wall between the
transversus abdominis and internal oblique muscles (Fig. 2-2). This space, termed the transversus abdominis plane, can be used for postcesarean analgesia blockade
(Chap. 25, Postpartum Analgesia) (Fusco, 2015; Tawfik, 2017). Others report rectus sheath or ilioinguinal-iliohypogastric nerve blocks to decrease postoperative pain
(Mei, 2011; Wolfson, 2012).
FIGURE 2-2
Intercostal and subcostal nerves are the anterior rami of spinal nerves. In this figure, an intercostal nerve extends ventrally between the transversus abdominis and
internal oblique muscles. During this path, the nerve gives rise to lateral and anterior cutaneous branches, which innervate the anterior abdominal wall. As shown by
the inserted needle, the transversus abdominis plane (TAP) block takes advantage of this anatomy. (Modified with permission from Hawkins JL: Anesthesia for the
pregnant woman. In Yeomans ER, Ho man BL, Gilstrap LC III, et al: Cunningham and Gilstraps’s Operative Obstetrics, 3rd ed. New York, McGraw Hill Education, 2017.)
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Near the rectus abdominis lateral borders, anterior branches of the intercostal and subcostal nerves pierce the posterior sheath, rectus muscle, and then anterior
sheath to reach the skin. Thus, these nerve branches may be severed during a Pfannenstiel incision creation during the step in which the overlying anterior rectus
sheath is separated from the rectus abdominis muscle.
In contrast, the iliohypogastric and ilioinguinal nerves originate from the anterior ramus of the first lumbar spinal nerve. They emerge lateral to the psoas muscle and
travel retroperitoneally across the quadratus lumborum inferomedially toward the iliac crest. Near this crest, both nerves pierce the transversus abdominis muscle
and course ventromedially. At a site 2 to 3 cm medial to the anterior superior iliac spine, the nerves then pierce the internal oblique muscle and course superficial to
it toward the midline (Whiteside, 2003). The iliohypogastric nerve perforates the external oblique aponeurosis near the lateral rectus border to provide sensation to
the skin over the suprapubic area (see Fig. 2-1). The ilioinguinal nerve in its course medially travels through the inguinal canal and exits through the superficial
inguinal ring, which forms by splitting of external abdominal oblique aponeurosis fibers. This nerve supplies the skin of the mons pubis, upper labia majora, and
medial upper thigh.
The ilioinguinal and iliohypogastric nerves can be severed during a low transverse incision or entrapped during closure, especially if incisions extend beyond the
lateral borders of the rectus abdominis muscle (Rahn, 2010). These nerves carry sensory information only, and injury leads to loss of sensation within the areas
supplied. Rarely, chronic pain may develop (Whiteside, 2005).
The T10 dermatome approximates the level of the umbilicus. Analgesia to this level is suitable for labor and vaginal birth. Regional analgesia for cesarean delivery or
for puerperal sterilization ideally extends to T4.
EXTERNAL GENERATIVE ORGANS

Vulva
Mons Pubis, Labia, and Clitoris

The pudenda—commonly designated the vulva—includes all structures visible externally from the symphysis pubis to the perineal body. This includes the mons
pubis, labia majora and minora, clitoris, hymen, vestibule, urethral opening, greater vestibular or Bartholin glands, minor vestibular glands, and paraurethral glands
(Fig. 2-3). The vulva receives innervations and vascular support from the pudendal nerve (Pudendal Nerve).
FIGURE 2-3
Vulvar structures and subcutaneous layer of the anterior perineal triangle. Note the continuity of Colles and Scarpa fasciae. Inset: Vestibule boundaries and openings
onto vestibule. (Reproduced with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New
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York, McGraw-Hill Education, 2016.)
The mons pubis is a fat-filled cushion overlying the symphysis pubis. A er puberty, the mons pubis skin is covered by curly hair that forms the triangular escutcheon,
whose base aligns with the upper margin of the symphysis pubis. In men and some hirsute women, the escutcheon extends farther onto the anterior abdominal wall
toward the umbilicus.
Labia majora usually are 7 to 8 cm long, 2 to 3 cm wide, and 1 to 1.5 cm thick. They are continuous directly with the mons pubis superiorly, and the round ligaments
terminate at their upper borders. Hair covers the labia majora, and apocrine, eccrine, and sebaceous glands are abundant. Beneath the skin, a dense connective
tissue layer is nearly void of muscular elements but is rich in elastic fibers and fat. This fat mass provides bulk to the labia majora and is supplied with a rich venous
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plexus. During pregnancy, this vasculature may develop varicosities, especially in multiparas, from increased venous pressure created by the enlarging uterus. They
appear as engorged tortuous veins or as small grapelike clusters, but they are typically asymptomatic and require no treatment.
Each labium minus is a thin tissue fold that lies medial to each labium majus. The labia minora extend superiorly, where each divides into two lamellae. From each
side, the lower lamellae fuse to form the frenulum of the clitoris, and the upper lamellae merge to form the prepuce (see Fig. 2-3). Inferiorly, the labia minora extend
to approach the midline as low ridges of tissue that join to form the fourchette. The labia minora dimensions vary greatly among individuals, with lengths from 2 to
10 cm and widths from 1 to 5 cm (Lloyd, 2005).
Structurally, the labia minora are composed of connective tissue with numerous vessels, elastin fibers, and very few smooth muscle fibers. They are supplied with
many nerve endings and are extremely sensitive (Ginger, 2011a; Schober, 2015). The epithelia of the labia minora di er with location. Thinly keratinized stratified
squamous epithelium covers the outer surface of each labium. On their inner surface, the lateral portion is covered by this same epithelium up to a demarcating line,
termed Hart line. Medial to this line, each labium is covered by squamous epithelium that is nonkeratinized. The labia minora lack hair follicles, eccrine glands, and
apocrine glands. However, sebaceous glands are numerous (Wilkinson, 2011).
The clitoris is the principal female erogenous organ. It is located beneath the prepuce, above the frenulum and urethra, and projects downward and inward toward
the vaginal opening. The clitoris rarely exceeds 2 cm in length and is composed of a glans, a corpus or body, and two crura (Verkauf, 1992). The glans is usually less
than 0.5 cm in diameter, is covered by stratified squamous epithelium, and is richly innervated. The clitoral body contains two corpora cavernosa. Extending from the
clitoral body, each corpus cavernosum diverges laterally to form a long, narrow crus. Each crus lies along the inferior surface of its respective ischiopubic ramus and
deep to the ischiocavernosus muscle. The clitoral blood supply stems from branches of the internal pudendal artery. Specifically, the deep artery of the clitoris
supplies the clitoral body, whereas the dorsal artery of the clitoris supplies the glans and prepuce.
Vestibule
In adult women, the vestibule is an almond-shaped area that is enclosed by Hart line laterally, the external surface of the hymen medially, the clitoral frenulum
anteriorly, and the fourchette posteriorly (see Fig. 2-3). The vestibule is usually perforated by six openings: the urethra, the vagina, two Bartholin gland ducts, and
two ducts of the largest paraurethral glands—the Skene glands. The posterior portion of the vestibule between the fourchette and the vaginal opening is called the
fossa navicularis. It is usually observed only in nulliparas.
The bilateral Bartholin glands, also termed greater vestibular glands, measure 0.5 to 1 cm in diameter. On their respective side, each lies inferior to the vestibular
bulb and deep to the inferior end of the bulbospongiosus muscle (former bulbocavernosus muscle). A duct extends medially from each gland, measures 1.5 to 2 cm
long, and opens distal to the hymeneal ring—one at 5 and the other at 7 o’clock on the vestibule. Following trauma or infection, either duct may swell and obstruct to
form a cyst or, if infected, an abscess. In contrast, the minor vestibular glands are shallow glands lined by simple mucin-secreting epithelium and open along Hart
line.
The paraurethral glands are a collective arborization of glands whose numerous small ducts open predominantly along the entire inferior aspect of the urethra. The
two largest are called Skene glands, and their ducts typically lie distally and near the urethral meatus. Clinically, inflammation and duct obstruction of any of the
paraurethral glands can lead to urethral diverticulum formation. The urethral opening or meatus is in the midline of the vestibule, 1 to 1.5 cm below the pubic arch,
and a short distance above the vaginal opening.
Vagina and Hymen
In adult women, the hymen is a membrane of varying thickness that surrounds the vaginal opening more or less completely. It is composed mainly of elastic and
collagenous connective tissue, and both outer and inner surfaces are covered by nonkeratinized stratified squamous epithelium. The aperture of the intact hymen
ranges in diameter from pinpoint to one that admits one or even two fingertips. As a rule, the hymen is torn at several sites during first coitus. However, identical
tears may form by other penetration, for example, by tampons used during menstruation. The edges of the torn tissue soon reepithelialize. In pregnant women, the
hymeneal epithelium is thick and rich in glycogen. Changes produced in the hymen by childbirth are usually readily recognizable. For example, over time, the hymen
transforms into several nodules of various sizes, termed hymeneal or myrtiform caruncles.
Proximal to the hymen, the vagina is a musculomembranous tube that extends to the uterus and is interposed lengthwise between the bladder and the rectum (Fig.
2-4). Anteriorly, the vagina is separated from the bladder and urethra by connective tissue—the vesicovaginal septum. Posteriorly, between the lower portion of the
vagina and the rectum, similar tissues together form the rectovaginal septum. The upper fourth of the vagina is separated from the rectum by the rectouterine
pouch, also called the cul-de-sac or pouch of Douglas.
FIGURE 2-4
Vagina and surrounding anatomy. (Reproduced with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams
Gynecology, 3rd ed. New York, McGraw-Hill Education, 2016.)
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Normally, the anterior and posterior walls of the vaginal lumen lie in contact, with only a slight space intervening at the lateral margins. Vaginal length varies
considerably, but commonly, the anterior wall measures 6 to 8 cm, whereas the posterior vaginal wall is 7 to 10 cm. The upper end of the vaginal vault is subdivided
by the cervix into anterior, posterior, and two lateral fornices. Clinically, the internal pelvic organs usually can be palpated through the thin walls of these fornices.
The vaginal lining is composed of nonkeratinized stratified squamous epithelium and underlying lamina propria. In premenopausal women, this lining is thrown into
numerous thin transverse ridges, known as rugae, which line the anterior and posterior vaginal walls along their length. Deep to this, a muscular layer contains
smooth muscle, collagen, and elastin. Beneath this muscularis lies an adventitial layer consisting of collagen and elastin (Weber, 1997).
The vagina lacks glands. Instead, it is lubricated by a transudate that originates from the vaginal subepithelial capillary plexus and crosses the permeable epithelium
(Kim, 2011). Due to increased vascularity during pregnancy, vaginal secretions are notably increased. At times, this may be confused with amnionic fluid leakage, and
clinical di erentiation of these two is described in Chapter 22 (Identification of Labor).
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A er birth-related epithelial trauma and healing, fragments of stratified epithelium occasionally are embedded beneath the vaginal surface. Similar to its native
tissue, this buried epithelium continues to shed degenerated cells and keratin. As a result, epidermal inclusion cysts, which are filled with keratin debris, may form.
These are a common vaginal cyst.
The vagina has an abundant vascular supply. The proximal portion is supplied by the cervical branch of the uterine artery and by the vaginal artery. The latter may
variably arise from the uterine or inferior vesical artery or directly from the internal iliac artery. The middle rectal artery contributes supply to the posterior vaginal
wall, whereas the distal walls receive contributions from the internal pudendal artery. At each level, vessels supplying each side of the vagina course medially across
the anterior or posterior vaginal wall and form midline anastomoses.
An extensive venous plexus also surrounds the vagina and follows the course of the arteries. Lymphatics from the lower third, along with those of the vulva, drain
primarily into the inguinal lymph nodes. Those from the middle third drain into the internal iliac nodes, and those from the upper third drain into the external,
internal, and common iliac nodes.
Perineum
This diamond-shaped area between the thighs has boundaries that mirror those of the bony pelvic outlet: the pubic symphysis anteriorly, ischiopubic rami and
ischial tuberosities anterolaterally, sacrotuberous ligaments posterolaterally, and coccyx posteriorly. An arbitrary line joining the ischial tuberosities divides the
perineum into an anterior triangle, also called the urogenital triangle, and a posterior triangle, termed the anal triangle.
The perineal body is a fibromuscular pyramidal mass found in the midline at the junction between these anterior and posterior triangles (Fig. 2-5). Also called the
central tendon of the perineum, the perineal body sonographically measures 8 mm tall and 14 mm wide and thick (Santoro, 2016). It serves as the junction for
several structures and provides significant perineal support (Shafik, 2007). Superficially, the bulbospongiosus, superficial transverse perineal, and external anal
sphincter muscles converge on the perineal body. More deeply, the perineal membrane, portions of the pubococcygeus muscle, and internal anal sphincter
contribute (Larson, 2010). The perineal body is incised by an episiotomy incision and is torn with second-, third-, and fourth-degree lacerations.
FIGURE 2-5
Superficial space of the anterior perineal triangle and posterior perineal triangle. Structures on the le side of the image can be seen a er removal of Colles fascia.
Those on the right side are noted a er removal of the superficial muscles of the anterior triangle. (Modified with permission from Corton MM: Anatomy. In Ho man
BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New York, McGraw-Hill Education, 2016.)
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Superficial Space of the Anterior Triangle

This triangle is bounded by the pubic rami superiorly, the ischial tuberosities laterally, and the superficial transverse perineal muscles posteriorly. It is divided into
superficial and deep spaces by the perineal membrane. This membranous partition is a dense fibrous sheet that was previously known as the inferior fascia of the
urogenital diaphragm. The perineal membrane attaches laterally to the ischiopubic rami, medially to the distal third of the urethra and vagina, posteriorly to the
perineal body, and anteriorly to the arcuate ligament of the pubis (see Fig. 2-5).
The superficial space of the anterior triangle is bounded deeply by the perineal membrane and superficially by Colles fascia. As noted earlier, Colles fascia is the
continuation of Scarpa fascia onto the perineum. On the perineum, Colles fascia securely attaches laterally to the pubic rami and fascia lata of the thigh, inferiorly to
the superficial transverse perineal muscle and inferior border of the perineal membrane, and medially to the urethra, clitoris, and vagina. As such, the superficial
space of the anterior triangle is a relatively closed compartment.
This superficial pouch contains several important structures, which include the Bartholin glands, vestibular bulbs, clitoral body and crura, branches of the pudendal
vessels and nerve, and the ischiocavernosus, bulbospongiosus, and superficial transverse perineal muscles. Of these muscles, the ischiocavernosus muscles each
attach on their respective side to the medial aspect of the ischial tuberosity inferiorly and the ischiopubic ramus laterally. Anteriorly, each attaches to a clitoral crus
and may help maintain clitoral erection by compressing the crus to obstruct venous drainage. The bilateral bulbospongiosus muscles overlie the vestibular bulbs
and Bartholin glands. They attach to the body of the clitoris anteriorly and the perineal body posteriorly. The muscles constrict the vaginal lumen and aid release of
secretions from the Bartholin glands. They also may contribute to clitoral erection by compressing the deep dorsal vein of the clitoris. The bulbospongiosus and
ischiocavernosus muscles also pull the clitoris downward. Last, the superficial transverse perineal muscles are narrow strips that attach to the ischial tuberosities
laterally and the perineal body medially. They may be attenuated or even absent, but when present, they contribute to the perineal body (Corton, 2016).
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The vestibular bulbs are almond-shaped aggregations of veins that lie beneath the bulbospongiosus muscle on either side of the vestibule. They measure 3 to 4 cm
long, 1 to 2 cm wide, and 0.5 to 1 cm thick. The bulbs terminate inferiorly at approximately the middle of the vaginal opening and extend upward toward the clitoris.
Their anterior extensions merge in the midline, below the clitoral body. During childbirth, veins in the vestibular bulbs may be lacerated or even rupture to create a
vulvar hematoma enclosed within the superficial space of the anterior triangle (Fig. 41-11).
Deep Space of the Anterior Triangle

This space lies deep to the perineal membrane and extends up into the pelvis (Mirilas, 2004). In contrast to the superficial perineal space, the deep space is
continuous superiorly with the pelvic cavity (Corton, 2005). It contains portions of urethra and vagina, certain portions of internal pudendal artery branches, and
muscles of the striated urogenital sphincter complex (Fig. 2-6).
FIGURE 2-6
Deep space of anterior triangle of the perineum. Structures on the right side of the image can be seen a er removal of the perineal membrane. Also shown are
structures that attach to the perineal body: bulbospongiosus, superficial transverse perineal, external anal sphincter, and puboperinealis muscles as well as perineal
membrane. (Reproduced with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New York,
McGraw-Hill Education, 2016.)
Urethra
The female urethra measures 3 to 4 cm and originates within the bladder trigone (Ovaries). The distal two thirds of the urethra are fused with the anterior vaginal
wall. The epithelial lining of the urethra changes from transitional epithelium proximally to nonkeratinized stratified squamous epithelium distally. The walls of the
urethra consist of two layers of smooth muscle, an inner longitudinal and an outer circular. This is in turn surrounded by a circular layer of skeletal muscle referred to
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as the sphincter urethrae or rhabdosphincter (see Fig. 2-6). Approximately at the junction of the middle and lower third of the urethra, and just above or deep to the
perineal membrane, two strap skeletal muscles called the urethrovaginal sphincter and compressor urethrae are found. Together with the sphincter urethrae, these
constitute the striated urogenital sphincter complex. This complex supplies constant tonus and provides emergency reflex contraction to sustain continence.
Distal to the level of the perineal membrane, the walls of the urethra consist of fibrous tissue, serving as the nozzle that directs the urine stream. Here, the urethra
has a prominent submucosal layer that is lined by hormonally sensitive stratified squamous epithelium. Within the submucosal layer on the dorsal (vaginal) surface
of the urethra lie the paraurethral glands, described earlier (Vagina and Hymen).
The urethra receives its blood supply from branches of the inferior vesical, vaginal, or internal pudendal arteries. Although still controversial, the pudendal nerve is
believed to innervate the most distal part of the striated urogenital sphincter complex. Somatic e erent branches from S2–S4 that course along the inferior
hypogastric plexus variably innervate the sphincter urethrae.
Pelvic Diaphragm
Found deep to the anterior and posterior triangles, this broad muscular sling provides substantial support to the pelvic viscera. The pelvic diaphragm is composed of
the levator ani and the coccygeus muscles. The levator ani, in turn, contains the pubococcygeus, puborectalis, and iliococcygeus muscles. The pubococcygeus
muscle is also termed the pubovisceral muscle and is subdivided based on points of insertion and function. These include the pubovaginalis, puboperinealis, and
puboanalis muscles, which insert into the vagina, perineal body, and anus, respectively (Kearney, 2004).
Vaginal birth conveys significant risk for damage to the levator ani or to its innervation (DeLancey, 2003; Weidner, 2006). Evidence supports that levator ani avulsion
may predispose women to greater risk of pelvic organ prolapse (Dietz, 2008; Schwertner-Tiepelmann, 2012). For this reason, current research e orts are aimed at
minimizing these injuries.
Posterior Triangle
This triangle contains the ischioanal fossae, anal canal, and anal sphincter complex, which consists of the internal anal sphincter, external anal sphincter, and
puborectalis muscle. Branches of the pudendal nerve and internal pudendal vessels are also found within this triangle.
Ischioanal Fossae
Also known as ischiorectal fossae, these two fat-filled wedge-shaped spaces are found on either side of the anal canal and comprise the bulk of the posterior triangle
(Fig. 2-7). Each fossa has skin as its superficial base, whereas its deep apex is formed by the junction of the levator ani and obturator internus muscles. Other borders
include: laterally, the obturator internus muscle fascia and ischial tuberosity; inferomedially, the anal canal and sphincter complex; superomedially, the inferior
fascia of the downwardly sloping levator ani; posteriorly, the gluteus maximus muscle and sacrotuberous ligament; and anteriorly, the inferior border of the anterior
triangle.
FIGURE 2-7
Anal canal and ischioanal fossa. (Reproduced with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology,
3rd ed. New York, McGraw-Hill Education, 2016.)
4/11/2018
The fat found within each fossa provides support to surrounding organs yet allows rectal distention during defecation and vaginal stretching during delivery.
Clinically, injury to vessels in the posterior triangle can lead to hematoma formation in the ischioanal fossa, and the potential for large accumulation in these easily
distensible spaces. Moreover, the two fossae communicate dorsally, behind the anal canal. This can be especially important because an episiotomy infection or
hematoma may extend from one fossa into the other.
Anal Canal
This distal continuation of the rectum begins at the level of levator ani attachment to the rectum and ends at the anal skin. Along this 4- to 5-cm length, the mucosa
consists of columnar epithelium in the uppermost portion. However, at the pectinate line, also termed dentate line, simple stratified squamous epithelium begins
and continues to the anal verge. At the verge, keratin and skin adnexa join the squamous epithelium.
The anal canal has several tissue layers (see Fig. 2-7). Inner layers include the anal mucosa, the internal anal sphincter, and an intersphincteric space that contains
continuation of the rectum’s longitudinal smooth muscle layer. An outer layer contains the puborectalis muscle as its cephalad component and the external anal
sphincter caudally.
Within the anal canal, three highly vascularized submucosal arteriovenous plexuses, termed anal cushions, aid complete closure of the canal and fecal continence
when apposed. Increasing uterine size, excessive straining, and hard stool create increased pressure that ultimately leads to degeneration and subsequent laxity of
the cushion’s supportive connective tissue base. These cushions then protrude into and downward through the anal canal. This leads to venous engorgement within
the cushions—now termed hemorrhoids. Venous stasis results in inflammation, erosion of the cushion’s epithelium, and then bleeding.
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External hemorrhoids are those that arise distal to the pectinate line. They are covered by stratified squamous epithelium and receive sensory innervation from the
inferior rectal nerve. Accordingly, pain and a palpable mass are typical complaints. Following resolution, a hemorrhoidal tag may remain and is composed of
redundant anal skin and fibrotic tissue. In contrast, internal hemorrhoids are those that form above the pectinate line and are covered by insensitive anorectal
mucosa. These may prolapse or bleed but rarely become painful unless they undergo thrombosis or necrosis.
Anal Sphincter Complex

Two sphincters surround the anal canal to provide fecal continence—the external and internal anal sphincters. Both lie near the vagina and may be torn during
vaginal delivery. The internal anal sphincter (IAS) is a distal continuation of the rectal circular smooth muscle layer. It receives predominantly parasympathetic fibers,
which pass through the pelvic splanchnic nerves. Along its length, this sphincter is supplied by the superior, middle, and inferior rectal arteries. The IAS contributes
the bulk of anal canal resting pressure for fecal continence and relaxes prior to defecation. The IAS measures 3 to 4 cm in length, and at its distal margin, it overlaps
the external sphincter for 1 to 2 cm (DeLancey, 1997). The distal site at which this overlap ends, called the intersphincteric groove, is palpable on digital examination.
In contrast, the external anal sphincter (EAS) is a striated muscle ring that anteriorly attaches to the perineal body and posteriorly connects to the coccyx via the
anococcygeal ligament. The EAS maintains a constant resting contraction to aid continence, provides additional squeeze pressure when continence is threatened,
yet relaxes for defecation. The external sphincter receives blood supply from the inferior rectal artery, which is a branch of the internal pudendal artery. Somatic
motor fibers from the inferior rectal branch of the pudendal nerve supply innervation. Clinically, the IAS and EAS may be involved in third- and fourth-degree
lacerations during vaginal delivery, and reunion of these rings is integral to defect repair (Chap. 27, Laceration and Episiotomy Repairs).
Pudendal Nerve
This is formed from the anterior rami of S2–4 spinal nerves. It courses between the piriformis and coccygeus muscles and exits through the greater sciatic foramen at
a location posterior to the sacrospinous ligament and just medial to the ischial spine (Barber, 2002; Maldonado, 2015). Thus, when injecting local anesthetic for a
pudendal nerve block, the ischial spine serves an identifiable landmark (Chap. 25, Central Nervous System Toxicity). The pudendal nerve then runs beneath the
sacrospinous ligament and above the sacrotuberous ligament as it reenters the lesser sciatic foramen to course along the obturator internus muscle. Atop this
muscle, the nerve lies within the pudendal canal, also known as Alcock canal, which is formed by splitting of the obturator internus investing fascia (Shafik, 1999). In
general, the pudendal nerve is relatively fixed as it courses behind the sacrospinous ligament and within the pudendal canal. Accordingly, it may be at risk of stretch
injury during downward displacement of the pelvic floor during childbirth (Lien, 2005).
The pudendal nerve leaves this canal to enter the perineum and divides into three terminal branches (Fig. 2-8). The first of these, the dorsal nerve of the clitoris, runs
between the ischiocavernosus muscle and perineal membrane to supply the clitoral glans (Ginger, 2011b). Second, the perineal nerve runs superficial to the perineal
membrane (Montoya, 2011). It divides into posterior labial branches and muscular branches, which serve the labial skin and the anterior perineal triangle muscles,
respectively. Last, the inferior rectal branch runs through the ischioanal fossa to supply the external anal sphincter, the anal mucosa, and the perianal skin
(Mahakkanukrauh, 2005). The major blood supply to the perineum is via the internal pudendal artery, and its branches mirror the divisions of the pudendal nerve.
FIGURE 2-8
Pudendal nerve and vessels. (Reproduced with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd
ed. New York, McGraw-Hill Education, 2016.)
4/11/2018
INTERNAL GENERATIVE ORGANS

Uterus
The nonpregnant uterus lies in the pelvic cavity between the bladder anteriorly and the rectum posteriorly. Almost the entire posterior wall of the uterus is covered
by serosa, that is, visceral peritoneum (Fig. 2-9). The lower portion of this peritoneum forms the anterior boundary of the rectouterine cul-de-sac, or pouch of
Douglas. Only the upper portion of the anterior uterine wall is covered by visceral peritoneum. At the caudal border of this portion, the peritoneum reflects forward
onto the bladder dome to create the vesicouterine pouch. As a result, the lower portion of the anterior uterine wall is separated from the posterior wall of the
bladder only by a well-defined loose connective tissue layer—the vesicouterine space. Clinically, during cesarean delivery, the peritoneum of the vesicouterine pouch
is sharply incised, and the vesicouterine space is entered. Dissection caudally within this space li s the bladder safely o the lower uterine segment for hysterotomy
and delivery (Chap. 30, Hysterotomy).
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FIGURE 2-9
Anterior (A), right lateral (B), and posterior (C) views of the uterus of an adult woman. a = oviduct; b = round ligament; c = ovarian ligament; Ur = ureter.
The uterus is pear shaped and consists of two major but unequal parts. The upper, larger portion is the body or corpus, whereas the lower smaller cervix projects into
the vagina. The isthmus is the union site of these two. It is of special obstetrical significance because it forms the lower uterine segment during pregnancy. At each
superolateral margin of the body is a uterine cornu, from which a fallopian tube emerges. This area also contains the origins of the round and ovarian ligaments.
Between the points of fallopian tube insertion is the convex upper uterine segment termed the fundus.
The bulk of the uterine body, but not the cervix, is muscle. The inner surfaces of the anterior and posterior walls lie almost in contact, and the cavity between these
walls forms a mere slit. The nulligravid uterus measures 6 to 8 cm in length compared with 9 to 10 cm in multiparas. The uterus averages 60 g and typically weighs
more in parous women (Langlois, 1970; Sheikhazadi, 2010).
Pregnancy stimulates remarkable uterine growth due to muscle fiber hypertrophy. The uterine fundus, a previously flattened convexity between tubal insertions,
now becomes dome shaped. Moreover, the round ligaments appear to insert at the junction of the middle and upper thirds of the organ. The fallopian tubes
elongate, but the ovaries grossly appear unchanged.
Cervix
This portion of the uterus is cylindrical and has small apertures at each end—the internal and external cervical ora. The endocervical canal runs through the cervix
and connects these ora. The cervix is divided into upper and lower portions by the vagina’s attachment to its outer surface. The upper portion—the portio
supravaginalis—begins at the internal os, which corresponds to the level at which the peritoneum is reflected up onto the bladder (Fig. 2-10). The lower cervical
portion protrudes into the vagina as the portio vaginalis.
FIGURE 2-10
Uterus, adnexa, and associated anatomy. (Reproduced with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams
Gynecology, 3rd ed. New York, McGraw-Hill Education, 2016.)
4/11/2018
Before childbirth, the external cervical os is a small, regular, oval opening. A er labor, especially vaginal childbirth, the orifice is converted into a transverse slit that is
divided such that there are the so-called anterior and posterior cervical lips. If torn deeply during labor or delivery, the cervix may heal in such a manner that it
appears irregular, nodular, or stellate (Fig. 36-1).
The cervical surface that radially surrounds the external os is called the ectocervix and is lined predominantly by nonkeratinized stratified squamous epithelium. In
contrast, the endocervical canal is covered by a single layer of mucin-secreting columnar epithelium, which creates deep cle like infoldings or “glands.” Commonly
during pregnancy, the endocervical epithelium moves out and onto the ectocervix in a physiological process termed eversion (Chap. 4, Cervix).
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The cervical stroma is composed mainly of collagen, elastin, and proteoglycans, but very little smooth muscle. As described in Chapter 21 (Cervical Ripening),
changes in the amount, composition, and orientation of these components lead to cervical ripening prior to labor onset. In early pregnancy, increased vascularity
within the cervix stroma beneath the epithelium creates an ectocervical blue tint that is characteristic of Chadwick sign. Cervical edema leads to so ening—Goodell
sign, whereas isthmic so ening is Hegar sign.
Myometrium and Endometrium

Most of the uterus is composed of myometrium, which contains smooth muscle bundles united by connective tissue with many elastic fibers. Interlacing myometrial
fibers surround myometrial vessels and contract to compress these. This anatomy allows hemostasis at the placental site during the third stage of labor.
The number of myometrial muscle fibers varies by location (Schwalm, 1966). Levels progressively diminish caudally such that, in the cervix, muscle makes up only 10
percent of the tissue mass. The uterine body’s inner wall has relatively more muscle than its outer layers. And, in the anterior and posterior walls, the muscle content
is greater than in the lateral walls. During pregnancy, the upper myometrium undergoes marked hypertrophy, but cervical muscle content does not change
significantly.
The uterine cavity is lined with endometrium, which is composed of an overlying epithelium, invaginating glands, and a supportive, vascular stroma. As discussed in
Chapter 5 (Estrogen and Progesterone Action), the endometrium varies greatly throughout the menstrual cycle. This layer is divided into a functionalis layer, which is
sloughed with menses, and a basalis layer, which serves to regenerate the functionalis layer following each menses. During pregnancy, the endometrium is termed
decidua and undergoes dramatic hormonally driven alterations.
Ligaments
Several ligaments extend from the uterine surface toward the pelvic sidewalls and include the round, broad, cardinal, and uterosacral ligaments (Figs. 2-10 and 2-11).
Despite their appellation, the round and broad ligaments provide no substantial uterine support, which contrasts with the cardinal and uterosacral ligaments.
FIGURE 2-11
Pelvic viscera and their connective tissue support. (Reproduced with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds):
Williams Gynecology, 3rd ed. New York, McGraw-Hill Education, 2016.)
4/11/2018
The round ligament originates somewhat below and anterior to the origin of the fallopian tubes. Clinically, this orientation can aid fallopian tube identification
during puerperal sterilization. This is important if pelvic adhesions limit tubal mobility and thus, hinder fimbria visualization and tubal confirmation prior to ligation.
Each round ligament extends laterally and down into the inguinal canal, through which it passes, to terminate in the upper portion of the ipsilateral labium majus.
Sampson artery, a branch of the uterine artery, runs within this ligament. In nonpregnant women, the round ligament varies from 3 to 5 mm in diameter and is
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that Hervey’s precipitate arrival had scattered on the floor.
“I went kerflop, hey?”
“You certainly did,” said the young man.
Since Hervey was in the seat he remained there a few minutes.
“Oh, bambino, you’re a lucky guy!” he said, noticing the pasters on
the stranger’s suitcase. “That’s where I’m going all right.” This was
true only in the sense that Hervey intended to go everywhere. He
had never planned to favor Montana at the expense of other states.
“I hope you won’t arrive there so roughly,” said the young man.
The word roughly caught Hervey and he glanced sideways at the
young man rather more interestedly than he usually did at chance
acquaintances. For indeed all people were pretty much the same to
Hervey. What he saw was a young fellow of perhaps twenty who
gave the impression of being so correct in his deportment that his
sudden discomforture made him look ridiculous. He was so utterly
out of the spirit of Hervey’s prank! Fate had certainly brought
together an all-assorted pair. He was an oldish young fellow, a
perfect gentleman assuredly; too nearly perfect for his age.
“Did you lasso any ponies out there?” Hervey demanded briskly,
as if these exploits were Montana’s single claim to importance.
“I don’t think I even saw any,” said the young man.
“Didn’t even see any? They’ve got train robbers.”
“Well, I couldn’t exactly deny that.”
“Were you running away from home?” Hervey asked, in his rapid
fire fashion.
“I was attending a musical convention,” said the young fellow.
“Oh, music. Can you play the harmonica?”
“I never tried.”
“Bet your life I’m going to Montana; yop, soon as I get the price.
And believe me, I know where I’m going to get it.”
“You seem to be sure of everything,” said the stranger.
“I’m going to collop it,” said Hervey.
“That might be interesting if I knew what it meant,” his companion
observed.
“You don’t know what collop means?”
“I must confess I don’t.”
“Good night!” ejaculated Hervey. “You know what bandits are,
don’t you?”
“You mean to be a bandit?”
“Jiminetty, they’re not so bad. Look at Robin Hood; don’t they write
poems and operas about him and everything? You’re supposed to
know all about music, gee williger!”
This deft reasoning which seemed in a way to place music lovers
in the category with outlaws did reach the young fellow’s limited
sense of humor and he smiled. “Well, you’re certainly a queer
youngster,” said he.
Pity the boy of twenty who calls another boy a youngster!
“How much do I have to have to go to Montana?” Hervey
demanded.
“Well, you have to have considerable.”
“A hundred bucks?”
“At least.”
“That’s me, all right,” said Hervey.
It was characteristic of him that his resolution to go to Montana
had originated at the moment of his noticing the stranger’s suitcase.
It was also characteristic of him to say that he knew how he was to
obtain the money to go there, when in fact he had no such
knowledge. Yet it was not exactly an untruth since he had many
singular plans for earning money. Did not he intend to join a circus?
Moreover, it was characteristic of him that he did not linger in the
seat. Soon the train entered another curve and that was his cue to
depart almost as unceremoniously as he had arrived, leaving the
strange young fellow staring after him rather curiously.
Hervey’s second attempt was no more successful than his first.
He would not check his staggering progress by using his hands
because of a rhymed couplet which was part of his creed:
Try a stunt and make a rule,
Break it and you’re one big fool.
Again he went sprawling, this time upon the lap of a kindly old
gentleman, who smiled upon him and made a place for him on the
seat.
“Maybe you think that’s easy,” said Hervey.
CHAPTER V
CHANCE ACQUAINTANCE
When Hervey told the councilor at Temple Camp that he had a
stepfather, he told something less than the whole story. He had both
a stepfather and a stepmother. His father had died when he was very
young and his mother had married a man named Walton who had
been not only a good guardian but a very patient guardian to Hervey.
Then, when he was old enough to feel a bereavement more keenly
his mother had died, and after several years his stepfather had taken
a second wife who had always been an affectionate stepmother to
the twice orphaned boy.
So here was the odd situation of a boy living in the home of his
childhood in the care of two people who were in no way related to
him. It was characteristic of Hervey to get into odd situations and
predicaments, and perhaps this position which he occupied in his
own home in a fashion symbolized the position which he occupied in
scouting and among boys generally. It was a position hard to
duplicate, just as all of his stunts and resultant predicaments would
have been hard to duplicate. He stood alone, or hung by his feet
alone, or stood on his head. He was different, and everything about
him was different. Of course, he did not regard having two step-
parents as a stunt. But, you see, even in this he went a little further
than most boys. He could handle two step-parents as easily as one,
and he went upon his way rejoicing.
No sentimental pity for Hervey is justified by this step-parent
condition in his colorful career. The worst that can be said of Mr. and
Mrs. Walton is that they did not understand him. But then no one
understood him. He, on his part, accepted them as he accepted
everything. He had nothing against them; he had nothing against
anybody. Scout rules, wandering pedlers, railroad conductors,
scoutmasters, school principals, tramps, carnival actors, step-
parents, were all the same to Hervey. He leaned a little toward
carnival actors.
I have sometimes wondered whether he ever had any wistful
thoughts of his own mother so lately gone from him. And what his
story might have been if she had been spared. If he was capable of
deep sentiment we shall have to find that in this narrative. He was
certainly blithesome and content at this point of taking up the trail of
his aimless and adventurous progress. Like the miller of Dee in the
nursery rhyme, “he cared for nobody, no not he.” But he was
incapable of malice. Perhaps that was the keynote of his nature. And
it was not a bad keynote.
It was to this home, a pretty little house in Farrelton in the
Berkshires, that Hervey returned after his summer at Temple Camp.
And he overlooked the trifling matter of reporting that he had been
dismissed and forbidden ever to return to those scenes of his roving
freedom.
Hervey was akin to those boys who point a suggestive finger in
the direction an automobile is going in the hope of getting a lift. But
his method was far better than that of most boys. It had an original
quality all his own which motorists found it hard to resist.
He would saunter diagonally across the road with a nonchalant air
of preoccupation the while tossing a ball into the air. This he would
dextrously cause to drop into the car which he had designs on. His
preoccupied manner of crossing usually had the effect of slowing up
the car. The truant ball gave him the opportunity to request its return.
For the rest he depended on his personality to get a ride. He figured
that if he could bring a passing auto to a halt the rest would be easy,
as it usually proved to be.
As he emerged from the railroad station on the day of his return,
he espied a Ford touring car starting off. He had not his trusty rubber
ball with him so he was forced to make the usual direct request.
Perhaps his rather cumbersome suitcase won him favor from the
somewhat hard looking young man who drove the car.
This young man did not look like the sort who think too seriously
about good turns. He was poorly dressed and wore a cap at that
villainous angle affected only by young men of the strong-arm
persuasion. He had also (what seemed to harmonize with his cap) a
livid scar on his cheek, and he sat in that sophisticated sideways
posture at the wheel which suggested the taxi chauffeur.
“You going up Main Street?” Hervey queried, as he took his seat
beside the stranger. “I’m going as far as Hart Street.”
“I got yer,” said the young man accommodatingly. “Yer one er dem
boy scouts?”
“Scout in looks only,” said Hervey laconically, alluding to his khaki
attire.
“Youse guys is a lot of false alarms,” said the driver. “What can
yez do?”
“Give me a dare,” said Hervey.
“Sure, I’ll give yer a dare.”
“Just give me one and I’ll show you,” said Hervey.
His rather bizarre challenge caused the stranger, whose remarks
had been altogether casual, to glance sideways at him rather
curiously.
“You just give me a dare, that’s all,” said Hervey complacently.
It seemed as if the young man’s mood of banter had changed to
one of inquiring interest. His criticism had been surly, but not serious;
now suddenly, he flattered Hervey by a kind of lowering inspection.
“Sure, I’ll give yer one,” said he; “only yer mother don’t leave yer
out nights.”
“Oh, don’t she,” Hervey sneered. “You just give me a dare—you
just give me one. I refused to take dares from people that wouldn’t
even ride in a Ford, I did.”
Still the young fellow scrutinized him. “Yare?” he queried cynically.
“Sure I did; I called a bluff from a cowboy and I chucked his dare
in his face.”
“Get out.”
“You just give me one and see,” said Hervey.
“Well, if yer mother will leave yer out,” said the young man, “you
meet me in the parking space in back of the post office at ten o’clock
to-night and I’ll give yer a dare all right; I’ll give yer a good one. I’ll
show yer you’re a flat tire.”
“You call me a flat tire?”
“Sure, you’re a blowout—all noise and no action.”
This was too much for Hervey. He forgot that this was the evening
of his welcome home. He forgot that he had ever been to Temple
Camp or that this tough young stranger meant nothing to him. He
never approached toward acquaintanceship by the usual slow
process. And his sense of discrimination was conspicuous by its
absence.
“I’ll be there all right, you leave it to me,” he said.
“Ten bells,” said the tough young fellow.
“You leave it to me,” said Hervey.
CHAPTER VI
THE INSPIRED DARE
That was Hervey Willetts all over, to make a ridiculous
appointment with a stranger before he had so much as greeted his
step-parents. And for such a purpose! Truly, he was hopeless.
The house in which he lived and in which he had been born was a
plain house, immaculately white, with well kept grounds about it. It
was a typical New England place; old-fashioned, a model of order
inside and out, eloquent of simplicity and unostentatious prosperity.
Mr. Walton owned a large stationery store on the main street and
his quiet, uneventful life was spent between this peak-roofed, white
and green homestead and his attractive store which was a medley of
books, post cards, pennants, Indian souvenirs and stationery. Mrs.
Walton was not above waiting on customers in her husband’s store,
especially in the season when Farrelton was overrun with “summer
folks.”
On this momentous evening, the returning prodigal found his step-
parents at home and he received an affectionate greeting. The
occasion would have been favorable for telling about the ultimatum
he had received at camp, but he did not do it. Next summer seemed
such a long time off! Why worry about next summer when he had an
appointment to “throw down” a dare that very night?
“Well, Hervey,” said Mr. Walton, “we’re glad you had a good
summer. You didn’t write often, but I always told Mum that no news is
good news. And here you are safe and sound.
“And as brown as a mulatto,” said Mrs. Walton, drawing him to her
and caressing him affectionately.
“Now for school, hey?” said Mr. Walton pleasantly. “Next summer,
or maybe the summer after that, Mum and I are going to have a
jaunt, maybe. Will you let us go, Herve?”
“Sure thing, go as far as you like with me,” said Hervey.
Mrs. Walton laughed, and drawing him close again, caressed him
fondly. “Well, that’s a long way off,” said she. “Maybe you’ll be
entering Harvard by then; we’re such slow pokes, dad and I. We’ll
probably end by not going at all. Europe seems so terribly far.”
“Europe is nothing,” said Hervey. “I’m going to Montana.”
“Well, first you’re going to school,” laughed Mr. Walton.
“Pity the poor school,” said Hervey.
“Oh, not as bad as that,” his stepfather commented pleasantly. “I
kind of think you’re going to be different this fall. Not get into any
scrapes, huh? Study hard, stay in the Scouts, and not give your
mother any worries. What do you say?”
“You know me, Al,” said Hervey, which reply was not altogether
explicit or satisfactory. But it moved Mrs. Walton to embrace him
again.
“And you’re going to stay in the Scouts, aren’t you?” she asked.
“Of course he is,” said Mr. Walton. “They weren’t all as lucky as
you, Hervey, to be up at a fine camp all summer. I saw Bert Alston
yesterday. He was asking when you were coming back. I told him we
wouldn’t know till we saw you.”
“That’s me,” said Hervey. “I’ve got nothing against the Scouts.”
“Well then, I hope you’ll stay more among them,” said Mr. Walton.
“They’re a good sort.”
“They don’t stay among me very much,” said Hervey. “What’s fair
for one is fair for the other.”
Mr. and Mrs. Walton glanced at each other laughing.
“Well, of course the scouts didn’t join you; you joined them,” said
Mr. Walton. “You put the cart before the horse, so to speak.”
“Oh bimbo, there’s one horse up there I’d like to ride,” said
Hervey. “That’s what I want to do, ride a horse.”
During the evening, he strolled out to “see if any fellers were
around,” as he said, and at ten o’clock he wandered into the public
parking field behind the post office. He did not more than half expect
to find his chance acquaintance there, but he was not going to be a
quitter in this sacred matter of not taking dares. In these matters, at
least, he was a model of honor and punctiliousness.
There were but a few cars parked in the dark field. Entrance to
this convenient, though poorly patronized place was from Main
Street and motorists were required to make their exit through a lane
which led out between buildings into Piper Street. Here, almost
directly opposite the exit, was the Farrelton Fire House.
Hervey found his outlandish friend sitting on a fence which
bordered the lane. The stranger looked atrocious enough in the
darkness and even Hervey, who took everything as it came, was
momentarily conscious of the utter absurdity of this tryst. He would
go to any length to confound one who “gave him a dare.” But he had
never before gone to so much trouble to hear the dare pronounced.
And at such a time!
“Well, am I a flat tire?” he asked.
“Wait till I see how you roll,” said the challenger.
“I wouldn’t take a dare that I’d do something mean for anybody,”
said Hervey, “or like if you wanted me to do an errand or something
like that —I wouldn’t call that a dare. It’s got to be a stunt.”
“Yer startin’ ter hedge?”
“No, I’m not starting to hedge, only it’s got to be a stunt. Suppose
you dared me to go and buy you a pack of cigarettes. Nothing doing,
I’m not so easy as that.”
“Suppose I dared yer to bust a winder.”
“Maybe that would be different,” said Hervey.
“Suppose I dared yer ter—ter—tie a tin can on one uv them cars.”
“Maybe that would be all right,” said Hervey.
“Yer ain’t such a bad kid. Suppose—no, gee, yer only a kid.”
“Go on, what is it?” Hervey urged.
“I dare yer ter—ter get a bottle and bust it up and throw it down in
front of one uv them cars—dat big Packard over dare.”
“No, sir, what’s the use of cutting somebody’s tire? Anybody could
do that. You call that a stunt?”
“Yer scared a gettin’ caught.”
“I’m not ascared of getting caught, but what’s the good cutting
somebody’s tire? Gee, he might be a nice feller, how do I know?”
“I dare yer ter go down ter New Street and—leave us see—I dare
yer ter go dare and ring de fire alarm box. Dare’s a hot one for yer.
All dem fire guys gits is a good run for nartin’. Give ’em somethin’ ter
keep ’em from fallin’ asleep. Dare’s a pippin’ fer yer—take it or leave
it. Put up or shut up. Baby, dare’s a knockout!”
Hervey did not know whether this was a “pippin’” or not. It
certainly appealed to him as a knockout. To him it seemed to contain
none of the ingredients of meanness. He had a system of moral
reasoning quite his own. He would not damage any one’s tire.
Breaking a window did not seem so bad. Sending in a false fire-
alarm was certainly an inspiration. Nobody’s property would be
damaged. There would just be a big rumpus over nothing. He had to
confess that it was the kind of a thing to be “dared” to do. It was
harmless, yet a thing that most boys would not risk. It seemed a
pretty good dare; a sudden inspiration of the stranger’s.
“You mean where the new houses are?” Hervey asked.
The tough young fellow stood pat upon his inspiration and did not
deign to discuss details. “Dare’s a hot tamale fer yer,” was all he
said.
“There’s fire boxes nearer than that,” said Hervey, flirting with the
idea.
“Yed hedgin’? Give ’em a good run. Dat’s some sizzlin’ tamale!”
It did seem a sizzling tamale.
“Come ahead,” said Hervey.
“Nah, wot’ll I come ahead fer?” said the stranger. His attitude
seemed to be that the genius of this enterprise, the originator of the
stunt and propounder of the inspired dare, should not go to any
trouble in the matter. “If yer pull it, I’ll be wise to it all right,” he said.
“Won’t I hear de fire whistle? I’ll be here when de big noise starts; I’ll
be hip to it, don’t never worry ’bout me.”
That was very true. The striking effect of Hervey’s stunt would be
visible and audible throughout the length and breadth of that small
town.
“I told you I wouldn’t take a dare from anybody, didn’t I?” he said.
“It’s up ter you,” said the genius of the big dare.
CHAPTER VII
GONE
The funny part of the whole business is this; that if Hervey had
hunted up Bert Alston that night, he might have gone trailing in the
woods north of Bridgeboro. He might have hunted for Skinny Grover
who had been appointed to hide and baffle his pursuers. And if he
had trailed Skinny Grover he would have been the one to find him.
There is not the slightest doubt of it. And it would have been a stunt.
A sizzling tamale, even. But you see no one dared him to do that.
As it was, he hastened up Main Street to Van Doran’s Lane and
through this till it petered out in the fields down by the river. Beyond
these fields was New Street, a straggling tentacle of road which
reached away from town in a sweeping curve, skirted the river for
half a mile or so, then ended abruptly.
It was toward the dead end of this detached street that Hervey
was taking a short-cut. The neighborhood looked remote enough
beyond the area of intervening meadows. First he could see only the
broken line of lights which identified the houses. Then, as he
approached nearer these houses emerged slowly out of the
darkness.
There was no sign or sound of life about as he entered the street
crossing the grounds between two cottages. Then a dog barked. It
was only a perfunctory bark and Hervey made his way up the street
till he came to a sturdy post surmounted by a fire-alarm box. It
marked the end of the postman’s route along this lonely street and
was decorated with a dozen or more unsightly mail boxes belonging
to the residents living beyond this point.
Glancing cautiously about as he advanced, Hervey crept up and
opened the little metal door of the fire box. The lights in a nearby
house went out. He heard the slamming of a door. He paused,
listening intently. Somewhere in the darkness nearby was a creaking
sound. Nothing but some rusty clothesline pulley probably, but it
made him hesitate. Suddenly, he gave the little metal handle a turn,
then ran pell-mell down into the fields. He had done it.
Yet nothing happened. He ran and ran. Then suddenly, he paused
in his steps as the deafening peal of the fire whistle smote his ears. It
shook the night with its ghoulish siren call. Its uncanny variations
filled the darkness with horror. And just because of the turning of a
little handle! It moaned and cried and seemed to be calling to the
dead to rise. Four slow, variated, suffering wails. Then a pause.
Then three long screams of anguish. Then silence. Forty-three. New
Street district.
The sound of the clamorous siren affected Hervey strangely, as if
a flood light had been thrown upon him. He stood in the dark field,
unable to budge. Then he got hold of himself and ran desperately.
As he glanced hurriedly back, he saw lights reappearing in the
houses where sleep had reigned. Then he heard in the distance the
piercing gong of the speeding engines. He could see the luminous
headlights advancing along the sweeping curve of that runaway
street. For just a moment they shimmered up the frog pool along the
distant road and, looking back, Hervey saw clearly the familiar little
spot with the willow tree overhanging it. Then he heard voices, thin
and spent in the distance.
He did not pause nor turn again, but ran with all his might and
main till he reached Main Street where he found it strangely difficult
to walk with a leisurely air of unconcern. A man whom he passed
turned and glanced at him and he was seized with a momentary
terror. He passed some boys running to the fire. He liked fires, real
fires, and in different circumstances it would have been his delight to
join them. He would have been able to sneak inside the fire lines and
have an advantage over other boys.
Even Hervey, who had no sense of values, was vaguely
conscious now of the lack of proportion in this whole affair. To do so
much at the idle behest of a dubious chance acquaintance! And to
what end? To prove what—and why? There was no rhyme nor
reason in the thing. Hervey was of course, incapable of formulating
these thoughts. The nearest he got was just to feel silly. He was not
naturally mischievous, much less vicious. But he could not take a
dare. Alas for all the fine spirit and energy that went to waste!
And here was the anti-climax of the whole crazy business. His
challenger was not waiting for him in the parking space. There was
no triumph, no “Well, what do you say now?” There was no gloating
over the humbled dare giver. He had gone away. Evidently he had
no sporting interest in the matter at all. Hervey had thought to give
the genius of the “hot tamale” a chance to purge his soul of shame
by letting him treat to ice cream sodas. But our hero was not
permitted flauntingly to enjoy his triumph. Therein lay the only “kick”
in the enterprise. It was reduced now to the level of a mischievous
prank. No achievement, no victory, no public recognition. No
recognition even from a young tough who meant just nothing at all in
Hervey’s young life.
Well, there you have Hervey Willetts.
CHAPTER VIII
SAFETY IN SILENCE
But there was a triumph, though it was not Hervey’s. The
daredevil had not even the doubtful glory suggested by that name.
He was just a dupe. The next afternoon the Farrelton Call bore the
following glaring headline on its usually modest front page:
DARING ROBBERY AT FIRE HOUSE
THIEVES BREAK INTO SAFE AND TAKE CARNIVAL
FUND AMOUNTING TO FOUR HUNDRED DOLLARS
False Fire-alarm Thought to Have Been Used
by Robbers. No Clew to Miscreants.
“Shortly after ten o’clock last night,” the article ran, “the
Farrelton Fire House was entered by one or more burglars who
forced the little, old-fashioned safe and stole a sum slightly less
than four hundred dollars. Most of this money constituted the
fund belonging partly to the exempt firemen’s organization and
partly to the active service men, and was intended to be used to
finance the Firemen’s Carnival to be held in Stebbin’s Field. No
one was in the fire-house when the robbery occurred.
“A few minutes after ten last night, an alarm was sent in from
the fire-box in the outlying section of town where New Street
was lately extended. It was a false alarm and there is no clew
which affords any hope of identifying the sender.
“It is thought by the police that the alarm may have been sent
by a confederate of the burglars in order to empty the fire-house
of its occupants at a particular time. If this was the case, it would
argue that the crime was executed by men familiar with facts
about the fire-house.
“Charlie Winthrop, driver of the engine, is on vacation and his
place is being filled by one of the other men, Fred Corway.
Corway, who was injured in the McElroy fire last year, usually
remains in the fire-house when an alarm is received.
“But last night, there being still another man absent because
of illness, Corway went out with the others. It is believed that the
robbery was planned by some one who knew that the fire
company was short-handed. The robbers may have sent in the
alarm in the hope of completely emptying the building, or at the
worst of having but one crippled occupant to deal with.
“The police are following up several rather unpromising clews
which they refuse to divulge. Chief Bordman persists in the
belief that the job was done by local talent and points to the fact
that very little money is kept in fire-houses and also that the
projected carnival is not known about outside of Farrelton.
“When seen this morning, County Detective Burr said, ‘It
looks to me like a home town affair. Burglars don’t ransack fire
headquarters, because there usually isn’t anything worth
stealing in such places. They must have known about this
money. And they probably had some hopes of clearing out the
place for a while with a false alarm. It looks to me as if they had
inside knowledge. They probably knew the safe was an out-of-
date affair, too. They had to work quick. And the quicker we
work clearing a lot of young loafers away from the neighborhood
of the fire-houses and other hang-out spots in this town, the
better it will be.’”
The same issue of the newspaper carried an editorial hurling

blame this way and that. The police should watch the lunch wagons
which were infested with young loungers. The fire-fighting contingent
was “disgracefully inadequate.” The remote end of New Street had
never been policed. And so on, and so on. Presumably the Farrelton
Call was the only thing properly conducted.
Hervey read this article with mounting interest—and agitation. His
blithesome, devil-may-care nature was for the first time surprised
into something like soberness, not to say apprehension. Spectacular
stunts and dares were all very well—except for the upkeep.
But the robbery, to which he seemed an accessory, did not entirely
obliterate another shock with which the gods had visited him. He had
intended to ask permission to dive from the top of the dizzy ladder
which would be held by sloping wires above a perilously small tank
of water at the carnival, and failing to obtain permission he had
intended to do it without permission. But now he could not do it. He
had knocked down the spectacular ladder on which he had intended
to climb up; for there probably would not be any carnival. Farrelton
had always been too tame for Hervey and now he had, it seemed,
killed the most promising diversion which the brief pre-school season
offered.
Of course, he had no intention of telling the authorities about his
encounter with the young fellow of the Ford car. He could not give
them a clew without incriminating himself. He made sure of this by
certain questions casually propounded to his stepfather that evening
at supper.
“Well, I hope they catch the whole crew of them,” said Mr. Walton.
“They’re potential murderers. If they had found the lame fireman
there they would have killed him if necessary. That kind stops at
nothing.”
“Mr. Tonelson who was here about the apples this afternoon thinks
there was only one man,” said Mrs. Walton. “And he thinks he was
an amateur.”
“There were two of them anyway,” said her husband. “There was
the one who sent in the alarm.”
Hervey, eating his dessert, was all ears. “Ringing an alarm box
isn’t—jiminies, a fellow that does that isn’t a criminal, is he?” he
ventured.
“He is if he’s working with a burglar,” said Mr. Walton. “He’s an
accessory. You know what that is, don’t you?”
“Like something you put on an automobile?” Hervey said.
Mr. and Mrs. Walton laughed heartily. “He’s a confederate,” said
Mr. Walton.
“Well, I certainly hope they’re caught and sent to jail,” said Mrs.
Walton, whose gentle voice and manner seemed to belie any unkind
thought, even toward robbers. “To think the carnival was to raise
money for the Children’s Home! It almost seems as if they had stolen
the money from little waifs and crippled children. Why, there are two
little blind tots in the Home.”
Hervey did not like the sound of that; it made him feel
uncomfortable, contemptible.
“They might better have turned over the four hundred dollars to
the Home,” said her practical husband.
“Oh, they didn’t know,” said Mrs. Walton. “But it’s unspeakable.”
“You never loiter around with any of that crowd down at Huyler’s
or the lunch wagon, do you, Herve?” Mr. Walton asked suddenly.
“Such a question!” his wife exclaimed in surprised reproof.
“Well, I’m glad he doesn’t.”
“Of course, he doesn’t,” said Mrs. Walton.
“Anyway,” said Hervey, feeling very uncomfortable, and fearful lest
he say too much, “I don’t see how a fel—a man that sends a false
alarm is a—like a murderer. How do they know the burglar had
anything to do with that?”
“Yes, how do they know that?” queried Mrs. Walton as a sort of
affectionate compliment to Hervey’s reasoning.
“Well,” said Mr. Walton, “they put two and two together. I guess
they know their business. I didn’t say a man who sends in a false
alarm is a murderer—necessarily. Considered by itself it’s just
malicious mischief. I suppose it’s a misdemeanor, if you want to be
technical about it,” he added.
“I bet you couldn’t go to jail for it,” Hervey ventured cautiously.
“I bet you could,” said Mr. Walton.
Of course, Hervey knew that what he had done was
reprehensible. He had not thought of it in that light, for that was just
Hervey, but in the light of the robbery, he thought about it a good
deal. He had put out this feeler to his stepfather in order to get Mr.
Walton’s reaction.
He was not afraid that he would be implicated in the robbery,
though he felt mean to think that he had been an innocent participant
in an affair which his mother had branded as contemptible and
unspeakable. Mrs. Walton did not ordinarily use those terms. It
seemed to Hervey that she had called him contemptible and
unspeakable. And he knew he was not that.
He had thought that if he could ascertain with certainty that his
“stunt” was quite innocent, he might tell the authorities or Mr. Walton
about his encounter with the young tough. But if he had been guilty
of malicious mischief (appalling phrase) and could go to jail for it,
why then he had better hold his peace. Here again fate baffled him
for he would have relished an opportunity to track a real robber. But,
he reassured himself, he was not concealing facts about the robbery.
He was just concealing the little episode of his stunt.
If you call it a stunt....
CHAPTER IX
STRANDED
Before the meal was over Mr. Walton swept aside the whole
subject and in pleasant contrast to those sorry matters observed
cheerily, “I hope you’re going to stick with the Scouts, Herve. They
represent about the best we’ve got in boys in this town. That
Burroughs chap was in the store to-day wanting a jack-knife and he
was asking when you were coming back. You didn’t get in touch with
the troop yet, hey?”
“They spend too much time making plans,” Hervey said.
“Well, they have a lot of fun when they carry their plans out, don’t
they?”
“Sure, playing games.”
“What’s the matter with games?”
“Jiminies, they never want to do what I do.”
“Then why don’t you do what they do? What a half a million boys
want to do is better than what one boy wants to do, isn’t it? It seems
to me they do some pretty big things. I notice they get their names in
the papers.”
This remark about getting one’s name in the papers was not
altogether pleasant to Hervey. He was somewhat in fear of that very
thing. “Sure, that’s all they do,” he said. “Didn’t I beat them all
running to East Farrelton? And I didn’t get anything out of it. Nix on
that outfit.”
“I think that was a shame,” said Mrs. Walton.
“Sure, it was no fair,” said Hervey.
“Your scoutmaster told me you cut across Allen’s farm,” Mr.
Walton observed, smiling. “And that’s private land you know, Herve.”
“He’s a sap,” said Hervey. “I got there the quickest way and beat
them all, and then I get a comeback. You’re supposed to be

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Williams Obstetrics, 25e >

CHAPTER 2: Maternal Anatomy

—J. Whitridge Williams (1903)

ANTERIOR ABDOMINAL WALL

EXTERNAL GENERATIVE ORGANS

Mons Pubis, Labia, and Clitoris

York, McGraw-Hill Education, 2016.)

Vagina and Hymen

Superficial Space of the Anterior Triangle

Deep Space of the Anterior Triangle

Anal Sphincter Complex

INTERNAL GENERATIVE ORGANS

Myometrium and Endometrium

The same issue of the newspaper carried an editorial hurling

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