Paper - Some points in the nomenclature of the external genitalia of the female
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Wood-Jones F. Some points in the nomenclature of the external genitalia of the female. (1913) J. Anat. Physiol. 148: 73-80. PubMed 17232984
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Some Points in the Nomenclature of the External Genitalia of the Female
By Frederic Wood Jones, D.Sc.,
The London School of Medicine for Women.
The present communication is intended as an introduction to a study of the development and morphology of some of the cloacal derivatives of the mammalia.
Some such preliminary survey is necessary, since there is so great a lack of deﬁnition concerning some of the terms in common use that the correct comparison of similar parts in different forms becomes diflicult, and detailed description often well nigh meaningless. I imagine that this state of affairs arises directly from the extraordinary wealth of names which has accumu- lated in the literature of the female genito-"urinary oriﬁces. It is only necessary to turn to the authors of the seventeenth century to appreciate what a multitude of names had then been bestowed as general terms for the whole external genitalia. Thomas Gibson (1688), after giving a long list of classical and popular terms for the pudendum, says that it is known by all these “and many other names that fancy has imposed upon it.” One of these more popular terms is worthy of some note. In describing the pudendum, Helkiah Crooke (1651) gives many synonyms, but puts them all aside with the brief sentence: “ We will call it the lap ” ; and with this name he heads his chapter.
It is surely a rare transition for a word, when once so used, to acquire a more polite signiﬁcance with the passage of time—the change of usage being commonly in the opposite direction. Such a use of the word, however, makes the term “ dew lap ” more easy of understanding, for I imagine that the deﬁnition of the dew lap as “the ﬂesh that hangs from the throat of oxen, which laps or licks the dew on grazing” (Ogilvie), does not represent its true signiﬁcance, and that a parallel may possibly be found in “ dew claw.”
Among the many synonyms used by the older anatomists, note must be made of “ vulva,” “ fossa navicularis s. scaphoides,” and “ vestibulum.” All these terms have been used to signify the whole of the external genitalia of the female, comprising that depression which lies between the two labia majora (labio scrotal folds, outer genital folds, labia externa, labia magna pudendi, alae, alae magnae, etc. ). A great deal of interest, and much confusion, is attached to the word vulva or volva. Its original use was without doubt restricted to the womb, and though in lay usage it was commonly conﬁned to the uterus of lower animals, it became the orthodox term for the uterus of women, and as such it is used by Galen and others. i At a later period the term became applied to the external genitalia, but if this transition came about by a mere extension of meaning, or by way of the word valva, —the folding doors or ﬂood-gates, — does not seem quite clear (on this point see Bartholin and Crooke).
Be this as it may, the word vulva, although having least claims to do so, has been alone retained in modern literature as the accepted term for the external genitalia of the female; and, since this word has monopolised such a meaning, successive generations of anatomists have been at great pains to delimit parts of the vulva to which other words, originally denoting the whole of the pudendal cleft, could be applied.
Fossa navicularis and vestibulum are the two terms which have been most commonly retained in descriptive anatomy. Both are terms which have lost their original signiﬁcance, and consequently there is much uncertainty, even to-day, as to the exact parts of the genitalia to which either is properly applied. It is correct to say that in the text-books which are in everyday use among students of anatomy and gynecology these terms bear variable ineanings. '
Fossa navicularis s. scaphoides was used by the older anatomists (see Th. Bartholin) as a descriptive term for the whole vulva, because the depression between the two labia majora is shaped somewhat after the fashion of a boat; and it should be noted that in its original use the long axis of the imaginary boat is in the long axis of the pudendal cleft.
This use of the word survived for long, and still remains current; for instance, Dr F. H. Ramsbotham states that the fossa navicularis “contains within its precincts the clitoris with its prepuce, the nymphae, the vestibule, and the meatus urinarius ” (p. 40). See ﬁg. 1.
The almost exclusive employment of the word vulva as the scientiﬁc term for the pudendal cleft caused a modiﬁcation in the use of the term fossa navicularis ; and it was restricted to the posterior part of the cleft (James Keill), or with more precision to that part of the cleft where the labia minora fall short posteriorly. In more modern usage its signiﬁcance has become still more limited, but still it is far from precise. According to different authorities the term fossa navicularis may denote :—
(1) The space between the hymen, or the oriﬁce of the vagina, and the bond which is supposed to unite the labia minora posteriorly (Luschka and others). See ﬁg. 2.
(2) The space between the hymen, or the oriﬁce of the vagina, and the bond which is supposed to unite the labia majora posteriorly (Winslow, Sappey, Broca, and others). See ﬁg. 3.
(3) The space between the hymen, or the oriﬁce of the vagina, and the “ fourchette,” such fourchette being a derivative of neither labia majora or labia minora (Farre and many gynecologists).
(4) The space between the bond which is supposed to unite the labia majora and the bond which is supposed to unite the labia minora, which bond may or may not be called a fourchette (John Lizars, etc.).
(5) The space between the bond which is supposed to unite the labia majora and a -fourchette which is not derived from the labia minora (Gray and others). See ﬁg. 4-.
(6) By a strange variant (I know not if by mere printer’s error) as the space in front of the vagina limited anteriorly by a fourchette and posteriorly by the oriﬁce of the vagina (Robert Knox).
Fig. 1.—The fossa na.vicularis (stippled area). The area as deﬁned by most early anatomists (Bartholin, etc.) partially by many modern gynecologists (Ramsbotham, etc.).
Fig. 2.—The fossa navicularis (stippled area). The area as deﬁned by most gynecologists and many anatomists (Luschka, etc.).
It should be noted that in all these different delimitations the fossa navicularis is so disposed that the long axis of the imaginary boat is at right angles to the long axis of the pudendal cleft.
A like change has taken place with regard to the word vestibulum. First meaning the outer court into which the chambers of the bladder and the uterus both opened, its use has become steadily more restricted and confused. In its original and correct sense it was in common use with anatomists and gynecologists: “ the vestibulum or fossa navicularis is a smooth depression between the nymphae and perineum; it leads to the urethra above and the vagina below” (Archibald Robinson). Such a use of the word is retained in the latest edition of Morris’s Anatomy, but, of course, it is not there a synonym for the fossa navicularis. ‘ See ﬁg. 5.
With the restriction of the term fossa navicularis to the hinder part of the pudendal cleft, the vestibulum became the recognised term for the anterior part, and such is its accepted use to-day; but even now the term is ill deﬁned. By different authorities the word vestibulum is stated to denote :—
(1) The triangular space between the labia minora extending as far back as the margin of the oriﬁce of the vagina (Gray, Farre, and others). See ﬁg. 6.
FIG. 3.—The fossa navicularis (stippled area). The area as deﬁned by Winslow, Sappey, Broca, Monro, Cloquet, and many other anatomists.
FIG. 4.—The fossa navicularis (stippled area). Area in which the anterior boundary is the “ fourchette,” which may or may not be derived from the labia minora (Gray and others).
(2) The triangular space between'the labia minora extending as far back as the urinary oriﬁce or a line drawn through the centre of this oriﬁce (Sappey, Lewers, etc.). See ﬁg. 7.
(3) A still more limited area which stretches from below the clitoris to the entrance of the urethra. This deﬁnition is found most usually in works on gynecology, and such a vestibulum might well correspond to the “ bride masculine du vestibule” of Pozzi, or the “ habenulae urethrales ” of Waldeyer.
Considerably more diﬂiculty is experienced when we attempt to deﬁne exactly what is meant by the fourchette, for this word appears to be one that is surrounded by uncertainty. Its use may be summarised as follows :—
(1) The term fourchette may signify a posterior junction of the labia majora: 73.e. it may be a synonym for the commissura inferna of Bartholin, the inferior commissure of Winslow, the posterior commissure of many authors, the frenulum labiorum of Verheyen, or the frenulum pudendi of Cunningham (Practical, Ed. 2). See ﬁg. 8.
(2) It may signify a posterior junction of the labia minora and so be a synonym of the frenulum vulvae of Luschka, or the frenulum labiorum pudendi of Cunningham (Practical, Ed. 5). See ﬁg. 9.
(3) It may signify a fold unconnected with either of these, derived from the anterior edge of the perineum (Robert Knox and others); or
FIG. 5. — The vestibulum (shaded area) as deﬁned by earlier anatomists, adopted by many gynecologists, and retained by some anatomists (Archibald Robinson, Alfred von Behr, Morris, etc.).
FIG. 6. — The vestibulum (shaded area.) as defined by many gynecologists and anatomists (Farre, Gray, etc.).
FIG. 7. — The vestibulum (shaded area) as deﬁned by many gynecologists and anatomists (Lewers, Sappy, etc.).
(4) A fold further Within the pudendal cleft, but still not a direct derivative of either of the genital folds (Farre and many gynecologists). As such it has been named the “ fourchette,” “ the fork” (Keill, 1703), “the skinny ligament” (Crooke, 1651), or “frenulum pudendi” (Gray, 1882). See ﬁg. 10.
The actual constituent of the external genitalia from which the fourchette is derived and with which it is anatomically continuous is therefore a matter of considerable uncertainty.
The uncertainty is increased by an attitude frequently manifested by authorities on gynecology, that to a certain extent the demonstration of the fourchette and fossa navicularis is a matter of manipulation during examination. This idea ﬁnds free expression in the Works of many authors. “ The fossa navicularis only assumes the form of a boat-shaped depression when it is stretched laterally by an index ﬁnger placed in it on each side” (Galabin, p. 5).
“The fossa navicularis is ﬁrst formed, and gets its boat -shape, when they (labia majora) are separated from each other. On stretching them from side to side We see the posterior commissure advance until it reaches the level of the posterior border of the entrance of the vagina. Thus a fold in which the labia majora meet in which the labia minors. meet III. in which the free edge 13 to form a free edge, the'labia _ to form a free edge; the labia derived from neither labium. minora falling short posteriorly. majora. may or may not form a junction at a posterior commissure.
FIG. 8. The fourchette. Type I.
FIG. 9.—The fourchette. Type II.
FIG. 10.—The fourchette. Type III.
and a hollow are formed. The fold is the fourchette: the hollow is the fossa navicularis” (Garrigues, p. 40). I think that although such expres- sions would seem to make the issue more confused, they are in reality the clues for understanding the true nature of the fourchette: especially so I when taken in conjunction with a further statement of the last author that, “in virgins the fourchette projects a little forward, even Without stretching.” It would seem that concerning the fourchette there is only one point ‘of agreement among all authors, and that is that at the posterior limit of the pudendal cleft there is a projecting margin which is more or less pronounced in the virgin, but which loses much of its prominence in women who are not virgins, and commonly disappears altogether after the birth of the ﬁrst child. '
According to Bartholin, “inferior commissura labiorum in virginibus tensa est”; or to Crooke, “in those that have brought forth the skinny ligament is much more lax and loose.”
What, then, is the anatomical structure which produces this sharp posterior edge of the virgin pudendal cleft?
According to many modern authors it is the backward extension of the labia minora around the vaginal oriﬁce.
Now it must be admitted that the degree of development of the labia minora varies enormously; but I am convinced that for them to be pro- longed so far back as to meet behind the vagina is a somewhat unusual event even in the foetus. A consideration of the true morphology of these folds does not warrant the conclusion that, even in an abbreviated form, it should be their normal condition to meet behind the vaginal oriﬁce. Indeed, itis a comparatively recent innovation into anatomical description that makes such a meeting normal. That they extend backwards “reaching about half the breadth of the oriﬁce of the vagina ” (Gibson) is a common description of the older anatomists, which is still retained in some modern text-books (Morris), and which applies to the virgin and non—virgin condition. In a very large proportion of female foetuses it is quite obvious that although the labia minora fall short. about half-way down the vaginal oriﬁce, there is yet a sharp margin at the back of the pudendal cleft. In some cases, it is true, there is an apparent continuation of the line of the labia minora further back than the mid-point of the vaginal oriﬁce, and in some there is an apparent meeting of their backward continuation at the posterior margin of the cleft; but this condition I do not think is the normal one, and it is one that is certainly accentuated by manipulation.
Just as the older anatomists were deﬁnite about the failure of the labia minora to meet posteriorly, so many authors are deﬁnite about the failure of the labia majora to meet in a posterior commissure or fourchette. “ Inferiorly the labia majora do not meet or run together, but terminate apart in front of the perineum” (Robert Knox, p. 508).
Concerning the labia majora, there is ample reason for suggesting that they do not end by becoming united behind the vaginal oriﬁce in front of the anus. It is, I think, merely the unnatural position, and the straining open of the pudendal cleft on examination which makes such a meeting apparent. In the natural position of the parts, with the thighs approximated, the skin ridges which compose the labia majora run straight backwards and fail by becoming of diminishing prominence at a variable distance on the perineum towards the anus.
If, then, neither labia minora nor labia majora normally meet behind the pudendal cleft at a median bond of union, what other anatomical structure may form the basis of the fourchette ?
In the London Dissector (J. Scratchley), which reached its eighth edition in 1832, the student was taught that “the perineum anterius projects forwards forming a kind of valve” (p. 89), and such appears to me to be the proper statement of the facts. It is the anterior margin of the “perineum,” free of either genital fold, that forms the fourchette, and the disappearance of the fourchette after the ﬁrst labour represents the minimum—and normal—rupture of the “perineum ” accompanying normal labour. The deﬁnition of this “ perineum” I reserve for a future paper.
There is one other point concerning which there is some difference of opinion shown in text-book descriptions and text-book illustrations, and that is the anterior origin or point of union of the labia minora. To appreciate the true morphology of these structures it cannot be made too deﬁnite that they arise as free folds upon the under surface of the clitoris, and not from the preputium of the clitoris with which their apparent continuity is only secondary.
The labia minora start upon the under surface of the clitoris and end upon the sides of the vaginal oriﬁce: the labia majora run as prominent margins along the whole length of the pudendal cleft, but fade away before and behind by becoming merged with the general skin surface. Such, I think, should be the description of the normal disposition of these ridges.
Detailed References to Some of the Works Quoted in the Text
(1) BARTHOLIN, T., Anatome, 1673, p. 287.
(2) CRooKE, H., Mikroscosmographia, 1651.
(3) KEILL, J., Anatomy, ed. 2, 1703, p. 9.
(4) FARRE, A., In Todd’s Cyclopedia, vol. v., 1859, p. 709.
(5) SAPPEY, Ph. C., Anatomic descriptive, 1879, vol. iv., p. 783.
(6) BROCA, BONAMY, AND BEAU, 1850, vol. iii., plate 64.
(7) KNOX, R., Manual of Anatomy, 1853, p. 508.
(8) WINsLoW, J. B., 1734, sect. viii., p. 206.
(9) GIBSON, T., 1688, p. 196.
(10) GALABIN, A. .L., Diseases of Women, 1893, .ed. v.
(11) GARRIGUES, H. J ., Diseases of Women, 1900, ed. iii.
(12) RAMSBOTHAM, F. H., Obstetric Medicine and Surgery, 1844.
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