Open Journal of Obstetrics and Gynecology, 2012, 2, 223-226 OJOG Published Online September 2012 (
Influences on the study of vulvar anatomy and disease
Ian S. C. Jones
Women’s and Newborn Services, Royal Brisb ane an d Women’s Hospital, Brisbane and University of Queensland, Herston, Australia
Received 24 May 2012; revised 30 June 2012; accepted 12 July 2012
The study of Gynaecology over the years has been
influenced by the culture and social attitudes of so-
ciety to the body as a whole and to the genital organs
in particular. Variations in these attitudes between
different cultures and at different times have influ-
enced the subsequent rate of progress in the study of
the vulva and i ts dis eases.
Keywords: Vulvar; Cancer; Attitudes; Communication;
Scientific Developments
Overviews of medical history usually commence with
reference to stone figures and cave drawings that date
back to between 40,000 and 16,000 BC. However, Aus-
tralia’s Aborigine people who arrived in Australia be-
tween 60,000 and possibly 125,000 years ago [1] are
known to have used stone tools and red ochre pigment
dating back over 60,000 years to depict various aspects
of their semi-nomadic hunter gatherer life style and rela-
tionships between other persons including religious and
ceremonial activities.
The temptation to enter into the debate [2] as to whe-
ther rock art is indeed art as it may be considered by
western society has been resisted, as has the use of such
terms as rock imagery, pictograms, petroglyphs and rock
Prior to the arrival of Europeans (European colonisation),
Australian Aborigines lived in communities variously
referred to as tribes or mobs. They lived in close associa-
tion with nature and depended absolutely on what their
physical environment had to offer. They had a significant
and interrelated three-fold relationship between them-
selves and other group members; between themselves
and nature; and between themselv es and gods, spirits an d
supernatural beings [3]. In addition, their traditional
health beliefs are interconnected with these relationships
In Australian Aboriginal society food gathering and
fertility were of great importance. As regards fertility the
basic emphasis was on food and sex. In some situations
sex was treated frankly whereas in other situations sex
was expressed in song-poems, ritual objects, emblems,
rock art and bark paintings [3]. Some of these objects are
of medical interest with representations of the human
form showing the female breast, menstruating females,
sexual activity, (some of which can be considered por-
nographic [5]), and male and female external genitalia.
Female figures usually have small breasts but large ana-
tomically detailed vulvas [6]. The depiction of large ex-
ternal genitalia in the drawings of these “love magic fig-
ures” from both sexes was considered by Taylor [6] to
suggest the licentious behaviour of th e various spirits. In
Aboriginal culture there are strong links between the
ancestral spirit world and th e m a te r i a l w o r l d . A s D e a n [ 7 ]
also points out “there is no sharp distinction between the
sacred and the secular, since the spirit world and human
world interpenetrate”.
Traditional healers were trained to remove the influ-
ence of sorcery and evil spirits and to restore the well-
being of the soul or spirit [8] and because of these skills
were held in high regard [9]. Traditional healers tended
to be male dominated, although there were female hea-
lers in some communities [10]. Following colonisation
the life-style of many Australian Aborigines changed
significantly. Much of this change came about as a result
of dispossession of their land, social disruption, racism,
cultural suppression and discriminatory government prac-
tices. As a result of these changes the use of traditional
medicine and healing practices also changed according to
the impact of these changes on the local groups being
considered [11]. At present the consequences of these
actions we can only guess as to how this change/absence
to the use of traditional medicine and healing practices
affected the management of various conditions affecting
the female external genitalia.
Care must be taken in making generalised statements
about Australian Aborigines because of the great diver-
sity among different communities and societies [11].
I. S. C. Jones / Open Journal of Obstetrics and Gynecology 2 (2012) 223-226
Also the literature which considers the health beliefs of
Australian Aborigines from more recent times must
distinguish between those who still live in rural and
remote regions and those who live in metropolitan areas
Until the arrival of Europeans Australian Aborigines
did not develop writing skills but relied on various art
forms e.g. rock and bark drawings, songs, dance, rituals,
other performances and story telling to pass on their cul-
tural heritage and knowledge. In Australian Aboriginal
culture there is a clear cut division between men’s and
women’s business and this is important when considering
gender specific health problems [13]. However this divi-
sion between the sexes does not seem to be an issue
within the realm of Australian Aboriginal art. Informa-
tion promoting The Indigenous Collection within The Ian
Potter Centre of the National Gallery of Victoria claims
that Aboriginal art is the oldest continuing tradition of art
in the world. Hence the art form and specifically the rep-
resentations of human anatomy have not changed sig-
nificantly over time unlike that reported in the English
literature which we are about to consider.
In the English literature and prior to 1800 the history of
Obstetrics and Gynaecology showed that obstetrics, more
correctly midwifery, was documented in greater detail
than the prac ti s e of wh a t we now refer to as gynaecology.
In comparison with midwifery the sparse records on gy-
naecology favoured writings about menstruation, the
uterus, ovaries and fallopian tubes with little recorded
attention paid to the female external genitalia. The re-
cords on the female external genitalia that are available
extend back over several thousand years. Although the
earliest representations of the human body in the form of
cave drawings and stone figures date back to the Middle
Aurignacian period (40,000-16,000 BC), it is not until
the ancient Egyptians (2000 BC) that specific references
to the vulva were recorded in the Kahun Papyrus [12].
In India the ancient documents of the Hindus, known
as the Vedas, were written 1500 years before the Chris-
tian era [14]. Charaka (a Hindu writer on medical issues,
born 300 BC) described tumours occurring on the vulva
and pruritus vulvae in the 30th chapter of his 120 chapters
in the “Ayur Veda” [14].
In Western countries social attitudes to the body as a
whole and to the genital organs in particular, influenced
the subsequent rate of progress in the study of the vulva.
For instance, the Greeks in the time of Hippocrates (460-
370 BC) referred to the external genitalia as “the sha-
meful parts”. Although they inspected the external geni-
talia their initial descriptions of vulvar pathology were
only recorded in vague terms such as ulcerations, aph-
thae and vegetations [14]. As time went by their descrip-
tions became more explicit. During the first century AD,
Celsus (27 BC-50 AD, it is unknown if he was a prac-
tising physician or where he was born) described the
imperforate hymen and Rufus (Ephesian, who resided in
Rome 98-117 AD, physician and anatomist) wrote a de-
tailed text of the hu man body in wh ich he named var ious
structures including parts of the vulva [14]. An extract of
this writing follows using terminology not in current
The privates of women, the triangu lar extremity of the
hypogastric region is called the comb, while others speak
of it as the episeion. The ap erture of the genitals is called
the skisma. The nymphe or the murton are the names
applied to that pendulous fleshy body in the midline;
others call it the hypodermis; while some prefer to call it
the clitoris. Titillation of this structure for lascivious
purposes is design a ted as clitorising.
Soranus (An Ephesian physician who worked in Rome
during the period 98-138 AD) described the vagina and
the external genitalia. He wrote of the hymen and the
difference between that of the virgin and that of the
non-virgin. Galen’s (130-199 AD, physician and anato-
mist) fame in gynaecology was based on his anatomical
dissections and descriptions of the female genitalia.
Galen mentions the use of a “scalpellus” in incising an
imperforate hymen [14].
During the Byzantine period (fourth to seventh century
AD) Vindicianus, an African born Latin physician [14]
wrote a “Gynaecia” dealing with anatomy, embryology
and physiology of the female genitalia. Aetius of Amida
(700 AD, Mesopotamian physician) was the first eminent
Christian physician and writer of texts. In his writings
“Diseases of the External Genitalia” he described a Bar-
tholin’s cyst recognising its location and the possibility
of it being bilateral. He also described hypertrophic
changes of the clitoris and “various ulcerations of the
pudenda and labia which may assume a malignant nature
and bleed freely, especially after coitus, exercise or fol-
lowing a speculum examination.” [14] (p. 185). Paulus
Aegineta (625-690 AD, Greek the last of the Byzantine
medical writers and surgeon) wrote on pudendal ulcers,
condylomata, haemorrhoids about the female genitalia
and hermaphrodites recommending excision of the su-
perfluous parts and treating the raw surfaces like an or-
dinary wound [14].
Ricci summarises the gynaecological data in the Ara-
bian medical manuscripts (800-1200) as being “scanty
and reflective of the views of the Greeks with gynaeco-
logy being neglected even more than obstetrics with the
practice of both specialties being left to midwives.” [14]
(p. 221). He suggested that this occurred because their
physicians and the population as a whole had a “profound
Copyright © 2012 SciRes. OPEN ACCESS
I. S. C. Jones / Open Journal of Obstetrics and Gynecology 2 (2012) 223-226 225
aversion to both gynaecology and obstetrics based on a
mistaken sense of values and prudery.”
Further progress in understanding anatomy was delayed
until the sixteenth century when anatomical dissection of
the human body was permitted and the findings obtained
were recorded with accurate drawings. However, at this
stage in time there was still considerable confusion on
the function of the Fallopian tubes and the number of
compartments in the uterine cavity. This confusion had
arisen as a result of the extrapolation of findings from
animal dissections to the human. Even the records of
Vesalius (1514-1564, anatomist and military surgeon)
demonstrated the influence of Galen’s teachings as shown
in his drawing of the uterine cavity which indicated a
fundal septum protruding into it. Apart from this possible
error (questioned because a uterus subseptus of minor
degree can have this appearance), he accurately de-
scribed each organ within the whole g enital tract with the
anatomical illustrations attributed to John de Calcar and
published in 1543 as his “De Corporis Humani Fabrica”.
Fallopio (1523-1562, professor of anatomy, surgery and
botany at Padua) of fallopian tube fame was the first to
mention the clitoris as a muscular structure and rede-
scribed the hymen as a definite structure [14]. Fabricius
(1537-1619, anatomist), wrote in his textbook of sur-
gery “Opera Chirurgica” brief chapters on the imperfo-
rate hymen and adherent labia in addition to other gy-
naecologi c al pr o b le ms.
In the seventeenth century a more detailed assessment
of anatomical structures became possible with the de-
velopment of preserving anatomical specimens and in-
jecting blood vessels [14]. Seventeenth century texts
solely devoted to gynaecology are few. In 1618 the post-
humous “Opuscula Medica” of Ronsseus (1525-1596,
Flemish physician) was published and contained a sec-
tion on diseases of women. De Gr aaf (1641-1673, Dutch
anatomist) accurately described not only the ovary and
its follicles, but the entire genital tract. His text on the
female genital tract contains chapters on the pudendum,
the clitoris, clitoral crura and its blood supply, the mons,
the hymen, the urinary meatus [14].
At about this time Leeuwenhoek (1632-1723, Dutch
microscopist) and Hooke (1635-1703, English micro-
scopist and curator of the Royal Society of London) de-
veloped the prototype of the microscope. Further devel-
opment of this instrument was to advance the study of
vulvar pathology cons iderably but that was still two hun-
dred years in the future. In 1693, Vater-Schondorff re-
corded a case of carcinoma of the labia majora in his
Wittenberg thesis, and the lymphatic drainage of the
genitalia was correctly detailed in Anton Nuck’s (1650-
1692, Dutch anatomist) textbook of anatomy which was
published in 1722. The way was now clear for further
meaningful studi es of v ul va r m a l ignancy.
Gynaecology and gynaecological surgery as a distinct
specialty did not occur in the eighteenth century. How-
ever, by the eighteenth century obstetrics was well on the
way to becoming a definite speciality [14]. Smellie
(1697-1763, Scottish obstetrician who practiced in Lon-
don) gave a description of the vulva in his chapter enti-
tled “Of the external and internal Parts of Generation
proper to women” [14] and provided a detailed illustra-
tion in Plate IV [15] published in 1783.
The concept of pre malignant lesions developed nearly
150 years later when Schwimmer (1877, German) re-
ported white lesions in the mouth and tongue describing
them as leukoplakia. It was then recognised that similar
lesions could occur at other sites on the body. In 1885
kraurosis vulvae was described by Breisky (1832-1889,
Czech gynaecologist) and two years later in 1887 Hallo-
peau (1842-1919, French dermatologist) described what
is now known as lichen sclerosus. These were conditions
considered to be premalignant lesions of the vulva.
The use of histology for the stu dy of vulvar conditions
gained momentum. Webster (1863-1950, Canadian gy-
naecologist) in 1891 and Sanger (German gynaecologist)
in 1894 studied vulvar tissue excised from patients with
intractable pruritus vulvae. They reported upon an in-
flammatory affection of the corium and noted excision
cured the symptoms. Since that time many authors have
added to the literature on vulvar disease, its causes and
treatments. However this more recent history is beyond
the current study’s time period.
Distance and modes of transport have played an im-
portant part in how once isolated communities were ab le
to literally expand their horizons and share knowledge.
Initially Europe, England, Egypt, Middle East and India
were isolated from each other but adventurers broke
down the barrier of distance and expanded their know-
ledge. However the Australian Aborigines remained iso-
lated because of distance and the lack of long distance
transport which in turn slowed their progress in th e study
of medicine and its diseases as we now know it. How-
ever isolation did bring the benefit of isolating them from
western diseases until they were introduced by the colo-
History shows how culture, religion and social attitudes
(together with natural and man made disasters and the
laws of the times), influenced the subsequent rate of
progress in the study of medicine and its diseases. This is
nowhere more apparent than with the study of the vulva
Copyright © 2012 SciRes. OPEN ACCESS
I. S. C. Jones / Open Journal of Obstetrics and Gynecology 2 (2012) 223-226
Copyright © 2012 SciRes. OPEN ACCESS
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