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The vulva (Latin: wrapper, covering, plural vulvae or vulvas)[1] consists of the external female sex organs.[2] The vulva includes the mons pubis, labia majora, labia minora, clitoris, vestibular bulbs, vulval vestibule, urinary meatus, the vaginal opening, and Bartholin's and Skene's vestibular glands.[3][4] The urinary meatus is also included as it opens into the vulval vestibule.[5] Other features of the vulva include: the pudendal cleft, sebaceous glands, the urogenital triangle (anterior part of the perineum), and pubic hair. The vulva includes the entrance to the vagina, which leads to the uterus, and provides a double layer of protection for this by the folds of the outer and inner labia. Pelvic floor muscles support the structures of the vulva. Other muscles of the urogenital triangle also give support.

Human vulva
Genital Diversity Expanded.jpg
Vulvas of different women (pubic hair removed in some cases)
Details
Precursor Genital tubercle, urogenital folds
Artery Internal pudendal artery
Vein Internal pudendal veins
Nerve Pudendal nerve
Lymph Superficial inguinal lymph nodes
Identifiers
Latin pudendum femininum
MeSH D014844
TA A09.2.01.001
FMA 20462
Anatomical terminology

Blood supply to the vulva comes from the three pudendal arteries. The internal pudendal veins give drainage. Afferent lymph vessels carry lymph away from the vulva to the inguinal lymph nodes. The nerves that supply the vulva are the pudendal nerve, perineal nerve, ilioinguinal nerve and their branches.

Following the development of the vulva, changes take place at birth, childhood, adolescence, menopause and post-menopause. The vulva can be affected by many disorders which may often result in irritation. Vulvovaginal health measures can prevent many of these.[2] Other disorders include a number of infections and cancers. There are several vulval restorative surgeries known as genitoplasties, and some of these are also used as cosmetic surgery procedures.

Contents

Structure

 
Labeled image of a vulva, showing external and internal views

The main structures of the vulva are: the mons pubis, the labia majora and labia minora, the external parts of the clitoris – the clitoral hood and the glans, the urinary meatus, the vaginal opening and hymen, and Bartholin's and Skene's vestibular glands.[6] Other features include: the pudendal cleft, pubic hair, sebaceous glands, the vulval vestibule, and the urogenital triangle.

Mons pubis

The mons pubis is the soft mound of fatty tissue at the front of the vulva, in the pubic region covering the pubic bone. Mons pubis is Latin for "pubic mound" and is present in both sexes to act as a cushion during sexual intercourse. Sometimes a variant term is used specifically to women—the mons veneris ("mound of Venus").[7]. At the lower part of the mons pubis it is divided by a fissure the pudendal cleft, which separates the mons pubis into the labia majora. The pudendal cleft is also known as the cleft of Venus (the Roman goddess of love). The clitoral hood and the labia minora protrude into the pudendal cleft to a lesser or greater degree. The mons and labia majora become covered in pubic hair at puberty.

 
The pudendal cleft separates the mons pubis into the labia majora

Labia

The labia majora and the labia minora protect the vulval vestibule. The outer pair of folds divided by the pudendal cleft, are the labia majora, (New Latin: larger lips). They contain and protect the other, more delicate structures of the vulva. The labia majora meet again at the urogenital triangle (the anterior part of the perineum) between the pudendal cleft and the anus. The color of the outside skin of the labia majora is usually close to the overall skin color of the individual, although there is considerable variation. The inside skin and mucous membrane are often pink or brownish.

The grooves between the labia majora and labia minora are called the interlabial sulci, or interlabial folds. The labia minora (smaller lips) are the inner two soft folds, within the labia majora, and contain numerous sebaceous glands.[8] They meet posteriorly at the frenulum of the labia minora, a fold of restrictive tissue. The labia minora meet again at the front of the vulva to form the clitoral hood, also known as the prepuce.[5]

The visible portion of the clitoris is the clitoral glans. Typically, this is roughly the size and shape of a pea, although it can be significantly larger or smaller. The clitoral glans contains as many nerve endings as the much larger homologous glans penis in the male, which makes it highly sensitive.[5] The clitoral hood, is a protective fold of skin that normally covers the clitoris, however, this may not completely cover larger than normal clitorises. The clitoral hood is the female equivalent of the male foreskin. Often the clitoral hood is only partially hidden inside of the pudendal cleft.[9]

Vestibule

 
Muscles underlying the vulva and perineum

The area between the labia minora where the vaginal opening and the urinary meatus are located is called the vulval vestibule, or vestibule of the vagina. The urinary meatus is below the clitoris and just in front of the vaginal opening which is near to the perineum. The term introitus is more technically correct than "opening", since the vagina is usually collapsed, with the opening closed. The introitus is sometimes partly covered by a membrane called the hymen. The hymen will usually rupture during the first episode of vigorous sex, and the blood produced by this rupture has been seen to signify virginity. However, the hymen may also rupture spontaneously during exercise or be stretched by normal activities such as the use of tampons and menstrual cups, or be so minor as to be unnoticeable, or be absent.[5] In some rare cases, the hymen may completely cover the vaginal opening, requiring surgery.[10]

On either side of the back part of the vaginal opening are the two greater vestibular glands known as Bartholin's glands. These glands secrete mucus and a vaginal and vulval lubricant.[11] They are homologous to the bulbourethral glands in the male.The lesser vestibular glands known as Skene's glands, are found on the anterior wall of the vagina. They are homologues of the male prostate gland and are also referred to as the female prostate.[12]

Supporting muscles

Pelvic floor muscles help to support the vulvar structures.[4] The voluntary, pubococcygeus muscle, part of the levator ani muscle partially constricts the vaginal opening.[13] Other muscles support the vulvar area. These are the transverse perineal muscles, the bulbospongiosus, and the ischiocavernosus muscles.[14] The muscles are part of the urogenital triangle.

 
Variation in the appearance of women's external genitalia (genetic variation) in frontal view: in some women the labia minora and clitoral hood protrude between the labia majora and are clearly visible in upright standing position, while being completely hidden in others. (Pubic hair trimmed or removed in most examples.)

Blood, lymph and nerve supply

The tissues of the vulva are highly vascularised and blood supply is provided by the three pudendal arteries. Venous return is via the external and internal pudendal veins. The organs and tissues of the vulva are drained by a chain of superficial inguinal lymph nodes located along the blood vessels.[4][14]

The ilioinguinal nerve originates from the first lumbar nerve and gives branches that include the anterior labial nerves which supply the skin of the mons pubis and the labia majora. The perineal nerve is one of the terminal branches of the pudendal nerve and this branches into the posterior labial nerves to supply the labia. The pudendal nerve branches include the dorsal nerve of clitoris which gives sensation to the clitoris.

The pudendal nerve enters the pelvis through the lesser sciatic foramen and continues medial to the internal pudendal artery. The point where the nerve circles the ischial spine is the location where a pudendal block of local anesthetic can be administered to inhibit sensation to the vulva. A number of smaller nerves split off from the pudendal nerve. The deep branch of the perineal nerve supplies the muscles of the perineum and a branch of this supplies the bulb of the vestibule.[4][15]

Variations

There is a great deal of variation in the appearance of female genitals.[5] Much of this variation lies in the significant differences in the size, shape, and colour of the labia minora. Though called the smaller lips they can often be of considerable size and may protrude outside the vagina or labia majora. This variation has also been evidenced in a large display of 400 vulval casts called the Great Wall of Vagina created by Jamie McCartney to fill the lack of information of what a normal vulva looks like. The casts taken from a large and varied group of women showed clearly that there is much variation.[16] Pubic hair also varies in its colour, texture, and amount of curl.[5]

Development

Prenatal development

 
Genital tubercle of female at fourteen weeks
 
Development of genitals showing homologues from indifferent at A to both sexes - female on right

The appearance of the external genital region is the same for males and females until the eighth week.[17] During the sixth week, the genital tubercle develops in front of the cloacal membrane. The tubercle contains a groove termed the urethral groove. The urogenital sinus (forerunner of the bladder) opens into this groove. On either side of the groove are the urogenital folds. Beside the tubercle are a pair of ridges called the labioscrotal swellings. Beginning in the third month of development, sexual differentiation takes place and in the development of the female the genital tubercle becomes the clitoris; the urogenital folds become the labia minora, and the labioscrotal swellings become the labia majora.

Organs in the male and female with a shared common ancestry are said to be homologous. The clitoral glans is homologous to the male glans penis, and the clitoral body and the clitoral crura are homologous to the corpora cavernosa of the penis. The labia majora, labia minora, and clitoral hood are homologous to the scrotum, shaft skin of the penis, and the foreskin, respectively. The vestibular bulbs beneath the skin of the labia minora are homologous to the corpus spongiosum, the tissue of the penis surrounding the urethra. Bartholin's glands are homologous to the bulbourethral glands in males.

Childhood

At birth, the newborn's vulva may be swollen or enlarged as a result of having been exposed, via the placenta, to her mother's increased levels of hormones. The clitoris is proportionally larger than it is likely to be later in life. Within a short period of time, as these hormones wear off, the vulva will shrink. From then until puberty the vulva does not change in appearance, other than growing in proportion with the rest of the body.

Puberty

The onset of puberty produces a number of changes. The structures of the vulva become proportionately larger and may become more pronounced. Coloration may change and pubic hair develops, first on the labia majora, and later spreading to the mons pubis, and sometimes the inner thighs and perineum. Pubic hair is much coarser than other body hair. It appears at puberty and is considered a secondary sex characteristic.[14][13] Pubarche is the first appearance of pubic hair and can occur independently of puberty. Premature pubarche may indicate underlying endocrine conditions.[18] Apocrine sweat glands secrete sweat into the pubic hair follicles. This is broken down by bacteria on the skin and produces an odor,[19] which some consider to act as an attractant sex pheromone.

The labia minora may grow more prominent and undergo changes in color.[20]

In preadolescent girls, the vulva appears to be positioned further forward than in adults, showing a larger percentage of the labia majora and pudendal cleft when standing. During puberty the mons pubis enlarges, pushing the forward portion of the labia majora away from the pubic bone, and parallel to the ground (when standing). Variations in body fat levels affect the extent to which this occurs.

Menopause

During menopause, hormone levels decrease, and as this process happens, reproductive tissues which are sensitive to these hormones shrink.[21] This is known as vulval atrophy and affects the mons pubis, labia, and clitoris, but they are not usually reduced to prepubertal size. The decrease in estrogen can cause pale, itchy, and sore skin.[21]

Function and physiology

The vulva has a sexual function; these external organs are richly innervated and provide pleasure when properly stimulated. There are a number of different secretions associated with the vulva, including urine, sweat, menses, sebum, and secretions from the vestibular glands and vaginal wall. These secretions contain a mix of chemicals, including pyridine, squalene, urea, acetic acid, lactic acid, complex alcohols, glycols, ketones, and aldehydes. During sexual arousal, vaginal lubrication increases. Smegma is a white substance formed from a combination of dead cells, skin oils, moisture and naturally occurring bacteria, that forms in the genitalia. In females it collects around the clitoris and labial folds.[22] It is also found in other mammals.

Some women produce aliphatic acids. These acids are a pungent class of chemicals which other primate species produce as sexual-olfactory signals. While there is some debate, researchers often refer to them as human pheromones. These acids are produced by natural bacteria resident on the skin. The acid content varies with the menstrual cycle, rising from one day after menstruation, and peaking mid-cycle, just before ovulation.[citation needed]

Sexual arousal

 
Vulva with enlarged and shiny labia minora from vaginal lubrication and vasocongestion

Sexual arousal results in a number of physical changes in the vulva. Vaginal lubrication begins first. Vulva tissue is highly vascularised; arterioles dilate in response to sexual arousal and the smaller veins will compress after arousal,[4][17] so that the clitoris and labia minora increase in size. Increased vasocongestion in the vagina causes it to swell, decreasing the size of the vaginal opening by about 30%. The clitoris becomes increasingly erect, and the glans moves towards the pubic bone, becoming concealed by the hood. The labia minora increase considerably in thickness. The labia minora sometimes change considerably in color, going from pink to red in lighter skinned women who have not borne a child, or red to dark red in those that have. Immediately prior to orgasm, the clitoris becomes exceptionally engorged, causing the glans to appear to retract into the clitoral hood. Rhythmic muscle contractions occur in the outer third of the vagina, as well as the uterus and anus. Contractions become less intense and more randomly spaced as the orgasm continues. An orgasm may have as few as one or as many as 15 or more contractions, depending on its intensity. Orgasm may be accompanied by female ejaculation, causing liquid from either the Skene's gland or bladder to be expelled through the urethra. The pooled blood begins to dissipate, although at a much slower rate if an orgasm has not occurred. The vagina and vaginal opening return to their normal relaxed state, and the rest of the vulva returns to its normal size, position and color.[23][24]

Clinical significance

Irritation

Irritation and itching of the vulva is called pruritus vulvae. This can be a symptom of many disorders, some of which may be determined by a patch test. The most common cause of irritation is thrush, a fungal infection. Vulvovaginal health measures can help to prevent many disorders including thrush.[25] Infections of the vagina such as vaginosis and of the uterus may produce vaginal discharge which can be an irritant when it comes into contact with the vulvar tissue.[26][27]Inflammation as vulvitis, and vulvovaginitis can result from this causing irritation and pain.

Ingrown hairs resulting from pubic hair shaving can cause folliculitis where the hair follicle becomes infected; or give rise to an inflammatory response known as pseudofolliculitis pubis.[28] A less common cause of irritation is genital lichen planus another inflammatory disorder. A severe variant of this is vulvovaginal-gingival syndrome which can lead to narrowing of the vagina,[29] or vulva destruction.[30] Many types of infection and other diseases including some cancers will cause irritation.

Sexually transmitted infections

 
Water warts of molluscum contagiosum
 
Pubic hair with crab lice

Vulvar organs and tissues can become affected by different infectious agents such as bacteria and viruses, or infested by parasites such as lice and mites. Over thirty types of pathogen can be sexually transmitted,[31] and many of these affect the genitals.

Bacterial infections include: chancroid – characterised by genital ulcers known as chancres; granuloma inguinale showing as inflammatory granulomas often described as nodules; syphilis –the primary stage classically presents with a single chancre, a firm, painless, non-itchy ulcer, but there may be multiple sores[32]; and gonorrhea that very often presents no symptoms but can result in discharge.

Viral infections include human papillomavirus infection (HPV) – this is the most common STI and has many types.[33] Genital HPV can cause genital warts. There have been links made between HPV and vulvar cancer, though HPV most often causes cervical cancer.[34] Genital herpes is mostly asymptomatic but can present with small blisters that break open into ulcers.[35] HIV/AIDS is mostly transmitted through sexual activity, and the vulva in some cases can be affected by sores.[36] A highly contagious viral infection is molluscum contagiosum which is transmissible on close contact and causes watery warts.[37][38]

Parasitic infections include trichomoniasis, pediculosis pubis, and scabies. Trichomoniasis is transmitted by a parasitic protozoan and is the most common non-viral STI.[39] Most cases are asymptomatic but may present symptoms of irritation and a discharge of unusual odor.[40] Pediculosis pubis commonly called crabs, is a disease caused by the crab louse an ectoparasite. When the pubic hair is infested the irritation produced can be intense.[41] Scabies also known as the seven year itch is caused by another ectoparasite, the mite Sarcoptes scabiei, giving intense irritation.

The practice of safe sex can greatly reduce the risk of infection from many sexually transmitted pathogens.

Cancer

Many malignancies can develop in vulvar structures.[4] Most vulvar cancers are squamous cell carcinomas and are usually found in the labia particularly the labia majora.[42] The second most common vulval cancer (though not very common) is vulval melanoma.[43] A vulvectomy may need to be performed in order to remove some or all of the vulva. This procedure is usually performed as a last resort in certain cases of cancer,[44] vulvar dysplasia or vulvar intraepithelial neoplasia.[45]

Signs and symptoms can include: itching, or bleeding; skin changes including rashes, sores, lumps or ulcers, and changes in vulval skin coloration. Pelvic pain might also occur especially during urinating and sex.[46]

Other

Labial fusion, also called labial adhesion,[47] is the fusion of the labia minora. This affects a number of young girls and is not considered unduly problematic. The condition can usually be treated using creams, or it may right itself with the release of hormones at the onset of puberty.[48]

Vulvodynia is chronic pain in the vulvar region. There is no single identifiable cause. A subtype of this is vulvar vestibulitis but since this is not thought to be an inflammatory condition it is more usually referred to as vestibulodynia. Vulvar vestibulitis usually affects pre-menopausal women.

A number of skin disorders such as lichen sclerosus, and lichen simplex chronicus can affect the vulva. Crohn's disease of the vulva is an uncommon form of metastatic Crohn's disease which manifests as a skin condition showing as hypertrophic lesions or vulvar abscesses.[49] Papillary hidradenomas are nodules that can ulcerate and are mostly found on the skin of the labia or of the interlabial folds. Another more complex ulcerative condition is hidradenitis suppurativa which is characterised by painful cysts that can ulcerate, and recur, and can become chronic lasting for many years.[50][51] Chronic cases can develop into squamous cell carcinomas.[51]

A subtype of psoriasis, an autoimmune disease, is inverse psoriasis in which red patches can appear in the skin folds of the labia.[52]

Childbirth

The vulvar region is at risk for trauma during childbirth.[53] During childbirth, the vagina and vulva must stretch to accommodate the baby's head (approximately 9.5 cm (3.7 in)). This can result in tears known as perineal tears in the vaginal opening, and other structures within the perineum.[54] An episiotomy (a pre-emptive surgical cutting of the perineum) is sometimes performed to facilitate delivery and limit tearing. Perineal tearing or cutting does leave scar tissue. Among the methods of hair removal evaluated for pre-surgeries, pubic hair shaving was seen to increase the risk of surgical site infections.[55] No advantages have been demonstrated in the routine shaving of pubic hair prior to childbirth.[56]

Surgery

Genitoplasties are surgical procedures that can be carried out to repair, restore or alter vulvar tissues, particularly following damage caused by injury or cancer treatment. These procedures include vaginoplasty which can also be performed as a cosmetic surgery. Other cosmetic surgeries to change the appearance of external structures include labiaplasties.

The use of cosmetic surgeries has been criticized by clinicians.[57][58] The American College of Obstetricians and Gynecologists recommends that women be informed of the risks of these surgeries. They refer to the lack of data relevant to their safety and effectiveness and to the potential associated risks such as infection, altered sensation, dyspareunia, adhesions, and scarring.[59] There is also a percentage of people seeking cosmetic surgery who may be suffering from body dysmorphic disorder and surgery in these cases can be counterproductive.[60]

Society and culture

Altering the female genitalia

 
The Labia pride movement resents the ideals of female cosmetic genital surgeries: The Muff March in London, 2011

In some cultural practices, particularly in the African Khoikhoi and Rwanda cultures, the labia minora are purposefully stretched by repeated pulling on them and sometimes by using attached weights.[61] Labia stretching is a recognised, familial cultural practice in parts of Eastern and Southern Africa.[62] This is a desired and encouraged practice by the women (starting at puberty) in order to promote better sexual satisfaction for both parties.[63][5] The acheived extensions can hang down below the labia majora for up to seven inches.[5]

In some cultures, including modern Western culture, women have shaved or otherwise removed the hair from part or all of the vulva. When high-cut swimsuits became fashionable, women who wished to wear them would remove the hair on either side of their pubic triangles, to avoid exhibiting pubic hair. Other women relish the beauty of seeing their vulva with hair, or completely hairless, and find one or the other more comfortable. The removal of hair from the vulva is a fairly recent phenomenon in the United States, Canada, and Western Europe, usually in the form of bikini waxing or Brazilian waxing, but has been prevalent in many Eastern European and Middle Eastern cultures for centuries, usually due to the idea that it may be more hygienic, or originating in prostitution and pornography. Hair removal may include all, most, or some of the hair. French waxing leaves a small amount of hair on either side of the labia or a strip directly above and in line with the pudendal cleft called a landing strip. Islam teaching includes Muslim hygienical jurisprudence a practice of which is the removal of pubic hair.[64]

 
Female genital piercings include the Christina piercing and the Nefertiti piercing.

Several forms of genital piercings can be made in the female genital area, and include the Christina piercing, the Nefertiti piercing, the fourchette piercing, and labia piercings. Piercings are usually performed for aesthetic purposes, but some forms like the clitoral hood piercing might also enhance pleasure during sex. Though they are common in traditional cultures, intimate piercings are a fairly recent trend in Western society.[65][66][67]

Female genital surgery includes laser resurfacing of the labia to remove wrinkles, labiaplasty (reducing the size of the labia) and vaginal tightening. In September 2007, the American College of Obstetricians and Gynecologists issued a committee opinion on these and other female genital surgeries, including "vaginal rejuvenation", "designer vaginoplasty", "revirgination", and "G-spot amplification". This opinion states that the safety of these procedures has not been documented. ACOG recommends that women seeking these surgeries need to be informed about the lack of data supporting these procedures and the potential associated risks such as infection, altered sensation, dyspareunia, adhesions, and scarring.[59]

With the growing popularity of female cosmetic genital surgeries, the practice increasingly draws criticism from an opposition movement of cyberfeminist activist groups and platforms, called the labia pride movement. The major point of contention is that heavy advertising for these procedures, in combination with a lack of public education, fosters body insecurities in women with larger labia in spite of the fact that there is normal and pronounced individual variation in the size of labia. The preference for smaller labia is a matter of a fashion fad and is without clinical or functional significance.[68][69]

The most prevalent form of non-consensual genital alteration is that of female genital mutilation. This mostly involves the partial or complete removal of genital organs.[70] Female genital mutilation is carried out in thirty countries in Africa, and Asia with more than 200 million girls being affected, and some women (as of 2018).[70] Nearly all of the procedures are carried out on young girls. The practices are also carried out globally among migrants from these areas. Female genital mutilation is claimed to be mostly carried out for cultural traditional reasons.[70]

 
A gynaecological examination being carried out in 1822

Etymology

The word vulva was taken from the Medieval Latin word volva or vulva ("womb, female genitals"), probably from the Old Latin volvere ("to roll"; lit. "wrapper").[71]

The naming of the female (and male) genitals as pudenda membra, meaning parts to be ashamed of, dates from the mid-17th century.[72] The naming clearly influenced the general perception of the vulva and this is shown in depicted gynaecological procedures. The examiner shown in the Obstetrical examination dated 1822, is adopting the compromise procedure where the woman's genitals cannot be seen.

Alternative terms

As with nearly any aspect of the human body involved in sexual or excretory functions, there are many sexual slang terms used for the vulva.[73] Cunt, a medieval word for the vulva and once the standard term, has become a vulgarism, and in other uses one of the strongest offensive and abusive swearwords in English-speaking cultures. The word has been replaced in normal usage by a few euphemisms including pussy (vulgar slang) and fanny (UK) which used to be a common pet name.[74] In the UK these terms have other non-sexual meanings that lend themselves to double entendres.[75][76][77] In North American informal use the term pussy can also refer to a weak or effeminate man,[78] and fanny is a term used for the buttocks.[79]

Religion and art

Some cultures have long celebrated and even worshipped the vulva. The ancient Sumerians regarded the vulva as sacred[80][81] and a vast number of Sumerian poems praising the vulva of the goddess Inanna have survived.[81] Vaginal fluid is always described in Sumerian texts as tasting "sweet"[81] and, in a Sumerian bridal hymn, a young maiden rejoices that her vulva has grown hair.[81] Clay models of vulvas were discovered in the temple of Inanna at Ashur;[82] these models likely served as some form of amulets, possibly to protect against impotency.[82] Some Hindu sects revere the vulva and vagina under the name yoni.[83]

Sheela na gigs are figurative carvings of naked women displaying an exaggerated vulva. They are found in ancient and medieval European contexts. They are displayed on many churches, but their origin and significance is debatable. A main line of thinking is that they were used to ward off evil spirits.

L'Origine du monde ("Origin of the world") painted by Gustave Courbet in 1866 was the first realistic painting of a vulva to be exhibited in Western art.

 
A 12th century sheela na gig on a church in England

British artist Jamie McCartney used casts of four hundred vulvas to create the installation known as The Great Wall of Vagina in 2011. The vagina casts are life-size. Explanations written by the project's sexual health adviser accompany these. The purpose of the artist was to "address some of the stigmas and misconceptions that are commonplace".[84][85][86]

Starr Goode explores the image and possible meanings of the Sheela na gig and Baubo images in particular, but writes also about the recurring image worldwide. Through hundreds of photographs, she demonstrates that the image of a female displaying her vulva is not an anomaly of European religious art or architecture, but that similar images are found in the visual arts and in mythical narratives of Goddesses and Heroines parting their thighs to reveal what she calls, "sacred powers." Her theory is that "the image is so rooted in our psyches that it seems as if the icon is the original cosmological center of the human imagination."[87]

Additional images

References

This article incorporates text in the public domain from page 1264 of the 20th edition of Gray's Anatomy (1918)

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