- Email: [email protected]
The male clitoris
Volume 159 Number 2
these patients tend to be easily hypnotizable (implying high levels of suggestability)' and that specific environmental triggers can be identified and modified by the use of behavioral techniques. 2 These findings are entirely consistent with the observed phenomenon in which patients with hyperemesis improve dramatically in the hospital with intravenous hydration and attentive care in the protected environment, but rapidly deteriorate upon return to the home situation, resulting in frequent recurrent admissions for this problem. Furthermore, behavioral treatments have been shown to be extremely effective. 2-4 Admittedly, the authors set out to find whether there are biologic factors that can explain their previous finding that women who had severe nausea and vomiting deliver sons who have an elevated risk for cancer of the testis. Therefore, it is not surprising that their results did not include a comprehensive model for the understanding of hyperemesis gravidarum. Their total absence of any mention of the psychologic and behavioral aspects of this phenomenon, however, is striking. Certainly, biologic aberrations should be sought and studied to more completely understand this syndrome. In my opinion, however, this is most fruitfully done within the framework of current knowledge and longstanding clinical observations.M John]. LaFerla, MD Associate Professor Department of Obstetrics and Gynecology Wayne State University School of Medicine Hutzel Hospital 4707 St. Antoine Detroit, MI 48201
Correspondence
533
Our findings are consistent with this hypothesis. Dr. LaFerla is incorrect in suggesting that we have concluded that the estrogen levels of women with hyperemesis are abnormal. We can conclude only that, on average, the levels are higher than those of women who do not have extreme nausea or vomiting during pregnancy. This does not preclude individual variation over a pregnancy for a particular woman, nor does it preclude the observation that a woman may have high estradiol levels and not have the condition. Dr. LaFerla is concerned that we have not examined psychologic or behavioral factors associated with hyperemesis gravidarum. The data used for this study were obtained from the Collaborative Perinatal Project, a prospective study of pregnancy and pregnancy outcome conducted between 1958 and 1965 by the National Institute of Neurological and Communicative Disorders and Stroke. That study did not include psychologic or behavioral assessments of participants. We agree with Dr. LaFerla that hyperemesis, like all diseases, is multifactorial in origin, and as such it may be interesting to examine these factors as contributory to the development of hyperemesis in some women. Unfortunately, we were unable to do so with our existing data base. Robert Depue, PhD Leslie Bernstein, PhD Ronald K. Ross, MD Brian E. Henderson, MD Department of Preventive Medicine Parkview Medical Building University of Southern California School of Medicine 2025 Zonal Avenue Los Angeles, CA 90033
REFERENCES I. Apfel RJ, Kelley SF, Frankel FH. The role of hypnotizability in the pathogenesis and treatment of nausea and vomiting of pregnancy. J Psychosom Obstet Gynecol 1986;5: 179-86. 2. Callahan EJ, Burnette MM, DeLawyer D, Brasted WS. Behavioral treatment of hyperemesis gravidarum. J Psychosom Obstet Gynecol 1986;5:187-95. 3. LaFerla JJ. Editorial note-Hyperemesis gravidarum. J Psychosom Obstet Gynecol 1986;5: 177-8. 4. Macy C. Psychological factors in nausea and vomiting in pregnancy: A review, J Reprod Infant Psycho! 1986;4:2355.
Reply To the Editors: Vomiting is a condition that affects more than half of all pregnant women. We believe that in most such pregnancies this condition has a physical basis. In our epidemiologic study we examined risk factors and laboratory parameters that might indicate a hormonal etiology for the most extreme form of this condition, hyperemesis gravidarum. Of particular interest to us was whether women who experience hyperemesis during pregnancy have higher levels of estradiol for a given gestational age than age- and parity-matched controls.
The male clitoris To the Editors: I would like to draw attention to a few observations about the theory of male and female urogenital homologues and to pose the question, "Is there a male clitoris?" According to the present theory, the clitoris and the part called the clitoral glans are homologues of the penis and the penile glans, respectively. Facts long known to science lead me to believe that these traditionally accepted premises should be reconsidered. For example, the theory itself recognizes that the homologue of the corpus cavernosum penis is the corpus cavernosum clitoridis.' Embryologically, anatomically, histologically, and physiologically, these male and female parts are similar. Both are derived from the shaft of the phallus; they each have a crown, corpus, and crura; and because both contain similar tissue structure, they are able to perform a similar sexual function. However, it is also an accepted fact that whereas the tip of the clitoris is the distal extremity of the corpus cavernosum, the penile glans is not similarly an extension of the corresponding corpus cavernosum penis, but rather
534 Correspondence
the anterior end of the corpus cavernosum urethrae (spongiosum). The given facts make it seem therefore illogical for one to accept the plausibility of the proposition that the tip of the female corpus cavernosum, a clitoral structure anatomically distinct from the urethral structure, is the embryologic homologue of the tip of the structure that surrounds the male urethra. Unlike the penis, the clitoris in normal female development has no urethra, a fact observed by scientists of the past and this century as well. In 1672 the Dutch anatomist Regnier deGraaf pointed out that because the glans of the clitoris is not perforated like that of the penile glans its similarity to the male glans is thus deceptive. In making the same observation in 1951, Katsuyoshi Yamada also presented convincing data to prove that, although the clitoris has long been thought of as the homologue of the penis, there are many histologic differences between the two adult structures. It is also generally accepted that the female part is far more sensitive than the male glans because of its much higher density of sensory nerve endings. A scrutiny of relevant ancient medical texts, some of them translated into English by me for the first time, 2 reveals that the notion of the penis/clitoris homology came about not through the normal rational processes of scientific research, but as the result of considerable semantic confusion in the translation of anatomic terms. The early Arabic and Greek physicians never meant to convey, as they have been purported in translation to have meant, that the part now called the clitoris is the homologue of the penis; rather, Avicenna, Galen, and Rufus believed the female homologue of the penis to be the vagina. 2 Nevertheless, because of the distortion of the original meaning of the term "clitoris," the penis/ clitoris idea had by the sixteenth century become accepted by leading scientists, including Fallopio. In 1561, when Fallopio provided the first detailed description of the deeper structure of the clitoris and stated, "this small part corresponds to the male penis," the idea became firmly established in medical thinking. Embryologists have made it clear, however, that the entire female clitoris is the homologue of only one component of the penis, the penile corpus cavernosa, not the penis as a whole. If true, and if consistency of argument and reason are not to part company, then the proposition that the clitoris and the penis are homologous is not correct and this rather dubious idea should be replaced by a more plausible concept. I propose that in such an endeavor one perceive the problem from a slightly different perspective and first ask the question posed above, "Is there a male clitoris?" Existing anatomic and histologic data suggest a logical answer. There is indeed a male clitoris, and the part that should be recognized as such is the penile corpus cavernosa." I hope that my observations will stimulate a greater interest in studies of the genital anatomy that make use of contemporary technology, including the electron microscope, in an effort to augment the microscopic stud-
August 1988 Am J Obstet Gynecol
ies of the past century. I recognize that more research remains to be done, and hope that over time embryologists will be prompted to reexamine some of the thinking of the past concerning differentiation of the external urogenital anatomy. ]. Lowndes Sevely Female Research Fund 365 Harvard St. Cambridge, MA 02138 REFERENCES l. Arey B. Developmental anatomy: a textbook and manual
of embryology. Philadelphia: WB Saunders; 1965. (The first edition of this work was published in 1924.) 2. Sevely JL. Eve's secrets: a new theory of female sexuality. New York: Random House; 1987. (Full references to texts mentioned in the letter are included.)
Is hygiene enough? Circumcision as a possible strategy to prevent neonatal group B streptococcal disease To the Editors: A great deal continues to be written regarding the diagnosis and preferred means of preventing prenatal group B streptococcal vaginal colonization and subsequent neonatal sepsis. t-• With an estimated 7200 neonates annually afflicted and an all-inclusive economic burden of $727 million per year, strategies that are both cost-effective and pragmatic could be usefulY The current position of the American Academy of Pediatrics on newborn circumcision holds via its Ad Hoc Task Force on Circumcision report of 1975 that "education leading to continuing good personal hygiene would offer all the advantages of routine circumcision without the attendant surgical risk." 6 In 1978, the Executive Board of the American College of Obstetricians and Gynecologists in a brief statement gave its support to the American Academy of Pediatrics Ad Hoc Task Force on Circumcision position that "there is no absolute medical indication for routine circumcision of the newborn." Presumably the board believed that personal hygiene is a satisfactory alternative. Whereas better hygiene of the preputial space may well be an answer (to my best awareness still never demonstrated in any published study), "the contaminated areas under the prepuce may not be accessible to even the best of penile hygiene care" 7 and represent a reservoir for a variety of sexually transmitted diseases.• The recent findings of bacterial adherence of Proteus, an organism that is a common cause of urinary tract infection in young boys and patients with repeated infections, to squamous mucosa epithelial cells9 as in the prepuce; of group B streptococci adhering to similar type squamous mucosal vaginal cells 10 ; and of Escherichia coli clinging to the preputial mucosal lining after a thorough washing but not clinging to the outer stra-
these patients tend to be easily hypnotizable (implying high levels of suggestability)' and that specific environmental triggers can be identified and modified by the use of behavioral techniques. 2 These findings are entirely consistent with the observed phenomenon in which patients with hyperemesis improve dramatically in the hospital with intravenous hydration and attentive care in the protected environment, but rapidly deteriorate upon return to the home situation, resulting in frequent recurrent admissions for this problem. Furthermore, behavioral treatments have been shown to be extremely effective. 2-4 Admittedly, the authors set out to find whether there are biologic factors that can explain their previous finding that women who had severe nausea and vomiting deliver sons who have an elevated risk for cancer of the testis. Therefore, it is not surprising that their results did not include a comprehensive model for the understanding of hyperemesis gravidarum. Their total absence of any mention of the psychologic and behavioral aspects of this phenomenon, however, is striking. Certainly, biologic aberrations should be sought and studied to more completely understand this syndrome. In my opinion, however, this is most fruitfully done within the framework of current knowledge and longstanding clinical observations.M John]. LaFerla, MD Associate Professor Department of Obstetrics and Gynecology Wayne State University School of Medicine Hutzel Hospital 4707 St. Antoine Detroit, MI 48201
Correspondence
533
Our findings are consistent with this hypothesis. Dr. LaFerla is incorrect in suggesting that we have concluded that the estrogen levels of women with hyperemesis are abnormal. We can conclude only that, on average, the levels are higher than those of women who do not have extreme nausea or vomiting during pregnancy. This does not preclude individual variation over a pregnancy for a particular woman, nor does it preclude the observation that a woman may have high estradiol levels and not have the condition. Dr. LaFerla is concerned that we have not examined psychologic or behavioral factors associated with hyperemesis gravidarum. The data used for this study were obtained from the Collaborative Perinatal Project, a prospective study of pregnancy and pregnancy outcome conducted between 1958 and 1965 by the National Institute of Neurological and Communicative Disorders and Stroke. That study did not include psychologic or behavioral assessments of participants. We agree with Dr. LaFerla that hyperemesis, like all diseases, is multifactorial in origin, and as such it may be interesting to examine these factors as contributory to the development of hyperemesis in some women. Unfortunately, we were unable to do so with our existing data base. Robert Depue, PhD Leslie Bernstein, PhD Ronald K. Ross, MD Brian E. Henderson, MD Department of Preventive Medicine Parkview Medical Building University of Southern California School of Medicine 2025 Zonal Avenue Los Angeles, CA 90033
REFERENCES I. Apfel RJ, Kelley SF, Frankel FH. The role of hypnotizability in the pathogenesis and treatment of nausea and vomiting of pregnancy. J Psychosom Obstet Gynecol 1986;5: 179-86. 2. Callahan EJ, Burnette MM, DeLawyer D, Brasted WS. Behavioral treatment of hyperemesis gravidarum. J Psychosom Obstet Gynecol 1986;5:187-95. 3. LaFerla JJ. Editorial note-Hyperemesis gravidarum. J Psychosom Obstet Gynecol 1986;5: 177-8. 4. Macy C. Psychological factors in nausea and vomiting in pregnancy: A review, J Reprod Infant Psycho! 1986;4:2355.
Reply To the Editors: Vomiting is a condition that affects more than half of all pregnant women. We believe that in most such pregnancies this condition has a physical basis. In our epidemiologic study we examined risk factors and laboratory parameters that might indicate a hormonal etiology for the most extreme form of this condition, hyperemesis gravidarum. Of particular interest to us was whether women who experience hyperemesis during pregnancy have higher levels of estradiol for a given gestational age than age- and parity-matched controls.
The male clitoris To the Editors: I would like to draw attention to a few observations about the theory of male and female urogenital homologues and to pose the question, "Is there a male clitoris?" According to the present theory, the clitoris and the part called the clitoral glans are homologues of the penis and the penile glans, respectively. Facts long known to science lead me to believe that these traditionally accepted premises should be reconsidered. For example, the theory itself recognizes that the homologue of the corpus cavernosum penis is the corpus cavernosum clitoridis.' Embryologically, anatomically, histologically, and physiologically, these male and female parts are similar. Both are derived from the shaft of the phallus; they each have a crown, corpus, and crura; and because both contain similar tissue structure, they are able to perform a similar sexual function. However, it is also an accepted fact that whereas the tip of the clitoris is the distal extremity of the corpus cavernosum, the penile glans is not similarly an extension of the corresponding corpus cavernosum penis, but rather
534 Correspondence
the anterior end of the corpus cavernosum urethrae (spongiosum). The given facts make it seem therefore illogical for one to accept the plausibility of the proposition that the tip of the female corpus cavernosum, a clitoral structure anatomically distinct from the urethral structure, is the embryologic homologue of the tip of the structure that surrounds the male urethra. Unlike the penis, the clitoris in normal female development has no urethra, a fact observed by scientists of the past and this century as well. In 1672 the Dutch anatomist Regnier deGraaf pointed out that because the glans of the clitoris is not perforated like that of the penile glans its similarity to the male glans is thus deceptive. In making the same observation in 1951, Katsuyoshi Yamada also presented convincing data to prove that, although the clitoris has long been thought of as the homologue of the penis, there are many histologic differences between the two adult structures. It is also generally accepted that the female part is far more sensitive than the male glans because of its much higher density of sensory nerve endings. A scrutiny of relevant ancient medical texts, some of them translated into English by me for the first time, 2 reveals that the notion of the penis/clitoris homology came about not through the normal rational processes of scientific research, but as the result of considerable semantic confusion in the translation of anatomic terms. The early Arabic and Greek physicians never meant to convey, as they have been purported in translation to have meant, that the part now called the clitoris is the homologue of the penis; rather, Avicenna, Galen, and Rufus believed the female homologue of the penis to be the vagina. 2 Nevertheless, because of the distortion of the original meaning of the term "clitoris," the penis/ clitoris idea had by the sixteenth century become accepted by leading scientists, including Fallopio. In 1561, when Fallopio provided the first detailed description of the deeper structure of the clitoris and stated, "this small part corresponds to the male penis," the idea became firmly established in medical thinking. Embryologists have made it clear, however, that the entire female clitoris is the homologue of only one component of the penis, the penile corpus cavernosa, not the penis as a whole. If true, and if consistency of argument and reason are not to part company, then the proposition that the clitoris and the penis are homologous is not correct and this rather dubious idea should be replaced by a more plausible concept. I propose that in such an endeavor one perceive the problem from a slightly different perspective and first ask the question posed above, "Is there a male clitoris?" Existing anatomic and histologic data suggest a logical answer. There is indeed a male clitoris, and the part that should be recognized as such is the penile corpus cavernosa." I hope that my observations will stimulate a greater interest in studies of the genital anatomy that make use of contemporary technology, including the electron microscope, in an effort to augment the microscopic stud-
August 1988 Am J Obstet Gynecol
ies of the past century. I recognize that more research remains to be done, and hope that over time embryologists will be prompted to reexamine some of the thinking of the past concerning differentiation of the external urogenital anatomy. ]. Lowndes Sevely Female Research Fund 365 Harvard St. Cambridge, MA 02138 REFERENCES l. Arey B. Developmental anatomy: a textbook and manual
of embryology. Philadelphia: WB Saunders; 1965. (The first edition of this work was published in 1924.) 2. Sevely JL. Eve's secrets: a new theory of female sexuality. New York: Random House; 1987. (Full references to texts mentioned in the letter are included.)
Is hygiene enough? Circumcision as a possible strategy to prevent neonatal group B streptococcal disease To the Editors: A great deal continues to be written regarding the diagnosis and preferred means of preventing prenatal group B streptococcal vaginal colonization and subsequent neonatal sepsis. t-• With an estimated 7200 neonates annually afflicted and an all-inclusive economic burden of $727 million per year, strategies that are both cost-effective and pragmatic could be usefulY The current position of the American Academy of Pediatrics on newborn circumcision holds via its Ad Hoc Task Force on Circumcision report of 1975 that "education leading to continuing good personal hygiene would offer all the advantages of routine circumcision without the attendant surgical risk." 6 In 1978, the Executive Board of the American College of Obstetricians and Gynecologists in a brief statement gave its support to the American Academy of Pediatrics Ad Hoc Task Force on Circumcision position that "there is no absolute medical indication for routine circumcision of the newborn." Presumably the board believed that personal hygiene is a satisfactory alternative. Whereas better hygiene of the preputial space may well be an answer (to my best awareness still never demonstrated in any published study), "the contaminated areas under the prepuce may not be accessible to even the best of penile hygiene care" 7 and represent a reservoir for a variety of sexually transmitted diseases.• The recent findings of bacterial adherence of Proteus, an organism that is a common cause of urinary tract infection in young boys and patients with repeated infections, to squamous mucosa epithelial cells9 as in the prepuce; of group B streptococci adhering to similar type squamous mucosal vaginal cells 10 ; and of Escherichia coli clinging to the preputial mucosal lining after a thorough washing but not clinging to the outer stra-