World Journal of Urology, vol. 17, no. 3 (June 1999): pp. 133-136.


Frederick M. Hodges

Phimosis in antiquity



Abstract
   The medical term phimosis has been in use since antiquity, but in contrast to the imprecise definition of the term that is characteristic of nineteenth-century and some controversial modern medical writing, Greek and Roman medical writers imbued it with a clinically precise definition. Using the tools of the history of medicine, an analysis of the medical writings of antiquity reveals that phimosis was defined exclusively as a rare, inflammatory or cicatricial stricture of the preputial orifice consequent to a true pathological condition rather than a disease process in itself. Putative associations between phimosis and diseases such as urinary tract infections or cancer were not made in antiquity and are reflections of modern, geographically isolated social anxieties. The modern European scientific conceptualisation of phimosis, however, represents a return to the precise terminology and conservative therapeutic approach characteristic of Greek and Roman medicine.



Since the nineteenth century, medical writers have argued for the existence of a complex and broadly defined disease construct to which they have attached the ancient Greek word phimosis. In this context, phimosis has been conceived of as a morphological deviation from a mythical penile norm. Phimosis has, accordingly, been described as a foreskin that is "too long" (hypertrophic phimosis), a foreskin whose orifice is not as expandable as the foreskin of most adults (often called "true" phimosis), or a foreskin that has not yet completed the developmental process of physiological detachment from the glans (congenital phimosis). Rather than a symptom of disease, phimosis has been classified as a disease sui generis as well as a cause of disease, and as such, for nearly 200 years, presumably responsible physicians, writing in leading medical journals and textbooks have further claimed that the results of their research 'prove' that phimosis is the cause of such diseases as cancer of the male and female reproductive organs, venereal disease, malnutrition, epilepsy, hydrocephalus, insanity, idiocy, masturbation, heart disease, homosexuality, deafness, dumbness, urinary tract infections, criminality, and death, to name but a few. The drive to cure and prevent phimosis, thus, has been presented as a surgical solution to the most pressing social and moral problems [15].

The European medical concept of phimosis, however, has made a significant departure from its nineteenth-century roots and from the current ideology of American medicine, which still clings to nineteenth-century notions in this respect. The vanguard of European medical experts no longer conceive of phimosis as disease or as a cause of disease. Phimosis is now defined as a stricture of the preputial orifice caused by lichen sclerosus et atrophicus (LSA), also known as balanitis xerotica obliterans (BXO), a rare, dermatological condition of unknown aetiology. In Britain, Rickwood et al. have successfully argued that the definition of phimosis should be divested of any notions of preputial non-retractability, physiological balanopreputial attachment, or preputial length [19]. The new definition of "true phimosis" refers to a condition where "the tip of the foreskin is scarred and indurated and has the histological features of Balanitis xerotica obliterans" [20]. More recently, Rickwood has refined this to the formulas: "Phimosis = BXO", and "No BXO = No Phimosis" [21]. In the historical context, the contemporary European refinement of the definition of phimosis represents a return to an earlier definition of the term, one that is found in the classic medical writings of Greek and Roman antiquity.


Phimosis in antiquity

The word phimosis is derived from the Greek. For this reason, medical writers in the nineteenth century asserted that phimosis, as they defined it, was recognised by the Greeks as a genuine penile defect. An analysis of the corpus of ancient medical literature, however, demonstrates that the nineteenth-century conceptualisation of phimosis does not correspond with the Greek and Roman definition of the term.

Throughout the greater portion of the span of antiquity, phimosis as a medical term did not exist. Indeed, Greek physicians of the classical era were evidently uninterested in the foreskin from a medical perspective. Significantly, the word phimosis does not appear in the Hippocratic corpus of the fifth century BC. Reference to the foreskin as a distinct part of the penis, however, is characteristic of the corpus. One such reference is found in the Hippocratic aphorism that states:

Here we meet the useful Greek word acroposthion, which designates the visually defining, tapered, fleshy, nipple-like portion of the foreskin that advances beyond the terminus of the underlying glans penis. The acroposthion, especially in early youth, can run to impressive lengths. Distinguished from the acroposthion is the posthe, which is the portion of the foreskin that merely enfolds the glans penis, beginning at the coronal sulcus. While it is not possible to make a definitive interpretation of the above-cited Hippocratic aphorism, one might surmise that the allusion to the severing of the acroposthion confirms that the originator of this aphorism was aware of the foreskin-despoiling blood rituals peculiar to some of the Semitic tribes inhabiting those regions that lay south-east of Greek-inhabited lands.

As demonstrated by their visual art, the Greeks highly esteemed the foreskin as a defining feature of the male body. Indeed, Galen speaks of the foreskin as a brilliantly useful adornment. [10]. It is not surprising, then, that half a millennium would pass before the word phimosis entered the medical lexicon. Although it makes its first appearance in the medical writings of the Roman era, writers first used the term phimosis loosely to indicate a condition of being constricted, irrespective of the part afflicted. For instance, Galen [14], Heliodorus [12], and Andromachus [1] used the term to refer to inflammatory strictures of the anus or the eyelid, but not the foreskin.

In his Materia Medica, the Greek physician Dioscorides of Anazarbus, who flourished under the reigns of Claudius and Nero (41-68 AD), mentioned briefly that a concoction of the juice of the leaves of the herb cotyledon and wine would "soften constriction of the genitals, help inflammation, erysipelas, chilblain, and when plastered over, help scrofula and sore throat" [8]. The original Greek wording does not specify what part of the genitals of what sex Dioscorides recommends as the target for the healing powers of this herb. Furthermore, rather than use the word phimosis, he uses the etymologically related term phimos, which, in this case, could, with equal validity, refer to an imperforate anus or a urethral stricture of either sex. Still, the historically portentous association had now been made between the genitals and the idea of stricture.

Even if Dioscorides did not make the association in terms of the foreskin, one or more of his coeval compatriots must have, for Aulus Cornelius Celsus, who in all probability lived during the reign of Emperor Tiberius (14-37 AD), says that they did. In his great work, De Medicina, Celsus reports:

The first surgical treatment that Celsus describes is a ventral slit, a minor, tissue-sparing procedure that would have imposed a fairly minimal cosmetic defect. The second procedure, being a variation on the first, involves the removal of a small amount of sclerotic tissue. Here again, the ventral site of the incision would largely preserve cosmesis and preputial mechanical function.

Elsewhere, Celsus provides a more detailed exposition of his concept of preputial pathology, without, it must be emphasised, using the word phimosis. In this instance, he stresses the abnormal induration of the preputial tissue as the primary diagnostic key:

Celsus continues this passage with advice on diet, rest, and the application of fomentations. Given the strict emphasis on cankerous ulcerations, it is obvious that Celsus' concept of phimosis is that of a pathological inflammation of the foreskin as a complication of canker. The notching of the inflamed foreskin, in order to release the purulent discharge, indicates that a true pathological condition is at work. In contrast to the nineteenth-century medical conception of phimosis, Celsus does not define phimosis as a "redundant", "tight", or "adherent" foreskin. For Celsus, phimosis is a diagnostic description of the effects on the foreskin caused by a real pathological condition, which, in the post-bacteriological era, we might recognise as being of likely microbial origin. Of special relevance is the first description of phimosis as an induration of the foreskin, which neatly matches the modern European medical understanding of the effects of LSA (i.e. BXO) on the foreskin.

The second known use of the word phimosis is found in the extant writings of the Greek physician Antyllus, who lived in the second century AD. The writings of Antyllus enjoyed wide currency and were directly copied into the encyclopaedic medical compilation of Oribasus, from which the following passages are drawn, and Paulus Ægineta [18]. Proceeding where Celsus left off, Antyllus further refines the medical conception of phimosis to include reference to inelastic scar tissue and pathological granulations as the cause of symptomatic preputial nonretractability. The cure that he proposes entails a series of incisions in the scar tissue in order to expand it and allow the foreskin to function properly.

The thematic and lexicographic connection that Antyllus draws between phimosis and paraphimosis underscores the importance of the existence of an inflammatory process implicit in a diagnosis of phimosis.

In a separate chapter, Antyllus describes a condition in which the previously retractable foreskin becomes adhered to the glans because of ulcerations of either part. The recommended cure entails freeing the adhesions. Antyllus is careful to avoid calling this condition phimosis, and instead calls it simply "adherence of the foreskin".

Although in the nineteenth century it was common to use the word phimosis to denote, among other things, both the pathological, ulcerative balanopreputial adhesions of adult suffering the dermatological effects of sexually transmitted diseases and the natural physiological balanopreputial attachment characteristic of youth, Antyllus makes no such error, restricting the term phimosis to inflammatory nonretractability of the foreskin rather than pathological balanopreputial adherence. Neither Antyllus nor any other Greek writer confused the developmental, physiological, and transitory balanopreputial attachment of the juvenile penis with pathological adhesions. As such, the strict definition of the word phimosis was maintained.

One common misuse of the word phimosis by nineteenth-century and some modern medical writers concerns the length of the foreskin. Penises were and are frequently diagnosed with phimosis because the foreskin has arbitrarily been determined to be "too long", "redundant", or "hypertrophic". The Greeks, however, recognised no such disease. In antiquity, the problem was not having too much foreskin, but having too little. Consequently, classical medical writers were concerned with a deformity called lipodermus, a condition in which the foreskin was not long enough to cover the glans penis completely. Galen [11], Soranus [23], Dioscorides [9], and Antyllus [2], among others, published lengthy descriptions of lipodermus and made detailed recommendations for its correction. Greek medical writers also devoted considerable space to surgical and non-surgical methods of foreskin restoration following posthectomy [22].

The wealth of classical medical writing devoted to the correction of lipodermus and posthectomy, when considered against the relative paucity of writing on phimosis as defined by medical writers in antiquity, lends strength to the argument that inflammatory or cicatricial stricture of the preputial orifice was a rare and unusual urological condition.


Conclusions

In contrast to the nineteenth-century conceptualisation of phimosis, which is predicated upon an alleged universality and defined purely in terms of a misunderstanding of preputial development and a biased view of penile morphology, the conception of phimosis in antiquity was based on rarity and on clinically verifiable histological pathology. The nineteenth-century conceptualisation of phimosis was predicated on the pathologisation of the three defining characteristics of the juvenile foreskin: physiological preputial nonretractability; physiological balanopreputial attachment, and generous length of the acroposthion. These pathologised, but not genuinely pathological, attributes were believed to be diseases in and of themselves that could cause other diseases. In antiquity, phimosis was defined strictly as a stricture of the preputial orifice that had been caused by a genuine dermatological disease process. The differing conceptualisations of phimosis provide an important example of how nineteenth-century medicine pathologised the natural body and sought justification and legitimacy for this culturally motivated process by asserting a false analogy with classical medical concepts.

Finally, the current European concept of phimosis can be viewed as a return to the original classical understanding of phimosis as a symptom of clinically verifiable pathological conditions. This change is reflected in the increasing move towards establishing evidence-based pharmacological treatments [16, 17] and tissue-preserving surgeries [7] that, like their classical antecedents, are focused on treating underlying pathology, maintaining foreskin function, and preserving natural cosmesis.


F. M. Hodges
Wellcome Unit for the History of Medicine,
University of Oxford,
45-47 Banbury Road,
Oxford OX1 6PE, UK
e-mail: frederick.hodges@history-of-medicine.oxford.ac.uk


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