In striking contrast to late nineteenth century Britain and twentieth century United States, there was no sign in eighteenth century Europe of the “congenital phimosis” which suddenly became so common in boys after the 1860s. Quite the contrary: in the sixteenth century Gabriele Falloppio had observed that it was considered shameful and unhealthy for the glans to be uncovered (in classical times regarded as a pathological condition known as lipodermos) and prescribed means for lengthening inadequate foreskins. He thought that a penis with an exposed glans looked like a horse’s rump. The English anatomist William Harvey (discoverer of the circulation of the blood) wrote that in some men “the glans is never uncovered” without regarding this as a problem in need of surgical correction. The concept of phimosis as a pathological condition requiring medical treatment emerged only in the late seventeenth century, probably as a result of the syphilis epidemic, since the disease often produced scabs which fused foreskin to glans. One of the first to notice phimosis was perhaps the French surgeon Pierre Dionis (d. 1718), who defined it as a condition in which “the extremity of the prepuce is so tight that it will not permit the glans to be uncovered”. He observed that it could occur naturally but more commonly arose from a wound or venereal chancre which caused the preputial orifice to shrink. The muzzled or phimotic condition was normal (“physiological”) in infants and boys, but if it persisted into adulthood and was troublesome, the patient should treat it himself by pinching the foreskin shut while urinating and allowing the pouch to fill with urine, taking advantage of its elasticity and thus stretching the skin. In cases of where the condition arose from an accident or disease, treatment involved nicking the lip just enough to permit retraction.
In his Medicinal Dictionary (1743-45) the English physician Robert James (1705-76) included an entry for phimosis in which he pointed out that this was usually a natural condition which demanded no medical attention at all:
Some … have the foreskin naturally so long and so straitened [i.e. narrow] that the glans can either be not at all or very little uncovered; but as this neither occasions trouble in discharging the urine, nor any impediment in procreation, it requires no aid from the surgeons, unless it be attended with an inflammation, violent pain or any remarkable inconvenience in coition.
Phimosis became a medical problem only if the foreskin became “so contracted by a violent inflammation that it cannot be drawn backwards behind the glans”, the usual cause of which condition was “impure coition” (i.e. venereal disease) producing a chancre which caused inflammation and possibly adhesion of the foreskin to the glans. The first line of treatment was to bathe the parts in a decoction of “barley mixed with honey of roses”, followed by bleeding and fomentations; only if these measures failed was surgical intervention required – first by slitting the foreskin and, in desperate cases, by an operation similar to “the Jewish circumcision”, but noticeably less radical.
Paraphimosis
Cutting was never indicated for paraphimosis, cases of which occurred most commonly in young husbands with tight foreskins who exerted themselves vigorously during intercourse; and similarly endowed boys who “lasciviously” drew their foreskin back while the penis was flaccid but found they could not return it after the ensuing erection. The only treatment needed was cold water to make the erection subside; lubrication of the penis with olive oil or butter; and manual manipulation if that was not sufficient. Such benign and simple therapies naturally became unthinkable as the masturbation taboo tightened its grip on medical profession and public alike from the late eighteenth century onwards. The eighteenth century English anatomist John Hunter gave similar advice and tended to regard all true phimosis as arising from venereal disease, particularly chancres and syphilis which caused ulcers and scabs which fused the foreskin to the glans and/or caused the orifice to tighten. He also observed that the non-retractability of the foreskin in many boys before puberty was perfectly natural and was often overcome by the boys’ own manual explorations and fondling:
This natural phymosis is so considerable in some children as not to allow the urine to pass with ease, but in general becomes larger and larger, as boys grow up, by frequent endeavouring to bring it over the glans, which effect often prevents the bad consequences that would otherwise ensue in it when affected by disease.
This is an interesting comment, revealing what a down to earth observer Hunter was. What he is suggesting is that no treatment was needed for phimosis because boys naturally stretched their foreskin when playing with their penis, gradually loosening it and achieving mobility at their own pace. With the Victorian masturbation scare, genuine phimosis at older ages might have become more common, since boys were now instructed not to play with or even to touch their penis, with the result that these manipulations could have become less frequent, and this gentle process of loosening disrupted.
It was, therefore, only in the eighteenth century that a recognisably modern understanding of phimosis emerged, but even then it was a condition described only in adult men, never in infants or boys. John Marten makes no mention of phimosis in his description of the “defects, diseases and infirmities” of the genitals (1708), and describes only his treatment for a short frenum (frenulum breve), easily fixed by a snip to the offending filaments, in much the same way as recommended by Nicolas Venette and later practised by Philippe Ricord in France and William Acton in Britain. There is no mention of phimosis at all in Jane Sharp’s Midwives’ Book (1671), nor in any eighteenth century baby or child care manual. The conceptualisation of phimosis as pathological defect in immature boys had to wait until the identification of masturbation as a disease agent had spread from the denunciatory texts into mainstream medical works, and from there the demonisation of the foreskin followed.
The increasing concern with phimosis in adult men was probably a response to the syphilis epidemic, which drove many to present themselves at doctors’ surgeries with suddenly non-retractable foreskins as a result of swelling, ulceration and other nasty side-effects of venereal disease arising from sexual promiscuity. Such infections often did produce sores which fused the foreskin to the glans as they healed and otherwise caused the foreskin to tighten and become less elastic. We have already seen the descriptions of these conditions by Pierre Dionis and John Hunter, both of whom stated that phimosis (non-retractability) in childhood was normal, and it is worth recalling Hunter’s streetwise observation that boys commonly loosened tight foreskins by their ineradicable urge to play with their penis. This, indeed, was the advice given by Robert James for treating paraphimosis: cold water to make the erection subside; lubrication of the penis with olive oil or butter; and manual manipulation if that failed. Such conservative therapies (especially the last) obviously became impossible once the masturbation taboo had taken hold. It was thus the conjunction of the venereal disease epidemic and the masturbation phobia which gave rise to the twin delusions that an adherent prepuce in boys was pathological, and that pre-emptive amputation of the foreskin was an effective defence against syphilis and chancre.
In the late eighteenth and early nineteenth centuries the distinction between venereal chancre and phimosis was so blurred that the terms seemed almost interchangeable. The physician William Buchan barely mentioned phimosis in his Domestic Medicine (1772), leaving the subject to be covered in his Observations Concerning … Venereal Disease (1796), where he reported that phimosis was an occasional problem in adult men, usually associated with venereal infection, and that the best treatment was conservative: hot and cold poultices, fomentations and bathing. Small incisions were sometimes necessary in severe cases. Buchan accepted the great variability of foreskin length as a biological fact and did not try to impose his own standards of what was allowable:
These parts are so differently formed in different men that some may be said to have a natural phimosis; while others have the reverse. I have seen the foreskin so long that above three inches of it were amputated [i.e. would need to be], in order to discover the glans. In others the glans is never covered but remains exposed during life. Neither of these is attended with any considerable degree of inconvenience, unless in a diseased state.
Buchan also warned that phimosis, and more often paraphimosis, were often caused by ill-advised interference:
I have known some young men bring on a violent paraphymosis by acting on a wrong principle. One who had pulled back the skin and kept it there until it could not be returned without making incisions on both sides, said he did it on purpose to keep the glans cool. In this case, though the stricture was removed … the foreskin remained thickened.
Most cases of phimosis caused by venereal infection could be cured by conservative treatment, and it was only in rare and obstinate instances that surgery was needed. Only after “all endeavours” to draw the foreskin back, using fomentations etc, had failed was it necessary to slit it open. Buchan was aware that this was a desperate step, since “many people” considered incision to imply “mutilation”, and he was at pains to point out that such mutilation was necessary only when the problem had been neglected. Early treatment would ensure that no more than a small incision was required. He described any cutting of the penis as “mangling and maiming” and assumed that nobody would allow it to be done except to save his life, and that he would still regret it.
A similar classification of phimosis as a venereal disease was made in the 1820s by Sir Astley Cooper, who stated that phimosis arose from “slight inflammation of the cellular tissue, and effusion of serous matter into it”. The cure was mercury, purges, and fomentations. Although it was the consequence, not the cause, phimosis induced by venereal chancre or other infection was a serious condition, and treatment was certainly needed (not that the nineteenth century could offer any effective treatments). But the idea that phimosis (meaning non-retractability) was pathological in men neither infected with venereal disease nor suffering from other injury, and whose foreskins varied enormously in length and tightness, developed as a result of the confounding of these two quite separate categories. The outcome was the extension of phimosis as a disease condition to men who were perfectly healthy, and from there to infants and boys whose tightly covered penises were perfectly normal.
For further details and references see Robert Darby, A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain (University of Chicago Press, 2005), chapters 2 and 10.