Lipodermos

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Lipodermos (λιποδερμος, lit. "lacking skin") is an ancient Greek medical disease concept which describes a penis with little or no foreskin. [1][2] The Greeks valued a longer prepuce, and pathologized the state of having a deficient prepuce, especially one that has been surgically ablated(i.e. circumcised).[3] It must be remembered that this medical conceptualization happened in the historical context of the legal efforts to abolish ritual circumcision throughout the Seleucid and Roman empires.[4]

(See also aposthia.)

Contents

Treatment of Lipodermos

It could be said that Greek attempts at treating so-called "lipodermos" are some of the most ancient methods of foreskin restoration. Depending on the severity of the condition or its cause, lipodermos was treated in the following ways:

Medicinal Treatment

In his Materia medica, Dioscorides of Anazarbus (41–68 C.E.) suggested that the prepuce could be made supple to allow it to stretch by soaking it in honey and warm water repeatedly, provided the lipodermic condition not be due to circumcision.[5] Dioscorides also recommended herbal treatment with the rubefacient plant thapsia (T. garganica). This plant was said to have the property of augmenting the volume of the parts onto it was applied, again, provided the condition was congenital and not the result of circumcision.[6] Galen also advocated the use of thapsia and hinted that there were several topical preparations that were helpful for the treatment of lipodermic men.[7]

Stretching

In ancient Greece, athletes or komasts used preputial ligature to keep the prepuce covering the glans of the penis, as its exposure was seen as rude and vulgar (see kynodesme). The Ephesian physician Soranus, who lived under the reigns of Trajan and Hadrian (98–138 C.E.) indicates that there was a wider use of a ligature and a more general cultural diffusion of the concept of lipodermos. In his work Gynecology, Soranus justifies the medically prescribed stretching of the foreskin by an appeal to aesthetics. He advises wet nurses to massage the newborn child periodically, and to pay particular attention to performing manipulations designed to improve the appearance of the congenitally lipodermic penis:

"If the male neonate appears to be lipodermic, [the wet nurse] should gently draw the akroposthion forward or even hold it together with a strand of wool to fasten it. If gradually stretched and continuously drawn forward, it easily stretches and assumes its normal length, covers the glans penis and becomes accustomed to keep [a] natural good shape.[8]

Preserved in their original setting in De methodo medendi,[9] Galen's nonsurgical methods of elongating the prepuce involve different applications of traction and tension. The abridged account of Galen's exposition that appears in Oribasius's compilation states:

"When the skin of the penis needs only a short stretch in order to give it a natural appearance, I have often obtained the desired result through simple tension: I roll around the circumference of the penis a strip of strong and soft papyrus, after having coated the skin with glue. It is clear that it is necessary to glue the end of the strip of papyrus to the part of the same strip placed on the underside of the end. In effect, this device dries quickly and pulls without discomfort. One places under the skin of the posthe, on the interior fold, a rounded object of suitable dimension, that one can easily remove when the strip of papyrus is adhered. When I have no such object at my disposal, I often roll up and introduce a piece of papyrus of average size to serve as a support for the one with which I surround the penis. I want to be careful to provide the patient with a way to urinate easily when the paper rolled around his penis is completely solidified and the supporting one is removed. Some of those who use thapsia to return the posthe over the glans construct the round object in question in the form of little lead spout. They stretch the skin of the posthe over the exterior of this spout and secure it with a soft leather cord.This procedure can sometimes also be useful for those individuals who are missing a large amount of posthe. I also treat this surgically."[10]

The alternative method that Galen outlines, that of inserting a lead spout under the prepuce and holding it in place by binding the enveloping prepuce with a leather cord would have added weight and perhaps tension, depending on the length of the lead spout, to the restorative technique.[11]

Like the technique of Soranus, Galen's method of manually stretching the deficient preputial skin over the glans and winding a leather cord around the "akroposthion" would have a similar effect to that of the kynodesme. These techniques depend for their efficacy on the principles of tissue expansion, today a major reconstructive technique. Given sufficient application of constant tension, new and permanent skin can be induced to grow. Penile skin, noted for its great elasticity, is especially responsive to expansion techniques.

Surgical Treatment

The surgical techniques developed in antiquity to repair the lipodermic penis have been described in modern medical journals,[12] but these papers erroneously portray these operations as having the sole objective of surgically repairing the circumcised penis rather than the lipodermic penis, which, as the ancient sources show, need not necessarily have been caused by circumcision. For instance, Celsus prefaces his account of his surgical technique by specifying that it is to treat "those in whom the defect is natural,"[13] rather than those in whom it is caused by circumcision. The Latin translation omits the term lipodermos, but the subject matter and composition fit so well with other explicitly denominated descriptions of lipodermos repair (see below)that the attribution may be taken to be legitimate:

"And, if the glans is bare and the man wishes for the look of the thing to have it covered, that can be done; but more easily in a boy than in a man; in one in whom the defect is natural, than in one who after the custom of certain races has been circumcised; and in one who has the glans small and the adjacent skin rather ample, while the penis itself is shorter, rather than in one in whom the conditions are contrary.
Now the treatment for those in whom the defect is natural is as follows. The prepuce around the glans is seized, stretched out until it actually covers the glans, and there tied. Next the skin covering the penis just in front of the pubes is cut through in a circle until the penis is bared, but great care is taken not to cut into the urethra, nor into the blood vessels there. This done the prepuce slides forwards towards the tie, and a sort of small ring is laid bare in front of the pubes, to which lint is applied in order that flesh may grow and fill it up. <It is seen that a large enough part of the penis has been bared, if the skin is distended little or not at all, and if> the breadth of the wound above supplies sufficient covering. But until the scar has formed it must remain tied, only a small passage being left in the middle for the urine. But in one who has been circumcised the prepuce is to be raised from the underlying penis around the circumference of the glans by means of a scalpel. This is not so very painful, for once the margin has been freed, it can be stripped up by hand as far back as the pubes, nor in so doing is there any bleeding. The prepuce thus freed is again stretched forwards beyond the glans; next cold water affusions are freely used, and a plaster is applied round to repress severe inflammation. And for the following days the patient is to fast until nearly overcome by hunger lest satiety excite that part. When the inflammation has [Page 399] ceased, the penis should be bandaged from the pubes to the corona; over the glans the plaster is applied with the other end of the probe. This is done in order that the lower part may agglutinate, whilst the upper part heals without adhering."[14]

In addition to the surgical technique outlined by Celsus, the compilations of Paul of Aegina and Oribasius contain abridged accounts of a similar surgical treatment, originally from the Cheirourgoumena (preserved only in fragments), a lost work by Antyllus, a second-century C.E. Greek physician.[15] Unlike Celsus, Antyllus freely uses the term lipodermos, but like Celsus, he stresses that this operation is of little value in circumcision-caused lipodermos. In a brief commentary, however, Paul of Aegina voices his disapproval of Antyllus's operation, expressing his doubt that anyone would choose to submit to its dangers.

References

  1. Hodges FM. The Ideal Prepuce in Ancient Greece and Rome: Male Genital Aesthetics and Their Relation to Lipodermos, Circumcision, Foreskin Restoration, and the Kynodesme. Bull. Hist. Med., 2001 Fall; 75(3): 375.
  2. Pseudo-Galen, but presented as Galen in Definitiones medicae 164, in Kühn, MG (n. 9), 19: 445. See Jutta Kollesch, Untersuchungen zu den pseudogalenischen Definitiones Medicae (Berlin: Akademie-Verlag, 1973).
  3. Hodges FM. The Ideal Prepuce in Ancient Greece and Rome: Male Genital Aesthetics and Their Relation to Lipodermos, Circumcision, Foreskin Restoration, and the Kynodesme. Bull. Hist. Med., 2001 Fall; 75(3): 375.
  4. Hodges FM. The Ideal Prepuce in Ancient Greece and Rome: Male Genital Aesthetics and Their Relation to Lipodermos, Circumcision, Foreskin Restoration, and the Kynodesme. Bull. Hist. Med., 2001 Fall; 75(3): 375.
  5. Dioscorides, De materia medica 2.82.2, in Pedanii Dioscuridis Anazarbei De materia medica, ed. Max Wellmann, 3 vols. (Berlin: Weidmann, 1907), 1: 166.
  6. Ibid. 4.153.4–5 (Wellmann, 2: 300).
  7. Galen, De compositione medicamentorum per genera 7.7 (Kühn, MG [n. 9], 13: 985).
  8. Soranus, Gynaeciorum 2.36.103.20–25, in Sorani Gynaeciorum libri IV, ed. Johannes Ilberg (CMG, IV)(Leipzig: Teubner, 1927), p. 79; translation adapted from Owsei Temkin, trans., Soranus' Gynecology (Baltimore: Johns Hopkins Press, 1956), p. 107.
  9. Galen, De methodo medendi 14.16 (Kühn, MG [n. 9], 10: 1000–1001).
  10. Oribasius, Collectionum medicarum reliquiae 50.1 (Raeder, OCMR [n. 36 ], 4: 55).
  11. Hodges FM. The Ideal Prepuce in Ancient Greece and Rome: Male Genital Aesthetics and Their Relation to Lipodermos, Circumcision, Foreskin Restoration, and the Kynodesme. Bull. Hist. Med., 2001 Fall; 75(3): 397.
  12. Jody P. Rubin, "Celsus' Decircumcision Operation: Medical and Historical Implications," Urology, 1980, 16: 121–24; Dirk Schultheiss et al.,"Uncircumcision: A Historical Review of Preputial Restoration," Plast. & Reconstruct. Surg., 1998, 101: 1990–98.
  13. Celsus, De medicina 7.25.1 (Spencer [n. 21], 3: 421).
  14. Ibid. (Spencer, 3: 421–23)(angle brackets in original).
  15. Paul of Aegina, 6.53 (Heiberg [n. 36 ], 2: 94)-—a greatly abridged account; Antyllus apud Oribasium 50.1–2 (Raeder, OCMR [n. 36 ], 4: 55–56).
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