What can we learn from past mistakes in genital surgery?

The obvious answer to this question is ‘everything’—everything we do now in andrology is based on what has gone before, good and bad, this is why we read history and why we must learn from it. “Those who cannot remember the past are condemned to repeat it” (1) or, more positively, “We are dwarfs perched on the shoulders of giants. We see more and farther than our predecessors, not because we have keener vision or greater height, but because we are lifted up and borne aloft on their gigantic stature”, a concept commonly ascribed to Sir Issac Newton (1643–1727), but certainly predating him being a well-known saying in the mediaeval period (2).

However, the question is clearly asking to look at errors, things we once thought were good, were the right things to do for our patients but, with that amazing magical mirror of hindsight, we now know to have been wrong. There were several avenues I could have taken. I thought about how from the early Twentieth Century we would tie off penile veins for that concept we used to call venous leak, we now know this is not a long-term solution (3). Or the catastrophe of orchidectomy for chronic testicular pain. But I settled on two stories from the history of andrology; one penile and one testicular.

Circumcision

Circumcision is an operation carried out from antiquity and before. Often with religious meaning, such as in Judaism or Islam, but also as a transitional, coming of age, procedure; sometimes the meanings for this rite are too obscure and have been lost forever (Figure 1). Surgical procedures on the foreskin, that is, those carried out by surgeons for pathology, were less common prior to the Nineteenth Century. Dorsal slit for phimosis, often caused by sexually transmitted diseases, was done reluctantly and excisions of obstructing or destructive venereal or cancerous lesions were acceptable but rare. “It is a dangerous thing if the prepuce be cut” wrote Giovanni Sinibaldi (1594–1658) “because it cannot be rejoyn’d” (4).

Figure 1 The Circumcision of Christ, engraving c.1780. Author’s collection. Permission is not required.

In the Christian West, loss of one’s foreskin was seen as a terrible thing, not only emasculating but the practice of barbarians and heathens. On 1^st January 1586, the 100-ton merchantman, the Jesus, sailed from Falmouth in Elizabethan England on a trading voyage bound for Tripoli. Unfortunately, the ship and crew were captured by the local king. At least two of the crew, James Smith and Richard Bureges, the purser, were forcibly circumcised and “made Turke”. The sad story was retold by a survivor in a pamphlet published in 1587 in which it was made clear that this act of removing the foreskin was shameful to the Christian sailors essentially indicating that physically at least, they had been made in Muslims (5).

From the late Eighteenth Century onwards, the concept of the foreskin began to change as a great religious and social worry began to emerge. In a book first published around 1710 the anonymous author, likely a quack doctor, warned of the heinous sin of masturbation and suggested, for a price, a cure; only obtainable from him of course (6). This early book was more about the dangers of masturbation as a sin but, following the appearance of another book in 1760, increasingly, masturbation, onanism or self-pollution began to be seen as pathological—literally causing illness, weakness, blindness, deafness and mental illness (7). This book was written by a doctor, Samuel Tissot (1728–1797) and saw the beginnings of the medicalisation of masturbation, a movement significantly enhanced by the 1835 three volume work of Claude Francois Lallemand (1790–1853) (8), who warned of the evils of involuntary seminal discharge or spermatorrhoea (9). Multiple solutions, some really quite brutal, were proposed for this terrible medical problem, one of these was to remove the potential source of sexual excitement—the foreskin.

The foreskin had long been seen as a source of heightened sexual pleasure, for men and women. Ancient Arabic and Jewish writers attributed the reasoning for religious circumcision to this; with his foreskin removed, a man would think more of God than of worldly pleasure. Moses Maimonides (1138–1204) felt the foreskin was so sensual that if a woman were to lay with an un-circumcised man, her pleasure would be such, she could never be parted from him (10). Sinibaldi in his Geneanthropeia, arguably the first work on sexuality (11), agreed that it was the seat of both male and female pleasure (4) as did Gabriele Falloppio (1522–1562) the famous renaissance anatomist (11).

Of course, away from religious texts, the pleasurable foreskin was seen by most men as a good thing, so, even during this increasing “Spermatomania” (9) circumcision was a last resort. Nevertheless, the increase seen in medical circumcision (Figures 2,3) particularly in the Nineteenth Century was partly related to the fear of masturbation and extramarital sex or indeed any sex for pleasure rather than for procreation (13), however, towards the end of that century, a new concept emerged.

Figure 2 Clamping the foreskin prior to circumcision. Operative surgery by Joseph Bryant, 1900 (12). Image in the public domain. Permission is not required.

Figure 3 Trimming the foreskin. Operative surgery by Joseph Bryant, 1900 (12). Image in the public domain. Permission is not required.

In February 1870, Lewis Sayre (1820–1900), an American orthopaedic surgeon was examining a five-year-old boy with paralysis of the legs; he noted a painful phimosis. Not unreasonably, he performed a circumcision. After this, the boy’s paralysis resolved. He repeated his experiment in a teenager with a similar story and once again he was cured. He theorised that genital irritation was causing neurological disorders in these boys and published his idea that circumcision could thus be a cure for many nervous diseases (14).

Sayre was a well-known figure in US medicine and his opinion was respected, leading others to take up the circumcision banner. For example, Dr. Walker, who claimed circumcision had cured a young boy of bedwetting and a weak back (15). Along with the ‘anti-masturbation’ movement, there began to begin a move towards prophylactic circumcision, why not remove the foreskin before it caused problems?

In Britain, Jonathan Hutchinson (1828–1913), working in a hospital serving a large Jewish population suggested syphilis was less common in the circumcised Jews. Whilst he pointed out that every ‘right thinking man’ would dismiss the idea of universal circumcision to prevent this ‘loathsome vice’, he asks, should Christians adopt childhood circumcision for medical reasons, to reduce syphilis (16). Later, he begins to advocate for more circumcision, this time clearly to prevent masturbation (17). William Acton (1813–1875) writing in London in 1875 thought the prepuce “a significant cause of genital irritation and problems”, he also was very worried about the problem of masturbation, however, he did not agree with universal circumcision and wrote “Circumcision is never likely to be introduced amongst us” (18). Nevertheless, in Britain and even more so in America, there was a slow but certain push for childhood prophylactic circumcision.

It is important to appreciate what else was happening in the medical world at this time. Surgery was becoming a little safer with the introduction of anti-sepsis and ether and chloroform anaesthesia and then local anaesthesia-topical cocaine could be used for circumcision. Essentially, surgery was becoming easier, safer and more acceptable to patients allowing surgeons to suggest more and more operative cures. In women there was a movement to remove ostensibly normal ovaries or clitorises to cure neurological disease and, in both sexes, colons were excised by Kellog in the America and Arbuthnot Lane in Britain for multiple afflictions due to autointoxication (19). Most of these clearly unnecessary surgeries faded away, but neonatal circumcision for hygienic reasons became normalised certainly in America and to some extent in Britain in the Twentieth Century.

The 1949, paper by Cambridge paediatrician Douglas Gardiner (1910–1992) called the Fate of the Foreskin began to turn British surgeons away from unnecessary childhood circumcisions by showing that the majority of so-called phimoses resolved without any need for the knife (20). This was reinforced by a subsequent paper showing 99% of congenital phimoses resolved by the age of 17 years (21). In Britain, childhood circumcision was more common in the upper and professional classes but this fell quite dramatically in the first half of the Twentieth Century from 30% in 1939, 20% in 1949 10% by 1963 and only 6% by 1975 (22). As well as the Gardiner paper, this has also be attributed to the introduction of the NHS in 1948 reducing any unnecessary treatments due to cost (23). In America, 80% of boys were circumcised in 1976 but only 61% in 1981(22) and 49.3% by 2022 (23).

Prophylactic childhood circumcision was born in the Nineteenth Century; its parents were fear of masturbation and sexual vice and an astonishing belief that it was cure for a multitude of nervous disorders. The pros and cons of neonatal circumcision are still strongly argued. The American Urological Association’s statement, “neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks” demonstrates this ongoing uncertainty (24). However, hopefully, no one now circumcises a child in the hope it will stop him masturbating or that it will cure or prevent neurological illness.

Testicular implants and rejuvenation

Throughout history, the loss of sexual power has terrified men and they have happily taken any medicine, herb or supplement which would put a halt to this; no matter how strange, unpalatable or downright odd this was. In 1869, the acclaimed French physiologist, Charles Edouard Brown-Séquard (1817–1894), began experimenting with extract of animal testicles to address this issue. Perhaps he too was prepared to do or take anything as old age caught up with him. Initially, he injected the extracts into other animals and then in 1889, at the age of 72 years, he began injecting himself with extract of pulverised dog and guinea pig testicles. In a presentation to the Société de Biologie in Paris, he claimed it had improved his mental and physical powers, increased his urinary flow and allowed him to evacuate his bowels with more ease (25)!

In Vienna, Eugen Steinach (1861–1944), another famous physiologist, was also investigating the testicular function of animals. He believed that ligation of the vasa of old rats led to their rejuvenation. His theory was that a process of negative feedback caused the interstitial cells to increase testosterone production (26). In 1918, assisted by the surgeon Robert Lichtenstern (1874–1952), vasectomy was first carried out in men, purely for the purpose of sexual rejuvenation. This ‘autoplastic rejuvenation’ became extremely popular. Many academics of the University of Vienna (some say almost 100) underwent the procedure. Sigmund Freud (1856–1939) and the Irish poet, William Yeats (1865–1939) both had a Steinach procedure; Yeats believed it had given him a ‘second puberty’ and it is said his best work was produced after it (27).

Robert Lichtenstern had already been transplanting testes into patients who had been injured during the Great War or due to infection by tuberculosis, however, it was a Russian surgeon working in Paris who went on to popularise this procedure; Serge Voronoff (1866–1951) (Figure 4). Whilst working in Egypt, Voronoff had observed that eunuchs appeared to age prematurely and postulated that testosterone would slow down the aging process. This led to his theory that implanting healthy testes in men would slow down the aging process and rejuvenate them. On 12th June 1920, Voronoff first transplanted testicular tissue from a chimpanzee into a human. Sections of chimp testis were sewn into the recipient’s testicle (Figure 5). Voronoff claimed that not only did this work but also that the positive effects of the vitalising secretions lasted for up to two years (29).

Figure 4 Serge Voronoff. Photograph by the Pierre Petit studio, Paris, 1920’s. Author’s collection. Image previously used in (28). Permission is not required.

Figure 5 The grafting of chimpanzee testicular tissue onto a human testis, testicular grafting from ape to man, by Serge Voronoff and George Alexandrescu, 1929 (29). Author’s collection. Image previously used in (28). Permission is not required.

Unsurprisingly, the idea of rejuvenation and the chance to slow aging, or turn back time, gripped the public imagination and monkey glands stories began to appear in public and popular culture. The plot of the 1922 comic novel, “The Gland Stealers” by Bertrum Gayton (1893–1969), is about an elderly grandfather being rejuvenated by testicular implants from a gorilla (named Alfred) (30). Injections of a rejuvenating potion appear in the 1923 Sherlock Holmes story, “The Adventure of the Creeping Man” and the 1929 Marx Brothers film, The Cocoanuts, includes an Irvine Berlin song, called Monkey Doodle-Doo which encourages men to “get yourself a monkey gland”. It was also in the 1920’s that the Monkey Gland cocktail first appeared in Harry’s Bar in Paris (28).

Testicular implantation for rejuvenation and to improve sporting prowess even involved football. The English team, Wolverhampton Wanderers were accused by Leicester City of cheating by giving their players monkey gland injections. Wolves’ eccentric manager, Major Frank Buckley (1882–1964), was alleged to have given all his players monkey gland extract. There followed a full investigation, but the Football league refused to ban monkey glands, but they did insist players only took them voluntarily (31).

Implanting or injecting testicular tissue or extract from animals to man was clearly scientifically flawed. The grafts were soon rejected and injections of testicular extracts contained little or no functional hormone. Testosterone was identified and synthesised in 1935 (32,33), soon becoming a useful and successful treatment for hypogonadism. The Monkey Gland phenomenon faded away.

Conclusions

Looking back into the history of medicine is always a useful exercise, everything we do now is based on what has gone before, we build on the successes of the past and learn from its mistakes. Removing the healthy foreskins of children in the hope that it would prevent nervous diseases or improve that child’s sexual morals or implanting the testicular tissue of dead monkeys, men or goats into a man with sexual dysfunction, appear now at best laughable and at worse criminal. It is easy to look back and criticise the doctors of the past, but scientific knowledge moves on and what we practice now is based on what we know now, it was the same for the surgeons before us. It is even easier to criticise the quack doctors who clearly were operating for gain in the knowledge that what they were doing was blatantly wrong, pointless or indeed dangerous. What is far more interesting and indeed useful in these two examples of historical medicine is to recognise that both childhood prophylactic circumcision and rejuvenation surgery were led by well-respected and senior clinicians of the day. They were also based on both clinical and laboratory experiments published in well-known medical journals. Lewis Sayre was a noted expert in the orthopaedics, paediatrics and neurological conditions. He was Professor of orthopaedics and of clinical surgery at the Bellevue Hospital, Commissioner of Public Health in New York, President of the American Medical Association and was made a Knight of the Order of Wasa by the King of Sweden (34). Brown-Séquard was one of the most famous physiologists of the Nineteenth Century and surgical rejuvenation techniques were presented and discussed at the International Congress of Surgery held at the Royal Society of Medicine in London in 1923.

What we should learn from these stories is that although we must keep upto date with new techniques and ideas, it is our duty as doctors to pause, think and reflect. It can be easy to be swept along with the latest surgical advances presented by the experts of our time and of course, this is how medicine and surgery improves and advances. However, we should all remember that in 100 years someone will be writing about us with a mix of horror and amusement.

Acknowledgments

This short article is based on a presentation given at the European Association of Urology (EAU) Annual meeting in London in March 2026. An invitation from the EAU Scientific Committee was extended to the EAU History Office and the title was provided.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Translational Andrology and Urology. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0740/coif). The author has no conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-Non-Commercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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