Historia Urologiae Europaeae series is

addressed to all European urologists. Its aim is

to make known the ideas and the work of our
predecessors, and to help us understand the cur-

DE HISTORIA UROLOGIAE EUROPAEAE 26

rent trends in the development of our speciality.
Unfortunately, the treatises written in Sanskrit,
ancient Chinese, Greek and Latin are both dif-
ficult to find and difficult to understand, and
should, therefore, be translated into English. The
same applies to more recent books published in
various languages.

Most of the treatises produced before

the 17th century, even the legendary ones, have
gaps, mistakes and inconsistencies. Modern
scientific research allows us to re-evaluate this
ancient knowledge and examine it from new
perspectives. The History Office of the EAU in
collaboration with internationally based urolo-
gists, historians, philologists and other experts,
conducts research, accumulates and shares this
fascinating information in their annual publica-
tion, Historia Urologiae Europaeae.

“Remember the days of old, consider the

years of many generations, ask thy father, and he
will shew thee; thy elders, and they will tell thee.”
(Deuteronomy 32:7)

DE HISTORIA
UROLOGIAE EUROPAEAE
volume 26 edited by philip van kerrebroeck
European Association of Urology and dirk schultheiss
2019
 De Historia
Urologiae Europaeae
Volume 26

Edited by:
Philip Van Kerrebroeck
and
Dirk Schultheiss

European Association of Urology

2019
1
The History Office of the EAU

P.E.V. Van Kerrebroeck (Chairman) Maastricht (NL)

C. Alamanis Athens (GR)
E. Cuenant Montpellier (FR)
L.A. Fariña-Pérez Vigo (ES)
J.F. Felderhof The Hague (NL)
J.C. Goddard Leicester (GB)
R. Jungano Naples (IT)
F.H. Moll Cologne (DE)
M.S. Rahnama’i Maastricht (NL)
I. Romics Budapest (HU)
D. Schultheiss Giessen (DE)
R. Sosnowski Warsaw (PL)
P. Thompson London (GB)
A. Verit Istanbul (TR)
N.M. Fredotovich (CAU representative) Buenos Aires (AR)
M.E. Moran (AUA representative) Linthicum, MD (USA)

2
 Contents of Volume 26
de Historia Urologiae Europaeae
(2019)

Foreword 7
Chris Chapple

Introduction 9
Philip Van Kerrebroeck

Innovators in Urology

Man into Woman: A History of Male-to-Female 13

Sex Reassignment Surgery
Rachel Oliver and Melissa Davies

Sir Henry Morris and the First Nephrolithotomy 29

Jonathan Charles Goddard

The Shock of Life: The History of Electro-Ejaculation 41

Mohammed Aldiwani

Hans Henrik Holm (1931-2016): An Homage to 49

a Danish Pioneer and his Contributions to Urology
and Urological Ultrasound
Jørgen Kvist Kristensen

3
The History of Urology

Urologists to the Desert Rats: Serendipitous Skills 61

of the World War II Urologists
Peter Grice and Jonathan Goddard

A Tale of Two Penises 71

Michael E. Moran

The Role of the Medical Illustrator in the Development 85

of Spanish Urological Endoscopy: Eighty years
of Endoscopia Urinaria by Antonio Puigvert and
Illustrated by Rafael Alemany
Luis Fariña-Pérez

The Beginnings of Medicine and Urology in Vilnius: 95

The Impact of Political Changes on Progress in Urology
and Medicine
Thaddaeus Zajaczkowski

Historical and Cultural Depictions of Urology

Genital and Sexual Symbols in the Pre-Columbian 125

Maya World
Javier C. Angulo and Carlos Figueroa Lemus

Urology in Modern and Contemporary Literature, 145

Music and Art
Wiking Månsson

4
Saint Liborius: Healer of Urinary Stones 167
Johan J. Mattelaer

5
6
 Foreword

It is my pleasure to present to you the 26th volume of the

de Historia Urologiae Europaeae series. Over the past 26 years this
series has been able to deliver an impressive overview of the history
of urology, not only in Europe but worldwide. Thanks to the many
authors, the persistent efforts of the EAU History Office, their
respective chairmen, consultants and experts, the numerous articles
are not only of the highest quality but fill up several gaps in our
historical knowledge. Therefore I would like to thank all those that
contributed for their valuable work.
I am sure you will like this 26th volume as it contains
several unique articles and deals with a nice variation in topics.
Mr. Goddard, the EAU History Office webmaster, discusses the
important urological contributions of Sir Henry Morris. In the
framework of the continuing effort to retrace the history of urology
in several geographical areas in Europe, Dr. Zajaczkowski presents
us with original information on the origins of Urology in Vilnius.
Dr. Kristensen presents a professional biography on Hans
Hendrik Holm who was responsible for some important develop-
ments that contributed to the development of urological diagnos-
tics, and Dr. Farina takes a recent anniversary as an opportunity to
examine the impact of medical illustrators on our field. Endoscopic
procedures were an important contribution to the urological care
during World War II as is discussed by Dr. Grice in the chapter
“urologists to the desert rats”.
As often this volume also contains articles that connect with
the art world. Dr. Mansson studied urological connotations in lit-
erature and in contemporary visual arts, and Dr. Mattelaer explores
depictions of Saint Liborius, considered by some as patron saint
of urologists. Dr. Angulo extends this interest to Pre-Columbian
Mesoamerica and reviews genital and sexual symbology in the
Maya world.

7
 I hope you can enjoy as much reading this 26 volume of the
de Historia Urologiae Europaeae as I did!

Chris Chapple
EAU Secretary General

8
 Introduction

The history of medicine is the history of the unusual1

- Robert M. Fresco
This quote applies also to the history of urology and defi-
nitely to this 26th volume of the de Historia Urologiae Europaeae
series. We were able to collect several original contributions that
prove that studying the History of Urology can not only be use-
ful for our current thinking and may have a positive effect on our
daily work, but also can reveal unusual and original aspects of our
profession.
In the medical world, governed by rationalisation, the need
for attention to the history of medicine is sometimes questioned.
Urologists are no exception to this, but fortunately the Board of
the European Association of Urology is convinced of the value of
paying attention to the historical aspects of our current knowl-
edge. Personally I like the quote of the Danish philosopher Søren
Kierkegaard “Life can only be understood backwards; but it must
be lived forwards.”2 We can apply this statement also to urological
developments, as they find their basis on inventions and principles
of the past.
This volume of the de Historia will allow you to get acquaint-
ed for example with Dr. Hans Henrik Holm (1931-2016), a vision-
ary Danish urologist, who is considered the father of interventional
ultrasound and a pioneer in urological diagnostics. His contribu-
tions were discussed during the special session on the History of
Urology during the annual meeting 2018 in Copenhagen, and we
are very happy that Dr. Kristensen accepted the offer to retrace his
life and contributions in an original article.
1. The history of medicine is the history of the unusual, is a sentence by Robert M Fresco from the
film Tarantula (1955). It is said by Prof. Deemer to Dr. Hastings who is suspicious of the death of Deemer’s
friend.
2. Life can only be understood backwards; but it must be lived forwards, is a quote from the
Journals (IV A 164, 1843) by the Danish philosopher Søren Kierkegaard (1813-1855). The full translation
would be: “It is perfectly true, as the philosophers say, that life must be understood backwards. But they
forget the other proposition, that it must be lived forwards.”

9
 As endoscopy of the urinary tract is an important diagnostic
tool that remained in the hands of urologists, the contribution by
Dr. Farina on the role of medical illustrators allows us to appreciate
the quality of our current methods as a result of so many develop-
ments from the past 75 years.
An important contributor to endoscopy, and indeed to the
study of the history of urology is Karl Storz SE, this year’s winner
of the Ernest Desnos Prize. The EAU Board accepted the History
Office’s nomination based on the company’s research into the past
of endoscopy and its contributions to history of urology-related
activities across Europe.
Every geographical area of Europe has had its pioneers that
contributed to the quality of Urology in their time but also have an
influence on future generations. Dr. Zajackowski tells us the history
of Urology in Vilnius and the many changes that came from territo-
rial and political changes to that city in the 20th century.
Mike Moran, the curator of the AUA’s William P. Didusch
Center for Urologic History. Mike tells us an intertwining tale… of
two penises, one fictional and one very famous.
As Urology and art seem to be good friends, three contribu-
tions in this volume have a particular focus on urology in cultural
depictions. Wiking Mansson presents the results of his search for
urological aspects in literature and in the visual arts. This impressive
selection features just some highlights of the many times urological
problems have been quoted in world literature and art.
Javier Angulo’s article connects the art world with the real
world as he deals with genital and sexual symbols in the Maya
world. The article is beautifully illustrated with many examples of
Mayan art works related to sexuality and that were used in some-
times sophisticated rituals.
Our Office’s former Chairman Johan Mattelaer brings us a
chapter on Saint Liborius, sometimes considered to be the patron

10
saint of our field. Europe-wide depictions in paintings, statues and
even an annual so-called “Liborifest” are examined and catalogued.
Two other articles expand the field of andrology and sexol-
ogy. Dr. Aldiwani describes the history, development and achieve-
ments of electro-ejaculation and Dr. Oliver presents the history of
male to female transition.
Jonathan Goddard provides a biographical chapter on Sir
Henry Morris and the first nephrolithotomy. Jonathan also contrib-
uted to the chapter on the ‘Desert Rats’: wars pose specific medical
challenges and this is also the case for urological problems. In an
interesting article Dr. Grice explains how urologists served in the
British Armed forces, or how some veterans went on to become
notable urologists themselves.
Hopefully I could convince you that it is worthwhile to leaf
through this volume and discover the different aspects of urological
history.
Philip Van Kerrebroeck
EAU History Office Chairman
Editor

11
 Figure 1: Pioneering German sexologist Magnus Hirschfeld.

12
 Man into Woman: A History of
Male-to-Female Sex Reassignment Surgery
Rachel Oliver, Melissa Davies
Salisbury District Hospital, UK

Since ancient times humans have cross-dressed and lived in

gender roles different to those assigned at birth. Early records of
gender variance include the Greek God Aphroditus, a female figure
with a phallus,1 and Roman Emperor Elagabalus (203-222AD) who
dressed in feminine clothing and offered riches to any physician who
could provide him with female genitalia.2 Anthropologists have
described instances of non-binary gender expression worldwide,
such as in the Native American Navajo tribes, the Hijra of Asia and
the Fa’afafine of Polynesia.
However, it was not until 1923 that the term transsexual-
ism was first introduced by pioneering German sexologist Magnus
Hirschfeld.3 (Fig. 1) At this time there was a lack of clarity between
the descriptions of transvestitism, homosexuality and transsexualism. By
the mid-20th century transsexualism was acknowledged as denoting
individuals who desired to live permanently in the gender role of the
opposite sex and undergo sex-reassignment surgery.4
Sex Reassignment Surgery (SRS) is often one of the final
steps in the transition between sexes. Male-to-Female (MtF) SRS
includes orchidectomy, penectomy, clitoroplasty, labiaplasty and
neovaginoplasty. Alongside genital reconstruction, many trans-
women undergo surgery for facial feminisation, breast augmenta-
tion and chondrolaryngoplasty to obliterate the appearance of the

1. Brisson, L. Sexual Ambivalence: Androgyny and Hermaphroditism in Graeco-Roman Antiquity. University of

California Press, 2002. pp54.
2. Dio, Cassius C. Roman History LXXIX. Cambridge (Mass.) Harvard University Press 2001.
3. Hirschfeld, M. The intersexual state (in German). Jahrbuch für Sexuelle Zwischenstufen. 23: 3, 1923.
4. Selvaggi, G et al. (2005) Gender Identity Disorder: general overview and surgical treatment for vaginplasty
in male-to-female transsexuals. Plastic and Reconstructive Surgery; 116(6): 135e-145e.

13
 Figure 2: Eugen Steinach,
Viennese physiologist renowned
for his work in gonadal
transplantation.

Figure 3: Rudolph Richter (left) and later as Dora Richter (right) – the first known recipient
of Male-to-Female Sex Reassignment Surgery.

14
‘Adam’s apple’. Here we review the history of genital reconstruction
in Male-to-Female (MtF) SRS.
Early experimentation
Notable early experimentation in sex reassignment was car-
ried out by Viennese physiologist Eugen Steinach. (Fig. 2) He per-
formed a number of experiments looking at sexual behaviour and
attracted international attention in 1912 for his work on gonadal
transplantation in rats and guinea pigs.5 He reported how castra-
tion of infant male guinea pigs and implanting ovaries into them
resulted in their development of female sexual behaviours and
vice-versa.6,7 For example, female guinea pigs implanted with testes
would attempt to mount their partner. Steinach’s work contributed
to early understandings of the effect of hormones in the develop-
ment of sex characteristics. His work directly influenced Hirschfeld
and other sexologists, including the eminent Harry Benjamin.

Dora Richter: the first transwoman to undergo SRS

The first widely cited case of a transsexual woman undergo-
ing sex reassignment surgery was that of Rudolph (Dora) Richter in
1931 in Berlin.8 (Fig. 3) Richter was born in the Erzgebirge region
of Germany in 1891 to a peasant farming family. During her early
childhood she was noted to act in a feminine manner and at the age
of 6 years she attempted to remove her own penis with a tourni-
quet.9
She later took the name Dora, began wearing women’s
clothing and living as a female. Such behaviours were not legal in
Germany at this time and Richter was arrested on several occa-
sions for crossdressing. After serving time in prison a judge released
5. Meyerowitz, J. (1998) Sex Change and the Popular Press: Historical Notes on Transsexuality in the United
States 1930-1955. GLQ 4(2): 159-87.
6. Steinach, E (1912) Willkürliche Umwandlung von Säugetiermännchen in Tiere mit ausgeprägt weiblichen
Geschlechtscharacteren und weiblicher Psyche (Arbitrary Transformation of Male Mammals into Animals with
Pronounced Female Sex Characters and Feminine Psyche. Pflügers Archiv; 144: 71-108.
7. Steinach, E. (1913) Feminierung von Männchen und Maskulierung von Weibchen (Feminization of Males
and Masculization of Females). Zentralblatt für Physiologie; 27: 717-723.
8. Stryker, S. Transgender History. Boston, Seal Press. 2008.
9. Abraham F (1931), Genitalumwandlungen an zwei männlichen Transvestiten. Zeitschrift für Sexualwissenschaft
und Sexualpolitik; 18: 223-226.

15
Figure 4: Hirschfeld’s Institut für Sexualwissenschaft (Institute of Sexual Science).

Dora into the care of Hirschfeld. She worked as a domestic serv-

ant at Hirschfeld’s Institut für Sexualwissenschaft (Institute of Sexual
Science). (Fig. 4)
Dora first underwent castration in 1922 by Dr Edwin
Gohrbandt, Director of the Surgical Clinic of the Urban Hospital
in Berlin, followed by penis amputation performed by Dr Ludwig
Levy-Lenz at Hischfeld’s institute.10 Dr Felix Abraham, a physician
working at the Institute, reported her castration resulted in devel-
opment of a fuller figure, restricted beard growth, the first visible
signs of breast development and a more prominent pubic fat pad.9
In June 1931 Dora underwent a highly experimental vagi-
noplasty performed by Gohrbandt. Abraham published the case of
Richter and another vaginoplasty patient, Toni Ebel, in the Journal
of Sexology in that same year.9 (Fig. 5) The surgeries involved use
of a non-genital skin graft taken from the upper leg draped over a

10. Mancini, E. Magnus Hirschfeld and the Quest for Sexual Freedom: A History of the First International Sexual
Freedom Movement. New York, Palgrave MacMillan. 2010.

16
mold as reported by Abbe in the treatment of congenital vaginal
atresia in the 19th century.11, 12
A catheter was inserted into the penis stump and then a
vertical incision was made into the perineum until the peritoneum
was reached, achieving a depth of approximately 12cm. A porcelain
speculum was then inserted to dilate the new vaginal cavity. Skin
grafts from the upper leg were then draped inside-out over a sponge
mould, which was introduced into the vaginal cavity through the
speculum. The speculum was then carefully removed and the sponge
and graft sutured in place to the neovaginal wall. The sponge was
kept in place for several weeks to absorb secretions and allow adhe-
sion of the graft to the neovaginal wall. Post-operative treatments
of rinsing and vaginal dilation were then performed.9 The method
was later popularised by Banister and McIndoe in 1938.13
Little is known about Dora’s fate following her surgeries,
although it is suspected she did not survive the Nazi attack on
Hirschfeld’s institute in 1933.
The Danish Girl
Another recipient of Gohrbandt’s vaginoplasty technique
was the highly publicised case of Lili Elvenes, more widely known
as Lili Elbe, subject of the 2015 Oscar-winning film The Danish Girl.
Born in Vejile, Denmark in 1882, Elbe began life as Einar Wegener,
a successful landscape painter whose transformation to Lili is often
misleadingly cited as the first case of MtF SRS.14 (Fig. 6)
Einar met Gerda Gottlieb whilst studying at the Royal
Danish Academy of Fine Arts in Copenhagen. The two married
in 1904. Gerda painted illustrations of stylish women for famous
Parisian fashion magazines, such as Vogue and La Vie Parisienne.

11. Bizic, M et al. (2014) An Overview of Neovaginal Reconstruction Options in Male to Female Transsexuals.
The Scientific World Journal 2014:638919.
12. Abbe, R. (1898) New method of creating a vagina in a case of congenital absence. Medical Record; 54:
836-38.
13. Banister, JB & McIndoe, AH. (1938) Congenital absence of the vagina, treated by means of an indwelling
skin graft, Proceedings of the Royal Society of Medicine; 31 (9): 1055–56.
14. Hoyer, N. Man into woman : the first sex change, a portrait of Lili Elbe : the true and remarkable transforma-
tion of the painter Einar Wegener. Jarrolds. 1933.

17
Figure 5: The first Male-to-Female vaginoplasty – published by Felix Abraham in 1931.

18
Figure 6: The Danish Girl: Einar Wegener (left) and subsequent transition to Lili Elbe (right).

Figure 7: Portrait of Lili Elbe

painted by Gerda Wegener
(1928).

19
One day, after her model failed to turn up, Gerda persuaded Einar
to pose in women’s clothing for her work. (Fig. 7) This proved a
turning point in the development of Einar’s female identity:
“I cannot deny, strange as it may sound, that I enjoyed myself in this
disguise. I liked the feel of soft women’s clothing, I felt very much at
home in them from the first moment.”14
Wegener began spending more time in the role of Lili,
attending social occasions under the guise of Einar’s cousin and
by 1930 sought surgical transition into the feminine form. After
being dismissed by several doctors as homosexual or suffering from
insanity, Einar was eventually referred to Hirschfeld. Under his
supervision at the institute and later under Dr Kurt Warnekros
at the Dresden Municipal Woman’s clinic, Einar underwent sev-
eral transformative surgeries to confirm her identity as Lili. These
included castration initially in 1930, followed by penectomy and
vaginoplasty in 1931 using the Gohrbandt technique that was used
for Richter earlier that year. The scrotal remnants were left intact
for later labiaplasty.5,14
During this time Lili divorced Gerda and began a relation-
ship with French art dealer Claude Lejeune. She longed for the
ability to mother a child with Lejeune and underwent a procedure
to implant an ovary into her abdominal wall musculature. Her final
surgery in 1931 involved a uterine transplant, complications of
which eventually lead to her death in September 1931.5,14
Lili’s surgeries allowed her to legally change her name and
receive a passport as a female. Her diary entries were published
posthumously and her story – Man into Woman – was translated
into English in 1933, attracting the attention of several U.S maga-
zines.5,14 These included a letter to a friend in which Elbe contem-
plated her demise:
“I, Lili, am vital and have a right to life I have proved by living
for 14 months. It may be said that 14 months is not much, but they
seem to me like a whole and happy human life.”14

20
 It appears that, despite directly leading to her death, Lili’s
surgeries allowed her to live congruently as the woman she truly
felt to be.
Sex change in wartime
During the rise of the Nazi party in Germany, further devel-
opment of sex reassignment surgery in Europe stalled. Writings
on sexology were burnt and those involved in such research were
persecuted. Hirschfeld went into exile after his Institute for Sexual
Science was destroyed by the Nazis in 1933 and he later died in
1935. The Dresden Women’s clinic was later destroyed by Allied
bombing.15 During the next decade only a handful of SRS opera-
tions were performed in Europe.
However, wartime advances in endocrinology and plastic
surgery later served to help the transsexual community. In 1946
pioneering plastic surgeon Harold Gillies used wartime flap surgery
to perform successful Female-to-Male (FtM) sex reassignment.16
Gillies later went on to use penile skin flaps in vaginoplasty.11 In
addition, the first synthetic oestrogens became available, including
Di-Ethyl-Stillbestrol, which were later used as hormone therapy for
MtF transsexuals.
Ex-GI becomes blonde beauty: the first genital skin grafts
In 1952 Christine Jorgensen made United States headlines
with “Ex-GI becomes blonde beauty”, thereby becoming the first
publically known case of an American transwoman to undergo
SRS. (Fig. 8) Born George William Jorgensen Jr in 1926 she was
drafted into military service shortly after graduating high school
towards the end of WWII. Since the onset of puberty, Jorgensen
reported feeling like a woman trapped in a man’s body. After
being discharged from the army she travelled to Copenhagen to
meet endocrinologist Dr Christian Hamburger. Under his care she
took the new name Christine in his honour and received hormone
therapy.5

15. Stryker, S. The Transgender Studies Reader. New York, Routledge. 2006
16. Ettner, R. Principles of Transgender Medicine and Surgery. New York. The Haworth Press. 2007

21
Figure 8: Christine Jorgensen, breaking US Figure 9: Sir Harold Gillies pioneered the
headlines in 1952 as the first American use of penile skin as a pedicled flap for
transwoman to undergo SRS. vaginoplasty in Male-to-Female SRS.

Jorgensen underwent sex reassignment in Denmark under

Dr Paul Fogh-Andersen with initial orchidectomy, penectomy and
later reported neovaginoplasty although some sources state she
underwent clitoroplasty with no vaginal cavity formation and vagi-
noplasty was performed later on her return to the U.S.17,18
Fogh-Andersen was the first to report the creation of a neo-
vagina using penile skin as a full-thickness graft although he did not
publish his work until many years after the reported vaginoplasty
on Jorgensen.19 His technique involved harvesting penile skin to
line the neovagina. The penile skin graft was fixed to a mould in
keeping with the McIndoe technique for congenital vaginal aplasia.
The result was a hairless neovagina with minimal scarring to the

17. Denny, D. Current Concepts in Transgender Identity. New York. Garland Pub. 1998
18. Gherovici, P. Please Select Your Gender: From the Invention of Hysteria to the Democratizing of
Transgenderism, Abingdon, UK. Routledge. 2010
19. Fogh-Andersen, P. (1969) Transsexualism, an attempt at surgical management,” Scandinavian Journal of
Plastic and Reconstructive Surgery; 3(1):61–64.

22
donor area with less risk of graft contraction compared to split-
thickness graft.4,11 In addition, such a surgery could be performed
in one-stage and did not cause traction on the abdominal pedicle,
avoiding creation of a skin fold that could obstruct the dorsal part
of the neovaginal introitus. However, limitations included the need
to dilate the neovagina post-operatively and the amount of penile
skin available.4
The Jorgensen case was one of the most widely publicised
cases of sex reassignment surgery at the time and it led to an
increase in awareness of transsexualism. More patients began to
seek such surgery and within a year of Jorgensen entering the public
domain, Hamburger received letters from 465 patients desiring to
alter their sex.5 Jorgensen remained a public figure and transgen-
der spokesperson until her death from bladder and lung cancer in
1989.17
Development of the Gold Standard: the Penile-Skin Pedicled Flap
During the World Wars, New Zealand-born surgeon Harold
Gillies developed techniques in reconstructive surgery including
pedicled skin flaps, microvascular surgery and limb reattachment,
earning him the reputation of the ‘father of modern plastic sur-
gery’.20 (Fig. 9) Following WWII he applied the skin flap tech-
niques he had developed to sex reassignment surgery. In 1951 he
performed the first Male-to-Female SRS in England on racing driver
and RAF pilot Roberta Cowell. Having only previously performed
the procedure on a cadaver, Gillies performed her vaginoplasty
with the assistance of American surgeon Ralph Millard.21 The pair
later went on to report the use of penile skin as a pedicled flap for
vaginoplasty in male-to-female sex reassignment surgery in 1957.22
The technique was performed in several stages. Firstly,
bilateral orchidectomy followed by penile dissection to expose the
corpora cavernosa, glands cap & urethra, the neurovascular bundle
and vascularised penile skin.11 Several flap techniques have been
20. Triana, RJ (1999) Sir Harold Gillies. Arch Facial Plast Surg, 1(2):142-143.
21. Kennedy, P. The First Man-Made Man. New York. Bloomsbury. 2007
22. Gillies, H & Millard, RD Jr. “Genitalia” in The Principles of Art of Plastic Surgery. London. Butterworth. 1957:
368-88.

23
described including the use of the inverted penile skin on an abdom-
inal pedicle as a single graft to form an inside-out tube that lines
the neovagina. Alternatively, the pedicled penile skin can be split
into a rectangular flap which is then joined to a rectangular scrotal
skin flap with posterior pedicle to providing a larger graft for the
neovagina. The use of a urethral flap embedded into the penile skin
tube has also been described.11
The penile skin pedicled flap remains the gold standard
in MtF vaginoplasty today. Interestingly, at the time that it was
used by Gillies and Millard, French gynaecologist Georges Burou
also independently developed this technique at his practice in
Casablanca and went on to perform over 800 vaginoplasties using
this method.23
Pedicled Intestinal Transplant Vaginoplasty
The utilisation of bowel in neovaginoplasty arose from the
treatment of vaginal agenesis in the late 19th century. In 1892
Sneguireff reported the use of rectum to create a vaginal cavity and
later in 1904 Baldwin reported incorporating ileum.11 However,
there was much morbidity associated with these procedures and it
was not until 1974 that Markland and Hastings at the University
of Minnesota first reported intestinal transplant vaginoplasty for
purposes of MtF sex reassignment.24
They experimented in 23 patients using a segment of cae-
cum supplied by the ileocolic artery and rotated this down into the
pelvis into a space created by deep dissection of the central peri-
neum to achieve a rectovesical perineal pouch. The caecal segment
was then anastomosed to the perineal skin in an anti-peristaltic
fashion. However, they experienced difficulties with achieving
adequate length of the caecal segment to reach the perineum. In
order to combat this, Markland and Hastings trialed the use of sig-
moid colon in 2 patients. In this approach they divided the sigmoid
mesocolon whilst taking care to preserve the longest distal sigmoid
23. Hage, JJ et al. (2007) On the Origin of Pedicles Skin Inversion Vaginoplasty: life and work of Dr Georges
Burou of Casablanca, Ann Plast Surg; 59(6): 723-9.
24. Markland, C & Hastings, D (1974) Vaginal reconstruction using cecal and sigmoid bowel segments in trans-
sexual patients, Journal of Urology; 111(2): 217–219.

24
branch of the inferior mesenteric artery to serve as the main arterial
supply to the vaginoplasty segment. This allowed for considerable
length to be achieved without causing undue tension on the mesen-
teric blood supply, which could result in ischaemic necrosis.24
Nowadays the use of recto-sigmoid colon is most popular
in pedicled intestinal vaginoplasty. It results in a self-lubricating
neovagina of adequate dimensions and blood supply with less
risk of stenosis and without need for longstanding post-operative
dilatation. However, issues with excessive mucus production, risk
of adenocarcinoma and mucocele have been described.11 In addi-
tion, there is need to enter the abdominal cavity and risks associated
with bowel anastomosis.25 Although the penile inversion technique
remains the most popular choice for vaginoplasty, pedicled intesti-
nal vaginoplasty is a good option where there is insufficient penile
or scrotal skin available or as a secondary procedure where skin
vaginoplasty has failed.26
Techniques of the late 20th Century: Non-Genital Skin Grafts
Further attempts to evolve vaginoplasty in the later 20th
century included the use of non-genital skin flaps in attempt to
achieve a neovagina of adequate depth with less risk of contraction
and reduced need for dilation.11 In 1980, Cairns and De Villiers
reported the use of a medial thigh flap for neovaginal reconstruction
in patients who had previously undergone penile inversion vagino-
plasty with insufficient results.27 Later in 1995, Huang reported the
use of two inguino-pudendal flaps sutured together in the midline
then to a penile flap to form a single large flap.28
The use of non-genital skin flaps was disadvantaged by
scarring of the donor area and absence of self-lubrication.11 They
were technically very demanding procedures producing bulky flaps
that threatened to decrease the functional dimensions of the neova-
25. 
Morrison, SD et al. (2015) Long-term Outcomes of Rectosigmoid Neocolporrhaphy in Male-to-Female
Gender Reassignment Surgery, Plastic and Reconstructive Surgery; 136(2): 386-94.
26. Kim, SK et al. (2003) Long-term results in patients after rectosigmoid vaginoplasty, Plastic and Reconstructive
Surgery; 112 (1):143-151.
27. Cairns, TS & de Villiers, W. (1980) Vaginoplasty, South African Medical Journal 57(2): 50-55.
28. Huang, TT (1995) Twenty years of experience in managing gender dysphoric patients: Surgical management
of male transsexuals, Plastic and Reconstructive Surgery 96(4): 921-30.

25
gina, making them a less popular choice for MtF vaginoplasty.4,29
However, like pedicled intestinal transplant vaginoplasty they are
more commonly used as a secondary procedure.
In recent years, the use of tissue-engineered grafts in vagi-
noplasty for congenital vaginal atresia have shown success and are a
promising prospect for MtF sex reassignment surgery.30,31
Conclusion
Since the first procedures described nearly a century ago,
there have been multiple advances in the field of male-to-female sex
reassignment surgery. The current gold standard remains based on
the penile skin inversion flap first described in late 1950s. Further
developments in surgical management centre on the goals of achiev-
ing an aesthetic neovagina with sufficient dimensions to allow pen-
etrative intercourse and adequate clitoral sensation with minimal
risk of complications.
Correspondence to:
Rachel Oliver
roliver087@gmail.com

29. Karim, RB et al. (1996) Neovaginoplasty in male transsexuals: review of surgical techniques and recom-
mendations regarding eligibility, Ann Plast Surg; 37 (6): 669-75.
30. Zhu, L et al. (2013) Anatomic and sexual outcomes after vaginoplasty using tissue-engineered biomaterial
graft in patients with Mayer-Rokitansky-Küster-Hauser syndrome: a new minimally invasive and effective
surgery. J Sex Med; 10(6): 1652-8.
31. Zhang, X et al (2017) The clinical outcomes of vaginoplasty using tissue-engineered biomaterial mesh in
patients with Mayer-Rokitansky-Küster-Hauser syndrome, Int J Surg; 44:9-14.

26
27
28
 Sir Henry Morris and the First
Nephrolithotomy
Jonathan Charles Goddard
Consultant Urological Surgeon, University Hospitals of Leicester NHS Trust, Curator of
The Museum of Urology at BAUS and member of the EAU History Office

Within the ancient art of urology, surgery of the kidney was

a late arrival. Early renal surgery was either superficial or accidental.
The first planned successful nephrectomy was carried out by Gustav
Simon in 1869 but it was not until Arthur Barker read papers to
the Royal Medical and Chirurgical Society of London in 1880 and
1881 that British surgeons became truly aware of this new surgical
horizon. In 1880 Henry Morris (1844-1926) surgically removed a
stone from the kidney of a 19 year-old woman. There was no loin
swelling, no pointing abscess, no discharging sinus. To all external
appearances, Henry Morris was operating on a normal kidney, an
unusual state of affairs.
The Background – kidney surgery
Although stones were cut from the bladder by the ancient
Hindu and Greek surgeons of the pre-Christian era, kidney stones
were not. This was likely due to the kidneys’ deep position behind
the peritoneum (a taboo area for surgeons) and poor accessibility
via the loin. Diagnosis of a bladder stone from lower urinary tract
symptoms and by sounding via the urethra was easier than diagno-
sis of a renal stone.
Ureteric colic was well described by Hippocrates but his
differential diagnosis of loin pain was more vague; unless of course
pyonephrosis developed. Then the hot mass could be felt in the loin,
which eventually pointed as an abscess. In this case the kidney stone
presented itself to the surgeon and a map to the kidney was clearly
given. Even Hippocrates suggested that cutting into a pointing
renal abscess was acceptable.1
1. Newman D. The History of Renal Surgery - 1. The Lancet 1901;157(4045):649 - 51

29
 Figure 1: Image of a
kidney with calculus
in situ removed by
lumbar nephrectomy by
Morris. From Morris, H.
Surgical Diseases of the
Kidney, Cassell & Co.
1885.

Occasionally stones discharged themselves through sinuses

in the loin allowing surgeons to probe and explore down towards
the kidney. This however was superficial surgery, the lancing of an
abscess. Even as late as 1901 David Newman (1853-1924), then a
recognised renal surgeon, said that the kidney was still seen as the
preserve of the physician, an internal organ;1 surgeons historically
dealt with external diseases, those you could see and stick a knife
into!
The nineteenth century saw the slow arrival of abdominal
surgery made possible by the introduction of anaesthesia in 1846.
One of the earliest abdominal procedures was ovariotomy and one
of its earliest advocates was Sir Thomas Spencer Wells.2 On occa-
sion, kidneys were removed in error during ovariotomies. Spencer
Wells reported unexpectedly finding a healthy kidney in the tissue
he excised with an ovarian cyst.
Similar accounts were filed by the American Erastus B.
Walcott (1804 - 1880) in 1861 who thought he was removing a

2. Wanis M, Goddard JC. The contribution of Sir Thomas Spencer Wells to Urology. De Historia Urologiae
Europaeae 2017;24:154 - 63.

30
liver cyst, Otto Spiegelberg (1830 – 1881) of Breslau in 1867 and
Edmund Peaslee (1814-1878) in 1868 in America again.3,4 These
reports, along with animal experiments that showed that removal
of one kidney was survivable led to planned nephrectomies. The
first was by William Hingston (1829-1907) of Canada in 1868 in
the Hotel Dieu in Montreal. Alas, immediately upon removal of the
kidney, the patient died on the table. The first successful planned
nephrectomy was by Heidelberg surgeon Gustav Christoph Jakob
Friedrich Ludwig Simon (1824 – 1876) on 2nd August 1869 under
chloroform anaesthesia.4
In Britain the first nephrectomy to be attempted was
on 14th May 1872 by Arthur Durham (1834-1895) of Guy’s
Hospital, it was done for a painful kidney, but the patient died.
The first nephrectomy for malignant disease in England was per-
formed by Thomas Jessop (1837-1903) of Leeds in 1877, this was
successful.5
Arthur Barker (1850-1916), Assistant Surgeon to University
College London, after carrying out a nephrectomy for a renal can-
cer in December 1879 presented the case at the Royal Medical and
Chirurgical Society of London on 9th March 1880. He also attempt-
ed to record all previous nephrectomies and presented a table of
28 cases, successful or not, in Britain and abroad. He noted that
this was not an operation familiar to English surgeons.3 In 1881 he
again discussed nephrectomy at the society; by this time his table
contained 54 cases.6 Renal surgery was becoming more acceptable.
(Fig. 1)
The Surgeon – Henry Morris
Henry Morris (Fig. 2) was born in Petworth, West Sussex
on 7th January 1844, the son and grandson of a surgeon. He was
schooled at Epsom College and entered medical training in London
at University College and Guy’s Hospital. He was House Surgeon at

3. Barker AE. Nephrectomy by Abdominal Section. Medico-Chirurgical Transactions 1880;63:181 - 215.

4. Moll F, Rathert P. The surgeon and his intention. Gustav Simon (1824-1876), his first planned nephrectomy
and further contributions to urology. World journal of urology 1999;17:162 - 67.
5. Goddard JC, Birks T. A short history of nephrectomy. Urology News 2016;21(1):56 - 57
6. Barker AE. Nephrectomy by Lumbar Section. Medico-Chirurgical Transactions 1881;64:257 - 81

31
 Figure 2: Sir Henry
Morris. Image in the
public domain.

Figure 3: Signature of Henry Morris as President on the 1906 Membership of the Royal
College of Surgeons of England certificate of Clifford Morson. BAUS collection.

32
Guy’s then became surgical Registrar at the Middlesex Hospital in
London in January 1870 and eventually a full surgeon there in 1879
working mainly in the cancer department. He took a great interest
in cancer, giving the Bradshaw lecture on that topic in 1903.
The Imperial Cancer Research Fund (now Cancer Research
UK) was started in his house at 8 Cavendish Square in 1901 with
Morris acting as treasurer and Vice President. Also a lecturer in
anatomy and surgery, he became an eminent London surgeon. In
1906 he became President of the Royal College of Surgeons (Fig. 3)
and was created a baronet in 1909.7
The Patient – Maria M.
Miss Maria M., “a well-nourished, rather stout, short girl
with florid cheeks”, was a 19 year old domestic servant living in
London. She presented three times over a period of a few months to
the medical wards of the Middlesex hospital complaining of worsen-
ing right loin to groin pain and haematuria, which was preventing
her from working.
On the third occasion, on 29th December 1879, she was
seen by Dr. Sydney Coupland (1849-1930), the attending physi-
cian at The Middlesex. By this stage her urine was described as
the colour of porter (a dark London beer favoured by the meat
porters of Smithfields market). She had been suffering from inter-
mittent loin pain for the previous 11 years. A diagnosis of renal
stone disease was made. There were of course no X-rays, Roentgen
did not introduce these until 1895. The earliest cystoscopes were
just being tried, but they were clumsy and ureteric catheterisation
was not practised. Dr. Coupland suspected a renal stone and gave
Maria a chloroform anaesthetic in an attempt to feel a stone or
renal swelling per rectum; he was unable to pass his hand in far
enough! Nevertheless, Coupland felt sure the diagnosis was that
of a kidney stone.

7. Anon. Plarr’s Lives of the Fellows Online. Morris, Sir Henry (1844 - 1926) Secondary Plarr’s Lives of the
Fellows Online. Morris, Sir Henry (1844 - 1926) 2012. http://livesonline.rcseng.ac.uk/biogs/E000219b.
htm.

33
Figure 4: The stone extracted by Morris from Maria M. From ref 8.

The Surgery - nephrolithotomy

Thus, based on this clinical diagnosis of an accurate history
and observation of haematuria, at 1:30 pm on 11th February 1880
Henry Morris, with a chloroform anaesthetic, cut into Maria’s right
loin. The four and a half inch incision was deepened through fascia,
muscle and fat until a tough areolo-fibrous envelope was reached.
Morris cut through this to reveal pale yellow perinephric fat.
He could feel a firm bulge in the kidney so he passed a bistu-
ary (a long-bladed scalpel) alongside his finger, through the renal
parenchyma and delivered a 31 grain (2g) mulberry stone. (Fig. 4)
The wound was closed with three silk sutures. By May 1881 she
had returned to domestic service and was well apart from a small
discharging wound sinus.8
The case was read before the Clinical Society of London on
22nd October 1880 and published in their Transactions in 1881.

8. 
Morris H. A Case of Nephro-lithotomy or the Extraction of a Calculus from an Undilated Kidney.
Transactions of the Clinical Society of London 1881;18:31.

34
Morris believed this was the first recorded open nephrolithotomy for
removal of stone in a kidney “not dilated or altered in form [and]
… apart from the stone … healthy”. Morris suggested the name
nephrolithotomy as nephrolithiasis was in use to describe stones in
the kidney, nephrectomy was used for removal and nephrotomy for
cutting into a distended kidney to drain it.8 By giving the procedure
a very specific new name he emphasised that the operation was on
a kidney that was externally normal. Previously, removal of renal
stones had been by cutting into a pointing renal abscess or discharg-
ing sinus but not blindly into an undilated kidney.
The precedent - was Morris the First?
The surgical concept of cutting down to an undilated
kidney to remove a stone had certainly been discussed by many
authors over the centuries, although it would appear few felt this
was a good idea. Serapion the Elder (d. 930AD) suggested that,
“Some of the Ancient Orders extracted kidney stones with a knife,
cutting back into the loin” but goes on to say, it was dangerous
and should not be done. It is unclear who these ‘Ancients’ were,
certainly it was not proposed by Hippocrates, Celsus, Galen or
Avicenna.9
Francois Rousset (1535-1590), in his book on caesarean sec-
tion suggested that incision down into the kidney could be possible
but he was not prepared to try it.10 The scientific surgeon anato-
mists of the eighteenth and early nineteenth centuries continued to
condemn it. Benjamin Bell wrote: “that when not directed by the
appearance of a tumour…. the operation of nephrotomy will never
probably be received into general practice”.11
“With regards to cutting into the kidney,” Samuel Cooper
wrote, there would “always be strong objections to the practice”12
and Sir Benjamin Brodie said, “the proposal is absurd and danger-

9. Bernard C. An account of a gentleman’s being cut for the stone in the kidney, with a brief enquiry into the
antiquity and practice of Nephrotomy. Philiosophical Transactions 1695;19:333 - 42.
10. 
Cyr R. Caesarian Birth: The works of Francis Rousset in Renaissance France - A new treatise on
Hysterotomotokie or Caesarian childbirth. Cambridge: Cambridge University Press, 2014.
11. Bell B. A System of Surgery. Edinburgh: Charles Elliott, 1790.
12. Cooper S. A Dictionary of Practical Surgery. London: Longman, Orme & Co., 1838.

35
ous if made with reference to ordinary cases of renal calculi, where
no abscess exists.”13
There were a few unusual historical cases that appeared in
the literature. In January 1475, a free archer of Meudon, near Paris
was due to hang for the crime of sacrilege (he was a thief, but as he
had stolen from the local church the crime was deemed more grave).
According to a contemporary chronicler the condemned man suf-
fered from chronic loin pain and the doctors of Paris petitioned
King Louis XI to allow them to open his abdomen to “look at the
sites where these diseases are formed in the human body”. This
vivisection was carried out, “his entrails were replaced”, he survived
and was pardoned.14
This case has been put forward by some as an early example
of nephro-lithotomy. Some believe the whole story to be a complete
fabrication (including Sir Henry Morris),15 but even if it were true,
there is no record of this exploratory operation being on the kidney
or of any stone being removed.
More feasible perhaps is the case described by Charles
Bernard FRS (1650-1711) writing in 1695 in the Transactions of the
Royal Society. Bernard describes the case of Mr. Thomas Hobson,
Consul for the English in Venice, who had a kidney stone extracted
by Dominic de Marchetti (1626-1688), the Professor of Surgery at
Padua. Again, Morris dismisses this case as implausible- however a
more detailed discussion by Downes argues that might not be the
case.16
Hobson was in such pain with his renal stone that he per-
suaded Marchetti to cut into his loin and extract some renal stones.
Marchetti:

13. Brodie B. Lectures on Diseases of the Urinary Organs. London: Longman, Rees, Orme, Brown, Green and
Longman, 1832.
14. Nutton V, Nutton C. The Archer of Meudon: A curious absence of continuity in the history of medicine.
Journal of the History of Medicine and Allied Sciences 2003;58:401 - 27.
15. Morris H. On the Origin and Progress of Renal Surgery. Philadelphia: P. Blakiston’s Son and Co., 1898.
16. Downes H. A contribution to the history of nephrothithotomy. The Medical Times and Gazette 1885;1:238
- 42.

36
 “began with his Knife, cutting gradually upon the Region of the
Kidney affected, so long, till the Blood disturbed and blinded his
Work so that he could not finish it at that attempt: where fore
dressing up the Wound till the next Day, he then repeated and
accomplished it, by cutting into the Body of the Kidney, and taking
thence two or three small Stones, he dressed it up again.”
Another stone discharged through the wound at some point later as
his wife was dressing it.9
Charles Bernard, a well-known London surgeon met with
Thomas Hobson in the Castle Tavern on Paternoster Row in
London some ten years later, along with Dr. Edward Tyson (1651-
1708) and Dr. John Downes (1627-1694) who had known Hobson
in Venice.9 They listened to his story and examined the chronically
discharging fistula in his back.
The story seems plausible, more so perhaps as the surgeon
had to attempt twice to cut down onto the kidney suggesting that
there was no pointing abscess. Also, the impression given was that
Marchetti had to be persuaded to operate, if there was an obvious
abscess or fistula that would have been unusual as any surgeon
would be happy to do that.
Another candidate for the first nephrolithotomist was
William Ingalls (1813-1903) of Boston, USA. In 1872 at the
Boston City Hospital, he removed a large stone from the kidney of
a woman who had refused nephrectomy. The case was not published
until 1882. However, the patient clearly had a chronic discharging
fistula, so, applying Morris’s definition of cutting into an apparently
normal kidney, this was not nephrolithotomy.17
On 27th April 1869 Thomas Smith (1833-1909) presented
a strong case at the London Medico-Chirurgical Society for nephrot-
omy for renal stones outlining a surgical approach, but he had not
personally performed this.

17. Bundy FE, Ingalls W. Nephro-Lithotomy — Recovery of Comparatively Good and Continuous Health during
the Past Eight Years. Boston Medical and Surgical Journal 1882;106(21):483 - 86.

37
 Finally, at a meeting of the Edinburgh Medico-Chirurgical
Society on 2nd June 1869 and in a subsequent paper, Prof. Thomas
Annandale presented a case of kidney stone removal by dilatation of
a fistula. He stated that he would have no hesitation in cutting into
a non-dilated kidney if “the history of renal stone was convincing”.18
[18]. Following these presentations there were four recorded cases
attempted by British surgeons, with an incision towards kidneys
in which there was no suppuration and no tumour; by Gunn and
Durham in 1870 and two by Annandale in 1875. Two other cases
occurred in America by Lente of Cold Spring, N.Y. and Barbour of
South Norwood, Conn. They were not successful.8
It is possible, but difficult to prove, that Dominic Marchetti
of Padua may have carried out a stone extraction from a ‘normal’
kidney in the second half of the seventeenth century. Henry Morris
however, gives the first clear published description of this operation
being both planned and successful. Morris does realise in his later
publications that he was not the first to use the word ‘nephroli-
thotomy’, he acknowledges its earlier use by Hevin in 1757.15 Also,
the German physician Martin Schurrig (1656-1733) used the term
in his book Lithologia Historico Medica, although he again appears to
be discussing the drainage of renal abscesses.19
More important than precedent was Henry Morris’s novel
aim, nephron-sparing surgery.
The legacy – nephron-sparing surgery
Closely associated with the introduction of laparotomy,
planned renal surgery was a child of the second half of the nine-
teenth century along with its siblings, anaesthesia and antisepsis. Sir
Henry Morris performed the first planned, recorded and successful
nephrolithotomy on an undilated kidney. Although this procedure
had been suggested as possible in the medical literature of the past,
it was usually dismissed as too dangerous.

18. Annandale T. Calculous sucessfully removed from a Cavity in the Kidney with observations on the operation
of nephrotomy. Edinburgh Medical Journal 1870;15(1):21 - 29.
19. Schurrig M. Lithologia Historico Medica. Desden: Frederick Hekel, 1744.

38
 With the realisation that nephrectomy was a feasible and
survivable operation, other renal procedures were contemplated
which were not extirpative and the idea seemed more reasonable.
Morris believed that by operating on a “healthy” kidney he was not
endangering it but rather saving it. The alternative was the new
operation of nephrectomy or drainage once it had become a “mere
abscess sac”.8,15
When, in 1898 as Hunterian Professor at The Royal College
of Surgeons of England, Henry Morris wrote about “this very
modern branch of surgery” he was describing renal surgery and he
had a good reason to be discussing this in his Hunterian lecture.
Sir Henry Morris was a pioneer not only of early renal surgery but
also of conservative minimally-invasive surgery of the kidney and
nephron-sparing surgery- a concept which is now so much in vogue
and which we erroneously believe is a modern idea.
Correspondence to:
Jonathan Goddard
jonathan.goddard@uhl-tr.nhs.uk

39
40
 The Shock of Life: The History of
Electro-Ejaculation
Mohammed Aldiwani
Specialist Registrar, Department of Urology, Imperial College Healthcare NHS Trust, London, UK

Ejaculatory dysfunction or anejaculation is a major cause

of infertility. In humans, anejaculation is most commonly seen in
patients with spinal cord injury but also in patients with diabetes
mellitus, spina bifida, multiple sclerosis and following retroperito-
neal lymph node dissection. Semen can be retrieved non-surgically
through two main techniques: Penile Vibratory Stimulation (PVS)
and Electro-ejaculation (EE).1,2 Penile vibratory stimulation relies
on an intact ejaculatory reflex arc. A mechanical vibrator is placed
on the glans of the penis to stimulate ejaculation. This can be
performed in a clinic setting and is considered a first-line option
in many spinal cord injury patients due to its minimally-invasive
nature. Many patients do not respond to this and thus, Electro-
ejaculation can be performed.
The electro-ejaculation (EE) technique allows for non-
surgical sperm retrieval and artificial insemination. This procedure
may require a short general anaesthetic or sedation dependent on
the level of completeness of spinal cord injury. The majority of
spinal cord injury subjects have complete spinal cord injuries. EE
is achieved using a rectal probe lined with three linear electrodes
facing anteriorly towards the prostate. Electrical stimulation is
administered with incrementally increasing voltages until ejacula-
tion occurs. Semen obtained by EE can be used for intra-uterine
and intra-vaginal insemination or in-vitro fertilisation techniques.
Semen can be frozen and stored for future usage. More recently, EE
has been used for sperm banking in adolescent boys with malignan-
1. Sonksen, J. & Ohl, D. A. Penile vibratory stimulation and electroejaculation in the treatment of ejaculatory
dysfunction. Int. J. Androl. 25, 324–332 (2002).
2. O’Kelly, F. et al. Electroejaculatory Stimulation and Its Implications for Male Infertility in Spinal Cord Injury:
A Short History Through Four Decades of Sperm Retrieval (1975-2010). Urology 77, 1349–1352 (2011).

41
Figure 1: Practical anatomy class with Dr. Gunn, circa 1922.

cy prior to commencing gonadotoxic chemotherapy which would

otherwise render them infertile.3
Electroejaculation was adapted from initial experiences in
the veterinary world, where it has a role in the agricultural industry
as well as medical research. Electro-ejaculation has been particularly
pivotal in its role for protecting endangered species from the brink
of extinction through structured breeding programs.
First Veterinary Applications
Electrical stimulation to produce ejaculation was first pio-
neered in sheep by Gunn in 1936.4 Reginald Montagu Cairns Gunn
was born in Sydney, Australia 1893. He enlisted in the Australian
Imperial Force in 1915 and travelled to Europe where he served on
the western front in WW1. In 1919, he was granted leave from
the Army to study at the Royal Veterinary College in Edinburgh
3. Hagenas, I. et al. Clinical and biochemical correlates of successful semen collection for cryopreservation from
12-18-year-old patients: a single-center study of 86 adolescents. Hum. Reprod. 25, 2031–2038 (2010).
4. Gunn, R. Fertility in sheep. Artificial production of seminal ejaculation and the characters of the spermatozoa
contained therein. Bull Coun Sci. ind Res Melb. 94, 1–116 (1936).

42
and after completing his postgraduate studies in Copenhagen and
Stockholm, he returned to Sydney in 1921 to take appointment as
lecturer in veterinary anatomy and surgery.5
Gunn had a reputation being stern and unapproachable. His
altercations with colleagues were legendary and his surgery classes
were known as “Black Wednesday”, where students “felt the lash of
his acid tongue”. (Fig. 1) Despite this, he was revered and respected
by students and colleagues as both a talented surgeon and scien-
tist. He served as a chair and professor of veterinary science at the
University of Sydney until his retirement in 1959.
Over his tenure, Gunn had a range of research interests,
most notably in the field of fertility. He completed his doctoral
research on fertility in sheep with focus on artificial ejaculation
and insemination. His work has led to many practical long-lasting
applications including electroejaculation for which he is considered
to be the pioneer. The University of Sydney continues to uphold
and honour his contributions with a building which bears his name
to this day.
Early Human Experiences
The first human applications of EE were reported in
1948 by Herbert W. Horne, a fertility specialist from Boston,
Massachusetts.6 Several groups subsequently published their own
short-term experiences in the 1970s and 80s.
In 1975, the first pregnancy was reported by Thomas et
al, however the offspring suffered perinatal death. Francois (1978)
published the results from a French group in of fertility specialists
comprising of urologists, gynaecologists and fertility specialists.7
Their early experimentation with monkeys enabled them to practice
and improve their technique before applying it to paraplegic men.
5. Taylor, R. I. Biography - Reginald Montagu Cairns (Rex) Gunn. Australian Dictionary of Biography (1996).
Available at: http://adb.anu.edu.au/biography/gunn-reginald-montagu-cairns-rex-10379. (Accessed: 14th
September 2018)
6. Horne, H. W., Paull, D. P. & Munro, D. Fertility Studies in the Human Male with Traumatic Injuries of the
Spinal Cord and Cauda Equina. N. Engl. J. Med. 239, 959–961 (1948).
7. Francois, N., Maury, M., Jouannet, D., David, G. & Vacant, J. Electro-ejaculation of a complete paraplegic
followed by pregnancy. Paraplegia 16, 248–51 (1978).

43
Figure 2: Electro-ejaculation probes.

Figure 3: Modern Seager electro-ejaculation equipment.

44
In their published series of 31 patients, a single first successful preg-
nancy and birth using this technique was reported. These reports
were followed by Brindley publishing UK successes in 1981 and
1984 however all these experiences were also met with disappoint-
ment due to high failure rates.8
Successful Applications and Contributions by Stephen Seager
Much of the subsequent technical refinements that have led
to EE being a feasible technique in the modern age can be attrib-
uted to Stephen Seager (1938-). Stephen W. J. Seager was born in
Dublin, Ireland. Both of his parents were physicians. He obtained
his initial degrees in Veterinary Sciences from Trinity College,
Dublin before relocating to the USA. It is here where he pursued
his specialist scientific interests in reproductive medicine in both
animals and men.
Seager was on the faculty of the University of Oregon
Medical Centre, Portland; Baylor College of Medicine, Houston,
and Texas A&M University where he was made full Professor. He
settled in Virginia, where he was a member of the clinical staff
at the National Rehabilitation Hospital, and the Department of
Urology at George Washington Hospital in Washington, D.C.
Seager started performing electroejaculation in the 1970s
where they reported on their first successful pregnancy in the
domestic cat.9
Once parameters, techniques and equipment became estab-
lished, they utilized their experience to collect semen from various
endangered animals to facilitate breeding programs. Initially this
started with wild cats including the leopard, snow leopard, tiger,
lion and others. Redesigned probes of various sizes were also adapt-
ed for a broad range of animals including bottlenose dolphins, giant
panda and larger animals such as the elephant and both black and
white rhinos. (Fig. 2)

8. Brindley, G. S. The fertility of men with spinal injuries. Paraplegia 22, 337–48 (1984).
9. Platz, C. C., Wildt, D. E. & Seager, S. W. Pregnancy in the domestic cat after artificial insemination with
previously frozen spermatozoa. J. Reprod. Fertil. 52, 279–82 (1978).

45
Figure 4: Successful pregnancies from EE.

During this time, it was apparent that there was role and
need for the technique to aid men with spinal cord injury wishing
to pursue fertility. Seager partnered with physician colleagues and
built up their human experiences resulting in the first successes dur-
ing the early 1980s.10-12 Over time, this led to the development of
successive electrical stimulators including those approved for human
use. (Fig. 3)
Excluding their earliest attempts, Seager’s group have
reported 100% success rate in obtaining ejaculate over nearly 3
decades.13 (Fig. 4) The vast majority of the applications have been
in spinally injured patients who showed reduced quality semen.14
Despite these adversities, EE in expert hands has demonstrated
comparable reproductive outcomes to men with general male factor

10. Bennett, C. J. et al. Electroejaculation of paraplegic males followed by pregnancies. Fertil. Steril. 48,
1070–2 (1987).
11. Bennett, C. J., Seager, S. W., Vasher, E. A. & McGuire, E. J. Sexual dysfunction and electroejaculation in
men with spinal cord injury: review. J. Urol. 139, 453–7 (1988).
12. Halstead, L. S., VerVoort, S. & Seager, S. W. J. Rectal probe electrostimulation in the treatment of anejacula-
tory spinal cord injured men. Spinal Cord 25, 120–129 (1987).
13. Seager, S W J, H. L. S. Electroejaculation (EE) For Fertility Treatment Of Men Who Cannot Ejaculate.
Conference Abstract. Int. Symp. Prostate, Androg. Men’s Sex. Heal. Conf. Abstr. (2013).

46
infertility.14,15 The EE equipment developed by Seager’s team is used
in over 300 fertility institutes worldwide. Over this time and to this
date, Stephen Seager has continued to support and provide training
to assist clinicians replicate these success rates around the world.
Conclusion
Electroejaculation is an established practice in obtaining
semen from animals. This concept has been successfully applied to
aid anejaculatory men to produce semen for assisted conception.
The refinement and successful application has been made acces-
sible and possible for many through the work of Stephen Seager.
The technology has not changed significantly since the 1990s and
remains a safe and viable option for non-surgical sperm retrieval in
men. In addition, it continues to be utilized and adapted to address
the always evolving environmental challenges posed by endangered
animal species around the world.
Correspondence to:
Mohammed Aldiwani
Mohammed.Aldiwani@doctors.org.uk

14. Hovav, Y., Almagor, M. & Yaffe, H. Comparison of semen quality obtained by electroejaculation and spon-
taneous ejaculation in men suffering from ejaculation disorder. Hum. Reprod. 17, 3170–3172 (2002).
15. Momose, H., Hirao, Y., Yamamoto, M., Yamada, K. & Okajima, E. Electroejaculation in patients with spinal
cord injury: first report of a large-scale experience from Japan. Int. J. Urol. 2, 326–9 (1995).

47
 ml/sec

7
6

2 5

Figure 1: The patient urinates into a funnel (1), which is at the end of a wide tube (2),
which opens under water at the bottom of a 1 litre bottle sealed with a cork (4). Through
the cork is a hose (5) through which the air during urination leads to a rotameter (6). This
contains a float (7), which is raised to a certain height by a certain amount of air (ml/sec).
(From: Diary of a Resourceful Doctor (2012) by Hans Henrik Holm)

48
 Hans Henrik Holm (1931-2016):
An Homage to a Danish Pioneer and his
Contributions to Urology and Urological
Ultrasound

Jørgen Kvist Kristensen

Retired Chairman of the Urology Department, Rigshospitalet, University of Copenhagen.

Hans Henrik Holm was born with genes from his ances-
tors expressing curiosity, ingenuity, entrepreneurship. His father
was a highly valued practitioner who continued to care for faith-
ful patients until he was well over 90 years old. At the same time,
until his death, his father tried to solve medical problems through
biochemical research in the primitive environment that a medical
practice could provide, including the kitchen in the living area.
The flow meter
Dr. Holm graduated from University of Copenhagen in
1958, and he served as an intern in a department of surgery with
a special interest in urology. It took him just a couple of days in
the department to realize the need for objective measurements in
patients with voiding complaints. During the past 75 years there
had been scattered attempts to perform urodynamic measurements,
but mainly in a laboratory setup, not applicable in a clinical context.
Dr. Holm devised and developed a flow meter useable in clinical
practice for objective measurement and recording of voiding. (Fig. 1)
In 1959, Dr. Holm took his new device to a nearby factory
and, in return for a beer, 141 men volunteered to pee into this
strange instrument. He recorded the maximum flow and voided
volume and concluded that with a voided volume of at least 200
ml a flow of at least 15 ml/sec may be considered normal in men,
figures that have stood the test of time.
The micromanometer
During the first half of the twentieth century, there were a

49
 3 mm

7
5
6

1 Rtg.

2 4

7
3
8

Figure 2: The principle was that a small drop of mercury visible on an X-ray (1) was placed
in a thin glass tube (2), with an opening (3) in one end and an air-filled container (4) in
the other end, which if kept at a constant temperature would change position in the glass
tube as the pressure changed in the surroundings. The position of the drop of mercury in
relation to two small equally visible metal rings (5) placed around the glass tube enabled
the calculation of the pressure from the X-ray when “MM” was inserted in the bladder. The
“micro-manometer” which would be read through an X-ray, was gradually reduced in size
and weight by using thicker and thicker pieces of the glass tube. I bent the tube pieces
over a small (approximately 5mm) gas flame and the entire thing could finally, apart from
the 90% which broke, be placed inside a thin-walled hard plastic tube the size of a match.
This was sealed at both ends (7) with ARALDIT, and for a counterweight for the bottom
end, I used a small silver chain (8), the last link of which enabled its extraction using a
magnet. (From: Diary of a Resourceful Doctor (2012) by Hans Henrik Holm)

50
number of reports on the measurement of bladder pressure through
a transurethral catheter, but the problem was to have measure-
ments of urinary flow and bladder pressure simultaneously. For this
purpose, Dr. Holm developed his ‘micromanometer’. (Fig. 2) He
ended up with a manometer 22 mm long and 3 mm in diameter.
That is approximately the size of half a match. The device could be
mounted on a special catheter to be introduced into the bladder,
where it would place itself vertically at the dome of the bladder.
Pressure readings could then be obtained from x-rays. The bottom
of the device had a magnetic string, so it could be removed by a
catheter with a magnet at the tip. With this rather complicated
instrument and procedure, pressure-flow studies were performed
in 14 men without urological symptoms and 74 men with various
urological disorders, mainly suspected infravesical obstruction.
The flow meter and the micromanometer and their clinical
use were described in the Journal of Urology in 1961 and 1962 respec-
tively1,2 and further elaborated on in Dr. Holms theses from 1964:
The Hydrodynamics of Micturition.3 For that time it was a breakthrough
in the investigation and understanding of the function of the lower
urinary tract and a major contribution to the platform from where
modern urodynamics emerged during the 1960s and 1970s.
Innovations in ultrasound
Dr. Holm’s work was noticed outside Denmark and in 1964
he was invited to New York to spend a month starting up urody-
namic investigations at a major hospital. He stayed in a modest
Brooklyn hotel and on a boring Sunday afternoon he was lying on
his bed, looking through a copy of Time Magazine that had been left
over by a previous inhabitant in the room. Suddenly his interest was
aroused.
There was an article describing the first weak attempts to use
ultrasound in medical diagnosis. At that time, he was little aware
1. Holm HH: Micro-manometer for measurement of intravesical pressure. J Urol. 1961 Aug; 86:280-5.
2. Holm HH: A uroflowmeter and a method for combined pressure and flow measurement. J Urol. 1962 Aug;
88:318-21.
3. Holm HH: The Hydrodynamics of Micturition. Examination by means of micro-manometer and uroflowmeter
of the hydrodynamic conditions in normal subjects and in patients suffering from obstruction in the posterior
part of the urethra. Acta Radiol Diagn (Stockh). 1964:SUPPL 231.

51
Figure 3: The Gentofte scanner, 1967. Figure 4: Cross-section of upper abdomen.

that at this moment his later world fame started. From that moment
on, Dr. Holm and a group of young doctors put their efforts into
the development of diagnostic ultrasound and Copenhagen became
a globally leading center over the next 25 years.
Ultrasound is produced in a transducer about the size of a
thumb, and sound waves can be emitted in a beam, like the light
beam from a torch. When the sound waves hit something on their
way, some will be reflected, echoed, and the transducer now func-
tions as a receiver and the echo is registered on an oscilloscope
screen. Echoes are seen as deflections from the baseline, and they
are placed on the x-axis according to the distance of the reflecting
object from the transducer.
This so-called A-presentation is the foundation of all ultra-
sound diagnostics but being a one-dimensional presentation its
diagnostic possibilities are very limited. It is also possible to register
the echoes as dots on the screen. If you place the transducer at vari-
ous sites in a specific sectional plane, you will end up with a two-
dimensional picture of the interior of the object studied, known as
B-scanning or just ultrasound scanning.
The first experiments were carried out with a patient in a
water tank with a transducer pointing at the abdomen from various
directions. However, you had to make a good guess to identify the
various organs on the pictures obtained. After some years, equip-

52
ment was developed where the patient was taken out of the water
tank and scanning was performed with the transducer in direct
contact with the skin, but the picture quality was still very poor.
On this background Dr. Holm decided to build his own
scanner where you manually move the transducer across the
abdomen in direct contact with the skin.4 (Fig. 3) This allows the
physician to see the abdominal organs in greater detail (Fig. 4)
and give valid diagnosis. From 1965 on and with further improve-
ment of the equipment, the clinical use of diagnostic ultrasound
was investigated and reported by Dr. Holm and his group. Bear in
mind that this was 20-30 years before the advent of CT-scanning.
Diagnostic ultrasound produced sectional images, a whole new
way of looking into the body. This gave new diagnostic possibili-
ties, and they were grasped by the team, resulting in more than
50 publications on innovations in international medical journals
during the years 1965-1975. Dr. Holm and his team were at that
time working at the Department of Urology at the Gentofte hos-
pital, located in a suburb of Copenhagen, so they were known as
the Gentofte team.
Ultrasonically-guided puncture
At an ultrasound congress in Vienna in 1969, Dr. Kratochwil,
an Austrian gynecologist, presented a method for ultrasound guided
amniocentesis. At that time the A-presentation (see above) was
still the most widespread way of performing ultrasound studies.
Kratochwil used the A-presentation method to locate the amniotic
fluid in an effort to avoid the placenta before amniocentesis and
ingeniously he bored a hole in the transducer and put the nee-
dle through the hole. The needle would then follow the path of
the ultrasound beam and the beam and needle could be directed
towards the amniotic fluid, outside the placenta.
The Gentofte team attended the Vienna congress and imme-
diately saw the possibilities in combining the needle guidance with
the scanning principle. In this way anything seen on an ultrasound
scan could be hit precisely by a needle. Back home a transducer
4. Holm HH and Northeved A: An ultrasonic scanning apparatus for use in medical diagnosis. Acta Chir
Scand. 1968;134(3):177-81.

53
 was built with a central canal for
the passage of a needle and the
transducer was mounted on the
ultrasound scanner. (Fig. 5)
In the ward, Dr. Holm
found a patient with a renal mass
seen on urography and the patient
was scheduled for arteriography,
in accordance with the procedure
at that time. Dr. Holm took the
patient to the ultrasound scan-
ner and found the mass to be a
cyst. He suggested to confirm the
diagnosis by puncture guided by
ultrasound scanning and aspira-
tion of fluid. This was approved,
the cyst was punctured, and the
fluid sent for cytological examina-
Figure 5: Transducer for ultrasonically tion, which revealed malignant
guided puncture. cells. The kidney was removed,
and subsequent histology demon-
strated a malignant cyst.
This was reported in a video “Ultrasound in Renal Diagnosis”
at the annual meeting in 1970 of the American Institute of
Ultrasound in Medicine. For a number of years thereafter it was
commonplace to puncture all renal cysts seen on ultrasound scan-
ning until it was realized that this was an extremely rare case and
that renal cysts are extremely common.
Urological applications
Following this success, the team performed ultrasonically-
guided puncture of almost any pathology seen on abdominal scan-
ning. One procedure revolutionized urology: the ultrasonically-
guided nephrostomy.5 Some urologists may remember the night-
mare to face a patient with uremia because of suspected bilateral
5. Pedersen JF, Kristensen JK, Holm HH et al.: Ultrasonically guided percutaneous nephrostomy. Ugeskr Laeger.
1976 Feb. 9;138(7):416-7.

54
ureteric obstruction, trying to catheterize the ureters cystoscopically
and if unsuccessful having to ask for a life-threatening general anes-
thesia to perform a nephrostomy by open surgery. Now the diag-
nosis of hydronephrosis was established quickly and without risk by
ultrasound scanning, and nephrostomy could be performed right
away under local anesthesia.
A needle could be put anywhere else under ultrasound guid-
ance to take a biopsy, to perform fine needle aspiration of cells, to
drain abscesses, to inject sclerosing agents, to perform radio ablation
of small tumours, to place radioactive seeds in the prostate etc. All
of these and an additional number of procedures were conceived,
and first time performed by Dr. Holm and co-workers, and it was
recognized by the ultrasound community worldwide by naming Dr.
Holm the “Father of Interventional Ultrasound.”
Further developments of equipment were real-time ultra-
sonic scanning, where you have several transducers mounted on a
rotating wheel to produce live pictures of the inside of the body.
And, of course, a needle was connected to this new scanner, so on
live pictures you could see the needle tip on its way to and into the
target. These technical developments were further refined and com-
mercialized by Brüel and Kjær, a Danish company that for 25 years
was world-leading in ultrasonic equipment, particularly in the field
of urology, based on the efforts of Dr. Holm and his department.
Today the company is known as BK Ultrasound.
ESWL
Dr. Holm’s ingenious, innovative mind and his technical and
clinical flair was constantly looking for solutions to clinical prob-
lems, and improvement of existing methods and equipment.
In 1982 The Lancet published a paper from Munich in
Germany describing a new way of treating kidney stones – disin-
tegration by means of shockwaves. (See also De Historia Urologiae
Europaeae Vol. 24) You could hardly believe it, and dr. Holm and
two colleagues went there to see for themselves. Dr. Chaussy, the
father of ESWL, kindly demonstrated the first ESWL machine in
clinical use and the treatment of a young woman with kidney stone.

55
 Figure 6: Dr. Holm with the
Danish lithotripter (From: Diary of
a Resourceful Doctor (2012) by
Hans Henrik Holm).

2 6
4
3
2
1

3 5
1

Figure 7: Ultrasound scanning via the urethra [right]. Bladder tumours (1 & 3) and
Transducer (2).The prostate scanner itself consists of [(left)] an encapsulated engine (1), which
rotates a thick tube on the opposite end of which an ultrasound probe (2) is placed. The
probe protrudes directly out of the cystoscope (3). The probe emits brief ultrasound impulses
1000 times a minute, and when these hit the bladder wall, part of the energy is reflected
as an echo, which is highlighted on a TV screen (4), as a light spot. When the audio head
is rotated, the echoes are picked up from the surrounding area, registering a cross-sectional
image of the bladder or prostate. The scanner is used so that the urologists as usual either
under local or general anaesthetic insert the cystoscope through the urethra, prostate (5) and
into the bladder (6). (From: Diary of a Resourceful Doctor (2012) by Hans Henrik Holm)

56
 The patient was placed in a ceiling-mounted suspension
and moved around to be lowered into a huge bath tub. The stone
was located by fluoroscopy from two x-ray tubes, and shock waves
were generated from sparks between two electrodes and focused on
the stone. At a dinner later that day Dr. Chaussy brought a glass
tube with stone fragments which the patient had passed during the
afternoon.
Dr. Holm and his colleagues were convinced and impressed,
but they had hardly left Munich before Dr. Holm suggested to take
the patient out of the 800 liters bath tub, fill the cylinder with the
shockwave-generating electrodes with one liter of water, place it
over, and in contact with the kidney region via a rubber sleeve, and
place an ultrasound scanner in the cylinder to locate the stone.
Dr. Holm had a brilliant concept and a brilliant project, but
it stumbled in economic problems before it finally ended up with a
clinically applicable machine in the late 1980’s.6 (Fig. 6) However,
in the meantime the big medical companies had discovered the con-
cept and with unlimited finances developed and commercialised it.
Transrectal ultrasound scanning (TRUS)
As a urologist, the cystoscope was an important tool in Dr.
Holm’s daily work, but he felt frustrated to see only the surface of
the interior of the bladder, and not to be able to see the extent of
invasion of a tumour into the bladder wall. He therefore devised
a transurethral ultrasound scanner, (Fig. 7) hoping also be able to
visualize the interior of the prostate.7
The scanner did work alright, but it was overtaken by a
better picture quality and less discomfort for the patient when scan-
ning the bladder from the abdominal side and the prostate from
the rectal side. So instead, Dr. Holm built a transrectal ultrasound
scanner8 (Fig. 8) that was further developed and commercialised by
Brüel & Kjær and also by other companies and has now been used
6. Holm HH, Hald T, Kristensen JK et al.: The Danish Extracorporeal Lithotriptor. In: JE Lingeman, DM Newman,
eds., Shock Wave Lithotripsy. New York and London, Plenum Press 1988.
7. Holm HH and Northeved A: A transurethral ultrasonic scanner. J Urol. 1974 Feb.111(2):238-41.
8. Gammelgaard J and Holm HH: Transurethral and transrectal ultrasonic scanning in urology. J Urol. 1980
Dec;124(6):863-8.

57
Figure 8: Transrectal ultrasound scanner.

Figure 9:
Transrectal
ultrasound
scanner with
puncture guide
for precise
placement of
radioactive
seeds in the
prostate.

Figure 10: Professor Holm

at his appointment as
honorary doctor at the University of
Bologna 2007

58
worldwide for 40 years for imaging and guiding biopsies of the
prostate. Dr. Holm took the method further and devised a tech-
nique for ultrasonically-guided implantation of radioactive seeds in
the prostate with cancer,9 (Fig. 9) one more branch on the tree of
interventional ultrasound, popularised as brachytherapy and still an
option in the treatment of prostate cancer.
Conclusion
Dr. Holm’s many contributions to medical sciences were
recognised over the years worldwide with guest lectures, visiting
professorships, awards, honorary memberships etc., and on top of it,
at the age of 78 years, Dr. Holm was bestowed a very special and
rare honour, the appointment as honorary doctor at the University
of Bologna, the world’s oldest university. (Fig. 10)
Several other people should be credited for their important
contributions to the development in the areas described, and I
apologize for not mentioning them, but this chapter is a tribute to
professor Hans Henrik Holm, a true pioneer in urology and urologi-
cal ultrasound.
Correspondence to:
Jørgen Kvist Kristensen
Fuglegårdsvej 26
2820 Gentofte
Denmark
kvistkristensen@mail.dk

9. Holm, H.H, Juul N. Pedersen JF et al.: “Transperineal 125 iodine seed implantation in prostatic cancer
guided by transrectal ultrasonography” J Urol 1983 Aug.130(2).283-286.

59
60
 Urologists to the Desert Rats:
Serendipitous Skills of the World War II
Urologists
Peter Grice, Jonathan Goddard
Leicester General Hospital, Gwendolen Road, Leicester. LE5 4PW

The defining skills of the early urologists were those of endos-

copy. It was the ability to use these modern diagnostic tools that
characterised the new speciality in the early 20th century. On the
outbreak of World War II, British doctors of every grade, speciality
and skill were mobilised into the Royal Army Medical Corps (RAMC)
and deployed to all theatres of war. One major battle zone of World
War II was the Anglo-American campaign in North West Africa.
This paper looks at the experiences of some of the doctors who were,
or subsequently became well-known British urologists and how their
expertise both contributed to and was enhanced in this desert war.1-3
Operation Torch
Operation Torch was the invasion of North Africa by British
and United States forces in November 1943. It was the first major
allied operation of World War II and the largest amphibious inva-
sion to that date.4 The strategy of opening a second front not only
helped the Soviet Union but provided a naval launch pad for the
subsequent invasion of the so-called ‘soft underbelly’ of Europe.5
A force consisting of 90,000 troops was escorted by a huge
naval fleet consisting of 350 warships and 500 troop transporters.6

1. Feggetter GY. Diary of an RAMC Surgeon at War, 1942-1946, by Lieutenant Colonel George Y. Feggetter,
RAMC. 1946. https://wellcomelibrary.org/item/b19687266#. Accessed September 17, 2018.
2. England RC of S of. Poole-Wilson, Denis Smith - Biographical entry - Plarr’s Lives of the Fellows Online.
https://livesonline.rcseng.ac.uk/biogs/E008850b.htm. Accessed September 17, 2018.
3. England RC of S of. Gow, James Gordon - Biographical entry - Plarr’s Lives of the Fellows Online.
http://livesonline.rcseng.ac.uk/biogs/E008637b.htm. Accessed September 17, 2018.
4. Beam JC. The Intelligence Background of Operation TORCH. 1983. http://www.dtic.mil/docs/citations/
ADA129136. Accessed September 20, 2018.
5. Walker DA. OSS and Operation Torch. J Contemp Hist. 1987;22(4):667-679. doi:10.1177/
002200948702200406.
6. Brown D, Hobbs D. Carrier Operations in World War II.; 2009.

61
The Allies faced Italian and German troops but the invasion was also
opposed by the Vichy French. For propaganda purposes, Winston
Churchill even suggested that British troops wear American uni-
forms due to animosity between the British and Vichy French
government at the time.7 All British troops were assigned to the
Eastern Task Force, which was under the command of Lieutenant-
General Kenneth Anderson.7 The British troops who fought in
North Africa in the Second World War have become known as the
Desert Rats; although strictly the name given to the troops of the
7th Armoured Division, it has become synonymous with all the
soldiers of this desert war.
Our Urologists enter the theatre of war
George Young Feggetter (1905 – 2000) (Fig. 1) became
interested in urology after working with George Grey Turner (1877
– 1951) in his native Newcastle. He subsequently furthered his uro-
logical training with a visit to Alexander von Lichtenberg (1880 –
1949) in Berlin in 1933, who had pioneered intravenous urography.
Feggetter then worked under Edward Canny Ryall (1865-
1934) and with Terence Millin (1903 – 1980) who were pioneer-
ing Transurethral Resection of Prostate (TURP) at All Saints
Hospital in London before the war.8 He published one of the earliest
British papers on TURP9 and in 1936 wrote a review on bladder
outflow obstruction whilst First Surgical Assistant to the British
Postgraduate Medical School.10
On the outbreak of war Feggetter worked in the Emergency
Medical Service on the home front then joined the RAMC in 1942.
He was posted to North Africa as part of Operation Torch.1 We
are fortunate to have a detailed account of his activities during the
war as Feggetter bequeathed his war diary to the Imperial War
Museum.
7. Mangold P. Britain and the Defeated French : From Occupation to Liberation, 1940-1944. I.B. Tauris; 2012.
8. England RC of S of. Feggetter, George Young - Biographical entry - Plarr’s Lives of the Fellows Online.
https://livesonline.rcseng.ac.uk/biogs/E008593b.htm. Accessed September 17, 2018.
9. Doyle RW, Feggetter GY. Endoscopic resection of the prostate: a critical survey of 150 cases. Br Med J.
1935;1(3864):147-151. http://www.ncbi.nlm.nih.gov/pubmed/20778807. Accessed October 9, 2018.
10. Feggetter GY. Bladder Neck Obstruction in General Practice. Postgrad Med J. 1936;12(132):404-413.
http://www.ncbi.nlm.nih.gov/pubmed/21313033. Accessed October 9, 2018.

62
Figure 1: Photograph of Figure 2: General view of the 69th British General
George Young Feggetter. Hospital, Alexandria. Image, Australian War Memorial,
https://www.awm.gov.au. Image in the public domain.

George Feggetter began his journey to Algiers under the com-

mand of General Eisenhower.1 Having performed an appendicectomy
en route, Feggetter landed in Bougie where he and his colleagues
were able to deliver only first aid as the Axis planes had sunk many
of the transporters containing their surgical equipment. They took
over a French civilian hospital, much to the chagrin of the French
surgeon and nurses who had sworn not to help the British. Using the
old surgical equipment available Feggetter set about operating on the
myriad of trauma patients now under his care following heavy Axis
bombing.1
The French soon added their help too; compassion for the
wounded presumably trumping their politics. A typical working
day at this point would mean relentless operating between 7am
and 10pm with sporadic ward rounds between cases.1 Eventually
the 69th British General Hospital was re-supplied and formed into
an efficient tented hospital. (Fig. 2) Soon Feggetter’s diary begins to
record some urological procedures, cystoscopies and ureteric stone
manipulations; his urological skills were being utilised in between
general and trauma surgery.1
In 1943, he was assigned to the Field Surgical Unit of the 1st
Army, which was designed to be mobile and function close to the

63
Figure 3: Photograph of Dennis Smith Poole-Wilson.

battlefield. The casualties included some brought in by Lt. Vladimir

Peniakoff (1897 – 1951); commander of the famous ‘Popski’s
Private Army’, a British Special Forces Unit who were attacking
Rommel’s fuel supplies. Drawing on his experiences, Feggetter
published a paper in the Lancet outlining his management of war
wounds and use of proflavine-sulphathiozole powder to prevent
post-operative infection.1 His urological knowledge came into play
as he encouraged the men to drink plenty of bland fluids to prevent
sulphonamide crystaluria in the hot climate.
In March 1944 Feggetter was posted to 33rd British General
Hospital in Syracuse, Sicily and was subsequently posted to Naples
where, aside from managing stone disease, his urological training
was once again of significant value in performing nephrectomies for
tuberculosis. Venereal disease was also a florid problem amongst
the troops, and Feggetter was required to perform circumcision or
dorsal slit operations for syphilis patients who were otherwise being
treated with intravenous arsenic preparations.1

64
 The hospital treated wounded German and Italian prisoners
of war as well as Allied casualties. Feggetter recalled that the Allied
capture of Rome in June 1944 was greeted with cheers from Italian
patients, sparking significant animosity from their German coun-
terparts.1 The majority of his war-time surgery was dominated by
trauma, although his skills as a Urologist bore fruit as a significant
increase in stone disease in the hot climate meant his cystoscopy and
retrograde studies coupled with his ability to manipulate ureteric
stones were of significant value.1
Denis Smith Poole-Wilson (1904 – 1998) (Fig. 3) was
born in Dublin in 1904, and trained at Trinity College there. He
was House Surgeon to J.B. MacAlpine (1882 – 1960) in Manchester
in the 1930’s. Here he learned his cystoscopic skill from MacAlpine
who formed the first genitourinary department at the Salford
Hospital. Poole-Wilson himself became surgeon to the Salford
Hospital in 1934 also specialising in urology. Already in the army
reserves, he was mobilised at the beginning of the war. With the
rank of Lt Colonel he was in charge of the surgical division of the
72nd British General Hospital going to North Africa and Italy. A
series of letters from Denis Poole-Wilson to his wife Monique sent
during the war give some idea of his time there.11
In April 1944 the 72nd Hospital was transferred from
North Africa to Cancello, near Naples. Poole-Wilson describes a
tented hospital overlooking the smoking volcano of Vesuvius. He
was particularly interested in trauma of the lower urinary tract and
although this was a condition easily diagnosed and treated in its
early stages by suprapubic diversion, he recognised the importance
of specialist urological care for definitive treatment. According to
Poole-Wilson it was through Brigadier Harold Clifford Edwards
(1899 – 1989), Consultant Surgeon to the Central Mediterranean
Force, that a Genitourinary Centre was established in Naples and
then in Rome. Poole-Wilson was asked by Edwards to set up this
centre and also to draw up suggestions for the treatment of urethral
injuries.12 This 100-bed unit became colloquially known as ‘Poole’s
11. Poole-Wilson DS. Letter to Mrs M Poole Wilson dated 05/04/1944. 1944.
12. Poole-Wilson DS. Missile injuries of the urethra. Br J Surg. 1949;36(144):364-376. doi:10.1002/
bjs.18003614407.

65
Figure 4: Photograph
of James Gow.

Figure 5: Leica cystoscopic camera with a reflex box,

1938, Leitz Company, Wetzlar. From Reuter, M. A.,
et al. (1999). History of Endoscopy: An Illustrated
Documentation. Stuttgart, Max Nitze Museum.

Figure 6: Schematic of a Swift-Joly cystoscope. This was the type of instrument used by
urologists for endoscopy before the Second World War

66
Piss Palace’ where he provided excellent care for open bladder and
urethral injuries as well as the heavy workload of stone disease.2
Poole-Wilson presented his work on urethral injuries as a
Hunterian Lecture to the Royal College of Surgeons of England
after the war12 and to the Royal Society of Medicine.13 In the latter
he describes the cases of 81 men treated for urethral rupture.13 At
the same meeting Geoffrey Parker (1902 – 1973) a surgeon who
had also worked in Africa and Italy stated that out of his series of 94
laparotomies for trauma, 36 involved the urinary system.14
James ‘Jim’ Gow (1917 – 2001) (Fig. 4) was born, raised
and trained in Liverpool. When war broke out he was qualified but
was not yet a surgical specialist. He served throughout the war in
the RAMC also in North Africa.3 In the aftermath of the battle
of El Alamein, Gow spotted a cystoscope with a Leitz (or Leica)
camera attachment left behind by a German surgical Unit. Gow, a
keen photographer, recognising its high quality, took it as spoils of
war.15 (Fig. 5) It was only after the war that Gow became a urologist
back in Liverpool and that his German Cystoscopic camera became
relevant to the future of urology.
Victor Wilkinson Dix (1899 – 1992) trained at The
London Hospital Medical College and subsequently worked for
George Neligan (1885 – 1956) at The London and with Frank Kidd
(1878 – 1934) in private practice; both were British urological pio-
neers who laid the foundations of urology at The London Hospital.
Like Feggetter he had visited von Lichtenberg in Berlin to study
early X-ray techniques in urology and he subsequently became
adept at localising urinary tract stones by stereoradiography.
Improving on Von Lichtenberg’s pyeloplasty technique, he
also became skilled at open renal surgery. Dix, who had flown with
13. Poole-Wilson DS. Injuries of the Urethra. Proc R Soc Med. 1947;40(13):798-804. http://www.ncbi.nlm.nih.
gov/pubmed/19993672. Accessed October 9, 2018.
14. Parker GE. Some Observations on a Personal Series of Battle Casualties Involving the Genito-Urinary System
[Abridged]. Proc R Soc Med. 1947;40(13):804-807. http://www.ncbi.nlm.nih.gov/pubmed/19993673.
Accessed October 9, 2018.
15. Le Fanu J. The rise and fall of modern medicine. London: Little Brown. November 1999. doi:10.1136/
BMJ.319.7219.1276.

67
the Royal Flying Corps in the First World War, joined the RAMC
in the second and served in Africa, Egypt and the Far East. While
serving in north Africa he saw large numbers of dehydrated young
troops develop ureteric calculi and developed a technique of open
ureterolithotomy to remove these that, according to his successor
John Blandy, was unrivalled for accuracy, speed, and simplicity.16,17
Post-war accomplishments
After the war, George Feggetter resumed his career in sur-
gery in Newcastle. He remained a general surgeon but always with
an interest in urology. He was a founding member of the British
Association of Urological Surgeons in 1945 and his son, Jeremy
followed in his father’s footsteps also becoming a noted urologist.8
Denis Poole-Wilson returned to Manchester where he shared
his wartime experiences of genitourinary trauma and accumulated
a wealth of experience of urothelial malignancy while working at
Salford as well as the Christie Hospital and Radium Institute.2 He
demonstrated a causative link between bladder cancer and the dye
workers of Manchester, gaining them compensation for their indus-
trial injury. Also a founder member of BAUS, he was its president
1965 – 1967.18
Geoffrey Edward Parker, only briefly mentioned above,
returned to surgical practice in London and continued to maintain
a lifelong interest in urology. Interestingly, after serving in North
Africa and Italy and training in parachute jumping, unarmed com-
bat and the use of small arms, he was parachuted into the Jura
mountains of France and worked as a surgeon for the Maquis resist-
ance fighters. He was awarded the Distinguished Service Order
and the Croix de Guerre with Palm and Gold Star and made a
Commandeur de la Légion d’Honneur.19

16. Blandy J. Obituary. Mr Victor Dix. Br J Urol. 1992;70:464.

17. Blandy J. Obituary, V.W. Dix. BMJ. 1992;305(Index 1992 Dec):3-28. doi:10.1136/bmj.305.Index_1992_
Dec.3.
18. Mitchell J. Obituary, Denis Smith Poole-Wilson. Biritish Medical Journal. https://www.jstor.org/stable/
i25179694. Published 1998. Accessed October 9, 2018.
19. England RC of S of. Parker, Geoffrey Edward - Biographical entry - Plarr’s Lives of the Fellows Online.
https://livesonline.rcseng.ac.uk/biogs/E006009b.htm. Accessed October 9, 2018.

68
 In 1957, James Gow, now a consultant urologist in
Liverpool, approached Harold Hopkins with his Leitz cystoscopic
camera bemoaning his poor quality pictures of bladder tumours.
With a £3000 grant from the Medical Research Council, Hopkins
worked with Gow to deconstruct existing endoscopes, identify-
ing the causative problem; poor light transmission.20 Hopkins
exchanged the series of air spaces and glass lenses for continuous
glass rods, as well as applying a reflective coating so that more light
would pass directly through the rods.20 The Rod Lens cystoscope
was introduced at the SIU in Munich in 1967 changing the face of
endourology forever.20 Cruel irony resulted in Gow succumbing to
bladder cancer in 2001.20
Victor Dix became Professor of Surgery at The London
Hospital from 1947 – 1964. His main interest was urology and
established a purpose-built urology outpatients department. He was
succeeded by John Blandy who became London’s first Professor of
Urology.
Conclusion
It is clear that surgery in WWII was for the general surgeon
who was capable of managing any trauma as well common surgi-
cal ailments. Cystoscopy (Fig. 6) was a specialist skill that could
only be provided by Urologists. It proved to be of huge importance
for a high-risk group of stone-forming patients in this desert war.
Feggetter and Poole-Wilson were already skilled in endoscopy and
Victor Dix brought his formidable skill in radiological diagnosis and
open stone surgery. Gow’s interest photography meant that, for dif-
ferent reasons, it was serendipitous that all these men were posted
in the same historically significant military operation.
Correspondence to:
Peter Grice
peter.grice@nhs.net

20. 
Goddard JC. A Series of Fortunate Events: Harold Hopkins. J Clin Urol. 2018;11(1_suppl):4-8.
doi:10.1177/2051415818775309.

69
 Figure 1: Peter Lefcourt’s 1997 novel Abbreviating Ernie.

70
 A Tale of Two Penises
Michael E. Moran
Curator, William P. Didusch Center for Urologic History, Linthicum, MD, USA

“I’m afraid this is going to be just a little bit uncomfortable,” he lied. It

was going to hurt. In fact, it was going to be thirty to forty seconds of fairly
excruciating pain. But he said it, as he always did in this situation, in the
hope that when his turn came, as it invariably would, it might somehow
turn out to be less painful.”
Ernest Haas, fictitious urologist1

In all of the long and lustrous history of urology, never

before has there appeared such a novel with an urologist at the heart
of the mystery than in Peter Lefcourt’s Abbreviating Ernie in 1997.1
(Fig. 1) Ernie Haas, M.D., so it turns out, is a urologist practicing in
upstate New York’s town of Schenectady (happens to be the home
of my wife- hence well familiar territory). Ernie just so happens to
like to cross-dress for kinky interludes with his wife, Audrey in their
kitchen.
One particular evening, our hero has donned a very stunning
beige knit suit with a fetching yellow blouse with off-white open-
toed heels and, using padded handcuffs, has locked his wife to the
kitchen oven door to provoke the attentions of Audrey. We are told
that the two can often share outfits because fortuitously, “they are
both a perfect size 8.”
During their interlude, just as Ernie is about to experience
his ultimate bliss he succumbs instead to a massive heart attack and
is instantly dead. Audrey is pinned beneath her husband and his
still erect member and must find a means of extricating herself. The
only object within her reach is the Sunbeam electric carving knife
1. Lefcourt, Peter: Abbreviating Ernie. Villard Books, New York 1997.

71
which has served the family’s functions so many times in the past.
It is called once more into duty for family and pride, following in
the wake of such real stories of John Wayne Bobbitt and his wife
Lorena in 1993.
“Ernest Haas looked at the thin old man bent over his
examining table, boxer shorts around his ankles, spindly legs
bowed, varicose veins trellising his distended scrotum, and
wanted to tell him that the prostate gland wasn’t designed
to do the job for more than seventy years. The simple fact was
that he had outlived his equipment. But instead he reached
into the cabinet for the box of disposable rubber gloves and
the tube of lubricant.”1
Thus begins the sordid tale of the Schenectady urologist,
Ernie Haas. Now I lived, practiced, married, and had children in
this region. In fact, my wife was a native of Schenectady and the
in-law’s neighbors were in fact a husband/wife combination who
could have literally been the protagonist of this novel- Dr. Robert
and Doris Pletman.
Bob, was a kindly urologist, soft-spoken and quietly intel-
lectual. Doris was lively and warm to both my wife and me. They
had dogs, just like Ernest and Audrey, but they loved Brittany
Spaniels. Bob Pletman was trained in SUNY Buffalo and came to
Schenectady where he practiced for most of his life before he and
Doris retired and moved to Florida. He was loved and admired by
most of his large practice.
We spent many an evening together discussing urology,
books, and life. I gave Bob a famous surgical painting by Joe
Wilder, a surgeon/artist from NY City when Gail and I moved
away from the Capital District in upstate New York.2 Their oldest
son was one of organizers of the Boston Marathon and he was pre-
sent, but thankfully not injured during the infamous bombing on
April 15, 2013. Bob and Doris Pletman were truly inspiring people

2. Schwartz, Seymour, and Joe Wilder. Surgical Reflections: Images in Paint and Prose. Taylor and Francis,
New York, 1993.

72
and not the cross-dressing couple of the novel, though I think that
Doris did own a Sunbeam electric carving knife.
Another unusual or perhaps unappreciated fact was there
was a renowned chairman of urology in Upstate New York named,
Gabriel P. Haas at Syracuse, New York at the time of this novel-
fascinating that the last name of Ernie and Gabe were the same.
Gabe was a good friend and innovative Chairman before he left the
area to return to the Midwest.
The City of Schenectady
“The sap was rising and the salmon spawning, and
he, Ernest Haas, diplomate in urology from the Cornell
medical school, was standing in his office on State Street in
Schenectady, New York, with his finger up an old man’s
ass. ‘Jesus, Doc…’ ‘Just a little longer, Mr. Nemic. We’re
almost finished.’ He thought of Audrey, in the aquamarine
kitchen of their Dutch Colonial on Van Schuyler Lane,
watching Oprah on the nineteen-inch Magnavox, drinking
decaf instant coffee and clipping coupons. At least she was
out of bed these days. Since she’d gone on Prozac, things had
been better.”1
There are no urologist’s offices on State Street which is
in the historical downtown of Schenectady, New York. In fact,
Schenectady is one of the many relics of the past, almost ghost-
like from its former glory days. It used to be the headquarters
for General Electric and the railroad industry because of steam
engines.
Of course, the town was related closely to the two rivers that
intersect and merge at the neighboring towns of Albany and Troy,
but these were not the original names, being Dutch settlements.
The great Patroon Kilian Van Rensselaer was the ambassador to
the Native Americans when Van Curler first described these Great
Flats along the Mohawk and Hudson rivers. He stated that it was
“the most beautiful land ever seen by the eye of man.” Conflicts at this early
time between the mixed Dutch and French settlers was common,
producing three early heroes: Symon (or Simon) Schermerhorn,

73
Figure 2: First known map of downtown Schenectady, called the Romer map. (Author’s
personal collection photograph).

Figure 3: Lawrence the Indian.

(Author’s personal collection photograph).

74
Adam Vrooman and Lawrence the Indian whose exploits have been
recorded. (Fig. 2)
During the Revolutionary War, Schenectady served as the
breadbasket for Washington’s Army and George Washington vis-
ited the town three times during this conflict. The American Field
Hospital was located at the corner of Union and Lafayette Streets in
downtown Schenectady. Union College was founded in 1795 as the
very first non-denominational college in the United States. The first
mayor of the town was Joseph C. Yates and he eventually became
the state’s seventh governor. The Stockade area near the Mohawk
river with 160 structures burned nearly to the ground, only seven
structures remained after the great fire of 1819, where the statue
of famed hero and Native American Lawrence stands. (Fig. 3) The
Erie Canal opened in 1825 and shifted travel business away from
Schenectady to its sister city of Troy. All of these now trivial histori-
cal facts come back to roost with the setting of Abbreviating Ernie.
Schenectady entered into a phase of heavy industrialization
with the Locomotive Works beginning in 1847 followed by Thomas
Edison building his Edison Machine Works in 1886 that became the
core for General Electric. General Electric rapidly expanded bring-
ing its upper management to Schenectady and the civic expansion
of the town resulted in Schenectady Civic Players, the Schenectady
Light Opera Company, and the Schenectady Symphony Orchestra
being established. Early industrialization corresponding with the
rapid expansion of health care facilities and one of the regions first
urological practices came to Schenectady.
The war years continued the economic success of the town
as the American Locomotive Plant turned out tanks twenty-four
hours a day. The General Electric Plant also built turbochargers for
American planes. But the town’s demise has followed the general
trend for almost every city in Upstate New York in the 20th cen-
tury.
The Bobbitt Case
“Audrey. The beautiful depressive with the milky white
skin and febrile eyes. Audrey the fair. Audrey, the absent.

75
 Figure 4: Amputated penile
remnant of John Wayne Bobbitt
from Dr. Sehn.

Figure 5: Wall Street Journal article on the case (photo courtesy of Dr. Sehn).

76
 Audrey the languid…Audrey wondered if you needed any
qualifications to work for the Weather Channel besides a
clean suit and decent posture. She watched the high and
low temperatures flash on the screen, listened as the woman
in the blue suit read them off in a nasal voice: ‘With lows
from the teens in the Berkshires to the low twenties in down-
town Albany…’ Siggy, the Rottweiler, wandered into the
kitchen and stared pointedly at his bowl. It was too early
for his dinner. And he knew it. Still, he went through the
starving-dog routine until she said to him tartly, ‘Get lost,
Siggy.’” 1
Now the history of this particular story dovetails nicely with
that of the urologist, James Sehn who was called in to see John
Wayne Bobbitt on June 23, 1993 at his small hospital in Manassas,
Virginia. In my role as Curator to the William P. Didusch Center
for Urologic History I have had ample opportunities to discuss the
case with the mild-mannered Dr. Sehn who also shared some of his
photographs with me during interviews and discussions about his
experiences.3
“I thought that being out here in the country would mean
a quiet, obscure life,” recalled Sehn. Just after dawn on that fateful
day Dr. Sehn received that memorable call the emergency room.
John Wayne Bobbitt, 26, had presented to the ER with bleeding
stump and no penile remnant. (Fig. 4) Mrs. Lorena Bobbitt, 24, had
amputated his penis and then called the police to inform them that
she had thrown it from the car window. “Once I looked at him, it
was pretty clear what I needed to do.” Sehn put a tourniquet on
the stump to prevent further bleeding and to Bobbitt, “I carefully
explained to him what I could do and could not do.”3
The police and fire/rescue found the organ on the roadside
grass and returned the severed member so that Sehn and plastic sur-
geon David E. Berman replanted the severed part later that morn-
ing in a 9.5 hour microscopic surgical procedure. Sehn would recall
3. Personal interview with James Sehn, M.D. by Michael E. Moran, M.D., Curator, William P. Didusch Center
for Urologic History, American Urological Association, at the AUA Annual Meeting in New Orleans, Sunday,
May 18, 2015.

77
that Bobbitt was “the most calm guy I’ve ever met in life. He gave
a high five wave and said ‘do your best for me, Doc’.”3
Sehn was most impressed by the amount of attention the
case had caused for the town and for his practice, people were wait-
ing for him on his emergence from the operating room. Dr. Sehn
recalled his first live interview was with a Las Vegas radio station
and stated, “everything I said provoked howls of laughter and it
dawned on me that this whole subject was a minefield.” News and
shows were in a literal frenzy vying with one another for attention.
(Fig. 5)
“It was 6:23 when Ernest Haas finally left his office. He
had spent the last two hours giving old men bad news, and
he was exhausted. All he wanted to do was go home and
get into bed with the March issue of the New York State
Journal of Urology [does not exist] …He drove quickly
through the State Street traffic and out Route 5 east till
he reached the Mohawk Mall, located halfway between
Schenectady and Albany. Parking in a handicapped zone,
he put his MD ON CALL sign on the dashboard [never
seen one of these, but I want one]…
The mall was uncrowded at this hour, and he was in and
out of Kmart in under ten minutes [the Kmart is actually
not near the Mohawk Mall, but it is on Route 5]. He got
two pair [of pantyhose], one light-cream, the other sheer. He
returned to his car, moved back into the thinning traffic on
Route 5, exited at Poltroon Road, and drove the three and
a half miles to the little pod mall that housed Ming Sun’s
Take-Out Chinese Cuisine.”1
Sorry if this story is making you hungry, but just empathise for a
moment with Siggy, you will know what I’m referring to shortly…
“He put the jewelry on the bed beside the suit, then took the
pantyhose from the Kmart bag to make the final choice. He
hesitated for a long time before going with the sheer. The
light-cream was overkill. Then he got a pair of scissors from
the night table and began very carefully to go to work.”1

78
Now the story is about to get interesting…
“But as soon as she heard the sound of the high heels on the
hardwood floor of the hallway, she knew she’d be lucky to
see any more than the last hour of the movie. He stood in the
doorway, one hand on his hip, a dark-brown patent-leather
pocketbook hanging from his shoulder. He was wearing too
much mascara. He had been sparing with the lipstick- the
Revlon crushed roses- but not the mascara.
‘The bag goes great with the shoes, doesn’t it?’ He smiled
before reaching inside the pocketbook and bringing out a
pair of handcuffs. ‘They’re padded inside. They don’t leave
marks,’ he added, showing them to her so that she could see
for herself. ‘I got them in the mail. From Santa Monica,
California.’…He dangled the handcuffs in front of her.
There was a foot of chain between the two shackles. ‘For
mobility,’ he explained as he led her across the kitchen,
slipping one end of the handcuffs around her left wrist and
attaching the other to the oven-door handle of the restored
O’Keefe and Merritt stove..
‘I adore you, Audrey. You know that, don’t you? There
is nothing I wouldn’t do for you,’ he whispered before tak-
ing out his compact [small portable mirror] and brushing
up his lipstick, smacking his lips together expertly…When
she looked back at Ernie, he was ready for action- his skirt
hiked up over his hips, his thing sticking out of the hole he
had cut in the sheer pantyhose. It didn’t quite work. Not
with the sheer pantyhose. He would have done better with
the light-cream. Especially with the white shoes. He needed
the color…
Ernie was beginning to ascend to the summit. It wouldn’t be
long now. She reached down to tickle him in the special place
that, she knew from experience, would release the safety in
preparation for firing. ‘Ohgodbabyjes…’ He didn’t get the
name of the Savior all the way out. It stuck in his throat.
Instead of the usual triumphant, piercing high note, he

79
 Figure 6: Cover story of John
Wayne Bobbitt in action on
the pornography circuit. (photo
courtesy of Dr. Sehn).

Figure 7: John Wayne Bobbitt reattached and with good perfusion post microscopic
revascularization.

80
 uttered a horrible, gurgling screech as his fingers clutched
the flesh of her buttocks and didn’t release. There was no
Hallelujah chorus…
‘Ernie?’ she whispered in his ear. There was no response.
Not even a grunt…Ernie wasn’t talking. He held her
tightly in his powerful grip, pinned against the O’Keefe and
Merritt, his hands riveted to her flesh, his thing stuck up
inside her like a champagne cork.”1
I know what you are thinking now, the situation is dire and
you don’t know who to feel sorry for the most, the urologist or the
wife, Bob or Doris Pletman or even Gabe Haas, but I think the
story should be left to your sordid imaginations. The point is that
poor Audrey was stuck in more ways than one.
In addition, to add pain to the pleasure, the house is being
robbed by a large Native American burglar who has a thing with
dogs. Wouldn’t you know, the only way for Audrey to extricate
herself is to amputate her dearly departed Ernest’s member with the
only implement capable of doing the job- the Sunbeam. The severed
member is given to the ravenous Siggy and the Indian (rather like
Lawrence now that I think about it) hightails it to Canada. There
ensues a media-circus the likes of which make the Bobbitt story
seem pedestrian.
Conclusion
In this tale of two penises, one real and one fictional, the his-
torical backgrounds for both are relevant to any in depth historical
consideration. The first reported case of penile replantation was in
1929 by Ehrich.4 Microvascular techniques were reported in 1977
and a series of over one hundred cases have now been reported.5
John Wayne Bobbitt eventually recovered with his reat-
tached member in prominent, public display in several porno-
graphic videos. (Figs. 6 and 7) Lorena Bobbitt also developed some
4. Ehrich,WS: Two unusual penile injuries. J Urol 1929;21:239-242.
5. Carroll,PR, Lue,TF, Schmidt,RA, Trengrove-Jones,G, McAnich,JW: Penile replantation: current concepts. J
Urol 1985;133:281-285.

81
Figure 8: Sehn’s collection of cartoons following his memorial case and encounter with the press.
A. Media circus. B. Everyday life and the “Bobbit” case. C. The White House.

82
degree of social awareness and was eventually exonerated of any
criminal wrong-doing.
That leaves the second penis, that of fictitious urologist Ernie
Haas. The details included are from the perspective of one historian
who personally lived and practiced urology in the community which
the fictitious severing of the penis occurred.
Lefcourt does acknowledge that some of the details of the
Bobbit case most definitely influenced his writing, especially regard-
ing the “media circus” aspects of the case. In the United States, John
Wayne Bobbitt and his wife Lorena did become household words
and topics of discussion and urologist James Sehn was at the center
of this media whirlwind. Sehn tells us that his life and office practice
also were influenced by large numbers of television and reporting
crews that were encamped outside of his office. He began to collect
all of the articles and news clippings, especially the cartoons that
would be published in magazines and news articles into a collection
that he maintains to this day.3 (Fig. 8)
Correspondence to:
Michael E. Moran, M.D.
Carolina Urology Associates
720 Jefferson St.
Whiteville, NC 28472

83
Figure 1: The dust jackets of the two first editions of Endoscopia Urinaria by editorial
Salvat (Barcelona): black and white in 1939 (left, editorial Salvat, Barcelona) and coloured
in 1962 (right, editorial ECO; Barcelona).

84
 The Role of the Medical Illustrator in the
Development of Spanish Urological Endoscopy:
Eighty years of Endoscopia Urinaria
by Antonio Puigvert and Illustrated by
Rafael Alemany
Luis Fariña-Pérez
Urologist, Povisa Hospital, Vigo (Spain). Member of the EAU and
Spanish Association of Urology History Offices.

This paper aims to celebrate this year’s 80th anniversary of

the first edition of Endoscopia Urinaria (Barcelona, 1939) by Antonio
Puigvert, a canonical Spanish book on a fundamental technique in
the beginning and early development of urology as a specialty. It
was the most complete text on diagnostic and therapeutic cystos-
copy to appear in Spain in the first half of the 20th century.
Two important editions of Endoscopia Urinaria were pub-
lished by A. Puigvert in 1939 and 1962, and its relationship with
other similar European and North American textbooks on diag-
nostic and operative cystoscopy were sensible. (Fig. 1) In fact, the
book seems to be inspired by books authored by pioneers of modern
European urology, names like Otto Ringleb from Munich, Alois
Glingar from Vienna, the Brits James B. Macalpine and Edward
Canny Ryall, and the Frenchmen Georges Luys, Edmond Papin
and George Marion. In fact, the book quoted G. Marion on its first
page, saying that cystoscopy was already “a fundamental explora-
tion of the urological specialty.”
Endoscopia Urinaria by A. Puigvert has a precise and up-to-
date text with chapters on the history of urinary endoscopy, techni-
cal aspects, normal and pathological findings in unspecific and spe-
cific cystitis, foreign bodies, stones and tumours, and three chapters
that could call the attention of present day readers: meatuscopy
(diagnosis of ureteral diseases through the observation of the ure-
teral meatus), hypogastric cystoscopy and ureteral catheterization.

85
 Figure 2: Antonio
Puigvert-Gorro
(left), founder of the
Urological Institute
Puigvert Foundation
(Barcelona) and one
of the leaders of the
Spanish urology in
the second half of the
20th century. Rafael
Alemany-Cremades
(right), medical
illustrator.

On the other hand, the book has extraordinary black and

white drawings and 52 colour paper sheet illustrations by Rafael
Alemany Cremades, (Fig 2.) and this is an occasion to review the
history of medical illustration in general and illustration in urology,
particularly their role in the divulgation of the knowledge of diag-
nostic endoscopy.
Antonio Puigvert, the urologist
The influence that Antonio Puigvert (1905-1990) had in the
second half of the 20th century largely persists thanks to his best
creation, the Fundación Puigvert, a center with clinical, research
and teaching activity that continues to lead from Barcelona several
areas of Spanish and European urology.
Thirty years after his death, Puigvert is still remembered for
his studies on lithogenesis, pioneering indications of partial nephrec-
tomy in stones and tumours,1 and the description of infrequent
renal anomalies such as megacaliosis.2 His efforts to invigorate the
value of the history of urology were not minor: he promoted the
knowledge of the work of Francisco Diaz from Alcalá de Henares
1. 1.Kirkali Z. Puigvert: a man with a visión. Nephron-sparing surgery 30 years ago in Europe. Eur Urol.
2006;50:175-85.
2. Pérez Albacete M. 100th anniversary of Dr Antonio Puigvert Gorro’s birth. Actas Urol Esp. 2005;29:807-
14.

86
and was responsible for one of the few reprints of Diaz’s 1588 work
Tratado nuevamente impreso de todas las enfermedades del riñón,
vejiga y carnosidades de la verga y orina (Newly printed treatise of all
the diseases of the kidney, bladder and carnosities of the phallus and
urine),3 and created the Francisco Diaz medal, a prize that rewarded
a urologist that had made notable contributions to the progress of
the speciality.4
Puigvert was also superb in the use of then-existing media
-press and TV, the few available “social media”- to self-marketing
both as a professional with a strong background in an area of
knowledge that was not well-known by the public, (i.e. urogenital
surgery) and with a great influence on sick people with positions of
social and political power (artists, politicians, dictators, the Pope).5
His books had an enormous influence in the Spanish-
speaking countries, since they were never translated into other lan-
guages. We should highlight the Atlas of Urography (1933) and the
Tratado de Urografia Clinica (Treatise of clinical urography, 1944),
again with illustrations by Rafael Alemany, in which clinical semi-
ology and radiological studies were correlated, at a time when new
constrast media were being investigation (endovenous urography,
retrograde pyelography).
In Tratado de operatoria urológica (Treatise of operative urol-
ogy, 1971), an encyclopedic work of maturity, Puigvert collected
and illustrated all genito-urinary surgery. From then on, urology
would be taught in collective, non-personal texts, as a consequence
of subspecialization and the growth of knowledge and the com-
plexity of the surgical techniques.
It is his third book, Endoscopia Urinaria (1939), which is one
of the most surprising and original works although, logically, it is
the result of a monumental personal library, and a very extensive
knowledge of what was published in the field of lower urinary tract
3. Puigvert A.Enfermedades de los riñones, vexiga y carnosidades de la verga by Francisco Díaz. Comments
on an old book. Eur Urol. 1978;4:232-5.
4. Montero Gómez J. The Francisco Díaz Medal: Puigvert’s idea. Arch Esp Urol. 1992;45:291-2.
5. Puigvert A. Mi vida … y otras más. Planeta, Barcelona, 1991.

87
 Figure 3: Some illustrations
by Rafael Alemany in
Endoscopia Urinaria
(clockwise) : 1. Several
benign bladder papiloma.
2. Endoscopic treatment
of a bladder tumour in
several stages and results
after 3 months. 3. Tumours
with “epitheliomatous
transformation”, treated by
open coagulation.

Figure 4: Although mostly

an illustrator and draftsman,
Alemany also painted and
made at least two painting
exhibitions in Barcelona.
Oil on canvas of unknown
landscape, 1942 (property of
L.A. Fariña).

88
diseases. A sample of it being the 43 texts consulted -with all the
possible names of universal urology-, and hundreds of bibliograph-
ic references at the end of the text.
Published in 1939, it was a difficult time for both the
country, devastated by a Civil War, and for Puigvert himself, who
went through several vicissitudes, among them his contribution
as a doctor to the war effort. The quality of the paper and the
interleaving of 52 magnificent sheets printed on one side, each
with 3 to 6 colour illustrations by Alemany, provide the highest
quality to this publication. (Fig. 3) The book had a second edition
in 1962 with some changes and new reprints in 1975 and 1983,
at the end of Puigvert’s active life, with text actualization of the
endoscopic techniques. But it was already a time when endoscopic
photography had improved and endourology was creating previ-
ously unimaginable techniques.
Rafael Alemany, the medical illustrator
Born in Alicante (Spain, 1895), Alemany came to the
medical world as an illustrator for Revista Española de Medicina y
Cirugia (the Spanish Journal of Medicine and Surgery). His drawings
were made with pencil and black ink, but also in watercolor and
since the 1930s with the airbrush technique, copying the most
frequent technique in medical books published in European coun-
tries. He also made at least two painting exhibitions of portraits
and landscapes. (Fig. 4)
In 1944 he was named anatomical draftsman of the Faculty
of Medicine of Barcelona, and illustrated texts of anatomy, sur-
gery and medicine by Drs Manuel Serés and Salvador Gil Vernet ,
and the “Tratado de patología y clínica médica” by P. Pons, a named
internist.
Pictures of endoscopic urologic and gastrointestinal disease
made him to be recognized in many medical fields, but the income
was insufficient and in 1947 he took advantage to move to the
USA, where he drew for several surgeons, in particular New York
eye surgeon Ramón Castroviejo, and for pharmaceutical labo-
ratories, a marketing world that was in full development. After
working for the Graduate School of Medicine, he was named PhD

89
Figure 5: Ladislao Tinao (1930-99) created nice endoscopic pictures for Dr. Carlos
Younger12 and Dr. Luis Cifuentes.

Figure 6: Ricardo Fuente Alcocer (1906-86) illustrated Cirugia urológica endoscópica and
Cistitis y cistopatías by Dr. Luis Cifuentes. Right: endometrioma.

90
by the University of Pennsylvania (Philadelphia) and in the end
he achieved a prestige and unparalleled recognition in the history
of Spanish medical illustration.6,7 After retiring in 1967, Alemany
returned to Alicante (Spain), where he died in 1972.
Discussion
Wide divulgation of modern diagnostic endoscopy was only
possible when instruments with good optical lenses were brought
to market, and when endoscopic findings could be reproduced with
scientific illustrations. Drawings, paintings or photographs may be
used to showing the endoscopic appearance of various diseases and
endoscopic techniques, so that they could be identified and repro-
duced by others.
Scientific illustration played a prominent role in the trans-
mission of knowledge before colour photography was perfected.
Colour drawings were essential to spread the knowledge of lower
urinary tract diseases and techniques, before colour photography
was possible. Nitze (1848-1906) was the first to explore endoscopic
photography with the cystoscope, but the intracorporeal electronic
flash that perfected the color photography and endophotography
was not possible until 1950-60, in particular with developments by
Hans J. Reuter and the Richard Wolf factory.
Many urologists trained in the 20th century could recognize
the colourful figures by Frank H. Netter (1906-1991), one of the
best illustrators of human anatomy and medical conditions,8 or
the drawings by William P. Didusch (1895-1981), the influential
illustrator in American urology that in 1968 proposed the creation
in Baltimore of the museum of urological instruments and memora-
bilia that officially opened in 1972 and now bears his name.9
Spanish illustrators in the field of Urology such as Rafael
Alemany, Ladislao Tinao Fernández (1930-1999) (Fig. 5) and
6. Lozano-Vilardell F J. Rafael Alemany: ilustrador médico. Universitat de Barcelona (doctoral thesis, 1991).
Retrieved from: https://www.tesisenred.net/handle/10803/405456
7. Simón-Tor JM, et al. Rafael Alemany Cremades (1895-1972): dibuixanta anatòmic de la Facultat de
Medicina de Barcelona. Gimbernat 2007;47:201-226. Retrieved from: https://www.raco.cat/index.php/
gimbernat/article/viewFile/123208/170995
8. Shivakumar N, Hammad AY, Gamblin TC. Frank Netter: A Man of Art and Science. Am Surg. 2016;82:377-
9.
9. Engel RM. William P Didusch (1895-1981): an illustrator of urology. World J Urol 1999;17: 187-40.

91
Ricardo Fuente Alcocer (1906-1986) (Fig. 6) created pictures of
formidable clinical acumen and exceptional quality, that are well up
to the greatest urology illustrators of the 20th century.
Endoscopia Urinaria by A. Puigvert, with pictures by
Alemany, is the most complete text on diagnostic and therapeutic
cystoscopy appeared in Spain in the first half of the 20th century.
It was the most influential in the entire scope of the Spanish lan-
guage, until the appearance of Cistitis y cistopatias (Cystitis and
cystopathies, two editions: 1944 and 1989) and Cirugia urológica
endoscópica (Endoscopic urologic surgery, two editions: 1961 and
1981)10,11
Correspondence to:
Dr. Luis Farina-Perez
Hospital Povisa
Salamanca 5
36311 Vigo
Spain
luisfarina@yahoo.com

10. Cifuentes Delatte L. Cirugía urológica endoscópica. Paz Montalvo, Madrid, 1981.
11. Cifuentes Delatte L. Cistitis y cistopatías (2nd ed). Bok, Madrid, 1989.
12. Virseda J.A., Younger de la Peña C, Tinao L. Atlas ilustrado de cistoscopia diagnóstica. Visto Bueno Equipo
Creativo, Madrid 2007.

92
93
94
 The Beginnings of Medicine and Urology in
Vilnius: The Impact of Political Changes on
Progress in Urology and Medicine
Thaddaeus Zajaczkowski
Retired Urologist, Essen, Germany

With currently almost 600,000 inhabitants, Vilnius is

Lithuania’s capital and largest city. Its history is long and compli-
cated. In previous centuries two nations – Poland and Lithuania
– claimed the city, and the powerful states of Russia and Prussia
sought to include Vilnius and the surrounding region in their
respective empires.
In 1387, Jogaila, who was both Grand Duke of Lithuania
and as King of Poland as Władysław II Jagiełło (1351/1362(?)-
1434), formally granted Vilnius its city charter. It was originally
a Lithuanian town, but with the Polish-Lithuanian Union of 1385
(designed to counter the growing threat from the Teutonic Order)
the two nations together grew to be the most powerful state in that
part of Europe. With the influx of Polish and German craftsmen
and Jewish refugees fleeing from persecution in the west of Europe,
Vilnius enjoyed a period of expansion, quickly becoming a vibrant,
multicultural centre in which trade and the crafts flourished.1, 2, 3, 4
Itinerant surgeons and the Vilnius Guild of Surgeons
At the Council of Tours of 1163, Pope Alexander III banned
clerics from involving themselves in studies of physical nature, as
anyone undertaking such studies was seen as being in league with
the Devil! Some saw this as a ban preventing clerics from practicing
surgery (“Ecclesia abhorred sanguine”), whereas the Pope was in fact
1. Poland History. Encyclopaedia Britannica. 15th Edition. 2003, vol.25: 940-956.
2.  Davies N.: Jogaila: The Lithuanian Union (1386-1572). In: God`s Playground. A history of Poland.,
Published in Columbia University Press. Printed by Billing and Sons, London Worcester. 1981, Vol. I: 115-
155 and vol. II: 375-434.
3. Alexander M.: Kleine Geschichte Polens. Reclam, Stuttgart, 2003, S 64-161.
4. Lithuania. Encyclopedia Britannica. 15th Edition, 2003, vol. 7: 400-402, vol. 12: 376-377 and vol.14:
702-707.

95
 simply encouraging clerics to con-
centrate on spiritual matters and
not go out into the world to study
earthly matters, which was not the
business of their profession.
As a consequence, the prac-
tice of surgery began to pass into
the hands of the uneducated, peo-
ple such as bath-house attendants,
barbers, and even executioners.
Some of them became itinerant sur-
geons through acquiring a measure
of surgical knowledge; bath-house
attendants, on the other hand, occu-
pied a more inferior position to sur-
Figure 1: Jesuit and theologian geons. The first barbers in Europe
Jakub Wujek (1541–1597) at first came mainly from both these
groups, often becoming itinerant
surgeons after acquiring some surgical skills. They tended to special-
ise in just one type of intervention, for example, lithotomy, cataract
couching, herniotomy, tooth-pulling, bloodletting, cupping, and
the like. Later on, in Central Europe, the training and the practice
of surgery was overseen by craft organisations, which set guidelines.
These organisations, which came to be known as guilds, arose in the
Middle Ages as craftsmen united to protect their common interests
and safeguard the “arts” and “mysteries” of their crafts.
Vilnius surgeons were first chartered in 1509 but, as in
other cities, their charter was not at that time confirmed by the city
authorities and the king. It was not until 25 December 1552 that
King Sigismund II August (1520-1572) approved the statute. In
1584, a new version of the statute was granted to them by King
Stefan Bathory (1533-1586). This charter governed, among other
things, how master craftsmen’s examinations were to be conducted,
specifying the exact scope of the theoretical elements.
But it was in the guilds of barber-surgeons that medicine
first started to be taught in Vilnius, and these guilds continued to

96
be active in Poland as late as in the 19th century, despite the found-
ing of medical departments at universities. Vilnius barber-surgeons
were associated in a guild called a kontubernis – the Universitas
Chirurgorum. Apart from barber-surgeons, the sick and afflicted
of Lithuania were also looked after by the international Order of
the Brothers Hospitallers of Saint John of God (the so called boni-
fraters), some of whose medics had received training abroad. The
most known Polish physician bonifrater was Ludwik Perzyna (1742-
1812. He was priest, writer and popularizer of medical knowledge.
5, 6, 7, 8, 9, 10

Vilnius University
In 1568, the Lithuanian nobility called upon the Jesuits
to create an institution of higher learning either in Vilnius or in
Kaunas. The following year Walerian Protasewicz, the bishop of
Vilnius, purchased several buildings in the city centre and estab-
lished the Vilnian Academy (Almae Academia et Universitas
Vilnensis Societatis Jesu). Initially, the academy had three faculties:
humanities, philosophy, and theology. On 1 April 1579, Stefan
Batory, King of Poland and Grand Duke of Lithuania, upgraded
the academy to create Vilnius University, which received approval
in Pope Gregory XIII’s bull of 30 October of that same year. As yet
the university had no medical faculty.
The university’s first Vice-Chancellors were Jakub Wujek
(1541-1597) (Fig. 1) and Piotr Skarga (1536-1612). Wujek was a
Polish Jesuit, religious writer, Doctor of Theology and the first to
translate the bible into Polish. Skarga was a Polish Jesuit, preacher,

5. Eckart W.: Illustrierte Geschichte der Medizin. Die monastische Medizin (5. bis 12. Jahrhundert). Springer,
Berlin, Heidelberg, Auflage, 2011, 2. 9-11.
6. Noszczyk W.: Chirurgia cechowa w Europie. S. 11-16 und Chirurgia w dobie zaborów. Wilno. In: Zarys
dziejów Chirurgii polskiej. Ed. W. Noszczyk Wydawnictwo Lekarskie PZWL, Warszawa, 2011, 215-233.
7. Fischer G.: Chirurgie vor 100 Jahren. Reprint: Springer-Verlag, Berlin Heidelberg, New York, 1978, 17-70.
8. Sokół S.: History of surgery in Poland. Part 1: Craftsmen dealing with surgery. Ossolineum, Wrocław,
Warszawa, Kraków, 1967.
9.  Perzyna L.: Nauki Cyrulickiey krótko zebranej. Drukarnia JO. Xcia Jmei Prymasa Arey Biskupa
Gnieźnieńskiego, Kalisz (Zbiory Głównej Biblioteki Lekarskiej, Warszawa), 1792.
10. Stanek A., Śledziński Z.: Dzieje nauczania medycyny w Wilnie. 1. Uniwersytet oraz Akademia Medyko-
Chirurgiczna w Wilnie 1778-1942. 1: 189-220. In: Żydowo MM (2001) Dzieje nauczania medycyny
na ziemiach polskich. Polska Akademia Umiejętności. Rozprawy Wydziału Lekarskiego. Tom I, Kraków,
2001.

97
hagiographer, polemicist and leading figure of the Counter-
Reformation movement in the Polish-Lithuanian Commonwealth.
11, 12, 13, 14

The first descriptions of autopsies (anatomical pathological

examinations) in Vilnius come from the time of the Jesuits. These
autopsies were performed during the process of embalming, as in
the case of the body of King Stefan Bathory, but descriptions of
rare cases also exist. The first planed autopsy was performed in 1770
at Vilnius University by Stefano Bisi (1720-1790), a Professor of
Anatomy from Pavia.
In 1783, following the dissolution (secularisation) of the
Jesuit Order, the Commission of National Education (CNE) took
custody of the school, changed its name, and granted it the status of
Principal School of the Grand Duchy of Lithuania. As a result, and
then having acquired additional funds, the educational programme
was extended and the medical and law faculties, among others, were
opened. Vilnius University was responsible for educating mainly
teachers for Lithuanian secondary schools, which it also oversaw.
The beginnings of pathological anatomy as a separate medical speci-
ality dates back to the founding of Vilnius University in the former
Polish-Lithuanian Commonwealth.10, 11
After the last partition of Poland in 1795, Lithuania became
a Russian province. Vilnius University became the Principal
School of the Grand Duchy of Lithuania and in 1803 the Imperial
University of Vilnius. The school was given wide-ranging autonomy
and until 1832 operated under a variety of names. The schools of
eight provinces with a total population of nearly 9 million people
were subordinated to the University. It was the largest university
not only in the region under Russian domination, but also in the

11. Jackiewicz M.: Universität Vilnius auf unterschiedlichen Ständen seiner Tätigkeit (ZW 47). Akademie und
Universität der Gesellschaft Jesu/Universitas et Universitas Vilnensis Societas Jesu (1579-1782). Publiziert
am 24. Februar. Hits: 2016, 1523.
12. Fatouros G.: Wujek Jakob. In: Biographisch-Bibliographishes Kirchenlexikon (BBKL). Bd. 15: Bautz Herzberg
Sp., 1999, 1549-1550.
13. Encyklopedia Polski. Kraków, Wydawnictwo Ryszard Kulczyński, 1996, 768.
14. Tazbir J.: Piotr Skarga Szermierz kontrreformacji. Rzeszowskie Zakłady Graficzne. Państwowe Wydawnictwo.
„Wiedza Powszechna” Warszawa, 1978.

98
Russian Empire as a whole. In spite of the partitioning of Poland,
the school maintained a high standard of education.
Following the failure of the November Uprising in 1832,
the Imperial University of Vilnius was closed down by order of
Tsar Nicolas I, and the Medical Faculty became the Academy of
Medicine and Surgery (AMS), though it too was closed down ten
years later. After 1803, thanks to Adam Jerzy Czartoryski (1770-
1861) and Jan Śniadecki (1756-1830) (Vice-Chancellor from 1807
to 1815), the university became the principal centre of Polish sci-
ence and the best university in the Russian Empire. It represented a
high level of exact sciences, medicine, and history.
After the Academy was closed down in 1842 and suspended
operations, medicine in Lithuania, including surgery, ceased to flour-
ish as it had before. Furthermore, with all social and cultural activities
being suppressed, Vilnius lost its reputation as a cultural and educa-
tional centre and turned into a quiet, poor provincial town.
For 77 years (from 1842 until 1919), Vilnius was without a
university. Only the Vilnius Medical Association (founded in 1805)
was still active, with its first President, Jędrzej Śniadecki (1768-1638)
and Secretary, Józef Frank (1771-1842). During this period, many
well-trained and committed doctors were working in Vilnius, includ-
ing a number of knowledgeable and skilful surgeons.15, 16, 17, 18, 19
The rebirth of the Polish State
The collapse of all established order in Central and Eastern
Europe after the First World War condemned the infant Polish
Republic to a series of existential wars. The Polish Second Republic
came into being in November 1918. Between 1918 and 1921, six
wars were fought by Poland concurrently.

15. Gawrońska-Garstka M.: Rys Historii Uniwersytetu Wileńskiego. Przegląd Naukowo-Metodyczny. Edukacja
dla Bezpieczeństwa. Muzeum Historii Polski.. 2009, 3: 71-78.
16. Supruniuk A.: Universität Vilnius 1579-2004. Głos Uczelni. Uniwersytet MK, Toruń, 2004, 11: 9-13.
17. Bojczuk H.: Vilnius Medical Association: the first half-century (1805-1850). Med Nowożytna. 2000, 7(2):
75-85.
18. Sabat D.: The historical outline of Vilnius pathological anatomy in the first half of the 19th century. Pol. J.
Pathol., 2004, 55: 2, 75-81.
19 Zajaczkowski T.: Uniwesytet wileński. Początki urologii w Wilnie. Urol. Rev. 2017, 18: 5(105): 85-94.

99
Figure 2: University of Stefan Batory in Vilnius (1919-1939)

Gravest of all was the Polish-Soviet war, which included an

invasion of Poland and Lithuania (1919-1920), in an attempt to
carry the communist revolution toward the west and threatening
the Polish Republic’s existence. An offensive by the Red Army drove
the Poles back to the outskirts of Warsaw, but the country was
saved from catastrophe by Marshal Józef Piłsudski’s counterattack
on August 16, 1920 (the ‘Miracle of the Vistula’). A few months
later Polish forces drove the Red Army out of Vilnius also.
Due to disputed possession of Vilnius following the
Lithuanian war, Vilnius was captured for Poland by General Lucian
Zeligowski in 1920. Lithuania was divided. Vilnius and surround-
ings were incorporated into Poland, a move that dug a chasm
between Lithuania and Poland. Since 1939 Vilnius has been again
Capital of Lithuania.1, 2, 4
Stefan Batory University (1919-1939)
After a 77-year break in university activities, on 28 August
1919, the Chief of State, Marshal Józef Piłsudski (1867-1935)
signed a decree founding the university in Vilnius. It was given the
lifetime name of Stefan Batory University (USB). (Fig. 2)10, 19, 20

100
 Prior to the outbreak of World War II, there were 3000
students enrolled at the university. In the first trimester of the
1934/1935 academic year, the Medical Faculty had 703 students.
The number included 369 Roman Catholics, 201 Jews, 117 ortho-
dox Christians, 10 Evangelicals, 2 Greek Catholics, and 4 Muslims.
In all, 99 graduates, including 59 Christians and 40 Jews, gained
their doctoral diplomas.21
By 1939 the population of Vilnius had risen to 209,000,
of whom 65% were Poles, 28% Jews, 4% Ruthenians, and 1%
Belarusians and Lithuanians. Within 20 years of the establishment
of Stefan Batory University, it had educated 2000 doctors, who
found employment throughout Poland. Stefan Batory University in
the north-eastern parts of the Second Polish Republic was an impor-
tant cultural and scientific centre, enhancing the prestige and rank
of the city of Vilnius.22, 23
World War II (1939-1945)
In October 1939, Stefan Batory University came under
Lithuanian rule, and on 15 December 1939 the Polish university
was closed down by the Lithuanian authorities. The Law Faculty
and the Humanities Faculty were transferred from the University
of Kaunas, and Professor Myklas Birzyska was appointed Vice-
Chancellor of Vilnius University. During the war, Lithuania was
alternately under Soviet and Nazi (German) occupation, which sig-
nificantly hampered Vilnius University’s development.22
Following the Soviet invasion in 1940 and the creation of the
Lithuanian Soviet Socialist Republic, a number of Polish professors
were arrested and deported deep into the Soviet Union. Some of the
Stefan Batory University faculties went underground. Many gradu-

20. Stanek A.: Historia Chirurgii w Uniwersytecie Stefana Batorego w Wilnie w latach 1919-1939. Akademia.
Medyczna w Gdańsku. Druk i oprawa: Endirpol, Gdańsk, 1995, 1-135.
21. Reicher M.: Sprawozdanie z działalnosci Wydziału Lekarskiego i Uniwersytetu Stefana Batorego w Wilnie
w roku akademickim. XIV rok działalności Wydziału. (Aktivität von Medizinischen Fakultät in Wilna.
Jahresbericht. 1934/35, 259.
22. Schultze Wessel M., Götz I., Makhotina E.: Vilnius. Geschichte und Gedächtnis einer Stadt zwischen den
Kulturen. Campus Verlag, Frankfurt am Main. 2010, 147,198f, 203-208.
23. Michejda K: Z dziejów chirurgii Wileńskiej. Pol. Przegl. Chir., 2060, 32(8-9): 755-759.

101
ates of secretly-taught medical studies received original diplomas
from Stefan Batory University. Some students of medicine contin-
ued their studies at Kaunas University. According to R. Zabłotniak,
during World War II there were around 130-150 Polish students in
Kaunas. In June 1941, seven students were awarded their doctoral
diplomas; later, during the German occupation, about 80-90 Poles
managed to complete their studies and get their diplomas.
The war had the effect of scattering a significant number
of the staff of Stefan Batory University’s institutes and clinics all
over the world. Others were killed or died in captivity in the Soviet
Union. However, at the end of the war, the majority of surviving
Stefan Batory University staff found work at the Nicolas Copernicus
University in Toruń (Thorn), in northern Poland.
On the other hand, many former staff of the Medical Faculty
of Stefan Batory University occupied important positions in many
honourable functions in Poland proper. Prof. Tadeusz Ginko, a
graduate of this university, documented the post-war lives of former
scholars and workers – professors, lecturers and assistants at Stefan
Batory University and Vilnius University graduates – who became
heads of departments, clinics, and hospital wards. The largest
group of independent research workers, consisting of Stefan Batory
University professors and employees or graduates who obtained
their post-doctoral degrees after 1945, found themselves in
Gdańsk (Danzig), Wrocław (Breslau),Warsaw, Łódź, or Białystok,
or in cities in the former German-held lands in the west of Poland.
A significant number of doctors made their careers in other parts of
the world.23, 24, 25
School of Medicine and Surgery and the School of Midwifery
In 1776, Antoni Tyzenhaus (1733-1785), an astute Polish
aristocrat, founded the School of Medicine and Surgery in Horodnica,
near Grodno (a city now in western Belarus), and the School of

24. Zabłotniak R.: Polacy studiujący medycynę I farmację w Kownie (1940-1944). Przegląd Lekarski, 1980,
37(1): 101-104.
25. Glinko T.: Zarys dziejów Wydziału Lekarskiego Uniwersytetu Stefana Batorego. In: Z dziejów Almae Matris
Vilensis. Księga pamiątkowa ku czci 400-lecia założenia i 75-lecia wskrzeszenia Uniwersytetu Wileńskiego.
Red. Piechnik L. Puchowski K.,Wydawnictwo WAM, Kraków, 1996, 185-201.

102
Midwifery, which was run by the Frenchman Jean Emanuel Gilbert
(1741-1814), who built a home for midwives and brought a trained
midwife instructor over from France. The Grodno school together
with the Vilnius school were incorporated into the Principal School
of Vilnius in 1780, and subsequently into the Medical Faculty (cre-
ated after 1781) of Vilnius University, where lectures in midwifery
were held.10, 26
Following the reorganisation of Vilnius University between
1780 and 1788, it was mainly Dr. Nicolas Regnier (1723-1800), a
native of Strasbourg, who taught midwifery from 1781 onwards. In
addition, a hospital was established where practical training could
be conducted, and in 1784 the regulations for midwives were issued.
In 1788, St Lazarus National Hospital was founded in Vilnius, to
which the school of midwifery and the clinic were ultimately moved.
Practical surgery in Poland was still based organisationally on the
guild system, while in the rest of Europe it was allowed to again
become part of conventional medicine.26, 27
Clinical Surgery prior to 1919
Nicolas Regnier was the first professor of theoretical and
practical surgery in Vilnius. He was a correspondent of the Surgical
Academy in Paris and “a teacher of the practical trades of barber-
surgeons and midwives”. Starting in 1781, and for many years
thereafter, Regnier taught theoretical surgery three times a week.
At the same time, Jacob Briotet (1746-1819) was also teaching
practical surgery. He taught his students how to operate on cadav-
ers, allowing only the most gifted among them to assist at opera-
tions performed in the hospitals of Vilnius and in the clinic. (Fig.
3)6, 10
His most talented student was Jan Niszkowski (1774-1816)
(Fig. 4), born and raised in Vilnius. He completed his studies in
philosophy and medicine at Vilnius University, where in 1799
he defended his doctoral dissertations (two). He learned anatomy
26. Wrzosek A.: Założenie Królewskiej Szkoły Lekarskiej w Grodnie za Stanisława Augusta. Arch Hist Filoz
Med Hist Nauk Przyr., 1925, 2(2): 149-168.
27. Stawiak-Ososińska M.: Kształcenie akuszerek w Wilnie w czasach Szkoły Głównej Wielkiego Księstwa
Litewskiego i Szkoły Głównej Litewskiej. (1780-1803). Rocznik Andrologiczny (Andrology Yearbuch). 2015,
22: 325-338.

103
Figure 3: Prof. Jakub Briotet (1746–1819). Figure 4: Prof. Jan Fryderyk Niszkowski
(1774–1816)

and surgery from Prof. Briotet and was reputed to be an excellent

operating surgeon and a brilliant teacher and scientist. He quickly
became a lecturer and his chief’s deputy. With the support of his
mentor and university Vice-Chancellor, he was awarded sufficient
funds by the authorities to be able to take a four-year study trip
abroad to help him develop his surgical skills. Between 1802 and
1806 he received training at the best clinics in Germany, France,
Italy, and Austria.6, 19, 28
In 1808, Jacob Briotet and his assistant Jan Niszkowski
opened the Surgical Clinic in Vilnius, 19 years after starting a
practical surgery sub-faculty. It should be underlined that Kraków
(Cracow, 1780) and Vilnius were at that time the leading university
centres of surgery in Poland.
When Jacob Briotet retired through mental illness in 1811,
Dr. Jan Niszkowski became a professor and took charge of the fac-
28. Bojczuk H.: Jan Fryderyk Niszkowski (1774-1816),Twórca litewskiej szkoły chirurgicznej, ojciec biednych I
pocieszyciel cierpiących. Arch Hist Fil Med., 1998, 61(2-3): 183-190.

104
ulty of theoretical and practical surgery. A skilful surgeon and lec-
turer, he performed a number of complicated operations. In 1806,
he was the first Pole and doctor in Vilnius to perform an operation
to remove a bladder stone. By 1809 he had successfully completed
28 lithotomies in Vilnius and nearby towns. Prof. Niszkowski was
the one who contributed most to the development of urology in
19th century Vilnius. Unfortunately, he died suddenly at the age of
42 due to left heart ventricular rupture.28
In 1817 Niszkowski was succeeded by Prof. Wacław Pelikan
(1790-1893) (Fig. 5), who submitted a dissertation on lithotomy.
He had learned it in St Petersburg, where he performed 19 lithoto-
mies. He was a great scholar and a well-educated surgeon. From
1818 onwards he performed several operations to remove bladder
stones. Two of these operations formed the subject of Sokołowski’s
doctoral dissertation. (Fig. 6) Józef Frank mentioned that in 1819
Wacław Pelikan performed, in his presence and that of the uni-
versity curator, an operation to remove a stone, which had proved
impossible to do using the perineal approach. Instead, he removed
the stone after performing a suprapubic access. Wacław Pelikan
published numerous papers and also a textbook: “Myology, or the
study of the muscles of the human body”.20, 28, 29, 30
Prof. Pelikan’s successors were Seweryn Gałęzowski (1801-
1878), Konstanty Porcyanko (1793-1841), and Józef Korzeniowski
(1806-1870), who belonged to a small group of outstanding Polish
surgeons. In the first four decades of the 19th century, surgery in
Vilnius attained a level matching the best that European centres
could offer.
Seweryn Gałęzowski
Gałęzowski was born into a Polish landed-gentry family on 25
January 1801 in the village of Kniaża Krynica, near Kiev. In 1816,
he graduated from a Basilian high school in Uman (now in Ukraine).
He completed his medical studies in 1824 at the Medical Faculty of

29. Podgórska-Klawe Z.: Wacław Pelikan Professor of the University in Wilno (1790-1893). On the occasion of
175th anniversary of his birth. Arch Hist Filoz Med., 1966, 28(1): 97-110.
30. Porcyanko K.: Steinbohrung mit Hilfe von Civiale. In: Dziennik Med. Chir. i Farmacyi, Wilna Bd.1; Nr. 4,
S. 495-504); (Tageszeitung für medizinische Chirurgie und Pharmazie), 1830.

105
 Figure 5: Prof. Wacław Pelikan
(1790–1873)

Figure 6: Dr. Josephus

Sokołowskj, thesis, 1819.

106
the Imperial University of Vilnius. After defending his thesis “De
variola mitigata” at that University, he gained his doctorate. He
learned surgery in Prof. Wacław Pelikan’s clinic, and quickly rose
through the university hierarchy – starting as a lecturer, he became
the clinic’s deputy head, and then from 1828 head of the clinic as a
professor. He was a brilliant teacher, skilful surgeon and dedicated
scientist. Thanks to his popularity, he was accepted for longer stays in
surgical clinics in Western Europe. In 1831, following the outbreak
of the November Uprising, he went to Warsaw, where he operated
on wounded insurgents in hospital as well as on the battlefield.
After the failure of the Uprising, he made his way to
Germany, for fear of being sent in exile to Siberia. In Hamburg, he
signed a contract with the agents of a Silver Mine in Mexico, where
he worked for two years. There he gained fame as a doctor, operat-
ing on Americans and French people in some of Mexico City’s most
expensive clinics, and later on in Veracruz too. During his time in
the country he managed to accumulate significant assets. After 14
years he moved to Paris, where he became famous as a prominent
operating surgeon. He was a caregiver and a benefactor to many
Polish emigrées (including the family of Adam Mickiewicz, Poland’s
national poet and political activist) and institution in the country
and abroad. Seweryn Gałęzowski died in Paris on 31 March 1878.6,30
Konstanty Porcyanko
Porcyanko was born in Vilnius, where he graduated from
high school and completed his medical studies. In 1818 he gained
his doctoral diploma, and in 1822 he became Prof. Wacław
Pelikan’s lecturer at a surgical clinic. Two years later he took charge
of the sub-faculty of general therapy and medical material, while
at the same time teaching surgery. When in 1832 the Medical
Faculty became the Academy of Medicine and Surgery, he became
a professor of surgery and ophthalmology, as well as being head of
a surgical clinic. He was known as a prominent operating surgeon.
He performed numerous operations to remove bladder stones. In
1830 he was the first surgeon in Poland to crush bladder stones
by a procedure known as transurethral blind lithotripsy using the
method pioneered by Jean Civiale (1796-1867). Following his death
in 1841, one obituary described him as “the most outstanding prac-

107
Figure 7: Dissertation, Theophil. Guilelmus Reichwald, 1823.

108
titioner that medical studies and attention in the medical profession
could ever shape”.
His successor, and at the same time the last professor of
surgery, was Józef Korzeniowski, who filled this function until
the Academy of Medicine and Surgery was closed down in 1842.
Korzeniowski also removed bladder stones. He remained in Vilnius,
where he died in 1870.30, 31, 32
Later on, there were many talented surgery department
heads in Vilnius. In addition to teaching and surgical activities, the
professors of Vilnius University also devoted considerable efforts to
research work, as evidenced by the numerous scientific publications
and books that they generated. This is reflected in the many pub-
lished dissertations on medicine and urology, and in the fact that, in
the 18th and 19th centuries alone, no fewer than 46 doctoral theses
in the field of general medicine and surgery were defended. (Fig. 7)
In 1824, the school started to go into a slow decline, a process that
owed much to the Philomaths and Filarets, two student organisa-
tions.6, 23, 30, 32
In the final decade of the 19th century, the population of
Vilnius was about 180,000 and had only 4 hospitals with 355 beds;
these were the Sawicz, St Jacob’s, the Jewish Hospital, and the hos-
pital of the Brothers Hospitallers of Saint John of God (Bonifrats).
The first three had surgical beds. Between 1843 and 1918, there
were four prominent surgeons working in Vilnius, who did their best
to maintain the standard of surgery in the city at the same level as
that in Russia and in Poland proper: Dr. Ludwik Lachowicz (1811-
1880), who introduced general anaesthesia, Dr. Hipolit Jundziłł
(1846-1898) – aseptic procedures, and Dr. Tadeusz Dembowski
(1856-1930) –modern and aseptic abdominal surgery. Dembowski
announced his own approach to kidney surgery in 1891. In 1894 he
expressed his view about the need to operate early in cases of incar-
cerated inguinal hernia, and in 1900-1904 he recommended acute
operations in severe cases of inflamed appendicitis.
31. Girsztowt P.: Konstanty Porcyanko. Tyg. Illustr., 1866, 13: 350, 261-262.
32. Szarejko P.: Korzeniowski Józef. Slownik lekarzy Polskich XIX wieku. T. II, Semper, Warszawa, 1994, 128-
129.

109
Figure 8: Prof. Józef Ziemacki Figure 9: Department of Surgery in Vilnius, 1930.
(1856–1925).

Figure10: Prof. Kornel Michejda

(1887–1960).

110
 Dr. Jan Napoleon Michniewicz (1870-1928) studied medi-
cine in Tartu (Estonia), where he became first assistant of a surgical
clinic. Following the Liberation of Vilnius, he was appointed head of
the surgical department at St Jacob’s Hospital. He was a co-founder
of the Philister Society in Vilnius, as well as being its vice-president
and treasurer.6, 10, 23, 30
Department of Surgery at Stefan Batory University in Vilnius
(1919-1939)
As mentioned, after a 77-year break in the university’s activ-
ities, on 28 August 1919 the Chief of State, Marshal Józef Piłsudski,
signed a decree establishing Vilnius University. It was to be called
Stefan Batory University “for all eternity”.
The first surgery professor was Józef Kazimierz Ziemacki
(1856-1925), who distinguished himself most in reviving and
restoring the university. In 1919 he was appointed Vice-Chancellor
and in 1922 was awarded a full professorship. From 1919 to
1924 he was head of the sub-faculty of General Surgery at Vilnius
University and gave lectures on this subject as well as on topo-
graphic anatomy.33 (Fig.8)
In 1922, Prof. Kornel Michejda was appointed head of the
Department of Surgery at Vilnius University. However, owing to
the lack of adequate buildings, patient admissions could not be
begun until the second half of 1924. After the reconstruction of the
old buildings and construction of an operating theatre, the surgical
clinic had a total of 110 beds. (Fig. 9)
Kornel Michejda (1887-1960) was born in Bystrzyca in
Lower Silesia, where he graduated from primary school. He gradu-
ated from Cieszyn high school in 1905, going on to complete his
medical studies in Kraków at the Jagiellonian University, receiving
the diploma of doctor of medical sciences in 1911. (Fig. 10) After
undergoing a two-year medical internship as an assistant at the hos-
pital in Ołomuniec (now in the Czech Republic), in 1913 he started
33. Noszczyk W., Andziak P.: Józef Ziemacki 1856-1925 In: Rudowski W, Śródka A.: Album Chirurgów
Polskich. PAN Wydział Nauk Medycznych. Ossolineum, Wrocław, Warszawa, Kraków, Gdańsk, Łódź,
(1990) 306—307.

111
his residency in the Surgical Clinic of Prof. Bronisław Kader (1863-
1937) in Kraków. During World War I, he was conscripted, but
after a short break returned to the clinic, keeping the assistant post.
After the war he was sent to the hospital in Wadowice. After demo-
bilisation in 1920, at the decision of the Medical Faculty Board of
the Jagiellonian University he headed the Surgical Clinic, where he
also lectured in surgery. He remained in this post until replaced as
head of clinic by Prof. Maksymilian Rutkowski (1867-1947).
As a young assistant, Dr. Michejda kept a keen eye on
advances in European surgery. He educated himself and performed or
improved innovative operations. He published his experiences, thanks
to which he became famous all over the country, quickly gaining a
reputation as a versatile surgeon with an apparent scientific mindset
and didactic talent among Poland’s leading surgeons.20, 33, 34, 35
In 1922, Dr Kornel Michejda was appointed Professor
and Director of the Surgical Clinic at Stefan Batory University in
Vilnius. Having taken up a surgery professorship, he became a
driving force behind the organisation and equipment of the surgical
clinic. Hard work and iron will helped Prof. Michejda to organise
the Clinic right from the outset. Thanks to his diligence, sustained
commitment, dedication, and the generous support of his col-
leagues, and in particular having overcome major difficulties with
premises, finances, materials, and other equipment, the Clinic was
ready to receive patients in 1924.
In this 85-bed surgical clinic there were two operating thea-
tres, two dressing rooms, two single wards, six multi-bed wards, an
X-ray department, an endoscopy room, a laboratory, and a Clinic
museum. This facility became a surgical and scientific centre serving
Vilnius and the surrounding area. Within a short space of time he
succeeded in raising developments in scientific research, educational
activity, and public services to a level capable of competing with the
best surgical clinics in Poland.

34. 
Kieturakis Z.: Z przemówiena prof. Z. Kieturakisa z okazji 30-leciaia działalności zawodowej prof.
Michejdy. Pol Przegl Chir. 1953, 25(2): 107-116.
35. Ciesielska M.: Professor Kornel Michejda-the Righteous Among the Nations. Nowa Medycyna. 2015,4:
124-127.

112
 In addition to treating diseases of the stomach and abdomi-
nal cavity and conducting neurosurgical and orthopaedic surgical
procedures, Michejda was also interested in urology, performing
operations for most of the disease of the urogenital tract, includ-
ing nephrectomies and pyelolithotomies. Patients with benign
prostatic hypertrophy were operated on by the two-stage Freyer
technique. Acute injuries of the genitourinary organs were also
operated. Michejda regularly lectured and ran courses for medical
students and junior doctors on subjects such as “Surgical diseases of
the urogenital system”. The clinic eventually became one of leading
surgical centres in the country. Michejda paid special attention to
the diagnosis of tuberculosis, neoplasms, and diseases of the urinary
tract, such as urolithiasis. To this end, he was always purchasing
the latest equipment. Prof. Michejda’s publications also concerned
tuberculosis and kidney stones and neoplasms of the urogenital
organs.19, 20, 34, 36, 37, 38, 39
Occupation and post-war period
During the German occupation and subsequent Soviet inva-
sion, Prof. Michejda worked on the wards of hospitals in the Vilnius
region and for prisoners-of-war at the municipal hospital in Vilnius.
When the country was under Nazi domination, Prof. Michejda
helped save the lives of some of his Jewish colleagues by hiding
them in his summer house.35
After the country was freed from German occupation by the
Soviets in 1944, Michejda left Vilnius. For a few months he was
head of the Surgical Department in Katowice (Kattowitz), and from
1945 to 1947 head of the Surgical Clinic of the Medical Academy in
Gdańsk. He held the post of first dean of the Medical Faculty, and
in 1946 organised the first post-war Congress of the Association of
Polish Surgeons in Gdańsk. In 1947 he became head of the newly-
created Second Surgical Clinic of the Jagiellonian University in

36. Stanek A., Matuszewski M., Wajda Z.: Urologia w Uniwersytecie Stefana Batorego. Urologia Polska. 2001,
54(4): 96-100.
37. Jocius K.K, Ramonas H., Mickievicius J.: The Development of urology in Lithuania. De Historia Urol Europ
Ed. Mattelaer J. J., EAU, Arnhem, 1999, 6: 101-119.
38. Michejda K.: Wspomnienia Chirurga, Wydawnictwo Literackie, Kraków, 1986, 1-340.
39. Zieliński J., Kopacz A., Kruszewski W.J.: Kornel Michejda – prekursor powojennej chirurgii Gdańskiej (Kornl
Michejda – precursor of the post-war Danzig surgery). Ann Acad Med Gedan., 2006. 36: 241-250.

113
 Kraków, and in 1950 he was appoint-
ed University Vice-Chancellor.
Prof. Kornel Michejda was an
excellent surgeon and academic teach-
er, who distinguished himself through
his outstanding contributions to the
activities of numerous scientific socie-
ties. From 1946 to 1960 he was edi-
tor of the Polish Journal of Surgery. He
died on 5 November 1960 in Kraków
and was buried in the Evangelical
Cemetery in Cieszyn.19, 34, 35, 38, 39
Figure 11: Dr. Simon Perlmann
(1898–1948). Urology in Vilnius 1928-1939
Even as late as the end of
World War II there was not a single
independent urology department in Vilnius, and urological surgery
was left in the hands of general surgeons and, as had been the case
for centuries, of academically uneducated practitioners, such as
bath-house attendants, barbers, and itinerant surgeons.36, 37
Starting from the 18th century, prominent Vilnius gen-
eral surgeons laid the foundations for the development of urology
in the city. By the 19th century the city had a number of highly
skilled surgeons, but only the most outstanding doctors engaged in
urology in Vilnius, and they mainly worked in university surgical
departments.
But it was not until the 1920s, in the inter-war period, that
the Urology Ward was opened by Prof. Kornel Michejda – the first
step to urology becoming an independent discipline. In 1928 he set
beds aside for urology patients in his Surgical Clinic.
Prof. Michejda was not only an outstandingly skilful general
surgeon in Vilnius, but also a visionary. He is believed to have been
the principal motive force behind the development of clinical urol-
ogy in the city. It was not until a few years later that his far-sighted
wisdom saw reality. In 1933, Prof. Michejda established a urology

114
ward in the clinic, but the catalyst behind the development of urol-
ogy in Vilnius was Dr. Simon Perlmann (1898-1948). (Fig. 11) 19,
20, 34, 36, 37

Dr. Simon Perlmann and the influence of political changes on

progress in urology in Vilnius
Perlmann had for many years been assistant to Prof. Eugen
Joseph (1879-1933), a urologist in Berlin. After the Nazis came
to power in Germany, and foreseeing the worst, Simon Perlmann
decided to flee together with his wife, Dr. Tauba Perlmann (1899-
1970). They elected to go first to Vilnius, their place of birth, as
a temporary stopping point, intending ultimately to leave Europe
altogether.19, 39, 40, 41, 42
In 1933 Prof. Kornel Michejda employed Dr. Simon
Perlmann at his Vilnius clinic. Prof. Michejda set up and officially
opened a Urology Ward, appointing Dr. Simon Perlmann as its
head. It was a very important local centre for the diagnosis and
treatment of patients with urological diseases. (Fig. 12) 19, 23, 34, 36, 41,
42, 43, 44

Berlin was at that time one of the leading urological cen-

tres in the world, where the most important diagnostic studies on
the urinary tract were developed and implemented; Dr Perlmann
brought these pioneering methods of diagnosis – chromocystoscopy
(indigocarmine test), retrograde pyelography, and excretory urog-
raphy – over from Germany to Vilnius, thereby raising the level of
urological treatment by enabling the early detection of urological
diseases and offering a better chance of treating urinary diseases. In
this way, urology became one of the clinic’s most important speci-
alities.19, 36, 43

40. Krischel M., Moll F., Bellmann J., Scholz A., Schultheiss D.: (Hrsg) im Auftrag der Deutschen Gesellschaft
für Urologie Urologen im Nationalsozialismus Zwischen Anpassung und Vertreibung, Hentrich & Hentrich
Verlag, Berlin, 2011, Band 1-2.
41. Winau R.: Medizin in Berlin. Walter de Gruyter, Berliner Medizin im Nationalsozialismus. Berlin, New
York, 1987, 324-335.
42. Lithuanian Central State Historical Archives, Vilnius, 2017.
43. Rathert P, Moll F, Schultheiss D.: Highlights in the history of urology in Germany.
44. Hierholzer K, Hierholzer J.: The Discovery of renal contrast media in Berlin. Am J Nephrology, 2002, 22:
295-299.

115
Figure 12: Founding of the Ward of Urology in Vilnius.

Figure 13: “Die Harnorgane im Röntgenbild”

(Urological Radiology),1931.

116
 During that period a wide range of urological procedures
were performed at the university and it was also responsible for
numerous publications, including two urological doctoral disserta-
tions.
In 1907, the journal “Zeitschrift für Urologie” and numer-
ous other urology Journals and textbooks were published in
Germany, including a textbook of urological radiology co-authored
by Dr. Simon Perlmann. (Fig. 13) In fact, Dr Perlmann published
dozens of experimental and clinical works in German-language
journals. He also presented his experiences at meetings of the
Berlin Urological Association, and his publications were also cited
in English-language periodicals. (Fig. 14)45, 46, 47, 48,49, 50
The transfer of this diagnostic knowledge to Vilnius led
to more frequent early detection of urological diseases. This is
evidenced by Dr. Perlmann’s exceptional level of scientific activ-
ity, and his numerous works presented at meetings of the Vilnius
Medical Association clearly demonstrate that he was working in
the Urological Department in Vilnius. His presence in the Surgical
Clinic in Vilnius is also testified to by a letter from the head of the
Surgical Clinic, Prof. Kornel Michejda, to the dean of the Medical
Department of Stefan Batory University dated 24 October 1934.
There are no documents in the archives confirming Dr Simon
Perlmann’s official employment at Vilnius University, but there is a
document stating that Dr. Simon Perlmann had taken all his docu-
ments (39 altogether) from the University Office on 9 April 1934.
19, 20. 23, 34, 42 49, 50

Simon Perlmann was born in Vilnius on 21 August 1898.

His father, Dr. Wulf Perlmann (1871-1958), was born in Latvia
and was a physician and gynaecologist. His mother, Masza, was
45. 
Hubmann R.: Publikationsorgane der deutschen Urologen. In: Urologie in Deutschland. Bilanz und
Perspektiven. Arbeitskreis Geschichte der Urologie (Hrsg.), Springer, Heidelberg, 2007, 59-62.
46. Perlmann S.: Über Verengungen der Ureteren. Z Urol., 1925, 19: 283-299.
47. Perlmann S.: Nahtlose Operationen am Nierenbecken und Ureter. Z Urol., 1930, 24: 530-533.
48. Perlmann S.: Erfahrungen mit Abrodil bei der intravenösen Pyelographie. Z. Urol., 1931, 25: 531-540.
49. 
Perlmann S., Stehler W.: Untersuchungen über die Ätiologie der Blasengewächse. (Experimentelle
Erzeugung von Blasengeschwülsten). Z für Urol Chir., 1933, 36: 139-164.
50. Protokoły z posiedzeń Wil. Tow. Lek. w Pam. Wil. Tow. Lek. Wydawnictwo „Pogoń”, Drukarnia „PAX”,
Wilno 1935, 11, zeszyt 4-5. p 265-269, and 1935, Heft 6, p 364.

117
a member of the legendary Katzenellenbogen family. Until 1915,
Simon spent his childhood, with a few breaks, in Poland. In 1915-
1918 he stayed with his parents in Russia (St Petersburg) – he
had Russian citizenship – to study medicine. His studies in St
Petersburg allowed him to complete at least the pre-clinical part of
his studies (theoretical subjects). From 1919 until 1933 he lived in
Berlin, where in 1922 he completed his medical studies. In 1923,
on the strength of his dissertation “Über Darm und Mesenterial-
Drüsentuberculose” (On intestinal and mesenteric-noduli tubercu-
losis), he was awarded a doctor’s degree in medical sciences from the
Medical Faculty of Berlin University. The supervisor of his disserta-
tion was Prof. August Bier (1861-1949), under whom he learned
surgery; his urology skills he learned under Prof. Eugen Joseph
(1879-1933).19, 20, 23, 40, 42, 51
It was an achievement of the Surgical Department, and of
Perlmann in particular, that they introduced pyelography to diag-
nostics, performed with colloidal silver solution, Collargol, enabling
the state of the upper urinary tract to be visualised. On the other
hand, in cases of advanced tuberculosis and of small bladders, visu-
alisation of the ureter was hampered. The next stage involved the
introduction of urography, with the use of organic iodide derivatives
(Abrodil, Terebril, and later Selectan and Hipuran. At the time,
these examinations were seen as innovative. Not only were they
beneficial for the patients, but they also increased the knowledge of
the clinic assistants and doctors in Vilnius and surrounding district.
19, 23, 36, 46, 48. 49

In 1935, Dr. Simon Perlmann and his wife emigrated

to Palestine. In 1936, he was appointed head of the Urological
Department at Hadassah Hospital in Tel Aviv. There he died child-
less in 1948. (Fig. 15)19, 20, 42, 52, 53
51. Perlmann S,; Über Darm- und Mesenterial-Drüsen-Tuberkulose“. Zusammenfassung in: Jahrbuch der
Dissertationen der Medizinischen Fakultät der Friedrich-Wilhelm-Uniwersytät zu Berlin, 1922/23 –
1929/30, Berlin, 1930, 267-269.
52. Offer M., Herzog R., Pasher Y., Ohry A.: Medicine and urology in Eretz-Izrael in the first half of the 20th
century and in the shadow of the Holocaust. In: Schultheiss D., Moll F. H.: Urology under the Swastika. EAU,
Davidsfonds, Uitgeverij, 2017, 226-253.
53. Yafo Municipal Archives. Tel-Aviv, Israel. In: book of Levy N, Levy Y (2012) „The Physicians of the holy Land,
1799–1948”. Itay Bahur Publisher, Zichron Yaakov, Israel, on Dr. Simon Perlmann, and his wife Dr. Tauba
Perlmann (Tatiana nèe Kamien), short biographies. 2017.

118
Dr. Jan Janowicz (1893-1964)
The doctor second in importance in Vilnius to Michejda and
who also became one of the pioneers of Vilnius urology was Dr. Jan
Janowicz. (Fig. 16) He studied medicine in Dorpat, present-day
Tartu (Estonia). In 1917 he was conscripted into the Russian army,
but some months later joined the Polish First Corps. On leaving the
army and being sent into the reserves he worked at Vilnius Railway
Hospital, where he was first junior head and later senior head of the
Surgical Department. He trained in surgery in Warsaw under Prof.
Zygmunt Radliński (1874-1941), in Berlin under Prof. Ferdinand
Sauerbruch (1875-1951), as well as in urology in Paris (twice, in
1930 and 1935) under Prof. Georges Marion (1869-1960). In 1925
he graduated as a doctor of medical science from the University of
Warsaw.54, 55
Between 1925 and 1939 Dr. Janowicz first founded and then
ran an outpatient clinic and also a Urology Ward at Sawicz Hospital
in Vilnius. At the same time, together with Dr. Alina Erdmann,
he was running a private urology clinic in the city. In addition, he
was performing operations at other institutions and holding private
consultations in the field of general surgery and urology. He also
treated and operated on urology patients at his private practice and
at Sawicz Hospital. All in all, he was undoubtedly one of the leading
pioneers of urology in Vilnius.
In 1939 he was drafted and appointed head of the Surgical
Department of the Garrison Hospital in Vilnius. Between 1941
and 1943 he did not hold any permanent post and worked instead
at his private practice. After the Soviet Army entered Vilnius he
returned to work at the Railway Hospital. During this period he
was imprisoned twice by the occupying powers – first Soviet and
then German.
In May 1945, Jan Janowicz moved to Olsztyn (Allenstein),
which became part of Poland following the war. Here he became

54. 
Pogorzelska D., Janowicz L.:Sylwetki polskich lekarzy - dr Jan Janowicz. Eskulap Świętokrzyski. Pismo
Świętokrzyskiej Izby Lekarskiej. Wyd.: Okr. Rada Lek. w Kielcach. : 2004, 12.
55. Dutkiewicz A.: Jan Janowicz 1893-1964. In: Rudowski W, Śródka A, Album Chirurgów Polskich. PAN
Wydział Nauk Medycznych. Ossolineum, Wrocław, Warszawa, Kraków, Gdańsk, Łódź, 1990, 100-101.

119
Figure 14: Publication of Dr. Simon Perlmann, 1930.

120
Figure 15: The Polish document used by Dr. Perlmann for emigration.

Figure 16: Dr. Jan Janowicz

(1893–1964).

121
head of three hospitals: the Railway Hospital, the District Hospital,
and the Polyclinic. In Olsztyn, which was destroyed during the war,
he built up surgical departments from scratch. He trained numer-
ous surgeons who were ultimately to become heads of Surgery
Departments in Olsztyn and surrounding towns. On his own initia-
tive, he established Urology Departments in Olsztyn and elsewhere.
Jan Janowicz died on 16 January 1964 in Warsaw and was buried
in Powązki Cemetery.20, 54, 55
Conclusion
Today it is safe to say that in the period between the First
and Second World Wars Polish urology, with special reference to
the Vilnius Urology Ward at the Surgical Clinic of Stefan Batory
University, kept pace with developments in this discipline in
Europe. Stefan Batory University, in the north-east of the Second
Polish Republic, was an important centre of Polish culture and sci-
ence, enhancing Vilnius’s reputation and prestige.
The forced escape from Berlin of the experienced urologist
Dr. Simon Perlmann was a blessing in disguise for the Surgical
Clinic in Vilnius. Its staff was able quickly able to catch up with
the latest developments in modern urology, helping to bring about
an immediate improvement in the urology service and in teaching
standards at Vilnius University. The clinical and academic activ-
ity of Simon Perlmann, however brief, nevertheless expanded the
expertise of individuals who were eventually to become the heads of
surgical clinics in Gdańsk, Białystok, and Olsztyn. One of the clinic
assistants, Dr. Antoni Szczerbo, became Professor of Urology in
Katowice and Lublin. In Vilnius it was not until after World War II
that urology acquired the status of an independent discipline.19, 37, 56
With the outbreak of World War II, the Polish University
in Vilnius was closed down in the face of the new political reality.
Lithuania regained its historical capital of Vilnius. However, it was
not until the occupying forces of Nazi Germany were finally driven
from the country that the university was able to resume its scien-
tific activities. Vilnius was incorporated into the Lithuanian Soviet
53. Ramonas H., Januskevicius T., Grigutis R.: The development of urology in Vilnius University. Theory and
Practice in Medicine. 2015, 21(2.2): 148-154.

122
Socialist Republic. New academic staff were brought in from north-
ern Lithuania, mainly from Kaunas University. An independent
urology clinic was not established in the Vilnius of the Lithuanian
SSR until long after World War II.19, 37, 56
After the Red Army occupied Vilnius in 1940, many Polish
professors were arrested and deported to the depths of the Soviet
Union. Five of them were murdered at Katyń. Polish scientists,
forced to leave the country, left Vilnius for Poland. Some started
new careers in other parts of the world. Only a few Polish employ-
ees of Stefan Batory University stayed in Vilnius, with almost the
entire Polish being expatriated, mainly to Silesia and the reclaimed
territories of north-west Poland.
The turmoil caused by World War II and occupation by
two totalitarian regimes brought tragedy to millions of inhabit-
ants of the former Poland. The westward shift of the Polish borders
after World War II altered the fates of the displaced populations,
who had been settled there for generations. However, it did also
undoubtedly afford to many the chance to start new professional
careers at universities in the reclaimed territories.
Both Kornel Michejda and Jan Janowicz were honoured as
“Righteous Among the Nations” by Yad Vashem for their contribu-
tions in risking their lives to help and save Jews during the war.35, 55
Today, Vilnius University is the largest in Lithuania, with a
student roll of 20,000 and 1300 academic staff. It has 14 faculties,
including the Medical Faculty, which is one of the largest and most
important faculties at Vilnius University, employing around 760
researchers.4, 19, 25
Correspondence to:
Dr. T. Zajaczkowski
Germania Platz 6
D-45355 Essen, Germany
th.genofewa@gmx.de

123
124
 Genital and Sexual Symbols in the
Pre-Columbian Maya World
Javier C. Angulo1, Carlos Figueroa Lemus2
1
Universidad Europea de Madrid, Hospital Universitario de Getafe, Madrid, Spain;
2
Urología Integral, Ciudad de Guatemala, Guatemala.

The Precolumbian Mayan people

In the second millennium before our era the Mayan people
settled in the Petén region and in the Yucatán Peninsula, adapt-
ing to the geographical and ecological environment complex of
Central America. They were able to develop an advanced civiliza-
tion around a ruling elite with specialized artisans and a culture of
farming and warlike habit. Paradoxically, they emphasized their
artistic sensibility, the development of architecture and of an astro-
nomical knowledge, and the establishment of the first organized
writing system of the American continent. This civilization was
organized around city-states, until the Spanish conquest. From a
cultural point of view, different periods are established that are
divided into Preclassic (1500BC-317AD), Classic (317-889) and
Postclassic (889-1696).1
The Preclassic period was characterized by a rapid techni-
cal advance in the dominance and expansion of agriculture, mainly
maize. During this period a complex social structure was organized
and at its end writing appeared, the basis of the later development
of the Mayan civilization. The most important cities at that time
were Kaminaljuyu in the Highlands and El Mirador in the central
area of the Lowlands. During the pre-classic terminal stage, the set-
tlements of the Highlands and the Pacific coastal plain fell, possibly
due to natural phenomena and changes in the model of trade rela-
tions. This decline favoured the prosperity of the central Lowlands,
which would be the dominant region of the classical period.2

1. Sabloff J.A., The New Archeology and the Ancient Maya, Scientific American Library, New York, 1990.
2. Schmidt P., De la Garza M., Nalda E., Maya Civilization, Thames & Hudson, London, 1998.

125
 The classical period was characterized by use of writing and
the calendar, and progressively the perfection of some of the char-
acteristic features of the Mayan world such as the dated stelae, an
architectural style with limestone vaults in projection, and beautiful
lavishly decorated ceramics. The progressive social transformation
led to the establishment of a state organization with well-defined
hierarchy in each different city-state. A brilliant architecture of
large public buildings, a stable aministrative class and specialized
craftsmen were developed. At the summit of this society was the
great Lord, known as Ahau, with divine right to govern, clad in
supernatural authority. Generally, the throne was inherited by the
firstborn male of the ruler and, sometimes by the eldest daughter of
the ruler; a female who acted as a bridge of real power and therefore
enjoyed a special consideration.
The state of political fragmentation varied greatly, but often
power and bloodline established alliances or conflicts between the dif-
ferent city-states and their lineages. Often these conflicts ended with
the capture and sacrifice of the ruler of one city for that of another.
Tikal was the most known and powerful political entity of the
time. Other important cities of the classical period were Uaxactún,
Calakmul, Caracol, Dos Pilas, Aguateca, Yaxchilán, Piedras Negras,
Palenque, Uxmal, Copán and Quiriguá, among others.2
At the end of the classical period the large cities of the
central Lowlands stopped recording dates in their monuments, in
relation to the disappearance of centralized dynasties and the emer-
gence of multiple local powers. Possibly the overpopulation and the
impoverishment of the lands by deforestation precipitated the revolt
against the monarchies and a new more feudal order.2 At that time,
in the Yucatan Lands, new centers and cities became the dominant
lands of the Postclassic period, especially Chichén Itzá, Mayapán
and Tulum.
The arrival of the Spaniards meant numerous changes in
the Mayan way of life, especially in religious and social aspects.
The conquest led to a spectacular decline of the native population,
although the inhabitants of Yucatán, Chiapas and Guatemala are
direct descendants of this ancient civilization.3

126
A cosmological view of the world
The Mayas conceived a peculiar vision of the origin of the
world and of the deities that inhabit it. These beliefs allowed them
to interpret the cosmos and to link with it for all the activities
of their daily lives, including the sexual sphere. All the activities
were ruled by the gods. Thus, the Mayas were part of a world in
which prosperity was achieved through faith and service to the
gods through their representatives on Earth. In this worldview the
individual is not important. The gods have the key to everything
and the universe works as long as men respect and serve them. The
great number and variety of gods show that religion was the main
binder of the Mayan Society, and the instrument of dominance of
the leaders.
The sexuality of the Mayas can be studied through numerous
cultural manifestations, often preserved in archaeological elements
that include stelae, buildings and architectural constructions, decorat-
ed ceramics and in codices before and after the arrival of the Spanish
Conquerors, and even in the chronicles written by the victors. Thanks
to all these elements we can perceive an abundant sexual symbolism
in the Mayan world, that far from being a purely belligerent and cruel
people (as interpreted to justify in its time the Spanish conquest) was
a cult people, elegant and of great artistic sensuality.
Like any aspect of life, sexuality and genitalia were also part
of that cosmological view of the world. For this reason, sexuality
among the ancient Mayas was closely linked to nature, the world
and its functioning Development of an art displaying an image of
the erotic was encouraged.4 Sexual desire was also a part of the rites
of war and religion. From the Preclassic period the Mayas compared
human fertility with that of the earth, while practiced a cult of
“ritual masturbation” or of male offering to the Earth. (Fig. 1) The
sexual union between individuals of different ethnicities was gener-
ally rare, because each society had in very high esteem its divine
origin and therefore it was not honorable to mix its blood with that
of another people.
3. Martínez de Velasco Cortina A. & Vega Villalobos M.E., Turner/Ambar Diseño/UNAM, Madrid, 2015.
4. Taube R., Figurines: Mesoamerica, The International Encyclopedia of Human Sexuality, Patricia Whelehan &
Anne Bolin Editors, John Wiley & Sons, London, 2015.

127
Figure 1: Phallic menhir in allusion to Figure 2: Itzamná (“Dew of the Sky”)
the primitive cult of fertilising through seducing a beautiful young woman.
masturbation (early Preclassic).

Complementary sexual duality

The Mayas expressed the sexual duality with the deities
Ixchel (The one who lies) and Itzamná (The dew of the sky), mother and
father of the gods.5
Ixchel is the mother of the Earth and life and is usually
depicted as a woman seated on the sign of the moon. When depict-
ed as a young woman she is a goddess of fertility, responsible for
sending rain to the crops. She tends to carry a turned-down vessel
that symbolizes the gift of water. This goddess also governs the
reproductive system of women and protects them during pregnancy
and childbirth. She has as a consort, the rabbit in spring as a sym-
bol of abundance. However, when she is depicted as an angry old
woman she is the goddess responsible for the floods, malicious cause

5. Guzmán Argáez P. & Servín Hernández B., Estuido y proyecto de exposición sobre la sexualidad y el ero-
tismo dentro del imaginario artístico del México prehispánico, Universidad de las Américas, Puebla, 2005.

128
of destruction and death, with the serpent in her head and bones
crossed over her clothes. The totem of this goddess is the serpent
by its constant rebirth when changing the skin. This duality in its
representation also symbolizes the phases of the woman’s menstrual
cycle.
Itzamná is the son of Hunab Ku (The Creator god). According
to Mayan beliefs, he lives in the clouds and sends the necessary rain
to the Earth. He was summoned at the New Year’s ceremonies. He
is a benevolent divinity, and some of the most important creations
for humans, such as medicine, calendar, fire or writing are attrib-
uted to him. Some ceramic figures show the seduction of a beautiful
young woman by Itzamná in erotism-laden flirting attitude.6 (Fig. 2)
The masculine and the feminine were considered indispen-
sable to each other, and at the same time complementary, because
they are a cosmic and life unit. So, the masculine is the Sky and the
feminine the Earth. Maize also represents the male and the bean the
female.7 The feminine is identified with the death that will be the
source of life, while the masculine is the life that precedes death.
This complementary duality advocates sexual division, and also jus-
tifies the division at work and the social roles of everyday life. There
are in fact few examples of important women in Mayan social life.8
For the Mayas the cosmic duality governed the three levels
of life: Sky, Earth and Underworld. The complementary opposites
maintain the balance of the cosmos. Sexuality was closely linked to
nature: love, pleasure and coitus allowed the ancient Mayas to com-
plete their existence and seek their offspring and continuity in the
world. In fact, male and female complementarity are present in dif-
ferent elements of life, as in the symbolic architecture of the Great
Square of Tikal.9 Temple I, known as the Great Jaguar, the tomb of
Sovereign Jasaw Chan k’awiil acquires a phallic sense as the shadow
5. Miller M.E., The Art of Mesoamerica, Thames & Hudson World of Art. 5th edition, London, 2012.
7. López Austin A., El cuerpo humano e Ideologías, concepciones de los antiguos nahuas, UNAM, México,
2010.
8. Joyce R. Recovering Gender in Prehispanic Mesoamerica, Klein C Editor, Dumbarton Oaks, Washington,
2001.
9. Harrison PD., La arquitectura maya en Tikal, Guatemala, In: Los Mayas. Una civilización milenaria, p 218-
231, Grube N, editor. Könemann, Colonia, 2001.

129
Figure 3: Gliph “AAT” that represents the
male genitals.

Figure 4: Coital image in

the Dresden Codex.

Figure 5: The bat emblem of the city of Copán that decorated a facade in allusion to the
Underworld of the Popol Vuh.

130
of its elongated plume daily visits Temple II, built as the tomb of
Lachan Uneh’Mo wife of that ruler, in an act of symbolic intercourse.
But the symbolic sexual duality described is far from reflect-
ing an egalitarian character in the Mayan Society. It seems that
although most of the phallic representations may have been lost
after the Spanish conquest, male genital representations are much
more frequent than the female. In fact, there is the “AAT” glyph to
describe the penis, but there is no homology for the female genita-
lia.10 (Fig. 3)
Women at the time of puberty are represented with a shell
of Spondylus covering their genitals, in allusion to the precious treas-
ure of her virginity. Often female sexuality is much more sensual or
suggestive than overtly sexual. It perceives a feminine sensibility in
subtle attitudes like the crossing of the legs of some figures, hugs,
exposure of the breasts, attitudes of the face or caresses. The evident
coital representation is rare, although it is explicitly represented
on several occasions in the Dresden Codex. Interestingly, the most
explicit penetration is between God Chahk (Thunder or God of the
rain) and a young woman given and receptive, in possible allusion
to the complementary duality referred to life and death or of the
reborn seed. (Fig. 4) Chahk is indeed one of the most popular Mayan
deities, the generator of corn.2
The bat that symbolizes the city of Copán, beheader of the
underworld according to the myth reflected in the Mayan book
Popol Vuh, exhibits male genitals in erection. (Fig. 5) In a vase from
the Museum of the Americas in Madrid a black-eyed anthropomor-
phic bat is the male character of a coital scene. (Fig. 6)
Another very curious image found in the decoration of
another vase, also loaded with eroticism, represents a reference to
the creative myth of the Hero Twins. It shows a dance in which a
character of the underworld points Zhou Chumaquic‘s belly with a
huge phallic nose. She is the mother of the Hero Twins Hunahpú
and Xbalanque, who turned into monkeys to fight monster beasts in
10. Stone A & Zender M., Reading Maya Art, Thames & Thudson. London, 2011.

131
 Figure 6: Mythological scene in which a
demonic creature or wahy is depicted as
a human-shaped bat in a coital embrace
(late Classic).

Figure 7: Mythical scene that shows the gestation of Zhou Chumaquic, who will give birth
to the Hero Twins. A lord of the underworld points at her with his phallic-looking nose in
allusion to her mysterious conception.

132
the Underworld and winning the ball game to the Lords of Death
managed to avenge and resurrect his father Hun Hunahpú, thus
making a world something safer for humans from a mythologi-
cal point of view. The pregnant maiden Zhou Chumaquic had been
mysteriously fertilized by the decapitated head of Hun Hunahpú. In
the vessel she raises her hand to separate from its body the phallic
nose, an allusion to the uncertainty generated by the origin of her
gestation. (Fig. 7)
Thus, the analysis of numerous Mayan archaeological pieces
available at present suggests genital and sexual symbology in this
culture is much more florid than originally considered, although the
information available is often partial and fragmented. Lust, love,
pleasure and sexuality had a profound value among the Mayas, who
used inconspicuous signs to alude to them, such as bird feathers or
certain types of flowers. Exaltation of the senses and carnality were
subtly reflected. Ruddiness and fatness were appreciated as sexual
attractiveness. The Mayas also took care of many cosmetic details,
like the use of ornaments, shaving and depilation of eyebrows, scari-
fications, tattoos or dental fillings and inlays.11
Gender role in the Mayan Society
Among the Mayas the man was the provider and sustenance
of power.12 The sons left the paternal house from the age of twelve
years to live in the communal houses where they were trained in the
art of war and religion. They used to stay there until their parents
elected for them a wife to unite in marriage. In these communal
houses they were subjected to rigorous military discipline and tests
of bravery. They were also instructed in the rites that keep the
gods pleased, such as fasting and self-sacrifice. The lobes of the
ears, sinuses, tongue and penis were pierced using stingray thorns
or maguey spikes. There is a suspicion that in their wars the Mayas
acquired male slaves to fulfil the role of sexual servants in these
schools, even if they could have made use of holy prostitutes, as the
Mexica later did. The aristocracy also acquired sexual slaves for the
11. Diego de Landa, Relación de las Cosas del Yucatán, Edición de Miguel Rivera Dorado. Alianza Editorial,
Madrid, 2017.
12. Joyce R., A precolumbian gaze: Male sexuality among the ancient Maya, In: Archeologies of Sexuality,
Schmidt RA & Barbara L, Editors. Routledge, London, 2000.

133
Figure 8: Image of an embrace between two males painted in the cave Naj Tunich.

134
male sons of the nobles, because premarital sex and heterosexual
encounters with slaves were frowned upon.13 (Fig.8)
The role of women was to generate life and sustenance, both
on a nutritious and affective level. From birth the woman was des-
tined to sustain life, to learn to keep her family, society and the gods
pleased.14 The daughters were requested in marriage and the future
sons-in-law were to pay a dowry and serve up to seven years to their
father-in-law in order to obtain a positive answer to his request. A
new house attached to that of the father-in-law was then built so
that this agreement could be fully fulfilled. When the daughter
went to live with her husband, it was the father-in-law of this one
who assumed the role of surrogate parentship, and she had to obey
him in everything.
On the other hand, as a woman she had her rights before
society. She could dismiss her husband if he was not able to support
his family, though if she had an immersion in adultery she could be
stoned and her husband had the right to mutilate his wife’s nose
or even crush her skull, and also her lover’s. It was strictly forbid-
den for a woman to be drunk or incur scandalous attitudes. When
she became old she was recognized as wise and treated with great
respect for the community.15
Polygyny was not rejected but also not totally accepted, and
it was mainly used to justify political or social affairs, such as alli-
ances with other lineages. In some murals or ceramics noble lords
appear surrounded by several concubines. In this sense a decorated
vessel shows the young God of maize being dressed by three naked
women in the presence of his sons Hunhpú and Xbalanque, thus
justifying polygyny.13 No doubt this practice seems reserved to the
upper class, and to those who were distinguished on the battlefields.
As we have pointed out the Mayans were also tolerant of homo-
sexuality.13 They considered it preferable to heterosexual premarital

13. Montejo Díaz M.A., La sexualidad Maya y sus diferentes manifestciones durante el período Clásico (250 al
900 DC), Universidad de San Carlos de Guatemala, Nueva Guatemala de la Asunción, Guatemala, 2012.
14. Joyce R., Women’s work: Images of production and reproduction in pre-Hispanic Southern Central America,
Current Anthropology, 34: p.255-274, 1993
15. Robin C., Peopling the past: New perspectives on the ancient Maya, PNAS, 98: p.18-21,2001.

135
Figure 9: A spider monkey copulates with a
woman in the decoration of a painted vase
from Uaxactun.

Figure 10: Prisoner with huge flacid

penis knotted around his neck.

sex, so the elites were able to get sex slaves for their children. In
addition, they understood that the origin of homosexuality was even
sacred, by representing homosexuality as the replacement of the
foot of Jasaw Chan k’awiil by a snake.
Sex between women and animals (monkey, deer, jaguar)
constitutes another of the most curious sexual representations of
the Mayan World. (Fig. 9) Possibly the animal figures represent
humans taking the characteristics of the animal to develop the
fertilizing ability of nature in the world.5 No records have been
described in which an anthropomorphic character implies a femi-
nine attribute, which again reveals masculine dominance in Mayan
thought schemes. In other words, the male element can have dif-
ferent human or animal forms, with their respective attributes, but
not the feminine.
Maya phallic cult
The National Museum of Anthropology in Mexico shows a
variety of evidence of an art of phallic exaltation, such as the sculp-

136
ture found in Campeche showing a captive male character whose
huge virile limb flaccid, out of all proportion, is knotted around his
neck in clear allusion to his impotence.16 (Fig. 10) Often the captives
of war were exhibited naked before being executed. Similarly, the
victorious warriors could exhibit their genitals as a sign of strength
and virility, in a similar manner to the heads of their enemies.
Even as a symbol of masculinity Yum Kaax, the god of maize, also
exhibits his genitalia in a decorated stele of the Preclassic period
in Kaminaljuyu. However, the phallic forms of public character in
open spaces became much more frequent in the Postclassic period,
as testified by multiple sculptural representations found in Uxmal,
Tulum, Xcaret, Oxkintok, Chichen Itza and other sites, especially
in the Yucatán peninsule.17
There are three types of sculptural phallic representations:
exempted monumental phalluses, free portable phalluses and phal-
luses attached to the walls of architectural structures. The first ones
are pieces of large dimensions, with aspects of carved menhir. Its
most probable function was that of monuments placed in the squares
to mark cosmological events or ancient myths. The Yucatecan Mayas
call them xkebtunich and most represent a phallus in erection that
shows glans, frenulum and urinary meatus. The second are repre-
sentations in stone, clay, wood and shell, of a portable character and
often of a natural size. They may have been used as ornaments or
pieces of use in the rituals of phallic cult. Some have been found in
funerary context and others in caves or cenotes. The third are phal-
luses attached to architectural or set-in structures, built in stone as
ornaments on the walls of some temples. In the phallus temple at
Chichen Itza cults related to rain rituals were worshipped. The rain
was considered to represent the divine semen that fertilized the earth,
which in turn symbolized the feminine. On its facade below the
cornice, a series of ornaments represent uncircumcised flaccid virile
members. Two atlantes guard the entrance to the temple with their
arms raised behind their head in an attitude to load the structure.

16. Miller M.E. & O’Neil M.E., Maya Art and Architecture, Thames & Hudson World of Art, 2nd edition,
London, 2014.
17. Amrhein LM., An iconographic and historic analysis of terminal Classic Maya phallic imagery, Fundación
para el avance de los estudios mesoamericanos, 2003 (in: http://www.famsi.org/reports/20001/index.
html, last access 09/15/2018).

137
 Figure 12: Scene of blood offering performed by
the ruler Jaguar Bird and his wife Lady B’ Alam
Mut on lintel 17 of Yaxchilan (late Classic).
Figure 11: Ritual of blood offerings
in the mural of San Bartolo (early
Preclassic).

Information concerning how the rituals of phallic cult were

carried out is relatively scarce. However, in Trocartesian Codex appear
four gods around a brazier or pedestal on which a turtle symbolizes
the earth, the feminine, traversed by a rope. These gods show their
penises pierced and joined by a rope that collects their precious
blood. This same ritual of hematic liberation was repeated by the
men of the elite, to legitimize their position, thus imitating the gods
and fulfilling the cycles of nature. In this way, rainfall and crops
were expected to be abundant.
The ritual of the blood offering is one of the most recurrent
themes of the Mayan culture throughout all periods, essential for
the religious and political order of the Mesoamerican societies. The
Mayas not only offered food, fragances and beautiful objects to the
gods. The blood offering was considered sacred and necessary for the
survival of the gods and humans because according to their belief

138
it raised the energy to the sky.18 Thus, the self-sacrifice of blood or
the sacrifice of human or animal victims served to express gratitude
to the gods, to redeem for guilt, to ward off bad feelings and even
to communicate with the dead. Even from a political standpoint,
the sacrifice of blood allowed the leader to legitimize his power.
The Divine descendants exercised this ritual as a passing ceremony
to their adulthood, without fear, demonstrating their ability to sur-
render not only to the gods but also to the society they would lead
in the future. This ritual of transit legitimized the future king and
was used as a major element of cultural connection between differ-
ent regions and/or state cities.
On the other hand, the blood-extraction ritual reveals the
maximum fertilizing power of the penis. The punctures of the prepu-
tial skin and male sexual organ were a cultural phenomenon spread
throughout the Mayan world.19 It has been documented not only in
the Trocartesian Codex, but also in the decoration of different stelae,
lintels and vases. In Quetzaltenango, a classic period clay figure was
found which, far from all other hieratic representations, shows the
pain factions in the face of the performer of the blood effusion ritual.
In the mural paintings of San Bartolo in Petén a mural displays four
figures that process a ritual of bloodshed by cutting the skin of their
phalluses before the four Trees of life.20 (Figure 11)
Another way to implement this ritual was using a rope
that absorbed the blood thus creating a stronger contact between
humans that carry out this ritual as a community, as shown in the
Trocartesian Codex in Madrid or the lintel 17 of Yaxchilan. In the
latter, man and woman perform the ritual simultaneously and con-
nected, drilling penis and tongue respectively. No doubt this image
is loaded with great sexual symbology, establishing a kind of marital
union around the blood sacrifice itself. (Fig. 12) Other variants of
this ritual have been recorded, such as ear and other parts of the
18. Dornan J., Blood from the Moon: Gender ideology and the rise of ancient Maya social complexity.,Gender
and History, 16: p.459-475, 2004.
19. Munson J., Amati V., Collard M., Macri M.J., Classic Maya bloodletting and the cultural evolution of
religious rituals: Quantifying patterns of variation in hieroglyphic texts, PLoS ONE 9(9): e107982.
Doi:10.1371/journal.pone.0107982
20. Saturno W., Staurt D., Beltrán B., Early writing at San Bartolo, Guatemala, Part 1, The North Wall. Center
for ancient American studies, Barnardsville, 2006.

139
body piercing. The non-ruling class of the Mayan people practiced
these rites to obtain fortune in their crops, the ruling class did it
also for legitimize in power. Performance of rituals of blood between
sterile couples as purifying practice to ask the deities send them
offspring was also described.11
Other rituals with sexual symbology
The blood offering in the Mayan world was considered nec-
essary even for the survival of the human groups. Thus, with the
sacrifice of the blood (either own or that of other animal or human
victims) gods were thanked thus encouraging benificent actions,
detracting from the evils and opening a connection to communicate
the dead.21 War was also very close to this kind of propitious rituals.
Often the purpose of war was to capture leaders, including rulers, to
have the right to sacrifice them and thus control the territory.22 The
Mayas lived a climate of almost constant war tension, as evidenced
by the scriptural records of the different Mayan cities that rivaled
each other. The war was really conceived as a privilege. To die in
war allowed one to spill the blood for the continuity of the cosmos
and the life itself. Thus, the warrior who died had the same consid-
eration as the parturient who died during childbirth.23 Therefore,
a link can be established between battle and sexual intercourse. In
both cases a life in danger allowed the renewal of the cosmos.
The captured warriors were booty of war, drastically dishon-
ored and publicly exhibited in humiliating attitudes with a lack of
control over their sexual attributes. Therefore, the naked captive
display of its virile members, often large, but flaccid, is part of the
imaginary characteristic of the defeated and dishonored warrior.13
Although not in such a massive way as the Aztecs, the Mayas prac-
ticed human sacrifice as well. A stele of the classic period in Piedras
Negras shows a man whose heart is extracted, giving evidence that
after the Toltec influence Mayan animal sacrifices were followed by

21. Stuart D., Royal Auto-Sacrifice among the Maya: A Study of Image and Meaning, Res: Anthropology and
aesthetics, 7-8: 6-20, 1984. (in https://doi.org/10.1086/RESvn1ms20166705, last access 09/15/2018).
22. Schele L., Miller M.E., The blood of kings: Dinasty and ritual in Maya Art,. Fort Worth: Kimbell Art Museum,
1986.
23. Gómez Pineda M., La concepción del cuerpo humano, la maternidad y el dolor entre muejres mayas yucate-
cas, Revista Mesoamérica, 39: p.305-333, 2000.

140
human sacrifices. Slaves, orphaned and illegitimate children and war
captives were sacrificed.24 The latter were reserved for important
dates, such as the takeover of a lord or the appointment of an heir.
Decapitation, the extraction of the heart and the arrow killing were
the main forms to carry out the sacrifice ritual.25
The ball game is another of the most characteristic ceremo-
nies in the Mesoamerican area.26 The ball was understood as an ele-
ment linked to the orbits of the stars, an element of cosmic struggle
between day and night, the sun and the moon, the sky and the
underworld, following the myth of the Hero Twins and celebrat-
ing the defeat of the gods of the underworld. The ceremonies were
celebrated as part of the cycle of religious festivities and to conse-
crate new courts in the ceremonial centers, which again supported
the power of the ruler and the playful control over his people. The
supernatural forces of ball players were also part of emerging lead-
ers’ legitimization strategies.27
In addition, the rubber balls used for the ball game were a
connecting element with the effusive rituals of blood. Latex is the
blood of the trees. These rubber balls were made by winding rubber
spirals and were burned in ritual offerings so that the resulting
smoke produced a kind of olfactory nourishment to the gods. In
addition, there was an analogy between the rubber ball canisters
and the heartbeat, between human sacrifice and the ball game itself.
Some sculptures used to collect the blood of the offering in the ritual
of extraction of blood had the form of a ball of rubber surrounded
by a rope, fundamental element also of the rituals of blood extrac-
tion. Even that kind of circular altar with helical groove has some
analogy with the stone-exempt phalluses that we have mentioned as
elements of the Mayan ritual landscape in the Postclassic period of
the Yucatán. The phallus, the blood, the ball game and the sacrifice
form thus a kind of complex liturgy in which male virility is the

24. Arden T., Empowered children in Classic Maya sacrificial rites, Childhood in the Past, 4: p.133-145, 2011.
25. Taube K.A., Zender M., Blood and Beauty. In: Organized violence in the art and archeology of Mesoamerica
and Central America, p.161-220, Orr HS & Koontz R Editors, Cotsen Institute, Los Angeles, 2009.
26. Fox J.G., Playing with power: Ballcourts and political ritual in southern Mesoamerica, Curr Anthropol., 37:
p. 483-509, 1996.
27. Blomster J.P., Early evidence of the ballgame in Oaxaca, Mexico, PNAS, 109: p.8020-8025, 2012.

141
common bond, explaining also the prominent representation of the
phallus of those who will be sacrificed.
Conclusion
Genital symbolism and sexuality are a constant in the pre-
hispanic Mayan world. The subtlety of Mayan art shows a complex
sexuality in many of the material representations that have survived
today. Mayan sexuality can be understood only by considering
their conception of the world through a characteristic cosmological
vision. Some distinctive ritual elements of the Classic and Postclassic
period with genital involvement such as the blood-extraction rituals
or the sacrifice of the captives were employed as a tool for legiti-
mizing and maintaining the ruling elite in power. These rituals are
loaded with sexual symbology and are a sophisticated evolution
of primitive fertility rituals, common in the Preclassic period of
Mesoamerican cultures. The ideological discourse associated to these
rituals was used by the ruling Mayan elite as a tool of political con-
trol. On the other hand, the Spanish conquest took advantage and
distorted these complex rituals to justify the necessity of the cultural
subjugation of these people.
Correspondence to:
Prof. Javier Angulo
Departamento Clinico, Facultad de Ciencias Biomedicas
Universidad Europea de Madrid
Carretera de Toledo Km 12.5
Getafe 28905
Madrid, Spain
jangulo@futurnet.es

142
143
Figure 1: The first successful organ transplantation in man by Joel Babb (1996). Oil on
linen. 187 x 224 cm. Harvard Medical School, Boston. Courtesy J. Babb.

144
 Urology in Modern and Contemporary
Literature, Music and Art

Wiking Månsson
Department of Urology, SUS, Malmö, Sweden

Health and illness, and ultimately death, are major issues in

life. Health is most often taken for granted as it is without symp-
toms. La santé est la vie dans le silence des organes, as expressed by the
French surgeon René Leriche.1 While illness can be defined as ‘having
something wrong with oneself,’2 disease is the illness as diagnosed in
medical terms and should be an objective description of that illness.
Today we are exposed to a cascade of information around
health and disease, particularly cancer. Death nowadays seems to be
almost unnatural, particularly when media and books declare that
‘the future is already here’, referring to how organs can be repaired
and transplanted with the intention of longevity.
Although the modern man is constantly advised by the
health industry and media on all possible diseases, we rather seldom
find the description of illnesses in the literature of today. Writers
seem more to be concerned with stories about relationships, migra-
tion, crime and money. There exists, however, some books that
have functioned as ‘pathographies’, i.e. “a form of autobiography or
biography that describes personal experiences of illness, treatment,
and sometimes death” with the purpose to “express the meaning of
the author’s experience.”3
Well-known examples are Tolstoy’s novella The Death of
Ivan Ilyich (1886) about a middle-aged man who has suffered a fall

1. Leriche R., Cited in: Canguilhem G., The Normal and the Pathological, Zone Books, New York, 1991
2. Brody H., Stories of Sickness, University Press, 2nd ed, Oxford, 2003
3. Hawkins AH., Reconstructing Illness, Studies in Pathography. 2nd ed, Purdue University Press, West
Lafayette, 1999

145
and then succumbs to a complication, The Magic Mountain (1924) by
Thomas Mann describing tuberculosis, and Aleksandr Solzhenitsyn’s
Cancer Ward (1967). Susan Sontag’s two books Illness as Metaphor
(1977) and AIDS and its Metaphors (1988) are also worth mentioning.
The Sick Girl (1885-1886) by Edward Munch and The Broken Column
(1944) by Frida Kahlo are two examples of pathographies in art.
In this chapter we will describe how urological conditions
and procedures have influenced authors, composers and artists in
the Western modern culture. Most examples have been collected
over a number of years by reading, observing and listening. In addi-
tion, suggestions have been given by friends and colleagues. The
peer-reviewed journal Literature and Medicine has provided valu-
able information.
Urology in Literature: Prostate cancer
i. The Lay of the Land (2006) by Richard Ford
In the beginning of the book, the main character Frank
Bascombe tells us that he has had a “life-modifying trip […] sixty
radioactive iodine seeds […] smart-bombed into my prostate at the
Mayo Clinic,” after which he “flew back from Mayo in a diaper and
in no mood for laughs.”
Diagnosis was made after Frank Bascome “happened to notice
some dried blood driblets at about pecker height on my bedsheets”. He went
to see his GP, who diagnosed:
 rostatitis. Your gland feels a little smooshy. Slightly enlarged. Not
P
unusual for your age. Nothing some good gherkina jerkina wouldn’t
clear up. […] Your PSA’s up because of the inflammation. I’ll put
you on some atomic-mycin…
However, his PSA is not coming down and his GP tells him:
“I’ll send you around the corner to my good friend Dr Peplum over
at Urology Partners, and he’ll get you in for a sonogram and maybe
a small biopsy.”

146
  o they do small ones? My lower parts gripped their side walls.
D
Biopsy! […] A biopsy. For cancer? My heart was stilled. I was
fully dressed, the office was freezing in spite of the warping New
Jersey heat, and silent in spite of the outside bangety-bangety […]
This near-silent, for-all-the-world unremarkable moment, I knew
was the fabled moment. Things new and different and interestingly
possibly were afoot. Changes could ensue. Certain things taken for
granted maybe couldn’t be anymore.
 opkins and Sloan Kettering were first-rate, but the real brain-
H
trust treasure trove was Mayo in Rochester. This came from computer
rankings, from a book she’d read overnight and from a Harvard
friend whose father was at Hopkins but liked Mayo and could prob-
ably get us in in a jiffy.
It is an easy-to-read book, often very funny, criticising and
joking with virtually all aspects of American life. Bascome’s prostate
cancer is made fun of or ridiculed, and you never get the impression
that it affects his life in any major way. The first symptom is uncom-
mon for prostate cancer. It is, in my opinion, not a true portrait of
a man with newly diagnosed and treated prostate cancer.
ii. Exit Ghost (2007) by Philip Roth
We meet Nathan Zuckerman, 71 years old. Eleven years
earlier he was diagnosed with prostate cancer and had a radical
prostatectomy in Boston. He now comes to New York because of
impotence and incontinence.
 here are no references to any threat of metastasis. He is most likely
T
cured.
[…] to see a urologist at Mount Sinai Hospital who specialized
in performing a procedure to help the thousands of men like me left
incontinent by prostate surgery [because I] never truly have become
accustomed to wearing the special undergarments and changing the
pads and dealing with the ‘accidents’, any more than I had mastered
the underlying humiliation […] there I was in the reception area of
the urology department of Mount Sinai Hospital, about to be assured
that with the permanent adherence of the collagen to the neck of the

147
 bladder I had a chance of exerting somewhat more control over my
urine flow than an infant.
 he doctor himself expected a considerable improvement, not exclud-
T
ing the possibility of the injection’s restoring close to complete bladder
control. On occasion the collagen ‘travelled’, he explained […].
 he procedure the next morning took fifteen minutes. So simple! A
T
wonder! Medical magic!
 he incontinence was wholly unaffected by the collagen treatment
T
[…] I lowered my trousers to learn whether the procedure had begun
to work. To blot out what I saw I shut my eyes, and to blot out what
I felt I cursed aloud. ‘A fucking dream!’ by which I meant the dream
of being suddenly like anyone else.
In the country there was nothing tempting my hope. I had made
peace with my hope. But when I came to New York, in only hours
New York did what it does to people – awakened the possibilities.
Hope breaks out.
[…] my heart pounded away with lunatic eagerness, as if the
medical procedure to remedy incontinence had something to do with
reversing impotence, which of course it did not –though, however
sexually disabled, however sexually unpracticed I was after eleven
years away, the drive excited by meeting Jamie had madly reasserted
itself as the animating force. As though in the presence of this young
woman there was hope.
 hen I set out for West 71st Street, yielded immediately to the
T
ruthlessness of a desperate infatuation guaranteed to be anything
but harmless to a man bearing between his legs a spigot of wrin-
kled flesh where once he’d had the fully functioning sexual organ,
complete with bladder sphincter control, of a robust adult male. The
once rigid instrument of procreation was now like the end of a pipe
you see sticking out of a field somewhere, a meaningless piece of pipe
that spurts and gushes intermittently, spitting forth water to no end,
until a day arrives when somebody remembers to give the valve the
extra turn that shuts the damn sluice down.

148
So, nothing is resolved and Zuckerman returns to the countryside.
 ll that happened is that things almost happened, yet I returned as
A
though from some massive happening. I attempted nothing really, for
a few days just stood there, replete with frustration, buffeted by the
merciless encounter between the no-longers and the not-yets. That
was humbling enough.
This book is of a better literary quality than the book by Ford. It is
the sensitive picture of a man frustrated by the consequences from
radical prostatectomy, retained libido and aging.
iii. Intoxicated by my illness (1992) by Anatole Broyard
The American literary critic and novelist, Anatole Broyard,
is diagnosed with metastatic prostate cancer and dies 14 months
later. He writes up to the end.
 hen you learn that your life is threatened, you can turn toward
W
this knowledge or away from it. I turned toward it […]. My friends
found me surprisingly cheerful […]. While I’ve always had trouble
concentrating, I now feel as concentrated as a diamond or microchip
[…]. Illness is primarily a drama, and it should be possible to enjoy
it as well as to suffer it. I see now why the Romantics were so fond
of illness – the sick man sees everything as metaphor. In this phase
I’m infatuated with my cancer. It stinks of revelation […]. Being
ill and dying is largely, to a great degree, a matter of style […].
Adopting a style for your illness is another way of meeting it on your
own grounds, of making it a mere character in your narrative […].
It’s important to stay in love with yourself. […] You mustn’t sur-
render to illness.[…] At the end you’re posing for eternity. It’s your
last picture. Don’t be carried into death. Leap into it.[…]
 nxiety is the cancer patient’s worst enemy. It reminds me of a
A
catheter, which all prostate cancer patients require at some point.
Anxiety is like a catheter inserted in your soul.
iv. The patient examines the doctor (1992) by Anatole Broyard
This essay is a sequel of the previous.
Now that I know that I have cancer of the prostate, the lymph nodes,

149
 and part of my skeleton, what do I want in a doctor? I would say
that I want one who is a close reader of illness and a good critic of
medicine […] not only a talented physician, but a bit of metaphysi-
cian, too. Someone who can treat body and soul. […] To get to my
body, my doctor has to get to my character. He has to go through my
soul. He doesn’t only have to go through my anus.
 e should be able to imagine the aloneness of the critically ill, a
H
solitude as haunting as a Chirico painting. I want him to be my
Virgil, leading me through my purgatory or inferno, pointing out
the sights as we go […].
I just wish he would brood on my situation for perhaps 5 minutes,
that he would give me his whole mind just once, be bonded with me
for a brief space, survey my soul as well as my flesh, to get at my
illness, for each man is ill in his own way. I think that the doctor
can keep his technical posture and still move into the human arena
[…].
I would also like a doctor who enjoyed me. I want to be a good
story for him, to give him some of my art in exchange for his […].
A doctor’s job would be much more interesting and satisfying if he
simply let himself plunge into the patient, if he could lose his own
fear of falling […].
The doctor is the patient’s only familiar in a foreign country.
These two essays by Anatole Broyard try to mobilize the
human resources within us when we are facing death. In The Patient
examines the Doctor, the medical profession is advised in how to
approach the patient. Advice that we unfortunately often tend to
forget or ignore. There are numerous physicians, the number of
doctors is less.
There are two other books on prostate cancer. Tote Hose:
Worüber Männer schweigen. Ein Tagebuch. in German by Walter
Raaflaub (2007), and L’Ablation in French by Tahar Ben Jelloun
(2014).

150
In the former book, the author is the patient, and in the French
book, the author describes a good friend. Both undergo radical pros-
tatectomy and suffer from impotence and incontinence.
Urology in Literature: Bladder cancer
i. In The Face of Death (Diktate über Sterben und Tod)
(1984) by Peter Noll
The 55-year old professor Peter Noll from Zurich is both the
patient and the author. The book is basically a diary with entries up
to a few days before his death due to invasive bladder cancer.
We learn that he has noticed haematuria and sees professor
Ernst J. Zingg at the University Department. IVP shows a big blad-
der tumour and soon there are symptoms of upper tract obstruction.
This was obviously a bladder cancer T2/T3. The treatment of choice
in 1981 was radical cystectomy. However, the patient refused, as
the operation would leave him “diminished and mutilated”.
The diary, which covers 10 months, has several references
to the increasingly severe symptoms of locally-advanced bladder
cancer.
However, what is most striking is his passionless way of dis-
cussing his personal life and imminent death. This is an intellectual
who is summing up, or “dying like an expert”, as the literary critic
Bruce Bawer describes it.
I am dictating these thoughts not so much to seek my own solace as
to portray dying and death as an event imposed on us all, but one
that can truly be overcome. […]
 e are in need of a reformation of dying and death […] Since we
W
live with death, we ought also think of it while living.
There are few or no signs of despair and anxiety. Dying and death
seem mostly to be an intellectual affair. His stand shows a willpower
that is, I believe, far beyond the capacity of most human beings.

151
The book also includes an epitaph written by his friend, the Swiss
novelist Max Frisch: “Peter Noll died free, not afraid of knowing
what he knows, and expecting the same from us.” That statement
is difficult for most of us.
Urology in Literature: Physical and psychological impotence
i. The sun also rises (1926) by Ernest Hemingway
Jake Barnes, an American living in Paris, has sustained an
injury during the WW1 at the Italian front. At the very beginning
of the book he picks up a prostitute.
S he cuddled against me and I put my arm around her. She looked
up to be kissed. She touched me with one hand and I put her hand
away. ‘Never mind’. ‘What’s the matter? You sick?’ ‘Yes’.
 ndressing , I looked at myself in the mirror of the big armoire beside
U
the bed […] Of all the ways to be wounded, I suppose it was funny.
An Italian liaison officer had told him in the hospital:
 ou, a foreigner, have given more than your life […]. Che mala
Y
fortuna! Che mala fortuna!
He had fallen in love with Brett.
I suppose she only wanted what she couldn’t have. - Our lips were
tight together […] there’s not a damn thing we could do.I started
to think about Brett […]. Then all of a sudden I started to cry.
Jake goes to Pamplona with friends, including Brett, for the Fiesta.
There is drinking, fighting within the group, and of course the bull
fights. His friends knows about his condition. “I’ll make you tell
me – he stepped forward – you damned pimp.”
 h, Jake, Brett said, we could have had such a damned good time
O
together. Ahead was a mounted policeman in khaki directing traffic.
He raised his baton. The car slowed suddenly pressing Brett against
me. Yes, I said, Isn’t it pretty to think so?

152
The sustained damage is a traumatic penile amputation, but with
intact testicles. There are numerous analyses of the book, of Barnes’
repressed sexual feelings, the possibility of phantom sensations, etc.
The baton can be seen as a phallic symbol.
Hemingway writes: “his testicles were intact and not dam-
aged. Thus he was capable of all normal feelings as a man but inca-
pable of consummating them.” And in a letter to Scott Fitzgerald
he insisted that he should have the publisher to change the title to:
The Sun Also Rises (Like Your Cock If You Have One) for the next edition.
ii. In Country (1985) by Bobbie Ann Mason
A 17-year old Kentucky girl, who lost her father in the
Vietnam War, tries to come to terms with the loss. Her best friends
are her uncle Emmett and Tom, the man she loves. They have also
been to Vietnam.
It seems to me like some vets I could name are afraid of women.
‘Women weren’t over there’, Emmet snapped. ‘So they can’t really
understand’.
‘This is embarrassing,’ he said, lying back with his hands across his
eyes. Her hand below his waist. She felt a pair of kittens. He didn’t
even have an erection […].
‘Here I’m on fire, but there ain’t nothing I can do about it’ […].
Did you get hurt down there too?’ she asked. ‘Is that what’s wrong?’
- ‘No. It’s just in my head. Like a brick wall […]. Well, my mind
gets in the way. It takes me where I don’t want to go. I thought it
would be different with you, but it’s not.’
Common causes of psychological sexual dysfunction are depression,
anxiety and different types of stress disorders. Studies have shown
that individuals who have undergone severe traumatic experiences,
like veterans, have an increased prevalence of sexual dysfunction,
especially ED and decreased sexual desire.4
4. Bentsen I.L. et al., Sex Med Rev., 3: 78-87, 2015.

153
Urology in Literature: Lower urinary tract infection
i. The Green Mile (1996) by Stephen King
In 1932 Paul Edgecomb is a block supervisor of the Cold
Mountain Penitentiary death row, called The Green Mile. He suf-
fers from recurrent UTI; STD is denied. He does not want to go to
his doctor, as he will be prescribed sulfa, which makes him throw
up. One of the prisoners is John Coffey, a huge black man, sen-
tenced to death for raping and murdering two white girls, a crime
he never committed. John possesses inexplicable healing abilities.
I t was the fall I had the worst urinary infection of my life, not bad
enough to put me in the hospital myself, but almost bad enough for
me to wish I was dead every time I took a leak. […] trying not to
scream while my prick was reporting that it apparently been doused
with coal-oil and then set afire.
He has increased frequency and is running a fever.
It felt like my urine had been filled with tiny slivers of broken
glass. The smell coming up from the toilet bowl was swampy and
unpleasant, and I could see white stuff – pus I guess – floating on
the surface of the water.
He goes into the cell of John Coffey.
 hat do you want, John Coffey? I asked […] ’Just to help,’ he said
W
[…] then put his hand down in my crotch, on that shelf of bone a
foot or so below the navel. ‘Hey’! I cried. ‘Get your goddam hand – ‘
A jolt slammed through me then, a big painless whack of something.
It made me jerk on the cot and bow my back […]. Then it was
over. So was my urinary infection. Both the heat and the miserable
throbbing pain were gone from my crotch, and the fever was likewise
gone from my head.
The book is an example of magical realism writing, as are many of
King’s books. Accurately described UTI. However, sulfa was not
available in 1932. Prontosil was introduced a few years later.

154
Urology in Literature: Stone disease
i. Straight Man (1997) by Richard Russo
Hank Devereaux is the middle-aged temporary chair of
the English department at an American college in this novel by
the American author Richard Russo. We follow Hank’s somewhat
chaotic life during a few days with economic and personal problems
within the department. He is married, but half in love with another
woman, and has strained relations with his daughter and his father.
He suddenly develops poor urinary stream and increased frequency:
a slow faucet drip - I spend a lot of time with my dick outside my fly
these days - Still, I would trade it all for a good pee - This morning
it took me a half hour to fill a thimble with urine, barely enough
to do a urinalysis.[…] and I feel the weight of my backed up urine
pressing down hard on my groin.
He has no episode of colic, but believes from the start that
he is suffering from a urinary tract stone, a disease that also had tor-
mented his father and grandfather. He seeks his GP, Dr. Watson,
who is also a good friend of his, and X-ray is performed. No stone
is found. The diagnoses discussed are enlarged prostate, prostate
cancer and “hysterical prostate”. With regard to the latter it says:
 ccording to Watson, who I suspect may have invented this condition
A
to entertain me and explain my otherwise inexplicable symptoms, it’s
a rare circumstance that is in part physical and in part psychologi-
cal, induced by stress, aided and abetted by antihistamines […].
However, Hank is correct:
 or with the first blast of urine against porcelain I’d heard a dis-
F
tinct plink, as of a small pebble on china, evidence, it seemed to me,
that I had been right all along. I had just passed a stone. Watson,
a man not easily taken in by poetry, merely smiled and reminded me
this simply could not be, that it would be impossible to pass through
a human ureter a stone large enough to make an audible plink.
Further, a stone that large would have caused considerable bleeding

155
 before, during, and after the event, and I had experienced none. […]
I am again peeing freely, regularly, and without discomfort.
Funny, witty and satirical about American college life. The main
character’s symptoms fit with a stone stuck at the bladder neck or
in the urethra. His doctor’s urological knowledge seems inadequate.
Urology in music
Ten pieces for wind quintet (1968) by György Ligeti
György Ligeti (1923-2006) was one of the forefront figures in
avant-garde music during the second half of the 20th century.
During the 1960’s, he was a guest professor for composition at the
Royal Swedish Academy of Music in Stockholm.
During those years, he had to undergo cystoscopy, that was still
performed with a rigid scope and urethral anaesthesia. This hap-
pened while he was composing Ten pieces for wind quintet (1968).
Piece no. 9 is a one-minute long piece with the tempo marking sos-
tenuto, and the added word stridente, which means piercing sound.
Ligeti has described the procedure as scary and painful, feeling a
kind of pain that he associated with a very high pitch, something
he then tried to reproduce in this piece of music (based on personal
communication with his son Lukas Ligeti).
Why does it hurt when I pee? (1969) by Frank Zappa
This song describes gonorrhoeal urethritis, a consequence of Joe’s
meeting with a taco stand lady. Written and performed earlier, the
song appears in Zappa’s record Joe’s Garage from 1979.
Urology in art
 enken ist interessanter als Wissen, aber nicht als Anschauen -
D
W. Goethe (“Thinking is more interesting than knowing, but not
than watching.”)
Art history knows numerous examples of men and women
peeing, a natural act performed multiple times daily. I would like to

156
Figure 2: Circumcision by Jackson Pollock (1946). Oil on canvas 142 x 168 cm. Permission
by The Salomon R. Guggenheim Foundation, Peggy Guggenheim Collection, 1976.
76.2553.145

recommend the comprehensive and beautifully illustrated book For

this Relief, Much Thanks! Peeing in Art by Johan Mattelaer, published
by the EAU in 2018. Here follow some examples in which urologi-
cal conditions or procedures have inspired artists in modern times.
The first successful organ transplantation in man by Joel Babb
(Fig. 1): This painting by the American artist Joel Babb shows the
first successful kidney transplantation, in Boston on December 23,
1954. In order to depict both the donor nephrectomy, performed
by Dr Hartwell Harrison, and the transplantation, performed
by Dr Joseph Murray, later a Nobel Prize laureate, the artist has
choreographed the scene to include both events. And so, in the
background we see the donor nephrectomy and in the foreground

157
 Figure 3:
Circumcision by
Sergej Jensen, 2016.
Acrylic on canvas.
110 x 100 cm.
Courtesy S. Jensen.

Figure 4: Untitled
by Richard Prince
(1993). Acrylic and
silkscreen on canvas
147 x 121 cm.
Courtesy R Prince.

158
Figure 5: <M132/826-Bladder_cancer, light_micrograph_SPL.jpg> by Damien Hirst (2006).
Silkscreen and household glass on acrylic polyester with glass and blades. 171 x 120 cm.
© Damien Hirst and Science Ltd. All rights reserved, DACS/Bildupphovsrätt i Sverige 2018.
Image courtesy Arken Museum, Copenhagen

159
 the transplantation. At the doorway
to the right we can see Dr Harrison.
The work, with its irregularities and
the persons involved are described by
Desai et al. in the American Journal of
Transplantation.5
Circumcision by Jackson Pollock
(Fig. 2): This magnificent paint-
ing from 1946, just before Pollock’s
famous “drip period” started, shows
an underlying grid in horizontal and
vertical forms, some with totem-like
structures, with a centre where an
enhanced colouristic activity is pre-
sent. His wife, Lee Krasner, did not
see the painting until it was fin-
ished and then immediately suggested
the name “circumcision”, probably
Figure 6: Clear Cell Renal because of the structure in the right
Carcinoma by Jens Henricson upper corner.
(2012). Charcoal on paper
185 x 100 cm. Courtesy Circumcision by Sergej Jensen
J Henricson. (Fig. 3): This acrylic painting by the
young Danish artist Sergej Jensen is a
composite painting composed of three
different motifs. To the left, a circumcision that seems to be based
on a Middle Age painting probably with an underlying religious
message.
In the middle follows a rune stone that has been identified
as the Tjängvide stone from Gotland, Sweden. On this rune, the
eight-legged horse Sleipner carries the god Odin in the Nordic
mythology.
Finally, on the right, the artist himself appears as a punk in
front of the Copenhagen department store Illum. What does the

5. Desai SP et al., Am J Transplant., 7: 1683-1688, 2007.

160
artist want to tell us? In the past, the gods of Nordic mythology
were worshipped, followed by Christianity. Today: commercialism?
Untitled by Richard Prince (Fig. 4): Richard Prince, a con-
temporary American artist known for his re-photographies, nurse
paintings and paintings examining different subcultural American
issues, also produced what has been called joke paintings. Figure 4
offers such an example. The text runs:
 man’s watch breaks. He walks down a street and spots a store
A
with an enormous watch hanging in the window. The man behind
the counter tells him, ‘Sorry, I don’t fix watches, I perform circumci-
sions’. Circumcisions?’ cries the man with the broken watch. ‘Then
what’s with the large watch hanging in the window?’ ‘Mister,
what do you suggest I hang in the window?
The Biopsy Paintings by Damien Hirst (Fig. 5): Damien Hirst
has fascinated the art world for decades with his provoking works
on issues like life, death, religion, and art. Examples are his Biopsy
Paintings, most often showing cancer cells obtained from science
photo libraries, then inkjetted or silkscreen-printed onto canvases.
Then Hirst added paint, broken glass, scalpel blades, and other
items. Seen from a distance, the viewer is fascinated by the abstract

Figure 7: Radiation by
Robert Pope (1989).
Acrylic on canvas
76 x 102 cm. Courtesy
The Robert Pope
Foundation.

161
Figure 8: Les trois masques by Juan Gris (1923). Oil on canvas 65 x 100 cm.

Figure 9: Still life with checked

tablecloth by Juan Gris (1915). Oil
and graphite on canvas 116 x 89
cm. Metropolitan Museum of Art,
New York.

Figure 10. Detail from Fig 9.

162
beautiful surface, but may be repelled by the shocking content on
closer view when reality is appearing. “I think I’ve got an obsession
with death, but I think it’s like a celebration of life, rather than
something morbid. You can’t have one without the other.”6
Clear Cell Renal Carcinoma by Jens Henricson (Fig. 6): When
the Swedish artist Jens Henricson was a teenager, his mother
underwent left radical nephrectomy due to renal carcinoma in
Lund. Drawing on a histopathology slide of the surgical specimen,
he has made a large charcoal on paper. He has described the work
as reflecting his mourning process, and a way of remembering and
meeting his mother. She died a few years after surgery, not a sur-
prising outcome seeing the tumour thrombus in a pararenal vessel/
vascular space in the specimen.
Radiation by Robert Pope (Fig. 7): The Canadian painter
Robert Pope became well known for his social realist paintings,
paintings from the healthcare and writings on disease and death. At
an early age, he got Hodgkin’s disease to which he succumbed 10
years later. The painting Radiation is an emotionally powerful work
of art. The underlying type of malignancy is of minor importance.
The inhuman meeting between the patient, solitary and lonesome,
and the medical technology, is further reinforced by the cross. It is
a painting depicting the vulnerable situation of the diseased cancer
patient.
Les trois masques by Juan Gris (Fig. 8): Juan Gris, perhaps the
most brilliant of the cubist painters, suffered from uraemia towards
the end of his life. His paintings also changed and, instead of the
colourful earlier works (see Fig. 9), his palette became dull and
sombre as seen in Figure 8. Philip Sandblom, former Professor of
Surgery in Lund, art collector and author of the book Creativity and
Disease, which has seen many editions, suggests that the change in
Gris’s way of using the colours might have been due to his urae-
mia.7

6. Damien Hirst, cited in an interview with Gordon Burns, The Guardian, October 6, 2001.
7. Sandblom P., Creativity and Disease: How Illness affects Literature, Art and Music, 3rd ed, Marion Boyars
Publishers, London, 1999.

163
 Still life with checked tablecloth by Juan Gris (Figs. 9 and 10):
This is an example of Juan Gris at the top of his career. It was
bought by the Metropolitan Museum of Art in New York for a
record $56.8 million in 2014. Strong colours and an intriguing
composition make it a masterpiece. There are grapes, a bull’s head
and a bottle with the letters “e”, “a”, and “u” visible. What do they
stand for? They do fit into words Beaujolais and taureau.
It is of considerable interest to note the resemblance to the logo of
the EAU!
Conclusion
An important part of the work of urologists, as well as other
healthcare providers, is to establish a relationship with the patient
that is professional, yet also human with understanding and empa-
thy as major parts. It is my belief that exposure to literature and art
can contribute to an increased understanding of human reactions
and needs.
In his book Illness and Healing, Images of Cancer,8 Robert Pope
describes his life, disease and treatment and manages to have a posi-
tive outlook on future, despite a grim prognosis. He writes:
 rt is powerful preventive medicine. Looking at a picture is like
A
walking through an endless series of doors, with each succeeding door
leading us deeper and deeper into a rich experience. This journey
stimulates our minds, our emotions, our souls; it makes us more alive.
Ultimately the aesthetic experience heals us and makes us whole.
The book is now used in various medical schools in Canada and
elsewhere in Medical Humanities Program. This subject has become
an important part in most medical schools, aiming at preparing the
medical student not only for handling the patient’s disease, but also
for meeting the patient as a human being.

8. Pope R. Illness and Healing, Images of Cancer, Robert Pope Foundation, Hantsport, Nova Scotia, 1991.

164
Correspondence to:
Wiking Månsson
Tullgatan 1A
223 54 Lund
Sweden
wiking.mansson@med.lu.se

165
Figure 1: This frontispiece was reprinted in the Acta Sanctorum (July vol. 5 [1727], 401)
to illustrate the observation that St. Liborius is often depicted with a book on which rest a
number of “calculi” or passed stones. The text below the saint is a prayer entitled Oratio
contra calculum, “A Prayer Against Calculus.”

166
 Saint Liborius: Healer of Urinary Stones

Johan J. Mattelaer
Urologist in Kortrijk, Belgium. Senior member of the EAU History Office.

He said to the Israelites, “In the future when your descendants ask their
parents, ‘What do these stones mean?’” Joshua 4:21
Altough surgeons and barber surgeons were able to per-
form operations for bladder stones, and even medical doctors with
a university diploma could prescribe some spasmolitics to help to
patients with renal colics, most patients did not have the budget
nor the opportunity to access them. The only hope for relief of their
disease was praying for help from above!
As, until modern times, effective medical help was not avail-
able, people chose special saints for help in a specific disease. In
Western Europe the saint that was invoked for help in patients with
renal, ureteral and bladder stones, was Saint Liborius.
Why saint Liborius was worshipped for stones is not known.
The first document invoking Liborius for renal stones was com-
municated in 1267 in a document when Archbishop Werner von
Mainz, who visited Paderborn, invoked Liborius to be liberated
from his renal colics. In seventeenth-century Siena it was said that
Liborius himself was a stone patient, but that was never proved.
In 1976 H. Sparwasser suggested to name him even the patron of
urologists!1
The papal nuncio Fabio Chigi, who later became Pope
Alexander VII (1599-1667) and played an important role in the
Peace of Münster in 1648, was said to have been cured from renal
stones by the advocacy of St. Liborius.

1. Sparwasser H., und S., Liborius, Schutzpatron der Urologen?, Der Urologe B., 16, 148-150, 1976.

167
Figure 2: Saint Liborius. Oil painting in the St. Walburga church in Bruges, Belgium.

168
 The Acta Sanctorum has accounts of a number of specific cures
of this affliction credited to Liborius, as well as poems and epigrams
celebrating the effectiveness of his intercession against it. His attrib-
ute is a book with several “calculi” or passed stones on it, as in most
depictions. As an alternative, the calculi on a plate are held by a
woman or angel.2 (Fig. 1)
The painting of Saint Liborius in Bruges
On one occasion, I discovered a painting of Saint Liborius
(Fig. 2) in the vestry of the Saint Walburga Church in Bruges. A
bishop with a book in his right hand with five big bladder stones
on the cover. As a urologist I was attracted by this painting and
became curious around this Saint and his role in the healing of blad-
der stones.
The oil painting in Bruges is situated just behind the door
between the church and the vestry of the Saint Walburga church
in Bruges. It measures 109 x 93 cm. It was painted in 1780 (?)
by an anonymous painter (Charles Janssens?). The only reference
we found is that in 1644 a new brotherhood of Saint Liborius was
founded in the parish of Saint Walburga.3
On the painting we see the portrait of Saint Liborius as a
bishop with staff and mitre. In his right hand he holds a missal book
or a bible with five bladder stones on it. Under the right hand is
mentioned: S.LIBORIUS.EP. (Saint Liborius episcopus).
Below we read a painted text in Old Dutch: BESONDEREN
PATROON VOOR DIE GHEQUOLLEN ZYN MET COLLYCK
ENDE GRAVEEL. DEN DAGH WORT GHEVIERT DEN
XXIII VII (‘Special Patron for these that are afflicted by colics and
gravel. The day is celebrated on XXIII VII’ -23 July)

2. Butler, Acta Sanctorum, III, 169-70, July vol. 5, 394-457, with a section at pp. 435-40 on cures of calculus
effected through the saint’s intercession, London, 1756-1759.
3. Columbanus [O.F.M.], ‘t bondelken van myrrhe besluitende seker oeffeninghe voor het vermaert en prince-
lyck Broederschap van de Seven Weeën der Heilige Moeder Gods Maria, Brugge, Breygel, 1644: het
nieuw broederschap van den H. Liborius inde vermaerde capelle van de H. Maghet ende opgeregt in de
parochiale kerke van de heylige Walburga.

169
 On top is painted a bible verse from Joshua 4,21: QUID
SIBI VOLUNT ISTI LAPIDES (What do these stones mean?) We
will see the same biblical verse in many other paintings, etches and
statures referring to renal, ureteral and bladder stones. In the bible
the stones refer to the miracle that God drained the Jordan to allow
his people to enter the promised land on their dry feet, but here
they relate to the advocacy against urological stones. The adoration
and worshipping of St. Liborius in 16th and 17th century Flanders
was not uncommon because also in Antwerp we find a reference to
a brotherhood of St. Liborius in 1711.4 Diercxsens noted5 that in
1711 a brotherhood was founded in the Keizerskapelle (Chapel of
the Emperor) in honour of Saint Liborius.
Saint Liborius, bishop of Le Mans.
Cenómanis, in Gállia, sancti Libórii, Epíscopi et Confessóris - At
Le Mans in France (Cenomanum was the Roman name for that city),
St. Liborius, Bishop and Confessor. This is today’s lapidary entry in
the Roman martyrology for St. Liborius, and in fact not much more
is known with certainty about his life than that he was ordained
bishop of this city in 348 and he died in 397. Tradition is that he was
the fourth bishop and a friend of Saint Martin of Tours. He fought
against the heresy of Arius (Arianism), the presbyter of Alexandria
who did not accept the dogma of the Holy Trinity. Liborius founded
many Christian churches and performed miracles during his lifetime.
In 836, 400 years later, Aldric, the bishop of Le Mans at
that time, consecrated an altar in the cathedral in honour of Saint
Liborius. But at the request of the emperor Ludwig the Pious (son
of Charlemagne) bishop Aldric decided to donate his relics to the
young diocese of Paderborn in Saxony. Paderborn, nowadays in the
state of North Rhine-Westphalia, was founded in 799 when Pope
St. Leo III stayed with Charlemagne at the source of the river Pader
for three months.
4. Lijst van Broederschapsdrukwerk, Kadoc Leuven, Antw EHC F 143173: Cort begryp van de regels ende
aflaeten van het nieuwe broederschap van den H. Liborius inde vermaerde capelle van de H. Maghet ende
Moeder Godts Maria in de Keyser-straat, door desselfen voorbidden by godt geholpen ofte verlost te sullen
worden, Antwerpen, Jouret, p.22., 1711
5. 
Diercxsens Joannes Carolus, Antverpia Christo Nascens et Crescens seu Acta Ecclesiam Antverpiensem
ejusque Apostolos ac Viros pietate...usque ad seculum XVIII (7 vols) Antverpiae (Antwerpen), Apud Ioannem
Henricum van Soest, 7 vols in-8°, 1773

170
 The whole body of Liborius (except his right arm, which
remained in Le Mans) was carried on May 1st, 836 in a solemn pro-
cession to Paderborn. Since then, the cult of St. Liborius has led to
an extraordinary devotion in Paderborn. (Figs. 3 & 4)
Saint Liborius and Paderborn
The feast of the translation of St. Liborius is still cel-
ebrated annually in Paderborn. (Fig. 5) Also, the strong relation-
ship between the dioceses of Le Mans and Paderborn exists until
today. The bishop of Le Mans regularly attends the festivities of St.
Liborius in Paderborn.
The traditional Liborifest in Paderborn originated in 1627
when a new shrine was made by Hans Krakos von Dringenberg.
After the relics had been robbed in 1622 by Duke Christian of
Brunswick in the Thirty Years’ War and recovered in 1626, the
duke melted the shrine down to coin Pfaffenfeindtaler (lit. ‘priests’ foe
thalers’, a satirical currency). Since 1627 the Liborifest is the main
event of the year in Paderborn.
In 2018 however, the episcopal chair of Le Mans was
vacant. That year, in addition to the diocesan administrator, Bishop
Pansard of Chartres and 13 other bishops from around the world,
Abbot Philippe Dupont OSB of Solesmes, which lies within the
diocese of Le Mans, were present. These festivities take place in the
week following the feast day.
On Saturday evening, the Triduum begins with Pontifical
Vespers in the Cathedral, at which the relics in their precious shrine
are elevated and exposed in the choir of the Cathedral. On Sunday
morning, Pontifical Mass is sung (Mozart, Coronation Mass) and the
Papal Blessing is imparted. Then the grand procession with the rel-
ics and the Blessed Sacrament leaves the Cathedral, makes a station
before the city hall and returns to the Cathedral.
After more Pontifical Masses on Monday (Haydn, Missa
S. Joannis de Deo) and Tuesday morning (Giovanni Croce, Missa
prima sexti toni), Tuesday afternoon another outdoor procession
with the relics takes place, after which they are again ‘buried’ in

171
Figure 3: Portrait of St. Liborius with inscription: ‘St. Liborius Episcopus Cenomanensis in
Gallia.’ Generalvicariat - archdiocese of Paderborn.

172
Figure 4: Detail of Figure 3.

Figure 5: Saint Liborius, relief in

the Trinity Chapel of Paderborn
Cathedral.

173
Figure 6: Procession with the holy relics of Saint Liborius entering the cathedral of Paderborn.

Figure 7: A flabellum
with peacock feathers is
always carried in front of
the shrine in procession
in Paderborn, and is put
behind the shrine while it
is exposed.

174
the Cathedral crypt. (Fig. 6) Pange lingua by Michael Haller is sung,
then part of the Te Deum of Charpentier. The festivities then go on
until the next Sunday; it is a huge celebration for the whole area,
with popular entertainment and more than a million visitors each
year.
Saint Liborius and the Peacock
In many representations Saint Liborius is accompanied by a
peacock. The oldest reference for this legend is found in 1702 by
Clementini d’Amelia from Umbria (Italy).6 The legend tells about
the transport of the relics of St. Liborius from Le Mans to Paderborn
in 836. During that transport a peacock is said to have flown in
front of the procession.
And “when the relics were accepted by the clerus on the Liboriberg,
the peacock stayed so long in the air till the festivity started in the cathedral.
At that moment he perched on the cathedral, but as soon the relics entered
the Dom he dropped dead to earth”.7 Because of this connection, a fla-
bellum with peacock feathers is always carried in front of the shrine
in procession in Paderborn, and is put behind the shrine while it is
exposed. (Fig. 7)
Saint Liborius and Music
A lot of hymns, music and songs were composed for Saint
Liborius. We reproduce only one of them with the sentence: Dass
nicht Griess und Nierenstein die Strafen unsere Sunden sein. (So that not
gravel and renal stone be the punishments of our sins).8 (Fig. 8)
Saint Liborius in Italy
In 1645 abbot Pellegrino Carleni from Amelia in Umbria
(Italy) participated in Münster at the Peace talks after the 30-years
war. At that time he presented heavy and severe renal colics and a

6. Stambolis Barbara, Libori, das Kirchen- und Volksfest in Paderborn. Eine Studie zu Entwicklung und Wandel
historischer Festkultur, p.20, Münster, 1996
7.  Quoted by: Conrad Mertens: Der heilige Liborius, sein Leben, seine Verehrung und seine Reliquien.
Paderborn 1873: Als die Reliquien vor der Stadt auf dem Liboriberg vom Klerus in Empfang genommen
wurden, hielt der Pfau so lange in der Luft inne, bis der feierliche Einzug in den Dom begann. Alsdann erhob
er sich wieder und setzte sich auf die Kathedrale. Sobald die Domkirche betreten war, fiel der Pfau tot zur
Erde.
8. Maréchal F., Urologie en Muziek, Liber Amicorum Prof. Dr. W.A. Moonen, Nijmegen, 1985.

175
 Translation:

You great Shepherd and Man of God

Liborius, call to halt, so that not gravel, renal stone
be the punishments of our sins.
You Light in the crowd of confessors
save us by your help
and bring us after completed struggle
the real Joy of Heaven!

Figure 8: Hymn to Saint Liborius to protect from renal, ureteral and bladder stones.

176
Capuchin monk recommended him to invoke Saint Liborius. The
colics stopped suddenly and he spontaneously evacuated several
stones. Abbot Carleni asked the Bishop in Paderborn for some rel-
ics to bring to Italy and he obtained two pieces (a fragment of
Liborius’s tibia and of the skull) on June 9th 1646. Capuchin father
Bona Ventura brought them to Amelia in Italy where they arrived
on 15th March 1647.
Abbot Carleni ordered to the printing of a special text to
commemorate the transfer of the relics. (Fig. 9) On the etching
we can see bishop Saint Liborius with six stones on a closed book,
and on either side a scroll with prayers to free the body from renal
stones. Underneath the depiction of Saint Liborius is the act of
transfer of the two relics (de cujus sacro corpore duae partes, una Tibiae,
altera Cranei), dated June 9th 1646.
In 1753 another memorial tablet was installed in the church
of Amelia but during the 1900 restoration of the church, the
numerous votives of Saint Liborius were lost. Today the church still
contains a painting from a German painter from the 17th century
with Liborius holding a big stone in his right hand, which he has
picked up from a book held by a kneeling angel. In the cathedral is
also a silver torso of Liborius from 1771 with the relic holder with
his two bones.
On September 28th 1665 the collegiate church of Saint
Celsus and Julianus in Rome also obtained a relic bone from
Paderborn. The same happened with another bone relic, that was
sent to the church of Saint Jacob in Como on September 11th
1662.
In 1658 an anonymous person who was healed from his renal
stones by Saint Liborius donated a painting of him to the church of
St. John in Conca in Milano, but the church was demolished and
the painting is lost.
Near Bologna we can find several paintings of statues of St.
Liborius. One is in the Basilica di Santa Maria dei Servi by Giuseppe
Maria Crespi and his son Luigi, but does not feature any stones.

177
178
< Figure 9: Abbot Pellegrino Carleni ordered a print to be made to commemorate the
transportation of the relics from Paderborn to Amelia. On the etching we can see bishop
Saint Liborius with six stones on a closed book, and on either side a scroll with prayers
to free the body from renal stones. Underneath the depiction of Saint Liborius is the act of
transfer of the two relics (de cujus sacro corpore duae partes, una Tibiae, altera Cranei),
dated June 9th 1646.

Figure 10: In the

façade of the church
in Colorno we see in a
niche on the left side a
statue of St. Liborius.

Figure 11: On the

island Elba is a capella
San Liborio with a
fresco of Saint Liborius
inside the chapel.

179
 Figure 12: A splendid
oil painting on canvas
by Gaetano Gondolfi
(1734-1802), a painter
from Bologna. Private
collection.

Figure 13: St. Liborius

carved on a door in
the Chiesa dei Santi
Marcellino di Festo in
Naples.

180
Another one was in the abbey of Monteveglio till 1962 but has
disappeared since.
A last interesting church concerning St. Liborius is the
ecclesia San Liborio in Colorno, 15 kilometres north of Parma. The
story is interesting because it was the second last duke of Parma,
Francesco Farnese (1678-1727) who suffered from heavy renal col-
ics and established at the improved Sanseverino castle an oratorio
committed to St. Liborius. Later on the duchy went to the Spanish
family Bourbon and Don Ferdinando (1751-1802), who was very
religious. They enlarged the oratorio in a church and collected a
reliquiarium that contained 81 relics. One of them was a fragment
of the cranium of St. Liborius from Paderborn. Don Ferdinando,
alias Ferdinand Maria von Bourbon, was a member of the brother-
hood of Saint Liberius, that still exists.
In the façade of the church in Colorno we see in a niche at
the left side a statue of St. Liborius (Fig. 10) and inside the church
is a splendid painting of a preaching Liborius by Gaetano Callani
(1736-1809) but again without stones. But in the sacristy we can
admire a beautiful painted and stitched towel with stones exposed
on a gold platter.
And even on the island Elba we can find a capella San Liborio
where we can see a fresco of Saint Liborius inside the chapel, but
without stones. (Fig. 11) We found also a splendid oil painting on
canvas by Bologna painter Gaetano Gondolfi (1734-1802), at an
online auction in 2018 that is now in a private collection. (Fig. 12)
At the fall meeting of the History Office of the EAU in
Naples in 2017, we had a joint-meeting with the Italian Society of
Urology on the history of Urology in the splendid Chiesa dei Santi
Marcellino. There, members of the History office could admire a
splendid carving of St. Liborius.9 (Fig. 13)
Saint Liborius in Germany
We have already mentioned that the most important pil-

9. Musiani U., Der Heilige Liborius in Italien, der Urologe [B], 25, p.45-51, 1985

181
Figure 14: In the church of St. Peter in Munich we can see a fresco by Johann Baptist
Zimmerman from 1753 where St. Liborius intercedes with the Virgin Mary and the child
Jesus for a woman in the lower left corner suffering from stones. Between that woman and
Liberius is a woman or angel holding a pan of calculi that have been passed.

182
grimage and worshipping of Saint Liborius is in Paderborn. But in
the church of St. Peter in Munich we can also see a fresco by Johann
Baptist Zimmerman from 1753.
On it, St. Liborius intercedes with the Virgin Mary and the
child Jesus for a woman suffering from this ailment, who lies in the
lower left corner. Between that woman and Liberius is a woman or
angel holding a pan of calculi that have been passed. As a bishop,
Liborius holds a crozier and wears a miter and cope. (Fig. 14)
On the right side of the main altar in the St. Mauritius and
Elisabeth in Halle-Mitte is also a neogothic statue of St. Liborius.
A very precious and beautiful lime wood carving by the famous
German woodcutter Tilman Riemenschneider (1460-1531) was
sold at an auction at Sotheby’s in 2013 and is now in a private col-
lection. (Fig. 15)
The most beautiful altar we can find in the Ulrichskapelle
of the Adelberg monastery near Göttingen, made by Niclaus
Weckmann in 1511. From left to right we can see the beautiful poly-
chrome wooden statues of Saint Ulrich (Volrich), Saint Claubilla, the
Holy Mary, Saint Catharina and Saint Liborius. (Fig. 16)
In the German-speaking Austria, the church of Maria
Himmelfahrt (Ascension Day) in Ollersbach is protected as a cul-
tural heritage monument and at the gate to the churchyard is an old
huge statue of St. Liborius, renovated in 1905. (Fig.17)
Saint Liborius in Spain and Portugal
Although St. Liborius was not very popular in Spain and its
colonies we found a San Liborio Obispo from the 18/19th century
from the Spanish school at an auction in Boston (USA) (Fig. 18) and
another one: San Liberio y la Virgen in the Museo Colonial in Bogota,
a big painting, measuring 170x176 cm. (Fig. 19)
In Portugal we can enjoy a beautiful sculpture of Liborius in
the Museo de São Roque in Lisboa. (Fig. 20)

183
Figure 15: A very precious and beautiful lime wood carving of St. Liborius by the famous
German woodcutter Tilman Riemenschneider (1460-1531)

184
 Figure 16: The
most beautiful altar
we can find in the
Ulrichskapelle of the
Adelberg monastery
near Göttingen,
made by Niclaus
Weckmann in 1511.
From left to right we
can see the beautiful
polychrome wooden
statues of saint
Ulrich (Volrich), Saint
Claubilla, the Holy
Mary, Saint Catharina
and Saint Liborius.

Figure 17: At the gate to the

churchyard of the church of
Maria Himmelfahrt (Ascension)
in Ollersbach, Austria, stands an
old huge statue of St. Liborius,
renovated in 1905.

185
Figure 18: San Liborio Obispo from the 18/19th century from the Spanish school. Private
collection.

186
Figure 19: San Liberio y la Virgen, painting in Figure 20: A beautiful sculpture of St.
the Museo Colonial in Bogota. Liborius in the Museo de São Roque
in Lisboa.

List of Saint Liborius in Belgium:

Living in Belgium, it is easy to give a more detailed list of
statues and paintings of Saint Liborius.
- S ilver relic holder of St. Liborius, Cloister Witte Paters, Antwerp
- Silver relic bust of St. Liborius, by Jan Baptist Buysens,
1701-1702,Cloister Witte Paters, Antwerp
- Polychrome wooden relic bust by Hubert Franciscus, 1811,
Cloister Witte Paters, Antwerp
- Silver piece on a book by an anonymous silver smith, 1701-1750,
Cloister Witte Paters, Antwerp
- Painting (158 x 88 cm) St. Jacob church, Ghent, 18th century,
by an anonymous painter

187
- A ltar St. Liborius, St. Jacob church Ghent
- Wooden statue of St. Liborius, St. Peter church, Ghent, 2nd half
18th century, anonymous
- Wooden statue of St. Liborius, 127 cm, 18th century, by
Aloïs Hoevenaers. Church of St. John Evangelist, Beguinage,
Hoogstraten
- Polychrome, wooden statue of St. Liborius, 1696, by Nicolas Van
der Veken, church of St. John Baptist and Evangelist, Mechelen
- Painted, wooden statue of St. Liborius, by an anonymous sculptor,
19th century, Church of St. Denijs, Roborst.
Conclusion
As a result of the discovery of a painting of Saint Liborius
in Bruges, we explored his notoriety in the treatment for urological
stones. We were amazed that he is still worshipped and present in so
many European churches. Although incomplete, we described a lot
of representations of Saint Liborius as they can still be seen to day.
Some of his relics, statues and paintings are very precious.
The good news is that for the 100th anniversary of the
department of Urology at the Semmelweiss University in Budapest,
Dr. Peter Nyiradi is renovating the small, but interesting museum
of Urology. In the main hall will be a statue of Saint Liborius!
Correspondence to:
Dr. J.J. Mattelaer
Albijn van den Abeelaan 12
8500 Kortrijk – Belgium
johan.mattelaer@skynet.be

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 Complete Index Of De Historia Urologiae
Europaeae Volumes 1-26
The complete list of volumes of De Historia Urologiae
Europaeae and their contents can be found on UROsource.com, the
EAU’s digital library. Search UROsource for ‘Historia Index’ for a
comprehensive and up-to-date overview of all volumes.

191
 2019
ISBN/EAN 9789492671080
Printed by GLD Grafimedia
Arnhem, the Netherlands
© EAU History Office

For extra copies of this series:

History Office EAU
P.O. Box 30016
6803 AA Arnhem
The Netherlands

Front cover:
Mythical scene that shows the gestation of Zhou Chumaquic, who will give
birth to the Hero Twins. A lord of the underworld points at her with his
phallic-looking nose in allusion to her mysterious conception.

Text correction:
Loek Keizer

No part of this publication may be reproduced, stored in a retrieval

system, or transmitted by any means, electronic, mechanical or photocopying
without written permission from the copyright holder.

192
 Historia Urologiae Europaeae series is
addressed to all European urologists. Its aim is
to make known the ideas and the work of our
predecessors, and to help us understand the cur-

DE HISTORIA UROLOGIAE EUROPAEAE 26

rent trends in the development of our speciality.
Unfortunately, the treatises written in Sanskrit,
ancient Chinese, Greek and Latin are both dif-
ficult to find and difficult to understand, and
should, therefore, be translated into English. The
same applies to more recent books published in
various languages.

Most of the treatises produced before

the 17th century, even the legendary ones, have
gaps, mistakes and inconsistencies. Modern
scientific research allows us to re-evaluate this
ancient knowledge and examine it from new
perspectives. The History Office of the EAU in
collaboration with internationally based urolo-
gists, historians, philologists and other experts,
conducts research, accumulates and shares this
fascinating information in their annual publica-
tion, Historia Urologiae Europaeae.

“Remember the days of old, consider the

years of many generations, ask thy father, and he
will shew thee; thy elders, and they will tell thee.”
(Deuteronomy 32:7)

DE HISTORIA
UROLOGIAE EUROPAEAE
volume 26 edited by philip van kerrebroeck
European Association of Urology and dirk schultheiss
2019