Historical Highlights of Erectile and Sexual Dysfunction An Illustrated Chronology

Introduction

This short introductory chapter is to give very selected impressions on some historical milestones from the field of erectile and sexual function and dysfunction. These highlights are arranged in chronological order and are not including the developments of the most recent years.

The idea for this article was born by the author and Prof. Alain Jardin - both members of the Historical Committee of the European Association of Urology (EAU) - during the 2nd International Consultation held in Paris. The concept was immediately supported by the board of the consultation.

Every reader who is familiar with the history of sexual medicine will realize that many dates and names have not been mentioned in this brief overview. So hopefully, the 3rd International Consultation will come up with an extended and complete research of all fields and aspects of the history of sexual medicine and not only a collection of selected spotlights.

Prehistoric Period

An early wall painting in the caves of Lasceaux, France, from the Late Stone Age (left) already depicts a man with an erect penis positioned beside a bison. Hunting as well as human reproduction were elemental tasks for prehistoric men and the basis for the survival of mankind. Both aspects are united in this painting as well as in a similar hunting scene from a Neolithic rock painting from Mongolia (right).

Pharaonic Egypt

Ithyphallic depictions – like that of the god Min in the Temple of Luxor (left) - are frequently found in ancient Egyptian culture as the erect penis was a sign of good fortune and masculine strength. Prescription 663 of the famous Papyrus Ebers (right) offers a variety of remedies for the cure of male impotence. Other passages of this Papyrus also address several contraceptive recipes for women

Ancient Greece

Square columns with the head of a man and an erect phallus – called “Herms” (left) - were set up besides roads, public places or at private houses to provide protection from robbery or other evil events. During the famous fertility festivals, named after the god Dionysos, large erected penises were exhibited and played a major role (right).

Greek Medical Literature

In “De aere aquis et locis” Hippocrates (5th-4th century BC) (left) described the high incidence of impotence and infertility in the people of the Scythians and explained it by continuous perineal trauma due to excessive horse riding. Aristotle (384 till 322 B.C.) - like the other Greek authors - outlined the physiological concept of “pneuma” (= wind, air) as the initiator of erection (right).

Priapus

The Greek god Priapos – son of Dionysos and Aphrodite – was always depicted with a gigantic and erected phallus (left) and became also very popular in later Roman culture. Poets like Catullus, Horace or Martialis wrote obscene verses – the “Priapea” and the famous wall painting of the “phallus weigher” in the House of Vettii in Pompeii (right) most likely also represents Priapus.

Ithyphallic Depictions In Other Cultures

Many cultures used ithyphallic symbols for fertility rites and other reasons. The antropomorphic terracotta vase (left) from the Mochica culture (Peru, 100 BC – 600 AD) depicts a priest with an exaggeratd phallus. The Swedish god Freyr (right) is represented with an erected penis in this small bronze figure (Sodermanland, 9th – 10th century AD)

Kama Sutra

The “Kama Sutra” (Aphorisms on Pleasure) is the earliest surviving example of a comprehensive love manual in the history of the world. It was compiled by the Indian scholar Vatsayana between 330 and 369 A.D. The descriptions of many lovemaking postures (illustrations shown here from 18th century) is only one aspect of the Kama Sutra besides the many psychological insights into the interactions and scenarios of love

Arab Medicine In The Middle Ages

In respect to sexual medicine the famous Avicenna (980-1037 A.D.) - also known as ABU ALI AL HUSAIN IBN ‘ABD ALLAH IBN-SINA or “Medicorum princeps” (Prince of Physicians) – was perhaps rather a philosopher than a physician. Although his notes on anatomy and physiology of the genital tract are full of errors he was a very subtle observer of human sexual behaviour, especially when writing about the difference between male and female orgasm.

Leonardo da Vinci

Leonardo da Vinci (1452-1519) – the great artist of the Renaissance - can not only be considered as the founder of modern medical illustration but is also the first author to describe the blood filling of the penis as the cause of erection. He drew this conclusion from his own observations in human corpses.

“Musculi Erectores”

Although the “Musculi erectores penis” (i.e. Mm. bulbospongiosi and ischicavernosi) had already been described by Galen in the 2nd century A.D., this knowledge was lost at the time of Costanzo Varolio (1543-1575), who re-discovered them and gave an astonishingly correct description of the mechanisms of erection.

Ambroise Pare

The book “De la generation de l.homme” (On the generation of man), written by the master of French Renaissance surgery Ambroise Pare (1510-1590) in 1573, constitutes a real guide to good sexual practices. In this book Pare described in very vivid language and with many details how to perform sexual intercourse to ensure the greatest chances of fertilization and how to diagnose pregnancy, how to follow pregnancy and finally how to conduct delivery.

The First Penile Prosthesis

Pare also suggested an “artificial penis” made of a wooden pipe or tube for patients after traumatic penile amputation in order to facilitate a proper micturition in the standing position. Although not intended for sexual activities one might call this device a 16th century “penile prosthesis” as per definition a prosthesis – in contrast to an implant - replaces the whole organ or part of the body.

Regnier De Graaf I

In his male book “Tractus de virorum organis generationi inservientibus, de clysteribus et de usu siphonis in anatomia“ (1668) the Dutch physician Regnier de Graaf (1641-1673) succeeded in causing an erection in a corpse by injecting water into the hypogastric artery. At that time a very meaningful example of experimental science.

Regnier De Graaf II

His book on the female genital organs “De mulierum organis generationi inservientibus“ (left) published four years later (1672) in many ways is astonishingly precise in explaining female sexual function and human reproduction. As to the function of the ovaries (right) the “Graafian follicles” were named after him.

Peyronie's Disease

Although the “Nodus penis“ had been described centuries before, Francois de LaPeyronie (1678-1747) gave the first extended clinical report on the disease named after him in his article “Sur quelques obstacles qui s’opposent a l’ejaculation naturelle de la semence“ (On some obstacles to the natural ejaculation of the semen) from 1743. In his opinion the plaque was predominantly caused by venereal diseases.

Spermatorrhce And Masturbation

Spermatorrhce and the involuntary loss of semen was an important aspect of the masturbation hysteria that coursed through western medicine following the publication, in 1758 of “De l’Onanisme, Dissertation sur les Maladies Produites par la Masturbation” (left) by the illustrious Swiss physician Simon Auguste David Tissot (1728-1797). A variety of preventive devices (right) and therapies emerged over the next 150 years.

John Hunter

The famous surgeon and anatomist John Hunter (1728-1793) from London is well-known for his contributions on venereal diseases, the prostate and urethral strictures. He also dedicated an interesting chapter on impotence in his book “ATreatise on the Venereal Disease” (1786) in which he clearly defined an impotence depending on the mind and an organic impotence as “from want of proper correspondence between the actions of the different organs”.

The Aging Male In 1813

The clinical features of this disorder have already been described adequately in the article “On the climacteric disease” from 1813 by Sir Henry Halford (1766-1844) from London. One of his statements is the following: “…I will venture to question, whether it be not, in truth, a disease rather than a mere declension of strength and decay of the natural powers.” Halford seems to be the first to connect the term “climacteric” with the symptoms observed in some men aged between 50 and 75 years.

Female Genital Mutilation In Victorian Times

Clitoridectomy, a part of female circumcision in many African and Eastern cultures, was also performed by certain doctors in Western society mainly in the 19th century in order to cure the serious consequences of masturbation in women. The main protagonist was the gynecologist Isaac Baker Brown (1812-1873) from London who started this procedure in 1859 and published his results in 47 patients in 1866. One year later he was dismissed from the fellowship of the Obstetrical Society of London.

First Neurophysiologic Experiments On Erection

In 1863 the German physiologist Conrad Eckhard (1822-1905) from Giessen published his results on animal experiments inducing penile erections by applying electrical stimulation at different levels of the nervous system. More detailed contributions were made by J.N. Langley and H.K. Anderson from England in the mid 1890’s.

Francesco Parona

In 1873 the Italian physician Francesco Parona (1842-1907) injected the varicous dorsal penile vein of an impotent young patient with hypertonic saline in order to cause sclerosis and by this reduce the excessive venous outflow (left). More then two decades after this first case report several American doctors started performing surgical dorsal vein ligation or resection as e.g. Frank Lydston in 1908 (right).

The Birth Of Androgen Therapy

The famous self-experiment of the French physiologist Charles Edouard Brown-Sequard (1817-1894) at the age of 72 years with several subcutaneous injections of a mixture of blood from the testicular veins, semen and juice extracted from crushed testicles of young and vigorous dogs and guinea pigs in 1889 was a first milestone of androgen therapy in the aging male although his “pharmaceutical” prescription must have been equivalent to a placebo.

The First Oral Drug For Erectile Dysfunction

In 1896 (left) the chemist Leopold Spiegel (1865-1927) from Berlin performed chemical characterization of yohimbine from the bark of the African yohimbe tree. He was well aware of the aphrodisiac effect that the bark was said to have in its country of origin and clinical application followed immediately in Europe. Spiegel patented his chemical discovery in the UK in 1900 (right).

Homosexuality And The “Third Gender”

Homosexuality, also addressed as the “Third Gender” in modern times (left, lay press publication against homosexuality from 1904), is documented in most cultures at all times but scientific interest in this issue only developed at the end of the 19th century. In 1897 the German sexologist Magnus Hirschfeld (1868-1935) founded the “Wissenschaftliche-humanitare Comitee” (scientific-humanitarian committee) dedicated to the study of homosexuality and edited a related yearbook (right).

Erectile Disorders And Psychoanalysis

Through the discovery and development of the psychoanalysis as an important psychotherapeutic school Sigmund Freud (1856-1939) from Vienna had great influence on sexual medicine. The essay with the remarkable title ”Uber die allgemeinste Erniedrigung des Liebeslebens” (The most prevalent form of degradation in erotic life) was published in 1912 and is one of the few publications in which Freud deals directly with male erection disorders.

Vacuum Devices For The Treatment Of Eerectile Dysfunction

The curative application of negative pressure to different parts of the body was well established in 19th century medicine (left). The American physician John King was the first to suggest a continuous and repeated application of a vacuum device to the penis for the cure of impotence in 1874. Finally, the Viennese physician Otto Lederer (1872-1944/45) made the significant improvement of adding a compression ring to the use of the vacuum device to facilitate an on-demand erection in 1913 (right); long before Geddings D. Osbon constructed his device in 1960.

Rejuvenation I

At the turn of the century the physiologist Eugen Steinach (1861-1944) from Vienna started animal experiments to study the sexual differentiation of the organism and the hormonal function of the gonads. Later he postulated that an increased hormonal production follows the cessation of the secretory output of the gonads after surgical ligation of the seminal ducts. In the 1920`s Steinach.s "autoplastic" treatment of aging., i.e. vasoligation, became very popular and was performed by many surgeons worldwide.

Rejuvenation II

At the beginning of the 20th century the transplantation or implantation of either human or animal testicular tissue was another appealing form of androgen therapy in hypogonadal and aging males. The most important protagonist in Europe during the 1920’s was the Russian Serge Voronoff (1866-1951) who worked in Paris and transplanted sliced monkey glands in hundreds of his patients who visited him from all over the world. According to his reports, hormonal secretion lasted for about one or two years and was then slowly decreasing due to fibrosis of the grafted tissue.

The Institute Of Sexology In Berlin

In 1919 Magnus Hirschfeld (left, 1868-1935) established the “Institut fur Sexualwissenschaften” (right) in Berlin. It was the first center of public information and education, treatment of patients and scientific research. Many scientist worked at the institute, e.g. Felix Abraham and Ludwig Levy-Lenz (transsexual surgery), Arthur Kronfeld (psychiatrist) and Bernhard Schapiro (first hormonal treatment of cryptorchidism). Due to the political circumstances Hirschfeld left Germany in 1930 and the institute was plundered and the library destroyed by the Nazis in 1933.

The Surgical Management Of Male-To-Female Transsexualism

In 1931 Felix Abraham (left), a physician at the Hirschfeld Institute in Berlin, published the first scientific report on two complete male-to-female transsexual operations including penectomy, orchiectomy, and the creation of a neovagina with a Thiersch’s graft (right). After the war in 1952 the American Christine Jorgensen underwent sex-change surgery in Denmark and although she was not the first patient this caused a sensational media circus and public awareness of transsexualism.

Surgical Treatment Of Erectile Dysfunction

Since the early 1930.s Oswald S. Lowsley (1884-1955) from New York was the main protagonist of surgical treatment for corporoveno-occlusive dysfunction. He combined simple dorsal vein plication with a surgically more advanced perineal crural technique in which he plicated the bulbocavernous and ischiocavernous muscles with several mattress sutures.

The First Penile Implant !

The first penile implant to facilitate an erection was used in a phalloplasty procedure performed by the Russian surgeon Nikolaj A. Bogaraz (1874-1952) in 1936. He used the patient.s rip cartilage and in later years he even performed this operation in patients with morphologic intact penis but suffering from erectile dysfunction.

The Kinsey Report

The biologist Alfred Charles Kinsey (1894-1956) from Bloomington, Indiana performed the the first epidemio- logic study on human sexuality collecting sexual histories from a large number of men and women, resulting in a final sample of around 18,000. The two volumes “Sexual Behavior in the Human Male” (1948) and “Sexual Behavior in the Human Female” (1953) are milestones in the literature on the anatomy, physiology and psychology of human sexuality.

Erectile Dysfunction Due To Arterial Vascular Occlusion

In 1948 the French surgeon Rene Leriche (1879-1955) firstly mentioned arterial vascular impotence in thrombotic obliteration of the aortic bifurcation, a syndrome he had already described in detail in the 1920’s and which today is named after him. During the following time several strategies were outlined to save or reconstruct the internal iliac artery during abdomino-pelvic vascular surgery to maintain or restore erectile function.

The G-Spot

The gynecologist Ernst Grafenberg (1881-1957) from Germany was a pioneer of intrauterine devices since the 1920’s favoring a ring of coiled silver wire (right). He emigrated to New York in 1940, where he finally published his milestone article on “The Role of Urethra in Female Orgasm” in 1950. The anatomical area described by Grafenberg was later named after him as the G-spot.

The Biochemical Basis Of Pde-5-Inhibitors

With his biochemical research, as outlined in the paper “Fractionation and characterization of a cyclic adenine ribonucleotide formed by tissue” from 1958, the American Earl W. Sutherland (1915-1974) discovered the physiological significance of cyclic nucleotides in the regulation of cell and tissue function. This basic knowledge – for which he was awarded the Nobel Prize in Medicine and Physiology in 1971 – was also fundamental for the understanding of the first effective oral treatment of ED at the end of the 20th century.

William H. Masters And Virginia E. Johnson: Practical Sex-Therapy

"There is no such entity as an uninvolved partner in a marriage contending with any form of sexual inadequacy." The therapeutic approaches used by Masters and Johnson are oriented towards therapy of the "marital-unit", i.e. the couple, with a strong component of exercising, rather than focussing on verbal aspects of therapy. “Human Sexual Inadequacy” from 1970 is one of their milestone publications.

Microsurgical Revascularization Of The Penis

In 1973 Vaclav Michal (left) from Prague reported the first microsurgical treatment of vascular ED by performing a direct anastomosis of the inferior epigastric artery to the corpus cavernosum (right). In the 1980’s further techniques were introduced by Michal himself, as well as by Ronald Virag from Paris and Dieter Hauri from Zurich.

Inflatable Penile Implants

The very breakthrough of penile implant surgery was initiated by F. Brantley Scott (left) from Houston, Texas, together with his colleagues William E. Bradley and Gerald W. Timm when they implanted the first silicone inflatable device (right) on February 2nd, 1973.

Intracavernous Injection Therapy For Erectile Dysfunction

The French vascular surgeon Ronald Virag (left) from Paris discovered the proerectile effect of the vasoactive drug papaverine when injected into the corpus cavernosum in 1982 (right). The injection of phenoxybenzamine was suggested by Giles S. Brindley from London the following year and Adrian W. Zorgniotti from New York introduced drug combination of papaverine and phentolamine in 1985

References

The material and information in this article is mainly taken from:

1. Mattelaer J.J. The Phallus in Art & Culture. EAU Historical Committee, Arnhem
2. Schultheiss D., Musitelli S., Stief C.G., Jonas U. Classical Writings on Erectile Dysfunction. ABW-Wissenschaftsverlag, Berlin

Correspondence: Dirk Schultheiss, M.D. Chairman, Historical Committee of the European Association of Urology (EAU), Department of Urology and Pediatric Urology, Hannover Medical School