“Partial Paralysis from Reflex Irritation, Caused by Congenital Phimosis and Adherent Prepuce” (1870), by Lewis Albert Sayre

Editor's note: The following article contains historical descriptions of medical procedures performed on children's genitals and other behavior that would be considered unethical and abusive by contemporary standards.

In 1870, Lewis Albert Sayre, an orthopedic surgeon, published “Partial Paralysis from Reflex Irritation, Caused by Congenital Phimosis and Adherent Prepuce,” hereafter “Partial Paralysis,” in the journal Transactions of the American Medical Association. In the article, Sayre describes using circumcision, or surgical removal of the prepuce, or foreskin, of the penis, to treat muscle paralysis in several young male patients. While circumcision has a long history as a religious and cultural practice, “Partial Paralysis” was one of the first articles to articulate a medical reason for performing circumcision. Sayre reports that each of his patients were experiencing muscle paralysis or hip joint pain and also had phimosis, a condition in which the foreskin tightly encases head of the penis, or adherent prepuce, a condition in which the foreskin fuses to the head of the penis. Suspecting a connection between the conditions, Sayre circumcised each patient and concluded that circumcision cured the boys’ medical problems. While doctors no longer use circumcision to treat muscle paralysis or hip pain, the medical justification for circumcision that Sayre articulates in “Partial Paralysis” helped to popularize its use among physicians at the end of the nineteenth century in the US.

Background and Context

At the time he wrote “Partial Paralysis,” Sayre was Professor and Chair of Orthopedic Surgery at Bellevue Medical Hospital in New York City, New York, as well as a member of the American Medical Association, or AMA, the professional organization that published the journal in which Sayre’s article appeared. He served as Vice President of the AMA in 1867 and as President in 1880. At the time of the article’s publication, Sayre had been practicing medicine for nearly thirty years, having graduated from medical school in 1842. He was a specialist in orthopedic surgery. Orthopedics is the branch of medicine that deals with problems of the bones, muscles, and joints. According to articles by his descendant James Sayre, a pediatric physician, and Pakdee Rojanasopondist, a medical researcher, Sayre was well known both in the US and internationally for honing a surgical procedure to remove the diseased head of the femur bone in patients with hip-joint disease, as well as for pioneering other, non-surgical treatments for musculoskeletal diseases.

As of 2026, doctors no longer recognize a connection between the foreskin of the penis and muscle paralysis, but at the time of publication, medical beliefs and social norms supported the idea that circumcision could treat such musculoskeletal disorders. According to David Gollaher, author of the book Circumcision: A History of the World’s Most Controversial Surgery, one can better understand Sayre’s rationale for linking genital irritation to muscle paralysis by understanding the then-popular notion of reflex neurosis, also called reflex irritation. That is the idea that nerves interconnect all organs of the body and that chronic irritation in one organ can cause dysfunction in another. Many scientists around the turn of the twentieth century subscribed to the notion. In fact, it was the basis for a variety of gynecological surgeries, including the removal of the uterus, or hysterectomy, and removal of the clitoris, or clitoridectomy, that doctors performed on women at the time in to treat psychological disturbances like hysteria. With the rise of the germ theory of disease at the end of the nineteenth century, the idea of reflex irritation as an explanation of disease and disorders lost credibility, but until then, it underpinned Sayre’s ideas about circumcision, as well as the ideas of those who agreed with him.

Prior to “Partial Paralysis,” other physicians had recommended and performed circumcision to prevent what they considered to be diseases, but Sayre’s paper offered a new medical rationale for the procedure, and his stature within the field increased the likelihood that people follow his medical opinion. For example, doctors in England and the US in the early part of the nineteenth century sometimes recommended and performed circumcision as a way to discourage masturbation, which many within medical science at the time believed could lead to insanity. But in those cases, circumcision was not a treatment for disease, rather, it was a way to prevent it. Later, in 1845, Edward H. Dixon, who practiced medicine in New York City in the mid-nineteenth century, did advocate circumcision as a treatment for a range of diseases in his book A Treatise on Disease of the Sexual System. But, according to Frederick Hodges, a medical historian who studies the history of circumcision, the medical establishment largely ignored Dixon’s recommendations. In 1865, a surgeon in London, England, named Nathaniel Heckford published a pamphlet titled Circumcision as a Remedial Measure in Certain Cases of Epilepsy, Chorea, etc. In that pamphlet, Heckford argued that circumcision was an effective treatment for epilepsy and other convulsive disorders. Heckford viewed masturbation as the instigating cause of those convulsion disorders, rather than phimosis. Not until Sayre’s article of 1870 did circumcision finally catch on in the US as a treatment for diseases of the nervous system based on the concept of an inciting cause located in the foreskin.

Article Roadmap

“Partial Paralysis” is a series of clinical case reports detailing Sayre’s use of circumcision in six young male patients. Case reports were then, and still are as of 2026, a common way for doctors to share their clinical experiences with other doctors. They often do not have the standard sections one might find in a research study, such as Methods and Results, and instead take a more narrative approach. They are also often shorter than research articles. Sayre’s case report is eight pages long.

“Partial Paralysis” contains six case reports for each of Sayre’s patients. While Sayre does not divide “Partial Paralysis” into defined sections, he does organize the narrative sequentially by case, and he groups related cases together. First, in a description of his experience with his first three patients, he explains that he used circumcision to treat individuals with leg muscle paralysis because he concluded that their paralysis was the result of nervous exhaustion stemming from chronic irritation of the penis due to phimosis or adherent prepuce. He reports that the treatment was successful at restoring muscle function in all three patients. Next, Sayre describes that after treating those three patients, he decided to use circumcision to treat three additional patients who had injured their hip joint and experienced repeated falls. Sayre suspected that the falls were due to partial paralysis of the legs muscles resulting from chronic irritation of the penis. He states the circumcision worked to alleviate the paralysis in each of those cases as well. Finally, he concludes by saying that he wrote “Partial Paralysis” to draw attention to an underappreciated cause of distress in young boys and highlight circumcision as its treatment.

“Partial Paralysis” begins with Sayre’s discussion of young boy with leg paralysis who he learned about from his colleague James Marion Sims, a physician who practiced gynecology in the US in the late nineteenth century. Sayre reports that Sims’s patient, a five-year-old boy, was having trouble standing and walking. He explains that the boy’s knees appeared stuck in a flexed position at a forty-five-degree angle. Sayre states that Sims believed the boy to be suffering from uncontrolled muscle contraction and wanted Sayre to perform a tenotomy, or a procedure in which Sayre would sever the tendons in the boy’s legs. But when Sayre examined the boy, he found that he could extend the boy’s legs with ease and, therefore, suspected that the problem was not uncontrolled muscle contraction but, rather, paralysis of the leg muscles.

To determine the source of the boy’s paralysis, Sayre reports that he performed a test in which he applied an electric current to the boy’s muscles to test his reflexes, and in the process, he discovered that the boy had phimosis. The boy’s longtime nurse who was present at the examination alerted Sayre to the state of the boy’s penis, which she said was very sore and sensitive. Sayre examined the boy’s penis and found the boy’s foreskin tightly enclosed the head, or glans, of the penis, and the opening of the urethra was irritated. Sayre reports that the boy’s penis was so sensitive that touching the opening of the urethra caused the boy to convulse. 

Having documented the boy’s phimosis, Sayre then explains how he came to the conclusion that circumcision might help treat the boy’s paralysis. He notes that what he terms excess venery, or sexual overindulgence, can sometimes cause nervous exhaustion, leading to paralysis. He therefore suspected that a similar sort of nervous exhaustion, caused by an irritated penis with a non-retractable foreskin, was the cause of the boy’s paralysis. Removing the foreskin through circumcision, Sayre concluded, would therefore calm the nervous exhaustion and relieve the paralysis.

Sayre next details the process of performing a circumcision and discusses the positive effects he witnessed. He reports that his medical team first anesthetized the boy with chloroform. Then, Sayre and his medical team stretched out the foreskin and cut a portion off with scissors. The foreskin is a double layer of tissue. In adults, the foreskin is typically easily retractable and glides smoothly over glans. In infants and young boys, however, the inner layer of the foreskin is fused to the glans and is not yet retractable. Thus, when Sayre cut the foreskin, the outer layer of the foreskin retracted, but the inner portion remained adhered to the glans, a condition Sayre terms adherent prepuce. Sayre used his fingers to physically tear the inner foreskin from the glans. Once he had freed the inner foreskin, he split it down the middle, folded it backwards on itself, then sutured it to the cut edge of the outer foreskin with a needle and thread. He then covered the penis with a well-oiled linen rag and applied cold water. Sayre reports that within two weeks, the wound had healed, and the section of foreskin that remained was freely mobile, able to glide back and forth over the glans. Almost two months after the circumcision, Sayre reports, the boy was able to walk alone with his legs straight, indicating that the procedure had cured his paralysis.

Sayre’s second case was a fourteen-year-old boy who had been suffering from leg muscle paralysis for more than a year, and he performed circumcision to treat his condition for that patient as well. Sayre states that the boy suffered from chronic, painful erections. Sayre reports that when he examined the boy’s penis, he found the foreskin was tightly constricted around the head. Sayre explains that he performed a circumcision and noted that, once again, the procedure had a beneficial result. Within six weeks, according to Sayre, the boy was walking normally.

Sayre next reports his experience and resulting circumcision with a third case, a fifteen-year-old boy with numbness and weakness in the legs. Sayre explains that the third patient reported having frequent, painful erections. He also had frequent nocturnal emissions. In addition, Sayre reports that the boy had trouble urinating. Quite often, Sayre related, urine would fill up causing the end of his penis to swell before exiting out the small orifice of the constricted foreskin. Sayre circumcised that boy, too, and reported that his numbness and weakness went away within six weeks.

The rest of “Partial Paralysis” concerns three young boys, age seven, nine, and thirteen, who all suffered from an injured hip joint, and Sayre circumcised all three boys to treat their pain. In the three boys’ cases, however, Sayre explains that he could determine no obvious cause for the damaged hip joint. He reports that while examining the thirteen-year-old boy’s hip, his thumb came into contact with the boy’s penis, which became erect. Sayre notes that the boy’s foreskin was very long. He states that the appearance of the boy’s genitals made him wonder whether the boy had experienced any loss of muscular power in his legs, similar to his previous patients. He therefore asked the father about it, who reported that his son was often very clumsy and tended to fall down a lot. Sayre states that he surmised that those repeated stumbles and falls were the cause of the hip injury, and further, that the clumsiness was the result of partial paralysis of the legs caused by irritation of the boy’s genitals. Sayre reports that he examined the other two boys with an injured hip joint and found that they, too, had a history of stumbling and falling as well as irritated genitals owing to phimosis. He therefore decided to operate on the foreskin of each of the boys to separate the foreskin from the glans, and the procedure quieted the boys’ nervous irritability, according to Sayre.

In the final three paragraphs of the article, Sayre tells his readers that his experience with the six boys led him to conclude that many cases of irritable children with restless sleep and digestive problems result from irritation of the nervous system, which in turn results from an adherent or constricted foreskin.

Impact and Legacy

Though the practice of using circumcision to treat disease did not originate with Sayre, his article “Partial Paralysis” provided a new medical justification for it, one that caught the attention of his peers. Leonard Glick, a historian who studied anthropology and author of Marked in Your Flesh: Circumcision from Ancient Judea to Modern America, credits “Partial Paralysis” with introducing the cure of paralysis as an entirely new medical rationale for circumcision. Gollaher argues that Sayre’s stature within the profession also meant that his views carried significant weight among doctors. As the previous Vice President and later President of the AMA, Sayre was well known in medical circles. He also taught many medical students as a professor at Bellevue Hospital Medical College.

Sayre continued to build on his work in “Partial Paralysis,” and for three decades, until his death in 1900, Sayre promoted the benefits of circumcision in various speeches and papers. In 1875, five years after the publication of “Partial Paralysis," Sayre gave another talk before the AMA entitled “Spinal Anaemia with Partial Paralysis and Want of Coordination, From Irritation of the Genital Organs,” which the AMA published in the Transactions of the American Medical Association later that year. In it, Sayre recounts the impact that his 1870 article had on the profession. He states that he received letters from all around the US, as well as from some of the most distinguished surgeons of Europe, thanking him for his contribution. In that same speech, he recounts many more cases of treating paralysis with genital surgeries, including on girls. During the discussion of Sayre’s 1870 paper, also recorded in the printed article, one doctor states that Sayre’s 1870 article, “Partial Paralysis,” will rank among the most important in the whole range of surgical science. In 1888, at a meeting of the ninth international medical congress, the President of that organization stated that no one had done more than Sayre to disseminate knowledge about the many ailments, including paralysis, epilepsy, and insanity, caused by phimosis and adherent prepuce through reflex action.

Like many ideas in the history of medicine, Sayre’s notion about genital irritation as a cause of nervous disease, and circumcision as a treatment to fix it, eventually fell out of favor. By the end of the nineteenth century, some doctors were beginning to criticize his ideas in print. An 1895 report by physician Edwin Walker, of Evansville, Indiana, in the Journal of the American Medical Association is a case in point. He states that the idea of reflex irritation is an error and a fad, one that gained traction mainly through the authority of those promoting it. Walker credits Sayre with bringing the idea of reflex irritation to his attention twenty years prior, but states that in the years since, he became disillusioned with the concept when the circumcisions he performed failed to cure a single case of epilepsy, insanity, catalepsy, hysteria, or any other disease.

Though the reasons for performing circumcision that Sayre articulates in “Partial Paralysis” eventually lost credibility, circumcision for medical purposes itself did not go out of fashion. In fact, the procedure only became more common in the decades that followed its publication. In part, that is because doctors found other reasons to perform the procedure. With the rise of the germ theory of disease at the end of the nineteenth century, for example, doctors increasingly viewed circumcision as a way to prevent, rather than simply treat, several conditions they thought were caused by germs, including sexually transmitted infections and cancer. Data suggesting that Jewish men, who typically receive circumcisions due to religious reasons, had lower incidences of both syphilis and penile cancer led some doctors to conclude that circumcision was the reason. More generally, many doctors and parents viewed circumcision as a way to ensure better hygiene and thereby protect young boys from diseases caused by germs lurking in dirt and other forms of filth.

Phimosis, the condition that Sayre argued was a source of reflex neurosis, continued to be a source of concern among doctors, even as reasons for that concern changed. Increasingly, doctors viewed a non-retractable foreskin in infants and young boys as itself a pathological condition in need of surgical treatment, even without evidence of other problems. Circumcision to correct so-called congenital phimosis became one of the most common reasons for performing the procedure on newborns and young boys in the early years of the twentieth century. That practice continued until the middle of the twentieth century, when scientists learned that essentially all newborns and boys up to about age five have a non-retractable foreskin. Congenital phimosis is, therefore, a misnomer, and surgery to correct the condition in infants and young boys is unwarranted. As of 2026, doctors strongly recommend that parents do not forcibly retract the foreskin of intact male infants and children, because doing so could harm the penis and create problems later in life. In cases where a tight foreskin makes retraction difficult in adolescents, doctors often recommend a topical steroid treatment as a safe alternative to surgery.

Today, as of 2026, doctors remain divided on whether routine infant circumcision has enough benefits to outweigh the risks of the procedure, with the division largely falling along national lines. Pediatric medical bodies in Europe and Canada do not endorse routine infant circumcision on the grounds that it is unnecessary, and the medical benefits do not outweigh potential procedural risks, while those in the US often state that there are benefits and that those outweigh the risks. According to the American Academy of Pediatrics, or AAP, those purported benefits include a lower risk of developing urinary tract infections in childhood, a lower risk of developing penile cancer, and a lower risk of contracting sexually transmitted diseases such as HIV. Many pediatric medical bodies in Europe and Canada contest the conclusions of the AAP.

As one of the first widely read medical articles promoting circumcision as a medical treatment, “Partial Paralysis” helped to popularize the procedure among doctors. For nearly thirty years, physicians in the US and England followed Sayre’s lead in using circumcision to treat muscle paralysis and other nervous disorders, including epilepsy. Those rationales for circumcision eventually became suspect, but the procedure itself only gained in popularity as a medical treatment in the coming decades.

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