Muskett and Littlejohn express Victorian foreskin fears

Dr Muskett offers helpful explanations of difficult medical terms, and avoids rude words like "penis", while Dr Littlejohn explains that tongue tie and phimosis are equally serious conditions in a newborn baby, requiring immediate surgery.

Philip Muskett: How the Australian climate demands circumcision (1903)

In the performance of circumcision the foreskin of the male organ is removed. This is the part which is medically known as the prepuce (pree'pews) . It owes its origin to the Latin, praeputium, the foreskin. The prepuce may be described as a kind of fleshy cuff which covers the end of the male organ. When the foreskin is unduly long, it gives rise to the condition having the medical name of phimosis (fi-mo'sis). The significance of this term will be better understood when it is explained that it comes from the Greek, phimosis, a muzzling or closure. As a matter of fact, many of these long foreskins cannot be drawn back so as to show the opening of the water pipe. The derivative meaning of phimosis – a muzzling or closure – is therefore very expressive. [1]

The front, rounded end of the male organ, which is covered by the foreskin, is called the glans. It is derived from the Latin, glans, an acorn, because of its fancied acorn shape. Behind the glans itself there is a collection of little cells which manufacture a whitish substance termed smegma (smeg'mah) – from the Greek, smegma, soap. When this material is allowed to remain undisturbed, it acquires a very unpleasant, even markedly offensive, odour. It is, moreover, particularly liable to accumulate under a long foreskin, and frequently produces considerable irritation of the parts.

A long foreskin may be troublesome in one of two ways.  The internal surface of the foreskin often grows to the top of the glans. When this has occurred, it will sometimes be possible to carefully peel back the prepuce. But the two parts may have so tightly grown together that this cannot be accomplished. In these circumstances the operation of circumcision is necessarily required, as it affords the only means by which the two adherent surfaces can be separated. [2]

In other instances, the orifice of the foreskin is exceedingly small. The opening may be so tiny that it will barely admit the end of a hair pin – after it has been made into a straight, long wire. A curious event often happens, when a foreskin has such an unusually small orifice. The urine, as it issues from the water pipe, cannot get away, but accumulates inside and distends the foreskin in a most remarkable manner. This is the so called "ballooning" of the foreskin. [3]

A long or tight foreskin is likely to be attended with many serious disadvantages. The parts under the prepuce often become irritated and inflamed from the accumulation of smegma and other retained products. Different disorders of the water pipe and bladder are also disposed to occur. There may be the ailment known as "wetting the bed". The straining in trying to pass water, occasioned by a long or tight foreskin, is liable to bring on rupture. The same condition of the prepuce predisposes to various nervous disorders. It is considered, likewise, that bad habits are frequently induced by boys meddling with themselves, in consequence of the irritation produced. Nor is it to be forgotten that an unnaturally tight foreskin may actually interfere with the proper growth and development of the organ.

In this semi-tropical Australian climate of ours, it would be infinitely better if circumcision were the rule and not the exception. Beside the Jewish race, many other eastern nations follow the practice. No male with a proper sense of cleanliness can feel that his bath has been complete, in the presence of a long or tight foreskin. Without the slightest exaggeration I may say that hundreds of male patients have told me how much they bitterly regretted that circumcision had not been performed on them, when  they were young. But never yet have I met with a single individual who was sorry that he had been circumcised. The operation is almost uniformly successful. It has its failures, at times, but they are, comparatively speaking, rare.

Philip Muskett (1903), The illustrated Australian medical guide (2 vols, Sydney: William Brooks, 2nd edn 1909), Vol. 1, pp. 219-20

NOTES

1.  Philip Muskett is an interesting character who had a lot of sensible things to say about food, clothing and lifestyle generally in the Australian climate, and he has been hailed by Michael Symons as an early prophet of modern Australian cuisine. His most general book, The art of living in Australia (1893), unites an attractive advocacy of outdoor eating, the consumption of fruit and the development of the wine industry, on the one hand, with some pretty bizarre medical advice on the other. He spends over a page discussing whether iced water is injurious to health and reports, in all seriousness, that "ice-water dyspepsia" has become "a definite malady" in the United States. I have not been able to find out much about Muskett, other than that he was senior resident medical officer at Sydney Hospital in the late nineteenth century. Considering his views on the importance of climate on lifestyle and the advisability of circumcision in hot conditions, I should not be surprised if he had been an army doctor in India at some stage.  See Michael Symons, One continuous picnic: A history of eating in Australia, 1982, Penguin 1984, pp. 259–60; Muskett, The art of living in Australia, reprinted by Kangaroo Press, 1987, p. 77

There is no entry for Muskett in the Australian Dictionary of Biography, nor in the Oxford Companion to Australian Literature, but the University of Adelaide has made his Art of living in Australia available as an e-text.

2.  If it is impossible to peel the foreskin from the glans, it is hard to see how it could be isolated for the purpose of amputation. In fact, the only situations in which the foreskin fuses to the glans are when it has been injured by premature forcible retraction, and the bleeding surfaces bind together, and/or when a clumsy circumcision has been performed, also leading to this result. See some ugly visual examples here.

3.  Many little boys go through a phase when their foreskin balloons out when they have a leak, and most boys find it very entertaining. In the early eighteenth century Pierre Dionis actually advised men with phimosis to pinch the foreskin shut while urinating and allow the liquid to stretch the foreskin and clean the inner surface. It has recently been shown that "ballooning" does not imply any obstruction or pathological condition and is certainly not an indication for circumcision. It is also common for boys in the seven to ten year age group to have competitions to see who can piss the furthest: it would be very cruel to deprive them of this harmless and simple entertainment.

Dr Littlejohn: Tongue-tie and phimosis the chief causes of breast-feeding problems (1907)

The nurse should always, in the case of a [newborn] male, examine the penis to see if the child is suffering from  phimosis. It is not at all uncommon to find that there is merely a pinhole opening in the prepuce, necessitating an early circumcision.

Now I must go into the matter of tongue-tie here, because I find that numbers of babies are sent to the out-patients by nurses, under the supposition that that they are suffering from tongue-tie, when as a mater of fact not one in six of them has any tongue tie at all. Hence he nurse should know how to examine a child's tongue to see if it is tied or not. The best way to do this is to place the child on its back on the bed, or on a table, and then place the tips of the fist and second fingers under the tip of the tongue, one on each side of the fraenum linguae, with the palm of the hand towards the child's face, and raise the tip of the tongue upwards. This procedure puts the fraenum linguae on he stretch, and if it stands out like a white band to any extent and holds down the tie of the tongue, then the child is suffering from tongue-tie to a sufficient extent to interfere with sucking, and it should be taken to a doctor to have it snipped.

Having examined the tongue and assured herself that it is not tied, the Nurse should next, if the child is male, examine the penis for phimosis. There is no more frequent cause of all sorts of troubles in young children than phimosis, and it is a very common cause of refusal to take the breast. The child takes a suck or two, then stops and cries, and obstinately refused to take any more; this is apparently because the taking of the breast causes a desire to micturate, and the child knows by experience that micturition causes him pain owing to the contracted orifice in the prepuce and adhesions between the prepuce and the glans, and he therefore refuses to take the breast, and holds his water frequently for 12 or even 24 hours. Hence it is that, what with increasing hunger and the discomfort of a distended bladder, the child cries and screams night and day, and there is no rest for mother or nurse.

I have frequently known this state of things to go on for days, until everybody was worn out, and the mother has at last consented to have the baby circumcised, when immediately he takes the breast freely for the first time, empties the bladder and sleeps all night, and so do the mother and the nurse, and all the trouble is at an end. Hence the nurse should always make a point of examining the child's penis, as it is very common to find only a pinhole orifice, and in rare case there may be no opening at all. In either of these cases circumcision should be performed without delay.

Then there are  cases in which, though the opening appears to be large enough to allow the child to pass water, yet the prepuce is firmly adherent to the glans and cannot be at all retracted, and the retained smegma praeputii becomes inspissated [1] and causes irritation. This condition often causes just as much trouble, and circumcision is just as necessary. Now I do not wish you to suppose that I am an advocate of universal circumcision. There are many cases in which the orifice in the prepuce is satisfactory, the child passes water freely, takes the breast freely, and there are no symptoms of irritation from adhesions or retained and inspissated smegma, and though the prepuce cannot be retracted thoroughly at first, as time goes on it will be possible to retract it more and more until retraction is complete, and the smegma can be cleared away. In these cases circumcision is not necessary. [2]

But I do say this, that if the orifice is so small as to prevent the possibility ultimately of complete retraction and clearing  away of retained smegma, the child should certainly be circumcised. For even if there is no immediate trouble with regard to passing water and taking the breast, there are various other troubles that frequently result subsequently. In the first place, owing to the adhesions and the contracted orifice, the child has to strain more or less in passing water, and the phimosis thus becomes a frequent cause of inguinal hernia. Many cases of inguinal hernia in young infants can be cured by performing a circumcision.

Then again, if  the prepuce cannot be retracted, the smegma praeputii accumulates and becomes inspissated, and is a source of constant irritation. Even in young infants I have found large, hard masses of inspissated smegma. The constant irritation results in enuresis and  constant erections, and later on in masturbation. Many cases of masturbation in young children have thus originated. In other cases various reflex nervous symptoms are produced, sometimes even epileptiform convulsions, and I have several times seen cases of paresis [paralysis] of the lower extremities so caused. A child of two or three and running about has entirely, to use the mother's expression, "lost the use of his legs", and the trouble has been quite cured by circumcision. Hence there are many strong reasons in favour of circumcision, and I do not know of a single one against it. [3]

Dr E.S. Littlejohn, "The management of babies: Lecture delivered to the Australasian Trained Nurses Association", Australasian Nurses Journal, Vol. 5, 16 September 1907, pp. 259-65

NOTES

1.  Inspissated was a favourite word of late Victorian and Edwardian medical men, who seem to have have sensed a profound affinity with it. The Shorter Oxford Dictionary defines inspissate as "to make thick or dense; esp. to reduce (a liquid) to a semi-solid consistency". From the Latin, spissus, meaning thick or dense.

2.  This was also the argument of (Sir) Frederic Truby King, the most influential authority on baby care in the period between the wars, who similarly stated that circumcision was necessary only if the foreskin could not be retracted within a week of the boy's birth. Since most foreskins are not retractable until much later, this policy actually meant a very high rate of circumcision. See discussion in A source of serious mischief, Part 3, and in McGrath and Young, History of circumcision in New Zealand.

3.  Dr Littlejohn's strictures against the evils of the adherent prepuce are drawn straight from Victorian medical dogma, and especially the mythology cooked up by the American orthopaedic surgeon Lewis Sayre. Further information on phimosis and the evolution of medical myths and knowledge about it available at CIRP.