Selected Passages from Schöberlein
Original German text

DR. MED. WERNER SCHÖBERLEIN
The Significance and Frequency of Phimosis and Smegma
Münchener Medizinische Wochenschrift 7. pages 373-377 (1966)
(translation R.Stuart)

Summary: 3000 young men, most of them between 18 and 22 years old, were medically examined. The relationship between the prepuce and the glans penis was examined and the frequency of smegma was recorded. In 8.5% no prepuce was present, among approximately half of these there had been no previous operation. A phimosis was determined among 8.8%. Smegma was found among 19.2%, including a 'large amount' among a 1/3. A comparison of the education and occupational groups of these young men revealed no difference in the frequency of uncleanliness. A hypospadie was found in 0.37%.

"Today cancer prevention is still a problem, however tomorrow the main concern will be the fight against cancer" (K. H. Baüer,1). Despite all progress with diagnostics and therapy, the percentage of deaths due to cancer constantly increases, from 13,5% (1935) to 20,04% (1961) (1). Part of cancer prevention concerns the recognition and elimination of cancerous materials. No more doubts exist about the cancerous effects of tobacco tar derivatives related to lung cancer (1, 39). Just as undisputed, but admittedly less known, is the cancerous effect of smegma (1, 3, 15, 19, 23, 24, 29, 33, 39).

Penis cancer is observed in Europe and North America in 1-3% of all male cases of cancer (1, 4, 6, 17, 19, 21).

In the USSR in recent years 0.5 to 1% of male cancer cases were registered as penis cancer (33). In North Vietnam 15.6%, in India up to 25.6% in China 15.8 to 18.3% and in Siam 22.0 to 33.0% of the male cases of cancer are penis cancer (1, 23, 33).

Thierch (1865) described the continuous friction of a phimosis as a cause of penis cancer and Czerny (1899) determined, that circumcision against penis cancer "immunised and encourages thorough cleanliness and removal of preputial secretions" (7, 37). Many authors later confirmed that penis cancer occurs practically only with phimosis (1, 6, 11, 17, 18, 20, 23, 31, 32, 38).

The observation that there is no penis cancer among the circumcised Jews is further proof of the causal connection between prepuce, smegma and penis cancer (1, 4, 21, 31).

The ever recurring idea that this concerns a Jewish race immunity (18), can be disproved by investigations in different countries and among other peoples. In India among 2260 cancer patients, penis cancer was found among uncircumcised Hindus in 25.6% cases, in contrast among the circumcised Muslims only 2.9% (25). Marchionini confirms this ratio for the Islamic population of Turkey (23). In 1964 it was reported in Kazachstan, that among 87 cases of penis cancer only 4 (4.6%) were found among the Muslims who circumcise at the age of 4 - 6 years, however they constitute 36% of the population. This difference can only be explained by circumcision. However the later this is performed, the smaller is the protection against the occurrence of penis cancer. Cancer has a characteristic time of latency even in this area (1, 33). Penis cancer, occurs at the average age of 54.5 years and is located 41% on the Glans, 32% on the inside of the prepuce and 25% at the sulcus coronarius of the glans (collum glandis: internally. Nomenclature, Paris, 1963) (21).

This fact is explained by a cancer stimulating agent within the preputial room: smegma, which is composed of degenerated fats, rubbed off and dead epithelial cells and not the secretion of any glands. Stieve could find glands neither on the surface of the glans nor on the inner foreskin. There are no tallow glands there (35). Smegma production occurs among newborns and reaches its high point during the teenage years (33).

The embryonic development of the prepuce begins in the 8th week as the epithelium sinks into connective tissue at the base of the glans. Thus a fold forms, which extends up until the 5th month as a fold of prepuce over the glans.

With the growth of this fold, the later epithelium of the glans and the inner foreskin remain together in a common layer, the glandarlamelle. Toward the end of the foetal life the central cells of this lamella begin to disintegrate. Cavities develop and unite forming a common preputial hollow area (9, 10) This procedure is only rarely completed at birth and it is unfounded to speak at this stage of anything being stuck or adhesions. For this condition the term "physiological phimosis" is particularly used by the pediatricians - coined by Winiwater 70 years ago - (13, 28). This expression is not completely harmless and should be avoided due to the danger of late recognition of a phimosis and problems increasing. The process under examination is the incomplete separation of the prepuce and the glans, which without active assistance can take place spontaneously up to the 6th month in 20%, up to the 12th. month in 50%, up to the 2nd year in 80% and to end of the 3rd year in 90% of boys (10). A phimosis with the marginal connective tissue narrowing the foreskin opening, should be recognised early and be operated as soon as possible.

The cancerous effects of smegma could be proven several times so far in studies on animals (5, 27).

Operationally created phimosis increased the frequency of experimentally produced penis cancer among Rabbits (33). The observations are interesting among horses, where due to the abundantly folding foreskin smegma is found in large quantities and penis cancer occurs particularly frequently, counting for 23% of all cancer illnesses in this animal species. Whales, among whom without erection the smegma is not emptied, become ill with penis cancer ten times more frequently than Studs (15).

Apart from other factors, the cancer encouraging agent smegma is responsible for cervical cancer among woman (1, 3, 11, 21, 39). Jewesses become substantially more rarely ill with cancer of the cervix than non-Jewish women; the relationship uterus to cervical cancer is among Jewesses 6:1, among non-Jewish women 1:8. This ratio is also confirmed in all countries where a proportion of the male population is circumcised (1).

"The smegma theory cannot be excluded as the cause of penis cancer among men, among women it is an important fact" (K. H. Farmer [1]).

To prevent the effect of this smegma which is recognised as so dangerous, in the USA for the last 15 years 80-90% of all male newborn children are circumcised straight after birth. Apart from episiotomy, which is likewise performed as a preventive measure, circumcision is the most frequent operation of the American birth aids (2l, 26). It is usually done with the "Gomco clamp", which in Germany has also proven to work satisfactorily as a safe and simply performed operation (14, 21).

From a personal report from Wynder (1965) the American insurance independently honour these preventive measures. The general introduction in Germany would fail due to this among other reasons, because for a long time other preventive measures demanded by the medical profession, for example a general Tetanus immunisation, has so far not been accepted by any health insurance companies .

In England 24% of the boys up to 4 years old, and at the same time 84% of Cambridge students were found to be without a prepuce. Physicians and midwives recommend circumcision there. Many Englishmen know the particularly impressive advantages of circumcision from the colonial times in India (16). In Germany the results of first experiences with routine circumcision were published in 1959 (14). 80% of the previously asked parents decided to give their permission for this operation, without knowing anything about the value and the meaning of this operation beforehand. Such open-mindedness was unexpected. The small operation with the Gomco Clamp did not result in any complications.

In Germany a statement from the medical profession has long been demanded on the question of the general ablatio praeputii among new born boys (16, 23, 30). The main argument against a general circumcision is stated again and again, that this problem can also be resolved by regular cleaning with soap and water (1, 7, 23, 33).

Own Investigations

In order to make an objective evaluation about this statement possible, 3000 young men were given a detailed medical examination of the penis, the prepuce, the glans, the sulcus coronarius and the foreskin's retractability. Whether "smegma" was present or even "a lot of smegma" was registered. The investigations were carried out by Dr. E. Moessmer, Specialist for Urology in Munich, whom I thank here for his assistance, and myself, each conducted half of the examinations in order to increase the objectivity. These were young men from Southern Germany. 2527 (84.2%) were of an age between 18-22 years; the exact breakdown of the age distribution is shown in tab. 1

Table 1
Age distribution

Age	17	18	19	20	21	22	23	24	25-28	29-33	34-38
Number	183	511	959	647	272	138	103	63	90	27	7	3000
%	6.1	17.,0	32	21.6	9.1	4.6	3.4	2.1	3.0	0.9	0.2	100

(Age 18-22 = 2527 = 84,2%)

In anatomical text books the relationship between the prepuce and glans is described as normal when the penis is not erect and the prepuce only partly covers the glans (2). The following 5 different forms of this relation prepuce : glans were specified by us:

A) Glans and sulcus coronarius lying exposed; prepuce missing or atrophic
B) Glans partly covered by prepuce.
C) Glans fully covered by prepuce. prepuce tube or trunk formed, extends partially. Sulcus coronarius can be completely revealed by retraction.
D) Glans covered completely by prepuce. Foreskin opening fibrous hardened, non-elastic; can be extended by retraction only to a few mm in diameter. Orificium urethrae and small front part of the glans can be seen. Revealing the sulcus coronarius not possible. Phimosis.
E) Prepuce covers glans completely. End of the foreskin opening is completely stiff, rigid. No retraction possible. Glans and orificium urethrae cannot be seen. Phimosis (rigid).

Results
The results are arranged in tab. 2

Table 2
Relationship of Prepuce to Glans and Incidence of Smegma.

	Number	%	Smegma (very much)	%
A . Glans and Sulcus free - lacking or atrophic	256	8.5
B . Glans partly free, partly covered	1258	41.9	149 (49)	11.8
C . Glans fully covered by prepuce, sulcus can be laid free	1223	40.8	297 (93)	24.3	Smegma in BCD=19,2%
D . Glans covered by foreskin Sulcus can not be revealed,	181	6.0	64 (32)	35.3
E . Phimosis rigid no retraction possible	82	2.8	-	-
	3000	100.0	510 (174)	17.0

Regarding group A, we found 256 (8,5%) of the examined to be without a prepuce. Among approximately one quarter of this group, reports or scars from a circumcision could be established. Among a proportion of these, the reports were questionable, the question of surgery was denied among approx. half the young men without prepuce, and no evidence of an operation could be found. In addition, among a large percent I received confirmation from the mother that no surgery had been performed on their son. There is no doubt, that the lack of, or atrophy of the foreskin occurs spontaneously among approx. 4% of young men.

We defined 1258 (41.9%) of the examined as "B" and found smegma among 149 (11.8%) of these; among approx.1/3 it was designated as "very much".

1223 (40.8%) of the 3000 examined were registered as "C". There were 297 (24.3%) with smegma and likewise among half "very much" was noted. In this group sometimes the long, tubular form of prepuce was found, which has also been called "pseudophimosis" (19). If the foreskin opening was elastic and retractable, this means the long foreskin was functional and presented no substantial obstacle to the possibilities of cleaning.

Due to the histological structure of the prepuce it is to be expected, that in the course of time in many of these "C" cases the relation of the glans to prepuce changes and develops into form "B". Both groups belong therefore together, particularly in view of the cleaning possibilities. It is clearly noticeable that the smegma frequency increases with the length of the prepuce (35).

Regarding form "D"; the phimosis with an inelastic, fibrous hardened preputial opening, where only with effort and under pressure small front parts of the glans show, we determined this form among 181 (6.0%) of the young men; 64 (35.3%) of whom had smegma, with half of these classified as "very much". The smegma here can only be partly removed; it is evidently present, but not always visible.

The condition "E"; the phimosis with a rigid, stiff preputial opening, without any possibility of expansion and where no glans or orificium urethrae can be seen, we found this among 82 (2,8%). In this group smegma is always present, objectively however not ascertainable. Therefore we registered this group separately to "D".

The phimosis (D + E) gives a total number of 263 = 8,8%. These are pathological conditions and should be eliminated operationally. Most of the subjects had not realised the unhealthiness of their condition. We advised them all to undertake the small operation and always found a thankful open-minded reception for the explanation. Also Haller (12) describes, that young men between 20 and 30 years frequently complain, that the operation was neglected in childhood.

In 1960 Saitmacher (29) studied 229 young men of an age between 15 and 17 years, and found 8.7% had phimosis. Gairdner (10) studied 200 uncircumcised boys between 5 and 13 year old and discovered a phimosis in 6%, and a foreskin which was only partially retractable among 14%. Otherwise substantially lower numbers for the frequency of the phimosis are indicated in the literature; thus Keil (16) quotes l% and Koester (19) only 0.5 to I%, however without indicating a source for this figure.

Smegma was found in our investigations among 19.2% of the groups B, C and D. Saitmacher (29) describes unceanliness of the preputial area in 33.2% of his 229 young men. Our young men were invited to the medical examination, thus some had surely washed themselves previously. When we include group E, among whom smegma production and accumulation are surely present, and consider the cleaning previous to an examination, a frequency of 30-35% smegma accumulation is no overestimation among young sexually mature men.

We determined a hypospadie among 11 of the 3.000 examined (0.37%). We saw no case of infant "adhesions", better called incomplete release of the foreskin.

It is often maintained, that genital hygiene is lacking, and general uncleanliness is found predominantly among the poorer or less educated sections of the population (19, 22). For this reason our 3000 young men were categorised according to their education (tab. 3) and their different occupational groups (tab. 4).

Table 3

Education	Number	%	Smegma	%
Folk school	1878	62,6	314	16,7
Middle school	534	17,8	94	17,6
High school graduates	588	19,6	102	17,3
	3000	100,0	510	17,0

Table 4

Occupation	Number	%	Smegma	%
1. unskilled assistants,	169	5,6	27	16,0
2. skilled workers, Craftsman.	1316	43,9	225	17,1
3. Employees, government officials, middle school without occupation,	927	30,9	156	16,8
4. high school graduates, Students	588	19,6	102	17,3
	3000	100,0	510	17,0

Both tables show, that neither the education nor the occupational group make any considerable difference in the frequency of uncleanliness (smegma). The social achievement levels examined by us do not correspond exactly to proportions in the general population. We had less unskilled workers and the percentage of high school graduates (19,6%) was nearly three times the proportion of the high school graduates (7,2%) of the resident population of the Federal Republic of 1964 among the same age group.

153 (5%) of the 3000 men were married, among these we found only 8,5% with smegma. It is doubtful, whether this is to be explained with greater cleanliness alone; regular cohabitation appears to help a form of cleaning.

Up until this time the necessity of regularly cleaning the preputial area as well as the dysfunctionality of phimosis was mostly unknown to the sufferers. During instruction about these questions the young men always showed themselves to be interested and open minded. There is insufficient sexual education of young men, especially about these problems, by the parents and by the school and house doctor. This is primarily due to a taboo, the people around him maintain distance, feeling embarrassed about instructing the boy on the subject of manipulation of the glans, and thereby perhaps arousing his sexuality prematurely. For decades such an education and instruction of young people has been demanded again and again. Our investigations show however a quite unsatisfactory picture.

By contrast, in view of the recognised danger of smegma, a general circumcision of all newborn children, as in the anglo-saxon countries, would mean a final and simple solution (4, 6, 14, 21). Apart from the advantages already described like:
a) prevention of penis cancer,
b) probable reduction of cervical cancer, also recognised are:
c) less venereal diseases (23),
d) improvement of the sexual physiology and psychology, by extension of the length of cohabitation among other aspects (8, 16, 23),
e) allegedly smaller frequency of prostate gland cancer (23),
f) avoidance of balanitis and balanoposthitis, e.g. with lack of water, during catastrophes, in the tropics or during war (21, 34).

Disadvantages are not known. The operation among newborn children using modern methods (Gomco clamp) is without danger and risk (14, 21, 29).

Whether and when the decision of the German medical profession will fall, regarding the already often repeated demand by respectable clinics recommending a routine circumcision, is uncertain (1, 14, 16, 19, 23, 29, 30). The purpose and intention of this work was the rare possibility, to systematically examine and report on such a large number of young men of sexually mature age in this subject afflicted with so many prejudices

In conclusion then again, without weakening the request for general circumcision, the urgent demand must be made for sexual education from the parents, teachers, house doctors, pediatricians, school and work doctors.

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Anschr. d. Verf.: Dr. med. W. Schöberlein, 8 München 27, Richard-Strauß- Str. 93.
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Selected Passages from Schöberlein
Original German text