penis,--that
which attacks the integument and that which attacks the glans. The
first of these varieties he observes as generally beginning as a
hardened nodule in the prepuce, which becomes at once more or less
thickened and indurated. He gives Lisfranc the credit of pointing out
the fact, that, even in the most hopeless-looking case, the glans and
body of the penis may be simply pushed back and compressed, but
otherwise sound, and that before resorting to an amputation of the whole
organ it is better to make a careful exploratory dissection in search of
the penis, as it oftentimes happens that the prepuce and integument can
be dissected off, leaving the organ intact. He also mentions that
elephantiasis of the penile integument generally begins in the prepuce.

Baron Boyer believed that the vitiated preputial secretion allowed to
remain beneath the prepuce was one of the causes of cancer of the penis,
observing that it would be interesting to know whether cancer of the
penis was a rarity among circumcised people, such as the Jews and
Mohammedans.[99]

It is easy to perceive why or how Agnew, Gross, Cullerier, and many of
those who have written on the subject, have failed to appreciate the
existence of the prepuce as an exciting cause, or as being, in the
majority of instances, the part primarily attacked. The nodule,
excoriation, or abrasion that develops into a cancer generally produces
more or less local disturbance; in many it produces a phimosis that is
only relieved by the ulcerative process that exposes the gland, which
may by that time itself be attacked or even destroyed. They are then
seen by either the rural practitioner or the family physician, but
before submitting to an operation they run the gauntlet of many
physicians, and, when it comes to operating, they generally apply to
some one of great skill and reputation. By this time there is little
left of the organ, and, as a rule, the party is unable to tell where the
disease originated, whether in the prepuce or glans, to them the swollen
prepuce seeming to be the whole organ. Of late years, however, it has
been pretty well established that it generally begins in the prepuce,
and the great number of amputations of the penis on record for this
disease does not lead one to believe that it is as rare a disease as was
formerly believed. In Langenbeck's _Archiv_, Bd. xii, 1870, Dr.
Zielewicz reports fifty cases of amputation of the penis by the
galvano-cautery