History of Circumcision from the Earliest Times to the Present Part 8

Phimosis is known to have been a cause of male impotence by its direct interference with the outward flow of the seminal fluid; but, although we have cases where impregnation has taken place by the aid of a warm spoon and a warm syringe, as in the case related in a former chapter, it must be admitted that the corona is not without some functional office in the act of procreation. Its shape indicates a valve action like that of the valve in a syringe-piston, and if we examine the two extremes of these conditions of glans--one devoid of corona, as many are, and the other with the corona in its most p.r.o.nounced form, when in a state of erection--the difference, either in the appearance of the two organs or in the different philosophical action and results that must necessarily follow the use of these two differently shaped glans, will at once be apparent. Unfortunately--or, as many may consider it, most fortunate--the female organs are not always so shaped as to be in themselves wholly favorable to impregnation. The wearing of corsets, the habitual constipation of females, the relaxed and unnatural condition of the uterine ligaments and v.a.g.i.n.a in civilized women, all favor uterine displacement, with any or all forms of uterine ailments. To this we may add the effect of repeated miscarriages, application of astringent washes, irregular menstruation, etc., all of which conditions often result in an elongation of the neck, constriction of the cervical ca.n.a.l, with the external os placed on the depended point of the sharply pointed cervix, which is liable to point in any direction. Just imagine one of these conditioned females and one of the mouse-headed, corona-deficient, long-pointed glans males in the act of copulation! The conical p.e.n.i.s finds its way in the reflected fold of the v.a.g.i.n.a, while the point of the uterus may be two or three inches in some other direction, making impregnation wholly impossible; besides, in the normal-shaped p.e.n.i.s, the corona acting as a valve, behind which the circular muscular fibres of the v.a.g.i.n.a close themselves, tends to retain the seminal fluid in front, while the very shape of the organ a.s.sists in straightening out the v.a.g.i.n.al ca.n.a.l and to bring the uterus in proper position. In the long, thin, narrow and pointed glans, devoid of corona, there is no mechanical means to retain the seminal discharge. Some years ago some one introduced the idea of postural copulation, to be tried in cases of sterility, and it has been found that impregnation would take place in some cases where it had formerly appeared impossible, this position having the effect of righting malpositions during the act, which were the cause of the sterility; but it stands to reason that, where the shape of the organ is such that it further favors malpositions, as well as where it offers no obstacle to the v.a.g.i.n.a immediately expressing or dropping out all the seminal fluid, impregnation is more difficult, and that, where the uterine deformity is coincident with this condition of p.e.n.i.s to a.s.sist, it becomes well nigh impossible. Fodere mentions a p.e.n.i.s about the size of a porcupine-quill on an adult male, and Hammond mentions one of the size of a lead-pencil in diameter and two inches in length. From total absence of the p.e.n.i.s, either through disease or accident, to the diminutive organs mentioned by Fodere and Hammond, and on up to the full-sized and normal-shaped organ, we have every degree of sizes and shapes, and with these go every conceivable degree of ability or faculty for impregnation.

Aside from the foregoing considerations, there are others equally important. Although Greece was involved for years in war and ancient Troy was destroyed and all its inhabitants slaughtered because of the seduction of one woman; and Semiramis, through her beauty, got all her successive husbands in chancery; and poor, susceptible Samson, from firing Philistine vineyards and killing lions bare-handed, and the Philistines by the thousands with the jaw-bone of an a.s.s, was reduced through Delilah to bitter repentance and turning Philistine mill-stones; and we know that the familiar infatuation of Antony for Cleopatra ruined Antony; and we are familiar with the well-known maxim of the French police-minister, that to catch a criminal it was but necessary to first locate _the woman_ and the man would soon be found,--society has determined to ignore the influence of the animal pa.s.sions as factors in our every-day life, or factors in the estrangements, coldness, and the bickerings that end in divorces. Not to shock the reader with detailed accounts as to what an important factor the shape of the p.e.n.i.s may be in the domestic economy, I will refer the reader to Brantome's works.

Although the councils of the older church were not above giving these conditions their calm and deliberate consideration, which resulted in the foundation of the present physical considerations in relation to divorce laws, such studies or considerations are at present only touched upon gingerly and with apologies for doing so, as if the "study of man"

was of any less importance to-day from what it was in the days of Moses, the elder church, or when Pope formulated his oft-quoted but little-followed maxim, that "the proper study of mankind is man." The present miscalled "delicacy of sentiment" is about as misplaced a condition of disastrous and misleading morality as was the out-of-place and untimely bravery of poor old Braddock when refusing Washington's advice at the Monongahela. The success and beauty of the Mosaic law is its squarely facing the conditions of actual life, and its absence from nonsense or nauseating sentimentality. Were our present churches to observe more of this plain talk, for which the good old Anglo-Saxon is as fully expressive and convincing as the old Hebrew, and deal less in rhetorical flourishes and figurative mean-nothings to tickle the ears of our modern Pharisees, mankind as well as womankind would be infinitely so much the better off, mentally, morally, and physically, and there would be less of the conflict between science and religion. Luther's dream of restoring religion to its primitive purity has come to but as poor realization at the hands of his so-called followers, which leads one to think that if the martyrs of the Reformation could come back and see the fruits of their martyrdom--suffered that pure religion might live--they would conclude that, for all the resulting good accomplished, they might as well have kept a whole skin and a whole set of bones.

In cases of p.r.o.nounced phimosis the aperture in the prepuce may not be in a line with the meatus, and the resulting discharge of urine or the e.j.a.c.u.l.a.t.i.o.ns of seminal fluid may from this cause be unable to find an egress. The fluid escaping from the urethra will, in case the opening is at the side or upper part of the prepuce, cause it to balloon out until a sufficient quant.i.ty is thrown out so as to distend, the opening as well as the prepuce, before it can find its way out; in such cases impotency is liable to be as complete as in those cases of stricture wherein the seminal fluid is forced backward into the bladder. Having given this general view of the effects of phimosis as it may affect man in the shape of his organ, which may have a serious result in his domestic relations or in becoming a father, we will proceed to the consideration of diseases and conditions that phimosis encourages and to which it renders man more liable. In the consideration of these cases it must not be forgotten that the s.e.xual relations are much more to man or woman than is generally acknowledged. The days for the establishment of the Utopian republic of Plato are not yet with us. That Platonic love does exist is true, as it has in the past and will in the future.

Scipio, refusing to accept the beautiful betrothed bride of an enemy as a present, or Joseph leaving his coat-tail in the hands of the amorous bride of the eunuch Potiphar, with the suicide of Lucretia, in the past, are events which virtue and modern continence probably duplicate every day; but these are exceptions to the rule. Physicians daily see evidences of the most devoted Platonic affection in either s.e.x, but they also see enough of the opposite side of the question to convince them that in the majority of cases the s.e.xual relations are the bond of union, as well as the mainspring of love. As observed by Montesquieu, the bride of a first-cla.s.s Turkish eunuch has but a sorry time, and a woman of the same calibre of mind as that possessed by the ordinary Circa.s.sian or Armenian bride cannot be in a much happier condition with a husband partly eunuchised by a constricted prepuce.

CHAPTER XIX.

IS THE PREPUCE A NATURAL PHYSIOLOGICAL APPENDAGE?

By many surgeons the idea of circ.u.mcision, unless connected with an immediate demand for interference,--such as a phimosis unmanageable by any other means, an induced phimosis from gonorrhoea or other irritation, syphilis in its initiatory sore, cancer or some such cause,--is looked upon as an unwarrantable operation, a procedure not only barbarous, painful, and dangerous, but one that directly interferes with the intentions of nature. The prepuce is by many looked upon as a physiological necessity to health and the enjoyment of life, which, if removed, is liable to induce masturbation, excessive venereal desire, and a train of other evils. The question then resolves itself, What is the real physiological status of this appendage, if it has any, and, if it is a physiological appendage, when does it merge into a pathological appendage? As by some it is held that the prepuce enjoys the same right to live and exist as the nose, ear, or a limb, which are only subject to amputation in case of a serious disease, they should be reminded that they are not taking into consideration that the nose and ear are calculated to warn us of danger, and that our legs are very useful; as even the great orator Demosthenes, by the timely and rapid use of his legs, was enabled to escape from a battle, where his oratory was of no avail against the illiterate javelins of the unscholarly Macedonians. If the prepuce only was endowed with an olfactory sense,--as, for instance, if a nervous filament from the first pair of nerves had been sent down alongside of the pneumogastric and then, by following the track of the mammary and epigastric arteries, had at last reached the prepuce, where the olfactory sense could have been turned on at will, like an incandescent lamp,--it might have been a very useful organ, as in that sense it could have scented danger from afar, if not from near, and enabled man to avoid any of the many dangers into which he unconsciously drops. But, seeing that the prepuce, to say nothing of being neither nose, eye, nor ear to warn one away from danger, or a leg to run away on after once in it, having not even the precautionary sensitiveness of a cat's moustachios, it cannot, in any way that we can see, be compared to any other useful part of the body.

All attempts to find reasons for its existence that are of real benefit to man have so far proved unsatisfactory, and, unlike the reasons for its removal, are, as a rule, founded on speculation. To further reason out the why and wherefore of its existence or of its summary surgical execution, we must consider its shifting positions as to the effects it produces, as well as to its conditions at different ages, sitting on its case like an impartial jury in the case of some unconvicted but diabolically-inclined criminal.

As before remarked, we are, as a rule, born with this appendage, just as much as we are with the appendix vermiformis, which rises up, like Banquo's ghost, whenever we eat tomatoes or any small-seeded fruit. This prepuce is then long, and the p.e.n.i.s is found at the end of an undilatable ca.n.a.l, which is formed by the constricted prepuce; at this early stage of our existence it is often additionally bound down to the glans by a greater or less number of adhesions. We are then in what many term a state of physiological phimosis, that being a perfectly natural condition, and one consistent with health; at least, we imagine it is normal.

Phimosis in childhood is generally considered a physiological state, only to be taken as a pathological condition under certain circ.u.mstances. Preputial adhesions may, according to many observers, also be cla.s.sed as physiological at an early period of life, as it is by them considered as congenital, and common enough to warrant its being cla.s.sed as normal. As to the first, or phimosis, it undoubtedly is a physiological condition during infancy; but why, we do not know; and it is also a fact that from birth to p.u.b.erty it remains so in fully over one-half of the cases. Out of 98 children, from one week to sixteen years of age, examined by Dr. Packard, the prepuce was entirely unretractable in 54, partly so in 3, and wholly so in 36; while in 1 it only half-covered the glans and in 4 the glans was wholly uncovered, 1 of these 4 being an infant only five weeks old.

Dr. Packard also gives the result of 172 examinations by himself, of from twelve to seventy-three years of age, and 106 examinations by Dr.

Maury, a total of 278, in whom 100 had a long prepuce, 97 a partly-covered glans, and 81 (of whom 2 had been circ.u.mcised) in whom the glans was exposed.[83] As to adhesions, there is an unaccountable diversity of opinion as to their constancy as a natural condition, being frequent enough to cla.s.s them as physiological occurrences. Dr. A. B.

Arnold, of Baltimore, states that his experience in reference to preputial adhesions leads him to conclude that the frequency of its occurrence has been much overstated. In the number of children that he has circ.u.mcised, which exceeds 1000, he has met with it in less than four per cent. of the cases. He also mentions that in the adult the adhesions show greater firmness.[84]

On the other hand, Dr. Bernheim, of the Paris Israelitish Consistory, observes that, of over 3000 newborn whom he has examined, with but few exceptions he found the presence of preputial adhesions. He remarks, however, that in the majority these are detached or broken by the first attempt at erection.[85]

Bokai, out of 100 children, found 8 who were over seven years of age, who were perfectly free; while of the remaining 92 under that age 6 more showed no adhesions and 86 had various degrees of adhesions.[86]

Dr. Holgate, of the out-door department of Bellevue, considered that all phimosic cases have adhesions; while Dr. Moses, of New York, out of some fifty circ.u.mcisions performed at the eighth day, found only adhesions three times.[87]

These observations are, however, in perfect accord. If we connect the statement of Dr. Arnold, in regard to the increasing character of the firmness in the adhesions of the adult, with the statement of Dr.

Bernheim, that the first erection is often sufficient to break up the existing adhesions in the infant, we must conclude that they are nothing more at first than a slight agglutination, which the slight manipulation required to properly locate the position of the glans, and to s.p.a.ce out the prepuce preparatory to the operation of circ.u.mcision, must, in the majority of cases, be sufficient to liberate the prepuce from the glans; this is evident also from the statement of Dr. Moses, who only found six per cent. of the cases operated upon by him as being so affected.

The writer has been present at a large number of Hebrew circ.u.mcisions performed on the eighth day, and from that up to the sixth month (as in many communities they wait until a number of children are collected, so to speak, before sending for the mohel, who may reside at quite a distance), and in all of those witnessed he has never seen any complications from adhesions; but cases of adhesion have been often encountered from the second to the eighth year, and it has always been the case, as a rule, that the older the child the greater the firmness of the adhesion. In these cases the practice generally advised of using a probe is not practicable, as the person is more apt to wound the sound prepuce than to tear the adhesions; the practice most effectual is to hold the glans firmly but gently with the thumb and forefinger of the right hand, and then to draw the prepuce as firmly back with its fold held in the forefinger and thumb of the other. It is a more expeditious mode, and the least painful; by this method extensive adhesions can readily be broken up; vaselin and a piece of fine lint should then be interposed for a couple of days to prevent a re-adherence.

Another co-existing condition with phimosis, very often found, is a shortening of the frenum. Dr. Jansen, out of 3700 soldiers of the Belgian army, found 12.3 per cent. with this pathological condition and 2.5 per cent. with a narrow prepuce.[88]

Take the three conditions above enumerated,--phimosis, preputial adhesions, and short frenum,--all are but a departure from a normal, in a greater or less degree; and whether the resulting discomfort consists in mere mechanical impediment to urination, erection, or as a factor in nocturnal enuresis, dysuria, impotence, either through reflex action or interference with emission, malposition of the urethral orifice during copulation owing to any of these conditions, or in any of the nervous derangements that may accompany this condition, or in the more serious results, ending in positive deformity of body or limb, or in the warping of moral sentiments, or, even further, in inducing insanity, it cannot well be seen how the conditions that will certainly produce these results, in a more or less degree, can ever, in any logical sense, be considered a physiological condition.

There are certain conditions to life, up to the time of birth, which, unless they then cease at once to exist, immediately become from a physiological into very serious pathological conditions. These are well understood, and have their reasons for existing during our pre-natal existence; but the prepuce has no known function during uterine life or subsequently; and there being no valid reason for its existence, there are certainly no logical grounds for its being considered a physiological condition, especially when the serious results attending the most accentuated form of the above three conditions are considered, and as its necessity, in cases of its entire absence, has not yet been demonstrated.

It can well be said that about two-thirds of mankind are affected in a greater or less degree with these pathological conditions, causing them more or less annoyance. Of these, a certain percentage suffer a life of continued misery, as a direct or indirect result of these conditions.

As to the actual necessity of a prepuce existing, or as to what annoyances or diseases persons are subjected to who are born without it, there is a most singular and expressive silence in medical literature.

It stands to reason that, if it is a necessity, some one person should have found it out long ago, and there should then be some evidence to present in relation thereto. There are cases reported in some of the older surgeries wherein an attempt has been made, in the absence of a prepuce, to restore or manufacture one by means of a plastic operation.

Vidal describes such an operation,[89] but there is no reason given as to why the operation was undertaken; there is no record of any diseased condition which it was intended either to cure or to alleviate; so that we are left to infer that the person simply submitted to the operation from purely cosmetic reasons. The Hebrews of Palestine, after the Roman conquest, or those in Italy or Spain, attempted a like operation, but not from any reason of lessened health or to restore any lacking physiological action, their aim having simply been to hide their ident.i.ty, for the purpose of escaping persecutions, exactions, or annoyances, either from their rulers or their fellow-citizens.

Dr. A. B. Arnold, in a paper on circ.u.mcision, read before the Academy of Medicine of Baltimore, argues that it is not difficult to divine the purposes of the prepuce, holding that it is necessary to protect the tactile sensibility of the glans, due to the presence of the Pacinian bodies which Schweigger Seidel discovered in the nerves, and that a better provision than the anatomy of the prepuce cannot be conceived for shielding the very vascular and sensitive structure of the glans from external sources of irritation and friction, that might rouse the sensibility of this organ, which, on physiological grounds, may cause early masturbation; further arguing that, the corona being undoubtedly the most excitable part of the glans, its denudation by circ.u.mcision leaves it more apt to be affected by chance t.i.tillations.[90] In this latter view of the case the preponderance of views is, however, in the opposite direction. J. Royes Bell states that, owing to the induration of the glans through the means of circ.u.mcision, masturbation and syphilis are less rife amongst the circ.u.mcised than amongst the uncirc.u.mcised.[91] M. Lallemand, whose experience in the treatment of seminal emissions is of the greatest value, looked upon circ.u.mcision as one of the means of curing those diseases, looking on the diminished irritability of the glans resulting from the operation as the curative element.[92] Dr. Cahen, in a "Dissertation sur la Circoncision," in 1816, before the Faculty of Medicine of Paris, called the attention to the diminished sensibility of the glans induced by circ.u.mcision. Dr.

Vanier, of Havre, looks upon the prepuce as the most frequent cause of onanism. "If the prepuce is lax, its mobility produces an irritation to the highly irritable and sensitive nervous system of the child by the t.i.tillation in its movements on the glans; if too tight and constricted, then it compresses the glans, and by its irritation it leads the child to seize the organ."[93] So that in either case he looks upon the prepuce, through the sensitiveness it retains and induces in the glans, as the principle cause of masturbation. M. Debreyne, the Trappist monk and physician of La Trappe, who has paid considerable attention to medicine as applied to morality, practically makes the same observations. In children who have not yet the suggestions of s.e.xual desire imparted by the presence of the spermatic fluid, the presence of the prepuce seems to antic.i.p.ate those promptings. Circ.u.mcised boys may, in individual cases, either through precept or example, physical or mental imperfection, be found to practice onanism, but in general the practice can be a.s.serted as being very rare among the children of circ.u.mcised races, showing the less irritability of the organs in the cla.s.s; neither in infancy are they as liable to priapism during sleep as those that are uncirc.u.mcised.

Dr. Bernheim says that "the prepuce may be said in general to be an appendage to man, if not positively harmful in some cases, at least useless, requiring constant care, the neglect of which is liable to entail disease and suffering; the irritation it produces through the sebaceous secretion is a frequent cause of masturbation which nothing short of circ.u.mcision will remedy."

Through middle life, unless the prepuce be the subject of some vicious conformation, little inconvenience may result from its presence, except it be from the dangers to infections already pointed out during this period of life; an ordinarily movable and retractable prepuce will not acquire the condition of phimosis, unless it be through disease or accident; but with our entrance into old age, or after having pa.s.sed our vigorous prime, the torment of the days of our infancy and childhood come to hara.s.s us again. Persons given to corpulency, with a long prepuce, are apt to become affected with phimosis in their latter years, as such persons are more subject to loss of their s.e.xual vigor and power of erection than lean and spare people; in these, the gradual diminution of the size of the erectile tissues of the organ and its retraction allows of the reconstriction of the preputial opening, which, in the end, will not allow the prepuce to be drawn back over the gland. These conditions are followed by the irritating affections incident to phimosis of our earlier life, with the modification that age has induced in making us subject to more serious and fatal ailments, both locally and generally.

CHAPTER XX.

THE PREPUCE, PHIMOSIS, AND CANCER.

In the _British Medical Journal_ of January 7, 1882, there is an interesting article by Jonathan Hutchinson on the "Pre-cancerous Stage of Cancer." In this article he states that, whereas, twenty years previously, his suggestion had been to treat all suspicious sores as being due to syphilis until a clearer diagnosis could be made out, he "had more recently often explained and enforced the doctrine of a pre-cancerous stage of cancer. According to this doctrine, in most cases of cancer, either of p.e.n.i.s, lips, tongue, or skin, there is a stage--often a long one--during which a condition of chronic inflammation only is present, and upon this the cancerous process becomes ingrafted. Phimosis and the consequent balanitis lead to cancer of the p.e.n.i.s.... A general acceptance of the belief that cancer usually has a pre-cancerous stage, and that this stage is the one in which operations ought to be performed, would save many hundreds of lives every year.... Instead of looking on whilst the fire smouldered, and waiting till it blazed up, we should stamp it out on the first suspicion.... What is a man the worse if you have cut away a warty sore from his lip; and, when all is done, a zealous pathologist demonstrates to you that the ulcer is not cancerous, need your conscience be troubled? You have operated in a pre-cancerous stage, and you have probably effected a permanent cure of what would soon have become an incurable disease. I do not wish to offer any apology for carelessness, but I have not in this matter any fear for it."

In view of the great frequency of the occurrence of cancer of the p.e.n.i.s, and the facts pointed out by Roux, that, after the removal of the cancerous prepuce or a portion of the p.e.n.i.s for cancer, in case of a recurrence the disease does not do so in the p.e.n.i.s, but that it attacks the inguinal glands, showing conclusively that the prepuce is the inciting cause as well as the initial point of attack, the sentiments in the foregoing paragraph, taken from the words of Hutchinson, are worthy of our most careful consideration.

M. Roux, Surgeon to the Charite, during the second decade of the present century, first called the attention of the French profession to the intimate relation or dependence that cancer of the p.e.n.i.s bears to phimosis. In England he was preceded in this field of surgical investigation by William Hey, whom Roux met in London in 1814. Hey had then operated by amputation of the p.e.n.i.s on twelve cases of cancer, nine of whom had had phimosis at the time of the development of the cancer.

Wadd at this time also published a work on the subject, but, although he noticed that phimosis was a cause of cancer, he did not fully grasp the subject as Hey and Roux had done, as he believed a cancerous diathesis a primary necessity, and did not then recognize that the primary cause was fully to be found in the prepuce itself.

Roux was probably the first to point out the peculiarly local character of penile cancer, as there is no locality wherein a timely operation is less apt to be followed by a recurrence. He records a number of cases where the prepuce alone was affected when first seen, but none wherein the glans was attacked and where the prepuce was exempt, giving ample evidence of the original starting-point of the disease.[94]

Erichsen also remarks on the little liability to recurrence of cancer of the p.e.n.i.s after a timely operation; he divides the cancer to which the p.e.n.i.s is subject to as being of two distinct kinds,--scirrhus and epithelioma. The latter variety commences as a tubercle in the prepuce, and, according to Erichsen, does not occur in the body of the p.e.n.i.s except as a secondary infiltration or deposit.[95] Travers states that Jews who are circ.u.mcised are not subject to either form of cancer.[96]

Repeated attacks of herpes preputialis and some consequent point of induration are looked upon by Pet.i.t-Radel, Chauvin, and Bernard as frequent starting-points for the cancerous affection of the prepuce. The aged or persons of lax fibre being more subject to these inflammatory attacks, are also the most frequent victims of cancer in this situation.

The celebrated Lallemand, in regard to the tendency to cancer induced by the presence of the prepuce, observes as follows:--

"Besides simple balanitis ... there also result various indurations, which are proportionate in their degree to the length or time and intensity with which the inciting inflammatory conditions have existed.

I have repeatedly found the mucous lining of the prepuce thickened, hardened, ulcerated, and nodulated; at other times converted into a fibrous or even into cartilaginous tissue of excessive thickness; in others, still, in which it had a.s.sumed a scirrhous and cancerous nature.

I have repeatedly operated on such cases, wherein the prolongation of the prepuce was the only recognized primary cause, the subjects being often countrymen of from fifty to sixty years of age, who had never known any women except their own, but who had, nevertheless, been long sufferers from balanitic attacks, accompanied by abundant acrid discharges, swellings of the prepuce, with more or less consequent excoriations and narrowing of the preputial orifice."[97]

Claparede sums up the inconveniences and dangers to which the possessor of a prepuce is liable to suffer from, as follows: "The retention of the sebaceous secretion is liable to alter its character, converting it into an acrid, irritating discharge, which induces more or less burning, smarting, itching, excoriations, and swelling, which, affecting the little glands situated about the corona and sulcus, induces them to secrete an altered and vicious secretion. In this manner a simple elongation of the prepuce will produce an inflammation of the surface of the glans (balanitis), or that of the prepuce itself (posthitis), or the two conjoined (balano-posthitis), complicated possibly with phimosis. By an extension to the mucous membrane of the urethra of the same condition of the inflammatory process, we have blennorrhagia; blennorrhagia is liable to be followed by inguinal swellings or tenderness, orchitis, stricture, and prostatic disease; the formation of preputial calculus, from retention of the urine in the prepuce; and cancer is apt to be the end of any of these conditions."[98]

J. Royes Bell, in Ashhurst's "International Encyclopaedia of Surgery,"

observes as follows: "Carcinoma attacking the genital organs usually a.s.sumes the form of epithelioma; the other kinds are rarely met with.

Epithelioma may invade the prepuce, or the whole p.e.n.i.s, or any part of it. The most common age for it is fifty years or over. In the great majority of cases there has existed a congenital or acquired phimosis. A contusion or a urinary fistula may be the exciting cause. With a phimosis the parts are not kept clean, but the gland is macerated and rendered tender and excoriated by retained secretions, and the irritation causes an epithelioma to grow in those predisposed to the disease, as is found to be the case when the tongue is irritated by a broken tooth, or the s.c.r.o.t.u.m by the presence of soot in its folds.

Syphilis has no direct influence in inducing the disease, but a syphilitic chap or ulcer may be the starting-point of an epithelioma.

Two kinds of epithelioma affect the p.e.n.i.s,--the indurated and the vegetating, or cauliflower growth.... The nature of the disease, in either the prepuce or the glans, is masked by a phimosis.... The prognosis in these cases is much more hopeful than in epithelioma, in other situations.... Sir William Lawrence operated on a patient who was quite well years afterward, and Sir William Ferguson amputated the p.e.n.i.s of a man of note in the political world, who lived many years after the operation, and died at an advanced age."

Agnew, of Philadelphia, describes an epithelioma of the prepuce occurring in persons past middle life, beginning as a tubercle, crack, or wart, for which he advises an early circ.u.mcision; he admits, however, to not having sufficient data to determine whether Jews and circ.u.mcised persons are exempt from carcinoma of the p.e.n.i.s; but as its usual starting-point he evidently admits to be in the prepuce, circ.u.mcision must certainly be a preventive to its appearance. Gross gives substantially the same opinion as Agnew in this regard. Dr. John S.

Billings, in his article on the "Vital Statistics of the Jews," in the January _North American Review_, of 1891, on the subject of cancer, observes as follows:--

"As regards cancer and malignant tumors, we find that the deaths from these causes among the Hebrews occur in about the same proportion to deaths from other diseases as they do in the average population. But as the ratio of deaths to population is less among the Jews, so the ratio of deaths from malignant diseases to population is also less. Among the living population the proportion found affected with cancer among the Jews was 6.48 per 1000, while of those reported sick by the United States census of 1880, for the general population, the proportion was 10.01 per 1000."