There is not a case recorded of this disease that particularized any other starting-point than the swelling, tension, active or passive congestion that takes place in the integument of the penis. By this it must not be understood that the initial disease or inflammatory action that produces the gangrene must necessarily have its seat in the integument, but that it is the integument of the penis (and especially that of the prepuce) in which, through the laxity of its tissues, passive congestion is favored that the gangrenous action begins. That this is the actual case there can be but little doubt about, as, even where the gangrene invades the body of the penis itself, even where the inflammatory action may have started from a violent urethritis, that condition of blood which favors gangrenous results will be found to have begun during its state of stasis, where it has parted with much of its watery element, as well as considerable of its vitality, while in its slow, tedious, and obstructed passage through the prepuce. Some of this dark, thickish blood, finding its way from the integumentary return circulation to that of the deeper structure, becomes there a mechanical as well as a pathological cause for that impediment to the free circulation of the parts, through its altered physiological condition. The deeper structures of the penis, besides their own blood-supply, carry back into the deeper or systemic circulation a large supply from the integumentary tissues, when in the latter, owing to the greater supply due to any inflammatory action, the blood-current is delayed and impeded in its lax and easily-dilatable tissues, and blood-changes occur favoring the gangrene in the deeper tissues, so that, whether the gangrene first takes place in the body of the penis or in the scrotum, it will be in the prepuce or adjoining integument that its real originating causes will be found. Baron Boyer, in speaking of the inflammation of the penis, observes that the intensity of the swelling, great pain, and difficulty of urination that follow have led many to believe that the inflammation of the deeper structures really always formed a part of the disease. In otherwise healthy and vigorous subjects it does not, however, extend beyond the skin, as has been demonstrated where the resulting gangrene from excess of inflammatory action has ended in resolution, the deeper tissues not having been found to be injured. It is only where the tone of the general system is lowered, through disease, age, or other deteriorating conditions, that the whole organ is liable to become affected or to break down.