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THE SHELTERING ARMS NURSERY. In selecting a subject for presentation to the society this evening 1 have been guided by two motives — first, the short time allovped Order Levitra Online Canada me for preparation necessitated the selection of some subject with which constant experience had rendered me familiar ; and, second, my own consulting and general practice has given me the impression that, by the profession generally, little attention is given to the treatment of the earlier stages of enlarged prostate, wliile the general man- agement of its more advanced phases seems equally a mat- ter of routine, based upon vague ideas of the conditions which really exist. Until Order Levitra Online Canada a very recent period, equally cele- brated authorities have differed as Order Levitra Online Canada to the gross anatomy and physiology of the organ involved ; and, as a conse- quence, many of the phenomena observed in the functional and pathological history of this portion of the genito- urinary apparatus are but imperfectly understood, rendering the treatment of some of its diseases in the highest degree empirical and unsatisfactory. Such being the case, I have thought it worth our while to run briefly over a few of the best-known facts which have been accumulated in regard to the prostate gland itself, and especially those bearing upon the diseased condition which is about to be described. The adult prostate, then, is an organ resembling in shape and size an ordinary horse-chestnut, lying in the erect position of the body, with its flattened Order Levitra Online Canada surface upward and its apex applied Order Levitra Online Canada to the Order Levitra Online Canada deep layer of the perineal fascia, or " triangular ligament," which here gives passage to the urethra. The base of the gland is applied closely to the vesical outlet, and through it the prostatic urethra runs, coursing along its upper portion in such a manner as Order Levitra Online Canada to have the mass of the gland below it, or between it and the rectum. Invested with a true capsule of its own, and held firmly in its place by the perineal fascia anteriorly, and the recto-vesical fascia, or rather a prolongation from it behind and underneath, the prostate shows, upon careful dissection, a complex arrangement of muscular fibers and glandular tissue. The former are derived from and are continuous with the muscular apparatus of the bladder, the longitudinal fibers of the viscus, or its external layer, going to form the mass of the gland at its base, while those of the circular or internal layer (which are a direct continuation of those of the bladder) are prolonged into the gland, and disposed around the tube of the urethra in an annular manner, gradually diminishing in thickness and quantity until they become a thin layer investing the membranous urethra, where they cease entirely on reaching the bulb. The glandular tissue, which, according to Thompson, ReaJ before the Brooklyn Pathological Society, March 11, 1886. forms about one third the bulk of the entire Order Levitra Online Canada organ, is found most freely distributed in what are known as the " lateral lobes " of the organ, or those portions lying to either side of its median line. It consi.sts of a lobular or racemose arrangement of glandular .structures mingled indiscrimi- nately with muscle fibers or bundles, having no definite anatomical arrangement, except a tendency to diverge from the center of the lobe toward its periphery, as demon- Order Levitra Online Canada strated by Kolliker and Thompson. The irregular distribu- tion of these muscular bands leaves numerous interstices, which are filled with the glandular or secreting structure. In the median portion of the gland, along the line of union of its two lateral lobes, another collection of glandular tis- sue exists, and is most densely deposited at a point which underlies the neck of the bladder. The secretion from all these glands is conveyed by twenty or thirty minute ducts to the floor of the prostatic Order Levitra Online Canada urethra, where they empty just back of the ejaculatory ducts and along the sides of the veru montanum. The lobed arrangement which characterizes the prostate is simply the survival in the adult organ of a type which, as in many other portions of the body, exists at an earlier stage of development. Up to the fourth month of intra- uterine life two oval bodies exist, one on either side of the urethra, and at a later period form by their union a single organ. The prostate is richly supplied with blood from three sets of vessels — the vesico-prostatic, branches of the inferior vesical, and pudic arteries. Its blood is returned to the heart by numerous veins, which are collected into a plexus about the neck and base of the bladder, and empty into the internal iliac vein. They are frequently the seat of phleboliths in aged men, and the source of persistent and dangerous h;emorrhage when wounded, whether by accident or during the Order Levitra Online Canada performance of operations involving the deep structures at the neck of the bladder. Order Levitra Online Canada A free nervous supply is also provided for from the in- ferior hypogastric plexus which sends a prolongation to the prostate and penis, called the prostatic plexus. From the brief description thus given, it will be seen that in the prostate gland we have an organ which, by its peculiarities of structure, is liable to processes in which tis- sue changes of a character resembling those of exaggerated nutrition may easily occur under favorable circumstances. And in Order Levitra Online Canada this fact the majority of writers upon its diseases have seen sufficient predisposing cause for the condition which is now under discussion. Accordingljf, excessive sexual excitement, local nutrition, as modified by gouty, rheumatic, or strumous dyscrasia, or increased by excessive vascular supply, stricture, inflammation, etc., have all been Order Levitra Online Canada adduced by them as exciting causes of prostatic enlarge- ment. The obvious objection to all these theories is the one adduced by Thompson, that the causes cited are all active during young adult life and manhood, a period at which enlarged prostate is all but unknown, except from acute diseases, which have nothing to do with the common form of the complaint. Approaching the question of aeti- ology from the opposite side, we find the ' testimony of all investigators as to the morbid histology of the growth 30 ROCKWELL: PAlHOLoGY AM) TREATMENT OF ENLARGED PROSTATE. [N. Y. Med. .loci.., agreeing that two conditions are found : 1. A true hyper- trophy of the secreting structures of the gland, or of its muscular elements, or of both, Order Levitra Online Canada the proportion varying with almost every case examined ; or, 2, a true fibrous outgrowth or tumor developing in the substance of the gland and act- ing precisely as in the other soft parts of the body. In a given case, any or all of the conditions described may exist, the largest masses, usually removed post mortem, containing variable proportions of both fibrous and gland elements, while, on the other hand, a prostate normal in size may contain a small fibrous outgrowth, and, from its anatomi- cal position, be as dangerous to the safety of the patient as