SACCULATION AND POUCHING OF THE BLADDER..
Pressure on the walls of a reservoir like the bladder is capable of causing certain alterations in the form of the viscus to which the terms, (1) sacculation and (2) pouching, have with some indiscrimination been applied.
By sacculation is understood that a limited portion of the vesi cal mucous membrane becomes herniated or prolapsed through the interstices of the muscular network surrounding it, and thus in dependent sacs of various shapes and dimensions are produced. Sacculations of the bladder may occur at almost any point, they may be intra- or extra-peritoneal, they are met with at all periods of life from birth onward, they have little or no independent means of exercising power over their contents as by contraction of their walls, and they are capable of being called into existence and of be ing disposed of in ways not unlike those which are more commonly illustrated by intestinal hernia. The causes of sacculation may be ranged under three headings : (1) intra-uterine, (2) arising from obstacles to micturition within either the prostate or the urethra, and (3) traumatic. As Targett has recently pointed out," some sac culations are of a congenital nature and are explainable either as con sequences of intra-uterine pressure or of developmental variations. The most frequent causes are, however, those which are included under the second heading as arising from the pressure exercised in overcoming an obstacle in front of the bladder. This can be readily understood, especially when, as is often the case, the muscular coat of the bladder is more or less hypertrophied. Traumatic causes leading to a sudden compression of a distended bladder have in some in stances which have come under my observation led to a similar con sequence.
The diagnosis of sacculation is not always easily made. In some in stances we have nothing to guide us- but the fact that the movement of a catheter, preferably a soft one, may unmistakably indicate the existence within the area of the bladder of more than one distinct re servoir for urine. In one or two instances not only was I able to rec ognize the probability of a sac in this way, but there was a marked difference in the appearance of the sample of urine removed from the two compartments. Guthrie," to whom we are indebted for a de scription of this condition, observes : " In one gentleman the existence of one or more pouches of this kind became evident on injecting the bladder; twelve ounces of warm water could be thrown into it befOre much uneasiness was produced, but on drawing it off ten ounces only could be obtained, and. rarely the whole twelve even by change of posi
tion." Careful examination of the contiguous parts about the bladder may sometimes tend to the detection of sacculation. The size of these diverticula is sometimes so considerable and the direction they take so unusual that in investigating growths and swellings in the neighborhood of the pelvis we should not forget to test the state of the bladder by the preliminary use of a catheter. A pelvic tumor has in this way been made to disappear. The presence of these sacs often occasions serious inconvenience to the patient and embarrassment to the surgeon. They are spaces in which urine collects and decom poses, not infrequently calculi descending from the kidney are trapped and concealed by them, and in some instances by retaining sharp fragments of stone after lithotrity they have contributed to the pro duction of a fatal cystitis. It must not be forgotten that these pouches, either by impaction with calculous matter or by decompo sition of the urine for which they are the receptacles, may undergo acute suppurative inflammation and by bursting within the pelvis occasion a most serious cellulitis.
Saccules most frequently come into prominence as complications in connection with other disorders. Of these I may mention stone, enlargement of the prostate, and cystitis. Calculi in the bladder thus complicated represent a state of affairs where, as a rule, the stone should be removed by a supra-pubic cystotomy and the sacculation dealt with by drainage. This is obvious not only for the reason that the latter may render a complete lithotrity impossible, but that, by retaining fragments and keeping up cystitis, they favor the speedy reformation of the stone. To determine the presence of a sacculus in the bladder where there are sufficient grounds to demand this, and with the object of treating it and bringing about its contraction by drain age, if its removal is found to be impossible, exploration of the blad der by the supra-pubic route might with advantage be oftener re sorted to.