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Business, Strategy, Development, Application, Second Edition, Gary J. Bissonette, McGraw-Hill
Ryerson Limited, 2015

Chapter 6: Developing a Business Strategy

Chapter Summary

This chapter provides students with an introductory overview of the concept of business strategy
and of the fundamentals of the strategic planning process. A key emphasis within the chapter is
the identification of the key elements that managers need to assess as they develop a strategy for
their business or organization. These include the creation of vision and mission statements,
defining the products/services to be offered, assessing the resources the organization has or has
the capacity to acquire, configuring the business system to ensure the execution of the intended
set of actions, and defining managerial responsibility and accountability to ensure its success.

Also discussed, in detail, is the strategic planning process itself and the key stages within it
(revisiting the organization’s purpose, I/E analysis, the identification of strategic choices, strategy
formulation, and strategy implementation). Included within this discussion is an understanding of
the difference between corporate-level strategies, business level-strategies, and operating plans,
and the linkages among the three.

The chapter closes with some thoughts relating to the challenges that strategy development poses
for small and medium-size businesses, as well as the unique influences that not-for-profits need to
consider when assessing and developing their organizational strategies. For not-for-profits,
strategic plan development is uniquely challenged by the balancing requirements between
financial stability and meeting the needs of a collective interest, defined by its social mandate
and, in many cases, the altruistic goals of an organized collective.

Learning Objectives

This chapter is designed to provide students with:

 An understanding of the concept of business strategy
 An appreciation of the importance of developing a strategy within a business
 operation
 An overview of the key areas around which business strategy is developed
 Exposure to the fundamentals of the strategy planning and implementation process
 An understanding of the unique strategy planning requirements of the not-for-profit
 sector

Management Reflection – The Need to Plan

Sun Tzu, in The Art of War, comments that “strategy without tactics is the long road to victory;
tactics without strategy is the noise before defeat.” For managers, regardless of the size of their
business, defining the direction of the company and determining where and how the business is
going to compete is essential. Successful businesses have one very common denominator: they
take the time to plan how the business will be positioned in the marketplace, and what markets it
will serve, and then they execute the critical components of their strategy better than their
competitors. A successful business person will be able to tell you why his/her business is different
from its competitors and unique to its customers. In essence, they know what their competitive
advantages are, and they know how to leverage them to ensure their business is “best of breed.”
In summary, then, what constitutes a successful strategy?

A successful strategy is one that properly assesses the external environment, defines the changes
and opportunities within market segments the organization intends to serve, and effectively
allocates resources and maximizes capabilities in a manner that is supportive of the products and
services it delivers to the marketplace. A key outcome of the strategy formulation process should
be the identification of the key competitive advantages the organization possesses and the
successful leveraging of these advantages within its marketing communication and operational
delivery processes.

To be successful, the organization must be able to transfer the knowledge gained during the
assessment process into a well-formulated strategy, which it then executes successfully to a
defined target market in need of the goods and services being offered. To be successful in this
regard, the organization needs to visualize this process from the customers’ perspective. This
means that as managers we need to fully understand the key buying criteria that customers are
using in making purchase decisions, and then determine how our organization can best align our
products and services to meet customer expectations identified via these criteria. This process is
what will enable us to develop and sustain competitive advantages, and will help us determine
how to most effectively allocate resources in order to drive innovation, efficiency, quality, and
customer responsiveness initiatives. Only when we have fully understood what the customer
wants, and how we can most effectively respond to this, will we be able to embark on a well-
thought-out path toward profitability and organizational wealth creation.

Business Updates

 Scotiabank, Cencosud S.A., Tangerine, ING Direct Canada, Canadian Tire, Cineplex,
National Hockey League (NHL), (Page 191)
 Royal Bank of Canada (RBC), Canadian Tire Corporation, Bombardier Inc. (Pages 194-
195)
 Suncor (Page 195)
 Apple Inc., Beats Electronics, MusicMetric (Page 197)
 Target Corporation (Page 197)
 Jamba Juice Company, Whole Foods, Target Corporation (Page 197)
 PayPal, Apple Inc., Google’s Google Wallet, WiMacTel, Toyota, Ford, GM,
Volkswagen, Tesla (Page 201)
 Canada Post, United States Postal Service, Wal-Mart, Costco, Loblaw Companies, Metro
Inc., Sobeys Inc., Whole Foods Canada, T&T Supermarkets, Group Epicia(Page 201)
 Bombardier, Boeing Company, Airbus Group N.V., Embrarer S.A., Republic Airlines,
 Walmart Supercentre, Canadian Tire, (Page 202)Starbucks, Tim Horton’s, McDonalds
(Page 204)
 JPMorgan Chase, Mars, (Page 204)
 Apple Inc. (Page 204)
 Shaw Communications Inc., ViaWest Inc., (Page 207)
 International Business Machines (IBM), Google, Amazon, Nokia, Alcatel-Lucent,
Huawei, Ericsson, Samsung (Page 213)
 Canadian Tire Corporation (Page 214)

For Discussion – Influence of Activist Shareholders

Canadian Pacific Railway Ltd boasts the lowest operational efficiency of the big 6 railways in
North America, with operating costs equaling 82.4% of revenue.1 Bill Ackman, manager of
Pershing Square Capital Management LP, a hedge fund based out of New York, is lobbying CP’s
board to replace the current CEO Fred Green with former CEO of CN Railway Hunter Harrison.
Harrison led the successful turnaround of CN Railway between 2003 and 2009.

How do you think replacing CP Railway’s CEO will influence business strategy? Specifically,
which of the six core areas do you believe that this change would have an effect on? How does
replacing the CEO influence the strategic planning process? What changes do you expect that
Hunter Harrison would make if appointed CEO?

Key Takeaways – Chapter Highlights

Page 192
The long-term success of an organization and its ability to evolve and grow is predicated on two
fundamental principles: the ability to define and create a strategic direction and market position
for the organization (strategic plan), and the ability to execute the core tactical initiatives within
the plan in a manner that ensures the organization’s success.

Page 193
Strategy can be summarized by the answers to three questions: “Where do we want to play,”
“Why is this the best use of our resources” and “How do we plan to win.”

Page 198
For businesses, a strategic plan is the road map to success. It defines a specific route the business
intends to undertake, provides benchmarks to measure its success along the way, and identifies
where and how the organization will interact with its customers as it seeks to meet its overall
mission and vision.

Page 204
Businesses need to anticipate and react to new initiatives and changes in strategy and market
positioning by their competitors.

Page 205
A customer analysis focuses on trying to identify what shifts have taken place in our customer
base in terms of attitudes, behaviours, and needs.

Page 210
At the end of the day, the strategy being recommended should define, for the organization, where
and how it intends to compete in the marketplace, which weapons of competitive rivalry it will
leverage as its products and services battle for market share, and the marketing and operating
plans that will be required to effectively and efficiently execute the plan.

Page 212
A key requirement of the execution phase is for managers to continuously monitor the success of
the implementation of the strategy and to take corrective action quickly in the event that things
are not going well.

1
http://www.theglobeandmail.com/globe-investor/cps-activist-investor-eyes-former-cn-ceo-hunter-
harrison/article2286688/
Page 214
The need to plan strategically is just as important for a small business as it is for a major
multinational organization.

Chapter Exercises

Exercise #1
Figure 6.1 on page 192 provides an overview of the interdependency of strategy and tactics. The
exercise below is designed to get students to experience a practical application of this
relationship. Although a bit historical this exercise can form the basis for a larger discussion
relating to the market convergence of tablets with laptops, as well as the subsequent flatting of
iPad sales and the company’s attempt to resurrect them.

During the fall of 2011, Amazon.com announced its intention to enter into the tablet market with
an enhanced version of its e-reader which it called the Amazon Kindle Fire. The Kindle Fire,
backed by Amazon’s strength of its overall online product portfolio was designed to succeed at
what others have failed to do to date; create a viable competitive option when positioned against
Apple’s iPad and iPad2 tablets. Unlike its predecessors, Amazon chose to go down market and
look to gain market profile and market share at the entry level end of the marketplace. The
exercise can be further expanded to consider Apple’s anticipated response to the new segment
threat.

Prior to coming to class for participation in this exercise students should be encouraged to
“google” the Amazon Kindle Fire and to read the various news reports relating to its launch.

The emphasis on this exercise is for students to discuss and form an opinion as to the potential
success of this positioning strategy and to discuss what Amazon must successfully due tactically
in order to create a sustainable position at the low end of this segment. An option used
successfully in the past with this exercise is to spit the students into two groups, with one taking
the position of Amazon and the other the position of Apple. Specific questions which can be used
to guide this discussion are as follows:

Amazon Team
• Start with the decision which has been made…identify the reasons for Amazon’s decision
and the activity patterns within Amazon which you believe support it. What is Amazon’s
specific positioning strategy for this product offering?

• Define what you believe are Amazon’s objectives and beliefs (macro assessment)
concerning this product offering. Does the anticipated approach fit with their current
organizational activity pattern? What about their current business model and the company’s
overall strategy? What would they effectively need to change (if anything) to make the
Kindle Fire a real threat? Is this a realistic move (in terms of probability for success) for
Amazon? Does it further leverage their competitive advantages?

Apple Team
• Does Apple need to respond? Identify what you believe are Apple’s options and the
decision-criteria which should guide this process.
• If you were Apple’s iPad management team…what would be your “macro- level”
response at this stage, given Amazon’s announced intended move? Is there a need for a
water-down version of the iPad to thwart Amazon’s market entry?

Exercise #2
The Bombardier Business-in-Action vignette, on page 202, offers an excellent framework for
discussion the challenges of strategic execution. This can bring into play the relationship
between strategy formulation and strategy execution and the outcome of company performance.
The strengths and weaknesses of the decision to commit to the C-Series aircraft can be explored
as well as the market and competitive dynamics influencing the overall rollout. Questions for
Discussion

1. What are the six key areas that managers need to assess when developing a business strategy?
How does managerial responsibility and accountability factor into this process?
This answer was compiled with reference to
pages 194-198.

The core elements of a business strategy are

pictured in Figure 6.3 to the right. I will
briefly summarize the information provided in
the chapter relating to each of these six areas.
First, purpose refers to the mission of the
organization, or its reason for existence.
Purpose also encompasses the vision
statement, which defines what the company
wants to become. Markets refer to the
specific markets or segments that the business
sees itself competing in. As a part of the
strategic planning process, managers need to
evaluate their current markets, and the
viability of entering into new markets.
Products and Services refers to a review of Core Elements of Strategy (Figure 6.3,
current and potential products and services in Page 194)
a business’ portfolio. The management team
must determine whether the products they are
offering satisfy the customer’s need and create value, or whether the products have become
obsolete. Resources refers to the way that the business will allocate resources in support of
strategic decisions. The strategic planning process involves making decision about where to
allocate a company’s scarce resources. Business system configuration is the modification of an
organization’s infrastructure to ensure the success of a strategic plan. Business system
configuration might involve making changes to distribution outlets, warehousing or product
delivery, or manufacturing and assembly processes. Finally, responsibility and accountability
involves assigning responsibility for each aspect of a business strategy to a member of the
organization.

Management is actively involved in each step of this process. Specifically, management

responsibility and accountability is addressed in the “Responsibility and Accountability” section.
During the strategic planning process, those tasked with crafting strategy (top-level management/
CEO) must assign and clarify decision rights to ensure that individuals are accountable for their
actions, and set SMAC performance goals for all individuals within the organization.

2. What are the major stages of the strategic planning process? Why is revisiting an
organization’s mission and vision such a critical beginning point of the strategic planning
process?

This question will be answered with reference to pages 199- 204 in the text.

As the chart above demonstrates, the key steps associated with the strategic planning process are:
1) revisiting purpose; 2) undertaking an internal/ external analysis to better understand our
environment; 3) assessing our view of our world; 4) choosing a direction; and 5) implementing
the strategy.

Revisiting mission and vision is a critical first step in strategy formulation because owners or
managers must ensure that these two factors, which are in place to guide strategy in a direction
that is aligned with company values, are still applicable and represent desired outcomes.

Purpose and values are organizational constants, while vision has a 10 to 30 year time horizon.2
Revisiting purpose focuses on assessing how the current/ proposed strategy fits with mission and
vision. If the strategy does not fit, then it should be abandoned. Therefore, vision and mission are
an essential first step in strategic planning, as they ensure that a proposed strategy fits with the
organization’s heritage, reason for being, and envisioned future.

3. Why do managers need to assess the internal and external environment as part of the strategy
development process? What key takeaways do you believe should be the result of this analysis?

Answered on pages 200- 205

The purpose of assessing the internal and external environment is to determine the prevailing
level of business risk in four areas: macroeconomic, industry, competitor, and company. On the
internal side, companies should use frameworks like SWOT and the 3C analysis to define
strengths, areas for improvement, sources of competitive advantage, and company-level business
risk. On the external side, Porter’s Five Forces, PESTEL, and competitive analysis help managers
summarize market and non-market trends or changes that stand to influence the firm’s or the
industry’s profitability.

Anticipating moves by competitors is a key component of external analysis, allowing firms to

adapt to changes in strategy, positioning, or new initiatives of competitors. A thorough I/E
analysis helps firms to better understand the customer, identifying any shifts that have taken place
in customer attitudes, behaviours, or needs.

2
James Collins and Jerry Porras, “Building your company’s vision,” Harvard Business Review (1996): 65-
77.
As a result of this analysis, the organization should be able to determine where and how it wants
to compete, given the competitive landscape and unique organizational competencies.
Furthermore, the firm aims to identify opportunities and threats that stand to advance/derail
strategy. Finally, the I/E analysis will help the organization identify any competitive advantages
its has over the competition.

4. What is the difference among corporate-level strategies, business-level strategies, and

operating plans? How are they interconnected?

Answered on page 207 of the text.

A corporate-level strategy defines what the organization intends to accomplish and where it plans
to compete. It identifies which businesses to compete in, which businesses to add, which business
areas to exit, and where emphasis should be placed.

A business-level strategy defines how the firm intends to accomplish its corporate-level strategy.
Business-level strategy identifies how the firm will compete in each of its identified business
initiatives or business units, and establishes objectives.

An operating plan is a set of tactics the organization will employ in order to ensure that the
business strategy, and therefore the corporate strategy, is met.

Figure 6.10 on page 208 illustrates the interconnection between mission and vision, corporate
strategy, business-level strategy, and operating plans. Essentially, mission and vision trickle down
through the organizational hierarchy, and inform processes and objectives throughout the
organization. For a case study on the interconnection between these levels of strategy, see the
Shaw Communications Inc. example on page 208 of the text.

5. How is strategy formulation different in the not -for- profit sector when compared to the for-
profit sector? In your mind, does this make the development of strategy in the NFP sector more
challenging? Why or why not?

Strategy formulation differs in the not-for-profit sector in two primary ways. First, NFP managers
must balance the effectiveness of their economic activities with the social goal or purpose of the
organization. Second, NFPs are accountable to government, a membership base, a collective
board, the community at large, or a combination of these. As a result, NFPs must balance these
interests in order to maintain access to financing – some NFPs do not generate any revenue.

Figure 6.14 on page 216 outlines five areas that NFP organizations must effectively address in
strategy formulation. It follows that the NFP strategy formulation process is equally if not more
difficult that for-profit strategy formulation because a number of additional interests must be
addressed, and bottom line performance is not the only valued outcome.

Additional Discussion Questions

What are the fundamentals of operating plan formulation? Do you believe that this is a static or
dynamic process? Explain your reasoning.

Answered on pages 208-211 of the text.

The Shaw Communications Inc. example, illustrated on pages 207 to 209 offers a good
framework for presenting the cascading decision-making effect of the relationship between
corporate-level and business-level strategies, and the operating plan.

There are a five of additional considerations that not-for-profit managers must make when
crafting strategy. What are they? Which do you feel is the most important/ has the ability to derail
the NPF’s course of business? Justify your answer.

Answered on pages 216-217 of the text. There exists room for subjectivity in responding to the
second half of the question. Figure 6.15 offers a summary insight into these additional, and
NFP-unique considerations.

Case for Discussion – Target Canada – Lessons Learned

What did Target Corporation fail to do, prior to its entry into Canada, which may have resulted in
its biased perception of the extent of opportunity in Canada? Target failed to establish a well-
defined strategy. As Brian Cornell stated, they tried to do too much at once. Target figured that
the standardized business model that worked for in the U.S. would be similar to what would work
in Canada. They failed to understand the Canadian marketplace and attempted to open all of their
stores all at once. They struggled to define a competitive advantage over their competitors and
position themselves high in the Canadian consumer purchase priority.

Looking back, what approach to entering Canada would you have taken in order to mitigate the
risk of failure? Responses will be varied, but look for students to question the assumptions made
by Target Corporation in their attempted Canadian expansion. Some possible suggestions include:
Target should have focused on defining its strategy before entering directional lock-in, and kept
its plans to itself rather than announcing its intentions a full two years before coming to market. It
should have focused on competitor locations in relation to the Zellers locations it was taking over.
It should have also ensured that supply chains were able to operate effectively. Perhaps Target
should have set up test stores in certain markets to research optimal operating procedures and
marketing efforts. Target could have been aware of the growth of e-commerce and set up online
distribution channels in order to become a more ubiquitous brand in both the physical and digital
spaces.

If you were a member on the Board of Directors for Target Corporation at the time of the
Canadian expansion proposal, what would be the three most important questions you would ask
the management team? Possible questions could include: What is the purchase behaviour of
consumers situated around our new stores? How do we expect to achieve the anticipated profit at
the end of the first year? How do we expect to capture our initial investment back? Can we
expect Canadian consumers to perceive Target in Canada the same as American consumers do in
America? Who are our main Canadian competitors, their competitive advantages, and how have
they achieved success? Can we take market share from them effectively? What is the Canadian
economic landscape currently? Are Canadian retail sales sufficient to provide ample revenue, and
profits?

Why have other retailers been successful in Canada? What is it that they have done that Target
did not do? Other retailers have been successful in Canada due to their savvy analysis of the
Canadian market. They have been on top of Canadian trends and are adaptive, adjusting their
strategic endeavours in tune with market shifts. Omni-channel distribution, which Target did not
employ, is a key driver of retailer awareness and consumer satisfaction, leading to greater sales.
Quiz Questions

1. Which of the following is NOT one of the six core elements for assessing business
strategy?

a) Markets
b) Resources
c) Business system configuration
d) Vision
e) All of the above are core elements

2. Which of the following statements best describes the distinction between mission and
vision statements?

a) Mission defines an organization’s purpose or reason for existence, while vision defines the
products that a company wants to produce
b) Mission defines an organization’s purpose or reason for existence, while a vision statement is
forward looking and defines what a company wants to become or where it wants to go.
c) Mission and vision statements are the same thing
d) Vision statements describe the organization’s strategic goals, while mission statements outline
the organization’s core values
e) None of the above statements accurately describe the distinction between mission and vision

3. Which of the following is NOT a tool companies can use during the internal assessment
stage of strategic planning?

a) PESTEL
b) SWOT
c) 3C Analysis
d) Porter’s Five Forces
e) Two of the above

4. Which of the following is NOT a desired outcome of an internal/ external analysis?

a) Identifying the competitive advantage of the organization over its competitors
b) Identify opportunities and threats facing the organization
c) Identifying key performance indicators relative to the competition, and assessing historical
performance using these KPIs
d) Identify any shifts that have taken place in the customer base’s attitudes, behaviours, or needs
e) Anticipating new initiatives and changes in strategy and market positioning by competitors

5. In what areas can an organization establish a competitive advantage?

i) Innovation
ii) Customer Responsiveness
iii) Low-cost leadership
iv) Quality
v) Differentiation
a) i, ii, iv
b) ii, iii, v
c) i, iv, v
d) ii, iii, iv
e) All of the above

6. Fill in the blanks. ____________ competitive advantages are the result of being able to
execute the ____________ activities required of the transformation and marketing support
processes within an organization in a manner that is superior to the same execution
requirements of ____________.

a) Strategic, planning, competitors

b) Operational, day-to-day, competitors
c) Operational, planning, regulators
d) Strategic, day-to-day, customers
e) None of the above

7. Which of the following statements best describes business-level strategy?

a) What the organization intends to accomplish and where it plans to compete

b) A detailed, immediate-term set of objectives and corresponding tactics designed to achieve a
specific business initiative
c) Where individual business units will compete, and the tactics that each business unit will
employ to ensure success
d) The fundamental purpose the business has identified as being its predominant reason for
existence
e) None of the above

8. According to Ken Wong, what are critical considerations when developing strategy?

i) Does your proposed strategy leverage your organization’s resources and capabilities?
ii) Does your strategy fit with current and anticipated industry/market conditions?
iii) Are the competencies that you plan to leverage considered to be sustainable for the required
period?
iv) Are the key drivers of your strategy consistent with the organization’s strategic objective and
position?
v) Do you have the ability and wherewithal to successfully implement the chosen strategy?

a) i, v
b) ii, iii, iv
c) i, ii, iv, v
d) i, iii, iv, v
e) All of the above are critical considerations
9. Which of the following is NOT a fundamental of operating plan formulation?

a) Value proposition and positioning analysis

b) Market opportunity identification
c) Revenue driver identification and sales forecasting
d) Business unit objective setting
e) Upfront and ongoing cost commitment requirements
10. Which of the following statements best describes the notion of directional lock-in?

a) The level of financial and operational commitment an organization incurs as a result of

implementing strategy
b) The management team’s level of financial commitment to the success of a corporate strategy
c) The inability to change strategy once the process of strategy execution begins
d) A bias that results from focusing on response to competitor actions in the marketplace rather
than on improving internal capabilities or positioning.
e) None of the above

11. Which of the following would NOT increase the level of directional lock-in?

a) Building a new plant

b) Purchasing new equipment
c) Selling cash equivalent investments to ensure that short-run cash position remains positive
d) Undertaking advertising and marketing campaigns
e) Funding R&D programs

12. Fill in the blanks. ______________ monitor and manage processes and materials
purchases, as well as labour levels, to ensure that ____________ stay in line.

a) Finance mangers, costs

b) Operations managers, costs
c) Sales managers, forecasts
d) Human resources managers, resources
e) Operations managers, objectives

13. Which of the following is NOT a strategy consideration for social economy enterprises/

a) Operational effectiveness
b) Access to funding
c) Vitality
d) Rootedness
e) Mission balance

14. Choose the statement that is NOT true.

a) In the private sector, a firm’s overarching objective is to maximize profitability

b) In the social economy, an enterprise is influenced by a democratic foundation or an organized
collective
c) In the private sector, firms acquire financing from the government, a membership-base, and/or
internal reserves
d) The predominant revenue generation model for social economy enterprises is government
sponsorship, the sale of goods and services, and/or philanthropy
e) All of the above are true

15. Which of the following statements best describes the notion of ‘rootedness’?

a) The extent to which a NFP is interwoven into the fabric of the community that it serves and
supported by a representation of businesses, organizations, and citizens
b) The extent to which the organization’s financial vitality is connected to the successful
execution of strategy
c) The idea that NFPs must constantly increase membership and community support in order to
survive
d) For a NFP to be successful, it must involve community members in the strategy formulation
process, which will increase donations
e) None of the above
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 The attempt will not be made here to picture nor go into a minute
description of the various forms of the cystoscope. Their use, like
that of the ophthalmoscope, requires special aptitude and training.
With the latter they are of great value; without them they confuse and
complicate. The cystoscope may be used for ordinary purposes of
inspection, for aid in introducing the ureteral catheter, or even for
photographic purposes, for it is now possible with the latest
instruments to photograph the image thus obtained of the bladder
interior. To one not accustomed to viewing the field seen in such an
instrument these revelations are of little interest. To the expert,
however, they may be made of the greatest value. Without further
description, then, allusions made below to the use of the instrument
must presuppose some familiarity with it, and the advantages and
even necessity of securing special training in its use.

CONGENITAL MALFORMATIONS OF THE BLADDER.

The lesser malformations of the bladder include mainly irregularity
in shape or the formation of diverticula, which are not extremely rare.
These are especially likely to be met during hernia operations. I have
repeatedly in operating for inguinal, and once in operating for
femoral hernia, found a diverticulum of the bladder complicating the
situation. Its possibility, then, should be borne in mind. It may be thin
and lie in such close relation to the hernial sac as to be mistaken for
the latter. When opened urine will escape and contaminate the
wound. It would probably be best to close the bladder opening and
discontinue the operation rather than run the risk of contamination of
the peritoneal cavity, postponing further work for a few days. As the
result of allantoic defects a double bladder may be met, each
perhaps having one ureter opening into it. More or less complete
partitions in the bladder are more frequently met. These conditions
could not be appreciated previous to opening the viscus or the use of
the cystoscope.
More complete forms of acquired vesical hernia may be found in
such conditions as cystocele, common in women after perineal
lacerations, and frequently constituting a most serious condition.
Ectopia or Exstrophy of the Bladder.
—By far the most serious and extensive of the congenital
malformations are those constituted by more or less complete
defects of the anterior portions not alone of the bladder, but of the
abdominal wall which should cover it, and which are known as
ectopia, exstrophy, or extroversion of the bladder. Of this condition
there are different degrees, from a small cleft just behind the
symphysis pubis, to that which is complicated by prolapse of the
remaining posterior wall, the umbilicus being situated just above it,
while the pubic arch itself is defective or rudimentary. Thus in the
male there is usually epispadias of a more or less rudimentary penis,
while in the female the clitoris is cleft and the vulva more or less
opened, the urethra being defective or entirely wanting, the vagina
often small, and the uterus generally infantile. Extreme cases of this
condition constitute one of the most serious and deplorable
congenital defects which are not inherently fatal. Obviously, with
these conditions, there is constant escape of urine, usually with
complete mechanical impotence, although in the female the ovaries
are usually present, and practically always the testicles in the male.
In the latter the opening of the seminal ducts may be frequently seen
on the floor of the urethra, more or less concealed by folds of cystic
mucous membrane. The condition is much more frequent in males
than in females. The prostate is usually at least rudimentary and may
be wholly wanting. Occasionally the testicles are undescended.
Double uterus has also been seen in these conditions.
Regarding its causes there is but little known. Doubtless these
have to do with allantoic defects, but the allantois is such a
temporary organ that there would seem to be some other
contributing cause not yet recognized.
Among its most distressing features are not only the lack of control
of urine, but the irritation of the exposed mucous surfaces
consequent upon friction with clothing, or decomposition of urine and
consequent uncleanliness. There is, therefore, nearly always
ulceration, with extreme irritability and more or less constant
suffering. It is not strange, then, that for its relief surgeons have
taxed their ingenuity, or that adult patients, finding the conditions
unbearable, are willing to submit to even extreme measures.
Treatment.
—So many operative measures have been devised that it is
impossible to include them all. First of all the procedure should be
adapted to the particular case. Much will depend, for instance, upon
the extent of the defect in the abdominal wall, or in the pubic arch,
and in the male upon the rudimentary condition of the penis or the
extent of the urinary canal.
Operations for this condition may be divided into palliative and
radical—i. e., those which are intended to make it more tolerable and
those which are really entitled to the latter term. Thus if only the
exposed mucous surface can be covered with a skin covering, the
condition may be mitigated since a urinal or some device may be
worn by which its worst features may be controlled. Trendelenburg
has recently called attention to the fact that a wide separation of the
pubic arch not only weakens the pelvis, but constitutes a serious
difficulty in closing the defect. He has, therefore, combined direct
operation with separation of the pelvic bones at the sacro-iliac joints,
afterward enclosing the pelvis in a comprehensive bandage, or
suspending the patient in an apparatus in such fashion that the bony
defect in front shall be narrowed, if indeed it be not completely
obviated. This, of course, is a measure to be carried out in the early
years of childhood; in connection with it the bones may even be
wired at the symphysis. In fact immediately after the birth of such an
infant the attempt should be made to narrow the pelvis, by
surrounding that part of the body with a wide rubber band, which
shall influence growth without too much interfering with nutrition.
Later subcutaneous osteotomy may be done if necessary. At all
events, the growing pelvis should be surrounded with an enclosure
by which a constant influence may be maintained.
The various plastic operations for this defect have the common
purpose of affording a covering, which must unfortunately be without
a sphincter to guard the outlet of the cavity. The best that can be
accomplished, then, by plastic methods is the formation of a more
perfect cavity without affording sphincteric control. A theoretically
ideal method would be one which should permit raising of skin flaps
around the margin of the defect, and so turning them in that the skin
should vicariate as mucous membrane. These flaps when united,
and the anterior wall when thus formed, could be covered by other
flaps or by skin grafts; but from these flaps hairs will grow into the
bladder. These will become encrusted with urinary salts and an
amount of irritation be produced which may become not only
intolerable but locally destructive.
In the selection of any plastic method much will depend on the
size of the defect and its completeness, the condition of the
surrounding wall, and varying complications in the surrounding
structures. The general method above suggested will answer
especially for the smaller exstrophies. Beck has suggested an
excellent device, namely, the dissection from the pubes of the recti
muscles, their insertions being severed, and the partial division of
the transversalis fascia until the muscles are so mobilized that they
can be reflected and united, thus forming an anterior bladder
covering. By a second operation these partially formed flaps may be
again dissected off from the wall and a complete osteoplastic
covering afforded. Practically no operation for extroversion can be
completed in one sitting. Frequently repeated efforts have to be
made, a little being accomplished at a time. One of the greatest
difficulties met with is securing primary union along surfaces more or
less bathed or in contact with escaping urine. These flaps, even if
united, may separate in a few days as a result of this urinary
maceration. Against this there is but little possible provision, save
perhaps by catheterizing both ureters, and emptying them into a
distinct receptacle.
 Fig. 648 Fig. 649

Roux’s autoplastic method of raising a Roux’s autoplastic method of raising a

perineoscrotal flap with which to cover perineoscrotal flap and its fixation.
the defect. Lines of incision. (Hartmann.) (Hartmann.)

More complicated methods of furnishing a complete cavity have

been devised by Rutkowski and Mikulicz, both of whom have
suggested to use a small loop of small intestine wherewith to
complete the bladder cavity. In each of these methods the abdomen
is opened, a loop of bowel brought down, a small portion completely
separated by double division, end-to-end anastomosis of the main
part being then made, while the separated part is in one method
closed at one end, while the other end is fitted over the exposed
bladder surfaces as a sort of cap. The method is exceedingly
complicated and hazardous, and depends for local success upon a
sufficient blood supply to the intestinal loop, which should be
carefully ensured by caring for its vessels and mesentery. It has,
nevertheless, been successful.
A far simpler method, perhaps the simplest of all, is that of
Sonnenburg, which consists in extirpation of the bladder proper, with
plastic closure of the opening, while the ureters are carefully
separated and sutured into the upper portion of the urethral gutter.
This removes all urinary cavity and provides only for continuous
escape; but this latter is now provided in an accessible and
convenient place, while the wearing of a urinal permits the
achievement of the main purpose of the operation. Sterson operates
upon young girls by suturing the loosened ureters to the labia
minora, which are then sewed together in the median line, after
which a urinal can be worn.[68]
[68] Cantwell has suggested the following method for bladder exstrophy,
namely, to pass catheters through a perineal fistula up into the ureters, then
to dissect off the bladder wall, bringing it over a small rubber balloon,
pushing the whole into position, and uniting the abdominal wall in front.

It has occurred to many operators to more completely divert the

urinary stream by displacing the ureters and turning them into the
rectum or the sigmoid. Operations for this purpose have been
described especially by Maydl (Fig. 650), and by Moynihan, while
modifications have been suggested by many others. In practically all
of these procedures catheters are first passed into the ureters for
their identification and control. Some would dissect out the trigone
with both ureters, and, making a sufficiently large opening in the
rectum, would transplant it in its entirety within that cavity, closing the
opening. Moynihan improved on this by making a vertical incision
and entirely dissecting away the bladder, separating it also from the
prostate, thus completely isolating it. Then the portion containing the
ureters is held upward, while at the bottom of the wound the rectum
can either be seen or made visible. The peritoneal reflection is then
lifted upward from the front of the rectum, which is opened along its
anterior surface by an incision perhaps three inches in length. Into
this opening the bladder is placed, being so reflected that its former
anterior surface now looks posteriorly. The ureters, instead of
passing forward, now pass backward and the catheters contained
within them are passed into the rectum and out of the anus. The
edge of the bladder and the cut edges of the rectum are carefully
sutured, after which the abdominal wound is closed. The sphincter is
then stretched, while the catheters remain in the ureters for four or
five days.
 Fig. 650

Maydl’s operation; diversion of ureters into rectum. (Hartmann.)

A choice may be made, then, between some such method as that

last described or that of Peters, who dissects out the ureters,
retaining only a small circular patch of bladder wall, which is folded
around the orifice of each, the rest of the bladder being extirpated.
Each ureter, with its button of bladder wall, is then drawn through a
small slip in the rectal wall, made large enough to admit it, and the
end of the ureter is then left hanging for 1 or 2 Cm. into the rectum. It
would probably be better to hold the ureters in place by a stitch
rather than run the risk of their retraction; but care must be taken that
these stitches make no unnecessary constriction. Others have
substituted the sigmoid for the rectum, the procedure being
otherwise the same, all of these rectal implantations having for their
purpose the utilization of the rectum as a cavity, which may not only
contain urine, but retain it reasonably under control. In many
respects they would be ideal were it not for the attendant dangers.
These are (1) those immediately connected with an operation which
is serious, and (2) those connected with secondary infection of the
kidneys, which seems to occur in almost all cases, no matter how
apparently successful at first.

INJURIES TO THE BLADDER.

Injuries to the bladder proper may be accompanied by those of the
parts without, or may be isolated. They divide themselves mainly into
ruptures and lacerations, or penetrations directly connecting with the
exterior. Among the causes which predispose to rupture and other
injuries may be mentioned intoxication, partly because it is often
accompanied by overdistention, and partly because of the partial or
incomplete insensibility of the patient. Distention, no matter how
permitted, is an important predisposing cause. The injuries usually
include blows, falls, and crushes, and gunshot or other perforations.
The location of the rent is more commonly in the upper and
posterior portion of the bladder—i. e., in its weakest part. Such tears
may vary from one-half to four inches in length. When accompanying
fracture of the pelvis the peritoneum is more likely to be injured.
The most significant symptoms are a desire to urinate and inability
to do more than perhaps expel a few drops of bloody fluid. Of course
the passage of any blood or bloody urine will suggest the occurrence
of such an injury. Patients are usually unable to stand upright, and
also show a strong tendency to flexion of the thighs. The introduction
of a catheter and the withdrawal of bloody urine do not necessarily
settle the question as to whether there has been any possible
laceration. Some surgeons have taught that normal urine is
comparatively harmless and that it is no more likely to produce
infection than the catheter used for diagnostic purposes; but this is
not safe teaching today. A clean metal instrument is of no more
danger than a clean probe under other circumstances. Weir has
suggested a valuable test, consisting of removal of all the urine
possible, after which a measured quantity of sterile fluid is injected. If
on using a catheter again this be all recovered it may be assumed
that the bladder is not ruptured, otherwise the contrary. If hours after
the injury a catheter be used and no urine secured, this fact will be
most suggestive. The cystoscope is usually disappointing, since a
bladder so injured cannot often be satisfactorily examined.
Another class of serious injury to the bladder includes the
perforations, such as may be effected by gunshot or stab wounds,
or, as in one case of my own, where a lad sat down upon an iron
spike, about three-quarters of an inch square and nearly six inches
in length. The point of the spike entered the anus, and the
consequence of the injury was a perforation of the anterior wall of
the rectum and the posterior wall of the bladder, with injury to its
anterior wall without complete perforation. Prompt operation saved
this case, as it will most such instances, although it was shown that a
piece of his trousers had been carried into and left in the bladder. I
opened the abdomen above the pubis, to be sure that the
peritoneum was not injured, and then drained by a tube passed into
the anus and out just above the pubis, after removing the piece of
cloth. Prompt recovery followed.
The bladder may also be injured by rude manipulation of
instruments, especially the metal catheter, by one unaccustomed to
using it, or when serious difficulties are offered by prostatic
enlargement.
Treatment.—Diagnosis or even serious suspicion of such injuries
to the bladder as above described require either
perineal or abdominal section, the choice of the procedure being
based upon circumstances. If there be reason to suspect
intraperitoneal extravasation, then the abdomen should be opened,
carefully cleaned, the bladder rent sought and sutured, the mucosa
being first closed with hardened gut, while the peritoneal aspect may
be sutured with silk or thread. The bladder should be drained, at
least by retention of a catheter, passed if necessary by perineal
section, and the abdomen drained. In the female drainage may be
made through the cul-de-sac. If there be urinary extravasation
behind the perineum, then perineal section should be made, and the
bladder, thus freely opened, should be drained with a sufficiently
large tube; while in the female it will probably be sufficient to dilate
the urethra and insert a tube of sufficient size. It is not always easy
to discover an opening placed posteriorly in the bladder wall, and
after a wide exposure, with emptying and cleansing of the pelvis, it
may be of great assistance to place the patient in the Trendelenburg
position. Under rare circumstances the rent may be so placed as to
justify a suprapubic drainage of the bladder.

FOREIGN BODIES IN THE BLADDER.

Foreign bodies other than calculi occur in the bladder in
consequence of both accident and of design. The former are, e. g.,
represented by pieces of broken catheter, while the latter are
materials introduced from without in consequence of sexual
perversion, during intoxication, or from some other vicious tendency.
The latter occur more often in girls and women, the former more
often in men. In such a collection of cases as was made by Poulet
(Foreign Bodies in Surgery) almost every imaginable object that
could be introduced into the bladder is mentioned. Some of these
have slipped in accidentally after external manipulation, as in
masturbation, and some have been deliberately introduced. Perhaps
as common an object as any is the ordinary hairpin. It is the short
urethra of women which is made the much more frequent resort for
such practices than the long urethra of men, in which latter foreign
bodies are often entangled or arrested before they reach the bladder.
Any object allowed to remain in the bladder will serve as a nidus
for the formation of a calculus, which will form in time, and it may
result that not until the removal of the calculus and examination of its
interior structure will the original foreign body be found.
 All objects of this kind should be removed as early as possible
after their introduction. Such removal may be easy and
accomplished by dilatation of the female urethra, with or without the
use of the cystoscope; or the bladder may require to be opened,
either above the pubis, through the perineum, or through the vagina,
in order that the object in question may be extracted.

INCONTINENCE, RETENTION, AND SUPPRESSION OF URINE.

Students often confuse not only terms but conditions, and it is
necessary to be accurate in teaching regarding these subjects.
Suppression of urine is purely a matter of cessation of renal function,
and has nothing to do with the bladder. Retention of urine, on the
other hand, has nothing to do with the kidneys, but is purely a
bladder affair. It may be due to spasm of the bladder outlet, or to its
obstruction by calculi, other foreign body, or by prostatic
enlargement, or it may be a consequence of paralysis of bladder
muscle. Such retention is the inevitable consequence of fracture of
the spine, since paraplegia is to be expected in such cases, and the
condition is to be atoned for by careful and regular catheterization.
Retention, again, is occasionally seen in hysterical patients. It
furnishes the distressing and sometimes permanent or even fatal
consequences of prostatic enlargement in old men. No matter how
produced, it must be relieved, for urine tends to accumulate and to
distend the bladder, which will finally burst unless the difficulty be
sufficiently overcome so that urine may in some way escape.
Distention of the bladder under these circumstances is recognized
by the formation of a rapidly increasing tumor, which finally rises to
the level of the umbilicus, fluctuates, and is accompanied or not by
pain according to the nature of the cause of retention. In paralytic
cases there will be little or no pain. In obstructive cases it will be
agonizing.
By natural efforts final rupture of the bladder is usually prevented,
as after a certain degree of distention has been attained urine begins
to escape drop by drop. This is simply an expression of an overflow,
and is not to be confused with incontinence in the proper sense of
the term. It may be spoken of as stillicidium, due to retention. The
young and indifferent practitioner may mistake this escape of urine
for incontinence, which would be a most serious error. Under any
circumstances, when such a condition may possibly occur, the lower
abdomen should be palpated, when the presence of a distended
bladder should be instantly recognized. The first indication is for its
prompt relief by the use of the catheter, while the necessary
catheterization should be done with the usual precautions. When the
passage of an ordinary instrument is made difficult or impossible the
cause of the retention is usually thereby revealed, and may be
shown to be so serious as to necessitate further operative
procedures.
When the bladder is distended and no catheter can be introduced
it is advisable to aspirate, the aspirating needle being introduced
through the sterilized skin just above the pubis, its point directed
toward the centre of the mass formed by the distended bladder.
Repeated aspiration may be necessary, and it has been suggested
to make more or less permanent use of such a tube or hollow
needle. At present no surgeon would continue this as a permanent
measure, but simply as a temporary relief, even if repetition be
necessary, until more radical procedure can be carried out. Whether
this be the removal of a foreign body or calculus, or of an enlarged
prostate, it is indicated just the same, the only exception to this
statement being those cases already too seriously involved to justify
more than perineal section (cystotomy for drainage). Retention of
urine, then, is always a preventable condition, and its continuance is
inexcusable.
Incontinence implies a paralytic condition, usually of the expulsive
muscles, but sometimes of the sphincter apparatus in either sex, by
which urinary control is lost and urine escapes involuntarily. It may
be a temporary and occasional phenomenon, occurring under the
influence of strong excitement or during sleep, especially in children,
or it may be due to spinal disease or traumatisms, with paralysis of
the lower segments of the cord and nerves given off from them.
When originating in the latter way it is usually a hopeless condition,
but nocturnal incontinence of children, or even of adults, or that due
to hysterical or other neurotic conditions, may usually be benefited.
For this purpose the surgeon should search for the cause from which
the reflex proceeds. This may be extreme acidity of urine, the
irritation of a tight prepuce in either sex, the presence of worms,
intestinal disturbances, or any one of a great number of possible
causes of disturbance of nerve control. Some of them permit of
surgical relief; others require simpler measures. Children thus
suffering should be given no fluid late in the evening, but should be
made to empty the bladder before retiring, and perhaps be aroused
once or twice through the night for the same purpose. In all cases
the urine should be examined and hyperacidity overcome. All forms
of genital excitement should be obviated. In the adolescent and in
adults thus annoyed, and in the insane, it has been shown to be of
great benefit to make a few intraspinal injections of sterile salt
solution, as for local anesthetic purposes, a little cerebrospinal fluid
being first withdrawn, and then from 2 to 10 or 15 Cc. of the solution
being introduced. This seems to have been empirically suggested by
a French surgeon, but has been found of value by Valentine and
others, including the writer.
The above forms of incontinence are to be distinguished from
intense irritability of the bladder, with frequent calls to empty it, which
accompany many such conditions as cystitis, tuberculosis, tumors,
calculi, and the like. This is the extreme irritability of local disease
rather than true incontinence. But there is also a form, in women,
characterized by falling away of the urethra and neck of the bladder
from the pubis, due usually to injuries received during parturition,
with consequent sacculation or dilatation of the urethra and
formation of a cystocele. (Dudley.) This may also be associated with
other results of perineal laceration. Here loss of urine is not constant,
but occasional or frequent. For its treatment the following methods
have been suggested: the injection of paraffin; partial torsion of the
urethra (Gersuny), i. e., a partial dissection of the urethra and
revolution upon its own axis, with subsequent suture, by which
incontinence may be overcome, but at the possible risk of sloughing.
Finally, Dudley has proposed the method of advancement of the
urethra. He makes a horseshoe denudation, between the meatus
and the clitoris, down on either side of the urethra, and nearly its
entire length. Its anterior end is then loosened sufficiently so that the
meatus can be drawn forward and secured below the clitoris by two
sutures. The balance of the wound is then closed, the effect of the
operation being to replace and retain the urethra and prevent its
sagging. Other surgical treatment, as for cystocele, laceration, etc.,
may be added as needed.

CYSTITIS.
The condition of true cystitis arises invariably either from the
irritation of a foreign body or the presence of bacteria; the former
need not necessarily be large, and minute and irritating crystals are
often sufficient to produce at least some of its features. Sooner or
later, however, the germ element enters, and from that time on
cystitis is a bacterial infection. Furthermore this infection is usually
secondary, rarely if ever primary, and may come from without or
within. Thus it may be the consequence of the introduction of
unclean instruments; is a very frequent consequence of gonorrhea,
including all forms of urethritis; or may be the result of local
tuberculous processes or those travelling downward from the
kidneys; or, again, of more general toxic or septic conditions, such as
typhoid and other infectious fevers. Certain conditions predispose,
such as the presence of calculi or the occurrence of traumatism.
Again, a bladder weakened by overdistention or paralysis, as in
cases of spinal injury, loses its natural resisting power and succumbs
to infection abnormally easily. It should be emphasized that the
absolutely healthy bladder wall is resistant to all germ activity, but
this resistance is easily lost or modified in the presence of disease,
either close by or distant. A bladder whose normal shape has been
greatly changed by enlargement of the prostate is again rendered
not only unhealthy, but incapable of acting normally. It becomes,
therefore, easily infected, and cystitis is a frequent accompaniment
of prostatic hypertrophy.
 Fig. 651

Internal appearance of bladder in some cases of inveterate cystitis; mucosa

sacculated by columns of hypertrophied tissue. (Launois.)

Symptoms.—The cardinal symptoms of cystitis are three in

number, i. e., pain, frequency of micturition, and
pyuria, the latter being the consequence of changes in the urine, as
well as in the bladder wall, while the pain and the thamuria are
expressions of irritation, especially of the base of the bladder and the
posterior urethra. In fact, all the more violent expressions of cystitis
are found at the lower part of the bladder rather than in its upper
portion. Obviously, then, irritation of adjoining organs is more easily
accounted for, e. g., of the urethra, the seminal vesicles, the
prostate, and the lower ends of the ureters.
The pain may be severe, and is especially complained of with
each act of urination. It is referred not only to the region of the
bladder proper, but along the urethra to the end of the penis in the
male, and down the thighs in both sexes. With frequency of urination
there is also distressing urgency, so that once the necessity be felt
nothing can restrain the promptness of the act. In fact so powerful is
the expulsive tendency that the tenesmus affects not only the
bladder but often the rectum, while the feeling or desire to urinate
continues after the bladder has been emptied of its last drop, even
for several minutes, and may cause the patient to sit in agony for
some time. The distress produced in acute cases of cystitis is
excessive, and sedatives and anodynes constitute no small part of
the treatment.
The amount of pus contained in the urine will vary with the degree
of acuteness and the stage of the disease. At first it is but slight, but
rapidly increases, until the urine may contain thick mucus and pus up
to one-third or more of its volume. Finally blood may appear, by
whose appearance a serious degree of inflammation is betokened.
Later, at a variable date, the putrefactive element is introduced;
and when the urine begins to smell of ammonia—i. e., when
ammoniacal decomposition has once begun—the bladder is thereby
the more irritated and the case made still worse.
No vesical mucosa left suffering from such acute inflammation will
remain unaffected in its tissue elements, but will rapidly become
more or less thickened. In fact the entire bladder wall undergoes a
process of thickening, from hypertrophy of its inner and its muscular
or middle coats, the latter due to extra activity in consequence of the
constant tenesmus. There results in time a marked eccentric
hypertrophy, whose result is really a contraction of the bladder cavity
and a distortion of its lining. Under these circumstances, also, the
mucosa becomes sacculated, and numerous little pockets, which
may contain decomposing urine, serve to complicate the situation;
while, finally, more or less incrustation or calculous degeneration and
implantation modify the character of the mucous coat. For all these
changes to occur requires time, but their combined effect is such
thickening and contraction of the bladder as to permanently alter it
and lead to a final concentric hypertrophy.
Tuberculous Cystitis.—The picture presented by tuberculous
disease of the vesical mucosa is, in the
beginning, one of miliary or disseminated involvement; but later,
when ulcerative changes have taken place, the end results are
scarcely different from those rehearsed above, save that the
ulcerative element is more predominant, and there is great
probability of involvement of the ureters or of any of the adjoining
organs. As conditions do not essentially vary, neither do symptoms,
and a diagnosis of tuberculous cystitis often must, in the early
stages, be reached by a process of exclusion, corroborated perhaps
by the cystoscope.
Postoperative Cystitis.—A different clinical type of irritation, or
mildly infective cystitis, is known to be a
sequel of certain operations, not alone those upon the pelvis. In the
majority of cases it occurs when catheterization has been required,
the first event being urinary retention, by which the bladder mucosa
must be more or less disturbed. It may be perhaps accounted for by
the fact that the urethra is practically never free from germs, which,
in that canal, seem to be innocent, but which, carried upward into an
irritated bladder may excite serious inflammation. These cases are
perhaps more frequent after pelvic operations for cancer. There
seems, however, no doubt but that repeated catheterization for
several days lowers bladder resistance.
Treatment.—When the occurrence of cystitis is imminent
prophylactic or preventive treatment is recommended.
This should consist in administration of large quantities of fluid, with
urinary antiseptics, in lavage of the bladder itself, and in reliable
antiseptic precautions in catheterization. Thus to operate upon a
bladder which has long held seriously infected or decomposed urine,
without previously cleansing it as much as possible, is simply to
invite further trouble.
The medicinal treatment of cystitis, on which we mainly rely,
consists in dilution of the urine by large amounts of fluid ingested, in
overcoming hyperacidity by the administration of alkalies, and in
combating putrefactive conditions, so far as possible, by antiseptics
which are eliminated through the kidneys. Balsams have been long
held in great repute; but remedies like urotropin and other synthetic
compounds have taken their place. Of them all, and especially in the
presence of ammoniacal urine, urotropin and the alkaline salts of
benzoic acid seem most reliable. Excessive irritability may be
overcome by local measures, such as frequent hot rectal douches,
hot sitz baths; by quieting irritation of the genitospinal centres by
administration, e. g., of cannabis indica, in doses pushed to the
physiological limit; by local anodynes, as by opium suppositories, or
in extreme cases by general anodynes like morphine.
Theoretically a seriously infected bladder should be washed out
and cleansed as any other pus cavity, but when so inflamed the
bladder becomes so intolerant and exquisitely irritable that the mere
act of washing can only with difficulty be borne by the patient.
Retention of a catheter, which might be advisable under most
circumstances, may also be impossible for the same reason. The
condition of a patient under extremes of this kind is pitiable, and
resort to general anodynes unavoidable. Still it is possible with
patience and the use of selected drugs to gradually allay even a
most acute cystitis. Confinement in bed and an almost fluid diet are
also necessary features of treatment.
If the introduction of an instrument can be borne it may be possible
to leave in the bladder some soothing solution after it has been
washed, such as a mild cocaine solution containing a little morphine,
or olive oil containing orthoform, or a mild preparation of ichthyol.
Even if these be retained but for a short time they will usually afford
relief.
Finally in severe forms of cystitis the bladder may be opened for
the purpose of giving it physiological rest, selecting either the
suprapubic or the median perineal route. The relief thus afforded is
usually gratifying, while drainage may be maintained until the local
treatment has been sufficiently effective to permit either spontaneous
closure of the drainage opening or its repair by suture. This measure
is known as cystostomy for the relief of cystitis.
Obviously if cystitis be due to the presence of any foreign body its
treatment becomes necessarily surgical, the same being true of
those forms due to or connected with hypertrophy of the prostate. It
is impossible to accomplish a cure here until the mechanical difficulty
is first overcome.

VESICAL CALCULUS.
 In the urinary bladder as well as in the gall-bladder mineral
elements held in solution by the contained fluids are precipitated, the
consequence being the formation of calculi or stones in the bladder,
which vary in size from the smallest concretions to those weighing
many ounces, and in number from one to scores, a large proportion
of these representing original concretions passed down from the
kidneys, i. e., minute renal calculi. Every calculus has a nucleus, and
in many instances this may be a clot, or clump of cells encrusted
with salts, which have formed within the bladder and not come down
from above. Such foreign bodies will become the nidus for a
calculus, while in vesical calculi are frequently found pieces of
catheter, of straw, chewing-gum, hairpins, and the like, which have
been introduced from without. These stones are constituted mainly
of the ordinary urinary salts, i. e., phosphates, urates, or oxalates,
deposited as described above. Much more rarely cystin and xanthin
are found. Instead of urates crystallized uric acid will be occasionally
seen. The oxalates are mostly those of calcium, while the
phosphates are those of calcium, magnesium, or ammonium, more
or less combined. The first requisite for a calculus is a nidus, the
second the deposition of one or more of these salts. Calculi are
sometimes composite in structure, some having a uric or urate
nucleus becoming later encrusted with phosphates. The oxalic
calculi are exceedingly hard and usually rough, being often spoken
of as mulberry. They rarely attain large size. The rapidly forming
phosphatic calculi are often so small as to disintegrate or break in
the process of removal. Thus there may be great differences in
density of these stones. Their formation is particularly favored by
retention of alkaline urine, as in many cases of prostatic
enlargement.
Symptoms.—Discomforts and symptoms produced by bladder
stone depend upon their size, number, roughness,
movability, and location. The larger and rougher stones, which are
more or less easily moved inside a tender and irritable bladder, will
cause a large amount of discomfort and actual pain, while a small
calculus, which may be formed within a pocket or become encysted
at some distance from the urethral opening may remain unnoticed.
The indications of calculi are essentially those of cystitis, pain,
frequency of urination, and pyuria, sometimes with hematuria. The
pain is local and referred, especially along the urethra, to the glans in
the male, and is often aggravated by the final expulsive movements
of the bladder at the termination of urination. Local discomfort is
aggravated by active exercise. Reflex pains have been known in
distant parts of the body. The frequency of urination is increased by
exposure to cold or by activity. Pyuria and hematuria do not differ
from those of non-calculous cystitis. A most significant feature is
sudden stoppage of the urinary stream, with more or less pain.
Statements to this effect, especially if accompanied by a history of
renal calculi in time past, are most suggestive.
Unless, however, particles of calcareous material have been
passed the positive diagnosis of calculus rests upon its detection by
examination, either with a stone searcher or with the cystoscope.
The former is essentially a short-beaked, light sound, which may be
more easily manipulated after introduction within the bladder. In
using it the same precautions are taken as for catheterization or
sounding, while the deep urethra may be made less sensitive by a
cocaine solution. The instrument is introduced exactly as is a sound,
and its beak is carried completely into the bladder. Sometimes even
before this has been accomplished will be noted the rough, grating
sensation which indicates contact with a stone. At other times it is
only after considerable search that a small stone is “touched.” A
stone easily found is within the possibilities of unskilled manipulation,
but to accurately examine a bladder, especially behind a large
prostate, is a fine art. For this purpose the bladder should be partially
distended with fluid, the patient should be in the horizontal position,
and the stone searcher so manipulated that its beak may be made to
traverse every portion of the lower part of the bladder and to come
into contact with its wall, for only in this way can an encysted
calculus be discovered. The beak must, moreover, be rotated so as
to be carried down into the pocket behind an enlarged prostate, as in
such pockets many calculi nestle. Some stones are felt even in
introducing a soft catheter; others are discovered only after such
manipulation as the above. Nothing but necrosed bone or a foreign
body can convey to the metal instrument, and through it to the finger,
the peculiar sensation produced by contact with a stone. By