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Statistical Process Control and Data Analytics 8th Edition
John Oakland & Robert Oakland Digital Instant
Download
Author(s): John Oakland & Robert Oakland
ISBN(s): 9781003439080, 100343908X
Edition: 8
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Language: english
Statistical Process Control
and Data Analytics

The business, commercial and public-sector world has changed dramatically since
John Oakland wrote the first edition of Statistical Process Control in the mid-1980s.
Then, people were rediscovering statistical methods of ‘quality control,’ and the book
responded to an often desperate need to find out about the techniques and use them on
data. Pressure over time from organizations supplying directly to the consumer, typically
in the automotive and high technology sectors, forced those in charge of the supplying,
production and service operations to think more about preventing problems than how
to find and fix them. Subsequent editions retained the ‘tool kit’ approach of the first but
included some of the ‘philosophy’ behind the techniques and their use.
Now entitled Statistical Process Control and Data Analytics, this revised and updated
eighth edition retains its focus on processes that require understanding, have variation,
must be properly controlled, have a capability and need improvement – as reflected in the
five sections of the book. In this book the authors provide not only an instructional guide
for the tools but communicate the management practices which have become so vital to
success in organizations throughout the world. The book is supported by the authors’
extensive consulting work with thousands of organizations worldwide. A new chapter
on data governance and data analytics reflects the increasing importance of big data in
today’s business environment.
Fully updated to include real-life case studies, new research based on client work from
an array of industries and integration with the latest computer methods and software, the
book also retains its valued textbook quality through clear learning objectives and online
end-of-chapter discussion questions. It can still serve as a textbook for both student and
practicing engineers, scientists, technologists, managers and anyone wishing to understand
or implement modern statistical process control techniques and data analytics.

John Oakland is one of the world’s top ten gurus in quality and operational excellence;
Executive Chairman, Oakland Group; Emeritus Professor of Quality & Business
Excellence at Leeds University Business School; Fellow of the Chartered Quality Institute
(CQI); Fellow of the Royal Statistical Society (RSS); Fellow of the Cybernetics Society
(CybSoc); Fellow of Research Quality Association (RQA).

Robert Oakland is Director in the Oakland Group and works across the globe helping
complex organizations unlock the power in their data using advanced analytical and
statistical techniques to improve the quality, cost and delivery of their products and
services.
Statistical Process Control
and Data Analytics
Eighth Edition

John Oakland and Robert Oakland

Designed cover image: © da-kuk/Getty Images
Eighth edition published 2025
by Routledge
4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
and by Routledge
605 Third Avenue, New York, NY 10158
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2025 John Oakland and Robert Oakland
The right of John Oakland and Robert Oakland to be identified as authors of this
work has been asserted in accordance with sections 77 and 78 of the Copyright,
Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in any
information storage or retrieval system, without permission in writing from the
publishers.
Trademark notice: Product or corporate names may be trademarks or registered
trademarks, and are used only for identification and explanation without intent
to infringe.
First edition published by Butterworth-Heinemann 1986
Seventh edition published by Routledge 2019
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
Names: Oakland, John, author. | Oakland, Robert James, author.
Title: Statistical process control and data analytics / John Oakland and Robert
Oakland.
Description: Eighth edition. | Abingdon, Oxon ; New York, NY : Routledge,
2025. | Includes bibliographical references and index.
Identifiers: LCCN 2024016148 (print) | LCCN 2024016149 (ebook) |
ISBN 9781032573717 (hbk) | ISBN 9781032569024 (pbk) |
ISBN 9781003439080 (ebk)
Subjects: LCSH: Process control—Statistical methods.
Classification: LCC TS156.8 .O23 2025 (print) | LCC TS156.8 (ebook) |
DDC 658.5/62—dc23/eng/20240430
LC record available at https://lccn.loc.gov/2024016148
LC ebook record available at https://lccn.loc.gov/2024016149
ISBN: 978-1-032-57371-7 (hbk)
ISBN: 978-1-032-56902-4 (pbk)
ISBN: 978-1-003-43908-0 (ebk)
DOI: 10.4324/9781003439080
Typeset in Sabon
by Apex CoVantage, LLC
Access the Support Material: www.routledge.com/9781032569024
For Susan, Jane and Debbie
Contents

Prefacexii

PART 1
Process understanding1

1 Quality, processes and control 3

Objectives 3
1.1 The basic concepts 3
1.2 Design, conformance and costs 7
1.3 Quality, processes, systems, teams, tools and SPC 11
1.4 Some basic tools 14
1.5 SPC, ‘big data’ and data analytics 15
Chapter highlights 18
References and further reading 20

2 Understanding the process 21

Objectives 21
2.1 Improving customer satisfaction through process management 21
2.2 Information about the process 23
2.3 Process mapping and flowcharting 26
2.4 Process analysis 30
2.5 Statistical process control and process understanding 34
Chapter highlights 35
References and further reading 37

3 Process data collection and presentation 38

Objectives 38
3.1 The systematic approach 38
3.2 Data collection 40
3.3 Bar charts and histograms 42
3.4 Graphs, run charts and other pictures 46
3.5 Data quality and sharing 49
Chapter highlights 52
References and further reading 53
viii Contents
PART 2
Process variability55

4 Variation – understanding and decision making 57

Objectives 57
4.1 How some managers look at data 57
4.2 Interpretation of data 58
4.3 Causes of variation 59
4.4 Accuracy and precision 64
4.5 Variation and management 69
Chapter highlights 70
References and further reading 71

5 Variables and process variation 72

Objectives 72
5.1 Measures of accuracy or centring 72
5.2 Measures of precision or spread 74
5.3 The normal distribution 76
5.4 Sampling and averages 77
Chapter highlights 83
Worked examples using the normal distribution 83
References and further reading 86

PART 3
Process control87

6 Process control using variables 89

Objectives 89
6.1 Means, ranges and charts 89
6.2 Are we in control? 98
6.3 Do we continue to be in control? 101
6.4 Choice of sample size and frequency and control limits 104
6.5 Short-, medium- and long-term variation 106
6.6 Process control of variables in the world of big data 110
Summary of SPC for variables 115
Chapter highlights 116
Worked examples 116
References and further reading 125

7 Other types of control charts for variables 127

Objectives 127
7.1 Life beyond the mean and range chart 127
7.2 Process control for individual data 129
7.3 Median, mid-range and multi-vari charts 133
 Contents ix
7.4 Moving mean, moving range and exponentially weighted
moving average charts 137
7.5 Control charts for standard deviation (σ) 145
7.6 Techniques for short-run SPC 150
7.7 Summarizing control charts for variables and big data 151
Chapter highlights 151
Worked example 152
References and further reading 153

8 Process control by attributes 154

Objectives 154
8.1 Underlying concepts 154
8.2 Process control for number of defectives or non-conforming
units 156
8.3 Process control for proportion defective or non-conforming
units 163
8.4 Process control for number of defects/non-conformities 166
8.5 Attribute data in non-manufacturing 170
Chapter highlights 173
Worked examples 173
References and further reading 176

9 Cumulative sum (cusum) charts 177

Objectives 177
9.1 Introduction to cusum charts 177
9.2 Interpretation of simple cusum charts 180
9.3 Product screening and pre-selection 183
9.4 Cusum decision procedures 186
Chapter highlights 190
Worked examples 191
References and further reading 196

PART 4
Process capability197

10 Process capability for variables and its measurement 199

Objectives 199
10.1 Will it meet the requirements? 199
10.2 Process capability indices 201
10.3 Interpreting capability indices 205
10.4 The use of control chart and process capability data 205
10.5 Service industry example of process capability analysis 208
Chapter highlights 209
Worked examples 210
References and further reading 211
x Contents
PART 5
Process improvement213

11 Process problem solving and improvement 215

Objectives 215
11.1 Introduction 215
11.2 Pareto analysis 218
11.3 Cause and effect analysis 225
11.4 Scatter diagrams 230
11.5 Stratification 232
11.6 Summarizing problem solving and improvement 234
Chapter highlights 235
Worked examples 236
References and further reading 242

12 Managing out-of-control processes 243

Objectives 243
12.1 Introduction 243
12.2 Process improvement strategy 244
12.3 Use of control charts and data analytics for trouble-shooting 246
12.4 Assignable or special causes of variation and big data 254
Chapter highlights 257
References and further reading 258

13 Designing the statistical process control system 259

Objectives 259
13.1 SPC and the quality management system 259
13.2 Teamwork and process control/improvement 262
13.3 Improvements in the process 264
13.4 Taguchi methods 270
13.5 System performance – the confusion matrix 274
13.6 Moving forward with big data analytics and SPC 276
Chapter highlights 277
References and further reading 277

14 Six-sigma process quality 279

Objectives 279
14.1 Introduction 279
14.2 The six-sigma improvement model 281
14.3 Six-sigma and the role of design of experiments 282
14.4 Building a six-sigma organization and culture 286
14.5 Ensuring the financial success of six-sigma projects 288
14.6 Concluding observations and links with excellence models and
data analytics 293
Chapter highlights 295
References and further reading 296
 Contents xi
15 Data governance and data analytics 297
Objectives 297
15.1 Introduction – data attributes 297
15.2 Data governance strategies 299
15.3 Data analytics and insight 310
15.4 Future of process control and assurance 315
Chapter highlights 321
Acknowledgements 323
References and further reading 323

Appendices325

Appendix A The normal distribution and non-normality 327

Appendix B Constants used in the design of control charts for mean 335
Appendix C Constants used in the design of control charts for range 336
Appendix D Constants used in the design of control charts for
median and range 337
Appendix E Constants used in the design of control charts for
standard deviation 338
Appendix F Cumulative Poisson probability curves 339
Appendix G Confidence limits and tests of significance 340
Appendix H OC curves and ARL curves for X and R charts 348
Appendix I Autocorrelation 353
Appendix J Approximations to assist in process control of attributes 355
Appendix K Glossary of terms and symbols 359

Index365
Preface

Stop producing chaos – a cry from the heart! When the great guru of quality manage-
ment and process improvement W. Edwards Deming died at the age of 93 at the end of
1993, the last words on his lips must have been ‘Management still doesn’t understand
process variation.’ Despite all his efforts and those of his followers, including the authors
of this book, we still find managers in manufacturing, sales, marketing, finance, service
and public sector organizations all over the world reacting (badly) to information and
data. They often do not understand the processes they are managing, have no knowledge
about the extent of their process variation or what causes it, and yet they try to ‘control’
processes by taking frequent action. This book is written for them and comes with some
advice: ‘Don’t just do something, sit there (and think)!’
The business, commercial and public sector world has changed a lot since John Oakland
wrote the first edition of Statistical Process Control: A Practical Guide in the mid-80s. Then
people were rediscovering statistical methods of ‘quality control,’ and the book responded
to an often desperate need to find out about the techniques and use them on data. Pressure
over time from organizations supplying directly to the consumer, typically in the automo-
tive and technology sectors, forced those in charge of the supplying, production and service
operations to think more about preventing problems than how to find and fix them.
The second edition of Statistical Process Control (1990) retained the ‘tool kit’ approach
of the first but included some of the ‘philosophy and wisdom’ behind the techniques and
their use. In writing the third to seventh editions over the years, the authors found it nec-
essary to completely restructure the book to address the issues found to be most impor-
tant in those organizations in which Oakland’s colleagues work as researchers, teachers
and consultants. These increasingly include service and public sector organizations. The
theme that runs throughout the book is still PROCESS. Everything we do in any type of
organization is a process that:

• requires UNDERSTANDING,
• has VARIATION,
• must be properly CONTROLLED,
• has a CAPABILITY and
• needs IMPROVEMENT.

Hence the five sections of this edition.

As we move further into the twenty-first century, we know that companies in every
market are experiencing fundamental shifts in how customers interact or seek to interact
digitally with them and their products and/or services and make purchasing decisions.
 Preface xiii
Understanding the dynamics of this and implementing the necessary changes is the con-
text for the area of information quality engineering and digital transformation. In this
lightning-fast environment, from research carried out by the authors, we understand that
changing customer behavioural patterns and disruptive technology produce enormous
growth opportunities, but, at the same time, organizations also face huge challenges
when it comes to ensuring the required changes are properly supported in terms of man-
aging quality and the supporting operations.
Organizations need to gain access to approaches, methods and tools to transform and
innovate better (higher quality) and faster (more efficient) so that they can generate new
growth opportunities and create a significant competitive advantage in the digital age.
Of course, it is still the case that to be successful in today’s climate, organizations must
be dedicated to continuous improvement, but this requires management – it will not
just happen. If more efficient ways to produce goods and services that consistently meet
the needs of the customer are to be found, use must be made of appropriate methods to
gather information and analyse it before making decisions on any action to be taken.
Part 1 of the book sets down some of the basic principles of quality and process man-
agement to provide a platform for understanding variation and reducing it, if appropri-
ate. The remaining four sections cover the subject of SPC and data analytics in the basic
but comprehensive manner used in the first seven editions, with the emphasis on a practi-
cal approach throughout.
John was joined in the second edition by his friend and colleague Roy Followell, who
has now passed away. In the seventh edition, John was joined by Robert, a partner in the
Oakland Group and an engineer/manager with extensive experience of bringing about
successful change based on improving the process–people–technology links through good
data analytics.
Developments in big data and data analytics have been huge, even since publication
of the seventh edition, so this brand-new eighth edition has the title: Statistical Process
Control and Data Analytics. The authors have done a large revision to bring the book
completely up to date. There is a completely new chapter on data governance and data
analytics which includes data strategy, architecture and predictive analytics, and the con-
cepts have been threaded throughout the revised Chapters 1–14, as appropriate – includ-
ing the dangers of increasing variation by measuring every ‘item’ and adjusting process
using the latest technology!
Rob and John have been helped by their colleagues in the Oakland Group and its
research and education division, now the Oakland Institute. The wisdom gained in con-
sultancy work, helping literally thousands of organizations to implement quality man-
agement, business excellence, good management systems, lean, six-sigma, SPC and data
analytics has been incorporated, where possible, into this edition. We hope the book
continues to provide a comprehensive guide on how to use SPC and data analytics ‘in
anger.’ Numerous facets of the implementation process, gleaned from many years’ work
in a variety of industries, have been threaded throughout the book as the individual tech-
niques are covered.
The book was never written for the professional statistician or mathematician. As
before, attempts have been made to eliminate much of the mathematical jargon that often
causes distress, whilst still providing explanations for the basis of the control charts and
techniques. Those interested in pursuing the theoretical aspects will find, at the end of
each chapter, references to books and papers for further study, and several of the chapters
end with worked examples taken from a variety of organizational backgrounds.
xiv Preface
The book is written, with learning objectives at the front of each chapter, to meet the
requirements of students in universities, polytechnics and colleges engaged in courses on
science, technology, engineering and management subjects, including quality assurance.
It also serves as a textbook for self or group instruction of managers, supervisors, engi-
neers, scientists and technologists. We hope the text continues to offer clear guidance and
help to those unfamiliar with either process management, SPC or data analytics applica-
tions. The book is fully supported by the Routledge website where can be found discussion
questions and short illustrative case studies.
We would like to acknowledge the huge contributions of our colleagues in the Oakland
Group. Our collaboration, both in a research/consultancy environment and in a vast
array of public and private organizations, has resulted in an understanding of the part to
be played by the use of SPC techniques and data analytics and the recommendations of
how to implement them.
John S. Oakland and Robert J. Oakland

Other titles by the same author(s) and publisher

Oakland on Quality Management

Total Organisational Excellence: The Route to World Class Performance
Total Quality Management and Operational Excellence: Text and Cases
Total Quality Management: A Pictorial Guide

Website: www.weareoakland.com
Part 1

Process understanding
1 Quality, processes and control

Objectives
• To introduce the subject of statistical process control (SPC) by considering the basic
concepts.
• To define terms such as quality, process and control.
• To distinguish between design quality and conformance quality.
• To define the basics of quality-related costs.
• To set down a system for thinking about SPC and introduce some basic tools.
• To introduce ‘big data’ and data analytics in the context of SPC.

1.1 The basic concepts

Statistical process control (SPC) is not really about statistics or control; it is about
competitiveness. Organizations, whatever their nature, compete on three issues: qual-
ity, delivery and price. There cannot be many people in the world who remain to be
convinced that the reputation attached to an organization for the quality of its prod-
ucts and services is a key to its success and the future of its employees. Moreover, if
the quality is right, the chances are the delivery and price performance will be competi-
tive too.

What is quality?

The word ‘quality’ is sometimes used to signify ‘excellence’ of a product or service – we

hear talk about ‘Rolls-Royce quality’ and ‘top quality.’ In some manufacturing compa-
nies quality may be used to indicate that a product conforms to certain physical charac-
teristics set down with a particularly ‘tight’ specification. But if we are to manage quality,
it must be defined in a way that recognizes the true requirements of the ‘customer.’
Quality is defined simply as meeting the requirements of the customer, and this has
been expressed in many ways by other authors:

Fitness for purpose or use (Juran).

The degree to which a set of inherent characteristics of an object fulfils requirements,
where an object is anything perceivable (ISO 9000: 2015).
The total composite product and service characteristics of marketing, engineering, manu-
facture, and maintenance through which the product and service in use will meet the
expectation by the customer (Feigenbaum).

DOI: 10.4324/9781003439080-2
4 Process understanding
The ability to meet the customer requirements is vital not only between two separate
organizations but within the same organization. There exists in every factory, every
department, every office a series of suppliers and customers. The PA is a supplier to the
boss – are the requirements being met consistently? Does the boss receive error-free infor-
mation set out as and when it is needed? If so, then we have a quality service. Does the
factory receive from its supplier defect-free parts that conform to the requirements of
the assembly process every time? If so, then we have a quality supplier.
For industrial and commercial organizations, which are viable only if they provide
satisfaction to the consumer, competitiveness in quality is not only central to profitability
but crucial to business survival. The consumer should not be required to make a choice
between price and quality, and for manufacturing or service organizations to continue to
exist, they must learn how to manage quality. In today’s tough and challenging business
environment, the development and implementation of a comprehensive quality policy are
not merely desirable – they are essential.
Every day people in organizations around the world scrutinize together the results of
the examination of the previous day’s production or operations and commence the ritual
battle over whether the output is suitable for the customer. One may be called the pro-
duction manager, the other the quality control manager. They often argue and debate
the evidence before them, the rights and wrongs of the specification, and each tries to
convince the other of the validity of their argument. Sometimes they nearly break into
fighting.
This ritual is associated with trying to answer the question: ‘Have we done the job
correctly?’ – ‘correctly’ being a flexible word depending on the interpretation given to
the specification on that particular day. This is not quality control; it is post-production/
operation detection, wasteful detection of bad output before it hits the customer. There is
a belief in some quarters that to achieve quality we must check, test, inspect or measure –
the ritual pouring on of quality at the end of the process – and that quality, therefore,
is expensive. This is nonsense, but it is frequently still encountered. In the office we find
staff checking other people’s work before it goes out, validating computer input data,
checking invoices and so on. There is also quite a lot of looking for things, chasing things
that are late, apologizing to customers for non-delivery and so on – waste, waste and
more waste.
The problems are often a symptom of the real, underlying cause of this type of behav-
iour, the lack of understanding of quality management. The concentration of inspection
effort at the output stage merely shifts the failures and their associated costs from outside
the organization to inside. To reduce the total costs of quality, control must be at the
point of manufacture or operation; quality cannot be inspected into an item or service
after it has been produced. It is essential for cost-effective control to ensure that articles
are manufactured, documents are produced or services are generated correctly the first
time. The aim of process control is the prevention of the manufacture of defective prod-
ucts and the generation of errors and waste in non-manufacturing areas.
To get away from the natural tendency to rush into the detection mode, it is neces-
sary to ask different questions in the first place. We should not ask whether the job has
been done correctly; we should ask first: ‘Can we do the job correctly?’ This has wide
implications, and this book aims to provide some of the tools which should be used to
ensure that the answer is ‘Yes.’ However, we should realize straight away that such an
answer will only be obtained using satisfactory methods, materials, equipment, skills and
instruction and a satisfactory or capable ‘process.’
 Quality, processes and control 5
What is a process?

A process is the transformation of a set of inputs, which can include materials, actions,
methods, data and operations into desired outputs, in the form of products, information,
services or – generally – results. In each area or function of an organization there will
be many processes taking place. Each process may be analysed by an examination of the
inputs and outputs. This will determine the action necessary to improve quality.
The output from a process is that which is transferred to somewhere or to someone –
the customer. Clearly, to produce an output that meets the requirements of the customer,
it is necessary to define, monitor and control the inputs to the process, which in turn may
have been supplied as output from an earlier process. At every supplier–customer inter-
face there resides a transformation process, and every single task throughout an organi-
zation must be viewed as a process in this way. To begin to monitor and analyse any
process, it is necessary first of all to identify what the process is and what the inputs and
outputs are. Many processes are easily understood and relate to known procedures, such
as drilling a hole, compressing tablets, filling cans with paint, polymerizing a chemical.
Others are less easily identified, such as servicing a customer, delivering a lecture, stor-
ing a product, inputting to a computer. In some situations it can be difficult to define the
process. For example, if the process is making a sales call, it is vital to know whether the
scope of the process includes obtaining access to the potential customer or client. Defin-
ing the scope of a process is essential, since it will determine both the required inputs and
the resultant outputs. A simple ‘static’ model of a process is shown in Figure 1.1. This
describes the boundaries of the process. ‘Dynamic’ models of processes will be discussed
in Chapter 2.

Figure 1.1 A process: SIPOC

6 Process understanding
Once the process is specified, the suppliers and inputs, outputs and customers (SIPOC)
can also be defined, together with the requirements at each of the interfaces (the voice of
the customer). Often the most difficult areas in which to do this are in non-manufacturing
organizations or non-manufacturing parts of manufacturing organizations, but careful use
of appropriate questioning methods can release the necessary information. Sometimes this
difficulty stems from the previous absence of a precise definition of the requirements and
possibilities. Inputs to processes include equipment, tools, computers or plant required,
materials, people (and the inputs they require, such as skills, training, knowledge, etc.);
information/data including the specification for the outputs, methods or procedure instruc-
tions; and the environment.
Prevention of failure in any transformation is possible only if the process definition,
inputs and outputs are properly documented and agreed upon. This documentation will
allow reliable data about the process itself to be collected (the voice of the process),
analysis to be performed and action to be taken to improve the process to prevent failure
or non-conformance with the requirements. The target in the operation of any process
is the total avoidance of failure. If the objective of no failures or error-free work is not
adopted, at least as a target, then certainly it will never be achieved. The key to success is
to align the employees of the business, their roles and responsibilities with the organiza-
tion and its processes. This is the core of process alignment and business process design
or re-design (BPR). When an organization focuses on its key processes, that is, the value-
adding activities and tasks themselves, rather than on abstract issues such as ‘culture’ and
‘participation,’ then the change process can begin in earnest.
Process design and particularly re-design challenges managers to rethink their traditional
methods of doing work and commit to a customer-focused process. Many outstanding
organizations have achieved and maintained their leadership through process re-design or
‘re-engineering.’ Companies using these techniques have reported significant bottom-line
results, including better customer relations, reductions in cycle times, time to market, increased
productivity, fewer defects/errors and increased profitability. BPR uses recognized tech-
­
niques for improving business processes and questions the effectiveness of existing structures
through ‘assumption busting’ approaches. Defining, measuring, analysing and re-engineering/
designing processes to improve customer satisfaction pay off in many different ways.

What is control?

All processes can be monitored and brought ‘under control’ by gathering and using data.
This refers to measurements of the performance of the process and the feedback required
for corrective action, where necessary. Once we have established that our process is
‘in control’ and capable of meeting the requirement, we can address the next question:
‘Are we doing the job correctly?,’ which brings a requirement to monitor the process and
the controls on it. Managers are in control only when they have created a system and cli-
mate in which their subordinates can exercise control over their own processes – in other
words, the operator of the process has been given the ‘tools’ to control it.
If we now re-examine the first question: ‘Have we done it correctly?,’ we can see that,
if we have been able to answer both of the questions: ‘Can we do it correctly?’(capability)
and ‘Are we doing it correctly?’(control) with a ‘yes,’ we must have done the job cor-
rectly – any other outcome would be illogical. By asking the questions in the right order,
we have removed the need to ask the ‘inspection’ question and replaced a strategy of
detection with one of prevention. This concentrates attention on the front end of any
 Quality, processes and control 7
process – the inputs – and changes the emphasis to making sure the inputs are capable
of meeting the requirements of the process. This is a managerial responsibility, and these
ideas apply to every transformation process, which must be subjected to the same scru-
tiny of the methods, the people, the skills, the data, the equipment and so on to make
sure they are correct for the job.
The control of quality clearly can take place only at the point of transformation of the
inputs into the outputs, the point of operation or production, where the letter is typed
or the artefact made. The act of inspection is not quality control. When the answer to
‘Have we done it correctly?’ is given indirectly by answering the questions on capability
and control, then we have assured quality and the activity of checking becomes one of
quality assurance – making sure that the product or service represents the output from an
effective system that ensures capability and control.

1.2 Design, conformance and costs

In any discussion on quality it is necessary to be clear about the purpose of the product or
service, in other words, what the customer requirements are. The customer may be inside
or outside the organization, and his/her satisfaction must be the first and most important
ingredient in any plan for success. Clearly, the customer’s perception of quality changes
with time, and an organization’s attitude to the product or service, therefore, may have
to change with this perception. The skills and attitudes of the people in the organization
are also subject to change, and failure to monitor such changes will inevitably lead to dis-
satisfied customers. The quality of products and services, like all other corporate matters,
must be continually reviewed in the light of current circumstances.
The quality of a product or service has two distinct but interrelated aspects:

• Quality of design
• Quality of conformance to design.

Quality of design

This is a measure of how well the product or service is designed to achieve its stated
purpose. If the quality of design is low, either the service or product will not meet the
requirements, or it will only meet the requirements at a low level.
A major feature of the design is the specification. This describes and defines the prod-
uct or service and should be a comprehensive statement of all aspects that must be pre-
sent to meet the customer’s requirements.
A precise specification is vital in the purchase of materials and services for use in
any conversion process. All too frequently, the terms ‘as previously supplied,’ or ‘as
agreed with your representative,’ are to be found on purchasing orders for bought-out
goods and services. The importance of obtaining information, materials and services of
the appropriate quality cannot be overemphasized and that cannot be achieved without
proper specifications. Published standards should be incorporated into purchasing docu-
ments wherever possible.
There must be a corporate understanding of the company’s position in the market
place. It is not sufficient that the marketing department specify a product or service
‘because that is what the customer wants.’ There must also be an agreement that the pro-
ducing departments can produce to the specification. Should ‘production’ or ‘operations’
8 Process understanding
be incapable of achieving this, then one of two things must happen: either the company
finds a different position in the market place or substantially changes the operational
facilities.

Quality of conformance to design

This is the extent to which the product or service achieves the specified design. What the
customer actually receives should conform to the design, and operating costs are tied
firmly to the level of conformance achieved. The customer satisfaction must be designed
into the production/operating system. A high level of inspection or checking at the end is
often indicative of attempts to inspect in quality. This may be associated with spiralling
costs and decreasing viability. Conformance to a design is concerned largely with the per-
formance of the actual operations. The recording and analysis of information and data
play a major role in this aspect of quality, and this is where statistical methods must be
applied for effective interpretation.

The costs of quality

Obtaining a quality product or service is not enough. The cost of achieving it must be
carefully managed so that the long-term effect of ‘quality costs’ on the business is a
desirable one. These costs are a true measure of the quality effort. A competitive prod-
uct or service based on a balance between quality and cost factors is the principal goal
of responsible production/operations management and operators. This objective is best
accomplished with the aid of a competent analysis of the costs of quality.
The analysis of quality costs is a significant management tool which provides:

• A method of assessing and monitoring the overall effectiveness of the management of

quality.
• A means of determining problem areas and action priorities.

The costs of quality are no different from any other costs in that, like the costs of main-
tenance, design, sales, distribution, promotion, production and other activities, they can
be budgeted, monitored and analysed.
Having specified the quality of design, the producing or operating units have the task
of making a product or service that matches the requirement. To do this they add value
by incurring costs. These costs include quality-related costs such as prevention costs,
appraisal costs and failure costs. Failure costs can be further split into those resulting
from internal and external failure.

Prevention costs

These are associated with the design, implementation and maintenance of the quality
management system. Prevention costs are planned and are incurred prior to production
or operation. Prevention includes:

Product or service requirements: The determination of the requirements and the setting
of corresponding specifications, which also take account of capability, for incoming
materials, processes, intermediates, finished products and services.
 Quality, processes and control 9
Quality planning: The creation of quality, reliability, production, supervision, process
control, inspection and other special plans (e.g. preproduction trials) required to
achieve the quality objective.
Quality assurance: The creation and maintenance of the overall quality management
system.
Inspection equipment: The design, development and/or purchase of equipment for use in
inspection work.
Training: The development, preparation and maintenance of quality training pro-
grammes for operators, supervisors and managers to both achieve and maintain
capability.
Miscellaneous: Clerical, travel, supply, shipping, communications and other general
office management activities associated with quality.

Resources devoted to prevention give rise to the ‘costs of getting it right the first time.’

Appraisal costs

These costs are associated with the supplier’s and customer’s evaluation of purchased
materials, processes, intermediates, products and services to assure conformance with the
specified requirements. Appraisal includes:

Verification: Of incoming material, process set-up, first-offs, running processes, inter-

mediates and final products or services, and includes product or service performance
appraisal against agreed specifications.
Quality audits: To check that the quality management system is functioning satisfactorily.
Inspection equipment: The calibration and maintenance of equipment used in all inspec-
tion activities.
Vendor rating: The assessment and approval of all suppliers – of both products and
services.

Appraisal activities result in the ‘cost of checking it is right.’

Internal failure costs

These costs occur when products or services fail to reach designed standards and are
detected before transfer to the consumer takes place. Internal failure includes:

Scrap: Defective product which cannot be repaired, used or sold.

Rework or rectification: The correction of defective material or errors to meet the
requirements.
Reinspection: The re-examination of products or work that has been rectified.
Downgrading: Product that is usable but does not meet specifications and may be sold as
‘second quality’ at a low price.
Waste: The activities associated with doing unnecessary work or holding stocks as the
result of errors, poor organization, the wrong materials, exceptional as well as gener-
ally accepted losses and so on.
Failure analysis: The activity required to establish the causes of internal product or ser-
vice failure.
10 Process understanding
External failure costs

These costs occur when products or services fail to reach design quality standards and are
not detected until after transfer to the consumer. External failure includes:

Repair and servicing: Either of returned products or those in the field.

Warranty claims: Failed products which are replaced or services redone under guarantee.
Complaints: All work and costs associated with the servicing of customers’ complaints.
Returns: The handling and investigation of rejected products, including transport costs.
Liability: The result of product liability litigation and other claims, which may include
change of contract.
Loss of goodwill: The impact on reputation and image which impinges directly on future
prospects for sales.

External and internal failures produce the ‘costs of getting it wrong.’

The relationship between these so-called direct costs of prevention, appraisal and failure
(P-A-F) costs, and the ability of the organization to meet the customer requirements is
shown in Figure 1.2. Where the ability to produce a quality product or service accept-
able to the customer is low, the total direct quality costs are high and the failure costs
predominate. As ability is improved by modest investment in prevention, the failure costs
and total cost drop very steeply. It is possible to envisage the combination of failure
(declining), appraisal (declining less rapidly) and prevention costs (increasing) as lead-
ing to a minimum in the combined costs. Such a minimum does not exist because, as it
is approached, the requirements become more exacting. The late Frank Price, author of
Right First Time, also refuted the minimum and called it ‘the mathematics of mediocrity.’

Figure 1.2 Relationship between costs of quality and organizational capability

 Quality, processes and control 11
So far little has been said about the often intractable indirect quality costs associated
with customer dissatisfaction, and loss of reputation or goodwill. These costs reflect the
customer attitude towards an organization and may be both considerable and elusive in
estimation but not in fact.
The P-A-F model for quality costing has a number of drawbacks, particularly the
separation of prevention costs. The so-called ‘process cost model’ sets out a method for
applying quality costing to any process or service. A full discussion of the measurement
and management of the cost of quality is outside the scope of this book but may be found
in Total Quality Management and Operational Excellence, 5th ed.
Total direct quality costs, and their division between the categories of prevention,
appraisal, internal failure and external failure, vary considerably from industry to indus-
try and from site to site. A figure for quality-related costs of less than 10 per cent of
sales turnover is seldom quoted when perfection is the goal. This means that in an
average organization there exists a ‘hidden plant’ or ‘hidden operation,’ amounting
to perhaps one-tenth of productive capacity. This hidden plant is devoted to produc-
ing scrap, rework, correcting errors, replacing or correcting defective goods, services
and so on. Thus, a direct link exists between quality and productivity, and there is
no better way to improve productivity than to convert this hidden resource to truly
productive use. A systematic approach to the control of processes provides the only
way to accomplish this.
Technologies and market conditions vary between different industries and markets,
but the basic concepts of quality management and the financial implications are of
general validity. The objective should be to produce, at an acceptable cost, goods and
services which conform to the requirements of the customer. The way to accomplish this
is to use a systematic approach in the operating departments of: design, manufacturing,
quality, purchasing, sales, personnel, administration and all others – nobody is exempt.
The statistical approach to process management is not a separate science or a unique
theory of quality control – rather a set of valuable tools which becomes an integral part
of the ‘total’ quality approach.
Two of the original and most famous authors on the subject of statistical methods
applied to quality management are Shewhart and Deming. In their book, Statistical
Method from the Viewpoint of Quality Control, they wrote:

The long-range contribution of statistics depends not so much upon getting a lot of
highly trained statisticians into industry as it does on creating a statistically minded
generation of physicists, chemists, engineers and others who will in any way have a
hand in developing and directing production processes of tomorrow.

This was written in 1939. It is as true today as it was then.

1.3 Quality, processes, systems, teams, tools and SPC

The concept of ‘total quality’ is basically very simple. Each part of an organization
has customers, whether within or without, and the need to identify what the customer
requirements are, and then set about meeting them, forms the core of the approach. Three
hard management necessities are then needed: a good quality management system and
the tools and teamwork for improvement. These are complementary in many ways, and
they share the same requirement for an uncompromising commitment to quality. This
must start with the most senior management and flow down through the organization.
12 Process understanding
Having said that, teamwork, the tools, the management system or all three may be used
as a spearhead to drive SPC through an organization. The attention to many aspects of a
company’s processes – from purchasing through to distribution, from data recording to
control charting – which are required for the successful introduction of a good manage-
ment system, use of tools or the implementation of teamwork will have a ‘Hawthorne
effect,’ concentrating everyone’s attention on the customer/supplier interface both inside
and outside the organization.
Good quality management involves consideration of processes in all the major areas:
marketing, design, procurement, operations, distribution and so on. Clearly, these each
require considerable expansion and thought, but if attention is given to all areas using
the concept of customer/supplier, then very little will be left to chance. A well-operated,
documented management system provides the necessary foundation for the successful
application of SPC techniques and teamwork. It is not possible simply to ‘graft’ these
onto a poor system.
Much of industry, commerce and the public sector would benefit from the improve-
ments in quality brought about by the approach represented in Figure 1.3. This will
ensure the implementation of the management commitment represented in the quality
policy and provide the environment and information base on which teamwork thrives,
the culture changes and communications improve.
SPC methods, backed by management commitment and good organization, provide
objective means of controlling quality in any transformation process, whether used in the
manufacture of artefacts, the provision of services, or the transfer of information.

Figure 1.3 A model for SPC

 Quality, processes and control 13
SPC is not only a tool kit. It is a strategy for reducing variability, the cause of most
quality problems; variation in products, in times of deliveries, in ways of doing things, in
materials, in people’s attitudes, in data, in equipment and its use, in maintenance prac-
tices, in everything. Control by itself is not sufficient, SPC requires that the process should
be improved continually by reducing its variability. This is brought about by studying all
aspects of the process using the basic question: ‘Could we do the job more consistently
and on target (i.e. better)?,’ the answering of which drives the search for improvements.
This significant feature of SPC means that it is not constrained to measuring conform-
ance and that it is intended to lead to action on processes that are operating within the
‘specification’ to minimize variability. There must be a willingness to implement changes,
even in the ways in which an organization does business, in order to achieve continuous
improvement. Innovation, resources and better use of data will be required to satisfy the
long-term requirements of the customer and the organization, and these must be placed
before or alongside short-term profitability.
Process control is vital, and SPC should form a vital part of the overall corporate
strategy. Incapable and inconsistent processes render the best designs impotent and make
supplier quality assurance irrelevant. Whatever process is being operated, it must be reli-
able and consistent. SPC together with good data can be used to achieve this objective.
Dr Deming was a statistician who gained fame by helping Japanese companies to
improve quality after the Second World War. His basic philosophy was that quality and
productivity increase as variability decreases and, because all things vary, statistical
methods must be used to measure and gain understanding of the causes of the varia-
tion. Many companies, particularly those in manufacturing industry or its suppliers, have
adopted the Deming philosophy and approach to quality. In these companies, attention
has been focused on performance improvement through the use of quality management
systems, data and SPC.
In the application of SPC there is sometimes an emphasis on techniques rather than
on the implied wider managerial strategies. SPC is not about pinning charts of data to
the walls of a plant or office; it must be a component part of a company-wide adoption
of ‘total quality’ and act as the focal point of never-ending improvement in business per-
formance. Changing an organization’s environment into one in which SPC can operate
properly may take it onto a new plain of performance. For many companies SPC will
bring a new approach, a new ‘philosophy,’ but the importance of the statistical tech-
niques should not be disguised. Simple presentation of data using diagrams, graphs and
charts should become the means of communication concerning the state of control of
processes.
The responsibility for quality in any transformation process must lie with the opera-
tors of that process. To fulfil this responsibility, however, people must be provided with
the data and tools necessary to:

• Know whether the process is capable of meeting the requirements.

• Know whether the process is meeting the requirements at any point in time.
• Correct or adjust the process or its inputs when it is not meeting the requirements.

The success of this approach has caused messages to cascade through the supply chains
and companies in all industries, including those in the process and service industries
which have become aware of the enormous potential of SPC, in terms of cost savings,
14 Process understanding
improvements in quality, productivity and market share. As the authors know from expe-
rience, this has created a massive demand for knowledge, education and understanding
of SPC, data analytics and their applications.
A management system, based on the fact that many functions will share the responsi-
bility for any particular process, provides an effective method of acquiring and maintain-
ing desired standards. The Quality Department should not assume direct responsibility
for quality but should support, advise and audit the work of the other functions, in much
the same way as a financial auditor performs his duty without assuming responsibility for
the profitability of the company.
A systematic study of a process through answering the following questions provides
knowledge of the process capability and the sources of nonconforming outputs:

Can we do the job correctly? (capability)

Are we doing the job correctly? (control)
Have we done the job correctly? (quality assurance)
Could we do the job better? (improvement)1

This information can then be fed back quickly to marketing, design, operations and the
‘technology’ functions. Knowledge of the current state of a process also enables a more
balanced judgement of equipment both with regard to the tasks within its capability and
its rational utilization.
It is worth repeating that SPC and data analytics procedures exist because there is
variation in the characteristics of materials, articles, services and people. The inherent
variability in every transformation process causes the output from it to vary over a period
of time. If this variability is considerable, it may be impossible to predict the value of a
characteristic of any single item or at any point in time. Using statistical methods and
data analytics, however, it is possible to take meagre knowledge of the output and turn it
into meaningful statements which may then be used to describe the process itself. Hence,
statistically based process control procedures are designed to divert attention from indi-
vidual pieces of data and focus it on the process as a whole. SPC techniques may be
used to measure and understand, and control the degree of variation of any purchased
materials, services, processes and products and to compare this, if required, to previously
agreed-upon specifications.

1.4 Some basic tools

In SPC numbers and information will form the basis for decisions and actions, and a
thorough data recording system is essential. In addition to the basic elements of a man-
agement system, which will provide a framework for recording data, there exists a set of
‘tools’ that may be applied to interpret fully and derive maximum use of the data. The
simple methods listed subsequently will offer any organization a means of collecting,
presenting and analysing most of its data:

• Process flowcharting – What is done?

• Check sheets/tally charts – How often is it done?
• Histograms – What does the variation look like?
• Graphs – Can the variation be represented in a time series?
• Pareto analysis – Which are the big problems?
 Quality, processes and control 15
• Cause and effect analysis and brainstorming – What causes the problems?
• Scatter diagrams – What are the relationships between factors?
• Control charts – Which variations to control and how?

A pictorial example of each of these methods is given in Figure 1.4. A full description
of the techniques, with many examples, will be given in subsequent chapters. These are
written assuming that the reader is neither a mathematician nor a statistician, and the
techniques will be introduced through practical examples, where possible, rather than
from a theoretical perspective. These techniques are still very applicable, even in our
modern world of social media and artificial intelligence.

1.5 SPC, ‘big data’ and data analytics

Improving product quality by reducing process variation has always relied on data. SPC,
whilst providing a long established and powerful set of tools, was developed decades ago
in a very different environment, and since then business has exploded with specialized
data handling technology and computing which support data analysis. Integrating these
tools is much more difficult than everyone has been led to believe, however, and there is a
need to unlock the next wave of improvements promised by SPC whilst making the most
of the new and remembering the learnings of the past.
We have gone from problems in the twentieth century of infrequent data to lots of very
frequent data; in fact, we’re generating terabytes of the stuff. There is a clear requirement
to effectively manage real-time applications by collecting, cleaning and providing useable
data, which is analysed correctly to make better decisions to improve product and service
performance.
‘Big data’ (very large complex data sets, sometimes explained by the use of five Vs:
volume, variety, veracity, value and velocity), machine learning (ML), robotics, artificial
intelligence (AI), the internet of things (IoT) and cloud computing will continue to greatly
impact industry and business/organization models. The amount of data is constantly
growing, but learning from more data depends massively on the data being collected and
used correctly if we are not going to see increases in variation in processes through lack
of understanding of aggregated or filtered data with selected algorithms. That is why the
application of modified SPC approaches, methods and tools is still an essential part of
making this transformation in the world of big data. When designing and using any large
complex system involving data streams, data collection/aggregation, data analytics and
algorithms, it is important to measure its performance in terms of the system’s ‘correctness’ –
how often it gives the right answer, the right decision/instruction.
Companies in every market are experiencing fundamental shifts in how customers
interact or seek to interact digitally with them and their products and/or services and
make purchasing decisions. Understanding the dynamics of this and implementing the
necessary changes is the context for the area of data quality engineering and digital
transformation. In this lightning-fast environment, executives understand that chang-
ing customer behavioural patterns and disruptive technology produce enormous growth
opportunities, but, at the same time, those executives also face huge challenges when it
comes to ensuring the required changes are properly managed in terms of managing qual-
ity and the supporting operations.
The challenges include ensuring the right quality data are used to feed into capable
processes, which can in turn operate at the required speeds to deliver the desired outputs.
16 Process understanding

Figure 1.4 Some basic ‘tools’ of SPC

 Quality, processes and control 17
With the amount of disruptive technology-based changes now taking place, data qual-
ity within digital transformation has become a central component of major successful
organizations’ strategies in the twenty-first century. To address this, data quality engi-
neering frameworks are needed that can provide essential support to modern businesses
and other organizations. The ability to quickly change and adapt core processes is a
key capability in digitally mature companies. Driven by the need for quality, speed and
agility, along with the need for efficiency and optimization, many organizations need
to adopt intelligent business process management systems to mitigate the challenges of
ongoing digital transformation initiatives.
Customer experience must lie at the heart of the business technology agenda, which
means simplifying customer-facing processes to make digital interactions efficient and a
‘delight.’ This means that many organizations need to change focus from cost-cutting
approaches to gaining control over all digital touchpoints both in terms of quality and
efficiency. This requires an alignment of customer-facing and operational teams in order
to deliver a quality customer experience in the most relevant channel.
With increasing amounts of data; digital interactions; and the number of processes,
tools and applications available on the market, even leading organizations are struggling
to keep pace with digital transformation challenges and are increasingly seeking solutions
to help them ensure quality and remain competitive. The challenge here is not primarily
related to insufficiently skilled employees or limited company resources; it is more about
the lack of methods and tools with strong modelling capabilities that can enable them to
implement changes and decisions faster without compromising on quality. Many organi-
zations need to gain access to approaches, methods and tools to transform and innovate
better (higher quality) and faster (more efficient) so that they can generate new growth
opportunities and create a significant competitive advantage or operational improvement.
Data analytics is the science of analysing data to draw conclusions about that informa-
tion and help make decisions. Many of the techniques and processes of data analytics,
including statistical process control, have been automated into computer processes and
programs that work on raw data and prepare it for human interpretation. In this context,
data analytics should help organizations make more strategically oriented decisions, opti-
mize performance – quality, effectiveness, efficiency, profitability or whatever is impor-
tant. Various approaches to data analytics include looking at what happened (descriptive
analytics), why it happened (diagnostic analytics), what is going to happen (predictive
analytics) or what should be done (prescriptive analytics).
The data analytics and capabilities framework shown in Figure 1.5 has been created
in the authors’ organization following years of research and experience helping clients
solve their toughest data challenges and improve businesses worldwide. There are three
core components:

• Governance – the processes, people, management systems, and methods by which

information is controlled in the organization.
• Core Capabilities – the foundational components of information management within
the organization.
• Enabling Capabilities – components that help to define, implement, and sustain infor-
mation management capability in the organization.

To create a successful data strategy, all three capabilities are needed, working together to
create sustained, long-term change.
18 Process understanding

Figure 1.5 Data analytics and capabilities framework

Data analytics relies on a variety of software tools, including spreadsheets, data visuali-
zation, reporting tools, data mining programs and open-source languages, for maximum
data manipulation. These topics, together with data strategy and governance, will be
covered in more detail in Chapter 15.

Chapter highlights
• Organizations compete on quality, delivery and price. Quality is defined as meeting
the requirements of the customer. The supplier–customer interface is both internal and
external to organizations.
• Product inspection is not the route to good quality management. Start by asking ‘Can
we do the job correctly?’ – and not by asking ‘Have we done the job correctly?’ – not
detection but prevention and control. Detection is costly and neither efficient nor effec-
tive. Prevention is the route to successful quality management.
• We need a process to ensure that we can and will continue to do it correctly – this is
a model for control. Everything we do is a process – the transformation of any set
of inputs into a different set of outputs using resources. Start by defining the process
and then investigate its capability and the methods to be used to monitor or con-
trol it.
 Quality, processes and control 19
• Control (‘Are we doing the job correctly?’) is only possible when data are collected
and analysed, so the outputs are controlled by the control of the inputs and the pro-
cess. The latter can only occur at the point of the transformation – then the quality is
assured.
• There are two distinct aspects of quality – design and conformance to design. Design
is how well the product or service measures against its stated purpose or the specifica-
tion. Conformance is the extent to which the product or service achieves the specified
design. Start quality management by defining the requirement of the customer, and
keep the requirements up to date.
• The costs of quality need to be managed so that their effect on the business is desir-
able. The measurement of quality-related costs provides a powerful tool to highlight
problem areas and monitor management performance.
• Quality-related costs are made up of failure (both external and internal), appraisal and
prevention. Prevention costs include the determination of the requirements, planning,
a proper management system for quality and training. Appraisal costs are incurred to
allow proper verification, measurement, vendor ratings, etc. Failure includes scrap,
rework, reinspection, waste, repair, warranty, complaints, returns and the associated
loss of goodwill among actual and potential customer. Quality-related costs, when
measured from perfection, are seldom less than 10 per cent of sales value.
• The route to improved design, increased conformance and reduced costs is the use of
statistically based methods in decision making within a framework of ‘total quality.’
• SPC includes a set of tools for managing processes and determining and monitoring
the quality of the output of an organization. It is also a strategy for reducing variation
in products, deliveries, processes, materials, attitudes and equipment. The question
which needs to be asked continually is ‘Could we do the job better?’
• SPC exists because there is, and will always be, variation in the characteristics of mate-
rials, articles, services, people, data, etc. Variation has to be understood and assessed
in order to be managed.
• Organizations need to gain access to approaches, methods and tools to transform and
innovate better (higher quality) and faster (more efficient) so that they can generate
new growth opportunities and create a significant competitive advantage in the digi-
tal age.
• There are some basic SPC tools. These are: process flowcharting (what is done), check
sheets/tally charts (how often it is done), histograms (pictures of variation), graphs
(pictures of variation with time), Pareto analysis (prioritizing), cause and effect analy-
sis (what causes the problems), scatter diagrams (exploring relationships) and control
charts (monitoring variation over time). An understanding of the tools and how to use
them requires no prior knowledge of statistics.
• ‘Big data,’ machine learning, robotics, artificial intelligence and the Internet of
Things are greatly impacting industry and business/organization models. The huge
amounts of data being collected need to be used correctly if we are not going to see
increases in variation in processes through lack of understanding of aggregated or
filtered data with the right algorithms. The application of modified SPC approaches,
together with data analytics methods and tools, is an essential part of making this
transformation.
• A data analytics and capabilities framework to help organizations solve tough data
challenges and improve businesses worldwide. There are three core components: gov-
ernance, core capabilities and enabling capabilities.
20 Process understanding
Note
1 This system for process capability and control is based on the late Frank Price’s very practical
framework for thinking about quality in manufacturing: Can we make it OK? Are we making it
OK? Have we made it OK? Could we make it better?, which he presented in his excellent book,
Right First Time (1984).

References and further reading

Beckford, J. (2023) Quality Management: Reconsidered for the Digital Economy, 5th edn, Routledge,
Oxford, UK.
Deming, W.E. (1986) Out of the Crisis, MIT, Cambridge MA, USA.
Deming, W.E. (1993) The New Economics, MIT, Cambridge MA, USA
Feigenbaum, A.V. (1991) Total Quality Control, 3rd edn, McGraw-Hill, New York, USA.
Garvin, D.A. (1988) Managing Quality: The Strategic and Competitive Edge, Free Press, New
York, USA.
Hammer, M. and Champy, J. (1993) Re-engineering the Corporation: A Manifesto for Business
Evolution, Nicholas Brealey, London, UK.
Ishikawa, K. (translated by David J. Lu) (1985) What Is Total Quality Control?: The Japanese
Way, Prentice Hall, Englewood Cliffs NJ, USA.
Joiner, B.L. (1994) Fourth Generation Management: The New Business Consciousness, McGraw-Hill,
New York, USA.
Juran, J.M. and De Feo, J.A. (2010) Quality Handbook, 6th edn, McGraw-Hill, New York, USA.
Oakland, J.S., Oakland, R.J. and Turner, M.A. (2021) Total Quality Management and Operational
Excellence: Text with Cases, 5th edn, Routledge, Oxford, UK.
Price, F. (1984) Right First Time, Gower, Aldershot, UK.
Shewhart, W.A. (1931) Economic Control of Manufactured Product, Van Nostrand, New York, USA.
(ASQ, 1980).
Shewhart, W.A. and Deeming, W.E. (1939) Statistical Methods from the Viewpoint of Quality
Control, Van Nostrand, New York, USA.
2 Understanding the process

Objectives
• To further examine the concept of process management and improving customer
satisfaction.
• To introduce a systematic approach to defining customer–supplier relationships,
defining processes, standardizing processes, designing/modifying processes, improving
processes.
• To describe the various techniques of block diagramming and flowcharting and to
show their use in process mapping, examination and improvement.
• To position process mapping and analysis in the context of business process re-design/
re-engineering (BPR).

2.1 Improving customer satisfaction through process management

An approach to improvement based on process alignment starting with the organiza-
tion’s vision and mission, analysing its critical success factors (CSFs) and moving on to
the key or core processes is the most effective way to engage the people in an enduring
change process. In addition to the knowledge of the business as a whole, which will be
brought about by an understanding of the mission→CSF→process breakdown links, cer-
tain tools, techniques and interpersonal skills will be required for good communication
around the processes that are managed by the systems. These are essential for people to
identify and solve problems as teams and form the components of the model for statisti-
cal process control (SPC) introduced in Chapter 1 and described in detail in Oakland’s
Total Quality Management and Operational Excellence, 5th ed.
Most organizations have functions: experts of similar backgrounds are grouped
together in a pool of knowledge and skills capable of completing any task in that disci-
pline. This focus, however, can foster a ‘vertical’ view and limits the organization’s ability
to operate effectively. Barriers to customer satisfaction can evolve, resulting in unneces-
sary work, restricted sharing of resources, limited synergy between functions, delayed
development time and no clear understanding of how one department’s activities affect
the total process of attaining customer satisfaction. Managers can remain tied to manag-
ing singular functions, with rewards and incentives for their narrow missions, inhibiting
a shared external customer perspective (Figure 2.1).
Concentrating on managing processes breaks down these internal barriers and
encourages the entire organization to work as cross-functional teams with a shared

DOI: 10.4324/9781003439080-3
22 Process understanding

Figure 2.1 Typical functional operation

horizontal view of the business. It requires shifting the work focus from managing func-
tions to managing processes. Process owners, accountable for the success of major cross-
functional processes, are charged with ensuring that employees understand how their
individual work processes affect customer satisfaction. The interdependence between
one group’s work and the next becomes quickly apparent when all understand who
the customer is and the value they add to the entire process of satisfying that customer
(Figure 2.2).
The core business processes describe what actually is or needs to be done so that the
organization meets its CSFs. If the core processes are identified, the questions will come
thick and fast: Is the process currently carried out? By whom? When? How frequently?
With what performance and how well compared with competitors? The answering of
these will force process ownership into the business. The process owners should engage
in improvement activities which may lead through process analysis, self-assessment and
benchmarking to identifying the improvement opportunities for the business. The pro-
cesses must then be prioritized into those that require continuous improvement, those
that require re-engineering or re-design and those that require a complete re-think or
visioning of the ideal process. The outcome should be a set of ‘key processes’ that receive
priority attention for re-design or re-engineering.
Performance measurement of all processes is necessary to determine progress so that
the vision, goals, mission and CSFs may be examined and reconstituted to meet new
requirements for the organization and its customers (internal and external). This whole
approach forms the basis of a ‘total organizational excellence’1 implementation frame-
work (Figure 2.3).
Once an organization has defined and mapped out the core processes, people need to
develop the skills to understand how the new process structure will be analysed and made
to work. The very existence of new process teams with new goals and responsibilities will
 Understanding the process 23

Figure 2.2 Cross-functional approach to managing core processes

force the organization into a learning phase. These changes should foster new attitudes
and behaviours.

2.2 Information about the process

One of the initial steps to understand or improve a process is to gather information about
the important activities so that a ‘dynamic model’ – a process map or flowcharts – may
be constructed. Process mapping creates a picture of the activities that take place in a
process. One of the greatest difficulties here, however, is deciding how many tasks and
how much detail should be included. When initially mapping out a process, people often
include too much detail or too many tasks. It is important to consider the sources of infor-
mation/data on processes and the following aspects should help to identify the key issues:

• Defining supplier–customer relationships.

• Defining the process.
• Standardizing processes.
• Designing a new process or modifying an existing one.
• Identifying complexity or opportunities for improvement.

Defining supplier–customer relationships

Since quality is defined by the customer, changes to a process are usually made to increase
satisfaction of internal and external customers, whether that is to do with quality,
24 Process understanding

Figure 2.3 Total organizational excellence framework

timeliness or costs. At many stages in a process, it is necessary for ‘customers’ to deter-

mine their needs or give their reaction to proposed changes in the process. For this it is
often useful to describe the edges or boundaries of the process – where does it start and
stop? This is accomplished by formally considering the inputs and outputs of the pro-
cess as well as the suppliers of the inputs and the customers of the outputs – the ‘static
model’ (SIPOC). Figure 2.4 is a form that can be used to provide focus on the boundary
of any process and to list the inputs and suppliers to the process, as well as the outputs
and customers. These lists do not have to be exhaustive but should capture the important
aspects of the process.
The form asks for some fundamental information about the process itself, such as
the name and the ‘owner.’ The owner of a process is the person at the lowest level in the
organization that has the authority to change the process. The owner has the responsibil-
ity of organizing and perhaps leading a team to make improvements.
Documentation of the process, perhaps through the use of flowcharts, aids the iden-
tification of the customers and suppliers at each stage. It is sometimes surprisingly dif-
ficult to define these relationships, especially for internal suppliers and customers. Some
customers of an output may also have supplied some of the inputs, and there are usually
a number of customers for the same output. For example, information on location and
amount of stock or inventory may be used by production planners, material handlers,
purchasing staff and accountants.
 Understanding the process 25

Figure 2.4 Describing the boundary of a process: SIPOC

Defining the process

Many processes in need of improvement are not well defined. A production engineering
department may define and document in great detail a manufacturing process but have
little or no documentation on the process of design itself. If the process of design is to be
improved, then knowledge of that process will be needed to make it tangible.
The first time any process is examined, the main focus should be to capture everyone’s
current knowledge of the process. A common mistake is to have a technical process
‘expert,’ usually a technologist, engineer or supervisor, describe the process and then
show it to others for their comment. The first information about the process should come
instead from a brainstorming session of the people who actually operate or use the pro-
cess, day in and day out. The technical experts, managers and supervisors should refrain
from interjecting their ‘ideas’ until towards the end of the session. The resulting descrip-
tion will be a reflection of how the process actually works. During this initial stage, the
concept of what the process could or should be is distracting to the main purpose of the
exercise. These ideas and concepts should be discussed later.
Flowcharts (see Section 2.3) are important to study manufacturing processes, but
they are particularly important for non-manufacturing processes. Because of the lack of
documentation of administrative and service processes, it is sometimes difficult to reach
agreement on the flowcharts for such a process. If this is the case, a first draft of a pro-
cess map can be circulated to others who are knowledgeable of the process to seek their
suggestions. Often, simply putting a team together to define the process using flowcharts
will result in some obvious suggestions for improvement. This is especially true for non-
manufacturing processes. There are available, of course, many excellent software pack-
ages that can aid the collection and presentation of process information but these should
not be used in place of the vital work needed by the process team.
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boys especially, convulsions, chorea, epilepsy, and various other
neuroses are produced, while, in addition, its perpetuation produces
a condition of unnatural excitability which leads again to habits of
masturbation or to sexual irritability and unnatural excitability.
Every newborn male infant should be carefully examined in order
that the above condition, if present, may be remedied. This remedy
will consist, in mild cases, of forcible retraction of the elongated
prepuce, with separation of any adhesions uniting it to the glans.
Preputial stenosis may be overcome in some cases by simply slitting
up the dorsum, which, if not too long, may be thus released and not
require circumcision. On the other hand a much elongated and
contracted prepuce should be sufficient justification for prompt
circumcision. At the same time any unnatural contraction of the
meatus may be overcome by trifling incision. If every boy baby were
thus carefully inspected and relieved, if necessary, there would be
fewer reflex disorders in young children.
Incidentally it may be said that, in lesser degree, the same thing
may apply to girl infants, in whom the clitoris, although small, should
nevertheless be freely uncovered by retraction of its miniature hood
or prepuce. When this is not easily possible it should be made so.
Disorders of the same general character as easily arise in girls, from
this same general cause, as in boys, nocturnal incontinence being a
frequent expression thereof. In my opinion the teaching of obstetrics
should not be considered complete without unmistakable reference
to these matters.
Phimosis in the adult may be brought about by disease, especially
in connection with a prepuce already retentive, or elongated and
difficult of retraction. Retained secretion beneath such a prepuce is a
fertile source of danger of all kinds, as well of venereal infection as
of cancerous growth. Surgeons in the Orient have described calculi,
even of considerable size, found in this location as the result of
retention of matter which should not have been at all retained, this
condition being noted most often among the Chinese.
Infection, usually gonorrheal, of the concealed surface of the
prepuce, which has a distinctly mucous character, is known as
posthitis; that of the covering of the glans as balanitis; while, in
effect, whatever appears in this location will essentially be a
balanoposthitis. If such a condition do not easily subside by
irrigation, with a small nozzle introduced beneath the margin of the
prepuce, it will then be necessary to slit up the dorsum, or make a
complete circumcision, in order that the affected surfaces may be
made accessible. The same is true in cases of chancroid and even in
cases of chancre; incision or circumcision being justifiable whenever
indicated.

PARAPHIMOSIS.
Paraphimosis implies an opposite condition, where the prepuce,
having been retracted, is caught behind the margin of the glans and
cannot be released nor brought forward. This may be the result of
undue effort to retract a very tight but otherwise normal prepuce, or
is frequently the result of an acute inflammation, where edema and
solid exudate so solidify the tissues as to make them inflexible and
almost immovable. In mild cases of paraphimosis cold applications,
or pressure with patient manipulation, may be sufficient to restore
the proper condition. An extreme degree of such constriction would
threaten the nutrition of the glans, to the extent even of possible
gangrene, and sloughing of some portion of the end of the penis is
not an infrequent result of a neglected condition of this kind. Under
these circumstances constriction must be released, it being usually
sufficient to apply or inject cocaine, and then with scissors or blunt
bistoury nick or incise the constricting ring, to a degree sufficient to
release it and permit the desired result; in one way or another this
must be attained, else more or less sloughing is sure to follow.
Other rare malformations of the urethra include its more or less
complete obliteration, in some portion at least, or, more often, its
sacculation or dilatation in certain areas, the result being the
formation of pockets or pouches. Such abnormality may persist to
adult life, and finally contain a considerable amount of retained
urine.
 EPISPADIAS AND HYPOSPADIAS.
Epispadias and hypospadias constitute defects in the urethral
construction, so that urine escapes at some point much nearer the
body than normally intended. A complete degree of epispadias
nearly always accompanies extroversion of the bladder, already
described. Milder conditions may be met in any degree. In these
cases the urethra becomes a canal open above, and the glans is
more or less defective. Cases of epispadias may be divided into the
balanic, where the urethra terminates on the upper portion of the
glans, and the penile, where it terminates between the glans and the
pubis; while cases of hypospadias may be divided into balanic and
penile, similar to the above, the penoscrotal, where the urethra
opens at the junction, and the perineoscrotal, where both the
perineum and scrotum are involved. While all of these defects are
more or less mutilating and unphysiological, none of them menace
life. The physiological requirements of either case demand conditions
permitting normal urination, and coitus to a degree permitting
fecundation. (See Fig. 667.)
 Fig. 667

Diagrammatic sections showing different varieties of hypospadias: 1,

hypospadias with imperforate glans; 2, hypospadias with blind canal in
glans; 3, with barrier placed between penile urethra and balanitic groove;
4, typical case of hypospadias; 5, hypospadias with normal meatus; 6,
penile urethra opening below glans; 7, absence of the whole inferior part
of the penile urethra; 8, hypospadias with absence of urethra through
glans; 9, case of d’Arnaud; 10, case of Lacroix; 11, case of Lippert with
normal meatus. (Kauffmann.)
 Fig. 668 Fig. 669

Hypospadias. Liberation of anterior Hypospadias. Drawing the liberated

urethra and tunnelling the glans. urethra through the tunnel in the glans.
(Hartmann.) (Hartmann.)
 Most cases of hypospadias are accompanied by other defects on
the inferior surface of the penis and the scrotum, which, more or
less, bind them down and interfere with the normal method of
urination as well as of insemination. The indications, then, in such
cases are to straighten the penis and to restore the continuity of the
urethra. The former may be accomplished by transverse incisions
through the bands which cause the curvature, or, if necessary,
division of the intracavernous septum, or even of the sheaths of or
the cavernous bodies themselves. Wedge-shaped pieces of
cavernosa have often been successfully excised. The restoration of
the urethra is a much more difficult matter, especially in an extensive
case, to make it sufficient for insemination. The methods may be
grouped under simple canalization or approximation and the
construction of flaps. Nearly all of these methods are more or less
simple in theory but difficult in practice, and frequently unpromising
because of the difficulties in securing final union of tissues, no
matter how neatly united, where the same may be interfered with by
the presence of urine or the occurrence of erections. The former
may be prevented by a perineal section, with drainage of the
bladder, and this is probably the best method to adopt in nearly all
of these cases. The latter is to some extent overcome by drugs, but
is sometimes produced by the local irritation of the operation and
the dressings. To describe all these methods would require a long
chapter. They have included efforts at tunnelling the glans, by the
passage of a trocar, maintaining the channel by keeping within it
some bougie or foreign body until its interior has healed, then
connecting this up with the balance of the urethra (Figs. 668 and
669). The urethral passage-way is rarely sufficiently wide to permit
of approximation of freshened edges by stitches, and these will
almost surely pull out. Therefore some more plastic method of
formation of flaps must be devised. Many ingenious expedients have
been suggested, among them the utilization of a strip of skin,
dissected up on one side, whose external surface is turned in and
made to vicariate as mucous membrane, while its raw surface, now
faced outward, is covered with another flap, raised either from the
penis itself or from the scrotum. It is the operations based on this
general plan which have given the best results in well-marked cases,
and yet they have to be conducted with great care. American
surgeons, among them particularly Beck, of New York, have done a
great deal to advance the plastic surgery of these parts and for
these purposes. He, for instance, has especially exploited the
movability of the urethra, and shown how by dissecting it out it may
be drawn forward and made much more available. Beck has
suggested a similar method of displacement and reëmployment of
the urethra for epispadias.
Epispadias is far more uncommon than hypospadias, occurring in
proportion of 1 to 150 cases of the latter, and is rarely seen except
in connection with vesical extroversion, except in minor degree, in
which the defect is simply a little grooving of the upper surface of
the glans. The best method of dealing with the urethra, in
epispadias, is to displace it, as suggested by Beck, separating the
cavernous bodies and dropping it down to its normal situation
beneath them, and uniting with this procedure more or less of the
transplantation suggested by him. It is surprising how much can be
accomplished by this method, even in extreme cases. The glans, if
necessary, may be tunnelled, and the anterior end of the urethra
may even be given a hypospadiac termination.

HERMAPHRODISM.
Hermaphrodism, spurious and actual, implies the existence of
sexual organs of both sexes in the same individual. It is a condition
actually existent in many of the lower forms of life, but its
occurrence in the human being is a matter of extreme rarity. There
are numerous malformations which, by the laity, are often mistaken
for indications of this condition, but the actual co-existence of both
testicle and ovary—e. g., which may perhaps be assumed as the true
test—is one of the rarest of all phenomena in human anatomy.
External malformations which more or less simulate the appearance
of the organs of one sex in those of the other include such
conditions in the male, for instance, as atrophy of the penis,
hypospadias, a more or less complete division of the scrotum into
halves, retained testicles with atrophy of the external organs, and
similar conditions by which the external genitalia are made to appear
divided or relatively too small. In the female, on the contrary, may
be seen occasionally an hypertrophy of the clitoris, which causes it
to assume almost the proportions and even the erectibility of the
male organ, while other deformities of the vulva simulate more or
less the scrotum. Again in the female one meets occasional
congenital absence of the uterus or of the ovaries, or congenital
atresia, or almost complete absence of the vagina, or vulvas which
are almost impassable by virtue of exceedingly dense hymens,
where the natural appearances are so perverted as to mislead the
ignorant. These are, however, cases of pseudohermaphrodism,
although in many of them there are certain general changes in
appearance, as of the breast, the figure, speech, and even in
manner, which are regarded as evidences of effeminacy in a male
individual, or of masculinity in a female.
Strange mistakes and errors have thus arisen, and children about
whose sex ignorant parents have been in doubt have been
mistakenly brought up, even to a point in life when it was
sociologically almost too late to remedy the error. Such cases require
careful study for the actual determination of sex, especially in young
infants.
True hermaphrodism is not to be denied, as certain historical
cases have proved, and as has been demonstrated in certain
individuals who travel from city to city, exposing themselves for a
consideration for scientific examination. In general it is sufficient to
say here that true hermaphrodism is a rare possibility, while spurious
or pseudohermaphrodism is a condition not uncommonly met.

INJURIES TO PENIS AND URETHRA.

The great vascularity of the penis makes it peculiarly liable to
obstinate hemorrhage in cases of incision or laceration. For the same
reason when strangulated, as may occur in some drunken orgy or
otherwise, it may swell enormously and quickly become gangrenous.
An actual fracture of the cavernosa has occurred, through violence in
the erected condition. Subcutaneous lacerations or contusions may
lead to extensive hemorrhages, possibly with gangrene as the result.
Any injury by which the urethra is lacerated, especially torn across,
will be followed by much hemorrhage, probably with urinary
extravasation, and perhaps great difficulty in establishing the
continuity of the channel. Under any circumstances urinary
infiltration of any part, deep or superficial, is likely to be followed by
abscess and sloughing. An absolute dislocation of the penis is not
unknown, it having been displaced beneath the integument of the
perineum, abdomen, or thigh, especially in extremely obese
individuals.
Urethral injuries are not all accidental. Some of them are the
result of design, or of the introduction of foreign bodies which
cannot be removed by the patient himself. Such articles may also be
introduced, during a drunken orgy, by another individual, or under
conditions of sexual perversion by the man himself; and such bodies
as pencils, slate-pencils, twigs, and almost every imaginable small
object have been found within the urethra. Again it has been
seriously injured and even punctured by the careless use of sounds,
or by the wire stillette of the old-fashioned linen catheter. Both the
anterior and deep urethra may be seriously injured by such
accidents as falls upon the external genitals, or upon the perineum,
and serious deep lacerations, with complete severance of the
membranous urethra, and the infliction of even greater damage, are
by no means unknown in such cases.
The first determination should be as to the presence of any
foreign body. This being eliminated an effort should be made to
check the hemorrhage, and to make sure that there is no such
obstruction of the urethra as to interfere with the freedom of the
urinary stream. The constant discharge of blood from the meatus, or
the admixture of blood with the urine, is always suggestive and
should lead to careful investigation. This should include not merely
the gentle passage of a sound or catheter, or at least attempt
thereat, but perhaps an inspection of the site of injury through the
endoscope. When the injury is compound, in the sense of being an
external laceration, the deep conditions are more easily ascertained.
 Fig. 670
If with gentleness
and yet with difficulty
a catheter can be
passed through the
injured portion of the
urethra it would be
well to leave it in situ,
at least for several
hours, perhaps for
three or four days, in
order that it may act
as a splint and the
parts more kindly
heal around it. If the
urethra be so
lacerated as to not
permit the passage of
an instrument, the
safer course is an
external perineal
section, for the
purpose of temporary
bladder drainage, or
to find a deep tear,
while a retrograde
catheterization may
perhaps be practised,
and an instrument
introduced and
carried through in the
Perineal section for deep rupture of urethra.
Posterior opening is identified and catheter, reverse of the
which has been introduced from the meatus, is ordinary direction;
guided through it into the bladder. (Lejars.) this may be possible
even when ordinary
methods fail. Extravasation of blood may be extensive and serious,
but extravasation of urine is always followed by disastrous
consequences, which should be prevented by external urethrotomy
and bladder drainage.
These cases may not be seen until the dangers have already
occurred. If it should so happen, an effort should be made, by deep
incision and free dissection, to open up all pockets containing urine
or blood and to afford free outlet from the bladder. Under some of
these circumstances, especially when attempted at night with poor
light, the performance of an external perineal urethrotomy is by no
means an easy matter, since the torn urethra may be lost in ragged
and infiltrated tissues, and may sometimes be found only after long
and tedious search.
What to do with a torn urethra, under these circumstances, is
sometimes a problem. If it be ragged and more or less torn away it
may sometimes be resected, and the ends re-united by sutures, if
necessary with a certain amount of dislocation of the urethra by
dissecting around it. Pringle and others have resorted to the fresh
urethra of the ox, for grafting into cases of recent or old defect, as in
instances of extensive deep rupture; as well as in cases of
hypospadias, with defect in the floor of the urethra throughout its
entire penile portion.
The removal of foreign bodies from the urethra is not easy when
these have passed into its deeper portion. With special instruments
it is sometimes possible to grasp and extract them, although a
pointed extremity may interfere with the ease of removal. More
harm will come from leaving them than from removing them.
Therefore when their extraction is impracticable there need be no
hesitation in button-holing the membranous or the deep urethra,
and by pushing the object down toward the opening, there effecting
its removal.
The urethral walls will take fine sutures, with every prospect of
repair, providing their vascular supply be not too seriously disturbed.
Therefore lateral or end-to-end suture may be attempted whenever
it appears promising, but in such cases it would be well either to
leave a catheter for a few days or to make bladder drainage back of
the injury.
 Cavernitis refers to an acute or chronic inflammation of the corpus
cavernosum on one or both sides. It may be the result of the
exudate connected with an injury or with the process of repair. It
may ensue in consequence of a local gonorrheal inflammation, or it
may be an induration due to chronic syphilis. The condition is one
which causes local tenderness rather than pain, while the induration
causes a perceptible lump or tumor, and infiltration of vascular tissue
interferes with symmetry during erection. Again pressure may cause
some ureteral obstruction. Cases of syphilitic origin are to be treated
by local inunctions of mercurial ointment, perhaps with ichthyol,
which are of benefit in any instance, while the internal
administration of the iodides is of more or less assistance. The non-
specific cases yield only to time and to massage.
Gummas of the penis may assume the above type, but usually
occur in more distinct form, either in the cavernous bodies or
between them. An abruptly limited nodule in any such locality will
always naturally arouse suspicion of specific disease and lead to its
appropriate treatment.
Upon the glans and the prepuce, especially, herpetic vesicles
frequently appear, constituting an annoying local lesion,
corresponding minutely to the ordinary “cold-sore” upon the lip. This
is known as herpes preputialis. It is the result usually of uncleanly
habits or local irritation. It is of no consequence, save that in some
individuals it occurs frequently, with considerable local irritation. The
broken surface thus produced is liable to chancroidal or septic
infection, which constitutes its greatest danger, while such a sore,
irritated by caustics or injudicious applications, is sometimes
mistaken for a specific lesion. A chronic herpes may frequently prove
a precancerous lesion.
The papillomas, or warty growths, are frequently noted about the
glans and prepuce, being expressions of local irritation, while, under
the conditions of local warmth and moisture which prevail, they
luxuriate and may develop into condylomatous masses, known as
“strawberry” or “mulberry” growths, which may attain large size. In
the female they occur on all parts of the vulva and anal region; in
the male they rarely appear except as above.
 All that such papillomatous growths require is complete excision or
extirpation (i. e. destruction), with cauterization of their bases and
subsequent local cleanliness. They are not infrequently referred to as
venereal warts, which, in effect, they usually are. The other benign
tumors of the penis are rare. Occasionally some dermoid cyst or
small fatty or fibrous growth may be seen. Sarcoma of the penis is
also rare, while epithelioma is not uncommon, constituting the
ordinary cancer of the penis.
Epithelioma in this region has its origin around some portion of
the mucous surface of the glans, spreading in time to the prepuce,
more or less involving the entire organ, while by its rich lymphatic
supply involvement of the inguinal and other nodes happens early,
whereby the situation is sadly complicated. Epithelial cancer here
evinces the same local tendencies toward extension and destructive
ulceration as elsewhere, made more rapid by exposure to surface
irritation. Its base is indurated, even if sometimes everted; it grows
irregularly, but destroys everything with which it comes in contact.
Epithelioma of the penis should be recognized and extirpated early
to offer any prospect of success. It is usually as unpromising a
condition as epithelioma of the tongue, because of the early
lymphatic involvement. A lesion of limited area may justify local
excision, but a distinctly marked lesion can only be successfully
treated by amputation, at least of the anterior portion of the organ,
perhaps of the entire structure of the penis, and thus ensure
complete eradication.
Amputation of the penis is easily effected with a circular sweep of
the knife, or by an abrupt cross-section, there being but little choice
of method, the intent being only to save sufficient of the organ so
that cleanliness during and after the act of urination may be
maintained. When any portion of the pendulous organ is preserved
the margin of the divided skin should be attached to that of the
urethra by a series, say, of four sutures, placed at equal intervals,
after hemorrhage, which will be somewhat difficult of control, both
from the larger vessels and from the cavernosa, has been subdued.
It may require buried sutures through the divided cavernosa in order
to permit of such control.
 If, however, it seem necessary to remove the organ close to the
pubis it will probably be found more desirable to make a more
complete dissection, taking out the corpora cavernosa entirely, and
then making a median incision in the perineum, dissecting out the
urethra, bringing it out through the wound, shortening it to the
proper extent, and fastening its termination to the skin margin, thus
making, as it were, a vulvar outlet, which will not interfere with
urinary control, but will permit urination to be satisfactorily
accomplished, though only in the sitting posture. This is usually
known as Demarquay’s operation.

CIRCUMCISION.
In children this requires a general anesthetic; in adults it can
almost always be satisfactorily performed under local cocaine
anesthesia; the intent being to remove the redundant foreskin. A
circular incision is necessary, which may be made with knife or
scissors. The parts being prepared for operation, the prepuce is
drawn forward, being caught either with forceps or fingers of an
assistant, and the little circular amputation is made just in front of
the corona of the glans. The first incision extends through the skin,
after which there remains a cuff of mucous membrane, which is
sometimes adherent to the glans, as in children, or may be
infiltrated with exudate, as by a concealed chancroid or chancre
beneath. Ordinarily this cuff is split in the middle line of the dorsum
and removed in halves, in order to avoid any possible injury to the
glans itself. The cut is made somewhat obliquely from above
downward and forward, the intent being to divide it at the frenum,
sufficiently far from the meatus in order to not distort the latter by
subsequent cicatricial contraction. These tissues are sometimes
inordinately vascular, and bleeding points need to be quite carefully
secured. In one case known to me an infant bled to death from an
unsecured vessel near the frenum, the operator having neglected it
at the time and having left the patient. In a clean case, the vessels
having been secured, a running suture of fine catgut should unite
the cut edges of the mucosa and of the skin. It is not necessary to
apply sutures in a venereally infected case, for raw surfaces will also
become infected, and would be best protected by immediate
cauterization, in which case primary union would be prevented.
The little procedure may be modified in various ways to meet
individual needs. After its performance there will occur considerable
local swelling and edema, which can be best kept under subjection
by a dressing moistened with cold saturated boric acid solution or its
equivalent. If the sutures have been too tightly applied there may be
a species of paraphimosis, with too much constriction, which would
require their division.

THE URETHRA.
In Chapter XII, on Gonorrhea, were described the usual specific
forms of urethritis, with their complications and results. To this
chapter the reader is referred for all data regarding gonorrhea as it
involves this passage-way, with its complications. Such lesions as
ulcers may persist for some time, while the papillomatous
outgrowths, polypi, etc., connected with gonorrhea and gleet, which
are not discoverable from without, are now easily examined and
estimated with the endoscope. Specific ulcers of the syphilitic type,
and virulent ulcers even of the chancroidal type, also occur, usually
within the first inch of the urethra, causing more or less discharge,
with local soreness, and leading, unless promptly recognized, to
cicatricial stricture formation.

STRICTURES OF THE URETHRA.

Strictures of the urethra may be of traumatic origin, as when
produced by external accident, with or without laceration, or by the
introduction of foreign bodies, or the minor injuries inflicted during
their extraction. Deep traumatic stricture is the result of serious
injuries to the perineum. The common type of urethral stricture is
the consequence of one or more attacks of gonorrhea, which, not
having been promptly cured, has merged into so-called gleet, and
this into these inevitable consequences, with more or less infiltration
of the peri-urethral tissues, and subsequent encroachment upon the
caliber of the urethra, either by irregular new tissue formations or
well-marked annular constriction. In addition to the above conditions
there is also known a spasmodic stricture, due to involuntary
contraction of the muscular fibers encircling the urethra, and of the
deeper perineal muscles which concern it. Otis held that such
urethral spasm is a frequent accompaniment of a contracted meatus,
and taught that the best method to deal with it is by first enlarging
the meatus, as may be easily done with a simple bistoury, under
local cocaine anesthesia (meatotomy), and the subsequent passage
of instruments of proper size.
To persistent and well-marked contraction of the urethra is given
the term organic stricture, and such a stricture is generally the
consequence of injury or disease, whereas purely spasmodic
stricture, mentioned above, is a not infrequent occurrence in
perfectly chaste individuals.
Organic stricture may be single or multiple, of large or small
caliber, or even impassable and impermeable—that is, from before
backward—so that even while urine may leak through, drop by drop,
from behind it seems impossible to introduce an instrument from the
front. In aggravated cases three or four inches of the urethral canal
may be involved in lesions of this kind, which constitute a formidable
condition for satisfactory treatment. The ordinary non-traumatic
organic strictures are all in front of the prostate and more common
near the meatus. The size of a stricture is determined either by the
urethrometer devised by Otis, or, more simply, by determining the
diameter of the bulbous bougie which may be made to easily slip
through it, the latter being the common method. These instruments
are indicated by numbers, which refer to the millimeters in
circumference of the bulb; thus No. 27 implies that the bulb has a
circumference of 27 Mm. The bulbous instrument is far better for
examination than the sound, since it indicates the exact depth as
well as the length of the strictured passage, and gives a better idea
of its density or resilience. (See Figs. 671 and 672.)
 The indications of stricture are difficulty in micturition, even to the
degree of impossibility, persistence of gleety discharge, and slowness
or impossibility of ejaculation, while sometimes cicatricial tissue can
be felt from the outside.
The strictured urethral canal should be restored to normal
dimensions at the earliest practicable moment. This may be effected
through gradual dilatation with a conical steel sound, passed at
intervals of two or three days, or rapidly, by the improved instrument
of Otis known as the dilating urethrotome, which, being passed
through the stricture, has its blades expanded by a mechanism at
the handle, while the stricture when it is stretched is divided by the
working of a concealed blade. The Otis instrument is illustrated in
Fig. 673.
A meatus too small to admit a suitable instrument should be
incised to the necessary degree.
Gradual dilatation may be employed in the milder cases, and has
been combined with a method of electrolysis, in which I have little
faith. No matter which method be adopted, the patient should be
impressed with the force of the old adage, “Once a stricture always
a stricture,” and should be warned that the occasional passage of an
instrument is necessary for a long period, and that while he may be
taught the procedure he should not neglect it. This is true alike of
every method of treatment.

Fig. 671

Bulbous sound.

Divulsion was a method employed during the past generation of

rupturing a stricture by forcible separation of the blades of a divided
instrument, tearing it instead of neatly cutting it, thus inflicting a
maximum instead of a minimum of local damage. Every divulsion
thus led to a subsequent stricture formation. The procedure has
been abandoned. Now by the employment of the Otis instrument, or
one of its substitutes, the stricture is first found, then penetrated
with the instrument, and divided to an extent easily regulated, thus
permitting exact work, which is preferable to the older methods of
drawing a large blade along the urethral tract.

Fig. 672

Otis’ urethrometer.

In tight strictures the operator proceeds at first with small filiform

bougies made of whalebone, with which, sometimes after
considerable effort with a bundle of them in the urethra, trying one
after another, he may succeed in passing one and causing it to enter
the bladder. The others are then withdrawn. It may now be possible
to thread over the whalebone a perforated tip made for the
urethrotome, and thus to slip the latter down into the depths over
the fine bougie as a guide, and then to push it farther, using now
more force because it must necessarily follow the urethral canal.
When, however, what seems to be judicious manipulation by this
method is unsuccessful the metal instrument should be withdrawn,
the whalebone bougie remaining in situ, and thus serving as a guide
for that which is now made necessary, namely, external urethrotomy.
[72]

[72] Van Hook has recommended the following excellent expedient for
the discovery of the urethral canal when apparently lost in the depths of a
dense, deep stricture: He gives a dose of potassium iodide two or three
hours before the operation. During the latter, and when seeking the
proximal end of the urethra, he drops a little acetate of lead solution at the
point where the urine is expected to appear. The formation of the bright-
yellow lead iodide will mark the actual appearance of the urine and indicate
its source.
 Fig. 673

Otis’ dilating urethrotome.

External urethrotomy is essentially a median perineal section,

carried down at least to the urethra. It is done preferably with a
guide, usually a fine bougie. With it the urethral channel may be
easily identified; without a guide, in aggravated cases, it is often a
difficult matter to identify and dissect out the urethra, and then to
find its tortuous passage-way and follow it into the bladder. Patience
and a knowledge of the anatomy of the perineum will lead to
success. Sometimes extensive dissections are necessary, and the
perineal wound needs to be widely retracted in order to better
expose the deep tissue. Once the urethra is identified it may be
followed in each direction, and the case should not be left until the
entire canal has been restored to its normal caliber. In these cases it
is best to leave a self-retaining catheter in the perineal wound for at
least a day, after which it is sometimes of benefit to introduce a
catheter through the meatus, and leave it in the urethra for two or
three days. Such a urethra is an infected channel, and must be so
cared for that no retention or infection of fresh wounds occurs.

PERINEAL ABSCESS.
Perineal abscess is the not infrequent consequence of a very tight
and deep stricture, having its beginnings as a folliculitis, with
subsequent extension and perforation, with escape of urine, and
sometimes with the formation of acute, diffuse phlegmon, which
may even extend into the scrotum or to the abdominal wall.
Ordinarily it constitutes a circumscribed collection of pus. Such a
phlegmon when neglected may be followed by extensive burrowing
of pus, or local sloughing, with gangrene, and partial or complete
destruction of the external genitals. When such a phlegmon occurs
above the triangular ligament there will be swelling about the
prostate, with edema of the anterior rectal wall, while the prostate
itself may become later involved. Such a collection may terminate as
an ischiorectal abscess, associated with perineal fistulas.
The inevitable results of such conditions have two or three
disastrous tendencies, such as burrowing of pus and the formation
of urinary fistulas, sometimes at considerable distance from the
urinary channels. The same is true in traumatic cases, for in such
cases there may be the expression of an old and neglected stricture.
To the chronic condition may be added that of tuberculous infection.
Treatment.—The treatment of such abscesses and fistulas is
based upon the principles of evacuation of pus and
restoration of the urinary canal to its proper size. This may be an
easy or a difficult task, but it should be accomplished by whatever
method will permit it with the least damage to tissues. When urinary
infiltration threatens gangrene extensive incisions should be made.
When the scrotum is swollen, as it may be to enormous dimensions,
free opening should be made into it to permit escape of serum and
pus if present. Even the surrounding tissues, including the penis,
may be enormously edematous. This swelling will rapidly subside
when pressure upon the deep veins has been relieved, but pus, no
matter where present, must be evacuated.

URINARY FEVER.
Instrumentation of any kind within the urethra may, in some
individuals, be followed by what has been called urethral or urinary
fever, including chill, pyrexia, with sometimes the development of an
acute inflammatory affection, either of the urethra or even of the
kidney, with not only retention but actual suppression of urine.
These manifestations are ordinarily regarded as due to toxemia, but
are sometimes difficult to explain, because their violence seems so
disproportionate to the amount of intervention. Thus I have known
an individual to die, of apparently acute uremia, within four days
after the painless passage of a sound for dilatation of an old
stricture, the same not being followed by any blood or local
disturbance.
These accidents were more prone to occur before the introduction
of antiseptic methods in all urethral instrumentation. At present they
are much rarer than in former days. Nevertheless the passage of any
instrument, even for legitimate examination, as for stone, may be
followed by unpleasant consequences. These are preventable to
some degree as well as curable, by antiseptic local measures, as well
as by the administration of quinine or urotropin, especially the latter,
with sitz baths and perhaps general antifebrile measures, while any
local disturbance thus set up is to be treated on general principles.

THE TESTICLES, THE CORD, AND THE VESICLES.

The testicle is originally formed by differentiation from the
Wolffian bodies, at a level above the pelvis. Its migration from its
original location into the pouch where it normally belongs is known
as the descent of the testicle. When it fails to appear at the external
ring it is spoken of as retained testicle, and when detained outside
the ring above its proper level the condition is referred to as
incomplete descent, these being purely arbitrary terms. The reasons
for incompleteness of the descent are as little understood as those
for its completion, and have but little reference to clinical surgery.
The surgical anatomy of the testicle may be only briefly
considered here. Each is essentially a double organ, consisting of the
testis proper, the secreting portion, with its more or less complete
double peritoneal covering (originally peritoneum), and the
epididymis, or conducting portion, variable in size, and
corresponding to the parovarium in the ovary in respect that it is
subject to cystic degeneration. The pathway made by the testicle as
it passes from the abdominal wall should be completely obliterated.
When unobliterated it facilitates the occurrence of hernia, while
when partially obliterated cystic dilatations of the enclosed portions
(hydroceles of the cord) occur. The lowermost portion of the
accompanying peritoneal pouch is normally left as a closed sac,
which constitutes the cavity of the tunica vaginalis testis. In the
ordinary standing posture the epididymis occupies toward the testis
proper the same relative position that the heel does toward the
anterior part of the foot, i. e., it lies to its posterior and inner sides.
While both portions of the organ may be involved in acute or chronic
diseases, each of them may be by itself involved with a minimum of
disturbance of the other.

RETAINED TESTICLE, OR CRYPTORCHIDISM.

As above indicated failure in descent varies in degree from
complete absence from sight and touch to a presentation of the
testicle at a point where it can be both seen and felt but still at too
high a level. Ordinarily the condition is symptomless, its only signs
being those above rehearsed. Strange to say the condition
sometimes passes unrecognized until adult life is reached.
Commonly it is early discovered. Pain is felt only when friction or
traumatism lead to the same unpleasant sensations which would be
produced by pressure upon a normal organ. Thus a testicle retained
at the external ring may be irritated by the clothing, and has been
many a time mistaken for an incomplete hernia, upon which a truss
pad has been applied with inevitably resulting suffering. While
accompanying malformations in other parts of the body may be
found it does not follow that the individual may not be otherwise
perfectly developed.
It is usually held that an incompletely descended testicle is more
or less functionless; often it is at least more or less atrophied. Its
functional capacity varies. It is usually more or less surrounded by a
cavity formed from the peritoneum. While the condition is ordinarily
one of minor importance, it has been established by numerous
observations that retained testicles are relatively prone to undergo
malignant degeneration.[73]
 [73] In the pathological museum of the University of Buffalo I deposited
specimens illustrating this fact, one testicle forming a tumor as large as the
patient’s head, the other as large as a cocoanut. These were both
successfully removed from an adult, and without the patient developing any
subsequent evidence of malignant infection. It is thus important in every
case of intrapelvic tumor in the male to examine the scrotum and be sure
that both testicles are in their proper position.

Treatment.—The proper early treatment of cryptorchidism has

been a matter of dispute, some advising to leave the
condition entirely untouched so long as it be not troublesome; others
that early intervention should be practised. If the organ be simply
displaced and not otherwise diseased, whatever be done may be
limited to freeing it from its abnormal surroundings and restoring it
as nearly as possible to the position where it belongs. If it be
actually diseased it should be removed. What may be accomplished
will depend much upon its movability and its blood supply.
Thus Keetley would liberate the testicle, when retained within the
inguinal canal, by division of the latter and lengthening of the cord
by blunt dissection, with division also of the lateral portions of the
gubernaculum near the pillars of the external ring and as far as
possible from the testicle. By traction upon this it is then often
practicable to bring the testicle down, without undue tension, to the
lower part of a new scrotal pouch, which is formed by making for it a
nest, as it were, with the finger, with an opening at its lower
extremity, through which forceps are thrust, passed upward and
made to seize the end of the gubernaculum, or through which a
suture may be passed for the same purpose. By means of this device
the testicle is now drawn downward into the scrotal pouch, where,
being once present, it is held by sutures, both direct and those
which close the pouch above it. It is then advisable to close the
inguinal canal, as after a hernia operation. In order to prevent
upward traction on the scrotum it is necessary to attach its lower
end to the skin of the thigh, by a suture which should remain for
several days. If this be done on both sides the limbs should be
snugly bandaged together and movement of all kinds prevented.
Complete separation of the scrotum from the thighs should not be
permitted for several weeks, unless unavoidable.
Beck recommends an incision from the external ring three inches
downward along the cord, after which he opens the pouch of the
testicle, lifts it from its bed, pulls it down, carefully dividing all bands
of connective tissue or peritoneum which tend to immobilize it. It is
then deposited in a scrotal pocket, in which it is held by a flap
dissected from the outer margin of the inguinal ring, and turned
downward in such a way that it can be attached to the opposite
layer in semilunar shape. Thus a band of aponeurotic tissue is made
to surround the testicle “like a necktie,” the organ being retained as
in a buttonhole, the length of the flap being determined by the
extensibility of the cord. The inguinal canal is then closed as after
any other procedure.
Other abnormalities of the testicle include congenital atrophy or
absence, while in a few cases a third testicle has been found, it lying
in contact with one or the other of the naturally separated normal
pair.

INJURIES TO THE TESTICLE.

Injuries to the testicle are of common occurrence, on account of
their exposed position, yet less common than would otherwise occur
were it not for their extreme movability. Aside from the lacerated,
incised, or punctured wounds which may be inflicted the testicle
suffers most often from contusions, always with resulting swelling,
and sometimes with considerable effusion, of which a large amount
may be accommodated in a distended tunica vaginalis.

HEMATOMA OF THE TESTICLE.

Hematomas of the testicle are also thus frequently produced.
When of a limited degree of severity spontaneous absorption of
blood may be expected, and should be favored by physiological rest,
i. e., confinement in bed, with elevation of the scrotum and the
application of water dressings. Large extravasations of blood, when
fresh, may be withdrawn by the trocar, but when clotted will require
incision and evacuation of clots, which should always be practised,
as it leads to great saving of time. Extravasation is usually followed
by induration, and more or less permanent enlargement, which will
be slow to disappear; absorption may be encouraged by the use of a
weak mercurial ointment.

TUBERCULOSIS OF THE TESTICLE.

Tuberculosis of the testicle simulates very closely that occurring in
the lungs, in that one may see a disseminated miliary process, with
subsequent coalescence and formation of caseous nodules,
subsequently breaking down into abscess cavities, while at the same
time the surrounding membranes, i. e., the tunica vaginalis, are
involved, and effusion (hydrocele) occurs just as in the pleural cavity.
In other words every appearance of pulmonary consumption may be
imitated within the small extent of the testicles and the epididymis.
Of these two parts the latter suffers much more frequently. Here are
caused irregular nodules, which may later unite, giving to the entire
epididymis a much enlarged, irregular shape, with induration,
frequently extending upward along the cord, and always tending so
to extend unless the disease be early seen and recognized. Too
often adhesions to the skin occur, with ulceration and formation of
fistulas, and perhaps more or less extensive ulcers, while in many
instances the entire length of the vas becomes infected, and
frequently even the prostate and corresponding vesicle become
involved. By this time there will be more or less involvement of the
inguinal lymphatics, and the patient may be already showing
evidences of general tuberculous infection, at least those of some
serious constitutional impression made by the local disease. One has
to differentiate as between tuberculosis, syphilis, and cancer, which
may be difficult in the early stages; but when the disease has
extended beyond the epididymis itself it is rarely difficult to
recognize, unless entirely masked by distention of the tunica
vaginalis with fluid.
Treatment.
—The treatment for tuberculosis of the testicle is extirpation, i. e.,
castration, which includes the removal not only of the diseased
organ, but of all the tissues, including the skin, to which it may be
abnormally adherent, and of the spermatic cord, which, if necessary,
should be followed into the pelvis by a long incision extending up
along the inguinal canal. To remove a tuberculous testis and leave a
tuberculous cord is to accomplish very little, while the latter, being
an extraperitoneal tissue, may be followed with relative safety, even
to the depths of the pelvis. Local applications in these cases give
little relief. This teaching is at variance with that of some writers, but
is justified by experience.

SYPHILIS OF THE TESTICLE.

Syphilis occurs in secondary and tertiary manifestations, usually
first in the testis, sometimes in the epididymis, but always in the
testicle before the cord. It produces nodules which may be mistaken
for those of tuberculous trouble, but which often attain much larger
size. They are usually painless. Nevertheless a syphilitic testicle is
sometimes tender, and constantly so, to a degree causing no little
annoyance. The occurrence of nodules in the epididymis, in
connection with other evidences of syphilis, is regarded by some as
pathognomonic. In this location the condition yields readily to
properly directed treatment.

CYSTS OF THE TESTICLE.

Cysts are frequently found along the course of the epididymis.
Some of them are expansions of the natural tubes of the
paradidymis, while others are distinctly new. Dermoids are
occasionally met, and either of these may attain considerable size.
Cyst of the epididymis proper is to be distinguished from encysted
hydrocele of the cord. All of these purely cystic conditions are
essentially innocent, and need similar treatment. They may be
evacuated and injected with an irritant like pure carbolic acid, which
is sometimes an effective way, or they are better treated by open
incision with extirpation of the cyst, which is, in the end, far the
more satisfactory course to pursue.

EPIDIDYMITIS AND ORCHITIS.

Each of the separate portions of the testis may have its own
nearly self-limited inflammations and infections, or both may
participate in a common lesion. The most frequent cause of an acute
epididymitis is gonorrhea, the infection travelling from the urethra
along the vas, and causing acute and well-marked swelling of the
epididymis, which becomes tender and painful in proportion to the
amount of exudate. It may come on early or late, during the course
of the urethritis. The condition is known to the laity as “swelled
testicle.” It has been frequently called orchitis, which is an error,
since however much the testis may later participate the primary
trouble is in the epididymis. It may be easily distinguished by
palpation, the enlarged and hardened epididymis, often very tender,
being prominent behind the testis proper. The condition may,
however, be masked by the acute effusion likely to occur in the
tunica vaginalis, constituting a mild degree of acute hydrocele. This
may be expected in nearly all severe cases, and serves to increase
the size of the entire mass. A testicle thus affected may assume
much more than normal dimensions, and, becoming thereby much
heavier, drag upon the cord, which is its normal support. More or
less fever and malaise accompany the condition, part of which may
be due to the toxemia of gonorrheal infection. Usually but one side
is involved. Both are rarely affected simultaneously, but one may
follow the other.
The acute stage of gonorrheal epididymitis persists for a week or
ten days, even under the best of treatment, and is followed by
gradual subsidence, characterized by amelioration of symptoms and
decrease in size.
Treatment.—This improvement is to be induced, first, by rest in
bed, with elevation of the scrotum, and the ordinary
eliminative treatment suitable for any febrile condition. Local relief
may come from the application either of heat or of ice-bags, the
latter being preferable, but will be made more effective by the
application over the scrotum of a mixture of two parts of olive oil
with one part of methyl salicylate, or of guaiacol reduced with equal
parts of oil or glycerin. The anointed surface should be covered with
some impervious material, and the dressing be changed every few
hours. Later, as the acute merges into the chronic condition,
absorption may be stimulated by the ordinary mercurial ichthyol
ointment.
In some exceedingly acute cases suppuration ensues, the
consequences being a collection of pus in the epididymis, which will
give the ordinary signs and call for the usual evacuation which every
collection of pus demands. Epididymitis, more or less acute, has
been known to follow the introduction of the catheter or sound, even
in cases so far as known not previously infected. It is difficult to
explain, but requires the same treatment as above.
Orchitis, or Inflammation of the Testis Proper.—This
condition is
rare except as an occasional complication of mumps, or, much more
rarely, of one of the other exanthems. Why after acute parotiditis
there should be a tendency to inflammation of the testis or the ovary
has never been fully explained. Nevertheless it is sufficiently
frequent to be well known to the laity, and is occasionally so
pronounced as to lead to actual atrophy, with loss of function of the
testis involved. In any true orchitis there will be considerable pain
and tenderness, because the testis proper is so tightly confined
within its tunica albuginea, i. e., a firm, inelastic membrane. By
proximity there will also be set up more or less involvement of the
tunica vaginalis, with effusion, so that some degree of acute
hydrocele may be looked for in every such instance.
Treatment.—The treatment of the condition above described
consists essentially in rest, with local soothing applications, of which
perhaps nothing will be more satisfactory than guaiacol, which,
however, should always be used with caution.

TUMORS OF THE TESTICLE.

 Dermoid cysts and tumors and teratomas, i. e., those of mixed
type, are frequently met in this region. Their explanation is doubtless
afforded by the extreme complexity of the elements which help to
make up the part, while in the embryonic condition, and the
confusion of tissue elements which may then and there arise. These
growths of embryonic origin vary from single cysts to a mass of
cystic tumors, which may replace the organ, or constitute neoplasms
of large size, while some of the teratomas have features causing
them to resemble the mixed growths occasionally found within or
about the ovary. In this way is to be explained the occurrence in
such masses of hair, teeth, and other epiblastic elements, as well as
of cartilage or bone or other mesoblastic elements. Taken together
these growths constitute an interesting group for the pathologist to
study. For the surgeon, however, they require essentially the same
class of treatment, namely, extirpation, or, if this be impossible,
complete removal of the organ, i. e., castration. There should be no
hesitation in performing this upon any such growth, as no testicle
thus affected is likely to be functionable, and the individual suffers
no possible deprivation of potency by its removal.
The other benign and simple tumors, especially fibromas and
chondromas, are occasionally met, and I have described one rare
case of large lipoma within the limits of the testicle proper.
Cancer of the Testicle.—This includes, usually, sarcoma,
developing from the mesoblastic
elements, although adenocarcinoma may be met here, but as an
extension from some growth occurring first in the skin or in the
immediate neighborhood. Deep cancer in this region is difficult to at
first distinguish from the induration produced by tuberculosis or
syphilis. In doubtful cases the therapeutic test may be tried in order
to differentiate it from the latter. From the former it is usually
separated by its more consistent and regular (i. e., its less nodular)
character. In all three cases the lymphatics of the groin may be early
involved, or perhaps not until late. As a rule cancer is met in the
later years of life, while the other conditions are more frequently
seen in the first half. In the more rapid cases there will be
considerable pain, with dilatation of the scrotal veins, and evidences
of constitutional involvement. Sarcoma may grow rapidly and
metastasis is almost invariably to the lungs.
Of tumors in the testicle, as of those in the breast, it may be said
that any new-growth which tends to enlarge, become more dense or
adherent, to spread, or to be accompanied by lymphatic involvement
should be removed; no mistake will be made in applying this rule in
these cases, especially if by the therapeutic test or otherwise syphilis
can be excluded. Malignant disease sometimes travels rapidly up the
cord, and the main fear is not so much of local recurrence as of
deep involvement within the pelvis. Cases of cancerous growth of
the testicle should be not only thoroughly extirpated from the
scrotum, but the inguinal canal should be opened, and the cord
followed as far as possible and completely removed.
Cases may arise where amputation of the scrotum may be
justifiable for the purpose of temporary relief, in order to avoid
discomfort, hemorrhage, or offensive ulceration.

HYDROCELE.
Strictly speaking the term hydrocele means accumulation of
watery fluid in any pre-existing cavity. By universal consent, unless
some other cavity be specified, the tunica vaginalis is understood.
The consequence is a more or less distended sac of serous fluid,
which first occupies a position in front, but finally is spread around
the lateral portion of the testicle, and may form a tumor the size
even of the individual’s head. It is an innocent collection of serum,
but the walls of such a sac will be thickened in proportion to its age
and size, and may in the course of time undergo such degenerations
as the calcareous, for instance, by which it becomes more or less
infiltrated or encrusted with calcareous material. Thus I have in my
possession a tumor of this kind, nearly the size and almost as hard
as an ostrich egg, the old tunic being converted practically into a
shell.
Acute hydrocele occurs, as above mentioned, in connection with
the acute infections, but is then ordinarily a matter of but a few days
or weeks.
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