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SURGICAL
INSTRUMENTATION
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SURGICAL SECOND
EDITION
INSTRUMENTATION
Nancymarie Phillips
RN, PhD, BA, BSN, MEd, RNFA, CNOR(E)
Australia ● Brazil ● Mexico ● Singapore ● United Kingdom ● United States
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CONTENTS
PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii CHAPTER 3 CATEGORIES OF SURGICAL

INSTRUMENTATION . . . . . . . . . . . . . . . . . . . . 23
CHAPTER 1 HISTORY OF SURGICAL Clamps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
INSTRUMENTATION . . . . . . . . . . . . . . . . . . . . . 1 Basic Hemostatic Clamps . . . . . . . . . . . . . . . . . . . . 24
Historic Surgical Instrumentation . . . . . . . . . . . . . . . . 1 Grasping Forceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Ritual and Magic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Ring-Handled Grasping Forceps . . . . . . . . . . . . . . 39
Non-Ring-Handled Grasping Forceps . . . . . . . . . . 41
CHAPTER 2 ANATOMY OF SURGICAL Dissection Instrumentation . . . . . . . . . . . . . . . . . . . . . 48
INSTRUMENTATION . . . . . . . . . . . . . . . . . . . . . 5 Sharp Dissection Instrumentation . . . . . . . . . . . . . 48
Evolution of Modern Surgical Instrumentation . . . . . 5 Debulking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Anatomy of a Surgical Instrument . . . . . . . . . . . . . . . . 6 Manual Debulking . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Handle Styles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Probes and Dilators . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Joint Styles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Measurement and Expansion . . . . . . . . . . . . . . . . . 62
Tip and Jaw Styles: Sharp Dissection . . . . . . . . . . . 11 Evacuation and Instillation Instrumentation . . . . . . 66
Tip and Jaw Styles: Clamping, Occluding, and Evacuation Instrumentation . . . . . . . . . . . . . . . . . . 66
Grasping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Injection and Irrigation Devices . . . . . . . . . . . . . . . 68
Tip Styles: Blunt Dissection . . . . . . . . . . . . . . . . . . . 15 Retraction and Exposure . . . . . . . . . . . . . . . . . . . . . . . 68
Categories of Surgical Instruments . . . . . . . . . . . . . . . 16 Retractors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
How Surgical Instruments Are Named . . . . . . . . . . . 17 Approximation and Closure Instrumentation . . . . . 77
Materials Used in the Manufacture of Surgical Suturing Instrumentation . . . . . . . . . . . . . . . . . . . . 77
Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Anesthesia Intubation Instruments . . . . . . . . . . . . . . 83
Metallics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
CHAPTER 4 CONSIDERATIONS FOR
Steel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Copper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
INSTRUMENT SET ASSEMBLY . . . . . . . . . . . . 86
Titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Instrument Containers and Trays . . . . . . . . . . . . . . . . 89
Silver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Perforated Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Surface Finishes of Metallic Surgical Instruments . . 19 Closed Rigid Containers . . . . . . . . . . . . . . . . . . . . . 90
Inspection and Quality Control of Metallic Specialty Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . 19 Assembly of Instrument Sets . . . . . . . . . . . . . . . . . . . . 91
Scissors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Determining Instrument Set Contents . . . . . . . . . 91
Clamps, Needle Holders, and Graspers . . . . . . . . . 20 Counts and Accountability . . . . . . . . . . . . . . . . . . . 92
Forceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Overview of Processing Options . . . . . . . . . . . . . . . . . 93
Retractors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
CHAPTER 5 SOFT TISSUE FOUNDATION
Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Cleaning and Lubrication . . . . . . . . . . . . . . . . . . . . 21 SETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Ultrasonic Cleansing . . . . . . . . . . . . . . . . . . . . . . . . 21 Short Foundation Set . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
v
vi Contents
Excisional Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 CHAPTER 10 BASIC BONE AND JOINT

Medium Foundation Set . . . . . . . . . . . . . . . . . . . . . . . 109 INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 244
Soft Tissue Dissection . . . . . . . . . . . . . . . . . . . . . . 109
Plates and Screws: Fracture Fixation
Long Foundation Set . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . 244
Laparotomy Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Drills and Power Equipment . . . . . . . . . . . . . . . . . . . . . . 250
Extra-Long “Add-On” Set . . . . . . . . . . . . . . . . . . . 135
Bone Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
CHAPTER 6 PLASTIC SURGERY Small Bone Instruments . . . . . . . . . . . . . . . . . . . . .254
INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 136 Large Bone Instruments . . . . . . . . . . . . . . . . . . . . . 254
Basic Plastic Surgery Instrumentation . . . . . . . . . . . 136
CHAPTER 11 HEAD AND NECK
Basic Plastic Surgery P rocedures . . . . . . . . . . . . . . . . 164
Rhytidectomy-Browlift . . . . . . . . . . . . . . . . . . . . . 164
PROCEDURE INSTRUMENTATION . . . . . . . 285
Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Ear and Mastoid Instrumentation . . . . . . . . . . . . . . . 285
Surface and Subsurface P rocedures . . . . . . . . . . . . . 164 Ear Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . 286
Debridement and Excisional Procedures . . . . . . 164 Mastoid Instrumentation . . . . . . . . . . . . . . . . . . . . 293
Liposuction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Nose and Throat Instrumentation . . . . . . . . . . . . . . 297
Breast Augmentation-Reduction Procedures . . . 165 Intranasal and Pharyngeal Instrumentation . . . . 298
Anterior Neck Instrumentation . . . . . . . . . . . . . . . . . 315
CHAPTER 7 GENERAL SURGERY Thyroidectomy and Neck Dissection
INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 166 Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . 315
General Surgery Major Laparotomy Tray . . . . . . . . 166 Tracheostomy-Tracheotomy
Gastrointestinal Instrumentation for Open Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . 317
Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Cholecystectomy Add-Ons . . . . . . . . . . . . . . . . . . 180 CHAPTER 12 NEUROSURGERY
Liver and Stomach Add-Ons . . . . . . . . . . . . . . . . .182 INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 319
Lower Gastrointestinal Instrumentation for Basic Neurosurgical Instrumentation . . . . . . . . . . . . 319
Open Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 184 Cranial Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
Bowel Resection Add-Ons . . . . . . . . . . . . . . . . . . . 184 Spinal Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . .340
Rectal-Anal Instruments . . . . . . . . . . . . . . . . . . . . . . 189
Hemorrhoidectomy and Rectal Excision . . . . . . 189 CHAPTER 13 CARDIOTHORACIC AND
VASCULAR INSTRUMENTATION . . . . . . . . . 342
CHAPTER 8 GYNECOLOGIC
INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 195 Basic Cardiothoracic and Vascular
Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . 342
Basic Gynecologic Instrumentation . . . . . . . . . . . . . 196 Basic Cardiothoracic and Vascular Procedures . . . 375
Basic Gynecologic Procedures . . . . . . . . . . . . . . . . . . 227
Abdominal Hysterectomy . . . . . . . . . . . . . . . . . . . 227 CHAPTER 14 MICROSURGERY
Vaginal Hysterectomy . . . . . . . . . . . . . . . . . . . . . . 227 INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 376
Vaginal-Perineal Procedures . . . . . . . . . . . . . . . . . . . 227
Dilation and Curettage . . . . . . . . . . . . . . . . . . . . . . 227 Basic Microsurgery Instrumentation . . . . . . . . . . . . 376
Cesarean Section . . . . . . . . . . . . . . . . . . . . . . . . . . 228
CHAPTER 15 ENDOSCOPIC
CHAPTER 9 UROLOGIC INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 395
INSTRUMENTATION . . . . . . . . . . . . . . . . . . . 229 Essential Components of Endoscopic
Open Urology Instrumentation . . . . . . . . . . . . . . . . . 229 Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
Nephrectomy, Cystectomy, and Percutaneous Endoscopy Procedures . . . . . . . . . 396
Prostatectomy Instrumentation . . . . . . . . . . . . 230 Nonpuncture Endoscopy . . . . . . . . . . . . . . . . . . . . 396
Testicular Instrumentation . . . . . . . . . . . . . . . . . . 238 Access and Creation of the Working Space . . . . . . . 396
Uroplasty Instrumentation . . . . . . . . . . . . . . . . . . 240 Illumination and Viewing within the Working
Circumcision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Contents vii
Manipulation within the Working Space . . . . . . . . . 397 CHAPTER 16 DECONTAMINATION

Irrigation and Evacuation within and from the AND STERILIZATION . . . . . . . . . . . . . . . . . . . 413
Working Space . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Decontamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414
Closure within the W orking Space . . . . . . . . . . . . . . 397
Instructions for Use (IFUs) . . . . . . . . . . . . . . . . . . 414
Specialty Instrumentation . . . . . . . . . . . . . . . . . . . . . 397
Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .414
Essential Endoscopic Instrumentation . . . . . . . . . . . 398
Inspection/Packaging . . . . . . . . . . . . . . . . . . . . . . . . . 416
Basic Endoscopic Procedures . . . . . . . . . . . . . . . . . . 409
Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416
Laparoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409
Disinfection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
Robotic-Assisted Percutaneous
Sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418
Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409
Sterile Storage and Packaging . . . . . . . . . . . . . . . . . . 419
Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412
Microbiological Concerns . . . . . . . . . . . . . . . . . . . 421
Neuroendoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 412
Reprocessing Flexible Endoscopes . . . . . . . . . . . . . . 422
Thoracoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .412
Mediastinoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 412 INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
Upper Airway Endoscopy . . . . . . . . . . . . . . . . . . . 412
Urologic Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . 412
PREFACE
This text, Surgical Instrumentation, Second Edition, is instrumentation and provides background infor-
designed for perioperative personnel in all surgical mation about the philosophy and contributions
disciplines. Surgeons, nurses, technologists, and techni- of different cultures to the discipline of surgery.
cians will find the design and collections in this book ●● Anatomy and Physiology of Surgical
informative and user friendly. Books about surgical Instrumentation. The materials and characteris-
instrumentation have been in print for more than tics of surgical instruments are explored, as well
100 years. However, none have offered comprehensive as the design from handle to tip.
collections of instruments used with foundation sets ●● Categories of Surgical Instrumentation. Surgical
for multiple specialties. They feature individual instru-
instruments are designed for specific functions
ments without providing guidance for establishing or
and are grouped into functional categories that
streamlining the set creation process.
define the purpose for each instrument.
Specific groupings make it easier to learn the
THE DEVELOPMENT OF THIS TEXT instruments.
The four foundation sets described in this text are ●● Considerations for Instrument Set Assembly.
designed to be base units for use during procedures Trays and containers for packaging instruments
that meet the needed instrument weight, length, gauge, are described in this chapter. Accountability is
shape, and material necessary for a safe, efficient surgi- a team effort that begins with the construction
cal procedure. The additional instrument groupings, and assembly of each set.
such as those specific to a particular organ or region of ●● Soft Tissue Foundation Sets. The foundation sets
the body, can be established as “add-on” sets to be used are designed to meet specific needs for a proce-
in combination with the appropriate foundation set. dure at a basic level by grouping instruments by
Every perioperative nurse or surgical technologist category and function.
who scrubs has encountered sets with instruments that ●● Plastic Surgery Instrumentation. Instruments spe-
have not been used for many years, yet the items con-
cific to the type of plastic surgery procedure are
tinue to be packed into the tray for no apparent reason.
described in combination with foundation sets.
This book may serve as a guide for establishing stan-
dardized instrument sets that will facilitate the count
●● General Surgery Instrumentation. Functional in-
process and ease the burden of inventory control. struments that are added to foundation sets for
general surgery are described by organ system
and body location.
ORGANIZATION OF THE TEXT ●● Gynecologic Instrumentation. Specialty instru-
This text is divided into 16 chapters. Images of the sur- mentation specific to the needs for surgery of
gical instrumentation are displayed in table form with the female reproductive tract is described.
descriptions and sizes listed. ●● Urologic Instrumentation. Instrumentation spe-
●● History of Surgical Instrumentation. The first cific to genitourinary procedures of the urethra
chapter describes the history of surgical and kidney is included in this chapter.
viii
Preface ix
●● Basic Bone and Joint Instrumentation. Many of the lungs, heart, and vascular system is
specialties utilize instrumentation to debulk, described.
dissect, or repair bony tissue throughout the ●● Microsurgery Instrumentation. Microsurgery is
body. The bone instruments are used in combi- usually performed on soft tissues. These sets
nation with soft tissue foundation sets accord- can be used in combination with foundation
ing to the location on the body. sets or as stand-alone sets.
●● Head and Neck Procedure Instrumentation. ●● Endoscopic Instrumentation. The application
Upper airway and otorhinolaryngology pro- of endoscopic techniques to multiple specialties
cedures require specialty instrumentation de- is described. Percutaneous and natural orifice
signed for narrow passages and the soft tissues endoscopy is described in functional terms.
of the anterior neck and throat. ●● Decontamination and Sterilization. A critical
●● Neurosurgery Instrumentation. Procedures of component in a complete understanding of
the brain and spinal cord use a unique blend of surgical instrumentation is understanding
soft tissue sets, compact tissue sets, and micro- decontamination and sterilization of the
surgical sets. Instrumentation for procedures of instruments. This new chapter includes infor-
the cranium and spine is described. mation on cleaning (manual and mechanical),
●● Cardiothoracic and Vascular Instrumentation. inspection, disinfection, sterilization, and
Instrumentation used for surgical procedures packaging.
ABOUT THE AUTHOR
Nancymarie Phillips, RN, PhD, BA, BSN, MEd, RNFA, CNOR(E). Dr. Phillips is the Professor Emeritus for
Perioperative Education at Lakeland Community College in Kirtland, Ohio. Her programs included Perioperative
Nursing, Registered Nurse First Assisting, and Surgical Technology. She has authored numerous articles and texts
about perioperative patient care. She was the 2006 recipient of the AORN Perioperative Clinical Education Award,
the 2006 Lakeland Community College Teaching Excellence Award, and was a nominee for the 2006 Ohio Magazine
Excellence in Education Award.
Dr. Phillips has been a perioperative nurse since 1975. In addition, she has worked as a scrub nurse, circulator,
first assistant, consultant, author, and educator. She can be reached at nancymphillips@aol.com. Her RNFA education
website is www.nvo.com/delphipro.
ACKNOWLEDGEMENTS
We thank Denell Lewalk, MLS, and Jennifer Gerres, Joseph Charleman, CST, CSFA, CRCST, LPN
DPM, for their assistance in this massive undertaking. Chapter 7: General Surgery Instrumentation
The author and Cengage Learning wish to extend
Chapter 10: Basic Bone and Joint Instrumentation
a deep gratitude to Berkeley College School of Health
Studies, Woodland Park, NJ campus for providing their Chapter 16: Decontamination and Sterilization
lab and instruments for a photoshoot. Special thanks to
Joseph Charleman for his assistance with the arrange-
Margaret Rodriguez, CST, CSFA, FAST, BS
ments, preparation, and logistics of this photoshoot. We
Chapter 2: Anatomy and Physiology of Surgical
would also like to acknowledge the following individu-
Instrumentation
als for their assistance with the photoshoot:
Chapter 4: Considerations for Instrument Set
Mike Gallatelli, photographer Assembly
Metroland Photo Chapter 5: Soft Tissue Foundation Sets
www.metrolandphoto.com Chapter 9: Urologic Instrumentation
Chapter 11: Head and Neck Procedure
Annadelia De La Cruz, AAS, BA
Instrumentation
Administrative Assistant
Surgical Technology & Surgical Processing
Department REVIEWERS
Mayra Y. Cabrera, AAS, CST Rob Blackston CST, CSFA
Clinical Coordinator Program Director of Surgical Technology
Surgical Technology & Surgical Processing North Idaho College
Department Coeur d’Alene, ID
Robert Torres, BA, CRCST, CHL David Braun, CST, CRCST

Clinical Site Monitor Program Director/Instructor School of
Surgical Technology & Surgical Processing Surgical Technology
Department Western Suffolk BOCES
Northport, NY
CONTRIBUTORS Julia Hinkle, RN, MHS, CNOR

The author and publisher would like to acknowledge Professor/Program Chair
the following professionals for contributing to the con- Ivy Tech Community College
tent of this book: Evansville, IN
xi
xii Acknowledgements
Rosemary Nagler Mecklin Soules, CST, AAS

Assistant Principal Health Careers/Clinical Education Surgical Technology Program Director
Coordinator of Surgical Technology Meridian Community College
Western Suffolk BOCES Meridian, MS
Northport, NY
Stefanie Vaughn, CST
Alisia Pooley, CST Program Director of Surgical Technology
Surgical Technology Instructor Angelina College
Mohawk Valley Community College Lufkin, TX
Rome, NY
Mary Seely, CST, AS

Surgical Technology Program Director
Monroe Community College
Rochester, NY
ABOUT THE INSTRUMENTS
The instruments appearing in this book have been gra- Scanlan International
ciously provided by the following manufacturers: www.scanlaninternational.com
One Scanlan Plaza
CareFusion Saint Paul, Minnesota 55107
Becton, Dickinson and Company International: 651-298-0997
1 Becton Drive U.S. & Canada: 800-328-9458
Franklin Lakes, NJ 07417-1880 Fax: 651-298-0018
Phone: 201-847-6800 Email: info@scanlangroup.com
Cook Medical, Inc. Sklar Instruments

www.cookmedical.com www.sklarcorp.com
P.O. Box 489, 750 Daniels Way 889 South Matlack Street
Bloomington, IN 47402-0489, USA West Chester, PA 19382
812-339-2235 Phone: 610-756-7863
Email: surgi@sklarcorp.com
Integra LifeSciences Corporation
www.integralife.com Sontec Instruments
JARIT Surgical Instruments www.sontecinstruments.com
Padgett Surgical Instruments 7428 South Tucson Way
R&B Surgical Instruments Centennial CO 80112
Ruggles Surgical Instruments 800-821-7496
311 Enterprise Drive
Plainsboro, NJ 08536 Teleflex Medical
Phone: 609-275-0500 http://www.teleflex.com
3015 Carrington Mill Boulevard
Intuitive Surgical, Inc. Morrisville, NC 27560
www.intuitivesurgical.com 919-544-8000
1020 Kifer Road
Sunnyvale, CA 94086-5304
Phone: 408-523-2100
xiii
CHAPTER 1
HISTORY OF SURGICAL
INSTRUMENTATION
OBJECTIVES CHAPTER OUTLINE

After reading this chapter the learner should be able to: Historic Surgical Instrumentation
1. Describe several historic findings that indicate ancient humans used surgical Ritual and Magic
instruments.
2. Discuss the countries that contributed ideas to the surgical armamentarium.
3. List several materials that comprised early surgical instruments.
INTRODUCTION
Since the beginning of time, man has sought to appease the gods and
remedy the failings of the human body with the medical and surgical
arts. Each culture has historically approached medicine and surgery
in a different way and has lent a societal touch to the evolution of
surgical practice.
HISTORIC SURGICAL INSTRUMENTATION

Forms of early surgical practice encompassed tending injuries and wounds
associated with animal encounters or battles. Some Neolithic tribes were
known to have practiced amputation for serious injury, tumors, or infec-
tion. Relics of surgical instruments, such as sharpened flints and natural
substances like shells, have been found wherever civilizations have been
uncovered. Scientists have speculated dates ranging from 10,000 bc for early
incisions to 2500 bc for suturing with horsehair or animal tendons.
Hindus developed the earliest known organized practice of surgery
(shastrakarma), which is one of the eight branches of Ayurveda (Indian
medicine). Shushruta (circa 800 bc), a medical practitioner from Benares,
India, wrote the Samhita. In this text he described the need for cleanli-
ness and precision in surgical treatment. His writings were captioned
under seven topics: esya (exploration), ahrya (extraction), chedya (excision),
lekhya (scarification), vedhya (puncturing), vsraya (evacuation), and sivya
(suturing). He based his methods of surgery on his studies of anatomy us-
ing dead bodies. Shushruta developed 121 separate surgical instruments of
natural materials, such as bone, ivory, mussel shell, and stone. He also advo-
cated the use of hypnosis and wine as anesthetics.
1
2 Surgical Instrumentation
RITUAL AND MAGIC the internal anatomy sacred. Archeologists discovered

papyri that described medical care during this period.
Prehistoric man performed documented incisional In 1862, American Edwin Smith purchased a 22-page
procedures as early as 6000 bc. Scientists speculate papyrus, dating from 1500 bc that contained many
that some procedures, such as opening holes into the treatments performed during ancient times. It was
skull (known as trepanation), were performed for ritu- later deciphered by James Henry Breasted. German
alistic or magic reasons. Significant numbers of skulls Egyptologist George Ebers purchased a similar papy-
have been found that indicate the patients lived for rus in 1872 that consisted of 110 pages that dated back
many years after the procedure, as new bone growth to the First Dynasty in 3000 bc. A later papyrus was
was identified around the cut edges of the bony holes. written as a guide for midwives and those who cared
Figure 1-1 depicts trepanation instruments used for for female patients. These papyri contained medi-
opening skull bone. cal and surgical references intermingled with magical
The ancient Egyptians did not feature cutting as a spells for protection against supernatural forces.
primary medical treatment. Egyptian temple and tomb Cataract surgery, known as couching in many an-
art indicates that most of the anatomic study involved cient lands, was a common procedure between 1345
the embalming of bodies for burial. The religious and 1200 bc. This surgery was performed by using a
sects were guardians of physical knowledge and held rodlike tool with a blunt end to tap the eye, causing
the lens to shift away from the pupil. This allowed light
to enter. Later methods of performing this procedure
included inserting a needle into the eye to dislodge
the natural lens (Figure 1-2).
Courtesy of the National Library of Medicine
Courtesy of the National Library of Medicine
Figure 1-1 Ancient trepanation instruments. Figure 1-2 Instruments used historically for cataract surgery.
Chapter 1 History of Surgical Instrumentation 3
Mesopotamian society (circa 3500 bc) exercised necessity to displace cataracts. Surgery was considered
generalized laws and rules governing conduct. They manual labor, and the ancient Roman physicians con-
had a concept of comparative worth concerning human tributed very little to surgical knowledge. In fact, artists
life and believed in medical training before commenc- frequently had a greater knowledge of the human body
ing practice. The physicians in Mesopotamia identified than physicians because they studied corpses during
specific procedures, named each drug used in medical postmortem dissection.
care, and kept records of medical and surgical activities Arabian surgeons established a school for brain
by carving cuneiform figures into clay tablets. Over surgery in Islam in 800 ad. Other surgical procedures
20,000 such tablets have been discovered. were also performed, such as couching. However,
Ancient Babylonians (modern-day Iraq) were led little was known of human anatomy because human
by the great King Hammurabi (1795–1750 bc). He dissection was banned by the Koran. During this era,
established the first known major metropolis and set Andalusia (Moorish Spain) was part of the Islamic
forth the law that bears his name. The law was clear Empire. A famous skilled Moorish surgeon of the
with regard to medical treatment. A surgeon who suc- time, El Zahrawi (940–1013 ad), wrote an encyclo-
cessfully treated his nobleman patient would be paid pedia of 30 volumes referred to as the At-Tasrif to
10 shekels for his labor. If he treated a slave, he was paid record methods of medical and surgical treatment.
2 shekels, and for treatment of a freeman, he would He taught his students to treat each patient as an
be paid 5 shekels. If the nobleman or freeman patient individual and to practice within ethical limits. His
died, the surgeon could lose a hand. If a slave died, the writings guided the development of most surgical text-
surgeon had to repay the cost of the slave to his master. books in European universities between the 12th and
The law was carved in black diorite stone that stood 17th centuries ad. Many of the surgical instruments
8 feet tall and was designed like a monument for dis- used during that period were designed by El Zahrawi
play in a public location in the city until it was taken by himself, who personally drew the 200 illustrations for
warring tribes as a trophy. It was discovered in Persia his texts. He is also credited with being the first to use
in 1901. The entire code of Hammurabi has been trans- ligatures for hemostasis in surgery. The history and
lated into English and is available online. images of El Zahrawi and other Muslim physicians
Greek civilization gave rise to more organized are available online at http://www.muslimheritage
written texts on medicine and health. The Greeks en- .com/surgery.
couraged a scholarly approach and established formal The Chinese practiced acupuncture and acu-
schools. Most of the surgery performed dealt with war pressure for at least 2000 years of recorded history.
wounds and orthopedic injury. The Greeks used palm The central belief of these practices is that there is a
bark and wood bound by moist clay and linen strips mind–body–spirit connection to health and wellness
like splints to stabilize broken bones. Hippocrates associated with the ch’i, or life force. The main focus
(460–377 bc) used instruments of hardened iron, cop- of health and wellness was not based in surgical pro-
per, bronze, and brass. His surgical armamentarium cedures, but in a pharmacopoeia of 1800 medicinal
consisted of more than 200 types of surgical instru- herbs, biologic materials, and chemicals.
ments. Although physicians were trained in medical The ancient Aztec civilization left little written
and surgical treatments, the main focus of healthcare history, but significant evidence of successful surgery
dealt with diet and exercise. has been unearthed in archeological explorations.
The early Romans had knowledge of steel. The an- They had a strong knowledge of human anatomy
cient ruins of Pompeii (circa 310 bc to 79 ad) revealed because their culture practiced human dissection
an instrument manufacturer’s place of business with on their enemies. They felt that they captured the
preserved bundles of surgical tools made of several essence of the life force if they cut the beating heart
metals wrapped in protective fabric. Homes of physi- from the chest of their captives. Blood sacrifice was
cians revealed beautifully carved boxes for instrument a daily event. The main feature of their surgical ar-
storage. Most of the surgical practice was borrowed mamentarium was sharp dissection of bone and soft
from other cultures. Couching was performed as a tissues.
SUMMARY knowledge base concerning human anatomy and

physiology led physicians to create new tools for
Throughout history, physicians have devised and
exploration and treatment of body regions never
modified available materials for use in surgical pro-
surgically treated before. With each successive era,
cedures. As scientists contributed new knowledge
the sophistication of surgical instrumentation has
of metals and eventually synthetics, such as plastics,
improved significantly.
instrumentation became more functional, incor-
porating the principles of physics. The increasing
REFERENCES Phillips, N. M. (2016). Berry and Kohn’s operating room

technique (13th ed.). St. Louis: Mosby-Elsevier.
Ahmed, M. (2008). Muslim scientists and scholars. Rutkow, I. M., & Burns, S. B. (1998). American
Retrieved from www.ummah.net/history/scholars. surgery: An illustrated history. Philadelphia:
Haeger, K. (1988). The illustrated history of surgery. Norman Publishing.
New York: Bell.
CHAPTER 2
ANATOMY
OF SURGICAL
INSTRUMENTATION
OBJECTIVES CHAPTER OUTLINE
After reading this chapter the learner should be able to: Evolution of Modern Surgical
1. Discuss the evolution of ancient surgical instruments into designs in Instrumentation
current use. Anatomy of a Surgical
2. Describe the ergonomics of instrument design. Instrument
3. List the three essential design components of every surgical instrument. Handle Styles
4. List the common metals used in modern surgical instrumentation. Joint Styles
Tip and Jaw Styles: Sharp
Dissection
Tip and Jaw Styles: Clamping,
Occluding, and Grasping
INTRODUCTION Tip Styles: Blunt Dissection
Surgical instrumentation is one of the essential elements of a safe Categories of Surgical
and efficient operating room. Even in the most skilled hands of a Instruments
surgeon, the instruments must be in good condition and function How Surgical Instruments Are
Named
as intended to prevent potential tissue damage. Surgical procedures
Materials Used in the
require the use of a variety of instruments of different sizes, shapes,
Manufacture of Surgical
and chemical compositions in order to achieve a safe and opti- Instrumentation
mal outcome for the patient. This chapter explores the broad range Metallics
of unique design specifications of surgical instrumentation used to Steel
perform invasive procedures on all types of tissues and anatomic Copper
structures. Titanium
Silver
Surface Finishes of Metallic
Surgical Instruments
Inspection and Quality Control of
EVOLUTION OF MODERN SURGICAL Metallic Surgical Instruments
INSTRUMENTATION Scissors
Clamps, Needle Holders, and
As discussed in Chapter 1, civilization has evolved and so, too, have sur-
Graspers
gical instruments and procedures. Conversely, human anatomy has not
Forceps
changed significantly over the centuries; however, the practice of surgical
Retractors
intervention has become increasingly complex in its goal to treat disease
Maintenance
while minimizing tissue trauma, pain, and recovery time for patients.
Cleaning and Lubrication
Ultrasonic Cleansing
5
Despite these changes, much of our basic modern ●● The functional or connecting joint mecha-
instrumentation has been modeled after long-standing nism that allows the instrument sides to stay
styles with modifications for contemporary surgical together in order to perform its task
procedures. ●● The tips and jaws are the working ends that
come into contact with the patient’s tissues
ANATOMY OF A SURGICAL and may be sharp, blunt, smooth, toothed, ser-
rated, crushing, or noncrushing, also known as
INSTRUMENT
atraumatic.
Basic design specifications are generally standardized
Keeping these components in mind, the design pos-
according to the required function of the instrument.
sibilities are nearly limitless. Surgical instruments
Modifications in size, shape, and design are made to
can be as simple as a flat sheet of metal or a single
accommodate the variety of human anatomic structures.
rod, or as complex as having up to 15 to 20 parts and
Instruments can be classified by their use and function,
pieces. Newer energized instrumentation can make
which then determine the unique designs and shapes. A
contact with the patient’s tissues through electrical
simple form of instrument anatomy is depicted by the
current, radio frequencies, or collimated laser light
small mosquito hemostat shown in Figure 2-1. It has
waves.
all the standard design components, such as jaws, box
locks, shanks, and handles. The essential standardized
design components include the following: Handle Styles
●● The handle or other form of hand grip held by Handles are designed to optimize the operator’s func-
the surgical practitioner tional grip and dexterity. The working parts of an
Tip
Jaws
Box Lock
Shanks
Ratchet
© Cengage®.
Finger Rings
Figure 2-1 Basic anatomy of a surgical instrument (Halsted mosquito clamp).
Chapter 2 Anatomy of Surgical Instrumentation 7
instrument’s jaws determine the style of the handle. on delicate tissues (Figure 2-3). Ratchets are used to
Controlled and precise actions such as cutting, dissect- lock and keep constant pressure from both sides of the
ing, and clamping require steady and secure manipu- instrument to occlude flow, provide traction, or hold
lation as provided by ring handles and compression structures together (Figure 2-4). Pistol grip handles
grips (Figure 2-2). Compression handles are pressure provide additional leverage for instruments with longer
sensitive for precision closing power on heavy or firm shafts used in narrow anatomic spaces or small inci-
tissues such as bone, cartilage, or fascia. Spring handles sions such as in open nasal or spinal procedures and
are preferred for microsurgery because activation of in laparoscopic instruments, which must be inserted
the jaws requires only minute motion to effect action through percutaneous trocar cannulas (Figure 2-5).
A. Ring handles
B. Grooved
handle
A: Courtesy of Sklar Instruments. B: Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ. C: © 2019 Cengage®.
C. Grooved
handle with
horn
Figure 2-2 Ring handles and compression handle grips.
A. Double-leaf spring
B. D
ouble-leaf locking
spring
C. Cam ratchet
A–B: © 2019 Cengage®. Photo by Margaret Rodriguez. C–D: Courtesy of Sklar Instruments. E: © 2019 Cengage®.
D. Bar and locking nut
E. Bar ratchet
Figure 2-3 Spring handles and locking handle grips.
A. Ratchet lock D. Single spring
B. Thumb screw E. Double spring
A, C: Courtesy of Sklar Instruments. B, D–E: © 2019 Cengage®. F: Courtesy of CareFusion, a divison of Becton, Dickinson and Co.
C. Twist screw
F. Double spring with ball and socket joint
Figure 2-4 Locking and opposition handle system.
A. S
tyle 1 pituitary or
Takahashi
B. Style 2 Kerrison
C. Style 3 Kerrison
A, C–D: Courtesy of CareFusion, a divison of Becton, Dickinson and Co. B: © 2019 Cengage®.
D. Style 4 Kerrison
Figure 2-5 Rongeurs handles.
Joint Styles tissue or other materials placed between the open jaws
The type and style of a joint facilitate the closing preci- of the scissors. Double-action joints use the principles
sion of the jaws and tips of an instrument. Three styles of pivots and levers to increase the closing pressure and
are most commonly used (Figure 2-6). Grasping and enable the jaws to grasp, cut, and debulk firm tissues.
clamping instruments with finger rings usually have box
lock joints. Hemostats and ringed tissue forceps have a
unique design of one side passing through the hollowed- Tip and Jaw Styles: Sharp Dissection
out center of the opposing side to create a box lock Sharp dissection is used to precisely cut and sepa-
between the jaw portion and the shanks. Overlapping rate tissue planes and divide tissue attachments. The
joint styles are common in sharp dissection instruments distal end or instrument tip styles of scissors may
such as scissors. The two sharp, flat blades are held be sharp or dull, curved, straight, or angled. Cutting
together with a screw, and the scissoring action slices graspers known as rongeurs or biters have two sides
A. Box lock
B. Scissor or lap joint
A–B: Courtesy of Sklar Instruments. C: © 2019 Cengage®. Photo by Margaret Rodriguez.
C. Double-action joint
Figure 2-6 Joint types.
that close, entrapping tissue in between hollowed Tip and Jaw Styles: Clamping,
depressions referred to as cups or in linear channeled
Occluding, and Grasping
grooves. Examples of these instruments may be found
Clamping jaws and grasping tips are used to hold tis-
in upcoming specialty chapters. Incisions are sharply
sue or items such as sutures or retraction material
made with a variety of scalpel handles and varying
(e.g., umbilical tapes, Silastic vessel loops, Penrose
shapes of disposable blades or other types of nondis-
drains) (Figure 2-10). The jaws of clamping instruments
posable knives (Figures 2-7, 2-8, and 2-9).
A. Straight
B. Slightly curved
C. Strongly curved
D. Forward angle
A, G: Courtesy of Sklar Instruments. B: Courtesy of Scanlan International. C–F: © 2019 Cengage®. Photo by Margaret Rodriguez.
E. Lateral angle
F. C
urved microsurgical spring
handled
G. Angled with tip guard
Figure 2-7 Sharp dissection tip styles: curvatures and angles.

A. Blunt–blunt
B. Blunt–tenotomy
C. Sharp–blunt angled
D. Sharp–sharp
A, C–E: © 2019 Cengage®. Photo by Margaret Rodriguez. B: © 2019 Cengage®.
E. Sharp–tenotomy
Figure 2-8 Sharp dissection tip styles.
Another random document with
no related content on Scribd:
The Project Gutenberg eBook of Carità
This ebook is for the use of anyone anywhere in the United States
and most other parts of the world at no cost and with almost no
restrictions whatsoever. You may copy it, give it away or re-use it
under the terms of the Project Gutenberg License included with this
ebook or online at www.gutenberg.org. If you are not located in the
United States, you will have to check the laws of the country where
you are located before using this eBook.
Title: Carità
Author: Mrs. Oliphant
Release date: November 25, 2023 [eBook #72221]
Language: English
Original publication: London: John Murray, Albemarle Street, 1885
Credits: Chuck Greif and the Online Distributed Proofreading Team at

http://www.pgdp.net (This file was produced from images
available at The Internet Archive)
*** START OF THE PROJECT GUTENBERG EBOOK CARITÀ ***

‘But nothing shall stand between us any more.’
CARITÀ
BY MRS. OLIPHANT
AUTHOR OF “WITHIN THE PRECINCTS,” ETC.
CHEAP EDITION
LONDON
JOHN MURRAY, ALBEMARLE STREET, W.
1885
All Rights Reserved

CONTENTS.
CHAPTER PAGE
I. The Beresfords 1
II. A Fright 10
III. Honeymooning 18
IV. The Three Charities 26
V. Coming Home 35
VI. The Consultation 44
VII. The Catastrophe 53
VIII. Consolation 62
IX. The Hill 71
X. The Square 80
XI. Mrs. Meredith 88
XII. The House next Door 98
XIII. The Young People 107
XIV. The Old People 117
XV. Roger 126
XVI. Sunday Evening 135
XVII. Edward 145
XVIII. Telling Tales 155
XIX. The Holy Inquisition 164
XX. The Perugino 173
XXI. A Confidence 183
XXII. Mystified 193
XXIII. A Remonstrance 202
XXIV. On the Other Side of the Wall 212
XXV. An Idealist 222
XXVI. In the ‘House’ 231
XXVII. The Wolf in Sheep’s Clothing 241
XXVIII. The Fireside 251
XXIX. The Old Folk and the Young 261
XXX. A Rebellious Heart 269
XXXI. The House of Mourning 279
XXXII. Taking up Dropt Stitches 288
XXXIII. Little Emmy’s Visitors 297
XXXIV. The Widow 308
XXXV. Roger’s Fate 317
XXXVI. Between the Two 326
XXXVII. The Crisis Approaching 336
XXXVIII. The Supreme Moment 346
XXXIX. The Hand of Fate 355
XL. Two—Parted 364
XLI. Two—To be One? 373
XLII. A Great Revolution 382
XLIII. The Worst Scrape of All 393
XLIV. Clearing Up 402
XLV. Conclusion 412
CARITÀ.
CHAPTER I.
THE BERESFORDS.
James Beresford and Annie his wife had been married for more than a
dozen years—their only child, indeed, had nearly attained the age of twelve
at the time when this history begins. They had both got footing on that
plateau of middle age which, if it comes to something like level ground at
thirty, need not think of a descending step for twenty years—the time of the
greatest enjoyments and most solid progress of life. He was at one end and
she at the other of the first decade; the one approaching the forties, the other
scarcely well out of the twenties; both ready to laugh at the advance of years,
which was as yet but a joke to them, and neither having thought of bidding
any grave farewell to youth. She was impulsive, enthusiastic and nervous; he
philosophical and speculative, a man ready to discuss any theory in earth or
heaven, and without any prejudices such as might make one subject of
discussion appear less legitimate than another. They were not very rich, but
neither were they poor in any sense of the word. He had been called to the
Bar, but had never gone any further in that career. They had enough between
them to live on without show, but without pinching, as so many people of
quietly social, semi-literary tastes do in London. They knew a number of
people. They saw all the pictures, read all the books, and heard all the music
that was going; not absorbed in any art, but with just enough devotion to all
to make their life full and pleasant. And there could scarcely be a pleasanter
life. The fantasies of youth, but not the sentiment of youth, had ended for
both. Mr. Beresford had some mildly scientific pursuits, was a member of
some learned societies, and of one or two new and advanced clubs where
clever men were supposed to abound. Occasionally in his comfortable
library he wrote an article for a review or magazine, which was very much
talked about by his friends, to the great edification and amusement of people
who live by writing articles and say nothing about them. This gave him an
agreeable sense of duty to add seriousness to his life; and he was never
without occupation—meetings of committees, scraps of semi-public
business, educational and other projects, which, for the moment at least,
seemed full of interest to the world, made him feel himself a not
unimportant, certainly not a useless, man. Mrs. Beresford, on her side, had
the natural occupation of her housekeeping, and her child, whose education
gave her much thought—so much thought that many people with full
nurseries listened with a certain awe to her ideas of all that was necessary for
her little girl, and sighed to think how much less was possible when there
were six or seven little girls to think of.
The child, however, was not so over-educated and over-cared for as might
have been fancied; for the parents were young, as has been said, very fond of
each other, and fond of their own way; which likings did not consist with the
burden of dragging a small child with them wherever they went. The
Beresfords liked to go about ‘honeymooning,’ as their friends called it, and
as they themselves were not displeased to call it, by themselves, over the
world. They would start sometimes quite suddenly, to the Riviera in the
middle of winter, to escape London fogs and wintry chills; to Paris at Easter;
to Scotland in the autumn; even to Norway sometimes, or such difficult
places; and it stood to reason that they could not take the child with them
when they started at a day’s notice on these delightful journeys. For their
journeys were delightful. They were well enough off not to require to count
the cost; they went lightly, with little luggage and no servants, and they went
everywhere together. But it would have been bad for the little girl; therefore
she stayed at home, under the care of the best of nurses, who had been Mrs.
Beresford’s nurse before the child’s; and the father and mother, like two
lovers, roamed lightly about the world. But when they were at home, Mrs.
Beresford talked a great deal about education, and had plans enough to have
educated six princesses, let alone one little girl of undistinguished lineage. It
was a very lucky thing for all parties, their friends said, that they had but this
one child. Had they been hampered by half-a-dozen, what could they have
done? It would have changed their life completely. And one of their many
felicities was, that whereas they were preserved from the old-maidishness of
childless married persons by having a child, their freedom of action was
preserved by the fact that they had but one.
And they were wonderfully free of other relations who might have
hampered them. Mrs. Beresford had been an orphan from her childhood,
brought up by her grandmother, who in the course of nature was dead too;
and Mr. Beresford’s only two relations were a wealthy aunt, Charity
Beresford, who lived in a pretty house in the country, within driving distance
of London, and with whom lived his elder sister, Cherry Beresford, named
after her aunt, and living in considerable subjection to that energetic woman.
Miss Beresford was the richest member of the family, and her nephew had
expectations from her; and Charity was the favourite female name of this
branch of the race. But the idea of calling her child Charity did not at all
smile upon young Mrs. Beresford when her baby was born. She was
beguiled, however, by the unusual look of it, which charmed her, into calling
the little girl by the more melodious name of Carità, contracted prettily into
Cara in the drawing-room, and Carry in the nursery. Aunt Charity growled
when she heard of this, but did not otherwise complain, and gentle Aunt
Cherry declared herself unfeignedly glad that her little niece had thus
escaped the worse consequences of a symbolical name. When the young
couple went away pleasuring, little Cara very often would be sent to
Sunninghill, to pass the quiet days there under the charge of the aunts; and
so all responsibility was removed from the minds of the parents. They had a
letter sent to them every day to assure them of their welfare, however far off
they might go—an extravagance which Aunt Charity condemned loudly, but
which Aunt Cherry was proud of, as showing the devotion of the parents to
little Cara. The child herself was very happy at Sunninghill, and was a much
more prominent person there than at home, where very often she was in the
way, and interrupted conversation. For a father and mother who are very
fond of each other, and have a great deal to talk of, often, it must be allowed,
are hampered by the presence of one curious child, with quick ears and an
inconveniently good memory. In this particular the half-dozen would have
been more easily managed than the one.
Thus the Beresfords led a very pleasant life. They had the prettiest house;
naturally, travelling so much as they did, they had been able to ‘pick up’ a
great many charming things. You could scarcely see their walls for pictures;
some very good, one or two wonderful windfalls, and the rest pretty enough;
nothing strikingly bad, or next to nothing. Where other people had ordinary
china, they had genuine old faïence, and one or two plaques which Raphael
himself might have seen perhaps—Urbino ware, with Messer Giorgio’s
name upon it. Not to speak of the Venice point which Mrs. Beresford wore,
there were brackets in the drawing-room hung with scraps of old point coupé
which many a lady would have been glad to trim her dress with; and, instead
of common portières, they had two pieces of old tapestry from an Italian
convent which devotees went down on their knees before. But I have not
space to tell you how many pretty things they had. It was one of the
pleasures of their life whenever they saw anything that pleased them to bring
it home for the decoration of that pretty drawing-room, or the library, which
Mr. Beresford had filled with old vellum-bound volumes of curious editions,
and pretty books in Russian leather which kept the room always fragrant.
What was wanting to this pleasant, warm, full, delightful living? Nothing but
continuance; and it had not struck either of them that there was any doubt of
this for long, long years at least. What a long way off threescore years and
ten look when you are not yet forty! and death looked further off still.
Neither of them thought of dying. Why should they? For, to be sure, though
we know very well that must happen to us some time, in our hearts we are
incredulous, and do not believe that we ever can die. The Beresfords never
dreamt of anything so frightful. They were well, they were happy, they were
young; and as it had been, so it would be; and a world so bright they felt
must mean to go on for ever.
When Cara was about ten, however, the mother began to feel less well
than usual. There was nothing much the matter with her, it was thought:
want of ‘tone,’—a little irritability of disposition—a nervous temperament.
What she wanted was change of air and scene. And she got that, and got
better, as was thought; but then became ill again. No, not ill—unwell,
indisposed, mal à son aise, nothing more. There was nothing the matter with
her really, the doctors thought. Her lungs and her heart, and all vital organs,
were perfectly sound; but there was a little local irritation which, acting upon
a nervous temperament—— The nervous temperament was perpetually kept
in the front, and all sorts of evils imputed to its agency. At Sunninghill, it
must be confessed, they did not believe in the illness at all.
‘Fudge,’ said Aunt Charity, who had always been strong, and had no faith
in nerves, ‘don’t talk to me of your nervous temperaments. I know what it
means. It means that Annie has fallen sick of always having her own way.
She has everything she can desire, and she is ill of having nothing more to
wish for. A case of Alexander over again in a London drawing-room—that’s
what it is, and nothing else, my word upon it; and I know my niece.’
‘Yes, Mr. Maxwell; perhaps there is some truth in what Aunt Charity
says,’ said Miss Cherry. ‘I think you know I don’t judge harshly——’
‘That means that I judge harshly,’ said Miss Charity, bursting in; ‘thank
you, my dear. Well, you may call me uncharitable if you please; but there’s
where it is; let James lose the half of his fortune, or all his china get broken,
and she’d come round in no time—that’s what ails Annie. But as she belongs
to a very refined society, and has a silly husband, it’s called nerves. Bless
me, Cherry, I hope I knew what nerves were, and all about it, before you
were born.’
‘You could not know Annie before I was born,’ said Miss Cherry, who
was devoid of imagination. ‘I hope you will give her your best attention, Mr.
Maxwell. My brother James is a very fond husband, poor fellow! If anything
happened to Annie, he would never get the better of it. As for marrying
again, or anything of that sort——’
‘Good heavens!’ said the doctor; ‘I hope there is no need to take such an
idea into consideration. We must not go so fast.’
Miss Charity laughed. She was a great deal older than her niece, but
much more sensible. ‘There’s the seventh commandment to be thought of,’
she said; for her remarks were sometimes more free than they ought to be,
and put Miss Cherry to the blush: and this was all the worse because she
immediately walked out into the garden through the open window and left
the younger lady alone with the doctor, who was an old friend of the family,
and contemporary of the second Charity Beresford. Very old friends they
were; even it was supposed that in their youth there had been or might have
been passages of sentiment between these two now sitting so calmly
opposite each other. Mr. Maxwell, however, by this time was a widower, and
not at all sentimental. He laughed, too, as Miss Beresford made her exit by
the window. He was very well used to the family, and all its ways.
‘She wears very well,’ he said, reflectively. ‘I don’t think she has aged to
speak of for these twenty years. When I used to be coming here in my early
days, when I was beginning practice——’
‘The rest of us have changed very much since then.’
‘Yes,’ said Mr. Maxwell, thinking most of himself; ‘but she not at all. I
could think when I look at her that I was still, as I say, a young fellow
beginning practice——’
Miss Cherry sighed—very softly, but still she did sigh: over forty, but still
in the position and with many of the sentiments of a girl. People laugh at the
combination, but it is a touching one on the whole. What ages of lingering
monotonous life had passed over her since her present companion began his
practice, since her Aunt Charity had begun to be an old woman! Dr.
Maxwell had married, had lost his wife, had gone through perhaps sharper
troubles than Miss Cherry had known. He was now middle-aged and stoutish
and weather-beaten—weather-beaten in aspect and in soul—while she was
slim and soft and maidenly still. The sigh was half for those uneventful
years, and half for the undevelopment which she was conscious of—the
unchangedness of herself, underneath the outer guise, which was changed;
but this was not safe ground, nor could it be talked of. So she brushed away
the sigh with a little cough, and added quickly:
‘I know perhaps what nerves are better than my aunt does, and I know
Annie better. Tell me seriously, Mr. Maxwell, now we are alone. You don’t
apprehend anything serious? Should she go on travelling and running about
as they do if there is really anything the matter? No one can be so much
interested as I am. You would be quite frank with me?’
‘It is the best thing for her,’ said the doctor. ‘You now—I should not say
the same for you. You are a tranquil person and patient; but for her, the more
she runs about the better. It distracts her and keeps her from thinking. If she
worries, it’s all over with a woman like that.’
‘She has so little to worry about.’
‘Just so; and the less one has to bear the less one is fit for; that is to say,’
said the doctor, getting up and going to the window, ‘the less some people
are fit for. There’s that old aunt of yours to prove me a fool. She has never
had anything to bear, that I know of; and she is strong enough to bear
anything. Sixty-eight, and just look at her. There’s a physique for you—that
is the kind of woman,’ Mr. Maxwell said, with a little outburst of
professional enthusiasm, ‘that I admire—as straight as a rod still, and every
faculty in good order. That a woman like that should never have married is a
loss to the world.’
Miss Cherry, who had gone to the window too, and stood by his side,
looked out somewhat wistfully at her old aunt. Cherry was not like her, but
took after the other side of the family, her own mother, who had died young,
and had not possessed any physique to speak of. ‘It is very sweet to-day in
the garden,’ she said, inconsequently, and stepped out into the world of
flowers and sunshine. Sunninghill was an ideal house for two ladies, a place
which people who were shut out from such delights considered quite enough
for happiness. Indeed, Miss Cherry Beresford’s friends in general resented
deeply the little plaintive air she sometimes took upon her. ‘What could she
wish for more?’ they said, indignantly; ‘a place that was just too good to be
wasted on two single women. There should be a family in it.’ This was
especially the sentiment of the rector’s wife, who was a friend of Cherry’s,
and who felt it a personal slight to herself, who had a large family and many
cares, when Cherry Beresford, with not a thing in the world to trouble her,
presumed to look as if she was not quite happy. The house stood upon a hill,
fringed round with small but delightful woods. These woods were on a level
with the highest turrets of the great beautiful royal Castle of St. George,
which lay full within sight in the afternoon sunshine. So you may imagine
what a view it was that was visible from the old smooth velvet lawn round
the house, which formed the apex to these woods. The quiet plain all around
lay basking in the light underneath, and the Castle upon its hill dominated,
with a broad and placid grandeur, that majestic sweep of country, with all its
lights and shadows. The royal flag fluttered on the breeze, the great tower
rose grey and solid against the sky. Green branches framed in this picture on
every side; the cuttings in the trees made a picture-gallery indeed of different
views for different hours, according to the lights. ‘What a lovely place it is!’
Mr. Maxwell said, with sudden enthusiasm; ‘I always forget how lovely it is
till I come back.’
‘Yes, it is beautiful,’ said Cherry, who was used to it. ‘If you are going to
send them away, I suppose Cara may come to us for the summer?—that
makes such a difference.’ Cherry was very well used to the different lights.
She acknowledged the beauty of her home, and yet I can fancy
circumstances under which she would have liked a little house in a street
better. Man or woman either cannot live by beauty alone any more than by
bread.
‘Here’s a pretty business,’ said Miss Beresford, briskly; ‘half of my roses,
I believe, spoiled for this year; no second show this time. Jones is the
greatest idiot; he pretends to know everything, and he knows nothing. Your
protégé, Cherry, of course. All the incapables hang on by you.’
‘I can’t see any signs of deficiency,’ said the doctor, looking round.
‘Not at this moment; if there were, he should have his dismissal on the
spot. If those two go off again, as you are always sending them off, tell
James I insist on the child coming here. Ah! that’s what your women of
nervous temperament do—leave their children at home in a poky London
square, while they go wandering over the world. Tell them I wish it,’ said
Miss Beresford, with a laugh; ‘they never go against me.’
‘They know how kind you always are.’
‘They know I’m old and will have something to leave behind me, that’s
the plain English of it—as if I was going to accept poor Cherry’s subjection,
poor soul, without rewarding her for it! It is she who will have everything
when I’m gone. I’ve told them that, but still they think there’s a chance that
Cara might cut her old aunt out. I can see through them. I see through most
people,’ she added, with a laugh, looking at him full. How could she know
the thought passing through his mind at the moment, which was the abrupt
reflection, uncalled for perhaps, that for a professional man, who had made
no extraordinary name in his profession, Cherry Beresford, though an old
maiden, would make not such a bad wife? Could the old witch see through
broadcloth, and the comfortable coating of middle-aged flesh and blood,
straight into a man’s heart? He grew red foolishly, as if that were possible,
and stammered a little in his reply:
‘I can believe everything that is clever of you as well as everything that is
kind; though why you ladies should make such a point of having a little chit
like that, who can only disturb your quiet in this paradise of a place——’
‘Oh, how can you say so!’ said Cherry. ‘The child’s voice and the child’s
face make all the difference—they are better than sunshine. They make the
place beautiful. I would give it all, twenty times over, to have the child.’
‘Whom her mother is very glad to leave behind her.’
‘Hold your tongue, Cherry,’ said the elder lady; ‘you mild little old
maids, you are always in a way about children. I never took up that line. A
child in the abstract is a nuisance. Now, a man—there are advantages about a
man. Sometimes he’s a nuisance too, but sometimes he’s a help. Believe
them, and they’ll tell you that marriage was always far from their thoughts,
but that children are their delight. That’s not my way of thinking. But I
happen to like little Cara because she is Cara, not because she is a child. So
she may come and take her chance with the rest.’
Cherry had turned away along the garden path, and was looking through
one of the openings at one of the views. She knew it by heart—exactly how
the light fell, and where were the shadows, and the name of every tower, and
almost the shape of every cloud. Was it wonderful that this was not so
delightful to her as to the strangers who could not see that view every day in
their lives? To some people, indeed, the atmospheric changes, the effects of
wind and colour, the waverings and dispersions of those clouds, would have
made poetry enough to fill up all that was wanting; but poor Miss Cherry
was not poetical in this big way, though she was very fond of pretty verses,
and even wrote some occasionally; but how she longed for the child’s
innocent looks—the child’s ceaseless prattle! Her gentle delicacy was hurt at
that unnecessary gibe about the old-maidishness, and her supposed sham
rejection of the husband who had never come her way. ‘Why should she talk
of men—especially before him? What do I want with men?’ said poor Miss
Cherry to herself; ‘but my own niece—my brother’s child—surely I may
wish for her.’ And surely there could not have been a more innocent wish.
CHAPTER II.
A FRIGHT.
‘Which you please; you are not gouty or rheumatical, or anything of that
sort,’ said Mr. Maxwell, almost gaily. ‘Homburg, for instance—Homburg
would do—or Baden, if you prefer that. I incline to the one you prefer; and
enjoy yourself as much as you can—that is my prescription. Open air,
novelty, change; and if you find you don’t relish one place, go to another.
The sea, if you take a fancy for the sea; and Sir William is of my opinion
exactly. Choose the place which amuses you most.’
‘It seems to me,’ said Mr. Beresford, ‘that these wise men are laughing at
you, Annie. They know there’s nothing the matter with you. If I were not
much obliged to them for thinking so, I should say you had some reason to
be offended. One knows what you doctors mean when you tell a patient to
do whatever she likes best.’
‘It means one of two things,’ said Mrs. Beresford; ‘either that it is
nothing, or that it is hopeless——’
Her husband burst into a soft laugh. ‘Well,’ he said, ‘it is very evident it
cannot be the last—so it must be as I say. It is injurious to our pride, my
darling; for I allow that it is pleasant to possess either in your own person or
your wife’s a delicate and mysterious malady, of which it can be said that it
baffles the doctors, without very much hurting the patient; but never mind. If
you can bear this disrespectful verdict that you have nothing the matter with
you, I assure you it makes me quite happy.’
Mrs. Beresford looked at the doctor with very keen, eager eyes—eyes
which had grown bigger and keener of late, perhaps from the failing of the
round, smooth outlines of the face. She noticed that, though Maxwell saw
very well that she was looking at him, he did not reply to those looks, but
rather turned to her husband and answered him, as if he had not observed her
at all.
‘I don’t mean to be at all disrespectful,’ he said; ‘there is a little
disturbance of the system, which might turn to something as serious as you
could desire, and take away the comfort of life perhaps more completely
than a regular disease; but I hope that is not likely to happen here.’
‘No; I don’t think it,’ said the easy man. ‘We shall try Baden, which is the
prettiest—unless you prefer some other place; in short, we shall go off
without guide or compass, and do exactly what pleases ourselves. We have
done so, it must be allowed, pretty often before—but to do it with the
sanction of the faculty——’
‘And the child—as usual—will go to Sunninghill?’
‘Why should you say as usual, Mr. Maxwell?’ said Mrs. Beresford, with a
suspicion of offence. ‘Do you think I ought to take her with me? Do you
suppose, perhaps, that I might not come back again—that I might never—
see——’
‘This is so unnecessary,’ said the doctor, remonstrating. ‘What must I
say? I wish I was as certain of a thousand a year. You will come back quite
well, I hope.’
‘When people are very ill don’t you say much the same things to them?
There was poor Susan Maitland, whom you banished to Italy to die. People
talked of her coming back again. Oh, no! I am not thinking of myself, but of
the subject in general. One needed only to look in her face to see that she
would never come back.’
‘People have different ideas of their duty,’ said Maxwell. ‘Some think it
best not to frighten a patient with thoughts of death. I don’t know that one
can lay down any rule; one is guided by circumstances. To some nervous
people it is best not to say anything. Some are more frightened than others—
just as some people are more susceptible to pain than others.’
‘Now I am going to ask you another question,’ said Mrs. Beresford.
‘Suppose you had a patient very ill—I mean hopelessly ill, beyond all cure
—do you think it is right to keep them alive as you do now, struggling to the
last, staving off every new attack that might carry them off in quiet, fighting
on and on to the last moment, and even prolonging that, when it comes so
far, with cordials and stimulants? Keeping their breath in their poor,
suffering bodies till you get to the end of your resources—your dreadful,
cruel resources, that is what I call them. Do you think this is right? I had an
aunt who died dreadfully—of cancer——’
‘Ah! An aunt? You did not tell me this,’ said the doctor, off his guard;
then, recovering himself, with something that looked like alarm, he said,
hurriedly: ‘What would you have us do—kill the poor creatures? neglect
them? refuse what aid, what alleviations we can——’
‘I’ll tell you what I should like you to do if it were me,’ she said, eagerly.
‘When it was all over, when you were sure I could not get better, when there
was nothing more in life but to suffer—suffer: then I should like you to
make a strong, sweet dose for me to put me out of my trouble. I should like
James to give it me. Do you remember what was said that time in India, in
the mutiny? I don’t know if it was true, but people said it. That the husbands
of some of the poor ladies kissed them and shot them, to save them; don’t
you remember? That is what I should like you to do—a sweet, strong dose;
and James would bring it to me and kiss me, and put it to my lips. That
would be true love!’ she said, growing excited, the pale roses in her cheeks
becoming hectic red; ‘that would be true friendship, Mr. Maxwell! Then I
should not feel afraid. I should feel that you two stood between me and
anguish, between me and agony——’
Both the men rose to their feet as if to restrain her vehemence, with one
impulse. ‘My darling, my darling!’ said James Beresford, in dismay, ‘what
are you thinking of?’ As for Mr. Maxwell, he walked to the window and
looked out, his features working painfully. There was a moment in which the
husband and wife clung together, he consoling her with every reassuring
word that he could think of, she clinging to him with long, hysterical sobs.
‘My love, what has put this into your head?’ he said, half sobbing too, yet
pretending to laugh. ‘My Annie, what fancy is this? Have you lost your wits,
my darling? Why, this is all folly; it is a dream; it is a craze you have taken
into your head. Here is Maxwell will tell you——’
But Maxwell made him a sign over his wife’s head so impassioned and
imperative that the man was struck dumb for the moment. He gazed blankly
at the doctor, then stooped down to murmur fond words less distinct and
articulate in her ear. Fortunately, she was too much excited, too much
disturbed, to notice this sudden pause, or that the doctor said nothing in
response to her husband’s appeal. She held fast by his arm and sobbed, but
gradually grew calmer, soothed by his tenderness, and after a while made a
half-smiling, tearful apology for her weakness. It was after dinner on a
lovely summer evening, not more than twilight, though it was late. The two
gentlemen had been lingering over their claret, while she lay on the sofa
waiting for them, for she did not choose to be shut up upstairs all by herself,
she said. After she had recovered they went to the drawing-room, where the

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PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii CHAPTER 3 CATEGORIES OF SURGICAL

Excisional Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 CHAPTER 10 BASIC BONE AND JOINT

Manipulation within the Working Space . . . . . . . . . 397 CHAPTER 16 DECONTAMINATION

Robert Torres, BA, CRCST, CHL David Braun, CST, CRCST

CONTRIBUTORS Julia Hinkle, RN, MHS, CNOR

Rosemary Nagler Mecklin Soules, CST, AAS

Mary Seely, CST, AS

Cook Medical, Inc. Sklar Instruments

OBJECTIVES CHAPTER OUTLINE

HISTORIC SURGICAL INSTRUMENTATION

RITUAL AND MAGIC the internal anatomy sacred. Archeologists discovered

Courtesy of the National Library of Medicine

SUMMARY knowledge base concerning human anatomy and

REFERENCES Phillips, N. M. (2016). Berry and Kohn’s operating room

Figure 2-1 Basic anatomy of a surgical instrument (Halsted mosquito clamp).

Figure 2-2 Ring handles and compression handle grips.

D. Bar and locking nut

Figure 2-3 Spring handles and locking handle grips.

A. Ratchet lock D. Single spring

B. Thumb screw E. Double spring

F. Double spring with ball and socket joint

Figure 2-4 Locking and opposition handle system.

Figure 2-5 Rongeurs handles.

B. Scissor or lap joint

A–B: Courtesy of Sklar Instruments. C: © 2019 Cengage®. Photo by Margaret Rodriguez.

Figure 2-6 Joint types.

G. Angled with tip guard

Figure 2-7 Sharp dissection tip styles: curvatures and angles.

A, C–E: © 2019 Cengage®. Photo by Margaret Rodriguez. B: © 2019 Cengage®.

Figure 2-8 Sharp dissection tip styles.

Author: Mrs. Oliphant

Release date: November 25, 2023 [eBook #72221]

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