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SURGICAL
INSTRUMENTATION
Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
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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 proof 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.
are designed to mechanically occlude the lumens of

vessels, ducts, intestinal tracts, and other structures.
Clamps, commonly called hemostats, are primarily used
to provide hemostasis, or the stoppage of blood flow.
Noncrushing styles of clamps are used to temporarily
© 2019 Cengage®. Photo by Margaret Rodriguez.

occlude structures with lumens, such as the bowel for
surgical repair or excision. Grasping tips are used to
hold tissue for manipulation, traction, or excision. Some
grasping tips have teeth for a more secure attachment to
the tissue. Most of these have serrations over the surface
of the instrument’s jaws. There are styles of jaw serrations
designed for specific use with soft tissue, bone, metal
needles, and blades and include horizontal, longitudinal,
Figure 2-9 Variations of scissors. atraumatic, and cross-hatched patterns (Figure 2-11).
A. Kocher clamp D. Lahey/Gemini/right angle longitudinal
E. Crile hemostat
A: © 2019 Cengage®. B–G: © 2019 Cengage®. Photo by Margaret Rodriguez.
B. Right angle/Mixter and Adson/Schnidt
F. Kelly hemostat
C. Rochester Pean G. Doyen noncrushing intestinal clamp
Figure 2-10 Hemostatic clamps: jaw and tip variations.
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CHAPTER XV.
MARKETING HONEY.
No subject merits more attention by the apiarist than that of

marketing honey. There is no question but that the supply is going to
continually increase, hence, to sustain the price we must stimulate
the demand, and by doing this we shall not only supply the people
with a food element which is necessary to health, but we shall also
supersede in part the commercial syrups, which are so adulterated
as not only to be crowded with filth the most revolting, but are often
even teeming with poison. (Report of Michigan Board of Health for
1874, pp. 75-79.) To bring, then, to our neighbor's table the pure,
wholesome, delicious nectar, right from the hive, is philanthropy,
whether he realizes it or not.
Nor is it difficult to stimulate the demand. I have given special
attention to this topic for the last few years, and am free to say, that
not a tithe of the honey is consumed in our country that might and
should be.
HOW TO INVIGORATE THE MARKETS.

First. See that no honey goes to market from your apiary that is
not in the most inviting form possible. Grade all the honey
thoroughly, and expect prices to correspond with the grade. See that
every package and vessel is not only attractive, but so arranged as
not to make the dealer any trouble or cause him any vexation. One
leaky can or crate may do great injury.
Second. See that every grocer in your vicinity has honey
constantly on hand. Do all you can to build up a home market. The
advice to sell to only one or two dealers is wrong and pernicious.
Whether we are to buy or sell, we shall find almost always that it will
be most satisfactory to deal with men whom we know, and who are
close at hand. Only when you outgrow your home market should you
ship to distant places. This course will limit the supply in the large
cities, and thus raise the prices in the great marts, whose prices fix
those in the country. Be sure to keep honey constantly in the
markets.
Third. Insist that each grocer makes the honey very conspicuous.
If necessary, supply large, fine labels, with your own name almost as
prominent as is that of the article.
Fourth. Deliver the honey in small lots, so that it will be sure to be
kept in inviting form, and, if possible, attend to the delivery yourself,
that you may know that all is done "decently and in order."
Fifth. Instruct your grocers that they may make the honey show to
the best effect, and thus captivate the purchaser through the sight
alone.
Sixth. Call local conventions, that all in the community may know
and practice the best methods, so that the markets may not be
demoralized by poor, unsalable honey.
Of course, the method of preparation will depend largely, and
vary greatly, upon the style of honey to be sold, so we will consider
these kinds separately.
EXTRACTED HONEY.
As before intimated, extracted honey has all the flavor, and is in
every way equal, if not superior—comb itself is innutritious, and very
indigestible—to comb-honey. When people once know its excellence
—know that it is not "strained"—let us, as apiarists, strive in every
way to kill that word—then the demand for this article will be vastly
increased, to the advantage both of the consumer and the apiarist.
Explain to each grocer what we mean by the word extracted, and
ask him to spread wide the name and character of the honey. Leave
cups of the honey with the editors and men of influence, and get
them to discuss its origin and merits. I speak from experience, when
I say that in these ways the reputation and demand for extracted
honey can be increased to a surprising degree, and with astonishing
rapidity.
HOW TO TEMPT THE CONSUMER.

First. Have it chiefly in small cups—jelly cups are best. Many
persons will pay twenty-five cents for an article, when if it cost fifty
cents they would not think of purchasing.
Second. Only put it in such vessels as jelly cups or glass fruit
jars, etc., that will be useful in every household when the honey is
gone, that the buyer may feel that the vessel is clear gain.
Third. Explain to the grocer that if kept above the temperature of
70° or 80° F., it will not granulate, that granulation is a pledge of
purity and superiority, and show him how easy it is to reduce the
crystals, and ask him to explain this to his customers. If necessary,
liquify some of the granulated honey in his presence.
Lastly. If you do not deliver the honey yourself, be sure that the
vessels will not leak in transit. It is best, in case jelly cups are used,
that they be filled at the grocery. And don't forget the large label,
which gives the kind of honey, grade, and producer's name.
COMB-HONEY.
This, from its wondrous beauty, especially when light-colored and
immaculate, will always be a coveted article for the table, and will
ever, with proper care, bring the highest price paid for honey. So it
will always be best to work for this, even though we may not be able
to procure it in such ample profusion as we may the extracted. He
who has all kinds, will be able to satisfy every demand, and will most
surely meet with success.
RULES TO BE OBSERVED.
This, too, should be chiefly in small sections (Fig, 50), for, as
before stated, such are the packages that surely sell. Sections from
four to six inches square will just fill a plate nicely, and look very
tempting to the proud house-wife, especially if some epicurean
friends are to be entertained.
The sections should surely be in place at the dawn of the white
clover season, so that the apiarist may secure the most of this
irresistible nectar, chaste as if capped by the very snow itself. They
should be taken away as soon as capped, as delay makes them
highways of travel for the bees, which always mar their beauty.
When removed, if demanded, glass the sections, but before this,
we should place them in hives one upon another, or special boxes
made tight, with a close cover, in which to store either brood-frames
in winter or sections at any season, and sulphur them. This is quickly
and easily done by use of the smoker. Get the fire in the smoker well
to burning, add the sulphur, then place this in the top hive, or top of
the special box. The sulphurous fumes will descend and deal out
death to all moth larvæ. This should always be done before shipping
the honey, if we regard our reputations as precious. It is well to do
this immediately upon removal, and also two weeks after, so as to
destroy the moth larvæ not hatched when the sections are removed.
If separators have been used, these sections are in good
condition to be glassed, and are also in nice shape to ship even
without glass, as they may stand side by side and not mar the comb.
Fig. 71.
The shipping-crate (Fig, 71) should be strong, neat and cheap,

with handles as seen in Fig, 71—such handles are also convenient
in the ends of the hives, and can be cut in an instant by having the
circular-saw set to wabble. With handles the crate is more
convenient, and is more sure to be set on its bottom. The crate
should also be glassed, as the sight of the comb will say: "Handle
with care."
Mr. Heddon also makes a larger crate (Fig, 72), which is neat and
cheap. Muth's crate is like Heddon's, only smaller.
It is well, too, to wrap the sections in paper, as thus breakage of
one will not mean general ruin. However, this would be unnecessary
in case the sections were of veneer and glassed, as before
described.
Fig. 72.
In groceries, where the apiarist keeps honey for sale, it will pay
him to furnish his own boxes. These should be made of white-wood,
very neat, and glassed in front to show the honey, and the cover so
fixed that unglassed sections—and these, probably, will soon
become the most popular—cannot be punched or fingered. Be sure,
too, that the label, with kind of honey, grade, and name of apiarist,
be so plain that "he who runs may read."
Comb-honey that is to be kept in the cool weather of autumn, or
the cold of winter, must be kept in warm rooms, or the comb will
break from the section when handled. By keeping it quite warm for
some days previous to shipment, it may be sent to market even in
winter, but must be handled very carefully, and must make a quick
transit.
Above all, let "taste and neatness" ever be your motto.
CHAPTER XVI.
HONEY PLANTS.
As bees do not make honey, but only gather it, and as honey is
mainly derived from certain flowers, it of course follows that the
apiarist's success will depend largely upon the abundance of honey-
secreting plants in the vicinity of his apiary. True it is that certain bark
and plant lice secrete a kind of liquid sweet—honey of doubtful
reputation—which, in the dearth of anything better, the bees seem
glad to appropriate. I have thus seen the bees thick about a large
bark-louse which attacks the tulip tree, and thus often destroys one
of our best honey trees. This is an undescribed species of the genus
Lecanium. I have also seen them thick about three species of plant
lice. One, the Pemphigus imbricator, Fitch, works on the beech tree.
Its abdomen is thickly covered with long wool, and it makes a
comical show as it wags this up and down upon the least
disturbance. The leaves of trees attacked by this louse, as also
those beneath the trees, are fairly gummed with a sweetish
substance. I have found that the bees avoid this substance, except
at times of extreme drouth and long protracted absence of honeyed
bloom. It was the source of no inconsiderable stores during the
terribly parched autumn of Chicago's great disaster. (See Appendix,
page 286).
Another species of Pemphigus gives rise to certain solitary plum-
like galls, which appear on the upper surface of the red elm. These
galls are hollow, with a thin skin, and within the hollows are the lice,
which secrete an abundant sweet that often attracts the bees to a
feast of fat things, as the gall is torn apart, or cracks open, so that
the sweet exudes. This sweet is anything but disagreeable, and may
not be unwholesome to the bees.
Another aphis, of a black hue, works on the branches of our
willows, which they often entirely cover, and thus greatly damage
another tree valuable for both honey and pollen. Were it not that they
seldom are so numerous two years in succession, they would
certainly banish from among us one of our most ornamental and
valuable honey-producing trees. These are fairly thronged in
September and October, and not unfrequently in spring and summer
if the lice are abundant, by bees, wasps, ants, and various two-
winged flies, all eager to lap, up the oozing sweets. This louse is
doubtless the Lachnus dentatus, of Le Baron, and the Aphis salicti,
of Harris.
Bees also get, in some regions, a sort of honey-dew, which
enables them to add to their stores with surprising rapidity. I
remember one morning while riding on horse-back along the
Sacramento river, in California, I broke off a willow twig beside the
road when, to my surprise, I found it was fairly decked with drops of
honey. Upon further examination I found the willow foliage was
abundantly sprinkled by these delicious drops. These shrubs were
undisturbed by insects, nor were they under trees. Here then was a
real case of honey-dew, which must have been distilled through the
night by the leaves. I never saw any such phenomenon in Michigan,
yet others have. Dr. A. H. Atkins, an accurate and conscientious
observer, has noted this honey-dew more than once here in Central
Michigan.
Bees also get some honey from oozing sap, some of
questionable repute from about cider mills, some from grapes and
other fruit which have been crushed, or eaten and torn by wasps and
other insects. That bees ever tear the grapes is a question of which I
have failed to receive any personal proof, though for years I have
been carefully seeking it. I have lived among the vineyards of
California, and have often watched bees about vines in Michigan, but
never saw bees tear open the grapes. I have laid crushed grapes in
the apiary, when the bees were not gathering, and were ravenous for
stores, which, when covered with sipping bees, were replaced with
sound grape-clusters, which in no instance were mutilated. I have
thus been led to doubt if bees ever attack sound grapes, though
quick to improve the opportunities which the oriole's beak and the
stronger jaws of wasps offer them. Still, Prof. Riley feels sure that
bees are sometimes thus guilty, and Mr. Bidwell tells me he has
frequently seen bees rend sound grapes, which they did with their
feet. Yet, if this is the case, it is certainly of rare occurrence, and is
more than compensated by the great aid which the bees afford the
fruit-grower in the great work of cross-fertilization, which is
imperatively necessary to his success, as has been so well shown
by Dr. Asa Gray and Mr. Chas. Darwin. It is true that cross-
fertilization of the flowers, which can only be accomplished by
insects, and early in the season by the honey-bee, is often, if not
always, necessary to a full yield of fruit and vegetables. I am
informed by Prof W. W. Tracy, that the gardeners in the vicinity of
Boston keep bees that they may perform this duty. Even then, if Mr.
Bidwell and Prof. Riley are right, and the bee does, rarely—for surely
this is very rare, if ever—destroy grapes, still they are, beyond any
possible question, invaluable aids to the pomologist.
But the principal source of honey is still from the flowers.
WHAT ARE THE VALUABLE HONEY PLANTS?

In the northeastern part of our country the chief reliance for May
is the fruit-blossoms, willows, and sugar maples. In June white clover
yields largely of the most attractive honey, both as to appearance
and flavor. In July the incomparable basswood makes both bees and
apiarist jubilant. In August buckwheat offers a tribute, which we
welcome, though it be dark and pungent in flavor, while with us in
Michigan, August and September give us a profusion of bloom which
yields to no other in the richness of its capacity to secrete honey, and
is not cut-off till the autumn frosts—usually about September 15.
Thousands of acres of golden rod, boneset, asters, and other
autumn flowers of our new northern counties, as yet have blushed
unseen, with fragrance wasted. This unoccupied territory,
unsurpassed in its capability for fruit production, covered with grand
forests of maple and basswood, and spread with the richest of
autumn bloom, offers opportunities to the practical apiarist rarely
equaled except in the Pacific States, and not even there, when other
privileges are considered. In these localities, two or three hundred
pounds to the colony is no surprise to the apiarist, while even four or
five hundred are not isolated cases.
In the following table will be found a list of valuable honey-plants.
Those in the first column are annual, biennial or perennial; the
annual being enclosed in a parenthesis thus: (); the biennial
enclosed in brackets thus: []; while those in the second column are
shrubs or trees; the names of shrubs being enclosed in a
parenthesis. The date of commencement of bloom is, of course, not
invariable. The one appended, in case of plants which grow in our
State, is about average for Central Michigan. Those plants whose
names appear in small capitals yield very superior honey. Those with
(a) are useful for other purposes than honey secretion. All but those
with a * are native or very common in Michigan. Those written in the
plural refer to more than one species. Those followed by a † are very
numerous in species. Of course I have not named all, as that would
include some hundreds which have been observed at the college,
taking nearly all of the two great orders Compositæ and Rosaceæ. I
have only aimed to give the most important, omitting many foreign
plants of notoriety, as I have had no personal knowledge of them:
DATE. Annuals or Perennials.

April Dandelion.
April and May Strawberry. (a)
May and June *White Sage, California
May and June *Sumac, California.
May and June *Coffee Berry, California
June to July White Clover. (a)
June to July Alsike Clover. (a)
June to July *[Sweet Clover.]
June to July *Horehound. [Weed.]
June to July Ox-eyed Daisy—Bad
June to July Bush Honeysuckle.
June to August *Sage.
June to August Motherwort.
June to frost *(Borage.)
June to frost *(Cotton.) (a)
June to frost Silk or Milk Weeds.
June to frost (Mustard)†
June to frost *(Rape.) (a)
June to frost St. John's Wort.
June to frost (Mignonette.) (a)
July (Corn.) (a)
July *(Teasel.) (a)
July to August *Catnip. (a)
July to August Asparagus. (a)
July to August *(Rocky M't. Bee Plant)
July to frost Boneset.
July to frost Bergamot.
July to frost Figwort.
August (Buckwheat.) (a)
August (Snap-dragon.)
August to frost (Golden Rod.)†
August to frost Asters.†
August to frost Marsh Sun-Flowers.
August to frost Tick-Seed.
August to frost Beggar-Ticks.
August to frost Spanish Needles.
DATE. Shrubs or Trees.

March and Ap'l Red or Soft Maple.(a)
March and Ap'l Poplar or Aspen.
March and Ap'l Silver Maple.
March and Ap'l *Judas Tree.
May (Shad-bush.)
May (Alder.)
May Maples-Sugar Maple (a)
May Crab Apple.
May (Hawthorns.)
Fruit Trees—Apple,
May. { Plum, Cherry, Pear, etc. (a)
May Currant and Gooseberry. (a)
May *(Wistaria Vine-South)
May (Chinese Wistaria Vine—South.)
May and June (Barberry.)
May and June (Grape-vine.) (a)
May and June Tulip-tree.
May and June (Sumac.)
June Wild-Plum.
June (Black Raspberry.) (a)
June Locusts.
June (Red Raspberry.) (a)
June (Blackberry.)
June to July *Sour-wood—South.
July (Button Bush.)
July Basswood. (a)
July (Virginia Creeper.) (a)
July to August *Pepper-tree, Cal'a.
July to Sept *(St. John's Worts.)
August (Late Sumac.)
August to Sept. *Red Gum, California.
DESCRIPTION WITH PRACTICAL REMARKS.
As this subject of bee pasturage is of such prime importance, and

as the interest in the subject is so great and wide-spread, I feel that
details with illustrations will be more than warranted.
Fig. 75.—Maple.
We have abundant experience to show that forty or fifty colonies

of bees, take the seasons as they average, are all that a single place
will sustain to the greatest advantage. Then, how significant the fact,
that when the season is the best, full three times that number of
colonies will find ample resources to keep all employed. So this
subject of artificial pasturage becomes one well worthy close study
and observation. The subject, too, is a very important one in
reference to the location of the apiary.
It is well to remember in this connection, that two or three miles
should be regarded as the limit of profitable gathering. That is,
apiaries of from fifty to one hundred or more colonies, should not be
nearer than four or five miles of each other.
Fig. 74.-Willow.
APRIL PLANTS.
As we have already seen, the apiarist does not secure the best
results, even in the early spring, except the bees are encouraged by
the increase of their stores of pollen and honey; hence, in case we
do not practice stimulative feeding—and many will not—it becomes
very desirable to have some early bloom. Happily, in all sections of
the United States our desires are not in vain.
Early in spring there are many scattering wild flowers, as the
blood-root (Sanguinaria canadensis), liver-leaf (Hepatica acutiloba),
and various others of the crowfoot family, as also many species of
cress, which belong to the mustard family, etc., all of which are
valuable and important.
The maples (Fig, 73), which are all valuable honey plants, also
contribute to the early stores. Especially valuable are the silver
maples (Acer dasycarpum), and the red or soft maples (Acer
rubrum), as they bloom so very early, long before the leaves appear.
The bees work on these, here in Michigan, the first week of April,
and often in March. They are also magnificent shade trees,
especially those that have the weeping habit. Their early bloom is
very pleasing, their summer form and foliage beautiful, while their
flaming tints in autumn are indescribable. The foreign maples,
sycamore, Acer pseudo-platanus, and Norway, Acer platanoides, are
also very beautiful. Whether superior to ours as honey plants, I am
unable to say.
The willows, too (Fig, 74), rival the maples in the early period of
bloom. Some are very early, blossoming in March, while others, like
the white willow (Salix alba) (Fig, 74), bloom in May. The flowers on
one tree or bush of the willow are all pistillate, that is, have pistils,
but no stamens, while on others they are all staminate, having no
pistils. On the former, they can gather only honey, on the latter only
pollen. That the willow furnishes both honey and pollen is attested by
the fact that I saw both kinds of trees, the pistillate and the
staminate, thronged with bees the past season. The willow, too, from
its elegant form and silvery foliage, is one of our finest shade trees.
Fig. 15.—
Judas Tree
In the south of Michigan, and thence southward to Kentucky, and

even beyond, the Judas tree, or red-bud, Cercis canadensis (Fig,
75), is not only worthy of cultivation as a honey plant, but is also very
attractive, and well deserving of attention for its ornamental qualities
alone. This blooms from March to May, according to the latitude.
The poplars—not the tulip—also bloom in April, and are freely
visited by the bees. The wood is immaculate, and i& used for
toothpicks. Why not use it for honey-boxes?
Fig. 76.—American Wistaria.
MAY PLANTS.
In May we have the grand sugar maple, Acer saccharinum (Fig,

73), incomparable for beauty, also all our various fruit trees, peach,
cherry, plum, apple, etc., in fact all the Rosaceæ family. Our beautiful
American Wistaria, Wistaria frutescens (Fig, 76), the very
ornamental climber, or the still more lovely Chinese Wistaria,
Wistaria sinensis (Fig, 77), which has longer racemes than the
native, and often blossoms twice in the season. These are the
woody twiners for the apiarist. The barberry, too, Berberis vulgaris
(Fig, 78), comes after fruit blossoms, and is thronged with bees in
search of nectar in spring, as with children in winter, in quest of the
beautiful scarlet berries, so pleasingly tart.
Fig. 77.—Chinese
Wistaria.
Fig. 78.—
Barberry.
In California, the sumac, the coffee berry, and the famous white
sage (Fig, 79), keep the bees full of activity.
Fig. 79.—White Sage.
JUNE PLANTS.
Fig. 80.—White or
Dutch Clover.
With June comes the incomparable white or Dutch clover,
Trifolium repens (Fig, 80), whose chaste and modest bloom
betokens the beautiful, luscious, and unrivalled sweets which are
hidden in its corolla tube. Also its sister, Alsike or Swedish, Trifolium
hybrida (Fig, 81), which seems to resemble both the white and red
clover. It is a stronger grower than the white, and has a whitish
blossom tinged with pink. This forms excellent pasture and hay for
cattle, sheep, etc., and may well be sown by the apiarist. It will often
pay apiarists to furnish neighbor farmers with seed as an inducement
to grow this par excellent honey plant. Like white clover, it blooms all
through June into July. Both of these should be sown early in spring
with timothy, five or six pounds of seed to the acre, in the same
manner that red clover seed is sown.
Fig. 81.—Alsike Clover.
Fig. 82.—Melilot
Clover.
Fig. 83.—Borage.
Sweet clover, yellow and white, Melilotus officinalis (Fig, 82), and
Melilotus alba, are well named. They bloom from the middle of June
to the middle of July. Their perfume scents the air for long distances,
and the hum of bees that throng their flowers is like music to the
apiarist's ear. The honey, too, is just exquisite. These clovers are
biennial, not blooming the first season, and dying after they bloom

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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.

are designed to mechanically occlude the lumens of

© 2019 Cengage®. Photo by Margaret Rodriguez.

A. Kocher clamp D. Lahey/Gemini/right angle longitudinal

A: © 2019 Cengage®. B–G: © 2019 Cengage®. Photo by Margaret Rodriguez.

B. Right angle/Mixter and Adson/Schnidt

C. Rochester Pean G. Doyen noncrushing intestinal clamp

Figure 2-10 Hemostatic clamps: jaw and tip variations.

No subject merits more attention by the apiarist than that of

HOW TO INVIGORATE THE MARKETS.

HOW TO TEMPT THE CONSUMER.

The shipping-crate (Fig, 71) should be strong, neat and cheap,

WHAT ARE THE VALUABLE HONEY PLANTS?

DATE. Annuals or Perennials.