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SURGICAL INSTRUMENTS IN AMERICA
SURGICAL INSTRUMENTS
IN AMERICA Mabel L Crawford, RN America’s contribution to the development of surgical instruments has been laudable. In this review, I shall show the historical development of surgical instruments. Discussion will be chronological rather than by specialty and cover primarily the period before World War 11. The first instruments dating back to about 2500 BC were sharpened flints or fine animal teeth. They were used Above. A transportetion valise for instruments. Although the instruments could be sterilized before the surgeon set out, a 19th century surgeon Hunter Robb recommended that they be sterilized where the operation was to be performed. They could be conveniently carried in a long sheet of canton flannel which was rolled up and tied around the middle with a broad tape. (Robb, Aseptic Surgical Technique, Lippincotf Co, 1894.)
150
to let blood, empty abscesses, and trephine skulls. When one sees instruments of the ancient Greeks, Egyptians, and Hindus, it is with amazement because they resemble present-day instruments. Theodor Billroth (1829-1894) said of surgical instruments found in the excavations of Pompeii and displayed at the National Museum, Naples, Italy, “It made a peculiar impression on me when I saw before me this 2,000-year-old surgical armamentarium of a Roman colleague, differing but slightly in the form of the more ordinary instruments from those of our time.”’ However, it was not until the late 1870s that surgery became an art and a science, perhaps not so much through the development of individual skills or specialization of instruments as through the introduction of anes-
AORN Journal, July 1976,Vol24, No 1
itchen and pen knives did duty as scalpels.
K
thesia, antiseptics, asepsis, roentgenology, and safeguards against shock. 1 776-1826. Because surgeons of the Revolutionary Army left few records of their experiences, the medical profession knew little of the management of military hospitals, supplies, the policing and hygiene of camps, diseases peculiar to troops, or the surgical conduct of the campaigns. John Jones, a New York surgeon, wrote a battlefield surgery manual for the inexperienced physicians of the Continental Army. In describing the surgeon, he wrote, “He ought to have firm, steady hands, and to use both alike, a strong, clear sight, and, above all, a mind calm and trepid, yet humane and compassionate, avoiding every appearance of terror and cruelty to his patients, amidst the most severe operations.”* Dr Jones gained much of his renown for his rapid speed, an invaluable attribute in the days of surgery without anesthesia.
Mabel L Crawford, RN, Los Angeles, Calif, is retired after 35 years of operating room nursing. She is a graduate of the Bishop Johnson College of Nursing, Los Angeles. Miss Crawford has donated supplies used in early operating rooms to AORN, as the beginning of a collection. She is author of A Manual of Operating Room Technic, 1945.
152
The surgical instruments of these years were imported or made by skilled American artisans from available materials the surgeon wished used. The surgeons had to make known their wants, explain the mechanism of the instruments, and supervise their manufacture. As a result, instruments were crude and expensive, and their manufacture took a great deal of the surgeon’s time. Steelworkers; coppersmiths; silversmiths; needlegrinders; turners of wood, bone, and ivory; sewers of leather; glassblowers; silk and hemp spinners-all these services were obtained by the surgeon t o equip himself properly for the practice of surgery. Requiring hand labor exclusively, the instruments were manufactured by workmen who devoted their entire time to making one class of instruments, thereby, gaining proficiency in their construction. The cutlers, who made and sold knives, kept small assortments of surgical instruments and changed their signs from “Cutler and Scissor Grinder” to “Cutler and Surgical Instrument Maker.” Thus began the physicians’ supply houses and surgical instrument making in America. In 1795, a surgeon a t Pennsylvania Hospital, Philip Syng Physick, invented the instrument for cutting the stricture of the urethra. The difficulty of postoperative hemorrhage led to the
AORN Journal, July 1976, Vol24, No 1
invention in 1802 of his needle and forceps for the ligature of this and other deep-seated vessels. In 1820, he invented the instrument to excise tonsils, and though numerous others were made, it remained popular for many years. 1826-1876. The physician’s principal tools of the early 1800s were his eyes, ears, and keen observations. With the use of ether in 1846, the practice of surgery changed radically. Operations on cavities of the body were still limited, however, and those of the thoracic cavity were limited to the treatment of empyema. In 1850, physicians Morrill Wyman and Henry I Bowditch of Massachusetts General Hospital devised a fine trocar and cannula to a n exhausting syringe to aspirate exudate from the pleural cavity. This met with great success in performing thoracentesis. The modern belief that the preListerian surgeon generally accepted the problem of infection and gangrene without question and made little attempt to solve it is false and unjust. During the late 1850s, a school of practitioners began to use quantities of pure, cold water that had been boiled and cooled to cleanse instruments and dress wounds. Amputation was the trademark of the Civil War. Federal records reveal three out of four operations were am-
putations, and there is a good reason to believe figures were the same in the Confederacy. A close look a t both medical services shows that conservative surgery was the rule and not the exception. Surgeons were scarce and medical instruments were almost nonexistent. Kitchen and pen knives did duty as scalpels. Carpenter’s saws did the job about as well as those forged. A table fork made a retractor. W W Keen, a pioneer of aseptic surgery in America, confessed, “We operated in our pus-stained coats . . . we used undisinfected instruments from undisinfected pus cases . . . surgeons nearly always imperiled and often actually caused death.”3 After the Civil War came the advent of entering the chest, the abdomen, and the cranial vault along with the knowledge of the administration of ether and chloroform. These demanded new ideas and methods of instrument manufacturing and care. 1876-1926. The late nineteenth and early twentieth century not only marked a n era in the science and art of surgery but also advancement in necessary surgical appliances and equipment. The division of general surgery into specialties increased the demand for the development of surgical instruments. Crude and unwieldy instruments gave way to smaller, more delicate instruments. It was dis-
AORN Journal, July 1976, Vol24, No 1
153
A semicircular table, designed by Johns Hopkins surgeon William S Halsted, held vessels containing the instruments and dressings and at the same time hedged off
the operator and his assistants from the bystanders. (Robb, Aseptic Surgical Technique,
covered that proper application of a delicate instrument was far more useful than the force of a heavy instrument. Instrument handles of wood, ivory, or rubber were discarded in favor of German silver, brass, or steel handles that could withstand repeated sterilization. Nearly all metallic instruments were sterilized by boiling; however, new designs of joints and locks that allowed instruments to be quickly disassembled and reassembled facilitated sterilization and renewed the demand for instruments with screw joints. French, German, Kelly, and other locks were used. The French lock caused difficulty because the oval, button-shaped head of the male blade into which the female blade fit had to be carefully put together or the instrument would be useless until repaired. One interesting development in 1890 was the Lane technic introduced
by Dr William Arbuthnot Lane. Asepsis was maintained by using instruments and excluding hands from all contact with tissue. Operating room nurses using this technic became amazingly adept at using sponge forceps for draping and even gowning the surgeons. Dr Lane used special forceps to attach sterile towels to the edges of the incision and no instrument that had been touched was allowed to enter the wound. Long dissecting forceps were used for sponging. This technic was adopted by orthopedic surgeons all over the world until sulfonamides and antibiotics came into use. With the development of stainless steel in Germany during World War I, better material was available for surgical instruments and other equipment used in the OR. Although some instruments were being made in America, until about 1924, most were manufactured in Europe. At this time, instrument crafismen were brought to the United
154
tippincot! Co, 1894.)
AORN Journal, July 1976, Vol24, No 1
States, mainly from Germany, Sweden, and England to teach their craft to willing apprentices. 1926-1976.Today’s surgeon can obtain special instruments for every known operation from a wide selection of patterns and manufacturers who have maintained an even pace with the advanced art of surgery. This is evident by the serviceable armamentaria found in hospital purchasing offices and operating room suites. People involved in manufacturing instruments now view operations to observe the surgeon’s needs. They make suggestions and do experiments, reducing the time formerly taken by the surgeon in developing instruments. Although many surgical instruments have been newly designed, several are modifications of those that have been in surgical suites for many years. Also, frequently a surgeon will find just the instrument needed from an antique collection of surgical instruments. This sometimes causes amusement among the staff but also renews their interest and is an incentive to collect and display old instruments.
lnterior of operating bag.
Operating room nurses have directly and indirectly contributed to the advancement of medical instrumentation through care, sterilization, and selection of the surgeon’s needs. AORN’s executive director, Jerry Peers, is one contributor with the Peers clamp. To eliminate punctures caused by the pointed prongs of clamps, Miss Peers designed a clamp with blunt, grooved prongs. The 200 years that have elapsed since America developed a n industry in the designing, research, manufacturing, and marketing of surgical instruments have been unequaled anywhere else in the world. To foresee future surgical procedures and needs of the surgeons would take the wisdom of Solomon. Yet, we eagerly look to the future. Notes 1. Girindranath Mukhapadhyaya, ”The surgical instruments of the Hindus with a comparative study of the surgical instruments of the Greek, Roman, Arab, and the modern European surgeons,” (essay, Calcutta University, 1913). 2. Mark Bloom, “Medicine on the eve of the revolution,” Medical World News 16 (Dec 15, 1975) 47. 3. Harvey E Brown, The Medical Depattment of the US Army 1775-7873 (Washington, DC: Surgeon General’s Office, 1873).
(Robb, Aseptic Surgical Technique,
Lippincolt Co, 1894.)
156
AORN Journal, July 1976, Vol24, No 1
IN AMERICA Mabel L Crawford, RN America’s contribution to the development of surgical instruments has been laudable. In this review, I shall show the historical development of surgical instruments. Discussion will be chronological rather than by specialty and cover primarily the period before World War 11. The first instruments dating back to about 2500 BC were sharpened flints or fine animal teeth. They were used Above. A transportetion valise for instruments. Although the instruments could be sterilized before the surgeon set out, a 19th century surgeon Hunter Robb recommended that they be sterilized where the operation was to be performed. They could be conveniently carried in a long sheet of canton flannel which was rolled up and tied around the middle with a broad tape. (Robb, Aseptic Surgical Technique, Lippincotf Co, 1894.)
150
to let blood, empty abscesses, and trephine skulls. When one sees instruments of the ancient Greeks, Egyptians, and Hindus, it is with amazement because they resemble present-day instruments. Theodor Billroth (1829-1894) said of surgical instruments found in the excavations of Pompeii and displayed at the National Museum, Naples, Italy, “It made a peculiar impression on me when I saw before me this 2,000-year-old surgical armamentarium of a Roman colleague, differing but slightly in the form of the more ordinary instruments from those of our time.”’ However, it was not until the late 1870s that surgery became an art and a science, perhaps not so much through the development of individual skills or specialization of instruments as through the introduction of anes-
AORN Journal, July 1976,Vol24, No 1
itchen and pen knives did duty as scalpels.
K
thesia, antiseptics, asepsis, roentgenology, and safeguards against shock. 1 776-1826. Because surgeons of the Revolutionary Army left few records of their experiences, the medical profession knew little of the management of military hospitals, supplies, the policing and hygiene of camps, diseases peculiar to troops, or the surgical conduct of the campaigns. John Jones, a New York surgeon, wrote a battlefield surgery manual for the inexperienced physicians of the Continental Army. In describing the surgeon, he wrote, “He ought to have firm, steady hands, and to use both alike, a strong, clear sight, and, above all, a mind calm and trepid, yet humane and compassionate, avoiding every appearance of terror and cruelty to his patients, amidst the most severe operations.”* Dr Jones gained much of his renown for his rapid speed, an invaluable attribute in the days of surgery without anesthesia.
Mabel L Crawford, RN, Los Angeles, Calif, is retired after 35 years of operating room nursing. She is a graduate of the Bishop Johnson College of Nursing, Los Angeles. Miss Crawford has donated supplies used in early operating rooms to AORN, as the beginning of a collection. She is author of A Manual of Operating Room Technic, 1945.
152
The surgical instruments of these years were imported or made by skilled American artisans from available materials the surgeon wished used. The surgeons had to make known their wants, explain the mechanism of the instruments, and supervise their manufacture. As a result, instruments were crude and expensive, and their manufacture took a great deal of the surgeon’s time. Steelworkers; coppersmiths; silversmiths; needlegrinders; turners of wood, bone, and ivory; sewers of leather; glassblowers; silk and hemp spinners-all these services were obtained by the surgeon t o equip himself properly for the practice of surgery. Requiring hand labor exclusively, the instruments were manufactured by workmen who devoted their entire time to making one class of instruments, thereby, gaining proficiency in their construction. The cutlers, who made and sold knives, kept small assortments of surgical instruments and changed their signs from “Cutler and Scissor Grinder” to “Cutler and Surgical Instrument Maker.” Thus began the physicians’ supply houses and surgical instrument making in America. In 1795, a surgeon a t Pennsylvania Hospital, Philip Syng Physick, invented the instrument for cutting the stricture of the urethra. The difficulty of postoperative hemorrhage led to the
AORN Journal, July 1976, Vol24, No 1
invention in 1802 of his needle and forceps for the ligature of this and other deep-seated vessels. In 1820, he invented the instrument to excise tonsils, and though numerous others were made, it remained popular for many years. 1826-1876. The physician’s principal tools of the early 1800s were his eyes, ears, and keen observations. With the use of ether in 1846, the practice of surgery changed radically. Operations on cavities of the body were still limited, however, and those of the thoracic cavity were limited to the treatment of empyema. In 1850, physicians Morrill Wyman and Henry I Bowditch of Massachusetts General Hospital devised a fine trocar and cannula to a n exhausting syringe to aspirate exudate from the pleural cavity. This met with great success in performing thoracentesis. The modern belief that the preListerian surgeon generally accepted the problem of infection and gangrene without question and made little attempt to solve it is false and unjust. During the late 1850s, a school of practitioners began to use quantities of pure, cold water that had been boiled and cooled to cleanse instruments and dress wounds. Amputation was the trademark of the Civil War. Federal records reveal three out of four operations were am-
putations, and there is a good reason to believe figures were the same in the Confederacy. A close look a t both medical services shows that conservative surgery was the rule and not the exception. Surgeons were scarce and medical instruments were almost nonexistent. Kitchen and pen knives did duty as scalpels. Carpenter’s saws did the job about as well as those forged. A table fork made a retractor. W W Keen, a pioneer of aseptic surgery in America, confessed, “We operated in our pus-stained coats . . . we used undisinfected instruments from undisinfected pus cases . . . surgeons nearly always imperiled and often actually caused death.”3 After the Civil War came the advent of entering the chest, the abdomen, and the cranial vault along with the knowledge of the administration of ether and chloroform. These demanded new ideas and methods of instrument manufacturing and care. 1876-1926. The late nineteenth and early twentieth century not only marked a n era in the science and art of surgery but also advancement in necessary surgical appliances and equipment. The division of general surgery into specialties increased the demand for the development of surgical instruments. Crude and unwieldy instruments gave way to smaller, more delicate instruments. It was dis-
AORN Journal, July 1976, Vol24, No 1
153
A semicircular table, designed by Johns Hopkins surgeon William S Halsted, held vessels containing the instruments and dressings and at the same time hedged off
the operator and his assistants from the bystanders. (Robb, Aseptic Surgical Technique,
covered that proper application of a delicate instrument was far more useful than the force of a heavy instrument. Instrument handles of wood, ivory, or rubber were discarded in favor of German silver, brass, or steel handles that could withstand repeated sterilization. Nearly all metallic instruments were sterilized by boiling; however, new designs of joints and locks that allowed instruments to be quickly disassembled and reassembled facilitated sterilization and renewed the demand for instruments with screw joints. French, German, Kelly, and other locks were used. The French lock caused difficulty because the oval, button-shaped head of the male blade into which the female blade fit had to be carefully put together or the instrument would be useless until repaired. One interesting development in 1890 was the Lane technic introduced
by Dr William Arbuthnot Lane. Asepsis was maintained by using instruments and excluding hands from all contact with tissue. Operating room nurses using this technic became amazingly adept at using sponge forceps for draping and even gowning the surgeons. Dr Lane used special forceps to attach sterile towels to the edges of the incision and no instrument that had been touched was allowed to enter the wound. Long dissecting forceps were used for sponging. This technic was adopted by orthopedic surgeons all over the world until sulfonamides and antibiotics came into use. With the development of stainless steel in Germany during World War I, better material was available for surgical instruments and other equipment used in the OR. Although some instruments were being made in America, until about 1924, most were manufactured in Europe. At this time, instrument crafismen were brought to the United
154
tippincot! Co, 1894.)
AORN Journal, July 1976, Vol24, No 1
States, mainly from Germany, Sweden, and England to teach their craft to willing apprentices. 1926-1976.Today’s surgeon can obtain special instruments for every known operation from a wide selection of patterns and manufacturers who have maintained an even pace with the advanced art of surgery. This is evident by the serviceable armamentaria found in hospital purchasing offices and operating room suites. People involved in manufacturing instruments now view operations to observe the surgeon’s needs. They make suggestions and do experiments, reducing the time formerly taken by the surgeon in developing instruments. Although many surgical instruments have been newly designed, several are modifications of those that have been in surgical suites for many years. Also, frequently a surgeon will find just the instrument needed from an antique collection of surgical instruments. This sometimes causes amusement among the staff but also renews their interest and is an incentive to collect and display old instruments.
lnterior of operating bag.
Operating room nurses have directly and indirectly contributed to the advancement of medical instrumentation through care, sterilization, and selection of the surgeon’s needs. AORN’s executive director, Jerry Peers, is one contributor with the Peers clamp. To eliminate punctures caused by the pointed prongs of clamps, Miss Peers designed a clamp with blunt, grooved prongs. The 200 years that have elapsed since America developed a n industry in the designing, research, manufacturing, and marketing of surgical instruments have been unequaled anywhere else in the world. To foresee future surgical procedures and needs of the surgeons would take the wisdom of Solomon. Yet, we eagerly look to the future. Notes 1. Girindranath Mukhapadhyaya, ”The surgical instruments of the Hindus with a comparative study of the surgical instruments of the Greek, Roman, Arab, and the modern European surgeons,” (essay, Calcutta University, 1913). 2. Mark Bloom, “Medicine on the eve of the revolution,” Medical World News 16 (Dec 15, 1975) 47. 3. Harvey E Brown, The Medical Depattment of the US Army 1775-7873 (Washington, DC: Surgeon General’s Office, 1873).
(Robb, Aseptic Surgical Technique,
Lippincolt Co, 1894.)
156
AORN Journal, July 1976, Vol24, No 1