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Advances in Intelligent Systems and Computing 482

Vincent G. Duffy
Nancy Lightner Editors

Advances in
Human Factors
and Ergonomics in
Healthcare
Proceedings of the AHFE 2016
International Conference on Human
Factors and Ergonomics in Healthcare,
July 27–31, 2016, Walt Disney World®,
Florida, USA
Advances in Intelligent Systems and Computing

Volume 482

Series editor
Janusz Kacprzyk, Polish Academy of Sciences, Warsaw, Poland
e-mail: kacprzyk@ibspan.waw.pl
About this Series
The series “Advances in Intelligent Systems and Computing” contains publications on theory,
applications, and design methods of Intelligent Systems and Intelligent Computing. Virtually
all disciplines such as engineering, natural sciences, computer and information science, ICT,
economics, business, e-commerce, environment, healthcare, life science are covered. The list
of topics spans all the areas of modern intelligent systems and computing.
The publications within “Advances in Intelligent Systems and Computing” are primarily
textbooks and proceedings of important conferences, symposia and congresses. They cover
significant recent developments in the field, both of a foundational and applicable character.
An important characteristic feature of the series is the short publication time and world-wide
distribution. This permits a rapid and broad dissemination of research results.

Advisory Board
Chairman
Nikhil R. Pal, Indian Statistical Institute, Kolkata, India
e-mail: nikhil@isical.ac.in
Members
Rafael Bello, Universidad Central “Marta Abreu” de Las Villas, Santa Clara, Cuba
e-mail: rbellop@uclv.edu.cu
Emilio S. Corchado, University of Salamanca, Salamanca, Spain
e-mail: escorchado@usal.es
Hani Hagras, University of Essex, Colchester, UK
e-mail: hani@essex.ac.uk
László T. Kóczy, Széchenyi István University, Győr, Hungary
e-mail: koczy@sze.hu
Vladik Kreinovich, University of Texas at El Paso, El Paso, USA
e-mail: vladik@utep.edu
Chin-Teng Lin, National Chiao Tung University, Hsinchu, Taiwan
e-mail: ctlin@mail.nctu.edu.tw
Jie Lu, University of Technology, Sydney, Australia
e-mail: Jie.Lu@uts.edu.au
Patricia Melin, Tijuana Institute of Technology, Tijuana, Mexico
e-mail: epmelin@hafsamx.org
Nadia Nedjah, State University of Rio de Janeiro, Rio de Janeiro, Brazil
e-mail: nadia@eng.uerj.br
Ngoc Thanh Nguyen, Wroclaw University of Technology, Wroclaw, Poland
e-mail: Ngoc-Thanh.Nguyen@pwr.edu.pl
Jun Wang, The Chinese University of Hong Kong, Shatin, Hong Kong
e-mail: jwang@mae.cuhk.edu.hk

More information about this series at http://www.springer.com/series/11156

Vincent G. Duffy Nancy Lightner
•

Editors

Advances in Human
Factors and Ergonomics
in Healthcare
Proceedings of the AHFE 2016 International
Conference on Human Factors
and Ergonomics in Healthcare,
July 27–31, 2016, Walt Disney World®,
Florida, USA

123
Editors
Vincent G. Duffy Nancy Lightner
School of Industrial Engineering Veterans Affairs U.S.
Purdue University Indianapolis, IN
West Lafayette, IN USA
USA

ISSN 2194-5357 ISSN 2194-5365 (electronic)

Advances in Intelligent Systems and Computing
ISBN 978-3-319-41651-9 ISBN 978-3-319-41652-6 (eBook)
DOI 10.1007/978-3-319-41652-6

Library of Congress Control Number: 2016944401

© Springer International Publishing Switzerland 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part
of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations,
recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission
or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are exempt from
the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this
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authors or the editors give a warranty, express or implied, with respect to the material contained herein or
for any errors or omissions that may have been made.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG Switzerland
Advances in Human Factors
and Ergonomics 2016

AHFE 2016 Series Editors

Tareq Z. Ahram, Florida, USA

Waldemar Karwowski, Florida, USA

7th International Conference on Applied Human Factors and Ergonomics

Proceedings of the AHFE 2016 International Conference on Human Factors
and Ergonomics in Healthcare, July 27–31, Walt Disney World®, Florida, USA

Advances in Cross-Cultural Decision Making Sae Schatz and Mark Hoffman

Advances in Applied Digital Human Modeling Vincent G. Duffy
and Simulation
Advances in Human Factors and Ergonomics in Vincent G. Duffy and Nancy Lightner
Healthcare
Advances in Affective and Pleasurable Design WonJoon Chung and Cliff (Sungsoo) Shin
Advances in Human Aspects of Transportation Neville A. Stanton, Steven Landry,
Giuseppe Di Bucchianico and Andrea
Vallicelli
Advances in Ergonomics In Design Francisco Rebelo and Marcelo Soares
Advances in Ergonomics Modeling, Usability & Marcelo Soares, Christianne Falcão and
Special Populations Tareq Z. Ahram
Advances in Social & Occupational Ergonomics Richard Goossens
Advances in Neuroergonomics and Cognitive Kelly S. Hale and Kay M. Stanney
Engineering
Advances in Physical Ergonomics and Human Ravindra Goonetilleke and
Factors Waldemar Karwowski
Advances in The Ergonomics in Manufacturing: Christopher Schlick and Stefan Trzcielinski
Managing the Enterprise of the Future
Advances in Safety Management and Human Pedro Arezes
Factors
Advances in Human Factors, Software, and Ben Amaba
Systems Engineering
Advances in Human Factors and Sustainable Jerzy Charytonowicz
Infrastructure
(continued)

v
vi Advances in Human Factors and Ergonomics 2016

(continued)
Advances in The Human Side of Service Tareq Z. Ahram and Waldemar Karwowski
Engineering
Advances in Human Factors in Energy: Oil, Sacit Cetiner, Paul Fechtelkotter and
Gas, Nuclear and Electric Power Industries Michael Legatt
Advances in Human Factors in Sports and Paul Salmon and Anne-Claire Macquet
Outdoor Recreation
Advances in Human Factors and System Isabel L. Nunes
Interactions
Advances in Human Factors, Business Jussi Kantola, Tibor Barath, Salman Nazir
Management, Training and Education and Terence Andre
Advances in Human Factors in Robots and Pamela Savage-Knepshield and Jessie Chen
Unmanned Systems
Advances in Design for Inclusion Giuseppe Di Bucchianico and Pete Kercher
Advances in Human Factors in Cybersecurity Denise Nicholson, Janae Lockett-Reynolds
and Katherine Muse
Preface

This book is concerned with human factors and ergonomics in healthcare. The
utility of this area of research is to aid the design of systems and devices for
effective and safe healthcare delivery. New approaches are demonstrated for
improving healthcare devices such as portable ultrasound systems. Research find-
ings for improved work design, effective communications and systems support are
also included. Healthcare informatics for the public and usability for patient users
are considered separately but build on results from usability studies for medical
personnel.
Quality and safety are emphasized, and medical error is considered for risk
factors and information transfer in error reduction. Physical, cognitive and orga-
nizational aspects are considered in a more integrated manner so as to facilitate a
systems approach to implementation. New approaches to patient handling ergo-
nomics, emergency and operating rooms, healthcare, medical device design, human
factors and ergonomics measurement and model validation are included. Recent
research on special populations, collaboration and teams, as well as learning and
training, allows practitioners to gain a great deal of knowledge overall from this
book.
Explicitly, the book is organized into nine sections that contain the following
subject areas:
I. Human Factors and Ergonomics in Surgery
II. Healthcare Professionals
III. Healthcare Systems
IV. Healthcare Safety
V. Medical Device Design
VI. Healthcare Testing
VII. Environmental Design
VIII. Healthcare Communications and Logistics

vii
viii Preface

Each of the chapters of the book was either reviewed by the members of
Scientific Advisory and Editorial Board or germinated by them. Our sincere thanks
and appreciation goes to the Board Members listed below for their contribution to
the high scientific standard maintained in developing this book.
P. Arnold, Germany
S. Bagnara, Italy
T. Bellandi, Italy
B. Bidassie, USA
S. Bogner, USA
F. Calisir, Turkey
Y. Donchin, Israel
A. Elfering, Switzerland
M. Eksioglu, Turkey
E. Fallon, Ireland
M. Fray, UK
A. Gramopadhye, USA
S. Hignett, UK
E. Hollnagel, France
J. Kalra, Canada
S. Kleefield, USA
B. Kutryba, Poland
N. Marmaras, Greece
J. Martin, UK
R. Mendonca, Brazil
K. Norris, USA
M. Ohkura, Japan
C. Or, Hong Kong
L. Page, USA
S. Prineas, Australia
P. Trucco, Italy
This book would be of special value internationally to those researchers and
practitioners involved in various aspects of healthcare delivery.

West Lafayette, USA Vincent G. Duffy

Indianapolis, USA Nancy Lightner
July 2016
Contents

Part I Human Factors and Ergonomics in Surgery

Analysis of Surgeons’ Muscle Activity During the Use
of a Handheld Robotic Instrument in Laparoendoscopic
Single-Site Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Francisco M. Sánchez-Margallo and Juan A. Sánchez-Margallo
Assessing the Influence of Personal and Organizational
Factors on Surgeon’s Performance: A Study on Surgeons’
Perceptions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Rossella Onofrio and Paolo Trucco
Human Reliability Analysis (HRA) for Surgery:
A Modified HEART Application to Robotic Surgery . . . . . . . . . . . . . . 27
Paolo Trucco, Rossella Onofrio and Antonio Galfano
Prospects and Problems of Smart Glasses as Tools for Surgery. . . . . . . 39
Kazuhiko Shinohara

Part II Human Factors and Ergonomics and Healthcare

Professionals
A New Elderly Clothing Design Reduces Nurse Aides’
Occupational Injury in Nursing Homes . . . . . . . . . . . . . . . . . . . . . . . . 49
Wen-Yu Yang, Fong-Gong Wu and Adam Book
Bedside Dialysis and the Occupational Safety and Health
Impact on the Healthcare Worker in an Acute Hospital . . . . . . . . . . . . 61
Wai Kuen Kam, Mohd Fahmy bin Abdul Kader Alkaff
and Paige Geek Pei Tan
Biomechanical Evaluation of Patient Handling Jobs in Healthcare:
A Case Study in India. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Dharmendra Sharma, Pradip Kumar Ray and Esha Saha

ix
x Contents

Difference in Problem-Solving Thought Concerning

the Infection Control of Japanese Nurse and Indonesian Nurse:
Comparison of the Result by 4M4E Matrix Analysis . . . . . . . . . . . . . . 75
Manami Nozaki, Hiromi Ogasawara and Reiko Mitsuya
Examination of the Validity of Anatomical Knowledge Associated
with Daily Lifestyle Issues: A Comparison Between Perspectives
of Anatomy and Nursing Researchers . . . . . . . . . . . . . . . . . . . . . . . . . 81
Masaaki Takayanagi, Manami Nozaki, Reiko Mitsuya, Teruko Takayanagi
and Fumi Sato
Study of Suitability of Computer Workstations Design
for Nurses’ Work Content. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Farman A. Moayed, April Savoy and Celeste Turpen

Part III Human Factors and Ergonomics in Healthcare Systems

A Flexible Toolkit for Evaluating Person-Centred Digital
Health and Wellness at Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Marilyn McGee-Lennon, Matt-Mouley Bouamrane, Eleanor Grieve,
Catherine A. O’Donnell, Siobhan O’Connor, Ruth Agbakoba,
Alison M. Devlin, Sarah Barry, Annemieke Bikker, Tracy Finch
and Frances S. Mair
Application of Lean Six Sigma Concepts to Medicine
Dispensation of Public Health Centers . . . . . . . . . . . . . . . . . . . . . . . . . 119
Marina Pazeti and Leonardo Calache
Lean Healthcare as a Tool for Improvement:
A Case Study in a Clinical Laboratory . . . . . . . . . . . . . . . . . . . . . . . . 129
Karine Borges de Oliveira, Eduardo Ferro dos Santos
and Lucio Veraldo Garcia Junior
Virtual Communities of Practice Success in Healthcare Sector:
A Comparative Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Haitham Alali
Overlook of Patient Time Log Entry Errors During
Emergency Department Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Byungjoon B.J. Kim
Incentives for the Acceptance of Mobility Equipment by Elderly
People on the Basis of the Kano Model: A Human Factors
Perspective for Initial Contact with Healthcare Products . . . . . . . . . . . 161
C. Brandl, P. Rasche, C. Bröhl, S. Theis, M. Wille, C.M. Schlick
and A. Mertens
Contents xi

Part IV Human Factors and Ergonomics in Healthcare Safety

Engaging and Effective Staff Training to Improve Patient
Safety and Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Gregg Alexander and Patrick Baker
Methodology of Care Humanitude in Promoting Self-care
in Dependent People: An Integrative Review . . . . . . . . . . . . . . . . . . . . 187
Rosa Cândida Carvalho Pereira Melo, Daniela Sofia Carvalho Fernandes,
Joana Sousa Albuquerque and Mariana Nunes Duarte
Application of User Experience Map and Safety Map
to Design Healthcare Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Jinhua Li, Long Liu and Yayan Zheng
An Assessment on the Level of Knowledge of Biosecurity
Measures in the Academic Environment . . . . . . . . . . . . . . . . . . . . . . . 205
Berla Moreira de Moraes, Adílio Moreira de Moraes,
Betanea Moreira de Moraes and Vanessa Mesquita Ramos
Methods to Characterize Operating Room Variables in Robotic
Surgery to Enhance Patient Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Anthony M. Composto, Luke A. Reisner, Abhilash K. Pandya,
David A. Edelman, Katrina L. Jacobs and Tandi M. Bagian
Low-Fidelity Simulation Versus Live Human Arms
for Intravenous Cannulation Training: A Qualitative
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Gary L. Boykin Sr.

Part V Medical Device Design

Improving the User Experience of Medical Devices
with Comparative Usability Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Anneliis Tosine and Hala Al-Jaber
&You: Design of a Sensor-Based Wearable Device
for Use in Cognitive Behavioral Therapy . . . . . . . . . . . . . . . . . . . . . . . 251
Aaron McEuen, John Proffitt, Jorge D. Camba and EunSook Kwon
Framework Proposal Including HFE in Product Development
Process: A Suitable Approach for the Brazilian Medical
Equipment Industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Ana Paula Almeida, Rodrigo Almeida, Renata Custódio,
Clarissa Trzesniak and Carlos Mello
xii Contents

A Systematic Approach to Improve the Reprocessing

of Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Nina Scheinberg, Bill Zhang, Leah Raschid, Rama Mwenesi,
Mark Grum, Moses Chan, Amy Cohn, Joseph DeRosier
and James Bagian
Building Safety into Medical Devices: The Non-injectable
Arterial Connector Preventing Wrong Route Drug Administration . . . . 287
Maryanne Mariyaselvam, Arun Gupta and Peter Young
Mobile Technology Improves Therapy-Adherence Rates in Elderly
Patients Undergoing Rehabilitation—A Crossover Design Study . . . . . . 295
A. Mertens, S. Becker, S. Theis, P. Rasche, M. Wille,
C. Bröhl, L. Finken and C. Schlick
Development of the Elderly Healthcare Monitoring System
with IoT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Se Jin Park, Murali Subramaniyam, Seoung Eun Kim,
Seunghee Hong, Joo Hyeong Lee, Chan Min Jo and Youngseob Seo
Development of an Intermittent Pneumatic Compression
System to Manage Soft Tissue Mechanical Properties . . . . . . . . . . . . . . 317
Chi-Wen Lung, Tse-Yu Cheng, Yi-Jhen Li, Ben-Yi Liau
and Yih-Kuen Jan

Part VI Healthcare Testing

Ergonomic Performance Measurement and Evaluation
for Worksystems in Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Pradip Kumar Ray and Esha Saha
Development of a New Psychometric Scale (PYTHEIA)
to Assess the Satisfaction of Users with Any Assistive Technology . . . . . 343
Yiannis Koumpouros, Effie Papageorgiou and Alexandra Karavasili
A Study on the Methodology to Analyse and Prevent
Medical Errors Due to Non-observance . . . . . . . . . . . . . . . . . . . . . . . . 355
Haizhe Jin, Masahiko Munechika, Masataka Sano, Chisato Kajihara,
Han Chen and Fu Guo

Part VII Human Factors and Ergonomics in Environmental

Design
Ergonomic Design of Bathrooms for People with Cerebral Palsy
in the Philippines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Quirby Alberto, Brian Atanacio, Cyrill Cucueco, Ana Mercado
and Benette Custodio
Contents xiii

The Place of Health Design for Health Promotion:

The Pediatrics Design Process Focus in Humanization
at Santa Casa’s Hospital Montes Claros—Brazil . . . . . . . . . . . . . . . . . 377
Janice Gomes Zumba
Supporting Phobia Treatment with Virtual Reality: Systematic
Desensitization Using Oculus Rift . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
José P. Monge, Gustavo López and Luis A. Guerrero
Intelligent Nano-Worlds: A New ICT Based Tool for Mental
Health Care of Children Living Under Social Vulnerability . . . . . . . . . 403
Fernando Pesántez-Avilés, Verónica Cevallos-León Wong,
Vladimir Robles-Bykbaev, Ana Pacurucu-Pacurucu,
Cristian Tapia-Jaya, Ismael San Andrés-Becerra,
Estefanía Borck-Vintimilla and Paola Ingavélez-Guerra

Part VIII Healthcare Communications and Logistics

Application of the Delphi Method in the Development
of a Triage Method for Vulnerable People in Disaster . . . . . . . . . . . . . 415
Taro Kanno, Chie Ishida, Yuko Kubo, Masako Saito, Mariko Ohara,
Kayoko Kawahara, Takuya Yamamto and Kazuo Furuta
Usability Testing an Electronic Health Record: Lessons
Learned and Ethical Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . 425
Helen J.A. Fuller, Kyle D. Maddox and Nancy J. Lightner
Demographics, Military Status, and Physical Health as Indicators
of Personal Resilience Among U.S. Active Duty Service Members
and Veterans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
Valerie J. Rice and Baoxia Liu
Language Sample Analysis Framework Utilizing the Natural
Language Toolkit and Social Media. . . . . . . . . . . . . . . . . . . . . . . . . . . 445
Ahmad Abualsamid and Charles E. Hughes
Georeferencing in Logistics Transplant . . . . . . . . . . . . . . . . . . . . . . . . 457
Cristina Corrêa de Oliveira, Camila Inácio Belo da Silva,
Antonio Rodrigues Carvalho Neto and Wellington Pinto de Oliveira
Erratum to: Examination of the Validity of Anatomical Knowledge
Associated with Daily Lifestyle Issues: A Comparison Between
Perspectives of Anatomy and Nursing Researchers . . . . . . . . . . . . . . . . E1
Masaaki Takayanagi, Manami Nozaki, Reiko Mitsuya, Teruko Takayanagi
and Fumi Sato
 Part I
Human Factors and Ergonomics
in Surgery
Analysis of Surgeons’ Muscle Activity
During the Use of a Handheld Robotic
Instrument in Laparoendoscopic
Single-Site Surgery

Francisco M. Sánchez-Margallo and Juan A. Sánchez-Margallo

Abstract The objective of this study is to assess the surgeon’s performance and
ergonomics during the use of a robotic-driven handheld laparoscopic instrument in
intracorporeal suturing tasks as well as in digestive and urological laparoscopic
procedures performed through single-site surgery, and comparing it with the use of
conventional instruments. Seven right-handed experienced surgeons took part in this
study. Four surgeons performed nine urethrovesical anastomoses on an ex vivo
porcine model and three surgeons a partial nephrectomy and a sigmoidectomy on an
in vivo animal model. Surgeons used both conventional laparoscopic instruments
and the robotic instrument. Execution times, leakage pressure for the anastomosis,
surgical complications and surgeons’ muscle activity were measured. Similar results
in surgical performance and ergonomics were obtained using conventional laparo-
scopic instruments and the robotic instrument. Muscle activity of the biceps was
significantly higher using the robotic instrument during both surgical procedures.

Keywords Laparoendoscopic single-site surgery
Handheld robotic instrument

Ergonomics Muscle activity

1 Introduction

Laparoscopic surgery has experienced rapid development in recent years, providing

multiple advantages for the patient such as the reduction in postoperative pain,
tissue trauma and infection rate, better aesthetic results, and shortened recovery
period [1–3]. In this sense, laparoendoscopic single-site surgery (LESS) is being

F.M. Sánchez-Margallo (&)

Jesús Usón Minimally Invasive Surgical Centre, Cáceres, Spain
e-mail: msanchez@ccmijesususon.com
J.A. Sánchez-Margallo
Department of Computer Systems and Telematics Engineering,
University of Extremadura, Badajoz, Spain
e-mail: jasmargallo@unex.es

© Springer International Publishing Switzerland 2017 3

V.G. Duffy and N. Lightner (eds.), Advances in Human Factors
and Ergonomics in Healthcare, Advances in Intelligent Systems
and Computing 482, DOI 10.1007/978-3-319-41652-6_1
4 F.M. Sánchez-Margallo and J.A. Sánchez-Margallo

consolidated as a real alternative to conventional laparoscopic surgery which further

reduces incision related complications and leads to better cosmetics results.
Numerous studies sustaining its feasibility, advantage in pain and recovery time
with respect to conventional surgery, and therapeutic safety [4–6]. In this surgical
approach, a multichannel surgical port is used to have access to the abdominal
cavity of the patient where articulated or prebent instruments are introduced.
LESS surgery as a new evolving surgical technique still represents a challenge
for surgeons, which requires surgical expertise [7]. This surgical approach presents
some technical difficulties such as the closer proximity of instruments and loss of
instruments triangulation, leading to clashing and crossing of the instruments both
inside and outside the patient [8]. These technical constraints lead to a restriction of
movements for the surgical instruments, which makes surgeons to adopt static
postures of head and torso and awkward body postures for long periods of time.
This could lead to deficient ergonomic conditions during surgery [9, 10], increasing
the possibilities of muscle fatigue and musculoskeletal injuries [11–13].
In order to overcome some of these technical difficulties in LESS, training is
necessary to become proficient in this new surgical approach as well as using its
specifically designed instruments. In addition, new handheld robotic systems have
been developed for laparoscopic surgery and single-site surgery [14–16]. They
provide precision-driven and articulating instrument tips, which increase the tri-
angulation, and therefore improve the performance of some surgical maneuvers.
One example of these systems is Kymerax™ (Terumo Europe NV, Leuven,
Belgium), which offers interchangeable articulating instruments controlled by its
handle interface.
Apart from dealing with some of the technical limitations of LESS, the use of
these handheld robotic systems could improve the ergonomic conditions as com-
pared to conventional instruments, reducing the risk of musculoskeletal injuries,
since they do not require adopting forced postures to perform certain maneuvers
within the abdominal cavity. The objective of this study is to assess the surgeon’s
performance and muscle activity during the use of a robotic-driven, handheld
articulating laparoscopic instrument in intracorporeal suturing tasks as well as in
digestive and urological LESS procedures, and comparing it with the use of con-
ventional instruments.

2 Materials and Methods

2.1 Participants

Seven right-handed surgeons took part in this study. Four experienced surgeons in
laparoscopy (>100 laparoscopic procedures) and with different experience in LESS
participated in the study with the training environment. Three experienced surgeons
in laparoscopy and LESS (>20 LESS procedures) and with experience using the
Analysis of Surgeons’ Muscle Activity … 5

robotic instrument participated in the study with the experimental animal model.
Participants used both conventional laparoscopic instruments (Conv) and the
handheld robotic instrument (Rob). The type of instrument (conventional or
robotic) to start the task or surgical procedure was randomly assigned to each
surgeon. All trials were performed at our centre’s experimental surgical theatres.
Participants gave informed consent and voluntarily agreed to participate in the
studies.

2.2 Handheld Robotic Instrument

The Kymerax™ system (Terumo Europe NV) is a handheld laparoscopic instru-

ment with articulating and interchangeable instruments (scissors, dissector, needle
holder and L-hook), which are driven by robotic technology. Surgeons control the
movements of the instrument tip through the manipulation of the handle interface.
The shaft diameter of its instruments is 8.8 mm.

2.3 Training Environment

The training environment consisted of a validated laparoscopic simulator

(SIMULAP®; JUMISC, Cáceres, Spain), with a 10-mm, 30° rigid laparoscope (Karl
Storz GmbH & Co. KG, Tuttlingen, Germany) as vision system, and the
GelPOINT® Advanced Access Platform (Applied Medical, Rancho Santa
Margarita, CA, USA) as surgical access port. The laparoscope was fixed to prevent
movements and changes in the instruments. Surgeons hold an angled inline
laparoscopic dissector (Epix®; Applied Medical) on the left hand. On the right
hand, they hold a straight laparoscopic needle holder (Karl Storz GmbH & Co. KG)
or the robotic instrument in its needle holder configuration for the conventional and
robotic groups, respectively (Fig. 1). Participants were asked to performed nine
urethrovesical anastomoses on an ex vivo porcine model in a period of two months
using both types of laparoscopic instruments (Fig. 2). The anastomosis was per-
formed on an ex vivo porcine bladder using 8 simple interrupted sutures.
During the first (T1) and last (T9) repetitions, execution time, leakage pressure
and surgeons’ muscular activity were assessed. The leakage test was performed at
the end of the task to test the integrity of the anastomosis. This test consisted of
introducing a silicone tube connected to an insufflator (Karl Storz GmbH & Co.
KG) through the end of the bladder. While the bladder was immersed in water, the
pressure at which air leaked from the anastomosis was recorded. The maximum
pressure was set at 30 mmHg.
6 F.M. Sánchez-Margallo and J.A. Sánchez-Margallo

Fig. 1 Setup for the study in the training environment using (left) a conventional laparoscopic
needle holder and (right) the robotic instrument

Fig. 2 Use of the robotic

instrument during the
urethrovesical anastomosis

2.4 Experimental Animal Model

Participants performed a partial nephrectomy and a sigmoidectomy on an experi-

mental porcine model through LESS approach. For the partial nephrectomy, an
artificial pseudotumor was previously created on the upper renal pole of the left
kidney. A mixture of alginate and saline was percutaneously injected to reproduce
the tumor. This study was reviewed and approved by the Institutional Review
Board of the Jesús Usón Minimally Invasive Surgery Centre.
Suturing tasks were analyzed during both surgical procedures. Specifically,
measurements were obtained during the hemostasis in the case of partial
nephrectomy and during the anastomosis between the descending colon and rectum
Analysis of Surgeons’ Muscle Activity … 7

Fig. 3 Setup for the study with the animal model. The surgeon is using the robotic instrument
with the needle holder end-effector during the surgical procedure. Surface electromyography is
used to record the surgeon’s muscular activity

in the sigmoidectomy procedure. The GelPOINT® Advanced Access Platform

(Applied Medical) was used as surgical access port. In all cases, surgeons hold an
articulated laparoscopic dissector (Dissect SILS®; Covidien, Mansfield, MA, USA)
on the left hand. On the right hand, they hold a straight laparoscopic needle holder
(Karl Storz GmbH & Co. KG) or the robotic instrument with the needle holder
end-effector for the conventional and robotic groups, respectively. For each pro-
cedure, the surgery time, surgical complications and the surgeon’s muscular activity
were measure (Fig. 3).

2.5 Surface Electromyography Protocol

For the electromyography (EMG) analysis, we used the MP150 System (Biopac
Systems, Inc., Goleta, CA, USA) connected to a laptop (VAIO®; VAIO
Corporation, Nagano, Japan) equipped with the AcqKnowledge 3.7 acquisition
software (Biopac Systems, Inc.).
EMG signals were obtained from right biceps brachii, right triceps brachii, right
forearm flexors and extensors, and right trapezius muscles, through triple-surface
Another random document with
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 FOOTNOTES:
[1] An East-Indian dancing girl.
 ANATOLE FRANCE, FORMER MAN AND
NEW

The biographies of some great men of letters are little different from
their bibliographies. For many years this would seem to have been
true in the case of Anatole France, for the man of public import—
apart from his literary productions—came not into being until fifty-
three years after his physical birth.
Every book-lover who goes to Paris must visit the banks of the Seine
and revel among the riches of that vast exhibition of old books, art
objects, rare prints, and fascinating what-not, which for generations
have been the despair and the admiration of collectors. Over an old-
book mart on the Quai Malaquis, Jacques Anatole Thibault—now
everywhere known as Anatole France—was born April 16, 1844.
From that day to this he has never left as a residence that Paris
whose every paving-block he knows, as he himself says, and whose
every stone he loves. Year by year he has increasingly stood as a
type of Parisian literary life and thought.
His father was one of the prosperous booksellers of the Seine banks
—meditative, thoughtful, and even a maker of verses. He brought
with him from Anjou in western France all of the Vendéean’s passion
for monarchism and clericalism. Just how this harmonizes with the
assertion of one of our author’s biographers that the elder Thibault
was of Jewish blood, I do not pretend to say, but the statement may
pass on its face value. Certain it is that the father was concerned
that Anatole should be educated under the auspices of clerical
teachers, the priests of the old Collège Stanislas, and his son’s early
mastery of the classics and attainments in literary style amply
justified the choice. Indeed, the clerical schools of the period did
more to establish French letters than has since proven to be the
case under the public schools of present-day France.
Growing up in this bookish atmosphere, rich tokens of the past all
about him, inheriting his father’s scholarly tastes, trained under the
rigid system of classicists, and in the school that developed Paul
Bourget and François Coppée, Anatole France needed only one more
element to bring out in him the varied temperament his life and
works exhibit—the inspiration of the refined and tender mother
whose love for romantic fairy-tales charmed into being the first
fancy-creations of her gifted boy.
In 1868 M. France produced his first book—a study of Alfred de
Vigny. This made no great sensation, but his first volume of poems—
many French literary men, like Daudet, Maupassant, and Bourget,
have opened their literary careers with essays at verse—was
published in 1873, Les Poèmes dorés.
About this time M. France became reader for the publisher Lemerre,
and under his auspices brought out various of the thirty-some
volumes which stand to his credit. In 1876 he became an attaché of
the Senate library. Later, he was known as a regular contributor to
Le Temps and other Parisian journals, much of this review material
being now accessible in book-form.
That part of M. France’s work which covers the first twenty years of
his writing, ending with 1896, has largely fixed his place in the
average opinion, for two reasons: those years witnessed his largest
and most popular production, including nearly all of his novels and
stories; and, in consequence, the preponderance of published critical
estimates cover only those two decades.
The “first” Anatole France, then, must be considered almost as a
separate being, so far as we regard his spirit; his literary style,
however, changed scarcely at all with time. Classical training was
reflected in a passion for the Greek magic of words, Latin harmony
of phrasing, and the hedonistic philosophy; there was not even the
suggestion of his later direct appeal to reason and “the rights of
man.” His personal tone—for much of his writing is personal and
even autobiographical—was pessimistic, though untinged with
bitterness; and here again there was little to forecast his vigorous
appeal for a social better day. No thought of social uplift, no ray of
hope, appeared in his treatment of Thaïs, a study of the Egypt of the
Ptolemies; The Red Lily, a picture of present-day Florence; The
Opinions of M. Jérome Coignard, the modernization of sentiments
exploited in Rabelais, “Wilhelm Meister,” “Gil Blas,” and Montaigne;
The Garden of Epicurus, wherein the shades of great thinkers, from
Plato to Schopenhauer, hold converse, “while an Esquimaux refutes
Bossuet, a Polynesian develops his theory of the soul, and Cicero
and Cousin agree in their estimate of a future life.” In a word, the M.
France of those days viewed life as a spectacle, with dispassionate
yet pitying irony. Convinced, with the Preacher, that all is vanity, this
dilettante proposed no remedies for its ills, and was even frankly
skeptical that any such saving medicine existed. This is Anatole
France as most readers know him—the Anatole France who “died”
fifteen years ago, leaving only the stylist and the keen observer to
identify him with the decidedly living man of to-day.
Two important events in the life of our author took place respectively
in 1896 and 1897. In the former year he was elected on the first
ballot to a seat in the French Academy—the seat occupied by
Ferdinand de Lesseps, and on the occasion of his séance de
réception M. France delivered a tactful and altogether admirable
eulogy upon the unfortunate genius whom he succeeded.
This distinction coming after more than fifty years of life would have
been enough to mark an epoch in his career, but one year later he
issued L’Orme du Mail, a series of notable comments upon
contemporary literary and social life. This may be regarded as the
outgrowth of the social, political, and literary notes which he had
been contributing to the newspapers, and which have been gathered
in several volumes, forming probably the most brilliant commentary
upon things French which is available to-day.
Doubtless this daily observation of the current trend gave birth to a
new man, for now Anatole France is no longer the satirical and
lightly ironical dilettante making excursions into the field of
speculation, but a robust devotee of the rights of the people. His
powerful arraignments of the social and political condition of the
French common-people are not the only proofs of a new birth in M.
France. Trenchant, witty, and apostolic as are his social sermons—for
now and then a sermon may ring true to its word-origin and be a
thrust—they were not so amazing and, happily, not so significant, as
his brave championship of the cause of Captain Dreyfus when there
were few who dared to lift voice against rampant militarism and a
prejudiced, Jew-baiting military tribunal.
From this courageous stand it was only a single step to a
propagandum to abolish the many abuses which he feels weigh
heavily upon the masses—war, plutocracy, clericalism, militarism. I
have said that it was only a single step, yet it represents a long
journey for the son of a monarchist, a boy educated by priests, the
smiling literary experimenter, the speculative pupil of Rénan, to have
mounted the Socialistic rostrum and produced anti-military and anti-
clerical papers of no doubtful sound. Such is M. France to-day; and
though he still fails not in his literary appeal to the intellectuals, the
cry that deeply stirs his being is that of the proletariat in need of
intelligent, vigorous leadership. Whether or not one agrees with his
propagandum, one cannot ignore its significance.
Anatole France has attained distinction in several literary forms. His
early poems are not of sufficient merit to make him famous, but they
consist of a piquant combination—humor, history, and philosophy.
His critical introductions to delightful editions of famous books are
charmingly done and sufficiently discriminating. His tractates on
questions of the times are earnest, direct, and vigorous. But it is to
his novels and stories that we must look to find his most
characteristic writings.
To the English reader, his best-known novel is The Crime of Sylvestre
Bonnard (1881), which was crowned by the Academy. Like all of M.
France’s novels, it is practically plotless—a fictional framework for
the skeptical observations and good-natured ironies of the old
philosopher, whose name gives the book its title. A second novel of
distinction, if novel it may be called, is The Book of Friendship (le
Livre de Mon Ami). It is made up of two parts—The Book of Peter
and The Book of Suzanne. The former owes its interest not alone to
charm of style, childlikeness of recital, and subtle beauty, but also to
its autobiographical character—which M. France has frankly
admitted. Three other works immediately rise up for comparison
when one reads this keen, sympathetic, and understanding story—
Dickens’s David Copperfield, Daudet’s Little What’s-His-Name (le
Petit Chose), and Loti’s The Story of a Child; and the very fact of
such inevitable comparisons may sufficiently suggest its ingenuous
charm, its pseudo-naïvete, and its mingled humor and pathos. No
Frenchman, except Victor Hugo, quite entered into child-life as did
M. France in this notable compound of fiction and fact, and I am not
forgetting either Alphonse Daudet or Gustav Droz in making this
assertion.
The inheritance of his mother’s love for fantasy is beautifully
illustrated in M. France’s Abeille, a fairy story of perhaps twenty-
thousand words. The author’s name will vouch for its style; the
simple outline will show the pretty framework for the fictional
conception.
La Duchesse des Clarides brings up her daughter Abeille, together
with Georges, the only son of la Comtesse Blanchelande, who at her
death had confided him to the care of her friend.
The two children one day set out secretly to find the distant lake
which they have seen from the high tower of the castle of Clarides.
The lake is the home of the Ondines, and the woods surrounding it
the realm of the Gnomes. Georges, seeking water and food for
Abeille, is seized by the Ondines. Abeille, waiting for Georges’ return,
falls asleep, to be wakened by the Gnomes, who carry her to their
King Loc. They keep Abeille in order to teach her the wisdom and
secrets of their race and they make her their Princess. Loc loves
Abeille and offers her all the treasures of his kingdom if she will
become his wife. She refuses, asking only to be sent back to her
mother, whom she is allowed to see each night in a dream, as her
mother also sees her. Loc finally learns that Abeille loves Georges,
but that he has disappeared. The Gnome king discovers that the
youth is with the Ondines, held prisoner because he wishes to leave
the Ondine queen—who also loves him—in order to seek Abeille. Loc
magnanimously rescues Georges and sends him to Clarides, but still
cannot bring himself to free Abeille. The youth learns of the fate of
Abeille from his mother and his serving man, and goes to the Gnome
kingdom to rescue her.
Loc cannot keep Abeille longer because of a law allowing mortals,
prisoners of the Gnomes, to return to the world after seven years, so
he betroths Georges and Abeille and gives them rich gifts, among
which is a magic ring having power to bring Abeille and Georges at
any time to visit the Gnome realm, where they will be always
welcome.
In the volumes, Mother-of-Pearl (L’Etui de Nacre) and St. Clara’s Well
(Le Puits de Sainte-Claire), we find our author’s best short-story
work.
As has been noted in previous introductory papers of this series,
there is a marked tendency among French writers of little fictions to
affect the sketch form, and in this field they have wrought with great
delicacy and spirit. It is hardly to be expected of a writer whose
novels give so much play to epigram, philosophy, dialogue, and witty
comment, that he should seek to tell his shorter stories with the
compression of a Maupassant and the plot-structure of a Mérimée.
But other qualities of the first-rate story-teller he does display—his
narration is lively and witty, and his climaxes are satisfying.
Only two of his short-stories can be given attention in this limited
space, both found in the first-named volume, and one of them
reproduced here in translation.
“The Procurator of Judea” tells in the author’s leisurely, pellucid style
how L. Ælius Lamia, after eighteen years of exile by Tiberius Cæsar,
returns to Rome. During his years of sojourn in Asia, here and there,
he has met Pontius Pilate. Now they meet again, and the physical
bulk of the story is taken up by their reminiscences. Just when that
seems to be all, they fall to discussing the charms of Judæan
women, when Lamia recalls with especial warmth a dancing girl.
“‘Some months after,’” he goes on, “‘I lost sight of her. I learned by
chance that she had attached herself to a small company of men
and women who were followers of a young Galilean thaumaturgist.
His name was Jesus; he came from Nazareth, and he was crucified
for some crime, I don’t know what. Pontius, do you remember
anything about the man?’
“Pontius Pilate contracted his brows, and his hand rose to his
forehead in the attitude of one who probes the deeps of memory.
Then after a silence of some seconds—
“‘Jesus?’ he murmured. ‘Jesus of Nazareth? I cannot call him to
mind.’”
This dramatic episode, which exists only for its climax, is no more
poignant than the pathos of that simple-hearted juggler-monk who
imitated the Widow, in that he gave all that he had.
 JUGGLER TO OUR-LADY
(LE JONGLEUR DE NOTRE-DAME)
By Anatole France
Done into English by the Editor

I.
In the time of King Louis, there lived in France a poor juggler, native
of Compiègne, named Barnabas, who went among the villages doing
feats of strength and skill. On market days he would spread out on
the public square an old carpet very much worn, and, after having
attracted the children and the gazing bumpkins by some suitable
pleasantries which he had adopted from an old juggler and which he
never changed at all, he would assume grotesque attitudes and
balance a plate on his nose.
The crowd at first looked at him with indifference. But when,
standing on his hands with his head downward, he tossed in the air
six copper balls which glittered in the sun, and caught them again
with his feet; or when, by bending backward until his neck touched
his heels, he gave his body the form of a perfect wheel, and in that
posture juggled with twelve knives, a murmur of admiration rose
from the onlookers, and pieces of money rained upon the carpet.
However, like the majority of those who live by their talents,
Barnabas of Compiègne had much difficulty in living. Earning his
bread by the sweat of his brow, he bore more than his part of the
miseries connected with the fall of Adam, our father. Moreover, he
was unable to work as much as he would have wished. In order to
show off his fine accomplishment, he needed the warmth of the sun
and the light of day, just as do the trees in order to produce their
blossoms and fruits.
In winter he was nothing more than a tree despoiled of its foliage
and to appearance dead. The frozen earth was hard for the juggler.
And, like the grasshopper of which Marie of France tells, he suffered
from cold and from hunger in the bad season. But, since he
possessed a simple heart, he bore his ills in patience.
He had never reflected upon the origin of riches, nor upon the
inequality of human conditions. He believed firmly that, if this world
is evil, the other cannot fail to be good, and this hope sustained him.
He did not imitate the thieving mountebanks and miscreants who
have sold their souls to the devil. He never blasphemed the name of
God; he lived honestly, and, although he had no wife, he did not
covet his neighbor’s, for woman is the enemy of strong men, as
appears from the history of Samson, which is reported in the
Scriptures.
In truth, he had not a spirit which turned to carnal desires, and it
would have cost him more to renounce the jugs than the women.
For, although without failing in sobriety, he loved to drink when it
was warm. He was a good man, fearing God and very devout toward
the Holy Virgin. He never failed, when he entered a church, to kneel
before the image of the Mother of God and address to her this
prayer:
“Madame, take care of my life until it may please God that I die, and
when I am dead, cause me to have the joys of paradise.”
 II.
Well, then, on a certain evening after a day of rain, while he was
walking, sad and bent, carrying under his arm his balls and knives
wrapped up in his old carpet, and seeking for some barn in which he
might lie down supperless, he saw on the road a monk who was
travelling the same way, and saluted him decorously. As they were
walking at an equal pace, they began to exchange remarks.
“Comrade,” said the monk, “how comes it that you are habited all in
green? Is it not for the purpose of taking the character of a fool in
some mystery-play?”
“Not for that purpose, father,” responded Barnabas. “Such as you
see me, I am named Barnabas, and I am by calling a juggler. It
would be the most beautiful occupation in the world if one could eat
every day.”
“Friend Barnabas,” replied the monk, “take care what you say. There
is no more beautiful calling than the monastic state. Therein one
celebrates the praises of God, the Virgin, and the saints, and the life
of a monk is a perpetual canticle to the Lord.”
Barnabas answered:
“Father, I confess that I have spoken like an ignoramus. Your calling
may not be compared with mine, and, although there is some merit
in dancing while holding on the tip of the nose a coin balanced on a
stick, this merit does not approach yours. I should like very well to
sing every day, as you do, Father, the office of the most Holy Virgin,
to whom I have vowed a particular devotion. I would right willingly
renounce my calling, in which I am known from Soissons to
Beauvais, in more than six hundred towns and villages, in order to
embrace the monastic life.”
The monk was touched by the simplicity of the juggler, and, as he
did not lack discernment, he recognized in Barnabas one of those
men of good purpose whereof our Lord said: “Let peace abide with
them on earth!” This is why he replied to him:
“Friend Barnabas, come with me, and I will enable you to enter the
monastery of which I am the prior. He who conducted Mary the
Egyptian through the desert has placed me on your path to lead you
in the way of salvation.”
This is how Barnabas became a monk.
In the monastery where he was received, the brethren emulously
solemnized the cult of the Holy Virgin, and each one employed in her
service all the knowledge and all the ability which God had given
him.
The prior, for his part, composed books which, according to the rules
of scholasticism, treated of the virtues of the Mother of God.
Friar Maurice with a learned hand copied these dissertations on
leaves of vellum.
Friar Alexander painted fine miniatures, wherein one could see the
Queen of Heaven seated upon the throne of Solomon, at the foot of
which four lions kept vigil. Around her haloed head fluttered seven
doves, which are the seven gifts of the Holy Spirit: gifts of fear,
piety, science, might, counsel, intelligence, and wisdom. She had for
companions six golden-haired Virgins: Humility, Prudence,
Retirement, Respect, Virginity, and Obedience. At her feet two small
figures, nude and quite white, were standing in a suppliant attitude.
They were souls who implored her all-powerful intercession for their
salvation—and certainly not in vain.
On another page Friar Alexander represented Eve gazing upon Mary,
so that thus one might see at the same time the sin and the
redemption, the woman humiliated and the Virgin exalted.
Furthermore, in this book one might admire the Well of Living
Waters, the Fountain, the Lily, the Moon, the Sun, and the closed
Garden which is spoken of in the Canticle, the Gate of Heaven and
the Seat of God, and there were also several images of the Virgin.
Friar Marbode was, similarly, one of the most affectionate children of
Mary. He carved images in stone without ceasing, so that his beard,
his eyebrows, and his hair were white with dust, and his eyes were
perpetually swollen and tearful; but he was full of strength and joy
in his advanced age, and, visibly, the Queen of Paradise protected
the old age of her child. Marbode represented her seated on a
bishop’s throne, her brow encircled by a nimbus whose orb was of
pearls, and he took pains that the folds of her robe should cover the
feet of one of whom the prophet said: “My beloved is like a closed
garden.”
At times, also, he gave her the features of a child full of grace, and
she seemed to say: “Lord, thou art my Lord!”—“Dixi de ventre matris
meæ: Deus meus es tu.” (Psalm 21, 11.)
They had also in the monastery several poets, who composed, in
Latin, both prose and hymns in honor of the most happy Virgin Mary,
and there was even found one Picardian who set forth the miracles
of Our-Lady in ordinary language and in rhymed verses.

III.
Seeing such a concourse of praises and such a beautiful in-gathering
of works, Barnabas lamented to himself his ignorance and his
simplicity.
“Alas!” he sighed as he walked along in the little garden of the
convent, “I am very unfortunate not to be able, like my brothers, to
praise worthily the Holy Mother of God to whom I have pledged the
tenderness of my heart. Alas! Alas! I am a rude and artless man,
and I have for your service, Madam the Virgin, neither edifying
sermons, nor tracts properly divided according to the rules, nor fine
paintings, nor statues exactly sculptured, nor verses counted by feet
and marching in measure. I have nothing, alas!”
He moaned in this manner and abandoned himself to sadness.
One night that the monks were recreating by conversing, he heard
one of them relate the history of a religious who did not know how
to recite anything but the Ave Maria. This monk was disdained for
his ignorance; but, having died, there came forth from his lips five
roses in honor of the five letters in the name of Maria, and his
sanctity was thus manifested.
While listening to this recital Barnabas admired once again the
bounty of the Virgin; but he was not consoled by the example of
that happy death, for his heart was full of zeal, and he desired to
serve the glory of his Lady who was in Heaven. He sought the
means without being able to find them, and every day he grieved
the more.
One morning, however, having awakened full of joy, he ran to the
chapel and stayed there alone for more than an hour. He returned
there after dinner. And beginning from that moment he went every
day into the chapel at the hour when it was deserted, and there he
passed a large part of the time which the other monks consecrated
to the liberal and the mechanical arts. No more was he sad and no
longer did he complain.
A conduct so singular aroused the curiosity of the monks. They
asked themselves in the community why Friar Barnabas made his
retreats so frequent.
The Prior, whose duty it is to ignore nothing in the conduct of his
monks, resolved to observe Barnabas during his solitudes. One day
that he was closeted in the chapel as his custom was, Dom Prior
went, accompanied by two elders of the monastery, to observe
through the windows of the door what was going on in the interior.
They saw Barnabas, who—before the altar of the Holy Virgin, head
downward, feet in air—was juggling with six brass balls and twelve
knives. He was doing in honor of the Holy Mother of God the feats
which had brought to him the most applause. Not comprehending
that this simple man was thus placing his talent and his knowledge
at the service of the Holy Virgin, the two elders cried out at the
sacrilege.
The Prior understood that Barnabas had an innocent heart; but he
thought that he had fallen into dementia. All three were preparing to
drag him vigorously from the chapel when they saw the Holy Virgin
descend the steps of the altar in order to wipe with a fold of her blue
mantle the sweat which burst from the brow of her juggler.
Then the Prior, prostrating his face against the marble slabs, recited
these words:
“Blessed are the pure in heart, for they shall see God!”
“Amen,” responded the elders as they kissed the earth.
*** END OF THE PROJECT GUTENBERG EBOOK SHORT-STORY
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