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Bioengineering
for Surgery
This page intentionally left blank
Woodhead Publishing Series in
Biomedicine: Number 84

Bioengineering
for Surgery
The Critical Engineer-Surgeon Interface

Edited by

WALID A. FARHAT AND JAMES DRAKE

Amsterdam • Boston • Cambridge • Heidelberg

London • New York • Oxford • Paris • San Diego
San Francisco • Singapore • Sydney • Tokyo
Woodhead Publishing is an imprint of Elsevier
Woodhead Publishing is an imprint of Elsevier
80 High Street, Sawston, Cambridge, CB22 3HJ, UK
225 Wyman Street, Waltham, MA 02451, USA
Langford Lane, Kidlington, OX5 1GB, UK
Copyright © 2016 by W.A. Farhat and J. Drake. Published by Elsevier Ltd.
All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any

means, electronic or mechanical, including photocopying, recording, or any information
storage and retrieval system, without permission in writing from the publisher. Details
on how to seek permission, further information about the Publisher’s permissions policies
and our arrangements with organizations such as the Copyright Clearance Center and
the Copyright Licensing Agency, can be found at our website: www.elsevier.com/
permissions.

This book and the individual contributions contained in it are protected under copyright
by the Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional
practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge
in evaluating and using any information, methods, compounds, or experiments described
herein. In using such information or methods they should be mindful of their own
safety and the safety of others, including parties for whom they have a professional
responsibility.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
editors, assume any liability for any injury and/or damage to persons or property as a
matter of products liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the material herein.
ISBN: 978-0-08-100123-3 (print)
ISBN: 978-0-08-100130-1 (online)
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A catalogue record for this book is available from the British Library

Library of Congress Control Number: 2015943969

For information on all Woodhead Publishing publications

visit our website at http://store.elsevier.com/
CONTENTS
About the Editors ix
About the Authors xi
Preface xix
Acknowledgments xxi

1. Interface between Engineering and Medicine 1

Thomas Looi
1.1 Introduction to Systems Engineering 1
1.2 Summary 15

2. Clinical Translation and Commercialization 17

Andrew Sinclair, Paolo Campisi
2.1 Clinical Translation 17
2.2 Commercialization 21
2.3 Closing Remarks 27
2.4 Key Points of this Chapter 28
Suggested Reading 28

3. Image Fusion and Visualization 29

Robert A. Weersink
3.1 Registration/Fusion 29
3.2 Registration Methods 34
3.3 Visualization and Display 42
3.4 Case Studies 52
3.5 Summary 55
Acknowledgments 55
References 56

4. Image-Guided Procedures: Tools, Techniques, and Clinical

Applications 59
Cristian A. Linte, John T. Moore, Elvis C.S. Chen, Terry M. Peters
4.1 Background and Introduction 59
4.2 Common Components of Image Guidance Platforms 61
4.3 Accuracy Considerations: Clinical Requirements versus Engineering
Performance 65
4.4 Clinical Applications 66

v
vi Contents

4.5 Limitations, Constraints, and Challenges 85

4.6 Summary and Future Directions 86
References 87

5. Surgical Robotic Tools 91

Hamidreza Azimian
5.1 Synopsis 91
5.2 Design Considerations 92
5.3 A Review of the Technology 93
5.4 Our Experience 106
5.5 Future Directions 109
References 110

6. Simulation in Minimal Access Surgery 113

Pavan Brahmamdam, Georges Azzie
6.1 Introduction 113
6.2 Video-Box Training 115
6.3 Virtual Reality Training 116
6.4 Validated Assessments of Simulated Training 118
6.5 Motion and Force Analysis in Minimal Access Simulation 119
6.6 Conclusion 122
References 122

7. A Simulation Hospital as a Model of Immersive-Based

Learning: The Concept and Challenges 125
Hani Lababidi, Ayed M. AlQahtani

7.1 Introduction 125

7.2 The Concept 126
7.3 Definition 126
7.4 Physical Structure of the Simulation Hospital 127
7.5 Categories of Healthcare Giver Trainees 131
7.6 Specialized Simulation Training Programs 133
7.7 Challenges in Establishing a Simulation Hospital 134
7.8 Conclusion 135
References 136

8. Virtual Simulation: Abdomen 137

Amanda Farah Khan
8.1 Introduction 137
8.2 Types of Simulation and Assessment Metrics 138
 Contents vii

8.3 Abdominal SimulationdPhysical Phantoms and Box Trainers 139

8.4 Abdominal SimulationdVR 143
8.5 Simulated Operating Room 145
8.6 Future of Abdominal Simulation 147
References 148

9. Application of 3D Printing in Medical Simulation

and Education 151
Carling L. Cheung, Nikoo R. Saber

9.1 Introduction 151

9.2 Three-Dimensional Printing 151
9.3 Modeling in Craniofacial Surgery 152
9.4 Silicone Modeling 155
9.5 Conclusions 165
References 165

10. Simulation Surgical Models: Surgeon Perspectives 167

Jen Hoogenes, Edward D. Matsumoto
10.1 Introduction 167
10.2 Evolution of Modern Surgical Simulation 168
10.3 Theoretical Constructs for the Basis of Simulation 170
10.4 Types of Surgical Simulations 172
10.5 Considerations for Surgical Simulation 180
10.6 Assessment in Simulation Training 182
10.7 Conclusion 184
References 185

11. Bioengineering and Regenerative Medicine in Surgery 189

Rano Matta, John E. Davies
11.1 Introduction 189
11.2 Cell Therapies 191
11.3 Biomaterial Design and Selection 192
11.4 Translation to the Operating Room: Regenerative Medicine in
Surgical Therapies 194
11.5 Conclusions 200
References 200

Concluding Remarks 205

Index 207
This page intentionally left blank
ABOUT THE EDITORS

Dr Walid A. Farhat graduated from the American University of Beirut

and joined the Division of Urology at The Hospital for Sick Children,
Toronto, Canada, as a staff surgeon in 2006. As a professor with the
University of Toronto and the Associate Surgeon-in-Chief of Education
for Perioperative Services with SickKids, Dr Farhat maintains a clinical
practice in pediatric urology and has a particular interest in minimally
invasive surgery, including laparoscopic and endourologic procedures in
children. He has a keen interest in disseminating his knowledge and
expertise in minimally invasive procedures for both clinical trainees and
his patients. He initiated the Paediatric Urology Laparoscopy Course in
2007 that has run for 9 consecutive years, with the goal to introduce and
improve training methods for teaching laparoscopy. The course has since
expanded to be offered both nationally (Canadian Urological Association)
and internationally (Kuwait and Brazil). Within his role, Farhat has been
concentrating his efforts on establishing a surgical simulation suite within
SickKids, with the hopes of this eventually leading to a surgical simulation
center through the Learning Institute. Dr Farhat’s basic science research
focus is tissue engineering, more specifically the identification of the
critical stages of bladder development. His research team is currently
investigating the mechanisms behind cellular differentiation during
bladder organogenesis. Dr Farhat has more than 130 peer-reviewed
publications and is consistently invited to present internationally and
nationally on laparoscopy and minimal invasive surgery.
Dr James Drake assumed his appointment in the Department of
Surgery, Division of Neurosurgery, at The Hospital for Sick Children,
Toronto, Canada, and has been on the surgical staff in the Division of
Paediatric Neurosurgery since 1988. His primary research and clinical
interests relate to engineering applications to neurosurgery including hy-
drocephalus, image-guided surgery, and robotics. This encompasses the
main themes of the Center for Image Guided Innovation and Therapeutic
Intervention, which are broadened to include applications of imaging,
robotics, and simulation for all pediatric surgical disciplines. Dr Drake has
more than 230 peer-reviewed publications and holds major grants from the

ix
x About the Editors

Canadian Institutes of Health Research/Natural Sciences and Engineering

Research Council of Canada and Brain Canada. His clinical interests relate
to the investigation and management of hydrocephalus including the use of
endoscopy, image-guided surgery for brain tumors and epilepsy, and the
management of complex spinal disorders.
ABOUT THE AUTHORS

Ayed M. AlQahtani, ME
Ayed M. AlQahtani is a registered mechanical engineer and he received
his BS in mechanical engineering at King Saud University, Riyadh. He is
highly experienced in the field of engineering, facility management,
project management, and operations works. In addition to exposure and
actual hands-on experience in the field of plant engineering in accordance
to Saudi Government policy and regulations, he has also gained knowl-
edge and experience in different areas of work including: general man-
agement, engineering design, facility management, project management,
contracts management, human resources, operation administration, and
supply chain management. Currently, he is working as executive director
of Operation/Strategic Construction Program Director at King Fahad
Medical City and responsible for the implementation of safety mainte-
nance operation compliance to national and international facility man-
agement standards of a safe functional practices at King Fahad Medical
City, ensuring an effective and efficient environment for patients, staff,
and other individuals. He also manages the operational modernized
building construction of the National Neurosciences Institute, Compre-
hensive Cancer Center, Cardiac Center, Proton Therapy Centre,
Cochlear Implant Center, and the laboratories and offices of the Central
Services Building.
Hamidreza Azimian, PhD
Hamid is currently a robotics senior project manager at the Center for
Image-Guided Innovation and Therapeutic Intervention at the Hospital
for Sick Children, Toronto, Ontario, Canada. He received a PhD in me-
chanical engineering from the University of Western Ontario, London,
Ontario, in 2012, an MSc in electrical engineering from K.N. Toosi
University of Technology, Tehran, Iran, in 2006, and a BSc in electronics
engineering from Iran University of Science and Technology, Tehran, Iran,
in 2004. His areas of interests include robotics, mechatronic systems, and
model-based control and optimization. He has published several articles
and is a reviewer for the Control Engineering Practice journal, Journal of Robotic
and Intelligent Systems, IEEE Transactions on Robotics, IEEE International
Conference on Robotics and Automation, and IEEE/RSJ International
Conference on Intelligent Robots and Systems.

xi
xii About the Authors

Georges Azzie, MD
Georges Azzie is a pediatric surgeon at the Hospital for Sick Children,
Toronto, and an associate professor in the Department of Surgery at the
University of Toronto. His scholarly interests revolve around education,
surgical simulation, and global surgery and international health.
Pavan Brahmamdam, MD
Pavan Brahmamdam is a fellow in Pediatric General and Thoracic Surgery at
the Hospital For Sick Children in Toronto, Canada. He obtained his medical
degree from the University of Missouri–Kansas City. He then completed a
general surgery residency at the University of Texas-Southwestern Medical
School. During his residency, he also completed a 2-year National Institutes
of Health–funded research fellowship studying the immunological effects of
sepsis at the Washington University in St. Louis School of Medicine. Before
his fellowship in Toronto, he also completed a surgical critical care fellowship
at Wayne State University and Children’s Hospital of Michigan in Detroit.
His main research interests are in perioperative care, quality improvement,
and the role of simulation in surgical training.
Paolo Campisi, MD
Dr Paolo Campisi joined the Department of Otolaryngology–Head and
Neck Surgery at the Hospital for Sick Children and University of Toronto
in July 2004 and currently holds the rank of associate professor. He earned
his medical degree from the University of Western Ontario and completed
his residency training at McGill University. He then returned to Toronto to
complete a fellowship in pediatric otolaryngology at The Hospital for Sick
Children. Dr Campisi holds a master’s degree in both pharmacology and
otolaryngology and has an interest in disorders of the head and neck, airway,
voice, and saliva management. He is the clinical director of the Center for
Pediatric Voice and Laryngeal Function, a subspecialty clinic designed for
the care of children with voice disorders and the Saliva Management Clinic
at the Holland-Bloorview Children’s Rehabilitation Center. Dr Campisi
served as the director of undergraduate education for the Department of
Otolaryngology–Head and Neck Surgery, University of Toronto, from
2005 to 2012 and as the Pediatric Otolaryngology Fellowship Director from
2007 to 2012. In July 2012, he was appointed the director of postgraduate
education for the Department of Otolaryngology–Head and Neck Surgery,
University of Toronto. In 2015, he was appointed vice chair of education.
He has a strong interest in medical education and has worked with Dr Vito
Forte in the development of an otoscopy simulator.
 About the Authors xiii

Elvis C.S. Chen, PhD

Dr Elvis C.S. Chen obtained his PhD in computer science from Queen’s
University, Kingston, Canada, in 2007. He works in the field of image-
guided interventions by applying techniques in robotics and computer
graphics to the field of surgery. His research interests include: joint kine-
matics, ultrasound-guided needle interventions, tool calibration and
tracking, and vision-guided laparoscopy. Currently, he is a research asso-
ciate at Robarts Research Institute with a cross-appointment with Western
University (Canada). He was the organizer and editor for Augmented
Environment for Computer-Assisted Interventions (2011 and 2012).
Carling L. Cheung, BCmpH, MESc
Carling L. Cheung is currently a medical student at the Royal College
of Surgeons in Ireland. Before that, she completed a bachelor’s of
computing specializing in biomedical computing at Queen’s University,
and a master’s in engineering science specializing in biomedical engi-
neering at the University of Western Ontario. She worked at SickKids
in the Center for Image Guided Innovation and Therapeutic Inter-
vention laboratory for 3 years as a project manager in medical imaging,
with a focus on creating and validating realistic physical models for
surgical and medical education.
John E. Davies, BSc, BDS, PhD, DSc
John E. Davies, who trained as an oro-maxillo-facial surgeon, is a professor
of Dentistry and Biomaterials at the University of Toronto. Davies received
his DSc from the University of London in 1998 for his sustained contri-
butions over a period of 20 years, to the field of biomaterials, and was the
2002 recipient of the Society for Biomaterials Clemson Award for Basic
Science. He was elected a Fellow of Biomaterials Science and Engineering
in 2000. In the mid-1980s, he devised the first in vitro biological methods
to study the mechanisms of bone bonding to bioactive ceramics. His work
has led to an understanding of the mechanisms by which bone grows on
implant surfaces and within tissue engineering scaffolds. He has developed
ceramics that can be resorbed by osteoclasts (this technology has also been
adopted by the Canadian Space Agency to investigate the cellular mech-
anisms of microgravity-induced osteopenia. See the Tomorrow Today
Web site for a feature article about Bone Loss in Zero Gravity), calcium
phosphates that stimulate increase in local bone mass, scaffolding materials
for bone regeneration, and extraembryonic cells as a potential source of
cell-based connective tissue repair.
xiv About the Authors

Jen Hoogenes, PhD candidate

Jen Hoogenes is a current PhD candidate in the Health Research Meth-
odology Program within the Department of Clinical Epidemiology and
Biostatistics at McMaster University in Hamilton, Ontario, Canada. She
completed a bachelor’s and master’s of science in Health Behavior/Health
Education at the University of Michigan. She is currently a research
coordinator within the Department of Surgery at McMaster University
with a primary focus on surgical education, residency training, and research
methodology.
Amanda Farah Khan, MSC, MD/PhD candidate
Amanda Farah Khan is an MD/PhD student at the University of Toronto
in the Faculty of Medicine and the Institute of Biomaterials and
Biomedical Engineering. She received both her bachelor’s (health sci-
ences) and master’s degrees (medical biophysics) from the University of
Western Ontario. In 2015, she was bestowed with the most prestigious
award given to graduate students, the Vanier Canada Graduate Scholar-
ship, in recognition of both her academic and research history and future
potential as a leader. Her research interests include medical simulation and
surgical education.
Hani Lababidi, MD, FCCP, FACP
Dr Lababidi is a senior consultant in Pulmonary and Critical Care
Medicine at King Fahad Medical City (KFMC) in Riyadh, Kingdom of
Saudi Arabia. He is an expert in medical simulation and he is currently the
director of the Center for Research, Education & Simulation Enhanced
Training (CRESENT) at KFMC. Besides the various leadership positions,
he chaired or participated in key hospital committees and functions. He
has special expertise in hospital accreditation and information manage-
ment. Dr Lababidi received his MD from the American University of
Beirut, Lebanon, and then did his internal medicine, pulmonary, and
critical care training in the United States. He holds American Board in
Internal Medicine, Pulmonary and Critical Care Medicine certification.
His academic and leadership career began as assistant professor of
Medicine at Cornell University, New York, NY, then chief of staff at
Makassed General Hospital, Beirut, Lebanon, and head of the Pulmonary
Division at King Fahad Medical City and most recently director of
CRESENT at KFMC.
 About the Authors xv

Cristian A. Linte, BASc, MESc, PhD

Cristian A. Linte is an Assistant Professor in Biomedical Engineering and
Chester F. Carlson Center for Imaging Science at Rochester Institute of
Technology. His research spans the development of tools and techniques
for image processing, modeling and visualization for surgical planning and
interventional guidance, as well virtual and augmented anatomy visualiza-
tion paradigms for simulation, teaching and training.
Thomas Looi, BASc, MASc, PhD, MBA, PEng
Thomas Looi is the project director for the Center for Image Guided
Innovation and Therapeutic Intervention at the Hospital for Sick
Children. He acquired a BASc in Engineering Science (aerospace) and an
MASc in Space Systems Engineering at the University of Toronto
Institute for Aerospace Studies. He has spent 6+ years in various industry
technical roles such as systems and control engineering at companies such
as Intelsys and MDA Corporation developing robotic applications in the
biomedical and space sectors. He completed an MBA (finance speciali-
zation) at the University of Toronto, where he developed an interest in
entrepreneurship and health care technology development. Currently,
he is completing his PhD (2015) in biomedical engineering at the
Institute for Biomaterials and Biomedical Engineering at the University
of Toronto, where he is developing noninvasive magnetic resonance–
guided focused ultrasound technology for thrombolysis and minimally
invasive robotic surgical tools. He is a registered Professional Engineer of
Ontario.
Edward D. Matsumoto, MD
Edward D. Matsumoto is an associate professor in the Faculty of Health
Sciences at McMaster University in the Department of Surgery and the
Division of Urology. He completed his medical degree and residency
in urology at the University of Toronto. During his residency, he
also obtained a master’s in Health Professional Education as part of the
Surgical Scientist Program at the University of Toronto and fulfilled
the requirements for the Royal College of Surgeons of Canada’s Clinician
Investigator Program. His academic interest has been in the field of sur-
gical education with a focus on technical skills training, simulations, and
assessment of skills. He has published extensively in surgical simulation
training and has received a number of awards in his field.
xvi About the Authors

Rano Matta, MD
Dr Rano Matta completed a bachelor of applied science in chemical en-
gineering at the University of Toronto, with a minor in bioengineering. He
went on to complete a master’s of applied science in biomedical engi-
neering, also at the University of Toronto. His research focused on um-
bilical cord stem cells for bone tissue engineering, completed under the
supervision of Dr John E. Davies. He received his medical training at
Queen’s University School of Medicine. He is now a resident in urologic
surgery at the University of Toronto.
John T. Moore, MA, MSc
John T. Moore received his MA in philosophy from McMaster University,
Hamilton, Ontario, Canada, and his MSc from Western University, London,
Ontario, Canada, in 2005. He is currently a research associate in the image-
guided surgery facility at Imaging Research Laboratories, Robarts Research
Institute, Western University, London, Ontario, Canada.
Terry M. Peters, PhD, FIEEE
Terry M. Peters is a scientist in the Imaging Research Laboratories at the
Robarts Research Institute, London, Ontario, Canada, and professor in the
Departments of Medical Imaging and Medical Biophysics at Western
University London, Canada, as well as a member of the Graduate Programs
in Neurosciences and Biomedical Engineering. He is also an adjunct pro-
fessor at McGill University in Montreal. Dr Peters’ laboratory focusses on
image-guided procedures of the heart, brain, spine, and abdomen. He has
authored two books, more than 270 peer-reviewed papers and book
chapters, and has mentored more than 85 trainees at the master’s, doctoral,
and postdoctoral levels.
Nikoo R. Saber, PhD
Nikoo R. Saber is the senior project manager of simulation at the Center
for Image Guided Innovation and Therapeutic Intervention at The Hos-
pital for Sick Children (SickKids) in Toronto, Canada, where she has led
projects in subject-specific laparoscopic surgery simulation, craniofacial
surgery modeling, and surgical tool development. She has also worked on
collaborative projects involving mathematical optimization and robotics in
pediatric cranial vault remodeling, with an aim to transfer the technology to
future operating rooms. Before her appointment at SickKids, Dr Saber
was a postdoctoral scholar at the California Institute of Technology, with
joint appointments at the Huntington Medical Research Institutes and
Children’s Hospital Los Angeles, with her research mainly focusing on
 About the Authors xvii

computational hemodynamics, myocardial modeling, and cardiovascular

prosthetic device design and simulation. Dr Saber received her MSc and
PhD in mechanical engineering from Imperial College London.
Andrew Sinclair, PhD
Andrew Sinclair is the chief executive officer of OtoSim Inc., a medical
simulation and training company initially focused on ophthalmoscopy and
otoscopy (ear and eye examination) training. He was involved in the initial
commercialization of the OtoSim technology as a senior director at MaRS
Innovation and transitioned to full-time chief executive officer at OtoSim
Inc., growing the company to more than $3 million in cumulative sales
between 2012 and 2014. Dr Sinclair joined MaRS Innovation in 2009,
working in the commercialization of early-stage Toronto-based technol-
ogies. He has also been a sessional lecturer at McMaster University, teaching
a Master’s of Engineering–level course in New Venture Business Strategy
in 2013 and 2014. Before MaRS Innovation, Dr Sinclair worked for
two decades, the last decade as vice president, in a contract research,
development, and testing organization. As vice president, he managed
laboratories in the Montreal, Toronto, Chicago, and Los Angeles areas.
He received a BSc and PhD in chemistry from the University of Toronto in
the early 1980s and worked in research and development in a multinational
and a startup in the late 1980s.
Robert A. Weersink, PhD, MCCPM
Dr Robert A. Weersink is a clinical physicist and scientist at the Princess
Margaret Cancer Centre. He is an affiliated faculty member of the Techna
Institute at the University Health Network and a member of University
Health Network’s Guided Therapeutics Program. His expertise covers
biomedical optics, image-guided surgery, and radiation therapy, with
particular interest in developing connections across these fields to create
new technologies. He has developed response monitoring and treatment
planning methods for clinical trials on photodynamic therapy and photo-
thermal therapy for the treatment of prostate cancer and aided in the
development of a new radiofrequency ablation device, and magnetic
resonance–guided robotics. As a clinical physicist specializing in radiation
oncology, he spends part of his time as a clinical physicist in the brachy-
therapy group in the radiation medicine program at Princess Margaret
Cancer Center. His recent research interests are in the registration of optical
imaging to volumetric imaging, especially as applied to radiation and sur-
gical planning. This includes the development of a unified treatment
xviii About the Authors

planning platform for head and neck patients receiving both radiation and
surgery. Building on his previous work on PDT planning, he is using tools
developed within the University Health Network Guided Therapeutics
program and his experience in radiation physics to apply the same quality
measures used in radiation therapy for ablative therapies using nonionizing
radiation. His mix of clinical activities and basic research has given
Dr Weersink the perspective and experience to deliver basic research ac-
tivities into useful medical devices that will have an impact on patient care.
PREFACE

Medical engineering encompasses the application of engineering science

and technology to the design and implementation of diagnosticdand
therapeuticddevices for clinical practice. The explosion of technological
advances with potential medical applications in the past decade has changed
the direction of fundamental research and impacted the interface between
medicine, engineering, and physical sciences. This close interaction has led
to an exponential rise in innovative applications in biomedical research
and the clinical arena. Work in this area now encompasses a wide range of
technology from advanced imaging, tool development, simulation, and
drug discovery directed to bedside applications in the clinic or operating
room.
Application of cutting-edge research in biomedical technology will have
an enormous impact on health care outcomes and quality of life. Surgeons
frequently have innovative technological solutions to challenging medical
problems, but not the knowledge or expertise to develop them. Engineers
with this expertise may have technological solutions, but not the expertise
to assess their possible clinical impact. Bringing surgeons and engineers
together maximizes the opportunities for high impact technological ad-
vances. The journey of surgery from a large open incision to a small/scarless
robotic surgery is an excellent example of how intertwined engineers are
with the surgeons.
The idea of this book stems from the interdisciplinary research projects
we have been undertaking at the Center of Image Guided Innovation and
Therapeutic Intervention at the Hospital for Sick Children Research
Institute and the University of Toronto. Like many other institutions, the
interface of engineering and medicine initially included research develop-
ment for intraoperative imaging, medical instrumentation, and robotics.
This subsequently expanded to include surgical simulation and disease/
organ modeling to bioengineering and regenerative medicine. This has had
major effects on basic and translational research, education including sur-
gical training, and the beginnings of improved clinical outcomes.
We are hoping that this book will introduce surgeons and engineers to
the broad and endless possibilities of collaboration. More importantly, we
envision this book to be a stepping stone for surgeons to learn that the
research and development process of any laboratory-created instrument and

xix
xx Preface

technology are the results of a series of carefully synchronized and mutually

interlocking process steps. We think engineers will be inspired to have their
discoveries make a difference to patients around the world. This complex
process involves many players from the biomedical device industry,
financial institutions, and universities while navigating through the patent
and commercialization process working together in an interdisciplinary
team. The process, although challenging, can have perhaps the most pos-
itive and satisfying impact of any scientific endeavor.
ACKNOWLEDGMENTS

Our gratitude extends to all of the people who wrote and contributed to
the chapters collected within this book. Considering that the concept and
idea behind the book is new and somewhat risky, we begin with a heartfelt
thanks to the engineers and students at the Center for Image Guided
Innovation and Therapeutic Intervention (CIGITI) at the Hospital for Sick
Children for their support.
Lisa Abreu deserves a special note of appreciation for her efforts on our
behalf. Lisa found innovative ways for us to meet our deadlines.
Thanks to the Chandos editors at the Kidlington (UK) office of Elsevier,
Harriet Clayton and Glyn Jones; the production manager at Woodhead
Publishing, Omer Mukthar; and the project manager at TNQ Books and
Journals, Jayanthi Bhaskar.
As always, we are grateful to our families and kids for their patience and
encouragement.

xxi
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CHAPTER 1

Interface between Engineering

and Medicine
Thomas Looi
Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children,
Toronto, ON, Canada

1.1 INTRODUCTION TO SYSTEMS ENGINEERING

1.1.1 Medicine and Engineering: Bridging the Divide
Biomedical engineering is the application of engineering principles to the
field of biology and medicine. When compared with other traditional fields
of engineering, such as mechanical and electrical engineering, biomedical
engineering is relatively young and sometimes considered a subspecializa-
tion of the broader specialties. However, biomedical engineering is unique
because it attempts to develop technology for the medical area that has
often been seen as distinct and unrelated to engineering. Historically,
medicine and engineering were considered to be at the opposite ends of the
education spectrum because one deals with the human body and life sci-
ences, whereas the other is involved in the study of math and physical
sciences. The education system has also reinforced this ideology because
university applicants to either program do not necessarily overlap in their
course work and preparation.
However, as medical knowledge becomes increasingly more broad and
complex, engineering can play a role in assisting and augmenting the
capabilities of a physician to be more precise and accurate. In addition, ad-
vances in mechanical, chemical, electrical, and information technology have
created new devices and sensors that provide new insight into biological
systems previously not available. Medical imaging is a perfect example of
how physics and electrical engineering have revolutionized the field of
radiology. Ultrasound, computed tomography, and magnetic resonance
imaging (MRI) enable physicians to look inside the body without needing to
make an incision. Imaging-processing software is able to highlight and select
vital anatomical structures and provides a three-dimensional model of the
pathology. These tools have enabled physicians to provide early diagnosis
and/or guidance when attempting to treat a specific diseased area.
Bioengineering for Surgery © 2016 by T. Looi.
ISBN 978-0-08-100123-3 Published by Elsevier Ltd.
http://dx.doi.org/10.1016/B978-0-08-100123-3.00001-4 All rights reserved. 1
2 Bioengineering for Surgery

These technological advances and innovations have reached across

clinical spectra from inside the operating room, where one can find image-
guided systems, surgical navigational systems, and surgical robotics, to the
patient side, with advanced ventilators and infusion pumps. This includes
not only clinical care, but also medical education, training, and teaching.
Staff members are able to use simulators to augment and enhance their
educational experience to create better future physicians without the ethical
concerns of training on a patient. With this rapid infusion of technology
into the clinical space, biomedical engineering serves to fill this gap between
two previously separate and unique professions.
As devices become more complex and medicine is more personalized
and unique, this creates a challenging environment to develop new solu-
tions in medicine. For example, early ventilators were simple pumps that
circulated air while removing carbon dioxide. However, modern ventila-
tors contain many additional functions and parameters where a physician
can monitor numerous parameters that can include peak lung pressure, flow
resistance, in-tidal volume, and respiratory rate. This allows the physician to
precisely tailor the ventilation parameters to meet a patient’s condition. In
some cases, the number of parameters is overwhelming and more complex
than required. Devices can be “overengineered” because there are more
controls and inputs available than needed to accomplish the treatment.
To create effective clinical solutions, there must be a common ground and
terminology to bridge the differences in the two professions’ language
and culture. In engineering, modeling, data gathering/analysis, and quan-
tification form some of the base tenets of the profession. In medicine,
understanding complex biological interactions of the human body is a core
element. As such, the first challenge is develop a common ground: an
interface in which clinicians can provide problems and feedback to engi-
neers developing the solution.

1.1.2 Systems Engineering: A Common Platform

Even though biomedical engineering and medicine come from different
environments and cultures, they share a common goal: developing better
clinical solutions. For the successful development of a clinical tool, a
common platform that provides an interface and terminology baseline to
facilitate accurate and timely feedback between the physician and engineer
is required. For simple projects, the stakeholders could be the clinicians and
engineers. For more complex projects or treatments, the stakeholders could
be expanded across the health care continuum to include other medical
 Interface between Engineering and Medicine 3

specialties, including nursing, pharmacy, and even the patient. For example,
the development of an MRI-guided device could involve a team consisting
of staff members from surgery, radiology, anesthesia, and nursing because
the equipment uses knowledge from different areas to accomplish its goal.
To help with this coordination, the focus of this section is the concept of
systems engineering.
By definition, systems engineering is defined as “interdisciplinary field of
engineering that focuses on how to design and manage complex engi-
neering systems over their life cycles.” Complex systems can range from the
development of vehicles (cars, ships, and airplanes) to manufacturing and
power plants. These systems are often composed of smaller specialized
elements. For example, an airplane consists of wings, fuselage, avionics, and
engines in which each of the elements are combined to create the func-
tionality of the plane. Hence, the role of systems engineering is to focus on
the project as a system rather than as individual elements. As such, the
concept of systems engineering is not necessarily new because it is a
common methodology that solves complex engineering problems, but its
application in medicine is novel. For the purpose of medical technology,
systems engineering is an ideal approach because clinicians have a medical
function that may not be solved by one technology but rather a set of
technologies that performs the desired function. Because the systems en-
gineer is involved in ensuring overall functionality, it is often seen as a
centerpiece of engineering that he or she will interact with the engineering
specialties to determine system feasibility (Figure 1.1). The engineer must
maintain sufficient competency in various areas to have an understanding of
how each of the components will affect the resulting performance.
Commonly, the systems engineer is referred to as the “jack of all trades”
because of the multidisciplinary role.
The definition of system is quite varied, but a common element is that it
focuses on the whole entity, for example: “A system is a construct or
collection of different elements that together produce results not obtainable
by the elements alone. The elements, or parts, can include people, hard-
ware, software, facilities, policies, and documents; that is, all things required
to produce systems-level results. The results include system-level qualities,
properties, characteristics, functions, behavior and performance. The value
added by the system as a whole, beyond that contributed independently by
the parts, is primarily created by the relationship among the parts; that is,
how they are interconnected.” Using this definition, one can identify a
variety of systems within the clinical setting. For example, an MRI device is
4 Bioengineering for Surgery

Software
Manufacturing
engineering

Electrical Test
engineering engineering

Structural / Civil Materials

engineering management

Mechanical Systems Sales and

engineering engineering marketing

Figure 1.1 Role of a systems engineer.

a complex system composed of electromagnets, liquid helium cooling,

control electronics, and computer console. On a smaller scale, an endo-
scope is an imaging system consisting of a lighting unit, camera control unit,
and scope. Individually, each of the parts performs a specific function that
contributes to fulfilling a feature required for the larger entity to accomplish
its tasks. Using an endoscope as an example, the lighting unit provides
ambient light through a fiber optic cable to the scope tip for illuminating
the target area, the camera control unit interacts with the imaging sensor,
and the scope provides the delivery mechanism to the target. When
developing clinical solutions, it is important to look at the problem as a
system to see what and how it interacts with its environment. Once the
general level system is defined, it can be further defined into smaller sub-
systems for in-depth analysis and design. For biomedical engineering, the
concept of systems engineering is a natural step to understanding complex
clinical systems as a means to see where and how they interact with bio-
logical systems since the biological environment not be straightforward.
The process of systems engineering is commonly referred to as a
“V-model or circular process with gate checks” in which the engineer starts
with a conceptual discussion with the end-user and results in a finished
product (Figure 1.2). As the project progresses, each step represents an
increasing level of detail and implementation. Once implementation is
complete, the project moves back toward from the high-level concept
 Interface between Engineering and Medicine 5

Acceptance Operations
review concept

System delivery System

and roll-out requirements

Requirements Requirements
check review gate

Fabrication and Preliminary

test design

Detailed Detailed design Preliminary

design review design review

Figure 1.2 Systems engineering process.

and operations where the goal is to test, verify, and validate the actual
hardware/software. After verification and validation, the system is delivered
to the customer and the role of the systems engineer shifts to an “operations
and maintenance” mode in which the engineer will support end-user op-
erations. Throughout this “V-model,” there is an iterative process in each
step between the end-user and engineer to ensure the correct requirements
and definitions are met. Initial concepts and operational procedures may have
been generated with a limited knowledge of the technological limitations
leading to a set of requirements that are not achievable. Naturally, the less
iteration, the faster and less costly a project becomes as changes later in the
implementation would require changes traveling upwards toward the
concept. These upward changes to the requirements may sound minor, but
can cause a performance shift in other subsystems. For example, if one is
designing a light source for an endoscope and realizes that a brighter bulb is
needed, this could impact the overall power required and heat dissipated by
the endoscope, which could result in changes to the electrical and cooling
systems. Thus, it is important to recognize that a system needs to be clearly
defined upfront with as much detail as possible to avoid costly changes and
performance impacts to budget, schedule, and feasibility.
To properly describe a system, the initial step is to develop a set of
requirements: a goal, term, or performance objective that a solution must
meet to be successful. These requirements will dictate what and how a
6 Bioengineering for Surgery

Performance Requirement
a) Operational work envelope
i) The system shall guide and support the anastomosis tool to the surgical worksite as defined in
MDAM20457-ICD.0001, KidsArm to operating room and patient interface control document.
ii) The system shall permit the placement of the anastomosis tool anywhere within a preselected 2 cm3
(according to medical advisor) workspace within the patient.
iii) The system shall permit the orientation of the anastomosis tool within ±90° of the selected
home position in both pitch and yaw to enable access to the surgical site.

Figure 1.3 Example of KidsArm requirements definition.

system should perform. The list may include both quantitative and quali-
tative measurements, but one needs to be careful when using qualitative
requirements because this could vary from one user to another. Figure 1.3 is
an example of the performance requirements for KidsArm, an autonomous
image-guided anastomosis robot. Initially, this may seem like a very simple
task, but if the requirements are not quantifiable, the process can prove to
be quite challenging because an engineer will not be able to design a
mechanism or actuator without a target value. For example, in the design of
a data acquisition system to record samples, there could be a requirement
that the sampling frequency must be 60 samples per second to properly
record the physical phenomenon. Yet, when this is applied to medicine,
biological interactions may not be quantified as clearly. This is not the fault
of medical research, but rather because of the complexity and heterogeneity
of the underlying biology in which behavior is not typically straightfor-
ward. For example, if one is to design a tool to retract tissue and take a
biopsy sample, an engineer may ask how much force is allowed. What is the
acceptable amount of tissue deformation? Even in reviewing the literature
and case data and interviewing clinicians, it is obvious that the answer is not
clear because for some cases there are no data or range of values available.
Yet, when surgeons operate and interact with the tissue, they are able to
instinctively navigate and manipulate tissue to prevent/minimize injury.
Therein lies the problem: surgeons have a vast amount of knowledge based
on their years of experience and training. As engineers, one must be able to
translate this experience to quantifiable parameters whereby engineering
solutions can be designed to meet the goals.
If we return to our design of retractor and biopsy, the question of
allowable force and deformation may be found in the literature, but more
than often it will require a separate set of experiments to generate these
force requirements. This is not an uncommon task; researchers recognize
the value of characterizing mechanical properties of tissue whereby these
properties would be used as guides to developing surgical tools and robots.
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The Project Gutenberg eBook of The Builder, No.
1, December 31, 1842
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Title: The Builder, No. 1, December 31, 1842

Precursor number

Author: Various

Release date: September 1, 2023 [eBook #71539]

Language: English

Original publication: London: Publishing Office 2 York Stree Covent

Garden, 1844

Credits: Charlene Taylor, David Garcia, Jon Ingram and the Online
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*** START OF THE PROJECT GUTENBERG EBOOK THE BUILDER,

NO. 1, DECEMBER 31, 1842 ***
The Builder, No. 1, December 31,
1842.

THE BUILDER.
PRECURSOR NUMBER.
THIRD IMPRESSION OF FIVE THOUSAND.

No. 1.] LONDON, DECEMBER 31, 1842. PRICE. {Unstamped, 1½ d.

{Stamped, 2½ d.
 ADDRESS.
Upon the occasion of addressing, for the first time, a particular
class, and that too through the medium of a decidedly class-paper, it
seems to us that the views and intentions of its conductor should be
unreservedly stated. We commence, then, in the spirit that will
characterize our future advocacy of the varied interests enumerated
in another page. It is avowed that we enter upon this portion of the
wide field of literature and science as our legitimate province,
inasmuch as we were brought up, educated, and have long wrought
in it; mere qualification for any undertaking is, however, but one
amongst the elements of success, and unless combined with well-
timed efforts, frequently disappoints the possessor:—we invite the
reader to judge of the timeliness of our own by the following incident,
the explanations it gives rise to, and of the result in the publication
before him.
Conversing a few months since with a leading bookseller and
publisher in this metropolis, we had occasion to remark upon the
costly, not to say exorbitant, price of Architectural books; this fact
was not disputed, and the cause at once ascribed to the smallness
of the number of readers, which made it impossible it should be
otherwise. We almost held up our hands in astonishment, as we
repeated his words “smallness of the number of readers!” Call you
five hundred thousand a small number? Can a class of half a million
male adults, whom we may emphatically term all readers, and
members of reading families; a class of half a million of the pick of
British Artisans; a class of the highest intelligence, and (measured by
their wages and numbers) highest in wealth: can we talk of the
smallness of the number of readers, and assume to know any thing
of this large and influential body? It was in this strain that we
interrogated our friend the bookseller; it was a burst of somewhat
indignant feeling, for we had long thought on the subject, and felt
convinced that the fault lay, not with the reader, but rather with the
writer and publisher. We have since put the case in a familiar way to
other parties, as we will now proceed to do to our readers.
Suppose the Grocers, whose business it is to supply the
commodities of their shops in a way suited to the daily wants of
customers, were to act upon the principle of refusing to parcel out
their tea and sugar, or to dispose of it in less quantities than a chest
of the former, or a hundred weight of the latter; or, bringing the
parallel nearer, suppose the Bakers, in dispensing the “staff of life,”
were to set themselves above the standard of purveying the
quartern, and half-quartern loaf; or again, that the Butcher should
sell his meat in nothing less than the carcase; or that these
tradesmen were to study only the palate and appetite of dainty and
refined stomachs; what, let us ask, would be the condition of men of
moderate means, and homely requirements? Why, just that which in
regard to the food of the mind is the condition of the Working Builder.
There are in England, Scotland, and Wales, one hundred and
twenty thousand Carpenters, of full age, and we may assume for
Ireland (the compiled accounts not assisting us here) thirty thousand
more, making a total of one hundred and fifty thousand, exclusive of
apprentices, in this trade alone, who, in common with the other co-
operating Building Artificers, require to read and study (and in some
instances to abstruseness) on all subjects connected with their craft.
For these hundreds of thousands there has hitherto been no retailing
of proper food for the mind; no books at moderate prices, and in
suitable parcels; and if we except the issue in parts and numbers of
works such as those of Mr. Peter Nicholson, the large sale of which
confirms the truth of our convictions, nothing in the shape of a trade
instructor, or magazine, adapted to their several pursuits has yet
been offered to this immense body. The “Architectural Magazine,” by
Mr. London, indeed, did wonders in its way; and other journals which
have followed in its track are, no doubt, well adapted to the particular
departments whose cause they espouse, and promote;[1] but what is
there, we ask again, for the work-shop, and for the fire-side circle of
the Building Artisan?
Examine our Prospectus, and contemplate the numbers forming
an array of what we have advisedly termed “the pick of British
Artisans.” Be it remembered, however, that we do not use these
words in an invidious sense, or in disparagement of other bodies of
the industrious citizens of the empire; but, considering the standard
of perfection, in body and mind, required for the proper practising of
the Building Arts, and considering also the healthful nature of their
occupations, it will not be deemed arrogant in us to speak thus of the
class to which we have the honour to belong; in addition, we have
the influence which numbers, intelligence, and wealth, if united, must
ever secure to us. With all these advantages present to literary eyes
and ears, in an age of professed catering, printing, and publishing, is
it not one of the greatest marvels—a huge paradox—that there is no
such thing as a Builder’s Newspaper and Magazine?
We have just said Newspaper and Magazine, for it has occurred to
us (rather happily, we opine and trust), to combine them; that is to
say, the particular features which distinguish either. We would relieve
the Working Builder from a double charge for matter less available to
him in practice, as well as from the still greater evil, in many
instances, of a dry magazine at home, and a well moistened
newspaper at a public-house. We have an eye to the superior
household and domestic economy which prevails, and which we
would have still more constant in the Builder’s Circle. We would give
him a book on his trade, worth preserving, and a newspaper for the
reading of his wife and family, as well as for himself; and, finally, we
would make the weekly pence set apart from his earnings, for the
gratification of a common feeling of curiosity, not begrudged by the
partner of his cares on the one hand, or to be regretted by the most
thrifty economist on the other, since, even the news will be the
vehicle of trade knowledge, and consequently of the means of trade,
with its advantages and profits.
In designating our paper, we use the word “Builder” in its most
extended sense—instancing a house, or other edifice, we regard it
from the procurement and preparation of the materials, to the fixing
upon its site, and to its full completion for the residence, use, and
enjoyment of man, and which includes the making of the design or
plan, “breaking” ground, as it is termed; the erection, or building up;
decorating, fitting, and furnishing; the supply of water and drainage;
and even the laying out of the garden, pleasure grounds, and park.
This is the whole art of building, or, in other words, of providing and
perfecting human habitations. To all, therefore, who are engaged in
the Art so defined, we address ourselves without distinction, and
without preference; the interests of all will, to the best of our power,
be consulted, promoted, and advocated.
It now becomes us to say a few words as to how far this step (that
is, the issuing of the “Precursor Number”) is to be considered on
our part as an experiment; for, without being clear and explicit, we
should, in case of failure, or rather abandonment, of our enterprise
(for failure there can be none, where provision is made against that
result), incur the blame of not having given our friends, the Building
Classes, a clear view of the part which we humbly conceive it is their
duty and interest to take in the business.
The “Precursor” is a trial number; and we make the avowal plainly
and distinctly. Our part of the affair is to make every effort to supply
what we consider a useful and most desirable public object. The part
of the building fraternity, to whom it is particularly addressed, and the
part of those who regard as a duty all the exertions they are making
in the cause of public education; and also of those who pursue the
arts out of a pure love and liking, is to support our humble efforts if
they deem them worthy of appreciation. The less the sacrifice called
for on either side the better. Let the covenants between us be of an
equitable nature, and as we start upon the principle of
discountenancing, as far as practicable, all lottery and riskful
speculation (of which we will say more presently), so in the basis of
this compact with our friends and readers, we would remove all
unnecessary hazard, or complexion of adventure. We give our best
exertion in what appears to us a work of common good; if our friends
think well and approvingly of these exertions, and that work, let them
contribute their part, were it alone for economy and fairness sake.
We do not rely upon the leviathan power of capital for our success;
but we purpose building it up by an honest and diligent pursuit of the
objects defined, aided by a fair share of judgment, and other
necessary qualifications; and we anticipate it in the cheerful and
generous response of our countrymen: and this Precursor Number,
as its name implies, has its office in searching out the way, and
exploring the track which its successor “The Builder” is designed to
follow. If the Precursor finds a ready passport, and a significant
welcome, of which we have no doubt, it will be promptly followed by
that of which it will have been the harbinger.
We invite, therefore, an active dispersion of the Precursor
amongst our friends; but, above all, we respectfully invite
communications from the many distinguished patrons and favourers
of works of this class. We invite also the Architect, Engineer,
Landscape Gardener, Master Builder, Manufacturers in ornamental
processes, and proprietors generally, Clerks of Works, Foremen, and
Workmen, to avail themselves of the ready means of the penny-
postage, to aid us by their supporting voices, and by any
suggestions they can commit to paper. A Supplement will be issued
with a subsequent impression of the Precursor (without increase of
price), and in that Supplement our correspondence, and additional
advertisements will appear; we, therefore, scarcely need say that the
more promptly our friends reply to the invitation the better.
It now remains for us to say something of the peculiar character
proposed to be given to the “Builder.” The Prospectus, which serves
as the basis of this exposition, sets forth that the trade essays and
descriptions will be accompanied by illustrations and diagrams: that
is, we shall supply drawings, to render clearer the accounts we may
give of mechanical inventions and processes; drawings of ornament,
or enrichment in Plasterwork, Painting, Sculpture, Carving, Iron, and
other metals; drawings of Mouldings, and Moulded work, for the
Carpenter, Mason, and Bricklayer; drawings of construction, in roofs,
floors, trusses, and framing, hand-railing, &c., centering of arches
and groining; drawings of Buildings, both ancient and modern; plans,
elevations, sections, and details: drawings of Architectural orders
and styles; drawings for instruction in perspective, geometry, and the
like; and, occasionally, coloured printing, in such matters as pertain
to painting and staining.
We shall also give patterns for the paperhanger and upholsterer,
and designs for furniture; and a comprehensive range of constructive
and ornamental design suited to that immense territory of British pre-
eminence, the Iron-foundry and its workshops: as connected with
these, we come to that creative and directing science, Civil
Engineering, and here drawings of constructed works, of Engines
and Machinery, will have a prominent place, accompanying the
descriptive treatises and essays.
From this enumeration it must be evident that a large space will be
devoted to the sciences in the nature of connected and consecutive
essays; another part to the record of progress in the Building Art;
and a third to news relating to Building and Builders.
Reviews and notices of publications intended for or likely to be
useful to Builders, will also be given, and biographical sketches of
eminent men connected with science and the arts. These separate
heads, together with correspondence and inquiries, will constitute
the peculiarities of our Journal, and the remaining space will assume
the aspect of the general weekly press—home and foreign news;
digest of Parliamentary reports; political opinions of the leading
Journals; dramatic notices; general literary reviews; police and law
reports; markets, and advertisements.
So ample is the field before us, that there can be no lack of matter
or subjects; our business will be to cull the choicest for the literary
banquet of our friends. Much that is valuable we hope and look for in
the shape of correspondence; one of the chief merits of “The
Builder” being, that it is a direct and fitting medium for conveying
instruction from the liberal and enlightened of every department—a
free exchange of knowledge—which we anticipate may result in
mutual good service to all.

[1] We would instance the Civil Engineer and Architect.

 WILLIAM OF WYKEHAM.
We have selected the portraiture of this illustrious man, whose
fame lives in national works, as the first wherewith to embellish our
Gallery of Architects—a man who was eminent, not only as an
architect, but as a liberal patron of the arts—not only as a builder of
colleges, but as a munificent donor to the cause of education, and
whose institutions still flourish among the proudest in the land. “Many
there are,” says Bishop Lowth, in his Life of Wykeham, “who have
felt the influence of his liberality, or who are actually partakers of his
bounty.”
It is rarely that instances approaching in interest to that of our
subject present themselves; of successful talent we have many, but
they are limited to its mere exercise for ordinary reward; others,
where ambition and ostentation, as in the case of Wolsey, stimulated
to a patronage of great works, while in that of Wykeham we have a
memorable example of true nobility of mind, soaring from humble
origin to the most elevated stations in church and state, and fulfilling
its duties by an active exercise of all the kindred virtues.
William of Wykeham was born at the village of that name in
Hampshire, in the year 1324, of reputable but poor parents, whose
deficiency of means to afford him education was supplied by the
generous intervention of Nicholas Uvedale, lord of the manor of
Wykeham, and constable of Winchester Castle, then one of the great
offices of the kingdom. After going through the course of study
afforded by the school at Winchester, we find him officiating as
secretary to Uvedale, and subsequently executing commissions of
trust as attorney for Edyngdon, Bishop of Winchester, his immediate
predecessor in that see, in whose service he appears at that time to
have been engaged.
The piety, diligence, and early acquirements of Wykeham had
recommended him to the notice of many patrons, both lay and
ecclesiastical, and paved the way for his introduction to that of the
reigning monarch, Edward III., and of his son, the renowned Black
Prince; he had already entered the subordinate ranks of the clergy,
and the fitness of his choice was confirmed in after times by the
dignities he attained to; that elevation was, however, preceded by
the execution of works which have stamped his fame as an
Architect.
It is natural that we should ask, how was this talent in architecture
acquired? We find no account of the preparation or training, beyond
that of the general knowledge he had gained at the school of
Winchester, aided by the intuitive genius and taste proper to
comprehensive intellectual powers. No record exists of his having
studied at either of the universities, and if it had been so, the regard
and confidence of the King must be attributed to acquirements very
superior to those at that time current at Oxford or Cambridge, where
theological controversy was the leading and absorbing theme. We
are told, indeed, that Wykeham had studied “arithmetic,
mathematics, divinity, and, above all, the canon and civil law;” and
we see no reason to the contrary. The school of Winchester, a city
then second to none in the kingdom in splendour and opulence,
would scarcely be deficient of teachers in these courses of study; in
the mode, and according to the then understanding of their relative
uses and value.
It is, upon the whole, probable that Wykeham gave the first proofs
of skill as an Architect in the extension and reparation of Winchester
Castle, during his employment by Nicholas Uvedale. That it was a
fortress of considerable extent and consequence, history abundantly
proves; and it continued so down to the period of the civil strife
between the adherents of Charles I. and the Parliamentary armies;
but whatever may have been the extent or description of building
previously executed by him, it led to his appointment, by patent,
dated May 10th, 1356, of Clerk of all the King’s works in the manors
of Henley and Yesthampstead; and by a second patent, under date
30th October of the same year, he was made Surveyor of all the
King’s works at the Castle and Park of Windsor; and subsequently of
all the royal castles south of Trent.
 In these capacities he was furnished with extensive powers; such
as directing the issue of the King’s writ to the sheriffs of counties,
requiring them to impress workmen, who were compelled to labour
at fixed wages; to purvey and apply all material fitted for building; to
hold courts for pleas of trespass and misdemeanours; and to inquire
of the King’s liberties and rights within his demesne lands. The
prelude to the erection of Windsor Castle was the assembling of 360
impressed workmen, by forties, from nine adjoining counties, in
addition to those voluntarily engaged; the original Norman building
was levelled, and on its site, under the eye of a warlike monarch who
delighted in embattled towers and gorgeous halls fitted for the
display of chivalric institutions, was reared this far-famed fortress
and palace of our kings.
Windsor Castle occupied from ten to twelve years of continued
labour, and comprised the King’s palace; the great hall of St.
George; buildings for various purposes, on the east and south sides
of the upper ward; the keep, or tower; the chapel of St. George; the
residences of the custos and canons, in the lower ward, with the
whole circumference of the walls, towers, and gates. Many parts of
the original building remain, but the lapse of nearly five hundred
years, frequent repairs, the enlargements and alterations required to
meet the conveniences or tastes of successive kings, most of whom
have expended immense sums in real or fancied improvements,
have, in a great degree, obliterated a plan and style which was, in
Castellated Architecture, the perfection of the fourteenth century.
His second work was the Castle of Queenborough, in the Isle of
Sheppy, which, from the lowness of the site, and nature of the
foundations, required unusual skill in the Architect. It was
commenced in 1361, and completed in about six years, when the
King, holding his court there, made the town a free borough, naming
it Queenborough, in honour of his Queen Philippa. Of this structure
no part remains; but its position and extent are ascertained by the
moat which surrounded it. There can be no doubt this was one of the
principal castles of the kingdom, designed both as a means of
defence against invasion, and as a point for the assembling of fleets
and armies for offensive purposes. We are told of this building, that it
was “large, strong, and magnificent;” a fitting residence for royalty,
and one of the strongholds of the realm; and its importance may be
estimated by the rank of its constables, who were, in the reign of
Edward III., John of Gaunt, Duke of Lancaster; Richard II., Robert de
Vere, Earl of Oxford; Henry IV., John Cornwall, Baron Fanhope;
Henry VII., Humphry Stafford, Duke of Buckingham; Edward IV.,
George, Duke of Clarence, &c. The last repairs were done in the
reign of Henry VIII., 1536.
Pending these works, Wykeham grew into high favour with his
royal master, and church preferment was heaped upon him with a
lavish hand; he filled also in succession the offices of Secretary of
State, Keeper of the Privy Seal, and Chancellor of England; and
upon the death of Edyngdon, Bishop of Winchester, in 1366, he
succeeded to that see, one of the richest and most influential in the
kingdom. With his career as a prelate or a statesman, we can have
little to do in this sketch, but we may be permitted to notice that it
was replete with great and disinterested actions. Prosperity so
brilliant had, however, its hour of adversity, but which only served to
place in bolder relief the virtues of the Christian and the dignity of the
man. In the dotage of Edward III., charges of malversation, in the
execution of his high offices, were preferred against the Bishop of
Winchester, at the instigation of John of Gaunt, Duke of Lancaster,
who had always manifested an irreconcilable jealousy of his
influence with the king. This proceeding was followed by an arbitrary
sequestration of the temporalities of the bishop, and he retired to the
monastery of Merton, and subsequently to the Abbey of Waverly,
near Farnham, amid the universal regrets of the nation. The
aspersion of a character so singularly exempt from the besetting sin
of avarice, and its twin vices, peculation and sensualism, could not,
however, be long sustained; and at the end of seven months he was
happily restored to the means of carrying forward magnificent
designs for the benefit of posterity.
From this period Wykeham seems, as much as possible, to have
relieved himself from the burthen of secular affairs, although we find
him again Chancellor in the unsettled reign of Richard II., but which
office he took the earliest occasion to resign. Long and faithful
services to the state had entitled him to repose; but there was no
cessation in the activity of a mind fraught with benevolent purposes.
Possessed of great wealth, he seems to have considered himself but
as a steward intrusted with a useful application of it, and he devised,
with as much judgment as human foresight is permitted to exercise,
the establishments we are now to mention.
With the year 1373 began the formation of a school at Oxford, that
of Winchester having much earlier been taken under his especial
care; at each, masters were provided, and scholars, to the number of
seventy, lodged and boarded at his sole charge. These were,
however, but preliminary steps to the great and original plans
contemplated, namely, the founding of colleges at Oxford and
Winchester, with buildings, masters, and suitable appointments, and
a perpetual maintenance for two hundred scholars, who, while
receiving the advantage of liberal support, were trained from
elementary learning through the whole circle of the sciences. So
costly was this undertaking, that no individual, with a single
exception, has had the means or generosity to emulate the example.
This occurred in the person of King Henry VI., whose colleges at
Eton and Cambridge were founded upon principles scarcely varying
from these models.
Wykeham was now fifty-five years old, and, in realizing his plans,
found full scope for the display of matured genius. Neither the cares
of state which he had encountered, nor the personal ease which so
frequently inclines even great minds to passive inaction, could
obliterate his predilections for architecture. Under this master of his
art were perfected improvements in Gothic style which have
procured for examples of this period the distinction of the pure or
decorated English. These consist in increased boldness, highly
wrought and varied sculpture, and enriched vaultings, with exterior
ornaments of statuary, niched or canopied, upon the western or
great entrance fronts of ecclesiastical buildings. With the taste to
dictate and the wealth to execute such magnificent designs, he
entered upon his tasks, and, in 1379, personally laid the first stone of
the college familiarly termed New College, Oxford, but by himself
“Sainte Marie College of Winchestre in Oxenford,” which was
completed and its establishment inducted with much ceremony in
1386.
We may here be permitted to observe, that with every disposition
to dwell upon the details and beauties of this and his succeeding
works, want of space compels us, for the moment, to relinquish an
intention to do so; but, as subjects of national interest, we shall recur
to them, aided by illustrations calculated to render many peculiarities
of this style available in modern practice.
But to resume our brief notices. Scarcely a year elapsed before
the second, or St. Mary’s College, at Winchester, was in progress,
and in six years fitted for the reception of its professors and students.
In extent and style this edifice bears the strong impress of its
founder, whose memory lives freshly in the veneration of his
children, for such we may term those who are here nurtured and
taught, and from amongst whom have stood forth many worthies of
the church, and others of the highest attainments in science.
The next, and last, work of this eminent and excellent prelate, the
construction of the western front, and the nave and aisles of his
cathedral at Winchester, was commenced in 1394, and the 70th of
his age; and in this instance the unimpaired vigour of his
conceptions, and the extreme liberality with which he appropriated
his resources, are equally subjects for lasting admiration. It was built
by Walklyn, the first Norman bishop after the conquest; and in its
governing features, extent and massiveness, is in the style so called.
We have before mentioned the western front as the work of
Wykeham, which, though mutilated by barbarian fanaticism, retains
much of its splendour, and is a marked example of his manner.
Entering by this door-way, we are at once upon the scene of his
mightiest achievement;—the eye becomes fixed for a moment by the
gorgeous colouring of the eastern window, then wanders upwards
amidst the infinite tracery and adornment of the vault, and, having
scanned the vastness of the pile, seeks repose in a more leisure
examination of the isolated, but not less beautiful, objects of
sculpture below.
 Apart from associations and impressions induced by the aspect of
Gothic temples upon the great scale, we here find the elements of
solidity, propriety, and uniformity carefully preserved, and the
enrichments distributed with a masterly hand; the groining of the roof
springs from single shafts rising from octangular bases; the capitals
are highly embellished with busts and foliage, and the frieze charged
with bold and finely-sculptured bosses; in fact, we have here before
us an era in the Gothic style, and a perfect adaptation of its
capabilities, carried out with all the originality that distinguished the
genius of the architect.
The various writers who have treated on the antiquities of
Winchester agree that the effect produced by the columnar vista of
the nave, in combination with the group of chantries and screens, is
not surpassed by any spot in England, or in Europe. In minute
Gothic, or shrine-work, it is also unrivalled. The tomb of Wykeham,
executed, according to the practice of the middle ages, under his
own direction, is the purest of all authorities in this style: it is placed
within the mortuary chapel, or chantry, occupying the fifth arch from
the west end, and is rich in canopies and tabernacle work; the latter
originally contained statues of saints, particularly that of the Virgin,
which stood against the same pillar, when in his youth he had
worshipped here; but these have long since been destroyed, and the
tomb despoiled also of the enchased escutcheons which adorned it.
The marble figure represents the prelate as possessing full features,
and a placid, benign, and intelligent countenance; it is clothed in full
episcopal costume, the head resting upon a pillow supported by
angels, and at the feet are three figures of one of the religious
orders, in the attitude of prayer.
The life so usefully spent closed in the year 1404, leaving more
durable and splendid memorials than it has been the lot of any other
individual to rear. Having, for nearly half a century, held the highest
stations, and possessed almost unbounded influence, we find it to
have been exerted in a spirit far in advance of his times; and
personal aggrandizement grew upon him as a consequence of
undeviating integrity and universal benevolence; these great and
marked qualities were evinced in pure and unabated loyalty to his
prince, courtesies and services to his equals of the church and the
nobles of the land; and, above all, in the kindness, forbearance, and
mercy which he caused to be exercised towards the people of a yet
unenlightened age.
William of Wykeham expired at his manor house, or palace, of
Waltham, Hants, A.D. 1404, in the eightieth year of his age, and his
remains rest under the tomb we have described. His life affords,
perhaps, the most brilliant example on record of the combined power
of industry and genius; the industry to acquire knowledge, and the
genius to apply it in advance of preceding theories. His earliest
employments seem to have been merely such as a tolerably well-
educated man of the fourteenth century would find little difficulty in
obtaining. Architecture was his diverging point from the monotony of
ordinary life towards the greatness he achieved, his first essays
appearing to have resulted from opportunities which casually fell in
his way, but embraced with an alacrity inspired by self-confidence.
Having once engaged in it, his fondness for the science knew no
abatement, for however lofty his position in the state, or onerous his
duties as a churchman, he found leisure to cultivate it; and having
engrafted new and more impressive features upon the style he
delighted in, may be said to have died in the exercise of this
profession, just before the completion of his cathedral at Winchester.
So exalted were the stations and so extensive the influence he
possessed, that the spirit of benevolence by which he was actuated
had full scope for exertion. While serving his prince with unswerving
loyalty, he found means to protect the people from oppression and
exactions, and by numerous courtesies and services to the nobility,
won them to a milder exercise of their territorial privileges; while in
the relations of private intercourse, we are told that he was “the
kindest and most generous of patrons, and the most constant and
affectionate friend, rarely changing his officers or domestics, none
leaving, or being deserted by him, and all receiving in their turn
testimonies of his favour.”
By his hand the revenues of the church were disbursed in her
service and to her honour, and, to use the words of Lowth, the whole
period from the meridian of life to the end of his days was employed
“in one continued series of generous actions and great designs, for
the good of his friends, of the poor, and of his country.”