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TESTIMONY OF DR. CHAUNCEY STARR, DEAN OF ENGINEERING,

UNIVERSITY OF CALIFORNIA AT LOS ANGELES, CALIF. Dr. STARR. Thank you, Senator Harris.

I will complete my own introduction by telling you that prior to January 1 of this year, I was vice president of North American Aviation and president of its atomic international division.

For the past 25 years, I have been intimately involved in the development of our national atomic energy program, as a physicist, engineer, and manager. I have served in various advisory capacities to Government agencies, to the Joint Committee on Atomic Energy, and as a member of the Scientific Advisory Board of the Air Force. It is with this background that I address myself to the questions raised by your committee concerning the field of biomedical development. My comments represent only my personal views, not those of any organization with which I am connected.

ENGINEERING-MEDICINE

Biomedical research covers a wide spectrum of activities extending from the pure science of the living cell to the clinical care and treatment of patients. In my present position as dean of engineering I have had occasion to study the opportunities for constructive cooperation at UCLA between our engineering department and our medical school. Therefore, I will particularly comment on that portion of biomedical development which pertains to the use of engineering and applied science in medical research and medical practice. For convenience, I will call this area of overlapping skills, engineering-medicine.

Although the techniques of the applied sciences and engineering have always played a role in the practice of medicine, the potential contribution of technology to the medical field has increased enormously during this past generation. As a result of the intensive national investment since World War II in research and development in all areas, there is now available a wide variety of new, sophisticated scientific instruments for research and diagnostic purposes, new synthetic materials, new control mechanisms for adjusting complex systems, new data processing systems for handling and analyzing large amounts of information, and new engineering machines for the treatment of patients. The catalog of such available developments is very large, and I am sure this committee has heard numerous examples in

In parallel with this development of our technological resources, there has been an increased national interest in achieving the maximum improvement in the health of the public. Providing the best medical care to 200 million people now and in the future will require the most efficient and imaginative use of all our technical resources.

the past.

MEDICAL PROBLEM AREAS In viewing the problems of medicine which might be assisted by the techniques of engineering, I have had the benefit of consultation with highly competent university physicians and medical researchers at UCLA. They have identified many medical problem areas which could receive major benefits from the participation of skilled develop

ment engineers and applied scientists. The following are some examples of such typical problem areas. This list is not intended to be complete or to indicate relative importance. 1. Measuring and diagnostic instruments

Both in the areas of research and clinical practice, the ability to measure a wide variety of biological and physiological characteristics is now and will always be a most important field. Medical research is always limited by the capabilities of available instruments. New instruments customarily stimulate new techniques and expand research significantly. 2. Emergency life support

It is essential that during patient examination, surgery and treatment, emergency equipment be available to support the damaged mechanism of the body so as to buy time for the curative process. Life support requires a system of engineering devices such as the familiar heart and lung machines, high-pressure oxygen chambers, electrocardiograph (EKG) and electroencephalograph (EEG) and other as yet undeveloped devices. During life support, diagnositic equipment should perform the role of monitoring the patient and provide an early warning of abnormal conditions. 3. Protective environment

Many patients are infection risks as a result of their illness or as a result of a medically induced decrease in the normal resistance to disease; as for example in the radiation treatment associated with transplant surgery. Under such conditions, the normal exposure of an individual to a hospital atmosphere is sufficient to provide serious risk of infection. The provision of a low-cost, individual antiseptic environment for such patients could be a major contribution to their eventual recovery. 4. Surgical supportive techniques

During complex surgery, the multiplicity of physical conditions and medical operations which must be controlled and performed successfully are often of a character which might be undertaken most reliably by mechanical systems. Such systems would include highly reliable monitoring instruments, automated control of anesthesia, artificial heart and lung mechanisms, surgical tools such as the cryogenic knife, and many others not as yet developed but technically feasible. 5. Biomechanics

This topic includes all medical problems involving the mechanical forces of nature. For example, accidental injuries and their treatment, as in automobile collisions, are of major importance to the public. In the attempt to specify for automobile design engineers the maximum permissible forces which the human body can accept without significant injury, it has become apparent that there is not enough information on the relationship between injury and the forces involved. As another example, there is at present insufficient knowledge on the properties of human bone with respect to external forces. In chest injuries, the effect of such injuries on the cardiovascular system is not well understood. All these fields require engineering study.

6. Prosthetics

A further area of biomechanics is the field of prosthetics—the use of artificial organs to replace damaged parts of the body. The replacement of body parts by artificial organs is a rapidly expanding area of medical research and is beginning to play an enlarged role in clinical medicine. The use of artificial limbs and orthopedic reconstructions has a long and continuing history. The development of successful lifeprocess artificial organs is quite recent, and is principally due to the availability of new materials, measuring devices, solid-state electronics, and control equipment.

Typical examples are the battery-operated pacemaker, the heart valve, and the artificial kidney. The pacemaker utilizes a miniature battery and solid-state electronic circuiiry, both initially developed for other purposes requiring compactness and reliability. The heart valve represents a use of new synthetic materials. The artificial kidney involves an external hydraulic filtering system of some sophistication.

The artificial kidney is now a costly device which could benefit from concentrated engineering and medical development. Because of the capital and operating costs of present equipment, its use is now restricted to a small fraction of the patients that need such care. The fundamental engineering process involved in the operation of an artificial kidney is simple enough to permit the eventual development of a much less expensive and less bulky device. This is an obvious application for engineering medicine as an interdisciplinary effort.

Heart-assist devices are another exciting area of engineering medicine. Their development is in its initial stages and depends upon continued development of materials, and the engineering of control and pumping systems. So much has been said about this work, that it needs only this brief mention here. 7. Cardiovascular fluid mechanics

The relationship between the bloodflow pattern in different parts of the body with the changes in other body characteristics is an extremely complex problem in the treatment of cardiovascular diseases. An understanding of these relationships can be obtained through the use of engineering techniques which have been developed for the study of the mechanics of fluids.

For example, a laboratory duplicate of the blood circulatory and pumping system in man would permit a study of the fluid mechanics of the cardiovascular system to a degree not otherwise possible. This is clearly an opportunity for engineering medicine. 8. Mass medical screening

This problem area arises from our national goal to make good medicine available to all of our people. Because of the numbers involved, the task of routinely examining our population for early recognition of disease can only be handled by an engineering approach to the automation of diagnostic examinations. With the associated development of high-speed data recording and retrieval, and automatic determination of abnormalities, our screening problem may become tractable. The development of such an information processing system is an engineering specialty.

In addition to such volume screening procedures, there must be a parallel data system for the storing of medical records so that any indi

vidual's medical history in which an abnormality is suspected could be made available quickly. 9. Mass medical treatment

The problem associated with providing high-quality medical treatment to a large section of our public will require the efficient utilization of our medical specialists. An essential element of this requirement will be a national communication network involving the rapid transmission of diagnostic data, including the transmission of X-ray film information.

ENGINEERING TOOLS

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The above listing represents some of the visible problem areas which require an engineering participation in medicine. The typical tools available to the engineer for such cooperation are illustrated by the following general techniques.

1. Instrumentation. Thanks to solid-state electronic circuitry, very complex measurement devices can now be obtained at reasonable cost and in convenient packages. The instrumentation recently devised for the manned space program illustrates that with sufficient incentive the most complex measuring systems can be made compact and reliable.

The proliferation of electronic equipment has also made it possible to apply the most complex and historically laborious scientific analytical methods in a semi-routine and rapid manner. Thus, diagnostic and research investigations which might be undertaken only rarely in the past, are now becoming more and more an integral part of modern medicine. This, in turn, has increased the need for further simplification and improvement in analytical instrumentation.

2. Analog biological systems.-Duplication in the laboratory of portions of living biological systems is an important method for investigating the relationships among the various parameters of such systems. In those laboratory systems, which are an analog or “mockup” of living systems, experiments can be conducted which would not be possible otherwise.

As another example, if one could properly duplicate the complex body chemistry in the laboratory, it would be possible to study the effects of chemical imbalance or the effects of drugs. Such research on living individuals is extremely difficult and complex.

3. Data analysis.—The pending availability of massive national computer networks now makes possible detailed analysis of medical information collected from all sources. Besides providing current public health information, such a national network can help speed up medical diagnosis and medical decisionmaking. The design and development of such information systems is a professional engineering field.

A future application of national data analysis of importance is the continuous assessment of pharmaceuticals. Data processing systems are ideal for collecting and analyzing information on efficacy, sideeffects, and unusual relationships to individual characteristics. Small statistical trends which may be easily hidden in large masses of information, can be easily and quickly revealed by a good data processing system.

A particularly interesting possibility for data analysis is the use of radiology to determine abnormalities on a mass scale. At the pres

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ent time, X-ray films are stored locally and are retrieved as required through the usual file cabinet process. Even for the limited clientele of a modern hospital, the handling of radiological diagnostic data has become a heavy burden. We need a conversion of the file information to a data memory bank in such manner as to reduce storage volume and permit rapid retrieval. If, in addition, the data processing equipment could be devised to automatically screen the information for abnormalities, the process could conserve the medical specialists' time for those patients who would require treatment. As a specific example of such a need, if the female population of this country is to be completely and regularly surveyed for the prevention of breast and cervical cancer, the diagnostic and information handling tasks would be overwhelming with our present techniques.

4. Control systems. The adjustment of the patient's medical environment on a continuous basis, in response to measurements being made on the patient's condition, is a typical control problem. This is a field of engineering with much promise for medicine.

Automating the operating room is feasible now. The anesthesiologist must continuously observe a variety of patient conditions and control the anesthetic accordingly. This is an appropriate task for an automatic control system. Although a specialist would be needed to set the initial conditions appropriate for the patient, the moment-tomoment regulation and quick emergency warning and corrective adjustment would be the functions of the control system.

5. Medical systems engineering.-In considering the total problem of patient care, the professional techniques of systems engineering are highly applicable. In fact, the increasing load upon our nation's hospitals will make such techniques mandatory. In the long term, the most effective way to reduce the cost of patient care, raise its quality, and handle increased numbers, is to increase the use of reliable equipment in a logically planned system to replace human services.

It is feasible to consider highly automated hospitals, with a limited number of doctors, nurses, and skilled technicians handling a large patient load. The hospitals must be designed initially with this systems requirement in mind. Continuous clinical monitoring of patients in intensive care units has already been performed on an experimental basis. In this way, a central recording station can observe the medical state of a large number of patients. Such a system can give early warning indications before an obvious crisis develops, and thus permit rapid preventive treatment.

I have tried to indicate some of the potential value in encouraging a joint approach by engineering and medicine to our health problems. Such joint efforts have been undertaken in the past for many specific tasks with varying degrees of success.

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IMPLEMENTATION PROBLEMS

There are certain obstacles inherent in any attempt to have two such diverse disciplines working as a team. First, is the hurdle of communication. The language, terminology, and concepts of engineering and medicine are quite different. As in any relationship involving aliens, the communication hurdle poses a situation of noncomprehension and nonconfidence.

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