Methods of Information in Medicine

@ F. K. Schattauer Verlagsgesellschaft mbH (1993)

K.-R Kaltenborn, O. Rienhoff Review Paper

Institute for Medical Informatics.
University of Marburg, Marburg,
Germany
Virtual Reality in Medicine
Abstract: Virtual reality (VR), as part of computer science, allows
computer-based models of the real world to be generated, and provides
humans with a means to inieract with these models through new human-
computer interfaces and, thus, to nearly realistically experience these
models. This contribution explores the technical requirements for VR,
describes technological advances and deficits, and analyzes the
framework for future technological research and development. Although
some non-medical applications are discussed, this contribution focuses
primarily on medical applications of VR and outlines future prospects of
medical VR applications. Finally, possible hazards arising from the use of
VR are discussed. The authors recommend an interdisciplinary approach
to technology assessment of VR.
Key-Words; Virtual Reality, Human-Computer I nterface, Hu man-Compu-
ter Communication.

1. Introduction 2. History, Terminology, of the real world to be generated and

Virtual reality (VR) has gained
wide attention in popular and scien-
tific conrputing journals, conferences
and, especially, in the mass media
[1-5]. Many contributions suggest that
VR will not only radically change our
awareness and thinking, but also so-
ciety as a whole [4-7]. New computer
applications in the field of medicine
will be made possible through VR and
will, thus, revolutionize medicine.
However. in contrast to the media
propaganda and the far-reaching ex-
pectations of medical applications of
VR, the subject has not gained sig-
nificant attention in scientific medical
literature. In March 1993, only three
minor contributions related to VR in
medicine were listed in the MED-
LINE data base [8-10].
A critical scientific discussion about
VR technology seems essential as it
would not be justified to reject the
development and application of poss-
ibly promising technology for the
benefit of patients. However, it is also
important to avoid unjustified expec-
tations from patients and to guarantee
the responsible use of limited financial
resources.
and Definition
Virtual reality, as part of the field
of computer science, originated in the
mid Sixties. At this time Sutherland,
who is generally regarded as the
founding father of VR, carried out
preliminary VR research and pub-
lished some basic thoughts on the
subject Ul, I2).
Terminology concerning this com-
puter-technology varies: the terms
"virtual reality", "artificial reality" and
"cyberspace" are used in the literature
either as synonyms or with slightly
modified meaningsl [13, 14].
VR can be defined as a system
which allows computer-based models
I The term virtual reality dates back to Lanier
who founded the VR technology firm VPL in
Redwood City, California (USA) [15, 16]. In
the mid Sevcntics Krueger. in conncclion
with the dcvelopment of his vrosoplacE tech-
nology, had already introduced the expres-
sion "artificial reality" [5, 15, 16]. "Cyber-
space" originatcd from Gibson's scicnce fic-
tion novel Neuromanccr and gained furthcr
popularity following the use of the term by
the VR company Autodcsk (CA, USA).
provides humans with a means to
interact with these models through
new human-computer interfaces and,
thus, to nearly realistically experience
these models [1, 13, 16-23]. The con-
cept of VR is charactefized by at-
tributes which produce an experience
for the user of being immersed in the
virtual world. These attributes are:
1. A three-dimensional representation
of the VR model by the computer.
-.Auditive, tactile and haptic infor-
mation can be added to the visual
representation in order to make the
virtual world more realistic. Special
equipment, such as head-mounted
displays, can be used to realize
these demands.
2. Real time interactivity.
3. A human-oriented interface design
which allows natural human com-
munication such as gestures and
language. Rather than the typical
computer-oriented interfaces suchr
as keyboard and mouse, VR tech-
nology offers special human-cen-
tered interfaces, such as data gloves
and vronopr- e,cn [15, 24].
Given these characteristics, VR is
regarded by many authors as the most
advanced computer technology in the

Meth Inform Med 1993: 32: 407-77 407

area of human-computer communica-
tion [1,23-25]. VR is not restricted to
single human-computer communica-
tion, but allows more than one user to
enter the system and, thereby, enables
human-human communication via the
VR system U5,26,211.
This comprehensive definition of
VR, including all of the attributes
listed above. also indicates that the
established radiological methods of
computer tomography (CT) and
magnetic resonance imaging (MRI),
especially with respect to three-dimen-
sional reconstructions, which are often
quoted in context with VR, are only
antecedents to VR, not full VR appli-
cations [6, 15].
In contrast to the technically
oriented definition of VR given
above, there are numerous characteri-
zations and definitions of VR which
describe primarily psychological as-
pects and experiences with VR. Ac-
cording to Heim [28], VR is charac-
terized by the following: "Danger and
caution pervade the real (existential)
world, but virtual reality can offer
total safety, like the law of sanctuary
in religious cultures... The ultimate
VR is a philosophical experience,
probably an experience of the sublime
or awesome." In similar approaches,
especially in the Californian VR
scene, VR is regarded as
"psychedelic" or a "technical" drug of
the Nineties |, 29-321. The lack of
scientific discourse pertaining to VR
in medicine may be attributed to the
wide range of VR definitions which
often create thrilling images of VR.
In this contribution, the technically
oriented definition of VR, outlined
above, will be used including the most
important attributes: "three-dimen-
sional representation", "real time in-
teractivity", and "human communica-
tion mode". Although the develop-
ment of VR is still in its infancy, the
following description of VR applica-
tions will not be limited to only certain
medical fields. However, if applica-
tions are described which include only
parts of VR due to current state of
research and development, this point
will especially be mentioned.
3. VR Equipment:
State of the art, Problems,
and Perspectives
Commercial VR equipment has
been available for nearly three years
[20]. Enrado [33] and Aukstakalnis
and Blatner [1] have given an over-
view of firms supplying VR technical
and software tools. Although VR sys-
tems are still expensive and the high
costs are viewed as a major threat for
the dissemination of VR [5, 7,20,26,
34], Pausch [35] was able to compile a
a survey of reasonably priced VR sys-
tems which offer basic functionalities.
In the following description of
necessary VR systems and single com-
ponents, the classification of Grims-
dale [36] (Table 1) will be used. Thus,
a differentiation is made between:
- Real Environment Sensing,
- Virtual Environment Display, and
- Virtual Environment Control.
3.1 Real Environment Sensing
Real Environment Sensing (RES)
systems are used to provide the VR
system with information pertaining to
the real world, i.e. body gestures and
positions of the user and possibly
speech as well. The objects of the
virtual world are mediated through
information input of the RES [36].
Currently, the most significant RES
input device is the data glove.2 This
Lycra glove is equipped with various
sensors which measure the position
and orientation of the user's hand and
finger movements. Finger movements
are measured through fiber-optic
cables equipped with a light-emitting
diode. The light from the diodes is
received by a photosensor and is then
converted into quantifiable digital
computer signals [1, 5, 15, 23, 26,
37-401.
Head-tracking systems are used to
define the spatial position of the user
and to supply the computer with this
information f23, 36, 41, 421. While
several devices are based on elec-
tromagnetic technology (".g., the
Polhemus system), recent tracking
systems are also based on optical tech-
nology (e.g., the optical 3D tracker)
laz]. The advantages of using optical
tracking include a faster update-rate
with low latency, better accuracy and
bqtter resolution. Furthermore, the
optical tracking system cannot be dis-
torted by electromagnetic fields.

VR Equipment
System
Real Environment Sensing
Virtual Environment Control
Virtual Environment Display
(Table adapted from Grimsdale [36])
application/modality device
body position data glove
body gestures head tracking system Different versions of the data glove are
body movements body suit available at various pricc and quality levels.
language eye tracking For example, in 1990 Carrabine [26] states
speech recognition that the DataGlove was being offercd by
VIDEOPLACE
VPL Research Inc. (Redwood City, CA,
object behavior hardware and software USA) for $ 8,800 in contrast to only $ 80 lbr thc
object dynamics Nintendo computcr game vcrsion Power
object relationships Glove. Other input deviccs include the Dex-
terous Hand Master (DHM) distributcd by
visual perception headmounted display Exos (Lexington, MA, USA), CyberGlove
auditive perception auditory display and Spaceball from Spatial Systems Inc.
tactile perception tactile display (Billerca, MA, USA), Waldo (Character
haptic perception haptic display
Shop, Van Nuys CA) and, finally, the VPL
force perception Data Suit to measurc whole-bodv movements
ll, 5, 23, 26,37. 40).

408
 Speech recognition systems are also
considered to be potential VR input
devices [1, 36, 43]; however, comput-
er-based general speech recognition is
still limited to command-like input
and must, therefore, be regarded as an
option for the future. In addition, eye
tracking systems are also included in
discussions of possible input
systems
lI, 4I, 441. Again, technical problems
have to be solved.
A completely different approach
has been adopted by Krueger [15],
who used video recordings for this
task instead of applying special de-
vices to measure human gestures [37].
These video recordings are analyzed
by the computer and interpreted as
special commands. This method does
not impair the user's freedom of
movement with cumbersome devices.
The system enables, for instance, the
production of computer graphics with-
out keyboard or mouse. Since several
users can be networked, the tasks can
also be performed cooperatively.
3.2 Virtual Environment Display
Virtual Environment Display
(VED) mediates virtual reality
through the use of special devices
which provide the user with visual,
audio, tactile, and haptic information.
The requirements for a visual,
three-dimensional representation of
reality, e.g., a moving scene in the
landscape, are extremely complex and
are characterized by the following
criteria [1]:
- static depth cues (interposition,
shading, brightness, size, linear
perspective, and texture gradient);
- motion depth cues (motion par-
allax);
- physiological depth cues (accom-
modation, convergence) ;
- stereoscopic cues.
In addition, the field of view,
frame-refresh rate and eye tracking
must concur with the physiological
visual laws of humans in order to
create a sense of visual immersion [1].
However, these requirements cannot
be realized by the Virtual Environ-
ment Display alone, but also require
good interactions between Real En-
vironment Sensing, Virtual Environ-
Meth. Inform. Med., Vol. 32. No. 5. 1993
ment Display and Virtual Environ-
ment Control.
Head-mounted displays, one of the
most significant devices of Virtual En-
vironment Display, are used to trans-
fer visual information. A head-
mounted display consists of a display
for each eye with each display offering
a slightly different image
which
creates depth and a stereoscopic view.
A distinction can be made between
"see-through" and "opaque" type dis-
plays. "See-through" head-mounted-
displays are based on CRTs (cathode
ray tubes) while opaque displays are
based on either LCD (liquid crystal
display) or LED (light-emitting-
diodes) technology3.
In general, the resolution of the
currently available displays is not suf-
ficient to create images close to reali-
ty. A combination of laser technology
and holography is viewed as a poten-
tial technology for developing future
displays [41].There are also ap-
proaches used to construct three-di-
mensional representations on a screen
using either holography or LCD with
superimposed cylindrical lens arrays
146-491. With regard to the discussion
of future display-developments, there
are proposals to produce the image
directly onto the retina through laser
beams [13, 41, 50].
The experience of the virtual world
can be constructed even more realisti-
cally if the visual information is sup-
plemented by audio, tactile, and hap-
tic information. At NASA. a 3-D
auditory display has been developed
which enables sounds to be perceived
from different spatial origins. Thus,
the ability to understand each of the
3 Colored LCDs have a resolution of
230
(vertical) x 320 (horizontal) pixel triads [23].
New modcls, which are also more expensivc,
reach a resolution nearly two times higher [1,
23, 36. 431. Reccntly, a monocular head-
mounted display was developcd which prod-
uces the pixels through red LEDs on a black
background with a resolution of 280 (v) x
'720 (h)
[a5]. The CRT displays provide a
significantly bettcr resolution (approximately
1,000 x 1,000 pixels in monochrome mode)
and allow computer-generated images to be
superimposed on the view of the real world
environment. Thus. thc user can pcrccive
both simultaneously [1, 23. 431.
sounds is enhanced even when the
sounds are transmitted simultaneously
151,521. VR devices for audio, tactile,
haptic and thermic perception are
being developed and partly applied
11,23,36, 39, 43, 47, 53-571.
3.3 Virtual Environment Control
The Mrtual Environment Control
(VEC) system can be defined as
mediator between Real Environment
Sensing and Virtual Environment Dis-
play. The VEC system must control
the behavior of the objects existing in
the virtual world on the basis of the
information and drive pulse obtained
from the Real Environment Sensing
and must then display the results in
the Virtual Environment Display [36].
The objects of the virtual world must
behave according to implemented reg-
ulations of the respective model, i. e.,
the objects' behavior is determined
by such regulations (e.g., u door is
moved about a fixed axis; if a blood-
vessel is cut with a scalpel, blood
extravasates).
For all these tasks, the VEC has to
compute a mass of data in a very short
time period. A negative influence on
the experience with VR can be ex-
pected if the VEC is not able to meet
basic laws of human nature. Examples
of this are not only image quality, but
also latency and perceptual delays,
i.e., delays between the input by the
user and responses from the VR sys-
tem. Only delays less than 10 ms are
able to provide humans with the feel-
ing of simultaneousness [58]; how-
ever, the best VR systems currently
available have an overall time delay of
between 60 and 70 ms [58]. Latencies
higher than 300 ms may cause motion
sickness. Even time delays of 120 ms
must be considered inadequate be-
cause the user may overcompensate
for the unusual delay of system
response. Again, this area requires
further improvement [1, 43, 58].
3.4 Prospects for the Development
of VR Tbchnology
From the technical assessment
above, it can be concluded that VR
technology available today does not
409
yet allow experiences close to the real
world [1, 2, 13, 19,23,36,39,41,43,
50, 58-62]. Saffo articulates this point
well in stating that "Mrtual Reality
(VR to enthusiasts) is a confusing
tangle of extravagant goals and inad-
equate technologies aimed at immers-
ing users in vivid computer-generated
information environments" 1621.
However, current developments in the
VR technology sector have shown
steady improvements which are ex-
pected to continue [21]. Considerable
financial investments will therefore be
needed for this.
In the past, large investments have
been made in VR development espe-
cially in the military sector. Due to
political changes in the world and
difficulties of national economies, fu-
ture military development of VR tech-
nology will be more financially re-
stricted [63]. In contrast, the industrial
sector is expected to expand invest-
ments in VR technology [64]. The
entertainment sector is another im-
portant area for VR in that it provides
large investments for VR and com-
puter game tool developments 16, 47,
54, 63, 65, 66]. Compared to these
mass markets (entertainment, indus-
try, military) which have sufficiently
large financial means, the financial
capacity of the market for medical VR
research and development is rather
limited [58].
4. VR in Non-medical Fields
The prospects of the VR approach
are promising enough to attract vari-
ous fields which have either started to
develop or are already using VR tech-
nology. One of the first VR applica-
tions was flight simulation for pilot
training in civil and military aircraft;
similar applications are being de-
veloped for astronautics [4, 14, 16,22,
23, 34, 41, 54, 67-'721. In industry,
potential applications include VR use
for robotics in industrial production or
even telepresence virtuality for robots
in areas which are difficult for humans
to access 123, 68,73-75). Computer-
based visualization and simulation,
which have reached a high standard in
industry and science [76-80], are also
considered promising fields for VR
4t0
[1, 19, 39,78,81]. VR is also being
discussed and developed as a front-
end for multi-media and as an instru-
ment for information transfer [1, 19,
24, 40,78, 82-84]. Thus, VR in com-
bination with visualization and simula-
tion techniques as well as with multi-
media is regarded as a promising
medium for education and training [1,
4, 9, 18, 69, 79, 84-86]. There are also
application areas for VR in fine arts
and music fl, 4, 15,39,87-93].
Financially, the most promising VR
field is the market for computer games
and entertainment [1, 13, 16, 32, 50,
72, 94, 95]. The applications of VR
vary from home computer games to
the supply of video arcades. One of
the first video arcades using VR tech-
nology was opened in Los Angeles
and offers the VR game "Battletech"
which, like many computer games, is a
war game.
In architecture and corresponding
fields of archeology, computer
graphics have developedinto high-
performance instruments used to
automate working drawings and pre-
sent multiple views of a building with-
out much delay [96]. Furthermore,
computer graphics have been used to
reconstruct the architecture of late
Gothic churches based on the original
ground plans [97-99]. According to
the given ground plan, the computer
creates a historical reconstruction of
the church following construction
rules commonly used in the late Goth-
ic period. VR technology, in this re-
spect, can be used to increase the
capacity.of computer graphics and to
allow a realistic perception of build-
ings in the preconstruction phase [56,
64,71,100, 101]. For example, at the
University of North Carolina an
"architectural walk-through" was
created. This model enables the
architect, wearing a head-mounted
display, to view the future building
and to even "walk through" it 137, 43,
102]. In addition, VR models have
been used to meet customers' needs
concerning the interior decoration of
kitchens [1, 50]. Some believe that
these virtual buildings could, in the
future, serve similar purposes to our
current "real" buildings (shopping
malls, information centers, art gal-
leries) [100].
5. VR Application in Medicine
In the following, a description will
be given of VR systems which are
either in the stage of development or
testing and which will likely be used in
the near luture. Discussions concern-
ing possible long-term VR applica-
ttons are not considered in the follow-
ing overview, €.g., VR-controlled sur-
gical miniature robots, advancing the
operation area via blood vessels
[103-105], telepresence surgery [106],
or the direct connection between the
human brain and VR systems [46].
5.1 VR Applications
for Persons with Disabilities
Computer, robot, or microtechnol-
ogy-based assistive devices can be
used to support persons with dis-
abilities. These technical devices can
help patients perform daily routines
and duties which they could not other-
wise perform due to a disability;
robots are also used for training and
educating the disabled, especially chil-
dren [107-117]. However, robotics re-
search and development is far from
providing reasonable rehabilitation
robots for patients with varying ill-
nesses, a fact which hampers its appli-
cation in this area [118-120]. The
most dominant problem with these
applications is the human-robotic in-
terface used to control the robot [108,
ll3, ll7, 121]. VR technologies may
contribute to a solution of this prob-
lern through their specific interface-
design.
The following three VR applica-
tions, under development in 1992 at
the US-company Greenleaf Medical
Systems, serve as examples lII0, 1221.
The "Movement Analysis System"
(MAS) is composed of a data glove
and the respective hardware and soft-
ware. The MAS system collects data
about wrist and hand movements us-
ing a data glove and then conducts
computer-supported movement anal-
yses. The results from these analyses
should improve the assessment of
therapeutic effects and rehabilitation
therapy. In addition, the MAS is con-
sidered as a tool for worksite ergo-
nomics for persons with disabilities
Meth. Inform. Med., Vol.32. No.5, 1993
and for the development of prostheses
[21, 110].
The "Gesture Control System"
aims to support patients limited in
their movement and coordination
abilities. The patient's gestures are
collected through the data glove and
then analyzed by a computer. Using
hand gestures the user activates pre-
programmed instructions which result
in the respective actions, e.9., operat-
ing telephone connections.
The "Glove Tälker", similar to
the above, enables vocally impaired
persons to communicate verbally.
The patient's gestures are collected
through the data glove, interpreted by
the computer and then transmitted to
a voice-synthesis system. For the latter
two applications the computer uses a
filter system in order to eliminate
unintended movements resulting from
the coordination disorder of the pa-
tient.
The sl-,q.nrt (Sign Languagc Recog-
nition) System, a similar project, aims
to identify the Auslan (Australian
Sign Language) gesture language and
to convert it into a suitable format
which can be used by a voice syn-
thesizer [123]. Another device which
aims to support persons with dis-
abilities is "BioMuse", a computer
control system which aims to provide
real time control of computers
through the use of bioelectrical signals
from the eyes, muscles and brain
(EEG). "BioMuse" can be used as an
eye-tracking system, i. e., the user can
direct the cursor on the screen through
eye movements. Together with an in-
telligent word processor, the vocally
and motorially disabled persons could
be offered new forms of communica-
tion. In addition, "BioMuse" could
also be considered as a tool for con-
trolling robots 144, 124]. Finally, VR
applications may even help the blind
through auditive and tactile VR com-
ponents which compensate for the loss
of sight and support spatial and geo-
graphicaf orientation 1125, 126].
The above described VR projects
for persons with disabilities do not aim
to provide a complete VR application,
but aim mainly to provide disabled
persons with a "human-centered inter-
face" for carrying out various tasks
using computers or robotics. From a
Meth. Inform. Med., Vol.32, No.5. 1993
technical point of view, this field of-
fers opportunities for the development
and application of single VR compo-
nents. However, a prerequisite for this
is the willingness of society to provide
financial resources for technological
research and development to support
persons with disabilities [17].
5.2 VR, Surgery and Image
Processing
Surgical procedures are seen as a
further application area of VR. Within
the field of surgery, there are two new
developments in which VR technology
could successfully be applied: the in-
troduction of minimal invasive surgery
(MIS) and the use of image processing
for either the preoperative or intra-
operative phase. This will briefly be
discussed below.
MIS has revolutionized operation
procedures and will be increasingly
applied in various surgical fields [127,
128]. In order to adapt traditional
operation procedures to the methods
of MIS, various problems must be
solved and new capabilities must be
developed. The problem of sight dur-
ing the operation phase is especially
important. The current video systems
used for MIS provide two-dimen-
sional images of three-dimensional
anatomic space, which leads to mal-
functions of hand-eye coordination as
well as difficulties with depth percep-
tion and spatial orientation ll27).
There is no doubt that the develop-
ment of three-dimensional image sys-
tems (stereoscopic or holographic)
would simplify laparoscopic surgery
considerably [127]. Another problem
with MIS is the loss of direct tactile
contact with the anatomical structure.
Major improvements in image pro-
cessing have, however, been made
within the last years to overcome these
problems. Ultrasound provides im-
proved intraoperative orientation and
information about the specific mor-
phology of tissue [127, 729, 130].
Novel developments aim at and al-
ready allow computer-based real-time
3-D ultrasound imaging, e.g. three-
dimensional ultrasound imaging of the
fetus offers impressive image quality
for the diagnosis of fetal abnormalities
[131-133]. Three-dimensional images
based on CT scanning or MRI in-
crease diagnostic capabilities and have
become an integral part of preopera-
tive planning [13a-1a0].
Several years ago, concepts regard-
ing the application of image process-
ing to support surgical robots were
formulated (e.g., the EC-research
proposal SCAMPI, Marburg 1989). In
the mean time, CT and MRI have
been used in neurosurgery to control
robotic systems and to perform brain
biopsies and resections U4l-144].
Again, future developments will in-
crease this field of application: "En-
hanced computer graphics and robotic
devices are important adjuncts to
neurosurgical procedures and will find
increasing use in the future" [141].
The following three research pro-
jects, conducted at the University of
North Carolina at Chapel Hill, de-
monstrate the integration of VR with
the ongoing technological trends [43,
1021. The project "X-Ray Vision"
aims to superimpose Ct MR, or
ultrasound images on a see-through
head-mounted display. The surgeon,
e.g., in reconstructive surgery, will be
able to directly view the surface and at
the same time evaluate the bone struc-
ture with reflected static 3-D-recon-
structions on his/her see-through
head-mounted display.
For the "See-through {Jltrasound"
project, real-time clinical ultrasound
data are computed, visualized and
composed with video images. The
physician views the images using the
hdad-mounted display [10]. At pre-
sent, the ultrasound images are still
two-dimensional. Stix [10] states that
it would be interesting to use current
developments in 3-D ultrasound imag-
ing techniques for this project.
The third project, "Radiation
Tieatment Planning", was launched to
support radiological therapy of neo-
plasms. It was designed as follows: the
physician wears a head-mounted dis-
play to view the anatomical structure
of the patient, computed from CT
scanning. At the same time, a beam
symbolizing the direction of the in-
tended radiation is projected onto the
display. According to the anatomical
conditions, e.9., tumor localization,
the physician can manipulate the di-
rection and position of the beam so
411
that by following the beam the radia-
tion hits mainly tumor tissue and only
a little healthy tissue.
The future of robot-assisted and
minimal invasive surgical procedures,
in conjunction with digital imaging,
will be characterized through further
technical improvements and a steadily
enlarging field of application. VR in
its complete form, i.e., including all
its attributes, would be most interest-
ing for this area, but is not yet avail-
able. Nevertheless, single VR at-
tributes and related technologies are
very likely to become functionally in-
tegrated in the technical development
of these areas.
5.3 VR for Visualization and
Simulation
Visualization of molecular struc-
tures through computer graphics pro-
vides a comprehensible view of spatial
structure, charge diffusion, and dy-
namic behavior [80, 145, 146). A po-
tential application area for visualiza-
tion techniques in this area is drug
design [146].
VR technology in this regard can be
used to optimize visualization tech-
niques [146]. York University, Glaxo
Research, VR pioneers Division Ltd.,
and IBM have launched a common
project Io analyze whether or not drug
development can be performed more
efficiently using 3-D visualization of
molecular structures using VR [29].
A visual-haptic display has been
developed at the University of North
Carolina at Chapel Hill to display
force fields of interacting protein
molecules [53]. With the visual-haptic
display, including a force-torque-
feedback, test persons were able to
reach the docking of drugs to a protein
molecule faster than with a visual
display alone. In addition, a better
perception and understanding of the
molecular docking forces was re-
ported. Because of these experiences,
the authors expect a more systematic
and efficient way of designing drugs
using these methods. The authors of
the study consider the following
biomedical procedures appropriate for
use with the visual-haptic display:
drug-enzyme docking, work with
DNA-intercalators, protein design
4t2
and protein folding [53, 94]. The
authors also believe that the phar-
maceutical industry offers substantial
application potential, but expect slow
development over the decade. The
entertainment sector is considered by
the authors as the fastest growing
application area for their haptic dis-
plays (haptic displays for toys, e.g.,
StarTours, HardDrivin').
VR applications which simulate the
operation of a virtual patient for the
purposes of education are often de-
scribed as another medical application
of VR 1L,22,72,l05,106, 147]. How-
ever, these applications are still far
from being realized and, thus, cannot
in the near future be considered
severe competition to the traditional
assistance on the operating table or
surgical videos. However, a good ap-
plication would be to use VR and
digital imaging techniques for virtual
operations as a tool for operation
planning.
5.4 VR in Psychiatry
Psychiatry has been considered as
the most promising sector of VR in
medicine [148], however, without any
thorough explanation.
In "Virtual reality in mental
therapy", Ward [149] describes per-
sonal experiences with the treatment
of arachneophobia. For this thera-
peutical purpose, a multi-media sys-
tem was used but not a complete
VR system. This multi-media system
provided patients with a therapeutic
setting in which they were able to
control film sequences with spiders.
This form of therapy resulted in a
reduction of fear [149, 150]. Similarly,
at San Francisco State University a
group of students has developed a
multi-media project which offers par-
ents of disabled children the oppor-
tunity to participate in a "virtual dis-
cussion group". The "virtual discus-
sion group" enables parents to talk
about sensitive issues that they may
not otherwise be able to discuss [151].
In an overview of future VR appli-
cations in psychotherapy, especially
for patients with multiple personality
disorders, Tart [152] emphasizes the
areas of diagnosis, induction, and
therapy. In the area of diagnostics,
Tärt states the possibility of construct-
ing patient specific psychodiagnostic
tests using virtual realities. Virtual
realities could be designed for the
specific problems of an individual pa-
tient by including material which the
patient has previously experienced as
problematic, e.9., people, special
events. Thus, through VR-testing in-
struments a more specific diagnostic
approach could be realized. Accord-
ing to Tärt, these applications could
be further improved through the poss-
ibility of allowing the patient to create
his/her own virtual reality which the
therapist could then experience using
the VR system.
Tärt describes induction as a tech-
nique whereby a patient is brought
into a specific state to elucidate certain
emotional or intellectual problems
which are inaccessible in his/her nor-
mal state. Tärt suggests that comput-
er-based virtual realities with specific
life events etc., be created as an induc-
tive tool; i.e., using VR as a trigger
mechanism. Potential side effects and
ethical issues are also discussed by the
author.
Finally. Tärt expects important
therapeutical improvements in psy-
chotherapy through VR. Similar to
diagnostic applications, VR systems
should be used in therapeutic settings
to simulate situations which are criti-
cal for the patient, e.g. training in a
virtual office if the client is plagued by
feehngs of rejection at his/her work
place.
In an anonymous contribution to
the Lancet, similar fields of applica-
tion for VR in psychiatry are de-
scribed, but more critically assessed
with regard to potential hazards: VR
could severely affect the perception of
reality of an already impaired patient
and could limit the freedom of therapy
[8]. Furthermore, the author discusses
the limits of VR with respect to the
way in which the patient interprets the
VR experiences because VR ex-
periences are limited to those which
man can design. The author states that
"For patients seeking to understand,
as many do, the purpose of their
suffering VR is as unlikely as hal-
lucinogenic drug use to provide access
Meth. Inform. Med., Vol.32, No.5, l9q3
to a deeper reality in their search for
meaning" [8].
An interesting psychiatric case in
which a computer offered a surprising
communication medium is described
in popular science literature. An autis-
tic adolescent, who had never verbally
interacted with his family, was en-
abled to communicate with his envi-
ronment through the computer [153].
This case illustrates that communica-
tion disorders may likely be reduced
through the use of an appropriate
medium, in this case the computer.
This experience with the computer as
a communication aid may justify some
expectations about computer-based
VR in psychiatry.
Nevertheless, future applications of
VR in psychiatry and psychology are
more difficult to assess than in other
medical fields, as they are different in
nature. Until now, there have not
been any real VR applications known
in psychiatry, i.e., applications which
meet the complete VR definition. The
use of VR in non-psychiatric domains
may focus on single VR attributes and
their underlying VR technology; i.e.,
VR may be applied successfully even
when used partly and in a primarily
technical way. In contrast, psychiatry
looks for the production of a complete
virtual reality. In psychiatry, the con-
structed reality should be included as
an additional reality in the communi-
cation process, to either improve the
communication of various realities
(reality of the patient, of the physician
etc.) or to make it easier to change
from one reality to another. The tech-
nical question is "if" and "when" VR
technology will be able to produce a
representative reality. From a psy-
chiatric point of view, questions arise
as to whether or not this additional
virtual reality really improves com-
munication within the diagnostic and
therapeutic processes. Consideration
must also be given to the potential
difficulties and side effects resulting
from additional realities. The expense
of the technical requirements must
be justified and compared with the
benefits.
Due to the fact that the entertain-
ment market will probably be flooded
with VR toys, child psychiatry
child psychology should evaluate poss-
Meth. Iniorm. Med., Vol.32, No.5, lt)93
ible consequences. Empirical research
concerning the impact of VR enter-
tainment games on children has not
yet been conducted. However, the
study by Brown and Robertson [154]
about home computer and video
games could be significant. The au-
thors conclude that the excessive use
of computer games at a psychological-
ly important developmental age can
cut children off from social contacts
and produce unrealistically simple
models of interpersonal communica-
tion. Furthermore, the use of military
VR games, such as "Battletech",
which are so similar to real military
VR applications, may lead to a fatal
alienation from reality which may
have already subtly begun during
childhood. Similar objections exist
against violence in VR games, particu-
larly for children [51.
6. Discussion
The desire to perfectly reconstruct
nature with technical means to make
the viewer believe that it is an act of
nature and not the work of man seems
to be as old as mankind. For example,
achieving a closeness to reality was a
main objective of art during the Re-
naissance period. Several techniques
were developed for this purpose, one
of which was the linear perspective, to
create the illusion of body and space
[155]. VR may be regarded as a con-
tinuation of this tradition, adding the
experience of simultaneousness and
immersion through interactivity with
the computer as well as through the
other attributes of VR.
The aim of VR, to make the com-
puter-simulated reality close to reality
and to make this simulated reality
interactively accessible, still requires
considerable technical research and
development. This aim can only par-
tially be reached within short and
medium-term periods. Furthermore,
reality does not only consist of visual,
tactile etc. perception but also implies
causality, chaos, etc. [1]. This fact is
responsible for a degree of complexity
and in nature that can only partially be
reached with a VR model.
There are two important issues con-
cerning the discussion of long-term
future perspectives of VR in medicine:
- The aim of photorealistic reality in
the development of VR is not as
dominant in the medical field as it is
in other fields, except in psychiatry.
-Methods in medicine are primarily
expected to deliver valid informa-
tion for diagnostic and therapeutic
decisions. For example, X-rays are
not at all realistic in a photorealistic
sense, but are still important for
diagnoses. Thus, requirements for
VR in medicine are different to
those in other fields and are, thus,
more likely to be realized.
- Medicine is mainly concerned with
problems and issues characterized
by three-dimensionality. This is
true for both the micro or molecu-
lar-level, e.g., where the function-
ality of proteins not only depends
on the correct amino-acid sequence
but also on the correct spatial pro-
tein structure, and for the macro-
level. e.9.. where operative
chances for tumor removal are in-
fluenced by the spatial localization.
Consequently, the interrelationship
between the three-dimensionality
of medicine and the three-dimen-
sionality of VR systems can con-
tribute to future developments of
VR applications in medicine [18].
Considering the current state of
VR, the following conclusions can be
drawn:
Further use of VR as a thrilling,
- -'fashionable,
but undefined term for
various novelties in the computing
sector will impair serious discussion
and research funding [156]. The use
of VR as a scientific term leads to
the necessity of a binding definition
to avoid confusion.
- The use of medical VR applications
outside of research will very likely
take more than 10 years given, in
comparison, the time between the
initial definition of the problem and
the first field trials in PACS (Pic-
ture Archiving and Communication
Systems) development in radiology
or the even longer period of the
evolution of knowledge-based sys-
tems.
- As already stated, with regard to
the prospects of VR in medicine,
413
 the authors consider the most
promising fields of application to be
the use of VR for support of per-
sons with disabilities. for visualiza-
tion and simulation and for the
support of surgical operations
through image processing. In gen-
eral, a satisfactory solution to the
problem of human-computer inter-
faces has not yet been found for
many medical computer applica-
tions. Therefore, the use of single
VR devices should be considered
for further development, in areas
where complete VR systems are not
available. For example, the above
described vTDEoPLACE [75, 31, I57]
could be tested as a potential inter-
face in digital radiography and tele-
radiology where the manipulation
of images and telecommunication
etc. still lack adequate interface
designs.
Wide future markets for VR, and
thus financial resources for the ad-
vancement of research, are ex-
pected primarily in the entertain-
ment and specific industrial sectors
(flight simulation, production auto-
mation, etc.). In comparison, medi-
cine can only be considered an
economic niche. With regard to the
distribution of resources, medicine
should not invest in expensive indi-
vidual VR developments but should
instead aim to import and adapt
technology for use in medicine. The
compact disc (CD) is an illustrative
case in that it was developed in the
entertainment industry but in the
mean time has become an impor-
tant information medium for medi-
cal databases [158, 159]. In con-
trast. PACS-development in recent
years, having been advanced sepa-
rately from the graphic capacities of
workstations, demonstrates the
high cost of parallel developments
and the danger of a technological
deadlock.
VR technology offers positive long-
term perspectives, but the techni-
cal, political, social, psychological
and ethical impacts are currently
difficult to assess. Therefore, future
research and development of VR
should be accompanied by an inter-
disciplinary research approach to
414
assessthe potential impact of this
new technology.
Considering the history of art as an
illustrative parallel, two further 1-'oints
are worth mentioning:
There has been an historical i iiange
in the understanding of reality irnd its
pictorial representation. Asiclc from
"deceptive realism" which presented a
deceptive realistic picture of physical
reality, there was also the movement
of "psychological realism" which, for
instance, distorted physical reality in
order to improve the representation of
psychological reality [155].
]ihus,
the
recreation of reality, in parntrng as in
VR, always implies interpretative ten-
dencies. Consequently, the simulated
reality of VR will include interpreta-
tion and, due to the complexity of
reality, a restricted representation of
reality. F{owever, if the VR model
replaces the direct perception of reali-
ty and at the same time serves as basis
for decision-making, more problems
and risks can be expected as the differ-
ence between reality and the VR mod-
el increases. In medicine, for example,
if the VR model remains constant with
respect to a specific disease and does
not take into account new symptoms
and an altered health state, the ap-
propriate therapy may not be deliv-
ered. From a political perspective, the
representation of reality in the VR
model could be misused as a mani-
pulative instrument, similar to the
mass media, influenced by social anfl
political powers.
The "conquest of reality" [16ü] for
the realistic, pictorial representation
in Renaissance painting was accom-
panied by an intensive study of reality,
as the anatomical studies of Leonardo
da Vinci and Michelangelo illustrate.
Similarly, VR nowadays also requires
the study of reality, especially now
that the reality of our "everyday life"
is perceived as a social construct
rather than an absolute [161].
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