The word "hospital" derives from the Latin hospes, meaning guest or host; the idea is to confine the sick to one place. 25 In early monastic hospitals the sick were confined so that they could be cared for by the monks and (perhaps more to the point, considering the level of medical treatment that was available) so that they could conveniently be assembled for religious services and speeded on their way to heaven; thus Filarete's famous plan for the Ospedale Maggiore in Milan consisted of immense cruciform wards with altars at the crossings and a chapel in the central courtyard. (In modern wards the centrally located altars are replaced by nursing stations.) Sometimes, as in hospitals for infectious diseases like Venice's island lazaretto and in asylums for the mentally ill like Bedlam and Charenton, the sick have been confined to keep them away from the rest of society. As medical expertise and increasingly sophisticated medical technology have developed in the twentieth century, confinement has been to places where skilled practitioners, medical records, and advanced facilities (such as surgical suites, pathology laboratories, and medical imaging installations) could be concentrated. And in teaching hospitals, the sick are assembled in places where students can observe them.
Before Pasteur, enlightened hospital designers arranged long, narrow wards to provide as much external wall surface, natural light, and fresh air as possible. So, for example, both Wren's early-eighteenth-century plan for the Royal Naval Hospital at Greenwich and Durand's ideal hospital plan of a century later are low, sprawling, symmetrical accretions of ward pavilions, courtyards, and immensely lengthy corridors. 26 But since the 1870s, when Pasteur fingered bacteria (rather than foul air) as the agents of infection and Lister developed antiseptic medicine, pavilions have become a thing of the past. Twentieth-century hospitals consist mostly of air-conditioned, artificially lit spaces packed closely together in deep, multistoried blocks to minimize staff, patient movement, and service system runs. The hospital designer's task-much like the task of microprocessor chip layouthas been to arrange a lot of identical storage units and a few specialized, central processing facilities for the greatest possible circulation efficiency under statistically predicted patterns of use. 27 Generally, the resulting places have not been very pleasant.
With the development of advanced telecommunications, bits are now beginning to transform hospital design as profoundly as bacteria once did. Telemedicine is emerging. It brings advanced medical care to widely scattered populations and makes old-style assemblies of patients around specialized medical facilities less necessary. As John McConnell, writing in The Lancet, summarized, "For any procedure that involves vision or sound (e.g., monitoring the progress of anaesthesia, or giving an opinion on a biopsy slide, fetal ultrasound, or computed tomography scan)-and potentially even touch-the physician need no longer be present in the same room, or even in the same country, as the patient or specimen." 28
The simplest and most obvious form of telemedicine is a straightforward teleconferencing. Using video hookups, specialists at major medical centers can examine patients and provide advice to colleagues in remote rural locations. Emergency room physicians can save precious time by examining patients in video-equipped ambulances, and military hospital medics can examine far-off wounded. Where outbreaks of fighting or natural disasters create sudden demands for medical care, capacity can quickly be switched from other parts of the world. Basic models of health care delivery may even begin to change; family practitioners might provide face-to-face patient contact while drawing on the expertise of distant specialists by video as needed. By the 1990s, then, numerous experiments in video-based telemedicine were under way. 29
But video is only the first step. Since modern diagnostic devices often produce streams of digital data, they can readily be adapted to provide their output remotely through network connections. So stethoscopes, otoscopes, endoscopes, electrocardiography devices, and medical imaging machines can all now be used in remote examinations. As homes get network connections, domestic diagnostic and monitoring devices will begin to allow virtual house calls; when your baby has an earache, you might connect to a virtual clinic and put the otoscope in the baby's ear to let the practitioner on duty take a look. 30 It's not as good as a real visit, perhaps, but it's a lot better than a telephone call.
By combining electronic viewing and diagnostic devices with appropriate telemanipulators, medical practitioners can begin to make themselves telepresent. 31 Consider, for example, a pathologist examining tissue samples or body fluids under a microscope in order to render a diagnosis; with a telepathology system consisting of a video camera mounted on a motorized microscope, this task can be performed remotely. 32 And with fancier teleoperators, head-mounted stereo displays, and sufficiently precise tactile feedback devices, telesurgery becomes a serious possibility. 33 A typical telesurgery system consists of master and slave units: the remotely located surgeon wears a helmet (the audiovisual master) that controls a stereo video camera (audiovisual slave) observing the surgery, and holds force-reflecting pseudotools that control a surgical robot. 34
Continuous care-involving constant monitoring and regular medication -might also be provided remotely. (Many of the necessary technologies were originally developed for battlefield use but can readily be adapted for more peaceful purposes.) 35 Houses and beds can contain sensors for tracking the conditions of their occupants and telecommunications for transmitting the information to distant monitoring sites. Electronic scales can log body weight. Noncontact, microwave vital-signs monitoring systems can measure heart rate, respiration rate, temperature, and blood pressure. Smart air-conditioning systems and inquisitive toilets might automatically take samples and perform analyses. Implanted wireless devices might be used for remotely controlled release of precise amounts of medication. Houses seem destined to evolve into increasingly sophisticated components of health care systems.
One promise of telemedicine is that the isolated, the immobilized, and those in sudden, acute need will be able to get care without difficult and time-consuming travel. Another is that family practitioners and paramedics who have direct contact with patients will be able to draw more effectively on specialized expertise and advanced medical technology as the traditional doctor's black bag mutates into a sophisticated digital telecommunications device. An obvious peril is that health care delivery may become an even more depersonalized and technocratic process. Either way, the logic of health care facility location and internal organization is changing dramatically; whereas the industrial, antiseptic care, and medical technology revolutions of the nineteenth and early twentieth centuries created powerful incentives to centralize medical care and concentrate it in major urban areas, the digital telecommunications revolution of the late twentieth century creates possibilities for decentralization and more equitable dispersion.
Itinerant healers are returning. They will ride the information superhighway.