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Telemedicine,
Telehealth and
Telepresence

Principles, Strategies,
Applications, and New Directions

Rifat Latifi
Charles R. Doarn
Ronald C. Merrell
Editors

123
Telemedicine, Telehealth and Telepresence
Rifat Latifi • Charles R. Doarn
Ronald C. Merrell
Editors

Telemedicine, Telehealth
and Telepresence
Principles, Strategies, Applications,
and New Directions
Editors
Rifat Latifi Charles R. Doarn
Department of Surgery Department of Environmental and Public
Westchester Medical Center and New York Health Sciences
Medical College University of Cincinnati
Valhalla, NY Cincinnati, OH
USA USA
Ronald C. Merrell
Virginia Commonwealth University
Mentone, AL
USA

ISBN 978-3-030-56916-7    ISBN 978-3-030-56917-4 (eBook)

https://doi.org/10.1007/978-3-030-56917-4

© Springer Nature Switzerland AG 2021

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword

Few would argue the benefits of telemedicine to the patient, society, the community,
the healthcare system, healthcare professionals, and funders. Despite the obvious,
the uptake of telemedicine over the last three decades has remained slow, nascent in
some parts of the developed world and a dream of unmet potential in the developing
world. It is too often inhibited by bureaucracy, regulation, fear of change, lack of
awareness, and ignorance. This is particularly unfortunate for the developing world
in which I work, where the unmet healthcare burden is greatest. Increasing general
awareness and knowledge of telemedicine in all settings is imperative.
The book’s editors, Ron Merrell, Chuck Doarn, and Rifat Latifi, have impeccable
telemedicine credentials and are acknowledged leaders in the field, having been at
the coalface for many years. Ron and Chuck, have been the co-editors of the presti-
gious Journal of Telemedicine and eHealth. Rifat is respected internationally for his
implementation of telemedicine in Kosova and Cabo Verde among others. All are
Fellows of the American Telemedicine Association. They have assembled 66 experts
from several countries to author the 28 chapters of this book which cover a wide
range of issues. These are divided into Principles of Telemedicine and Telehealth,
Strategies for Building Sustainable Telemedicine and Telehealth Programs,
Outcomes Based Evidence Clinical Applications of Telemedicine, and the Next
Generation of Telemedicine and Telepresence.
Rogers’ Diffusion of Technology Curve describes the growing number of users
of new technology as the innovators, the early adopters, the early majority, the late
majority, and finally the laggards—or perhaps the Luddites. Telemedicine in many
parts of the developed world has been at the stages of the early adopters, and in
some disciplines, the early majority. The developing world lags at the innova-
tor stage.
To paraphrase the 1956 Dinah Washington song, “What a difference a virus
makes.” The COVID-19 Pandemic has changed this. Telemedicine is alive and well.
Through necessity, many have been obliged to adopt it for their own and their
patients’ safety. The majority are now using information technology in some form
to provide care over distance, and in many countries in the developing world tele-
medicine is leapfrogging from the innovators to the early majority. Health profes-
sionals have discovered telemedicine, and many believe they are innovators because
they have changed and adopted it. The need for the evidence behind what they are
now doing in their daily telemedicine practice and advice on how to improve what

v
vi Foreword

they are doing has been of little importance to them—until now. They need this
information.
This book meets that need and will serve those who read it well, as they embrace
the culture of telemedicine and draw upon the hard-earned experience and battle
scars of the many authors. The surge in telemedicine and its widespread incursion
into daily practice will not go away when a vaccine is found. As Benjamin Franklin
said, “Out of adversity comes opportunity.” The timing of this book is serendipitous
and its content welcomed.

 Maurice Mars, MBChB, MD,

University of KwaZulu-Natal
Durban, South Africa
Preface

In late 2019 and early 2020, a Coronavirus 2019 (COVID-19) began to affect the
entire world. As of June 1, 2020, over 6.3 million (and counting) people worldwide
have been affected by COVID-19, with over 376,000 deaths in nearly every country.
This pandemic sickens our hearts and minds as we individually are affected and we
seem helpless to respond. As practitioners and researchers, we each have our own
stories and some have even been sickened by the virus. Returning back to a new
normal, whether the operating room, the hospital, or the office after working from
home for a few weeks, while recuperating from COVID-19 has been such a treat.
Our daily schedule is fuller than ever with virtual meetings using Zoom or Webex
as well as normal face-to-face meetings with social distancing ever present in our
minds. Yes, the world has changed rapidly and significantly. The old ways may be
gone forever. Medical and surgical practice have changed not only from a response
to patients with COVID-19 but how world health community has embraced tele-
medicine and telehealth. Is this a new world order for healthcare?
The pandemic caused by COVID-19 brought to light something that we, the
telemedicine and telehealth enthusiasts, have been fighting toward for decades. We
knew all along that telemedicine and telehealth can be an excellent model to care of
the sick and injured in just about every discipline. Today, a search on PubMed for
“COVID-19 and telemedicine or telehealth” results in over 500 manuscripts pub-
lished for a disease that is less than 6 months old. There is no precedent for this in
any field of medicine. These papers are from every aspect of medicine and surgery.
Finally telemedicine at center stage [1].
Have you thought, as a surgeon, medical doctor, or any healthcare practitioner,
how do we make a diagnosis and how do we create a plan for treatment? We teach
our students that history and physical exam are the most important. The diagnosis is
confirmed by studies. Yes, we still teach that. After all, most patients have some sort
of diagnostic test, including radiologic (usually CT scan, MRI, PET scan, etc.) and
other laboratory tests. Gone are the days when we made a diagnosis by examining
the patient alone, unless the patient has a clear-cut surgical problem (peritonitis) and
needs emergency surgery.
So what is the value of seeing a doctor in his/her office? If the medical and surgi-
cal history can be taken via interview across telehealth/telemedicine platform, if the
laboratory and radiologic studies are accessible from anywhere in the world through
sophisticated software, abundant and present in every laptop or other mobile

vii
viii Preface

devices, the question comes down to “why do we need to have a patient travel often
for hours, interrupt their life and work, and come to see us in our fancy and expen-
sive offices?” We can obtain the patient’s temperature and weight as well as mea-
sure blood pressure, pulse, respiratory volume, and other basic medical information
virtually while the patient remains in the comfort of their home, office, or where
ever they are. Pre-operative and post-operative care can also be accomplished in the
same manner so the patient does not have to come to the office.
Integrating telemedicine and telehealth into the healthcare system permits the
following: patient safety and elimination of all the inconveniences the patient expe-
riences, including interrupting their day, travel by car or other modality to the doc-
tor’s office, spending time parking (oftentimes they have to pay for parking), waiting
in the waiting room with other sick patients, and eventually be seen by the provider.
This process is long, arduous, and in many cases not necessary. Most clinical
encounters can be done virtually using telemedicine and telehealth.
Telemedicine and telehealth have consistently been shown to be effective in reg-
ular medical and surgical practice, primary care, and second opinion to extreme
conditions, such as crises, disasters, remote areas, or limited-resource locations. All
of these are carefully documented in this book. Each chapter is written with the
patient and the healthcare system in mind. Patients and the public at large want
telemedicine, and so do hospitals and most doctors. While many of us have known
the benefits that telemedicine and telehealth offer, convincing the majority of our
colleagues has been a struggle, at least until COVID-19 became a threat to
humanity [1].
The biggest advantage of telemedicine and telehealth in the current crisis is their
ability to continue providing health services at a physical distance. In the USA, the
majority of healthcare institutions use some form of telemedicine or telehealth
thanks to significant advances in telecommunications including and not limited to
improved high-resolution imaging and greater access to broadband. Although
nascent technologies, infrastructure, and legislation are increasingly discussed and
improved, they remain today at an early stage of integration and diffusion in the
current healthcare system. While, we truly believe that telemedicine and telehealth
are finally at the center stage, there are challenges to continue with this momentum
[1]. The most important challenges the widespread diffusion of telemedicine is fac-
ing are: lack of standardized approach and guidelines describing the uniform crite-
ria as to when telemedicine should be a part of the care; absence of clarity on the
ways and mechanisms of reimbursement; licensure issues when telemedical care
has to cross state lines; compliance with the Health Insurance Portability and
Accountability Act (HIPAA) privacy and security rules; and liability and malprac-
tice insurance issues. In addition, technology failures and human factors are also to
be considered, but with recent advances, the integration of technology with human
factors has become almost seamless. Moreover, with a perfect integration of tele-
medicine and telehealth in the care of chronic diseases, care continuity questions
may arise. The aforementioned factors are probably the reason why telemedicine
needs to be integrated into the current healthcare system. COVID-19 has changed
this. Imagine, you wake up and the doctor comes to your home or your office
Preface ix

virtually. If you have to wait, you are still working or enjoying your day wait ever
you are doing. Now, that is a great day in healthcare.
The new world order caused by the COVID-19 virus, associated with severe
acute respiratory syndrome, multiple organ failure, and very high mortality, has
brought about one major change. Suddenly, the medical community, and those who
finance the healthcare sector, realized that telemedicine and telepresence are appli-
cable, desirable, acceptable, and much sought after by our patients and we can man-
age just about every disease and condition [1]. Although, by and large, telemedicine
and telehealth have faced challenges and perhaps some resistance, despite their
great potential, it has become evident that they can provide rapid, safe, and high-­
quality care remotely during this pandemic, the largest one since 1918. Perhaps one
benefit of suffering through the COVID-19 pandemic will be the establishment of a
new virtual medical world order, and that telemedicine has taken its deserving place
in healthcare: prime time and a center stage. Let’s call this period the rebirth of
telemedicine.
We hope you find this text a worthy reference.

Reference

1. Latifi R, Doarn CR. Perspective on COVID-19: finally, telemedicine at center

stage. Telemed J E Health. 2020;26(9):1106–9.

Valhalla, NY, USA Rifat Latifi

Cincinnati, OH, USA Charles R. Doarn
Mentone, AL, USA Ronald C. Merrell
June 1, 2020
Acknowledgement

We would like to thank all the authors and co-authors for their selflessness and
major contributions to this book. In addition to their efforts, we would like to thank
the Springer team for both their patience and professionalism. Special thank you to
Geena George, MPH, a Research Coordinator in the Clinical Research Unit,
Department of Surgery, at Westchester Medical Center in Valhalla, NY. Without her
help, this book would have never been finished.

xi
Contents

Part I Principles of Telemedicine and Telehealth

1 First Trainees: The Golden Anniversary of the Early History
of Telemedicine Education at the Massachusetts General
Hospital and Harvard (1968–1970)����������������������������������������������������������   3
Ronald S. Weinstein, Michael J. Holcomb,
Elizabeth A. Krupinski, and Rifat Latifi
2 Initiate-Build-Operate-Transfer (IBOT) Strategy
Twenty Years Later: Tales from the Balkans and Africa����������������������� 19
Rifat Latifi
3 Clinical Telemedicine Practice: From Ad Hoc Medicine
to Modus Operandi������������������������������������������������������������������������������������ 43
Rifat Latifi
4 Incorporation of Telemedicine in Disaster Management:
Beyond the Era of the COVID-19 Pandemic ������������������������������������������ 51
Rifat Latifi and Charles R. Doarn
5 Telemedicine and Health Information Exchange:
An Opportunity for Integration��������������������������������������������������������������� 63
Dale C. Alverson
6 Telehealth Dissemination and Implementation (D&I)
Research: Analysis of the PCORI Telehealth-Related
Research Portfolio�������������������������������������������������������������������������������������� 77
Ronald S. Weinstein, Robert S. Krouse, Michael J. Holcomb,
Camryn Payne, Kristine A. Erps, Elizabeth A. Krupinski,
and Rifat Latifi
7 Standards and Guidelines in Teleheatlh: Creating
a Compliance and Evidence-­Based Telehealth Practice ������������������������ 97
Nina M. Antoniotti
8 Federal and State Policies on Telehealth Reimbursement���������������������� 115
Jordana Bernard and Mei Wa Kwong

xiii
xiv Contents

9 Legal and Regulatory Implications of Telemedicine������������������������������ 129

Geena George and Brandon E. Heitmann
10 Business Aspects of Telemedicine ������������������������������������������������������������ 141
Nina M. Antoniotti
11 Advancing Telehealth to Improve Access to Health
in Rural America���������������������������������������������������������������������������������������� 157
Charles R. Doarn
Part II Strategies for Building Sustainable Telemedicine
and Telehealth Programs
12 Innovative Governance Model for a Sustainable
State-Wide University-Based Telemedicine Program���������������������������� 171
Ronald S. Weinstein, Nandini Sodhi, Gail P. Barker, Michael
J. Holcomb, Kristine A. Erps, Angelette Holtrust, Rifat Latifi,
and Elizabeth A. Krupinski
13 Telehealth Patient Portal: Opportunities and Reality���������������������������� 189
Ronald C. Merrell
14 Technology Enabled Remote Healthcare in Public Private
Partnership Mode: A Story from India���������������������������������������������������� 197
K. Ganapathy and Sangita Reddy
15 International and Global Telemedicine: Making It Work���������������������� 235
Dale C. Alverson
16 Technological Advances Making Telemedicine and Telepresence
Possible�������������������������������������������������������������������������������������������������������� 257
Charles R. Doarn
Part III Outcomes Based Evidence Clinical Applications
of Telemedicine
17 Survey of the Direct-to-Hospital (DTH) Telemedicine
and Telehealth Service Industry (2014–2018)������������������������������������������ 275
Ronald S. Weinstein, Nicholas Rolig, Nancy Rowe,
Gail P. Barker, Kristine A. Erps, Michael J. Holcomb,
Rifat Latifi, and Elizabeth A. Krupinski
18 Telemedicine for Trauma and Emergency Care Management�������������� 293
Rifat Latifi
19 Telemedicine for Burn Care: The Commonsense Telemedicine������������ 307
Dylan Stewart, Joseph R. Turkowski, and Rifat Latifi
Contents xv

20 Telemedicine for Intensive Care �������������������������������������������������������������� 321

Rifat Latifi and Kalterina Osmani
21 Telehealth in Pediatric Care���������������������������������������������������������������������� 333
Jennifer L. Rosenthal, Jamie L. Mouzoon, and James P. Marcin
22 Overview of Child Telebehavioral Interventions
Using Real-Time Videoconferencing�������������������������������������������������������� 347
Alexandra D. Monzon, E. Zhang, Arwen M. Marker,
and Eve-Lynn Nelson
23 Telemedicine for Psychiatry and Mental Health������������������������������������ 365
Matthew Garofalo, Sarah Vaithilingam, and Stephen Ferrando
24 Telecardiology�������������������������������������������������������������������������������������������� 379
Milena Soriano Marcolino, Maria Beatriz Moreira Alkmim,
Maira Viana Rego Souza e Silva, Renato Minelli Figueira,
Raissa Eda de Resende, Letícia Baião Silva,
and Antonio Luiz Ribeiro
25 Telestroke and Teleneurology�������������������������������������������������������������������� 401
Benzion Blech and Bart M. Demaerschalk
26 Telemedicine for Prisons and Jail Population:
A Solution to Increase Access to Care������������������������������������������������������ 419
Rifat Latifi, Kalterina Osmani, Peter Kilcommons,
and Ronald S. Weinstein
Part IV The Next Generation of Telemedicine and Telepresence
27 Surgical Telementoring and Teleproctoring�������������������������������������������� 431
Rifat Latifi, Xiang Da Dong, Ziad Abouezzi, Ashutosh Kaul,
Akia Caine, Roberto Bergamaschi, Aram Rojas, Igor A. Laskowski,
Donna C. Koo, Tracey L. Weigel, Kaveh Alizadeh, Nikhil Gopal,
Akhil Saji, Ashley Dixon, Bertie Zhang, John Phillips,
Jared B. Cooper, and Chirag D. Gandhi
28 The Promise and Hurdles of Telemedicine in Diabetes
Foot Care Delivery ������������������������������������������������������������������������������������ 455
Bijan Najafi, Mark Swerdlow, Grant A. Murphy,
and David G. Armstrong
29 Telemedicine in Austere Conditions �������������������������������������������������������� 471
Charles R. Doarn
Index�������������������������������������������������������������������������������������������������������������������� 485
Contributors

Ziad Abouezzi Department of Surgery, Westchester Medical Center,

Valhalla, NY, USA
New York Medical College, School of Medicine, Valhalla, NY, USA
Kaveh Alizadeh Department of Surgery, Westchester Medical Center,
Valhalla, NY, USA
New York Medical College, School of Medicine, Valhalla, NY, USA
Maria Beatriz Moreira Alkmim Telehealth Center, University Hospital,
Universidade Federal de Minas Gerais; Telehealth Network of Minas Gerais, Belo
Horizonte, Brazil
Dale C. Alverson Health Sciences Center, University of New Mexico,
Albuquerque, NM, USA
Nina M. Antoniotti Interoperability and Patient Engagement, St. Jude Children’s
Research Hospital, Edgar, WI, USA
David G. Armstrong Southwestern Academic Limb Salvage Alliance (SALSA),
Department of Surgery, Keck School of Medicine of University of Southern
California, Los Angeles, CA, USA
Gail P. Barker Arizona Telemedicine Program, The University of Arizona’s
College of Medicine, Tucson, AZ, USA
Roberto Bergamaschi Department of Surgery, Westchester Medical Center,
Valhalla, NY, USA
New York Medical College, School of Medicine, Valhalla, NY, USA
Jordana Bernard InTouch Health, North Potomac, MD, USA
Benzion Blech Mayo Clinic College of Medicine and Science, Phoenix, AZ, USA
Akia Caine Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
New York Medical College, School of Medicine, Valhalla, NY, USA
Jared B. Cooper NewYork Medical College, School of Medicine, Valhalla, NY, USA
Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA

xvii
xviii Contributors

Bart M. Demaerschalk Medical Director of Center for Connected Care,

Cerebrovascular Diseases Division, Mayo Clinic College of Medicine and Science,
Phoenix, AZ, USA
Ashley Dixon New York Medical College, School of Medicine, Valhalla, NY, USA
Department of Urology, Westchester Medical Center, Valhalla, NY, USA
Charles R. Doarn Department of Environmental and Public Health Sciences,
College of Medicine, University of Cincinnati, Cincinnati, OH, USA
Xiang Da Dong Department of Surgery, Westchester Medical Center,
Valhalla, NY, USA
New York Medical College, School of Medicine, Valhalla, NY, USA
Kristine A. Erps Arizona Telemedicine Program, The University of Arizona’s
College of Medicine, Tucson, AZ, USA
Stephen Ferrando Department of Psychiatry, Westchester Medical Center Health
System, New York Medical College, Valhalla, NY, USA
Renato Minelli Figueira Telehealth Center, University Hospital, Universidade
Federal de Minas Gerais; Telehealth Network of Minas Gerais, Belo Horizonte, Brazil
K. Ganapathy Apollo Telemedicine Networking Foundation, Chennai, Tamil
Nadu, India
Chirag D. Gandhi New York Medical College, School of Medicine,
Valhalla, NY, USA
Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
Matthew Garofalo Department of Psychiatry, Westchester Medical Center Health
System, New York Medical College, Valhalla, NY, USA
Geena George Department of Surgery, Clinical Research Unit, Westchester
Medical Center, Valhalla, NY, USA
Nikhil Gopal New York Medical College, School of Medicine, Valhalla, NY, USA
Department of Urology, Westchester Medical Center, Valhalla, NY, USA
Brandon E. Heitmann Fitzpatrick & Hunt, Pagano, Aubert, LLP, New
York, NY, USA
Michael J. Holcomb Arizona Telemedicine Program, The University of Arizona’s
College of Medicine, Tucson, AZ, USA
Angelette Holtrust Arizona Telemedicine Program, The University of Arizona’s
College of Medicine, Tucson, AZ, USA
Ashutosh Kaul Department of Surgery, Westchester Medical Center,
Valhalla, NY, USA
New York Medical College, School of Medicine, Valhalla, NY, USA
Contributors xix

Peter Kilcommons MedWeb, San Francisco, CA, USA

Donna C. Koo Department of Surgery, Westchester Medical Center,
Valhalla, NY, USA
New York Medical College, School of Medicine, Valhalla, NY, USA
Robert S. Krouse University of Pennsylvania, Philadelphia, PA, USA
Elizabeth A. Krupinski Emory University, Atlanta, GA, USA
Mei Wa Kwong Center for Connected Health Policy, Sacramento, CA, USA
Igor A. Laskowski Department of Surgery, Westchester Medical Center,
Valhalla, NY, USA
New York Medical College, School of Medicine, Valhalla, NY, USA
Rifat Latifi Department of Surgery, Westchester Medical Center Health,
Valhalla, NY, USA
New York Medical College, School of Medicine, Valhalla, NY, USA
James P. Marcin Department of Pediatrics, UC Davis Health, Sacramento, CA, USA
Milena Soriano Marcolino Telehealth Center, University Hospital, Universidade
Federal de Minas Gerais; Telehealth Network of Minas Gerais, Belo Horizonte, Brazil
Arwen M. Marker Clinical Child Psychology, University of Kansas,
Lawrence, KS, USA
Ronald C. Merrell Virginia Commonwealth University, Mentone, AL, USA
Alexandra D. Monzon Clinical Child Psychology, University of Kansas,
Lawrence, KS, USA
Jamie L. Mouzoon Department of Pediatrics, UC Davis Health,
Sacramento, CA, USA
Grant A. Murphy Southwestern Academic Limb Salvage Alliance (SALSA),
Department of Surgery, Keck School of Medicine of University of Southern
California, Los Angeles, CA, USA
Bijan Najafi Interdisciplinary Consortium for Advanced Motion Performance
(iCAMP), Division of Vascular Surgery and Endovascular Therapy, Michael
E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
Eve-Lynn Nelson Pediatrics, University of Kansas Medical Center,
Kansas, KS, USA
Kalterina Osmani Department of Medicine, Westchester Medical Center,
Valhalla, NY, USA
Camryn Payne Arizona Telemedicine Program, The University of Arizona’s
College of Medicine, Tucson, AZ, USA
xx Contributors

John Phillips New York Medical College, School of Medicine, Valhalla, NY, USA
Department of Urology, Westchester Medical Center, Valhalla, NY, USA
Sangita Reddy Apollo Hospitals Group, Hyderabad, Telangana, India
Raissa Eda de Resende Telehealth Center, University Hospital, Universidade
Federal de Minas Gerais; Telehealth Network of Minas Gerais, Belo Horizonte, Brazil
Antonio Luiz Ribeiro Telehealth Center, University Hospital, Universidade
Federal de Minas Gerais; Telehealth Network of Minas Gerais, Belo Horizonte, Brazil
Aram Rojas Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
New York Medical College, School of Medicine, Valhalla, NY, USA
Nicholas Rolig Arizona Telemedicine Program, The University of Arizona’s
College of Medicine, Tucson, AZ, USA
Jennifer L. Rosenthal Department of Pediatrics, University of California Davis,
Sacramento, CA, USA
Nancy Rowe Arizona Telemedicine Program, The University of Arizona’s College
of Medicine, Tucson, AZ, USA
Akhil Saji New York Medical College, School of Medicine, Valhalla, NY, USA
Department of Urology, Westchester Medical Center, Valhalla, NY, USA
Letícia Baião Silva Telehealth Center, University Hospital, Universidade Federal
de Minas Gerais; Telehealth Network of Minas Gerais, Belo Horizonte, Brazil
Nandini Sodhi Arizona Telemedicine Program, The University of Arizona’s
College of Medicine, Tucson, AZ, USA
Maira Viana Rego Souza e Silva Telehealth Center, University Hospital,
Universidade Federal de Minas Gerais; Telehealth Network of Minas Gerais, Belo
Horizonte, Brazil
Dylan Stewart Westchester Medical Center and Maria Fareri Children’s Hospital,
Valhalla, NY, USA
New York Medical College, School of Medicine, Valhalla, NY, USA
Mark Swerdlow Southwestern Academic Limb Salvage Alliance (SALSA),
Department of Surgery, Keck School of Medicine of University of Southern
California, Los Angeles, CA, USA
Joseph R. Turkowski Department of Surgery, Westchester Medical Center Health,
Valhalla, NY, USA
Sarah Vaithilingam Department of Psychiatry, Westchester Medical Center
Health System, New York Medical College, Valhalla, NY, USA
Tracey L. Weigel Department of Surgery, Westchester Medical Center,
Valhalla, NY, USA
Contributors xxi

New York Medical College, School of Medicine, Valhalla, NY, USA

Ronald S. Weinstein Arizona Telemedicine Program, College of Medicine, The
University of Arizona’s, Tucson, AZ, USA
E. Zhang Pediatrics, University of Kansas Medical Center, Kansas City, KS, USA
Bertie Zhang New York Medical College, School of Medicine, Valhalla, NY, USA
Department of Urology, Westchester Medical Center, Valhalla, NY, USA
 Part I
Principles of Telemedicine and Telehealth
First Trainees: The Golden Anniversary
of the Early History of Telemedicine 1
Education at the Massachusetts General
Hospital and Harvard (1968–1970)

Ronald S. Weinstein, Michael J. Holcomb,

Elizabeth A. Krupinski, and Rifat Latifi

Recently, interest in creating curriculum in telemedicine for medical students, and

in telehealth for nurses and most other health professionals, has spiked because of
the healthcare industry’s rapid shift to providing care via telemedicine as a means of
infection control due to the Covid-19 pandemic [1, 2]. This commentary describes
the initial medical student and resident training in telemedicine at the Massachusetts
General Hospital (MGH) a half century ago.

John H. Knowles, MD, a Unique Academic Medicine Leader

John H. Knowles, MD, was an MGH-trained cardiopulmonary internist and the

MGH General Director who was a principal architect for the Logan International
Airport MGH Medical Station multi-specialty telemedicine program (LIA-
MGH-TP). He also touched the lives of both Michael Crichton and Ronald
S. Weinstein, MD, two of the initial trainees in LIA-MGH-TP. Crichton was a
Harvard Medical School (HMS) fourth year medical student, in 1969, and Weinstein
was a third year MGH pathology resident a year earlier, in 1968, when each of them,
separately, encountered telemedicine for the first time, unknowingly to become rec-
ognized as “pioneers in telemedicine training” a half century later.

R. S. Weinstein (*) · M. J. Holcomb

Arizona Telemedicine Program, The University of Arizona’s College of Medicine,
Tucson, AZ, USA
e-mail: [email protected]
E. A. Krupinski
Department of Radiology, Emory University, Atlanta, GA, USA
R. Latifi
Department of Surgery, New York Medical College, School of Medicine
and Westchester Medical Center Health, Valhalla, NY, USA
e-mail: [email protected] ; [email protected]

© Springer Nature Switzerland AG 2021 3

R. Latifi et al. (eds.), Telemedicine, Telehealth and Telepresence,
https://doi.org/10.1007/978-3-030-56917-4_1
4 R. S. Weinstein et al.

When John H. Knowles had enrolled in Harvard College, in the mid-1940s, he

focused his attention on extracurricular campus activities including sports and col-
lege theater where he was a Hasty Pudding Club’s Theater student performer.
Knowles’ fun-loving college years in Cambridge, and Scollay Square entertainment
in Boston, caught up with him when ten medical schools rejected him for admission
[3]. Fortunately for Knowles, and the academic medicine community as well, a curi-
ous dean at Washington University in St. Louis, Missouri took a chance on Knowles
and admitted him into their freshman class. Knowles rose to the occasion and ended
up graduating first in his class. He landed what was then the top prize for a medical
student anywhere in the United States, an internship in medicine at the MGH.
When Knowles arrived at the MGH as an intern, in 1951, he was riding high on
his widely admired Harvard reputation as a nine-varsity letter, three-sport, Harvard
College athlete with a high profile on campus as a Hasty Pudding Club’s Theater
performer. Everyone knew about his miraculous academic turnaround at a highly
ranked medical school in the mid-west. Knowles seemed comfortable with his
celebrity status and was accustomed to being in the limelight.
Knowles more than lived up to his advanced billing. In addition to his talents as
a physician, and his popularity throughout the MGH organization, he was strongly
committed to community outreach. That combination resonated with the MGH
power brokers in Boston’s financial district and the wealthy MGH trustees. They
were looking for a new kind of leader for the MGH, somebody who could help
transform their stodgy, but beloved, inward-looking Ivy League-minded institution
into an outward-looking community leader in healthcare.
Changes in the US healthcare industry, in the mid-1960s, also favored Knowles’s
emergence as a national leader. His interest in community outreach became relevant
to the US healthcare policy agenda. It is noteworthy that the passage of Medicare
and Medicaid legislation in 1965 was a game changer for the US university hospital
industry. Nineteenth century-style charity wards were eliminated, with their patients
being transferred into revenue-generating beds elsewhere in the hospital. Almost
overnight, community engagement became a hot topic as a new potential source of
revenue for hospitals. The seeds were sowed for the creation of a new wave of com-
munity health centers, in urban areas. Knowles had positioned himself to be a leader
in that arena [4–6]. It was in that setting that telemedicine popped up on the radar
screen in Boston, with Knowles cheering it on as one of its greatest advocates.

The First MGH Telemedicine Trainees

Historically, Michael Crichton was the first HMS student to take a clinical rotation
in the pioneering LIA-MGH-TP, in 1969. He is the only HMS student known to
have published a chapter in a book about that medical student experience. His book,
Five Patients. The Hospital Explained, provides an interesting picture of various
aspects of academic medicine at the time multi-specialty telemedicine appeared on
the scene in Boston, Massachusetts, in 1968 [7]. With respect to his subsequent
career, Crichton ultimately chose not to obtain a medical license, or practice
1 First Trainees: The Golden Anniversary of the Early History of Telemedicine… 5

medicine, but he followed the latest medical research advances throughout his
career. Crichton wrote his first best-selling novel, Andromeda Strain, as an HMS
student. He followed this up with his novel and movie Jurassic Park.
The first resident-trainee of LIA-MGH-TP was Ronald S. Weinstein, M.D., a co-­
author of this article. Weinstein is 81 years old and still works full time as the Founding
Director of the national award-winning Arizona Telemedicine Program, in Tucson,
Arizona. Weinstein is President Emeritus of the American Telemedicine Association.
He is a pathologist who had his fellowship training at the MGH and Harvard in cancer
biology research. He spent much of his research career studying cancer cell invasion
and metastasis and, later, mechanisms of cancer multi-drug resistance [8, 9]. Weinstein
has been recognized as the “father of telepathology,” a subspecialty of telemedicine.
He invented, patented, and commercialized robotic telepathology and introduced the
term “telepathology” into the English language [10, 11].

John H. Knowles, MD, as a Mentor

In 1962, John H. Knowles, MD, at age 35, became the youngest General Director in
the history of the 150-year-old MGH [6] (Fig. 1.1). A high-energy individual,
Knowles was actively involved in HMS training programs at multiple levels. As
MGH Hospital General Director, Knowles personally took ward service call a week
each month. Weinstein recalls Knowles participating in the weekly medicine

Fig. 1.1 (Left) Dr. John H. Knowles examining a patient. A highly competitive college athlete,
Knowles had been a standout three-sport Harvard varsity letterman, in baseball, hockey, and
squash. (Photo credit: Leonard McCombe/The Life Picture Collection/Getty Images). (Right)
MGH General Director John Knowles meeting with a group of visitors at the MGH. He was
“extraordinarily articulate, elegant in thought, scrupulous and respectful of language” [4]. Knowles
was the administrator behind the establishment of the Logan International Airport MGH Medical
Station telemedicine program. The MGH Medical Station was an integral component of Knowles
MGH community outreach program for Boston. (Photo credit: Leonard McCombe/The Life
Picture Collection/Getty Images)
6 R. S. Weinstein et al.

morbidity and mortality (M&M) meetings in the Bulfinch Building. Knowles took
pathology residents presenting their autopsy case results through their paces.
Knowles could discuss complicated medical cases on the fly, thinking out loud,
using brilliant reasoning, presenting his summaries and conclusions in verbal para-
graphs, always with theatrical flair. At the end of each commentary, he would stand
with that endearing smile on his face, and methodically nod with raised eyebrows,
individually, to each of the tenured Harvard professors in the conference room. In
other settings, Knowles strongly encouraged MGH trainees, such as Weinstein, to
step up into leadership positions that “would make a difference in the world” [4–6].
A decade later, still at the relatively young age of 45, Knowles was named President
of the Rockefeller Foundation in New York City. This provided Knowles with a
platform on which to continue his work on US healthcare delivery system reform
and community outreach.

 rigins Logan International Airport MGH Medical Station

O
Telemedicine Program

On October 4, 1960, an Eastern Air Lines, Lockheed Electra L-188 prop-jet com-
mercial airliner crashed immediately after takeoff from runway 9 the Logan
International Airport, in Boston. The airplane struck a flock of starlings at an alti-
tude of approximately 120 feet and crashed into Winthrop Harbor, an extension of
Boston harbor. Dozens of passengers were killed. While many on board were killed
instantly in the crash, there were also survivors with critical injuries that subse-
quently died without medical care. Getting emergency medical personnel out to
Logan International Airport (LIA) was a logistical nightmare as the only ground
transportation access was through the Callahan Tunnel, the single gateway to and
from downtown Boston. Telemedicine emerged as a practical solution [12–14].
Knowles was a strong proponent from the start, although the idea for it was not his
own. That came from his clinical counterpart, the cardiopulmonary internist,
Kenneth T. Bird, MD.
In 1962, the same year Knowles became MGH General Director, Ronald
S. Weinstein, a second-year medical student at Tufts Medical School (TMS) across
town, accepted a one-year post-Sophomore fellowship in biophysics and electron
microscopy in the MGH Department of Neurosurgery, which housed the Mixter
Laboratory for Electron Microscopy, headed by Stanley Bullivant, PhD, a pioneer
in a new field, freeze-fracture electron microscopy. Three years later, Weinstein was
awarded a pathology residency at the MGH, becoming the first TMS graduate
accepted into any MGH residency program. Knowles, and the MGH Chair of
Neurosurgery, William H. Sweet, MD, encouraged Weinstein to apply for a National
Institutes of Health (NIH) grant as a Principal Investigator on a Program Project
grant. Knowles personally signed the request letter for an NIH waiver allowing the
award [15–17]. Knowles liked Weinstein’s career trajectory. He proudly acknowl-
edged Weinstein’s accomplishments as a success story for community outreach
since Weinstein had been recruited to MGH from Tufts Medical School, across town.
1 First Trainees: The Golden Anniversary of the Early History of Telemedicine… 7

On January 3, 1963, the Logan International Airport MGH Medical Station, a

cooperative venture between MGH and the Massachusetts Port Authority, orches-
trated by Knowles, opened to patients with Dr. Kenneth T. Bird as its medical direc-
tor. Within a few years, the clinic was seeing 100 patients a day. The creation of a
Logan International Airport telemedicine service was Bird’s idea [12]. He was tired
of driving back and forth between the MGH and the Logan Airport. Telemedicine
stood out as a potential solution, and Knowles provided resources to support the
effort. John Knowles saw telemedicine from a larger perspective. For him, it was a
success in the development of his MGH community outreach programs. While
Knowles would never detract from the originality and importance of Bird’s contri-
butions, nor fail to give Bird full credit for his innovations and achievements in
LIA-MGH-TP, nevertheless LIA-MGH-TP was recognized as one of Knowles’ sig-
nature achievements as well [14] (Fig. 1.2). Dr. Bird coined the term “telemedi-
cine” [12].
To create the MGH telemedicine program, LIA was linked to the MGH, 2.7 miles
away, over a private bidirectional microwave telecommunication linkage [13]. At
that time, NASA (National Aeronautics and Space Administration) was exploring

Fig. 1.2 Telemedicine (initially called “Telediagnosis” at the MGH) was featured in the January
11, 1969, issue of the popular magazine “TV Guide,” nine months after the Logan International
Airport-MGH Medical Station telediagnosis program became operational, on April 8, 1968. (Left)
Cover of January 1969 TV Guide featuring the 65th birthday of the comedian Bob Hope. Hope
died at age 100 in 2003. (Right—two-page spread in this issue of TV Guide). (Upper photo) A
dermatology patient at the walk-in Logan International Airport MGH Medical Station
“Telediagnosis clinic” is being examined remotely by television. (Lower photo) Kenneth T. Bird,
MD, at the MGH, is examining the dark irregular purple skin lesion on the patient’s left foot, using
the robotically controlled-TV camera out at the Logan Airport. The patient’s left leg is covered
with a light-colored drape (Upper photo). Dr. Bird, looking straight ahead, is viewing the skin
lesion on a black-and-white TV monitor. (not shown). He is adjusting the TV image magnification
and focus of the patient’s foot lesion by manipulating a TV control panel with his right hand. Dr.
Bird uses ear buds to listen to heart and breath sounds coming from an electronic stethoscope
(not shown)
8 R. S. Weinstein et al.

terrestrial applications for technologies developed to care for astronauts in space

[18, 19]. The health of astronauts was constantly in the news. Many doctors and
nurses knew what an electronic stethoscope was and believed that it might even
outperform the traditional stethoscope. The MGH was following NASA’s lead in its
implementations of electronic devices for remote patient care. As a frame of refer-
ence, the first lunar landing took place just a few months after Crichton graduated
from HMS in 1969. The LIA-MGH-TP program was 4 years in the planning [12].

 richton’s and Weinstein’s Involvements with Telemedicine

C
as MGH Trainees

Crichton was a fourth year Harvard medical student when he rotated through the
Medical Station telemedicine service (initially referred to as a “Tele-diagnostic
Service”), in 1969.
In 1968, Weinstein had his first involvement with remote television microscopy. His
background in biologic research and medical imaging was unusual for a medical stu-
dent. He first became involved with high-resolution electron microscopy in 1960, when
he was Head Chemist in the Department of Research Services, at the Woods Hole
Marine Biology Laboratory (MBL), in Woods Hole, Massachusetts [20]. This was a
summer job, between semesters, first at Albany Medical College, in Albany, New York,
and then at Tufts Medical School, in Boston, where Weinstein became a transfer stu-
dent. His assignment as an MGH post-sophomore fellow in electron microscopy was
to redesign the equipment used for preparing biological specimens for high-resolution
freeze-fracture specimen electron microscopy [21]. The goal was to take the resolution
of freeze-fracture electron microscopy down to the molecular level.
Weinstein succeeded well beyond anybody’s expectations. Use of his “Type II
Freeze-Fracture Device” provided exquisite images of what became known as “con-
nexin complexes” and their hydrophilic channels that are the structural basis for
electronic and metabolic coupling between human epithelial cells [16, 17, 22]. He,
and a collaborator, N. Scott McNutt, went a step further and showed that deficien-
cies in these complexes are early manifestations of malignant transformation in
certain human cancers [23]. Weinstein’s special interests in medical imaging were
well known in the MGH Department of Pathology and at Harvard Medical School.
This interest led directly to his involvement with the LIA-MGH-TP [15].
In 1967 prior to the opening of the LIA-MGH-TP clinic, a Harvard Medical
School Professor and staff pathologist at the MGH, Robert E. Scully, MD, became
involved in testing television microscopy equipment to determine its suitability for
doing remote clinical microscopy (e.g., light microscopic examination of blood
smears and urine sediments using television). Scully kept Weinstein in the loop.
(Fig. 1.4) First, Scully examined the need for color television as compared with
black-and-white television. He demonstrated nearly 100% diagnostic accuracy
using standard black-and-white television [25]. This was not surprising since televi-
sion microscopy (later called “video microscopy”) had been used for biological
research starting in 1955. When Weinstein was Head Chemist at the MBL, during
1 First Trainees: The Golden Anniversary of the Early History of Telemedicine… 9

Fig. 1.3 (Left photo) Dr. Weinstein’s 2018 visit to the MGH, marking the 50th anniversary of his
original participation in television microscopy cases coming in from the Logan International
Airport. MGH’s White Building’s first floor main hallway entrance into the Emergency Ward. The
MGH Tele-diagnostic suite was on the first floor, in an alcove off the Emergency Ward. (Right
photo) Marking the 50th anniversary of television microscopy in the Pathology Department at the
MGH. Dr. David Louis, Castleman Chair of Pathology (left), is with Dr. Weinstein in the MGH
Pathology Department Library (April 27, 2018). Dr. Castleman, for whom the Chair is named, is
present in Fig. 1.4. (Fig. 1.4, front row). Dr. Robert B. Colvin, a former Castleman Chair of
Pathology, is pictured in the oil painting on the wall. In the 1968 MGH Pathology Department
annual photo (Fig. 1.4, taken 50 years previously, in 1968), Dr. Colvin was an MGH pathology
trainee (Fig. 1.4, last row, second from the left). (Reproduced with permission from [20])

his summer breaks in medical school, he had frequently visited laboratories where
video light microscopy experiments were underway and discussed the technology
with senior investigators. Based on his survey of the field, Weinstein was able to
reassure Dr. Scully that doing routine black-and-white television microscopy as a
substitute to traditional hands-on light microscopy worked well and had little risk.
One day in 1968, while Weinstein was signing out surgical pathology cases with
Dr. Scully, Dr. Scully invited him to lunch and said the reward would be “something
special.” Following lunch in the MGH staff cafeteria, they walked over to the tele-
medicine suite on the first floor of the White Building (Figs. 1.2 and 1.3). Once
there, Dr. Scully telephoned the nurse-manager at the MGH Walk-In Clinic at Logan
Airport. He reviewed the clinical history of the first patient with Weinstein and then
asked the nurse to place the blood smear of Case #1 on the stage of the television
light microscope out at the airport. An image of the blood smear popped up on the
television monitor in their darkened room. (Fig. 1.5) Dr. Scully instructed the nurse
on where to move the slide on the microscope stage, how fast to move it, and where
to stop and focus. Several times Scully said “higher” or “lower” to instruct the nurse
on bringing the blood sample on the glass slide into optimal focus. After examining
a Wright Stain stained blood smear for several minutes, Scully asked Weinstein for
10 R. S. Weinstein et al.

Fig. 1.4 1968 MGH Department of Pathology on the steps of the historic Bulfinch Building, a
National Historic Landmark. Robert E. Scully, MD, is in the front row, 3rd from the right. Dr.
Weinstein is in the 3rd row, 3rd from the right, standing behind Dr. Scully. Benjamin Castleman,
MD, Chair of the MGH Department of Pathology, is in the front row, 4th from the right, standing
next to Dr. Scully. Robert B. Colvin, MD, a future Castleman Chair, is in the last row, 2nd from the
left. In his long career at the MGH, Dr. Castleman trained 15 future pathology department chairs
and produced over 2000 professional publications, a nearly unimaginable number today.
(Reproduced with permission from [24])

a diagnosis. Weinstein and Scully agreed on the diagnosis of “hypochromic micro-

cytic anemia” which Scully then reported to the nurse over the telephone. They went
through the same routine for Case #2, which turned out to be a “normal” blood
smear. Dr. Scully said, “Well, Ronnie, we just made history.” They agreed that the
process had been straightforward, easy to do, that color television was not required,
and the black-and-white television images were surprisingly good.

 richton’s Medical Student Book “Five Patients.

C
The Hospital Explained”

Michael Crichton’s student involvement with telemedicine education and training

was much more extensive than Weinstein’s. Crichton’s experience was the subject
of a chapter in “Five Patients. The Hospital Explained,” a book he completed writ-
ing just months before his graduation from HMS and published in 1970 [7].
1 First Trainees: The Golden Anniversary of the Early History of Telemedicine… 11

Fig. 1.5 Example of a television microscopy (video microscopy) image of a Wright Stain blood
smear, originating at the Logan International Airport MGH Medical Station, and viewed on a
black-and-white television screen at the MGH. (Photo credit: Raymond LH, Murphy, JR,
“Telediagnosis: A new Community Health Resource: Observations on the Feasibility of
Telediagnosis Based on 1000 Patient Transactions.” American Journal of Public Health, February
1974; 64(2): 113 to 119, Figure 2, American Public Health Association [26])

While completing “Five Patients,” Crichton had discussions with Dr. Knowles
about his experiences on the MGH telemedicine service, and their potential implica-
tions for healthcare in the future. Knowles’ opinions and concerns show up in the
text as sage observations by a learned mentor. Knowles also enriched Crichton’s
telemedicine experience by connecting him with senior MGH staff and with emi-
nent professors at the Massachusetts Institute of Technology (MIT), a virtual temple
for research on medical computer applications as well as leading edge research on
Artificial Intelligence (AI).
Crichton’s book “Five Patients: The Hospital Explained” is somewhat of a time
capsule of what academic medicine was like a half century ago. On the one hand,
Crichton was intrigued by the technologies of healthcare and the complexity of
healthcare delivery, but on the other hand, hospital deficiencies were sobering to
him, and the ambiguities of medical diagnostics and frustrations of the medical staff
over uncertainties that permeate many aspects patient care, even in a world-class
hospital, discouraged Crichton from taking the final step into medical practice
(Fig. 1.6) . He did not apply for a medical license. Still, Crichton never lost his inter-
est in medical sciences and emerging technologies, and he stayed current with
advances in medical research for the rest of his life [27].
The “five patients” in Crichton’s book were five actual cases of men and women
in immediate need of medical help rushed to the MGH [7]. Crichton uses these
cases to explain how hospital practice was changing in the age of science-­technology
explosion. Crichton used one of his cases to discuss the patient-experience using
12 R. S. Weinstein et al.

Fig. 1.6 Michael Crichton, dressed in surgical scrubs, during a Harvard Medical School (HMS)
clinical rotation, in 1968. Crichton, a student of English literature, had a playful sense of humor
regarding his own towering height. Here, the 6’ 9” Crichton is dressed to recognize Sir Jeffrey
Hudson (see surgical cap label), a storied member of the Seventeenth Century court of the English
queen Henrietta Maria of France with height challenges. Crichton also wrote a medical mystery,
“A Case of Need,” for which he received an Edgar Award in 1968, using the pseudonym Jeffery
Hudson. He wrote a collection (“The Med School Years Collection”) of 8 paperback thrillers in
medical school using the pseudonym John Lange. (This Figure is reproduced from http://www.
michaelcrichton.com/doctor/, with permission from Taylor Crichton. Ronald S. Weinstein, M.D. was
a Teaching Fellow at HMS, while an MGH pathology resident and laboratory director, and taught
pathology to Michael Crichton’s HMS class)

videoconferencing with a doctor on the other end. He discusses the limitations of

the technology, and he considers advances in developing next-generation technolo-
gies for patient care, including decision support systems and Artificial Intelligence
(AI). Crichton realized that computer programs could offer extraordinary possibili-
ties: any community in the country, “or even a doctor’s office could plug into the
MGH program and let the computer monitor the patient and direct therapy” [28].
This sounds modern even today.

Crichton’s Telemedicine Patient Workup

The telemedicine patient Crichton assisted in working up, as a senior medical stu-
dent, was Mrs. Sylvia Thompson, a 56-year-old mother of three who began to expe-
rience severe, but not persistent chest pain over Ohio on a flight from Los Angeles
to Boston. After the plane landed, she was directed to the Logan Airport MGH
Medical Station near the Eastern Airlines terminal. After explaining her problem to
the secretary, she was led to the telecommunications-equipped clinical examination
room (Fig. 1.2). After a brief orientation by the nurse, Dr. Raymond Murphy, at the
Exploring the Variety of Random
Documents with Different Content
will provide a continuous covered passageway from the door of one’s
apartment to the station. As for ventilation, which is a puzzling
problem in city subways, it will be solved by a continuous opening
made by building the house three or four feet above the ground; the
Roadtown trains will therefore run in a covered trench rather than in
a subway.

Because of the rail straddling plan the Boyes car must be entered
from both sides. Three tracks will be required and these will be
arranged one beneath the other. The reason for this is obvious: if
arranged side by side, passengers would have to climb up the height
of the car and down again. Arranged vertically, they need climb only
up or down. Because the distance from rail level to car floor level is
practically eliminated in the Boyes car, this climb will be but seven or
eight feet instead of twelve as with present train service. The upper
track will be for local service. Passengers will walk from their house
along a continuous platform or hallway to the local stations, which
will be located about 100 yards apart. The object of having definite
stations or stopping places is simply one of gaining speed by having
the people in groups. The platform will be continuous and the trains
can be stopped at any house desired if there be a good reason for
so doing.

About every five miles there will be an express station. Here the
people will climb down eight feet, or sixteen if going the opposite
direction, and board a train that is not bothered with frequent stops
and can hence make very high speed.

The following is a sample specification of Roadtown train service

as submitted by William H. Boyes, using the Boyes Monorail System
at a speed of only ninety miles per hour. Line from New York to
Philadelphia, ninety miles. Daily traveling population, one to a family,
250 per mile, 11,250 to go each way. 3,916 per hour for three rush
hours. Speed, ninety miles per hour; time of round trip, two hours;
trains five minutes apart; stations, five miles apart. Trains, twenty-
four; seating capacity per train, 336; capacity of express service,
4,032 hourly. Local trains oscillating between express stations each
to carry 224 passengers per hour, eighteen required.

This specification submitted by Mr. Boyes gives a remarkably small

equipment for the traffic handled compared with present figures.
The chief difference is due to the high speed. There are many who
will not believe that a ninety-mile schedule will be maintained, not so
many perhaps as would two years ago have refused to believe that
man could fly from New York to Philadelphia, an account of the
accomplishment of which lies on my desk as I write. For those to
whom seeing is necessary to believing, the speed above may be cut
in half, which will then be about that in the New York Subway. The
express trains will then run on a two-and-a-half-minute schedule and
twice as many will be required, but the cost will still be much lower
than present day commuting service and efficient enough to make
the entire Roadtown from New York to Philadelphia as accessible for
commuters as is now a suburban home fifteen miles from New York
and a half mile from the railroad station.

The single train on the local track will make a round trip between
express stations about every fifteen minutes. Those near the middle
of the section will catch the train going in either direction, as the
time for the express to travel the distance of one express station is
negligible. In each Roadtown home there will be an electric buzzer
which, when the switch is so turned, will announce the approach of
a train in sufficient time to allow one to get to the station. The
buzzer will have two distinct sounds, one for trains in either
direction.

Roadtown parcels, such as are not cared for in a small mechanical

carrier described in Chapter VI, will be hauled on the local trains.
Roadtown freight service will be at night on the express tracks, the
trains stopping at stations located at suitable distances and distinct
from the passenger stations. At these freight stations there will be
elevators or inclines delivering freight to or receiving it from the land
outside, while furniture, etc., for the houses will be elevated to the
platform above and carried on the very early trips of the local trains
to one’s door.

Wrecks on such a railroad system can only occur from actual

breaking of some working part, a comparatively rare cause of
present wrecks. The local track collision cannot occur as there is only
one train in a section. On the two express tracks, “tail-end” collisions
will be prevented by a block system that turns off the power
automatically when trains approach within a certain distance of each
other. This system is in operation in the New York Subways.

The Street Upon the Roof.

Private stairs from each home will lead down to the monorail
platform and up to the roof. In the center of the roof will be a
promenade which will be covered, and in the winter enclosed with
glass panels and steam heated. On the outer edges of the roof will
be a path for bicyclists and skaters, who will use rubber tired roller
skates. The monorail, which is the business transportation system of
Roadtown, will be placed out of sight and run at high speed, but the
roof promenade will be the “street” for recreation and pleasure. In
winter the promenade will be a continuous sun parlor; in summer a
shaded walk. There will be benches in alcoves along the way and
occasional towers over the promenade and tower effects along the
edges of the roof beyond the cycle paths or some other architectural
effects to break the monotony. These towers will be used as
coöperative centers, such as stores, cooking and power, recreation,
schools, nurseries, etc. The tower effects are matters of architectural
ingenuity, and many architects are already interested in finding ways
to lend variety and beauty to the Roadtown as they have to our
existing public ways.

Certainly no street or boulevard in the history of the world was

ever more uniquely located. The splendid view to be obtained from
such a promenade in a dust-free and smoke-free country can hardly
be pictured to a city bred man or a countryman jogging along the
hedge and weed throttled country road. The view across the near
gardens and more distant grain fields, and back over woods and hills
to the dim line where land meets sky, will cure forever a score of
Latin-named diseases which the eye specialist tells us come from
gazing through the dust-laden street or across the dingy court into
our neighbor’s kitchen window.

It is upon the roof that the Roadtown will be upon dress parade.
Here maids with their lovers will stroll of evenings and matrons with
their baby carriages on Sunday afternoons. It is here that children
will have never ending sport. Skating and cycling can have an
unprecedented opportunity to develop for health and pleasure. It is
here that Easter hats will be shown and neighbors’ crops discussed
and new acquaintances made and local pride developed.

The question naturally arises as to the sound of conversation from

the roof reaching the living-rooms or the sound from the rooms
reaching the roof. The cement walls are practically sound proof and
for sounds to be heard from roof to house or house to house
requires that it pass into the open air and bend through a 180
degree angle. Sound does not travel in that way as one may readily
prove by trying to shout around the corner of a ledge of rock or over
a stone building. With all windows and doors wide open in the
Roadtown home, the only sound of ordinary magnitude to be heard
will be from the singing of birds and the play of children in front of
the window. The uncanny noise of city streets and of quarrelsome
neighbors across the air shaft will be missing. People who cannot
content themselves with the quiet of a Roadtown home will have to
use the telephone, electric music, roof promenade or go to the social
center. Promenaders cannot stare into nor listen at their neighbors’
windows. The Roadtowner’s home is his castle in the truest sense of
the word, and more private, notwithstanding the close proximity to
neighbors, and hence more consecrated to family life than any
previous style of dwelling known.
 The Roadtown will have no streets because it will need none. As it
is built through the country, there will, of course, be roads as well as
streets to cross. Here the monorail will run under, and the roof
bridge over the roads. At such road crossings and such other places
where roads are built back into the country, stables and garages will
be provided.

The natural desire to drive one’s own vehicles up to the door of his
own house will cause an occasional remonstrance against the plan at
first, but as people find that there is no need of such roadways they
will come to consider the Roadtown road crossings as their front
door, when viewed from the auto or equestrian’s standpoint, and no
more think of the necessity of a private roadway to their own house
than that of having their auto sent up the tenth story of an
apartment house.

Those who wish to pay a visit to a Roadtown home will come to

the nearest point where the railroad crosses the Roadtown or if
traveling by horse or auto where the public road crosses the
Roadtown and will leave their vehicle in charge of a caretaker and
have their name ’phoned in as one does at an up-to-date apartment
house or hotel. If the Roadtowner is at home, the caller will then
take the monorail or the roof promenade as the distance or his
inclination dictates, and thus reach the door of his friend’s home.

Such a system will give the humblest Roadtowner the opportunity

of the high class apartment house dweller to say that he is not at
home to unwelcome visitors, and yet the Roadtown home built on
the ground floor with its windows looking out into a private garden
will have all the home-like simplicity of a cottage, and at the same
time modern conveniences and luxuries which cannot be found in
any King’s palace.
 CHAPTER V
CIVILIZATION THROUGH PIPES AND WIRES

T HE economies of a continuous house under one roof and of

railroad and steam shovel, rather than hand and dump cart
methods, are sufficient to make the line construction far more
economical than any method now in vogue, but even they are
greatly exceeded by the additional saving involved in the installation
and operation of the pipes and wires of the Roadtown.

Witness the present situation. The farmer’s house is alone in the

middle of his farm. For every pipe, wire or rail utility with which he is
supplied, he must have a plant of his own. If he wishes steam heat,
he must put in a boiler; if he wishes electric lights, an engine and
dynamo.

In practice the farmer, with the occasional exception of the rural

telephone, is limited to the products of civilization that can be hauled
home in a wagon.

The city man is a little better off. City dwellers are close together,
close enough that one electric, gas or steam producing plant will do
for many hundreds or thousands of families, but by the present plan
which enables them to have these improvements, they pay not only
the expense of periodic tearing up of the pavements and the house
foundation, but a far greater price in the loss of air, sunlight and
privacy.

The Roadtown has these God-given utilities of country air and

light on two sides of the house. Upon the other two sides it has
blank walls, but the examination of the average isolated residence
will show that there is little to be gained in light or air by the two
extra sides and much to be lost in privacy. Upon the two remaining
sides, i. e., the top and bottom, the Roadtown house has its
sidewalk on the roof and its transportation by rails, pipes and wires
that are now in the city streets, it has on a far better and economical
plan in the basement, now used principally to store old trunks,
rubbish and coal.

Picture the installation of a new pipe line through a paved street.

The expense and the unsightliness, the danger to human life—and
this has nothing to do with getting the pipes into a private house.

Now suppose you are a resident on that line and conclude a

couple of months later to install the utility in your home. Again the
pavement is torn up, a gang of laborers spend several days on the
job, and you as consumer will pay the bill either in a lump or as stiff
rates on the utility sold. The result of this clumsy system has been
that pipe and wire utilities in the city are limited to those people who
use them to a sufficient extent to stand this criminal waste and
expense.

Moreover, in all large cities the matter of installing pipe or wire

conveyed utilities is also a question of reckoning with franchise-
selling politicians and private monopolists who generally work “hand
in hand.”

Compare these conditions, mechanical and political, with the

Roadtown where all pipes and wires will be bracketed in a runway
beneath the floor of a machine-made house on land at farm prices.
To put in a new pipe conveyed utility will cost the price of the
twenty-one feet of main and a branch pipe leading to the apartment
above through suitable openings made when the building is
constructed. The expense will be about equal to that of maintaining
the red lanterns which are now placed about the torn up city streets.

As a result of these differences there will be added to the

Roadtown home—and I mean to the home of the man of average
means—a number of utilities now available only to the rich, or not
available at all.

Beginning with the following paragraph I will enumerate some of

the inventions that will be available in the Roadtown home. I may
include in this list some inventions which, while demonstrated on a
small scale, may for some reason not now discernible, develop an
objection or difficulty in its use. But for every such a one that I may
here include, there will be several others that science has already or
will yet devise and which can be installed in Roadtown as soon as
perfected and demonstrated with no more expense than there would
be if it were put in when the houses were built. This feature alone is
a tremendous argument in favor of the Roadtown, for every previous
form of house construction once finished is set in its equipment and
soon gets behind the age and must be torn down to make room for
the new. At this time considerable humorous comment is being
made in the newspapers over the tearing down of a twenty-two
story building in Wall Street to make room for a forty story one. The
old one is only thirteen years old. The Roadtown will always be
“modern,” and increase in efficiency as it increases in length while
the separate building is a complete unit with its height and utilities
stationary.

Water.
The water systems of great cities are enormously expensive, as it
is usually necessary to build great conduits dozens and even as
much as one hundred and fifty miles long. The trouble with such
cities is that a very large population must be supplied with water
from a very limited area. The Roadtown with a population of about
1,000 to the mile will be able to get its water supply from suitable
sources all along the way. The length of line to be supplied from one
public station will not be great, but the entire main may be opened
so that one station can relieve another in case of excessive use of
water at any given point.

Sewerage.
The sewage system of the Roadtown will, like the water system,
be built in comparatively small units, and will require none of the
large and expensive sewers seen in city systems. Wherever the
Roadtown crosses a natural valley in the land the sewage can be led
off to a reasonable distance from the house line in pipes and used in
irrigating non-food crops. The income to be derived from the use of
this sewage for fertilization and irrigation will be a considerable
source of profit and wholly without the expense attached to city
sewage disposal works because of distance from the land and the
fact that the point of the city sewer outlet is almost always below
the level of land available for such uses.

Heating.
The Roadtown heating system will be of hot water circulated by
pumps. The heating plants will be located every two or three miles,
which, according to the engineers’ figures will be more economical
than to have them either at greater or less distance. The
temperature will be regulated to suit each and every tenant by the
use of the thermostat with a push button regulator in each room of
every apartment. This simple, but marvelously useful device, is now
in general use in thousands of first class hotels.

Refrigeration.
The refrigerating system of Roadtown which will be required for
food and drinking water purposes could be turned into the radiators
and a circulation of cooled water or brine pumped through the
houses. I do not say that such house cooling will be established, for
the Roadtown house, through which the breeze will have a full
sweep, and in which the electrical fans will be plentiful, will have
little need for a system of house cooling, but if the people in hot
countries wish it and care to pay for it, eventually they can have it.

Drinking Water.
The next utility for the Roadtown house will be that of pure, cool
distilled water for drinking purposes, cooled only to a healthful
temperature. Because of the small expense for piping, this
separation of the system of drinking water from that used for
bathing and for spraying the lawn will mean that no method known
to science for purifying the former need be spared.

In present city life the peddling of so-called “spring water” in

bottles, is a farcical affair, which would have about as much chance
to survive in Roadtown as an independent oil producer shipping oil in
barrels would have in competing with the trust’s tank cars and pipe
lines. If the Roadtown is piped for refrigeration, cooling will be very
simple. If this is not done the coolers may be placed in the
basement and filled with ice manufactured at the central
refrigeration plant and distributed by train. In either case, the
efficiency will be great as compared with any present system.

Bath and Toilet.

It goes without saying that every home in Roadtown will be
provided with good bath and toilet facilities. Because of the fact that
the house is of cement and has no lath and plaster ceiling to get
soaked, shower baths will probably be much in vogue in Roadtown.
If at any time it proves desirable to give up the space for the
purpose there can be shower baths installed in every sleeping-room
at a cost of only a few dollars for each. The soap for bath and wash
basin will probably be liquid, and while there will not be enough
used to make it worth while to pipe it, it can be supplied ten gallons
at a time by a man who will make the rounds and fill the reservoirs
at each home. This is comparatively a small matter and I merely
mention it to show the extent to which the natural coöperation of
line house building will gradually lead.

Gas.
For light cooking and local heating in the Roadtown home, to such
extent as is desirable, gas will be used.

Vacuum.
During the last few years a great vacuum sweeper craze has
swept the country. We are literally deluged with every type of
apparatus, from systems for installation in hotels and office
buildings, or wagon outfits that chase about the street and run a
hose into the parlor window, to the little pop gun arrangement that
is worked by hand. The ease of adaptability of the best features of
vacuum cleaning systems to Roadtown is too apparent to need
comment further than to say that a small pipe, with an opening at
each home, and a suction fan every half mile, will be sufficient to
give the best possible results.

A further use of this vacuum may be made in connection with

automatic movement of windows, doors, etc. Compressed air is now
frequently used for this purpose as in elevator doors in office
buildings. Vacuum will, of course, work equally well.

Disinfecting Gas.
A pipe dream of Roadtown that is absolutely practical, cheap and
a crying need, will be gas for disinfection.

Electric Light.
Electricity for lighting will, of course, be available in Roadtown at a
fraction of the present cost.

Electric Power.
Electricity will be used for fans, vibrators for massage,
shoeshining, and other household devices that may demand it as
time rolls on. Besides this there will be an industrial use for power
which I will discuss in a later chapter.[A]
[A] Until some cheaper source of power is developed electric
heating will remain an expensive luxury.

Telephones.
Electric buttons and signals and bells can be used for the “top”
and “bottom” doors of the house, signaling to central stations when
preferable to the telephone. The telephone, the cheapest of the pipe
and wire group of civilizing agents, common though it is, has not yet
come into universal use. In New York City alone there are over three
million people who have no telephones and in the United States
there are 60,000,000 deprived of that great necessity. In Roadtown
the cost of installing telephones will be practically the cost of the
instruments, switch-boards and twenty-one feet of wire. If the
automatic system is used, which is likely, in local service between a
public service center and the houses they wait upon, the cost will be
but those of interest on installation and cost of repairs. A telephone
expert has estimated that the system complete would be less than
ten dollars per family, and that the expense of operation or
telephone rent less than one dollar a year, net, per family, or eight
cents per month.

Dictograph.
At the present date there is in practical operation a loud speaking
telephone called the dictograph. If this modern invention is installed
in the Roadtown home, it will be possible by simply pressing a
button to talk over the telephone while sitting in a chair or lying in
bed. This instrument has been most successfully utilized in
conveying music, which, if received through a horn can scarcely be
told from the first-hand product. This wonderful invention, as many
other similar ones that now exist, cannot be put into practical use on
a large and systematic scale, because of the present city
construction, the conduit and other trusts.

Since the preceding paragraph was written, M. K. Turner, the

inventor and proprietor of the dictograph, has donated the use of all
of his wonderful patents to the Roadtown, and in addition has
offered to design an entire system of loud speaking telephones
especially adapted to Roadtown use, because of the great uplifting
influence he recognizes in its principles when put into practice.

This donation, together with the house pouring scheme of Mr.

Edison and the Boyes Monorail, gives to Roadtown fundamental
patents on house building, transportation and intelligence
transmission—the three great essentials of a new civilization.

Telegraphone.
The telegraphone, or recording telephone, is also a most
wonderful invention. The telegraphone records any sound sent over
a telephone by means of magnetic changes in a disc or wire. These
steel disc records or wire records can then be reproduced any
number of times with no loss of distinctness. As the dictograph may
be used to give a sermon, lecture or piece of music to any number
of people at one time, so the telegraphone may be used to record
and repeat it any number of times.

I could add other inventions to the list, but will not, for these
already given, though all practical existing devices, will be so
wonderful in application that I will not extend the list to any less
thoroughly proven inventions, lest the reader who can but judge
from the viewpoint of the present imperfect city civilization, confuse
the Roadtown which is the plan grouping of proven inventions with
the dreams of novelists who revel in inventions yet to be.
 CHAPTER VI
ROADTOWN HOUSEKEEPING

T HOUGH it is true that some work, which in the past rested

heavily upon the shoulders of women, has been taken into the
factory, notably the spinning, weaving and clothes making
trades, and on the farm the making of butter, still the bulk of labor
of the women of the average household comes in that group of
washing, ironing, dusting, sweeping, scrubbing, making beds,
cooking and dish-washing. This is woman’s work in the most of our
homes, and a servant’s work in the homes of the rich.

Woman’s Work not Specialized.

Industrial progress has not yet applied to this work of women the
specialization and labor saving machinery that has sent forward the
general work of the world at such a rapid pace. Another way of
expressing the same idea is to say that in at least nine-tenths of the
households, the woman is the household servant. If the work be
assigned to outsiders, then the privacy of the family circle is broken
up and the dearest ties of earth are disturbed by intruders. At
present there are two ways out of the difficulty. The way of the rich
is the employment of household servants. To counteract the
disturbance of family life an elaborate system of servant etiquette
has been established by means of which the servant is made to
resemble, as much as possible, the cookstove or the family horse.
This satisfies the family, but is disagreeable to the servant, and
incidently keeps a worker out of productive effort, raises the cost of
living to everybody, and deprives her of the most normal expression
of womanhood—that of marrying and coddling her own children.
 The second solution is for those too poor to employ servants. It
consists in eulogizing the “homely virtues” and writing poems about
the duties of women in the home and artfully associating the
scouring of a brass kettle with the instinct of motherhood. This effort
to satisfy the women in the home in playing the personal servant to
the rest of the family by enshrining the dish-rag and broom is
nothing new in the history of the world. Those who have benefited
from the work of others have always been quick to quote scripture
to keep the worker on the job, and as long as there is no other way
to get the work done, this plastering over of dirty work with beautiful
thoughts is indeed a makeshift virtue, but one of which we shall
some day be thoroughly ashamed.

In the Roadtown, this problem, old as civilization, will be solved,

not by bringing in outside workers to break up family life, but by
sending most of the present work out of the home and simplifying
that which must remain until the task becomes so light that each
member of the family will perform his share of the housekeeping just
as he now dresses himself, or walks to catch the trolley car.

No Laundry Work at Home.

The first function, washing and ironing, has long since been made
an industrial function by the rich everywhere, and also by the middle
class in our cities. Farmers’ wives and the wives of the city laborers
still do home laundrying. In the Roadtown, with its perfect system of
transportation, the trouble of sending soiled clothes to the
coöperative laundry will be very simple as compared with the
present wasteful method of city collection of laundry. The service will
indeed be so cheap that I fancy Roadtowners will vote to add the
expense of the laundry to the charge for rent, thus doing away with
the cost of accounts and collections. This would put a premium upon
cleanliness, to be sure, and might result in a slight increase of the
total expense since our clothes would be washed more often.
 In connection with the laundry will be a pressing and cleaning
establishment which will likewise be run coöperatively. The pressing
machine now used by clothing manufacturers will keep people
looking spick and span for a mere trifle.

How far the Roadtowners will carry the idea of a blanket rate to
cover the cost for all these things depends on traits in human nature
that are pretty hard to anticipate. We force people to coöperate, to
build parks and statues to beautify our cities. Do we want to tax
them for a chance to be well groomed, or do we prefer to see the
other fellow slouchy so that we will look better by comparison? I for
one, believe in allowing civic pride to include live citizens as well as
marble statues of the dead.

Dusting and Sweeping.

Dusting and sweeping must be done at home, we cannot send the
house out, but we can pipe the house for suction sweeping and
discard forever the broom, clothes brush and that arch nuisance, the
feather duster, which is used to chase the dust from room to room
without getting rid of it. Scrubbing and mopping will be greatly
simplified by the cement construction and the convenience of water
and sewage. These periodic tasks will be grouped into trades, so
that they can, when desirable, be given over to professional cleaners
as is window washing in city buildings.

Making Beds by Machinery.

The care of the beds is the next item on our list. The Roadtown
sleeping-room will in the daytime have the appearance of a sitting-
room or library. One essential piece of furniture will be a couch or
divan with good springs upholstered with fire proof material. Plush,
leather and linen divan and chair covers will be used alternately to
suit the seasons and varying requirements. The divan forms the
foundation of the bed. The bedding including a light pad or mattress
will be made about a foot longer than is customary. At the foot this
bedding and pad will be fastened together by a metal clasp, or
“bedding hanger” on the order of a trousers-hanger. In the morning
instead of making up the bed—that is, carefully folding up all the
germs and foul odors, the bed will be suspended by the hanger in an
adjoining fresh air closet. By reversing the action of the rod
supporting the bedding, which describes an arc over the unfolded
divan, the bedding is spread neatly in place—the bed is made. This
closet in which the bedding hangs freely exposed to the air has one
side, or rather edge, against the outside wall of the building. This
wall space will be formed of shutters which admit of free circulation
of air, thus the bed is aired every day and all day. But there are
certain species of “germs,” as every housekeeper can testify, that will
survive this fresh air device, for them another provision will be
made. This closet will be piped for a certain kind of gas which will be
selected by the Roadtown biologist. At stated intervals the outside
shutters will be tightly closed as well as door of the closet and the
bedding fumigated instead of aired. This method can also be used to
disinfect clothing.

There will be few rats or mice in the Roadtown home, for there
will be little food left around to attract them, and no places for them
to gnaw through or build their nests. In the average city building
used for factory purposes, the damage from rats and vermin, I am
told, is often over 10 per cent of the gross sales.

Coöperative Cooking Practical.

Coöperative cooking, in spite of the first natural antipathy, has
gained considerable ground in city life. We find it in two forms, the
dining-out habit and the delicatessen habit. The first is expensive of
time and money, and destroys the most delightful hours of home
life. The second is likewise expensive and results in a diet consisting
chiefly of bread, cheese, cold meat and pickles. The weakness in
both systems is in the matter of imperfect transportation. In the first
case the people must be taken to the food, and hence out of the
home. In the second, the food must be brought into the home by a
system of delivery that greatly increases expense and limits the
quality, quantity, and variety of the available meal. The Roadtown,
built in the one straight horizontal line, will make possible the use of
a mechanical delivery system which is not now available even for
hotel service.

The mechanical carrier will be on the order of that used in the

Library of Congress as a “book railroad.” It is inexpensive, noiseless,
and can by means of a “key” be set to switch automatically at the
house for which the “car” or “carrier” is intended.

The Roadtown cooking will not be done in a single kitchen, but in

a number of large establishments, such as bakeries, creameries,
boiling, roasting establishments, etc. The prepared foods will then be
sent in suitable quantities to serving stations located about half a
mile apart, and there kept hot in the warming closets. Here the
frying, broiling, and other such types of cooking will be performed to
order.

The bill-of-fare will be sent out by Roadtown mail. The people will
order by ’phone and the foods will be on the sideboard in the
Roadtown dining-room in less time than it takes to bring it by the
two-legged route from Delmonico’s kitchen to his dining-room. But in
the dining-room a difference arises. The carriers must be opened
and the dishes and food arranged upon the table by the women
folks—a homely virtue left that the household poet may not be
entirely without material.

The usual meal will require two carriers, one of which will be
heated, and the other containing butter, milk, ices, etc., will be
chilled. Many changes of fashion will be required in the form and
material of dishes for containing and serving food—changes that will
doubtless “upset” the good dames who have found virtue in soup
tureens that can slop over, but it is needless to add that their
Roadtown daughters will be more “upset” at the thought of a return
to present customs.

At the close of the Roadtown meal, the dishes, food remnants and
soiled linen, will be put into the carrier, and dropped down a little
chute where they will travel merrily to the public dish-washery. Here
a few men with the aid of machinery will do the work which now
occupies half a hundred mothers while their families adjourn to the
library, music-room or to indulge in a nap.

In the Roadtown household there will be no furnaces to tend, no

ashes to haul out, and no marketing to do. The garbage waste will
be only the table refuse which will be placed in a paraffined paper
receptacle and sent back with the dishes. A bag for waste cloth and
paper will complete the waste disposal system.

The End of Household Drudgery.

In such an environment with the baby cared for by experts in the
nursery or kindergarten only a thousand feet away, the mother will
have time to operate an electric sewing, knitting, or one of many
other automatic and noiseless machines, work in the garden, read,
visit, or attend the theater, lecture hall or church. Indeed the
Roadtown woman will be free to do anything and everything she
chooses except home drudgery.

The Roadtown idea will at first produce a long low wail from the
thousands of men readers which will begin and end with a plea for
“mother’s cooking.” The Roadtown cookshop is coöperative, but the
dining-room is not. And the cookshop will be there to fill the need of
the coöperators, not to make money. If there is demand it will have
uncooked food to send out as well as cooked food. Nor will there be
any law against the bringing into one’s home the fruits of one’s own
garden, berry patch, and poultry yard. Roadtown folks that keep a
cow can take their choice between setting the milk in the spring and
letting the cream rise or sending the milk to the creamery where it is
aërated, chilled, pasteurized, and bottled, and the fat contents
standardized, and thus sent back as 4 per cent milk to drink and 20
per cent cream for the strawberries. Personally having tasted both
kinds I prefer the scientific product.

Every Roadtown home will have a boiler for hot water, a chafing
dish and as much more cooking apparatus as may be desired. The
wealthy matron of to-day keeps alive the sentiment of mother’s
cooking by making the tea, frosting the cake or making the salad
dressing. The Roadtown mother can do the same, and as much
more cooking as she likes, but once the opportunity is given for
people to find the actual economy of coöperation and to see the folly
of heating up a whole house to do one family’s cooking, the amount
of cooking mothers will do will be decidedly limited.

Sentiments can bar out progress for a while, but where there is a
great economical saving with nothing to lose but sentiment,
economy generally wins. How would you, Mr. Home-is-sacred-man,
like to thresh or flail the wheat by hand in order that the family
might eat pies made of hand threshed wheat as well as to eat
mother’s pies made of machine prepared flour?

This game of jollying mothers into playing household flunkies by

complimenting their products is getting thin, and a lot of mothers
are beginning to see through it.

The coöperative preparation of food will have many indirect

effects. A Roadtown ten miles in length could well afford to have its
own canning factory, cold storage, and, if the trusts become too
dictatorial, also its own packing house. The Pure Food Law in
Roadtown will be a dead-letter, for the buyers will be food experts
and will have nothing to gain by defrauding the people, or helping to
keep them in ignorance. With a double cause for watchfulness,
economy and health, it is hardly likely that such a buyer would find it
worth while attempting to go in partnership with food adulterators.
Certainly the inducement to adulterate is much greater in the world
to-day, for every man involved in it, profits by the practice, the
consumer alone, woefully ignorant of the whole subject, is the only
dupe.

Not only will the Roadtown buyer get pure food, but he will get all
food at wholesale rates. The frightful waste, due to the putting up of
food in small cans, bottles and cartons, is little appreciated. I
recently tested this principle by buying olive oil. The oil was priced
me at $1.80 a gallon, but the oil I secured in fifty cent bottles I
found cost me $7.00 a gallon. Cotton seed oil was priced at sixty
cents a gallon. I purchased a five-cent bottle and found that I had
paid at the rate of $2.25 a gallon. These are indisputable facts and
they could be multiplied indefinitely. In barrel or car lots the above
gallon prices would be greatly reduced.

All Roadtown foods can be bought in bulk direct from the makers
at makers’ rates. The vegetables will be crisp and fresh from the
Roadtown gardens. The profits of the middlemen, of retailers, of
adulterators and advertisers, the cost of bottles and cans, of delivery
boys and bad grocery bills will certainly be eliminated with one fell
swoop. It will reduce the cost of living, mark you, at such a rate that
the unsophisticated will confuse a Roadtown meal with a charitable
soup kitchen. But if you don’t believe this, write to your country
cousins and find out just what is the producer’s price on the material
out of which a meal is made.
 CHAPTER VII
THE SERVANT PROBLEM IN ROADTOWN

T HERE will be no servant problem in Roadtown, as there will be

no need for servants.
 CHAPTER VIII
ROADTOWN AGRICULTURE.

M ARKET gardens near our cities are worth several hundreds of

dollars per acre. But there are millions of acres of land more
fertile than a Brooklyn market garden that cannot be used
because there is no way to get fertilizer to it or products away.
Transportation is more important to land values than fertility.

A modern city of a hundred thousand inhabitants is about six miles

in diameter, within “an air line” mile of the edge of that city will be
about twenty square miles of land, but this land will average three
and one half miles from the markets which are usually clustered in
the center of the city, but if the street system is of the checker-board
type, the edge of the city between the compass points will be five
miles by street from the markets.

A Roadtown with a hundred thousand inhabitants will have within

a mile of its house line “edge,” or “center,” two hundred square miles
of land area, ten times as much as in the above case, and this land
will average but half a mile from the market to which the gardener
must needs transport his produce, which is only one-tenth the
distance under the present day conditions.

Another advantage of Roadtown for intensive agricultural

development is that, because of the numerous other functions that
transportation is to serve, Roadtown agriculture has a perfected
system of transportation immediately at its service to say nothing of
an immense consuming population on the line.

The first impression of a casual reader when Roadtown agriculture

is mentioned, will be that reference is made to the play-farming,
chrysanthemum and chicken breeding indulged in by suburbanites.
On the contrary, though suburbanites living in Roadtown will
undoubtedly play at farming much to their physical and mental
betterment, we are here speaking of the agriculture that will be the
leading industry of the fully developed Roadtown.

The trouble in grasping the possibilities of Roadtown agriculture

comes from the difficulty of renouncing our old viewpoint. The
typical farmer with his house in the middle of a quarter section of
land, half of which is fallow, and on the other half of which he
carelessly grows food for live stock of which only 6 per cent of the
nutriment is recovered in the form of meat, will be inclined to make
light of the idea of farm houses being built touching each other. On
the other hand the city dweller, especially of the older Eastern cities,
which were located chiefly in reference to navigation and are more
likely to be surrounded with water, swamp, rock and sand than by
soil, find that when the little remaining land has paid toll to railroad
and coal yards, millionaire villas, and deer parks and land held by
speculators, who discourage its agricultural improvements, there is
little remaining to give one the picture of the close proximity of the
consumer and the food supply.

In spite of the previous bias of these two viewpoints, those

familiar with the possibilities of intelligent agriculture will see nothing
strange in the prediction that the farmer of the future will live next
door to the “city” consumer of his wares.

Sufficient Land to Support Population.

In the first place, the locations of Roadtown will be through
districts where there is little loss through uncultivatable soil. With
twenty-one foot houses, there would be almost two and one-half
acres per family for each mile one goes back from the Roadtown
line. Thus within a mile (counting both sides) of the house line will
be five acres per family. But in no section of the Roadtown will all
the families be engaged in agriculture. In typically agricultural
sections of the country to-day about one-third of the population live
in villages and towns. This population is composed of retired
farmers, traders and professional men who serve the farm
population. In Roadtown civilization this population would live in
Roadtown lines. Near cities the commuting population and
everywhere the manufacturing population who are only engaged in
agriculture on a small scale, or not at all, will release more land for
the Roadtown farmer. If the proportion of agriculture to other
enterprises is the same as in the country at large, the area available
to the support of an agricultural family within a mile of Roadtown
will be about twelve acres.

But we have limited our calculation to land within a mile of the

house line—why? Evidently for argument’s sake only, for there is no
other reason. In the country districts children frequently walk two or
two and a half miles to school. The average distance from the post
office is three or four miles. The average haul to the railroad, five to
seven. The average distance to the other good things of civilization
is so great that the farmer doesn’t go at all, he is often referred to
as a “Hayseed,” unsophisticated, civilized to the extent of the
civilization that can be shipped by rail and be hauled home in a
wagon. The Roadtown will pour into the farm home all the luxuries
and refreshments of civilization at its best. In return it brings him a
new problem in the relative location of his home to the land he
cultivates. The result will be a wonderful rearrangement of the whole
scheme of agriculture. The land, whether owned by private
individuals, the Roadtown corporation or the Federal government,
will be cut up into plots, larger and larger in size as the distance
from the Roadtown increases.

Next to the house on both sides will be plots or gardens about the
width of the house, and probably partitioned from the neighbor’s by
trellises of vines or hedges of shrubbery. These plots will be of
sufficient depth to give ample privacy to one’s doors and windows.
These front yards—there are no back yards or back alleys in
Roadtown—are but the outdoor part of private homes, and will
perhaps be devoted to shade trees and lawn on one side, and to
garden stuff on the other. Though these yards in Roadtown etiquette
will be strictly private as far as an outsider’s presence is concerned,
they will still be within easy view of promenaders on the roof, and
for the same reason one is not allowed to dump rubbish on the front
stoop in the city, the Roadtown yard will be under the general
oversight and supervision of the Roadtown landscape gardener.

Beyond the private gardens will be vegetable gardens, then

chicken yards, greenhouses or pigeon flies. Beyond these in larger
plots will be berry patches and coarser vegetables, and then
orchards and dairy barns and pastures, and farther still, grain fields,
and beyond that, forests.

The distance back which land will eventually be tilled by farmers

living in the Roadtown, is a matter on which I hesitate to express my
opinion for fear it will discredit the worth of my judgment in the
minds of those who have given the matter no thought, but I think I
can carry the points by examples: Imagine yourself to be a farmer of
the future, and accustomed to the luxury of civilization; suppose you
wish to raise flax as a main crop, and breed pigeons and grow dew
berries as side issues. The pigeons and berries you could have at a
few minutes’ walk from your Roadtown home. The flax would require
your attention, plowing and seeding a couple of weeks in the spring,
and harvesting again a week or so in the summer. Would you prefer
to go five miles to that field every day for fifteen or twenty days, or
even take a tent with you and go twenty miles and camp there, and
for the rest of the year enjoy the coöperative and waste eliminating
features of the Roadtown home life, or would you live in a frame
house on the land and wash your face in cold water and get up
winter mornings to start a fire and drink impure water from a
polluted well and make your wife a kitchen scullion, isolated and
lonely, and send your children two miles through the storm to an
inefficient country school?
 Two of the most immediate advantages of the Roadtown for
agriculture are heat and water for lawns, greenhouses and gardens.
How far this water service can be extended from the Roadtown main
will of course depend upon the nature of the supply. But it has been
abundantly proven that water for irrigation, even in the most moist
sections of the United States, was a wonderfully profitable
investment. Sewage will find a special use as fertilizer as before
mentioned, and the Roadtown garbage disposal works will
doubtlessly have a residue for the land.

Horse manure as a fertilizer is gradually vanishing from industrial

life, and the Roadtown will eventually depend upon the chemical
fertilizers, “green manure” crops, and from the animals upon the
land for fertilizer.

The distribution of fertilizer as well as the receipt of heavy freight,

will require a freight station located about every quarter or half mile.
The opening of the ground for access to the tracks will disturb a yard
or two which will lessen the rental value of the house above, just as
the rental value of thousands of city houses have been diminished
by the presence of elevated roads. In practice such locations in the
house line will doubtless be used for some of the numerous non-
residential purposes for which room will be occasionally planned to
suit the local conditions.

Transportation will enable the better development of coöperative

features, such as creameries, hatcheries and nurseries that now
thrive under adverse conditions and will doubtlessly encourage the
development of others not now anticipated.

Elimination of the Middleman.

The markets of Roadtown can hardly be compared to present
conditions at all. Where the farmers of to-day go to the railroad
station with their produce, Roadtown farmers will leave theirs in the
warehouse of the food department. The 25 to 75 per cent of the
price that now melts away between the producer and consumer will
of necessity be divided between the producer and the consumer.

The Roadtown, either through its central coöperation or in the

form of individual citizens will be a great consuming market for the
Roadtown farmer. Certain products, however, for which the locality is
especially adapted must necessarily be sold outside the Roadtown.
For such, salesmanship coöperation as is now carried on in the
Ontario and California fruit belts and in the creameries of the Middle
West and trucking districts of the South will be brought into play,
and with the Roadtown transportation system and storage
warehouses its farmers will surely not fail where the former have
succeeded.

Coöperative Ownership of Farm Tools.

Well managed coöperation will also find another field in Roadtown
agriculture in the form of coöperatively owned tools. I fully believe in
the electric plow, for instance; an invention which the writer worked
out some years ago in the form of a flexible cable which would
unwind from a cylinder on the plow as the plow moves out from the
electric plug, and will rewind as it returns. Such a device as I
propose is entirely practicable and has simply failed to be developed
because of lack of cheap electric power near the land to be
cultivated; however, the old reliable horse will be used back from the
Roadtown line and as near to it as he proves economical and
desirable.

The use of electricity for agricultural power, is a part of the future

programme of the world as the land becomes more thickly settled
and as land to raise horse food gradually diminishes. How fast the
change will come will depend upon how rapidly the storage battery
and the means of conducting electric power are cheapened through
invention. At present the electrical truck competes successfully with
the gasoline truck, and Edison storage batteries are now replacing
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