The White Plague
Tuberculosis is a highly contagious disease caused by the bacterium Mycobacterium tuberculosis. It can be inhaled, or swallowed with food or drink. The most common form is pulmonary (of the lungs) tuberculosis, but the tubercle bacteria can also be present in the kidneys, bones, and intestines, as well as in the lymph nodes (scrofula). Miliary tuberculosis, known colloquially as galloping consumption, occurs when infected pus spills into the bloodstream and spreads throughout the body. Tuberculosis meningitis, the most deadly form of the disease, is an infection of the tissue around the spinal column. People called tuberculosis the White Plague.
In 1908, the U.S. Office of Public Health had declared Seattle’s record of fighting tuberculosis to be the worst in the country. In 1909, a group of leading citizens, including Horace Henry, formed the Anti-Tuberculosis League of King County to combat it. A member of the League, J. V. Smith, declared that the city of Seattle was a tuberculosis camp. The League engaged a team of visiting nurses to bring TB sufferers to its attention, and uncovered at least 1,000 cases.
The Sanatorium Cure
By July 1909, the League was making plans for a sanatorium. The sanatoria movement began in Germany in 1849, and soon spread to Switzerland. Patients were treated with rest, wholesome food, and fresh air. The first American sanatorium, Dr. Edward L. Trudeau’s Adirondack Cottage Sanatorium, opened in Saranac Lake, New York, in 1885. The driving ideas behind the sanatoria movement were that isolating infected patients could check the spread of the disease, and that cure was possible, given early diagnosis and behavioral retraining.
In Seattle, the first attempt to set up a sanatorium on Queen Anne Hill met with neighborhood outrage, expressed by threats and waving broomsticks, at the idea of a resident "pesthouse." League president Horace Henry stepped forward with a donation of 34 acres of land 12 miles north of the (then) Seattle city limits in the Richmond Highlands area, along with $25,000 seed money. Firland was established on land bordered (2002) by Fremont Avenue N on the east, Palatine Avenue on the west, 195th Street on the north and 190th Street on the south.
Seattle voters passed a $10,000 bond issue in the spring of 1910 to aid in construction costs. Dr. Robert M. Stith (1874-1943), whose mother had died of tuberculosis, was appointed Medical Director, a position he would hold until his death.
On May 2, 1911, the Henry Sanatorium accepted its first patients. They were housed in open-air cottages. Nursing staff was initially forced to sleep on the floor, since the only non-patient areas of the facility had no beds. Since no paved road connected Seattle and the hospital compound, supplies were sent via the Interurban trolley. From the trolley station at Richmond Highlands, they were transported by wheelbarrow to the Sanatorium.
By 1913 the North Trunk Road, now Aurora Avenue N, was paved with bricks at the insistence of physicians so that they and patients’ families could have more ready access. Eventually, buses served Firland on the half-hour.
On July 13, 1913, ground was broken for the English Tudor-style Administration Building, also known as the Walter H. Henry Memorial Building. The Hospital Building, known as the Detweiler Building, and Jenner Hall were also built in 1913. Jenner Hall housed patients with non-tubercular infectious diseases. Although it was outside Firland’s scope, city health officials felt that having this municipal isolation hospital share Firland’s administrative staff would save money.
In 1920 the Koch and Nightingale buildings were completed and housed ambulant patients. A temporary structure built in 1913 to house children with TB (or with infected family members) was replaced in 1925 with a permanent facility, Josef House, named in honor of a deceased patient whose small financial legacy to Firland was used to furnish the facility.
All buildings featured gentle ramps between levels rather than stairs, in order that ambulant patients not over-exert themselves, and were connected by underground tunnels. Large vegetable gardens and orchards served the facility. A power generating plant and a well rendered the sanatorium self-sufficient, although Firland was eventually served by the municipal water supply. Over the years more buildings were erected, among them a laboratory and a recreational/occupational therapy facility.
The Downtown Public Health Clinic
A Health Department Free Clinic in downtown Seattle (close to King Street Station) screened citizens for TB. Dr. Robert Stith directed the clinic and had total authority to decide who would be admitted to Firland. Patients with financial means were encouraged to enter private sanatoria, such as Riverton or Laurel Beach. Patients with little or no means were admitted to Firland or, more commonly, placed on a lengthy waiting list. Firland’s maximum patient load consisted of 250 people.
Firland gave preference to patients with a reasonable chance to be cured, and only individuals who had lived in Seattle for at least one year were eligible. This policy screened out transient "Skid Roaders." Tubercular women with dependent children often jumped the waiting list, and their children, too, were admitted to the Josef House and given preventive treatment. Dr. Stith’s stated goal was to use available funds and limited beds wisely and to admit those who were, in his words, “worth saving” (Lerner, 28). Medical expenses for patients admitted to Firland were shared by the Seattle Department of Health and the state of Washington. Health Department nurses made regular visits to TB patients being cared for at home (more than 80 percent of Seattle’s diagnosed tubercular population).
The Rest Cure
The tools with which Firland’s medical staff could forge a tubercular patient’s cure were extremely limited. “Rest -- more rest -- and still more rest. Rest is the keynote. Rest for the body, rest for the mind. Rest from involuntary as well as voluntary activity forms the basis on which the cure is built” (Firland, 31). (Rest is no longer seen as particularly curative for TB.)
Restful regulations were endless: “All that is not rest is exercise. Don’t stand up if you can sit down. Don’t sit down if you can lie down” (MacDonald, 40). The rationale for rest was an attempt to wall off tubercle bacilli in the lungs with fibrosis. In order for the delicate fibroid tissue to form, lungs must be kept as close to completely still as possible. Patients were expected to have character and exercise will power to endure stringent inactivity. All newly admitted patients began their time at Firland in the Bedrest Hospital. Their assignment was to rest in a fully reclined position. Reading, writing, and talking were forbidden. Coughing, except to produce a morning sputum sample, must be suppressed for fear of stimulating a coughing frenzy among other patients and in order not to disturb delicate healing lungs. Even reaching was prohibited.
Fresh air was considered essential in the cure of TB, and screened windows were kept wide open year-round. Nourishing food was plentiful, and patients were expected to eat well to build their strength. Visiting hours were Thursdays and Sundays from 2-4. Patients were allowed three (adult) visitors only.
Some patients were treated surgically, by injecting air into the space surrounding each lung (artificial pneumothorax) or by removing ribs so the chest wall sank in on the underlying lung (thoracoplasty). Both techniques were designed to keep the lungs more still. Because tubercular lungs could not be subjected to general anesthesia, this thoracic surgery was performed under local anesthesia using Novocain or sodium pentothal.
Sex the Worst Complication
Any thoughts or activities that "heated the blood" (i.e. stimulated the libido) were forbidden. Public perception of tuberculosis included the notion that a frenzied sex drive accompanied the disease, and other sanatoria were rumored to abound with nocturnal trysting places. Director Stith guarded against this kind of activity at Firland by strictly segregating the sexes. “In tuberculosis, sex is the worst complication” (MacDonald, 212).
The men’s bedrest wards in the Detwieler Building were on the ground floor and were known as Forlanini and Murphy. Stith assigned older, more mature nurses to care for the men, in hope that the men’s libidos would remain at rest. The women’s bed rest wards occupied the second floor of the Detweiler Building and were known as Trudeau and Bodington. The only men regularly present on this floor were doctors, and several trusted older ambulant patients who cranked the heads of the beds up for meals.
Non-sexual activities considered harmful included “letter writing, reading, dolling up; for example, curling the hair, painting the face, etc., letting the mind dwell on any subject which hurries the circulation” (Firland, 43). Ambulant patients found that men and women had separate cafeteria lines and sat on opposite sides of the dining room, and on opposite sides of the aisle at the monthly movie screenings. "No communication of any kind, including winking, waving, smiling or note writing was allowed between male and female patients” (MacDonald, 207).
Rules were reiterated and patients continually warned that the many wait-listed tubercular Seattleites would be pleased to take their place if they could not comply. Instructional lesson pamphlets arrived on dinner trays: “[T]he Doctor is the only one who knows when enough rest has been taken. Don’t forget, the Doctor is the only one who knows” (MacDonald).
Firland had a nurse’s training program, and student nurses were essential to the facility’s smooth function. Additionally, nursing students from other hospitals could rotate through Firland for three-month shifts to learn the care of tuberculosis patients. Firland nurses were expected to train patients in the Way of the Cure with missionary zeal, to model and enforce discipline, and to maintain a spotlessly hygienic environment.
They were also expected to teach hygiene: Although Seattle had outlawed the use of a common drinking cup in public places in 1913, unsanitary practices were still common. People did not routinely cover their mouths when sneezing or coughing, and many thought nothing of spitting on the floor, a practice outlawed in public places in Seattle since 1898. Since infectious bacilli in saliva and sputum spreads tuberculosis, these practices are deadly. Patients were retrained.
Nursing tubercular patients was particularly unpleasant: infectious sputum, pulmonary hemorrhages, frequent vomiting especially during mealtime, and the high death rate made this arduous work. The highly contagious tuberculosis bacilli made it extremely dangerous work, and not a few nurses became tubercular and were admitted as patients. Many did not survive.
Death Stalks the Halls
The rooms in the Detweiler Building, where patients were the sickest, were divided by partitions that ended about a foot off the floor rather than by walls. The patients’ sense of each other was immediate and intense, since a bed against one side of a partition was only inches from the bed on the other side. Patients were housed two or four to a room. In the stillness of the resting ward, patients could hear each other cough, turn over, and even breathe.
Pulmonary hemorrhages and nurses’ response to them could be heard throughout the ward. Patients in the final stages of the disease were moved into a single room close to the nurses’ station. Everyone knew that tuberculosis was often fatal. Death seemed to stalk among them: “Up and down the halls he went, never hurrying, knowing that we’d wait for him” (MacDonald, 161).
Children at Firland
Tuberculosis in children was usually an infection of the lymph nodes rather than the lungs, and was considered easier to cure under the proper conditions. Josef House, the juvenile tuberculosis facility at Firland, took patients from birth to age 15. Some patients had tuberculosis, while some were treated prophylactically as they came from homes (often low-income) where a family member had TB. Some of the children’s mothers were undergoing treatment at Firland and were therefore unable to care for their children. For these women, Josef House was a godsend. Children underwent a period of complete bed rest similar to that of adult patients, although usually of a shorter duration.
The children wore minimal clothing year-round, indoors and out: light cotton shorts/trunks, hat, socks, and shoes. Older girls wore blouses. Josef House had a schoolroom, where the children were tutored and instructed in health and hygiene. When necessary, children were tutored at bedside. Birthdays were always celebrated with cake and candles. Supervised play, handwork, seasonal celebrations, picnics, and a large wading pool offered diversions from the business of resting, child-style. Josef House had beds for 40-50 children.
Once a patient’s daily sputum samples indicated he or she was no longer contagious, doctors began a gradual process of testing his strength. Patients who showed signs of recovery (weight gain, improved chest x-ray, negative sputum samples, normal temperature and pulse) were given "time up," which meant they could sit up in bed for a given number of first minutes and then gradually hours each day.
Additional privileges such as reading and writing time and, eventually, permission to walk down the hall to the bathroom followed if a patient showed no sign of relapse. Eventually a recovering patient was moved from the Detwieler Building into wards for ambulant patients, where they gained a degree of personal freedom and were allowed to take their meals in the dining room rather than on trays in bed. Since staff was instructed not to discuss a patient’s case with that patient, patients never knew exactly what their progress was or when they could expect additional privileges. Each added privilege was cause for hope and celebration.
Patients with "time up" engaged in occupational therapy, intended both to add focus to their days and as vocational training for eventual reintroduction into productive society. It also allowed doctors to observe patients testing their strength in a controlled environment. Patients were continually monitored to guard against relapse, and those whose temperatures or pulses increased were put back to bed. Even patients with "eight hours up," the maximum time allotted, were expected to spend 16 of the 24 hours at rest.
Patients delivered mail or library books, pushed wheelchairs or worked in the dining hall. Firland offered a woodshop, machine shop, print shop, beauty parlor, a full domestic arts department, and even a volunteer fire department, all staffed by recovering patients. Patients performed important tasks such as sewing surgical gowns and draperies, rolling bandages, and working on the Firland Farm. The Farm provided the institution with vegetables and fruit, eggs, poultry, and pork, as well as raising guinea pigs for use in Firland laboratory experiments. The Firland Exchange Store served patients and staff, with store-to-bed delivery available at no extra charge.
Grit and Grin, the monthly Firland magazine (later called PEP, then Firland Magazine) was established in 1915. Its purpose was to educate and inform patients and to boost morale. Patients produced it in the Firland print shop as occupational therapy. Monthly columns on subject such as famous literary tuberculosis patients, a joke column, "Your Sputum," "Health Grad News" of former patients were generously salted with exhortations to STOP and REST.
Birthdays, admissions, and discharges were listed. The names of patients who had died were listed as discharged. At times as many as one-third of the discharged had died. Discharged patients still alive often continued to subscribe to the magazine in order to keep up with their friends in the "San." Patient Helen Wiggen, reporting on A Ward in PEP’s December 1933 issue, announced: “Those clicking heels we hear herald the coming of Mae Hill and Anna Ekanger taking their daily stroll; after gaining seven pounds, it won’t be long until Lucille Lauren will be joining them. As a result of a vote this month, the one a.m. hot water bottle was unanimously elected as our ward’s best pal” (p. 16).
Perhaps the best-remembered Firland patient is Betty MacDonald (1907-1958), who detailed the year she spent there in The Plague and I. The book is dedicated “For Dr. Robert M. Stith, Dr. Clyde R. Jensen and Dr. Bernard P. Mullen without whose generous hearts and helping hands I would probably be just another name on a tombstone.”
Other well-known figures to have passed through Firland are environmentalist Hazel Wolf (1898-2000), baseball and basketball player Charlie France, artist William Cumming (b. 1917), Beatrice Roethke (wife of poet Theodore Roethke), and author Monica Sone, Betty MacDonald’s roommate.
Patients who successfully demonstrated that their tuberculosis was arrested and their strength regained were ready for discharge, again at the discretion of Medical Director Stith. Departing patients were cautioned to continue getting as much rest as possible, to return regularly to the Firland Clinic for checkups, to consult with their doctor when considering type of employment, and to remain on vigilant watch for the return of any tuberculosis symptoms. Women were cautioned against becoming pregnant. The National Tuberculosis Association found that Firland had a higher incidence of patients living a normal life five years following discharge than any other sanatorium in the country.
Some Firland patients chose to leave the hospital against medical advice. Knowing that these self-discharged patients would spread the disease through out the community, Stith considered them to be “vicious and willful” (Learner, p. 29).
The War Years
During World War II (1942-1945) Firland’s nursing staff, siphoned off to help with the war effort, was reduced to one-third of its pre-war level. Ragnar Westman, Seattle’s Commissioner of Health, considered Firland “barely operable” under such conditions (Westman, 146). Firland’s diagnostic case finding program was suspended due to lack of staff and funding.
Firland patients in occupational therapy participated in a U.S. Navy program to produce scale-model aircraft for use as a teaching tool to train plane spotters to identify American and enemy planes. Patients with "time up" also knit for the war effort.
Admission, discharge, and birthday listings in wartime issues of PEP suggest that there was no mass discharge of patients of Japanese descent due to Executive Order 9066 (which forced West Coast people of Japanese descent into internment camps). Three patients with Japanese surnames were discharged in April 1942, one mid-war (possibly a death), and then no others until June 1945. Japanese names continued to appear on the monthly birthday list and on PEP’s masthead throughout the war. Throughout the war, Quaker peace activists Floyd and Ruth Schmoe visited the Japanese patients, whose families had been interned at Camp Minidoka (Roger Daniels, 117).
The "New" Firland
In 1943 King County assumed responsibility for Firland, and on November 25, 1947, patients from Firland and the former King County tuberculosis sanatoria, Morningside and Meadows, were ferried by ambulances to the "new" Firland, a decommissioned Naval Hospital at 15th Avenue NE and 150th Street. This operation was termed “the greatest mass movement of patients from one tuberculosis sanatorium to another in the history of any United States civilian hospital” (Lerner, 44).
The new Medical Director was Dr. Roberts Davies. The new facility had 1350 beds. The increased number of available beds meant that the entire waiting list could be admitted. For the first time in Firland’s history, anyone who needed a bed at Firland could be admitted. Many Seattleites decried the bunker-like facility, which had been intended for temporary use during the war and constructed accordingly. A wire fence surrounded the compound.
In any case, the Rest Cure was about to be supplanted: in 1947 Firland physicians gained access to the newly invented antibiotic wonder drugs. Streptomycin, followed by Para-amino Salicylic acid (PAS) and isoniazid, were used in combination to successfully combat tuberculosis. Firland physicians, mindful of the tubercle bacilli’s demonstrable ability to quickly become resistant to antibiotics, continued to stress rest and good nutrition as important components of the Cure.
By 1954, the average time a patient spent at Firland had been cut in half. Mortality rates at Firland plummeted from 31 percent in 1948 to 6 percent in 1954. In 1957, a team of national officials evaluated Firland and proclaimed it one of the most outstanding sanatoria in the country. A 1948 affiliation with the University of Washington Medical School funneled a steady supply of medical students, nursing students, and resident physicians through Firland. This in turn attracted excellent medical personnel from around the country to Firland’s staff.
The promise of a true cure combined with changing social expectations led to a decline in docility among patients. Firland relaxed rules regarding smoking and the segregation of the sexes, and hired social workers, psychologists, and psychiatrists to address patient needs and provide vocational counseling. Firland took the lead among U.S. sanatoria in this regard.
A true cure for tuberculosis caused a marked shift in doctor’s expectations of what their work could do for society. Before the wonder drugs, doctors hoped to heal when possible, reintroduce cured patients into productive society, and educate the public about hygienic measures to stem contagion. Antibiotic therapy meant that doctors could hope to eradicate the disease.
To do this they must discover and treat every case of tuberculosis. Only by assuring total and complete treatment of all cases could they remove all possibility of contagion. TB patients had to receive treatment whether they wanted to or not.
Convicted of Tuberculosis
During the 1950s, Firland medical sociologist Joan K. Jackson addressed the problems of treating tuberculosis in alcoholics. A Firland chapter of Alcoholics Anonymous was founded in 1950. Concurrent to rehabilitation, however, Firland began to forcibly isolate alcoholics in order to prevent patients from leaving the institution against medical advice.
“Known as Ward Six and located in the old naval brig … it was equipped with both locked doors and heavily screened windows. Included on the ward were seven locked cells, which contained only concrete slabs covered by thin mattresses. Patients admitted to Ward Six (most of whom were intoxicated) spent the first twenty-four hours in one of these cells for the purpose of sobering up or delousing” (Lerner, 121).At first it was used sparingly, but by the mid-1950s fully 10 percent of Firland’s patients were involuntarily detained. Alcoholic patients who failed to adhere to antibiotic therapy after being discharged were often readmitted and operated upon prophylactically (with their consent, but in a manner generally thought to constitute overtreatment of the disease) and given a mandatory one year stay at Firland despite a negative sputum culture which would in a non-alcoholic patient have stimulated discharge.
Detention at Firland took place without formal legal process, although within Health Department quarantine regulations in accordance with state laws passed in 1903 and 1907, previously unenforced due to lack of available beds.
"Difficult" patients were also placed on Ward Six in an attempt to maintain order, and as punishment for breaking rules. Firland staff wrote articles for medical journals detailing the use of Ward Six, and directors of sanatoria around the country traveled to Seattle to see it in action.
In 1957, the Washington American Civil Liberties Union investigated Firland, but it was not until 1965, when District Court Judge Robert M. Elston began to hold monthly hearings addressing the needs of Ward Six inmates, that a system of due process was instituted. Still, in 1971, when the state of Washington assumed financial responsibility for Firland, one-third of Firland’s patients were under quarantine orders.
Firland Closes Its Doors
On October 30, 1973, Firland closed its doors. Washington had decided to consolidate the state’s tuberculosis treatment centers, and Firland’s 210 remaining patients were transferred to Mountain View Hospital in Tacoma. National trends encouraged integrating TB patients into mainstream hospitals, with most receiving outpatient antibiotic treatment under the supervision of private physicians or the Department of Health. The era of tubercular sanatoria, in which Firland had played such a crucial role for Seattle, was over.