Lost Landscape of Healing

Seattle's Firland Sanatorium

**NAZILA MERATI**

**Introduction**

As one wanders the remnant fir forests of the Richmond Highlands, one
may unknowingly encounter the remains one of Seattle's greatest
landmarks to public health and coercion of the early 20th century. The
buildings and the grand entrance remind me of a small college campus.
Residents take walks in the spring sunshine and school kids run from one
class to another before the next bell rings. It is only when you arrive
at the main entrance to the old Administration building that you see the
National Tuberculosis Association's double barred cross embedded in the
walkway, one of the subtle reminders of Seattle's struggle against
tuberculosis. Starting in 1912, the City of Seattle began its first
efforts to construct Firland, a municipal sanatorium to house, heal and
retrain Seattle's tuberculosis sufferers. Much of the curative powers of
Firland were due to its rural isolation and sylvan benefits.

I am interested in the spaces and landscapes of curing disease.
Architects and designers grapple with ideas of the restorative landscape
and finding ways to make healthcare environments more pleasant for
patients.[^1] Landscape architects often attempt to understand the
benefits nature has to those who are confined. In the case of
tuberculosis, we can see a whole culture focused on the notion of nature
as healer. Even as antibiotics and chemotherapy made tuberculosis
curable, these medical miracles were still combined with old therapy of
spending time in the landscape to rehabilitate the patient.

Many different types of sanatoriums were developed in the years from
1870-1940. Social engineers and health care activists of the Progressive
movement helped engineer the program of the sanatorium. This period of
time left its mark in the policies of controlling of behavior that are
hallmarks of subsequent public health campaigns. Though most sanatoriums
have vanished, been demolished or adapted for other reuses, the ideas
behind the control of patients in these spaces have not disappeared with
the cottages. In Seattle, Firland has survived- reused as the campus for
CRISTA ministries in Shoreline district.

In this paper, I will describe the movements that led to the development
of Firland- the City of Seattle Tuberculosis hospital from
1909-1947.[^2] Along with understanding the spaces and environment of
those confined for the cure comes the need to understand the control and
power of the Progressive movement and how it shaped the patient's
experience. I will document the programmatic elements of tuberculosis
facilities and their spatial needs and design considerations. I will
also describe how Washington State and Seattle dealt with the "problem
of tuberculosis" during the early 20th century. In the light of the new
tuberculosis threat and changes as once fatal diseases, such as AIDS
become managed as chronic, there is a lot one can learn from our past
landscapes of healing.

**Methodology**

My main goal was to understand how the spatial arrangement of the
sanatorium functioned in relation to nature. There is a broad base of
literature on subjects related to tuberculosis, sanatoriums and healing
landscapes. Medical literature is full of information on the treatment
of tuberculosis, especially in relation to the care of the patient. The
natural sciences and health specialties (other than medicine) discuss
varying forms of non-medical treatment for tuberculosis. Historians and
geographers have documented the westward migration of the cure seeker in
search of environmental cures.[^3] This information is important in
understanding what types of facilities were constructed for varying
populations. Social historians have researched the search for the cure
and how it affected American culture in the nineteenth and early
twentieth century. Sanatorium narratives prove very useful in
understanding how the sanatorium functioned. The patient's voice is
often lost in the technology that surrounds healing. The narrative gives
a human touch to the cure.[^4] If a personal narrative is not available,
sanatorium newsletters and national magazines devoted to helping the
tubercular provide an understanding of relationships within the
sanatorium walls. Local histories of Firland, interviews with people
involved with the site, the City of Seattle municipal archives and the
Shoreline Historical Museum archives added greatly to my Seattle
research.

**Tuberculosis- an overview**

Tuberculosis[^5] was the leading cause of death in the United States
throughout the nineteenth century and into the early 20th century. It
was a disease that crossed class, gender and race lines. It was
dramatized in the literature, for example, the Bronte sisters romantic
suffering.[^6] Those who fought its symptoms, including the racking,
productive cough, weight loss and painful death, did not see it as
romantic. Tuberculosis was the dreaded disease, its transmission was
easy, its results deadly. It was a virulent, often fatal, disease that
seemed to consume its victims' bodies and spirit. Until the source of
the disease was discovered, it was believed that transmission was
hereditary. Once the disease causing bacillus was identified,
tuberculosis was treated differently. When whole families became
consumptive, it was no longer a factor of inheritance, but of close
contact.

In 1882, Robert Koch identified the bacillus, *Mycobacterium*
*tuberculosis,* that causes tuberculosis. Transmission is very easy, a
victim can transmit the bacillus by coughing and expelling droplets into
the air. Mycobacterium is virulent for hours to months, so transmission
can occur without direct contact with the infected. Tuberculosis is
primarily pulmonary in nature. Those exposed may remain symptom-free for
years. Once triggered, active tuberculosis patients start coughing
uncontrollably bringing up sputum and blood. If the disease does not go
into remission, patients often die rapidly. Until the mid-1950's it was
thought that the best way to treat tuberculosis was to place sufferers
in environments that allowed them to take a rest cure. The development
of drug treatments in the 1950's rapidly decreased mortality rates and
frequently cured the tubercular.

**General site planning for tuberculosis sanatoriums**

The architecture of health care facilities was influenced by the
Progressive movement. The spirit of reform dominated social policy and
construction of new health care facilities. Sanatarians and
progressivists used the city as a type of laboratory.[^7] The lack of
adequate sanitation, combined with dark overcrowded rooms, were factors
in the transmission of tuberculosis. By bringing light and air into the
city dwelling, it was thought that risk of infection would be
decreased.[^8] Public health officials advocated confinement for the
tubercular to reduce the chance of infection. The sanatorium attempted
to cure the contagion.[^9]

The ideas of the sanatorium were derived from the German doctor
Brehemer, who cured himself with rest, exercise and good food in the
mountains of Germany. The idea of regimens to fight disease were brought
to the United States in the late 1870's. The ideas of Brehemer and
colleagues were modified by Trudeau at Lake Saranac. The notion was the
same; the use of good nutrition, exercise, rest and fresh air to cure
disease. The ideas of wilderness as a cure were tempered as the focus of
the disease turned to curing the urban poor by getting them out of their
squalid environment.[^10]

In the early 20th century, physicians versed in needs of the tubercular
wrote in the medical literature about planning and designs of
tuberculosis sanatoriums. These recommendations and plans were used by
architects and planners to design municipal institutions. The plans
discussed programmatic elements and environment effects and the results
on the recovery of the patients.

Tuberculosis facilities were generally placed a few miles away from the
city or county that they served. This had several effects. There were
cheaper and larger tracts of land for the facility to grow and develop.
The chances of a more "rustic or wilderness experience" to aid the
patients cure was greater. Lastly, the degree of isolation was a
perceived benefit for the patient and for the community dealing with the
idea of tuberculosis as a contagious disease.

Manuals suggested the sites should be at least 20 acres in size to
support the sanatorium. The site would be more valuable if it had forest
(for views) and orchards and land suitable for cultivation. This was for
two reasons, it is thought that patients cure better if they are able to
work under supervision, and by using patient labor, it also reduced
maintenance costs. Though sites were isolated, it was critical that
transportation to and from the site was available. Reliable
transportation (railroad spur lines or trolley lines) allowed visitors
to the site and lessened the feelings of isolation and confinement for
the patients.

Environment was important in the cure. Exposure to light and air were
critical for the treatment of tuberculosis. Site planners needed to
analyze meteorological and climatic conditions to determine building
arrangement and construction materials.[^11] Areas with damp and swampy
conditions were not suitable for construction. Patient's quarters were
to be located with a southern exposure on a hillside or mountain to
obtain the best conditions. Natural beauty of the site was also an
important factor since natural attractions may amuse and content
patients.[^12]

Since sites were often self-sustaining, infrastructure, generally the
largest cost, needed to be laid. Power houses, sewage and water systems
were developed. Manuals stated that, if possible, it was beneficial to
tap into existing municipal systems. This was interesting since sites
were then balancing between the need for isolation and the dependence on
city resources.

Sanatoriums were based on the necessity to bring order into the lives of
the patients. Administration buildings used for the intake and
registration of patients, record keeping and supervision were placed in
dominant places in the landscape. They were often two to three story
structures with observation areas to view the patient wards or cottages
without patrolling the grounds.[^13] In some instances, the
administration building was placed in a "semicircle with the
administration building in the front and center"[^14] with observation
in the front and offices in the back. Since the administration building
was the first thing that most visitors to the facility saw, they were
generally large, more high-style buildings that served as grand
entrances. It was thought was that solidity in design was important
since the administration building as a structure would last longer than
the most of the patients would.[^15]

Patients in sanatoriums benefited from the ideas of open-air housing at
different stages of their disease.[^16] Patients in need of acute
nursing were placed in infirmaries or hospitals. The wards attempted to
implement the ideas of outdoor life by providing floor to ceiling
windows, good ventilation and views to the outdoors. Experts estimated
that advanced cases should be housed with no more than two beds per

room. Those with prolonged coughing spells could then cause a chain
reaction throughout the ward. Patients of all stages needed at least
2000 cubic feet of air space and porch area of eight by ten feet to
place a chair, bed, reclining chair and table.[^17] Finishes in
treatment rooms and patient's quarters were to be simple and smooth,
such as hard plaster finishes or enamel to reduce the levels of dust and
make disinfecting simpler. Reinforced concrete, brick and terra-cotta
construction with concrete floors were preferred for fire safety.
Joinery and corners were to be rounded to lower the levels of
contamination.[^18] (Figure 1)

The two most common types of patient's quarters built in the early
twentieth century were the lean-to building and the free-standing
cottage. Both of these building types allowed the patient access to the
environment and a feeling of autonomy. The lean-to was based on the
common shed style. The lean-to had deep overhanging roof and the
entrances to the building were at either end. This allowed for maximum
air circulation for the patients. These buildings generally provided a
dressing room for patient's privacy, a stove for heat and vast porch
areas for taking the cure. The lean-to attempted to reduce the number of
patients housed together by dividing the open wards with
partitions.[^19] The orientation of the porches were based on climatic
conditions.

Cottage type of buildings were often used in private sanatoriums.[^20]
Well-to-do patients desired their own accommodations with privacy away
from the eyes of the administration. These were simple frame buildings,
much like a bungalow. They were simple to construct and easy to modify.
The floor plan often depended on the number of patients and the length
of the curing season. In the northern climates, it was necessary to add
heated rooms. The cottages had large "open-air" rooms, usually loggias
or deep porches. Cottages could be modified to house the families that
accompanied the patient to the sanatorium. Cottages generally did not
have kitchen or dining facilities, but their own toilet facilities.[^21]
In some cases, by consolidating administration and patient housing
together, the facility can economize on plumbing, heating and
administration costs. This type of arrangement works well on small urban
sites.[^22]

**Washington state legislation and how it affected tuberculosis
treatment**

In 1899, legislation was passed in Washington State that required
physicians to report tuberculosis patients to local Boards of Health.
The State Board furnished a written group of guidelines for limiting the
spread of the disease. In 1903, pulmonary tuberculosis was included in a
suite of diseases that physicians were to report to the State Board of
Health. Nine years later, persons who openly displayed signs of
tuberculosis were not allowed to handle food products in an opened
state. In the same year, an act was passed to prohibit the use of the
common drinking cup in public places. At a statewide level, spitting was
outlawed in public areas. The regulations also affected the workplace;
educators and janitors with tuberculosis were no longer allowed to work
in public or private schools. This group of laws attempted to reduce
exposure of vulnerable children.[^23]

Though much of the sanatorium movement focused on the urban poor in the
Northeast and the booming "health seekers" moving to the Southwest and
LA basin, Washington state's increasing population heightened the need
for tuberculosis control.[^24] It was in 1911, in a report of the
Washington State Board of Health "upon house bill 211 of the eleventh
legislature: relative to the establishment of a sanatorium for the care
and treatment of indigent consumptives",[^25] that for the first time it
was voiced that the State has "social and economic duty to perform in
relation to the tuberculosis question"[^26] The report stated that
educational campaigns must be extended and an efficient system of
registration and notification of consumptives needed to be enforced.
Experts believed that the "last stage, or dying case of tuberculosis is
most serious" and in need of intensive treatment, not in the county poor
farm or the general hospital, but in a different facility. Those in the
early stages were not to be treated in a sanatorium, but at home or in
teaching institutions. This report was one of the first attempts by the
State to handle tuberculosis institutionally. Though public health in
Washington was attempting to regulate those with tuberculosis, no public
facilities for the care of tuberculosis had yet been conceived. First
attempts by the State to authorize counties to erect hospitals for
treating tuberculosis occurred in 1913. A stipend of \$3.00 a week was
allotted for each patient's care at local hospitals.[^27] Later, \$2500
was earmarked by the Washington State Association for the Study and
Prevention of Tuberculosis for a state nurse to monitor tuberculosis
programs and provide community outreach.

At the time that Washington State was spending time and effort enacting
legislation for tuberculosis, on the City level, the Anti-Tuberculosis
League was pushing for city ordinances to reduce the spread of
tuberculosis through education, control and benevolence. As early as
1907, the City of Seattle required the reporting of tuberculosis cases
to the local Board of Health. Visiting nurses were employed to take care
of infirmed sufferers. The outpatient department of the Municipal
tuberculosis hospital, located at City Hall with a satellite office in
Ballard dispensed free sputum cups, paper napkins and advice.[^28]

In February 1909, the Anti-Tuberculosis League (ATL) was founded in
Seattle. The ATL consisted of wealthy businessmen and civic leaders. The
League's goals were to increase publicity about prevention programs and
to institute visiting nurse programs and demonstration projects in the
Seattle area. The emphasis was much the same as the reform movements of
the 19th century. The ideas of the ATL were a combination of need for
humanitarian relief of those suffering and the economic concerns of
social ills on society. Though the ATL was non-secular, there was a
strong religious undertone in their message.[^29]

As Seattle prospered, the rates of tuberculosis deaths increased from
103 deaths per 100,000 in 1908 to 120 per 100,000 in 1912.[^30] Visiting
nurses estimated there were 1000 people in Seattle that needed treatment
and untold numbers that were not surveyed. In the summer of 1909, a 40
acre tract on the west side of Queen Anne hill was offered by Colonel
Thomas W. Prosch to the ATL to set up a tent colony for tuberculosis
sufferers. As members of the Anti-Tuberculosis League and local churches
began to take material up to the site, they were met by a "broomstick
brigade of irate ladies"[^31] who objected to the idea of a tent colony
near their homes. The colony was never constructed, though many other
offers of sites came in.

The League's goals included the development of a sanatorium for the
citizens of Seattle. They initiated a search to find a place to build a
Sanatorium. On Jan 6, 1910, the County gave \$4,000 for the building and
equipment necessary for a sanatorium. The committee determined that a
building to hold 80-100 beds would be adequate at first. The estimate
was later revised to meet the needs of 250 patients.

**Henry Sanatorium to Firland - a shift in focus**

In February 1911, Horace Henry, Seattle railroad magnate, donated a 34
acre tract of land approximately 12 miles north of the city- to be used
"for any purpose in furtherance of the League's program." [^32] The
original tract of land is located in what is now known as the City of
Shoreline. (Figure 2) It is bordered by Fremont Avenue on the east and
Palatine Ave. on the west. The northern limit of the site is N. 195th
Street and the southern border is N. 190th street. The City later
purchased an adjacent 10 acres. In 1911, Henry gave an additional gift
of \$25,000 to build an administration building in memory of his son
Walter, who had died of tuberculosis.

The site of the new sanatorium was magical. A Douglas fir forest on
sloping site remained wilderness outside the newly bustling Seattle
landscape. The surrounding Shoreline area was being developed into farms
to fill the needs of the Seattle area. The Seattle-Everett interurban
railway's Richmond Highland station served the Richmond Highlands and
the newly founded Henry Sanatorium. As building plans crystallized and
funds were appropriated, the infrastructure was laid and the Henry
Sanatorium accepted its first two patients on May 2, 1911.

Henry Sanatorium was much more primitive than the subsequent
permutations. The patients lived in eight crude open-air cottages
nestled underneath fir trees. (Figure 3) The cottages were simple wood
framed structures with deep overhanging eaves. The interior consisted of
a small living space, a stove, dressing rooms and a large verandah for
taking the cure.[^33] Nurses traveled along wooden boardwalks to check
on patients, a great deal of their time and energy was spent moving
around the site. Cases that needed more acute management resided within
the infirmary.

In late 1911, an attempt was made to make the Henry Sanatorium and the
treatment of tuberculosis a public entity. The Anti-Tuberculosis League,
with the backing of business and civic organizations, determined that a
public sanatorium would benefit Seattle. A plan to construct a series of
buildings on the original Henry site was devised. A bond issue
(Proposition Six) to build a new tuberculosis hospital granting
\$125,000 to build the new facility was overwhelmingly passed (82% in
favor).[^34]

In 1912, the Henry Sanatorium, renamed Firland, was turned over to the
City Health Department. At that time the capacity of the sanatorium was
43 patients. The city wished to erect a larger sanatorium and isolation
hospital on the Highlands site. The City Council appropriated extra
funds to complete construction of the sanatorium buildings. The original
designer, DR Huntington, was responsible for the design of the overall
campus architecture. Construction was swift, the order of construction a
symbol of control as the administration building was the first one
constructed. The buildings were designed in Tudor revival style with
half-timbered and stucco construction, high gabled roofs and dormers.
The symbolism is of strength, power, endurance and stability in a site
that four years previously was virgin timber. The main structures
(administration building, hospital, power house) were constructed within
two years. By 1914, Firland housed 150 adults and 25 children. At the
time, there was a need for 1000 more beds for Seattle citizens. The
county pulmonary hospital and private sanatoriums attempted to fill the
need, but dealt with different populations.

Though sanatoriums specialize in the care of patients, it seems odd that
the first building to be erected as a city building was the
Administration Building. (Figure 4) Henry's pledge of \$25,000 along
with additional bonds helped facilitate the construction of the Walter
H. Henry Memorial Building. The building is three stories, approximately
175 by 32 feet. The first floor is of masonry construction, the
remainder is half-timbered with stucco. There are dormers in the roof
and a wooden tower that rises from the roof to a height of 50 feet.[^35]
Attached is a service wing of 99 by 41 feet.[^36]

The administration building served multiple functions. It served as the
ambassador or welcome mat for incoming patients. Patients were greeted
by the ornate fixtures and welcoming front hall, information and
evaluation occurred immediately after arrival. The administration
building also served as a laboratory for routine work at Firland, other
more complicated tests were sent out to the City Laboratory. Though
other administration buildings served to observe patients on the
grounds, the spatial arrangement of Firland did not facilitate this
element. Oddly enough, the operating theater was located in the
Administration building. Patients who were coming in for surgery
generally were not doing it under their own power and under more
stressful conditions. Reviewers recommended that the surgery move to the
hospital building.[^37]

Firland, like other sanatoriums of the time, stood as its own
self-supporting village. Though supplies could be ferried in from the
Interurban, food and electricity and heat needed to be generated on
site. A power house was constructed in the early 1914 to serve the
campus. The style of the powerhouse (40x184 feet) is remarkable
resembling an old castle or part of a fortification. The roof "features
a parapet and large smokestack".[^38] Constructed of reinforced
concrete, it contains of the boiler room, housing for interns, steam
plant, machine shops, storage and laundry for the site. The lower
portions of Firland site were devoted to food production for the site.
Vegetables, eggs, dairy and other animals were raised and slaughtered
on-site for patients meals.

The Detweiler Building (1914) served as the main hospital building.
(Figure 5) The open wards were separated by sex, the men on the main
floor and the women on the second floor. Located at each end of the
building, the wards were full of light and well ventilated. The
patient's beds were located underneath perpetually open windows.[^39] It
was thought that the fresh air would help heal injured lungs. The
central hallway served as reception and circulation areas for the
building. The nursing stations and observation areas were located within
the ward, limiting the amount of privacy of the patient. The hospital
was the first stop on the patient's road to recovery. Buildings and
wards named after scientists and physicians dedicated to the fight
against tuberculosis. (Trudeau and Forlanini)[^40] gave the patients a
sense of how everything at Firland was focused on fighting the disease.
Patients on the wards were ordered to bed rest, forced to lay still
looking out onto the wards instead of "nature" for the first part of
their treatment. Bed rest allowed for the rebuilding of muscles, gaining
of strength and regeneration of lung tissues.[^41] Patients at Firland
were given a set of rules that described behaviors and thoughts that
would help promote the cure. As patients got better, they were given
privileges such as visitors, reading material and opportunities to talk
to other patients. Isolation was the key here. Even on a full ward,
patients could feel like they were by themselves.

Ambulant wards were built east of the hospital building, in the same
Tudor style, replacing the rustic cottages that marked the Henry
Sanatorium. Those well enough to move to the cottages traveled to meals
and throughout the grounds on varied strict regimes. In the early
1920's, a modern reinforced concrete building dubbed the Nightingale
Ward was constructed for these patients. The style was no longer evoked
the feeling of permanence and deep history of the first Tudor style
buildings. The Nightingale building, with its modern look, flat roof and
nondescript style, used views to the landscape and an increased sense of
independence to push patients to the next step of recovery. (Figures 6
and 7) Patient spaces were more like private rooms than the wards of the
bedrest hospital. The physical detachment from the administration
building meant that the nurses were no longer in constant contact with
the patients. Patient rooms were attached to a long south facing
breezeway that acted as a porch would in an old lean-to style building.
Patients were able to take chair rest and visit with each other in a
more informal fashion than before. This was thought to increase morale
and bring patients back into congruent living conditions.[^42] The
environment may have also played a role in the placement of the ambulant
ward. The deep breezeway/porch looked out onto the orchard and "golf
course" for more ambulant patients. The flat roof of the building also
allowed patients to take in specifically prescribed sunlight treatments.

Often times patients ended up in isolation because they suffered from
more contagious debilitating illnesses. The isolation hospital was
placed the on the western boundary of the site. (Figure 8) In order to
not affect the "healthier" patients, the isolation wing (Jenner Hall)
had its own support system. The isolation hospital resembled the typical
lean-to configuration with covered breezeways connecting the hospital to
the service areas.

Firland's levels of circulation made it unique as a sanatorium. A series
of underground tunnels were used to transport patients from treatments
back to the wards. (Figure 9) The tunnels also facilitated movement of
staff, facilities (steam heat and water) and supplies throughout site.
Supplies could be centrally dropped off and then disbursed more
efficiently. The tunnels were well daylighted, so the trip for the
patient was not as terrifying. Today, the tunnels are used as storage.
From the outside the tunnels appear to be a series of elevated walkways.
The surface routes of circulation took ambulant patients throughout the
site on prescribed walks as well as to various therapies. It seems that
patients on bedrest ended up spending most of their time moving through
tunnels and not through in the environment that would make them better.

Children were admitted to Firland as patients and as dependents of
patients. Josef House, a reinforced concrete building with beds for 60
patients, was constructed to help the undernourished or tubercular
youngsters of Seattle. (Figure 10) The progressive thinkers believed
that malnutrition, poor conditions and unfit family life would
predispose children to tuberculosis. By preventive training, children
would fare better in the outside world. Josef House stood as its own
facility with separate kitchen and dining room. The wards were separated
by gender, though the children interacted with each other in classroom
and recreational situations. Large loggias on the southwestern side
allowed for sunlight treatments. Large schoolroom was provided so that
"the education of the young charges will not be neglected while they are
being made well again."[^43]The regime of children was different than
for adults; the ideas were similar to the open-air ideas of schools.
(Figure 11) Children were given ample opportunity to experience outdoor
life as well as to learn rules of better living that would be useful
when they were released. Children were isolated from adults, not
interacting with the patients, but primarily with staff.

**"If you are going to be blue, be bright blue"**[^44]

Firland's facilities were available to all citizens of Seattle, there
was no discrimination based on creed, religion or race. [^45] The
patient census data showed that patients were often of lower middle or
working classes, with some classified as "wanderers".[^46] The
sanatorium was often representative of an almshouse.[^47] It was often
difficult to determine who was to be treated. Though the state thought
that those with advanced cases were to be treated first, it seemed that
patients with the best hope of recovery were treated most often. Those
patients that were the biggest threat, those with active tuberculosis,
were often admitted. The indigent and homeless were also admitted to
remove them from the street or skid road environment, thus reducing the
chances of infecting others. Mothers or single breadwinners with small
children were also given preferential admission. Their children also
gained admission to the Josef House even if they didn't need treatment
just to give access to them better living conditions. Firland acted as a
benevolent institution; if patients did not have the means, they were
not turned away.[^48] The diversity in patient backgrounds may have
caused hostility among patients, but the treatment regimes were equal.

Patient life at Firland became a life of living by rules and
regulations, in some ways patients became infantilized to control their
therapy.[^49] Though public health attempted to place patients in
sanatoriums to cure the disease, a patient's time in the sanatorium also
served to "indoctrinate patients on the proper protocols"[^50] for when
they left Firland.[^51] Patients not willing to abide by rules could be
replaced by others who would. Some may argue that the loss of rights,
such as all levels of incoming patients taking to complete bedrest even
if they were physically strong, was a loss of control, but it equalized
the treatment regime of patients. Rules attempted to enforce the idea of
complete rest as a method of curing tuberculosis. Reading, writing,
talking (gossiping) and fraternization were prohibited because they
contradicted the idea of rest. Sanitary disposal of sputum and general
hygiene were also enforced by the "Rules". For new patients, reading the
lessons of Firland became a way to mark the days. A patient, Betty
MacDonald writes about fellow patients who talked about months and years
as if they were days. Time in the sanatorium could feel endless,
especially if the prognosis was unclear. Time at Firland was marked by
routine, patients were kept on rigid time schedules which were reviewed
by the house physicians. Visitors were allowed twice a week for a period
of two hours. Once a week, an ambulant patient would come by to pick up
orders from the store, flower "girls" would come to arrange flowers on
the ward. Bath day became a big event. Losing one's sense of
individuality, placed in an environment that was meant to cure but
always had the shadow of death, brought feelings of depression to some
patients. Experts believed that the interaction of long-time patients
with less severe cases would increase the chances of depression in those
with less severe cases.

Rehabilitation therapy and occupational therapy was part of the regime
of ambulant patients as well as a state-mandated program after the
1920's.[^52] Patients with three hours of ambulant time, thought to be
well on the road to recovery, began a regimen of occupational therapy.
Occupational therapy also had economic benefits for the sanatorium by
reducing the number of outside employees. Patients were paid for their
labor and the money could be used to pay for their treatment. This
increased the self-esteem of the patient since they were no longer being
a burden on society. [^53] At first, the activities were as simple as
helping bed rest patients sit up for meals. As the amount of time up
increased, the complexity of tasks increased.[^54] For some patients,
the possibility of going back to their former occupations was nil and
they needed to be retrained. Recovering patients at Firland were taught
trades and skills suited to the tubercular. Tasks were for the most part
based on gender, typical for its time. Women learned millinery, sewing
skills and secretarial skills. Men worked in the electronics and machine
shops. Products and crafts created by patients were sold in the Firland
Store.

PEP, the monthly magazine of Firland, (its initials stood for
**P**atience, **E**ndurance, **P**rinciples), served as the voice of the
patients and health community. Created by "ambulant" patients, it was
filled with chatty little anecdotes of sanatorium life and information
about upcoming events. (Figure 12) PEP published articles about new
treatments at other facilities. Local businesses often bought
advertising in these publications, hoping to increase trade among the
health graduates.[^55] The production of the sanatorium magazine offered
more than occupational therapy for patients, the gossip column was one
way that those in the "San" managed to spread information among patients
as well as to create a social scene in a classless environment.

**The end of Firland as we came to know it**

Little changed in patient life at Firland in the 1930's and early
1940's. Patients continued to be subjected to the strict regime laid
down by the Firland program. After the initial move towards isolation
and sanatorium construction, the public health shifted its focus to
tuberculosis prevention, screening and education. Non-communicable
health problems such as heart disease and cancer became the new health
concerns. Even with increased education, screening and fewer
environmental ills[^56], the rates of tuberculosis infection increased.
In 1943, there were 670 deaths in Washington State attributed to
tuberculosis, the majority in Puget Sound. A 1943 estimate stated that
700 beds were needed for King County. The amount of adequate facilities
was low. Morningside, the County facility, was an obsolete structure and
unfit due to fire hazard housed 200 patients.[^57] It was believed that
King County did not fulfill its legal responsibility to provide enough
beds.

Until 1945, tuberculosis efforts had been localized. A State Hospital
Building Commission was created in 1945. The State legislature allotted
\$3,000,000 in capital to initiate building tuberculosis hospitals. This
program assisted in the construction of facilities in Selah and Spokane.

Waiting lists to get into Firland continued to be long and Morningside
was woefully inadequate. Additionally, Firland had not been updated in
ten years and was in need of renovation. World War II contributed a
shortage of qualified staff to run Firland, a report by the city health
commissioner in 1943 stated that this shortage could endanger patients'
lives and if the situation got any worse, they would need to close
Firland down. The City made no attempt to add more wards to Firland
because there was not adequate space. (Figure 13) Efforts began to
locate a new tuberculosis facility on a more appropriate site. The idea
of building a new facility to house all patients seemed to be the best,
yet most expensive solution. In 1946, Seattle deeded the Firland
buildings and acreage to King County to consolidate the management of
the region's tuberculosis patients. In 1947, the War Assets
Administration offered the County an abandoned Naval Hospital in North
Seattle to be used for a tuberculosis hospital. [^58] The move was an
emotional one, Firland's patients moved from a beautiful, rural setting
to the mundane WWII barrack-like wards of the new facility. The County
shut down Morningside and transferred its patients to the new facility.
An additional 200 patients from the waiting list were admitted. In all,
the new Firland could hold upwards of 1600 patients, thus making the
waiting list a thing of the past. By 1950, there were more persons
hospitalized for tuberculosis in the Seattle area than in any other
metropolitan area. [^59] At the same time, new drug therapies
revolutionized the treatment of tuberculosis. Bed rest combined with new
"wonder" drugs dropped the death rate from 25% to 1.7%.[^60]
Tuberculosis appeared to have been conquered.

The old Firland site was taken over by Mike Martin, a Christian
businessman, who thought the site would make a good home for troubled
teenagers. Martin offered the County a one dollar per year lease for the
44 acre site. Even before the lease had been signed, Martin and his
followers had moved onto the site and began renovating the buildings.
Firland became the home of the King's Garden religious organization. The
site was ideal for the organization since the infrastructure and
facilities of Firland made taking over the site painless.[^61] The
County finally succumbed to the pressure of the organization and granted
Martin a five-year lease. In 1958, Martin purchased the site at auction
for the minimum purchase price (\$100,000) plus one dollar. There was
great opposition to this purchase as the site was worth much more than
the price Martin paid for it. Citizen groups from Shoreline and the
North County wanted to use 10 acres of the site for a park. Since the
City of Seattle had purchased the additional land, it was not subject to
restrictions. In the end, Martin ended up using the whole site for his
organization. King's Garden, now known as CRISTA Ministries, has
continued to use the old Firland structures as well as constructing more
for their own growing needs.

**Adaptive reuse?**

CRISTA currently uses the Nightingale Ward as independent living
apartments for the elderly. Windows off the breezeway have been removed,
and the porch now resembles the corridor of a nondescript apartment
building. Sylvan Hall and the old ambulant wards have been converted to
teaching labs for the high school. Detweiler Building now houses King's
High School; its library is in one of the men's ward. As one walks
through the facility, one can imagine the patients under the large
windows, waiting out their time in bed rest. Josef House is part of the
CRISTA Junior High School. Its bright and airy wards are used as
classrooms. Where there were once rules posted on behavior and
tuberculosis prevention, Bible verses are posted. The administration
building has been adapted to suit the needs of the CRISTA administrative
body. Much like a showcase building it was first designed to be, the
main entrance is still majestic. Sadly, the plaques in the doorway that
dedicated the building to the Henrys' and the fight against tuberculosis
are gone. Details such as gracious ramps throughout the Nightingale
Building and Josef House, doorknobs carved with the double barred cross
and the light and airy patient quarters are legacies of the past. The
more mundane reminders of sanatorium life, the isolation ward and
workers housing, were removed by CRISTA. The farm, which provided both
food and an important connection to the agrarian ideal was replaced by
sports fields. Areas that may have provided great open-space
opportunities are now either parking lots or infill construction.
Currently, only seven acres of the original site are left as unused open
space.

**Conclusions**

It is difficult to preserve the past, especially landscapes of a time
that wasn't so pleasant. At Firland, the individual buildings are well
preserved and good examples of their institutional type, but they speak
more eloquently when taken as a whole. No real preservation attempts
have been made for Firland, but the campus has been inventoried by the
City of Shoreline and Washington State. No landmark designation has been
made at any level. The current owners have attempted to preserve the
majority of older structures on the site[^62] and attempt to incorporate
the existing style in into new construction. For example, the new
cafeteria building adjacent to the ambulant patients' ward mimics the
low-lying Tudor architecture of Sylvan Hall. Adaptive reuse is an
important part of preservation. King's Garden and later CRISTA
successfully used the campus for somewhat similar activities as Firland.
Other sanatoriums around the county have been converted to nursing
homes, inpatient facilities and artists colonies. In most cases the
requirement for the facilities is similar to the sanatorium
requirements. These types of facilities are easy to adapt.

The resurgence of drug resistant tuberculosis leads one to think that
the fight against the "White Plague" is not over. It is strange to see
the reports of these new strains without thinking of the early twentieth
century accounts of tuberculosis control. The resemblance is eerie, the
situations very similar. The population newly affected is generally from
high density, low income areas with other problems that tend to make
treatment and compliance difficult. The approach of the Progressive
movement to isolate or quarantine the contagious population in order to
treat the disease; remove the patient from its "unsanitary"
surroundings; protect the public as well as caring for the patient,
would perhaps "cure" the non-compliant tuberculosis patient. Elements of
the sanatorium treatment: monitoring drug therapy, rest and good
nutritional regimes could be applied to the therapy of the new
tuberculosis population. Society has not forgotten the elements of
control and coercion that were part of this Movement. The health care
system has moved away from long-term monitoring and follow-up treatment
and now looks for fixes that are inexpensive and quick. The lost
landscape of the sanatorium can no longer be applied.

This paper serves as an exploration of my topic for Master's thesis in
Landscape Architecture. The landscape of disease is complicated. This
paper begins to understand the underlying themes of control as it
applies to the spatial relationships in this landscape of tuberculosis.
The municipal sanatorium is one of many types of facilities built in the
United States during the early 20th century. I would be interested in
looking at similarities in levels of control in different types of
tuberculosis facilities. I would also like to look at the amount
emphasis different types of facilities placed on the experience of
environment. The ability to regulate the experience may affect the
patient's experience and recovery. In my quest to understand how Firland
functioned as a sanatorium, I was baffled by the City's reluctance to
build larger wards on the Firland campus early in the fight.

**Acknowledgments**

I would like to thank Mike Martin Jr. of CRISTA Ministries for his tour
of hidden Firland and his loan of aerial photographs of the site.
Shoreline Historical Society, MOHAI and University of Washington Special
Collections contributed greatly to understanding the history of Firland.
Scott Cline's extensive database and collection of Firland photographs
were useful for site interpretation.

[^1]: There is a whole body of scholarship devoted to the effects of
    environment on well being of humans. Ulrich's seminal paper Ulrich,
    R. S. "View through a window may influence recovery from surgery",
    [Science]{.underline} , 224, 1984, pp. 420-421 on the more rapid
    recovery rates of patients with views of nature compared to patients
    with views to brick walls has spawned a new branch of study in
    landscape architecture. Other related papers worth reading include:
    Kaplan, R. " The psychological benefits of nearby nature" in [The
    Role of horticulture in human well-being and social development: a
    national symposium]{.underline}, 19- 21 April 1990, Arlington, VA.
    Ed. Relf, D., pp.125-133, Portland: Timber Press, 1992 and Ulrich,
    R. S. "Visual landscapes and psychological well-being" [Landscape
    Res.]{.underline}, 4, no.1,1979, pp. 17-23.

[^2]: In 1947, the city of Seattle and King County decided to join
    forces, they closed Firland and Morningside (King County sanatorium)
    and moved to the vacant Naval Hospital Site at 15th NE and NE 150th.
    The old Naval Hospital had a capacity of 1600 beds. The new facility
    was also named Firland.

[^3]: ^?^ A series of books have been written in the past 15 years that
    describe the social history and

    attempts at regulating the tubercular in the United States. Five
    excellent jumping off points for

    those interested include: Caldwell, M. [The last crusade. The war on
    consumption.1862]{.underline}

    [-1954]{.underline}. New York, NY: Atheneum, 1988 and Dubos, Rene
    and Jean Dubos. [The White]{.underline}

    [Plague. Tuberculosis, Man and society]{.underline}. New Brunswick,
    NJ : University Press, 1987.,

    and Ott, Katherine. [Fevered lives : tuberculosis in American
    culture since]{.underline}

    [1870.]{.underline}Cambridge, MA: Harvard University Press, 1996.
    Rosenkrantz, Barbara. ed.

    [From Consumption to Tuberculosis. A documentary
    history]{.underline}. New York: NY: Garland

    Publishing, 1994 and Rothman, Sheila. M. [Living in the shadow of
    death.:]{.underline}

    [Tuberculosis and the Social experience of illness in American
    History.]{.underline} New York, Books,

    1994\.

[^4]: Rothman discusses the importance of the narrative in understanding
    the sanatorium experience. In order to delve more into this, it is
    necessary to find out who resided in the sanatorium setting for any
    duration. Patient records and census information give us a good idea
    of the population, how strong their voices are is the question. In
    the case of Firland, Betty MacDonald, local author, gives an
    autobiographical account of her eleven month stay in the [Plague and
    I]{.underline}.

[^5]: ^?^ Tuberculosis is also referred to as consumption.

[^6]: ^?^ Susan Sontag's book, [Illness as metaphor]{.underline}
    discusses how illness has been described in literary accounts, thus
    shaping society's opinions of disease.

[^7]: ^?^ Rothman, S.M. [Tuberculosis and the Social experience of
    illness in American History. Living in]{.underline}

    [the shadow of death]{.underline}. New York: Basic Books, 1994, p.
    186.

[^8]: ^?^ According to Rothman, the New York City health department
    mapped levels of TB to the type of housing. It was found that
    highest levels were found in the tenement areas. Lerner states
    though Seattle didn't have tenement district, cases of TB were
    mapped to the more densely populated areas The ideas of increased
    light and air would be important in the ideas of Firland. Barron
    Lerner's dissertation on control of TB in Seattle discusses the
    first patient populations in Seattle.

[^9]: ^?^ Rothman, Sheila. M. [Living in the shadow of death.:
    Tuberculosis and the Social]{.underline}

    [experience of illness in American History.]{.underline} New York,
    NY: Basic Books, 1994.p. 183.

[^10]: ^?^ Lerner, Barron. "[On what authority is this being done?"
    Tuberculosis control, poverty, and coercion in Seattle,
    1909-1973]{.underline}. Ph. D. Dissertation, University of
    Washington, 1996,p.71.

[^11]: At this time, there was a lot of work done by climatologists
    trying to determine what types of climates would assist invalids in
    the struggle to get better. The American Society of Climatology
    would publish reports of where the best conditions were to cure.

[^12]: ^?^ National Tuberculosis Association. [Some plans and
    suggestions for housing consumptives. Pub by the National
    association for the study and prevention of
    tuberculosis,]{.underline} New York.\[Philadelphia: Press of W.F.
    Fell company\] 1909. p.17.

[^13]: [Ibid]{.underline}. p. 14.

[^14]: [Ibid.]{.underline}, p. 14.

[^15]: ^?^ [Ibid.]{.underline}, p.20.

[^16]: ^?^ [Ibid.]{.underline}, p.36.

[^17]: ^?^[Ibid.]{.underline}, p.68.

[^18]: ^?^ [Ibid.]{.underline}, p.68.

[^19]: ^?^ [Ibid.]{.underline}, p.143.

[^20]: ^?^ [Ibid.]{.underline}, p.163.

[^21]: ^?^ [Ibid.]{.underline}, p.173.

[^22]: ^?^ Carrington, T.S. [Tuberculosis hospital and sanatorium
    construction]{.underline}. New York: National

    Tuberculosis Association, 1914,p. 68.

[^23]: [National tuberculosis association. Tuberculosis hospital and
    sanatorium directory]{.underline}.

    New York: National Tuberculosis Association, 1938,p. 349.

[^24]: For more information on the health seekers affect on New Mexico,
    see Spidle, J. W. Jr. "An

    army of invalids: New Mexico and the Birth of a Tuberculosis
    Industry", [New Mexico]{.underline}

    [Historical Review]{.underline}, 61, 1986, pp. 179-201.

[^25]: Report of Washington State Board of Health upon House Bill 211,
    of the eleventh

    legislature, 1909 relative to the establishment of a sanatorium for
    the care and

    treatment of indigent consumptives. Olympia: E.L. Boardman, public
    printer, 1911,

[^26]: [Ibid.]{.underline}, p.13.

[^27]: ^?^ [National tuberculosis association. Tuberculosis hospital and
    sanatorium directory]{.underline}.

    New York: National Tuberculosis Association, 1938, p. 350.

[^28]: [Ibid]{.underline}. ,p. 350

[^29]: Lerner, Barron. ["On what authority is this being done?"
    Tuberculosis control, poverty, and coercion in Seattle,
    1909-1973.]{.underline} Ph. D. Dissertation, University of
    Washington, 1996, p. 77.

[^30]: [Ibid]{.underline}., p.129.

[^31]: I didn't have time to go through the local papers to get accounts
    of this. I think it would interesting. There is a publication put
    out by the NTA that deals with placement of TB sanatoriums and how
    it affects land use around it. I really need to read this for my
    thesis.

[^32]: Firland. [A story of Firland Sanatorium]{.underline}. Seattle:,
    WA: Firland Sanatorium, 1936.

    p.11.

[^33]: ^?^ This is conjecture based on other plans for cottages, I can
    guess from the pictures what type of form the cottages took.

[^34]: ^?^ The site (land, buildings and equipment) at the time of
    transfer to the city was worth 75,000 dollars. Source: history of
    ATL.

[^35]: ^?^ Shoreline Historical inventory.

[^36]: ^?^ The service wing served as the storage and kitchen facilities
    for the compound until ambulant patients wards were built.

[^37]: ^?^ Harborview p.97

[^38]: ^?^ Washington State Historical Resources inventory of the
    Firland site., n.d. p. 2.

[^39]: ^?^ MacDonald, Betty. [The Plague and I.]{.underline}
    Philadelphia, PA: J. B. Lippincott, 1948. Betty

    MacDonald often complained of the constant chill of those taking
    bedrest in the damp climate of

    her fictional sanatorium "The Pines".

[^40]: ^?^ Trudeau created the first sanatorium in the United states in
    Lake Saranac, NY and is considered the father of the sanatorium
    movement. Forlanini was an Italian scientist who developed type of
    flouroscope used to view infected lungs.

[^41]: Lerner, Barron. "[On what authority is this being done?"
    Tuberculosis control, poverty, and coercion in Seattle,
    1909-1973]{.underline}. Ph. D. Dissertation, University of
    Washington, 1996, p. 202.

[^42]: ^?^ Betty MacDonald talks of how great it was to be in promoted
    to the ambulant patients ward. The situation felt a bit less
    regulated, though rules were still enforced. She describes the joy
    at being able to fill up her own hot water bottle with very hot
    water any time she pleased instead of waiting for orderlies to do it
    twice a day.

[^43]: "Firland children get a new building" [Richmond Beach
    Herald]{.underline}, Jan.1, 1926.

[^44]: ^?^ MacDonald, Betty. [The Plague and I.]{.underline}
    Philadelphia, PA: J. B. Lippincott, 1948.

[^45]: ^?^ MacDonald describes her interactions with her Japanese
    roommate, Kimi Sanbo, as quite enjoyable.

[^46]: ^?^ Lerner, Barron. "[On what authority is this being done?"
    Tuberculosis control, poverty, and coercion in Seattle,
    1909-1973]{.underline}. Ph. D. Dissertation, University of
    Washington, 1996, p.87.

[^47]: ^?^ [Ibid.]{.underline},p.88.

[^48]: ^?^ Betty MacDonald was concerned about how she was going to pay
    for her treatment. The Medical Director, Dr. Stith told her that
    when she made money, she could repay the City for her care. Lerner
    estimates that only 3% of care was paid by patients, the rest was
    covered by the State and City funds.

[^49]: ^?^ [Ibid.]{.underline}, p. 217

[^50]: ^?^ [Ibid.]{.underline}, p. 84

[^51]: ^?^ Lerner also argues that the medical director at Firland, Dr.
    Robert Stith, stressed the use of public money for patient's
    benefits wisely. A way to do this was by following the rules of
    treatment.

[^52]: ^?^ In 1933, the state of Washington Legislature established a
    division of Vocational Rehabilitation. Since tuberculosis patients
    were thought to be physically handicapped, this allowed them to ask
    for additional federal moneys to develop occupational therapy
    programs.

[^53]: ^?^ Firland. [A story of Firland Sanatorium]{.underline}.
    Seattle:, WA: Firland Sanatorium, 1936., p.65

[^54]: ^?^ "Time up", a patient's ability to be active was factored by
    patient's prognosis.

[^55]: ^?^ Health graduate is a term related to those who had left
    successfully left Firland.

[^56]: ^?^ Lerner, Barron. ["On what authority is this being done?"
    Tuberculosis control, poverty, and coercion in Seattle,
    1909-1973]{.underline}. Ph. D. Dissertation, University of
    Washington, 1996, p. 135.

[^57]: ^?^ 1944 report.

[^58]: ^?^ King County Road to Health :a short history of the
    Seattle-King County Department of Health n.p

[^59]: ^?^ [Ibid.]{.underline}, np.

[^60]: ^?^ [Ibid.]{.underline}, np.

[^61]: ^?^ Interview with Mike Martin, February 26, 1998.

[^62]: ^?^ The original green house was demolished and a new one was
    erected near the old powerhouse. It is unclear if this is the site
    of the old greenhouse. Residents of CRISTA propagate plants for sale
    at local functions. It provides the same tools of therapeutic
    gardening and occupational therapy as before.