The material consumptive: domesticating the tuberculosis patient in Edwardian England

The proliferation of general and specialist hospitals, lunatic asylums, and workhouse infirmaries in the nineteenth century challenged the popular perception of the home as a suitable site of health care. Amidst the emergence of yet another type of institution, the tuberculosis sanatorium, tuberculosis control in the Edwardian period was re-sited and re-scaled to accommodate what might be termed a ‘preventive therapy’ of domestic space. Three interlinked perspectives demonstrate why and how this happened. First, I explore the role of the national and local state in legitimating domestic space as a scale and a site for the regulation of tuberculosis patients and prevention of the disease. Second, I investigate how tuberculosis self-help manuals promoted a technology of the self that was founded largely on the principles of sanatorium therapy but was necessarily reconfigured to reflect the social relations of domestic space. Third, I assess the marketing of consumer goods to the domiciled tuberculosis sufferer through the pages of the British Journal of Tuberculosis. It is suggested that a common tubercular ‘language’ of material consumption was fashioned in order to normalise the accumulation of possessions for use in the home. These arguments are situated in relation to recent historical research on material culture and identity at the turn of the twentieth century, which has stressed the cultivation of individuality and that the right sort of possessions appropriately arranged in domestic space signified well-regulated morality.

The nineteenth century witnessed an unprecedented transformation in the locus of care for the sick in Britain. General and specialist hospitals, insane asylums and workhouse infirmaries warehoused ever greater numbers of ill people. The perception that the home was the natural space in which to tend to the unwell was destabilised by this shift towards the institutionalisation of health care. Another type of institution was the tuberculosis sanatorium. Sanatoria emerged in Europe and the United States towards the end of the nineteenth century as part of an approach to controlling the disease that also included the dissemination of behavioural advice through health education and the regulation of meat and dairy products. These latter interventions were amongst the first public health policies to address the problem of tuberculosis directly and were related to the idea of tuberculosis as a 'social disease' that dominated policies in Britain and its colonies. 1 Whilst we know a great deal about the cultural and social significance of sanatoria in the Edwardian period, it nevertheless remained the case that the vast majority of tuberculosis patients were not institutionalised. The dawning realisation that it was unrealistic to hospitalise the mass of tuberculosis sufferers prompted a reformulation of regulation that focused efforts on the home as a viable site of intervention. The domestication of tuberculosis was achieved by moulding elements of existing public health policy with components of the sanatorium regimen into E-mail address: gmooney3@jhmi.edu a kind of domesticated 'preventive therapy' for tuberculosis. 2 This meant deployment of tuberculosis surveillance and disinfection, but without the threat of mandatory hospitalisation. The sanatorium formula of rest, exercise, and diet was adapted to the domestic environment and promoted a 'technology of the self' through the social relations of domestic space. 3 Equally significant was the fashioning of a tubercular 'language' of material consumption that promoted the accumulation of possessions for use in the home. The British Journal of Tuberculosis (BJTB) in particular endorsed and promoted a vast array of everyday objects and appliancesdbaths, reclining chairs, bed rests, reading stands and many, many mored that bridged the therapeutic divide between institutional and domestic space. 4 By encouraging a culture of possession, tubercular patients were drawn into the realm of mass consumerism that normalised their identity.
As a result of these multiple strategies, tuberculosis control was re-scaled and re-sited from the sanatorium to the home. The national and local state came to share the regulatory site of the home with alternate, but complementary, bureaucracies of power. Some experts outside formal government were armed with medical knowledge and hygienic ideas; others deployed marketing strategies, advertising skills and the language of selling. 5 The specifics of this sort of re-scaling and re-siting have largely been overlooked by historians, though the form and idea of 'home' and 'domesticity' have been much debated, particularly for the Victorian period. It is important, then to resist naturalising scale as a preexisting component of spatiality that historical actors operate within or pass between and through. For the purposes of this paper, sensitivity to the production of scale (for example, national, local, urban, rural, domestic) and site (such as sanatorium, home) helps disclose the underlying scope of moral regulation inherent in the tactics of tuberculosis control at the end of the nineteenth century and the beginning of the twentieth. For example, the cultivation of individuality and the right sort of possessions appropriately arranged in domestic space signified a well-regulated morality. 6 In the case of tuberculosis, a multitude of consumer goods were marketed to the domiciled sufferer as the material expression of a morality that conditioned the behaviour of patients. They nurtured domesticity, homely pastimes and healthy pursuits that were as much an antidote to morally corrupt activities as they were crucial to therapeutic success. Moral regulation here concerns how 'morality'dthat is, normative judgements about what is wrong or bad conduct across a broad range of behaviours 7 dwas channelled through disease and health, at a time when wider notions of subjectivity were undergoing change. The paper addresses these issues in four main sections. The first two parts outline the ways in which public health administrations re-scaled and re-sited tuberculosis strategies as 'domestic' and how these strategies can be understood in terms of subjectivity. In this respect, the discourses and practices around what was one of the most pressing health issues of the early Edwardian period are used to build on the recent work in historical geography by Sallie Marston, Alison Blunt and others on the political context of everyday and mundane activities. It is stressed that the production of 'domestic' as a geographical scale and the management of 'home' as a site of risk and opportunity reveals much about the structure and exercise of power. 8 The third and fourth sections examine the shifting terrain of subjectivity in the early twentieth century (from 'character' to 'personality') through tuberculosis self-help manuals that were written for domiciled patients, and the materialisation of domestic preventive therapy via analysis of a section in the BJTB which promoted products for tuberculosis patients. One of the key points to emerge is the extent to which the market for consumer goods operated as a crucial arena for moral regulation through health.

Subjectivity, site and scale in British public health
The Edwardian period witnessed a shift in subjectivity from one that was rooted in 'character' shifted to one based on 'personality'. The former pointed to conformity with a set of public virtues that 'comprised a citizen's moral constitution', while the latter was based around the formation of the unique self, associated with the tantalising quest for individuality. 9 Although this sort of narrative about subjectivity is undoubtedly over-generalised, its broad contours can be meshed with an account of the politics of public health in the nineteenth century in order to understand the process of how and why the 'domestic' came to be reconstituted as a necessary scale of tuberculosis therapy. 10 Scalar issues were significant in public health in the early Victorian period, when much activity centred on ambitious infrastructural projects that sought to remediate the detrimental environmental aspects of urban industrial growth. 11 Victorians struggled with the conceptual and geometric scale of these sanitary schemes. 12 The political tussle over sanitary measures was essentially a contest made through hierarchical scaledthe national 2 Today the term 'preventive therapy' is used in multiple medical contexts, though it is most commonly associated with tuberculosis. centre and the local province. 13 Yet Victorian sanitary reform was replete with tacit moral assumptions about domestic space, issues, and relations. 14 Connections between the intimate space of the home and the public space of the environment were several and layered. 15 Sanitarians argued that the degradation of urban places fostered immoral habits and vice. An environmentally-based public health offered the chance to create the appropriate conditions under which individuals (or more precisely, voting men) might achieve domestic propriety. 16 National debate about the electoral franchise between the 1830s and the 1860s constantly circled this issue and qualification for the vote in the 1867 Reform Act solidified the ideal of the domestic man with 'a house, a wife, children, furniture and the habit of obeying the law'. 17 Historians Patrick Joyce and Chris Otter have argued that drains, sewers and water mains were material expressions of liberalism that mediated the freedom of the governed to act rationally in public and private space. 18 From the 1870s, however, management of the physical environment in order to help create favourable domestic circumstances was complemented by a set of public health interventions that explicitly interfered with the social relations of individuals inside the home itself. 19 The notification of infectious diseases (under which private family doctors were paid by the local health authority to report infectious cases to its medical officer), the isolation of the infected, contact tracing, and the destruction or neutralisation of biological threats with disinfection, comprised a set of surveillance practices that disrupted the intimate channels of disease transmission between humans, even if those channels were barely understood. 20 Such techniquesdwhich excluded tuberculosis and focused mainly on childhood infections such as scarlet fever and diphtheriadwere adopted incrementally in the late nineteenth century, though they were most fully realised in towns and cities that had the political drive and financial wherewithal to implement them. These interventions preceded the emergence and acceptance of germ theory, though they were retrospectively endorsed and refined by the more precise knowledge of disease transmission furnished by bacteriological research. 21 Infectious disease surveillance characterised a more individualised approach to public health at the turn of the twentieth century that mirrored and was constitutive of the broader shift to subjective individuality.
Establishing and preserving a biologically risk-free home was a barometer of hygienic citizenship. But the administrative structures, policies and techniques of infectious disease surveillance in Britain were poly-scalar and poly-sited. Infectious patients were medically managed in multiple sites, such as isolation hospitals or separate wards in general hospitals and poor law infirmaries. A lack of available beds restricted hospital admissions in many places, but the Sanitary Act of 1866 declared that patients would be hospitalised if their home did not have 'proper lodging or accommodation, or lodged in a room occupied by more than one family'. The definition of 'proper' was left to the discretion of local health authorities and interpretation of the law implicitly preserved the privacy of middle-class householdsdpoor families were more likely to lodge together and rarely had enough space at home to demarcate a sickroom.
Meanwhile, national government trod a cautious scalar path: public health policy debates were driven by the conflicting demands of international/national, local/national, urban/rural, and individual/community constituencies. As a consequence, much national public health legislation was permissive rather than compulsory. For example, while some districts adopted infectious disease notification through local acts of parliament, it took more than two decades for central government to impose it on all local authorities. Discourse on infectious disease surveillance was strongly influenced by a scalar argument: it was pointless to have city-wide policies to regulate urban residents yet not subject the inhabitants of the surrounding rural hinterlands to the same sorts of restrictions. 22 The solution to this uneven and biologically dangerous geography was to mandate infectious disease notification across the whole nation, which finally happened in 1899.
The contested status of tuberculosis as a communicable disease provided an interesting dilemma for advocates of infectious disease surveillance. The position of tuberculosis as the biggest (though declining) killer provoked multiple explanations as to its proximate causes. As Michael Worboys has shown, between 1880 and 1930, sanitary conditions (including housing), person-to-person contact, behaviour and lifestyle, inherited susceptibility, and herd immunity were all put forward as possible reasons for why tuberculosis was declining. 23 To varying degrees, components of the first three influenced the way in which domestic space was articulated as a site and scale of intervention to regulate patients and prevent the disease.

Disinfection, tuberculosis, and mobilisation of the domestic
The characterisation of a risk-abundant domestic space was fairly commonplace by the 1860s. 24 The mid-1870s and early-1880s were replete with warnings about the evils of dust. Particular ire was reserved for the dust-retaining properties of carpets, curtains and ornate hangings. 25 In his address on 'Domestic Health' delivered to the annual meeting of the Sanitary Institute in Brighton, the wellknown public health activist Alfred Carpenter said in 1881 that, 'there is scarcely a house in the kingdom in which excreta are not to some extent retained'. 'Excreta' here means not just drain flush, but all forms of bodily seepage that never made it beyond the confines of the home: The most civilised and luxurious home is, in some cases, carefully prepared for the cultivation of disease-germs or factors, if they come into our midst: carpets, curtains, and comforts of all kinds retain the débris from our skins and our pulmonary membranes; the excreta from our sweat-glands are allowed to settle upon our uncleaned windows, out-ofthe-way cornices, useless ledges, and so-called architectural or upholstering ornaments. 26 By shifting the geography of risk ineluctably inwards, public health forced itself into the space of the mundane, the everyday and the domestic. 27 There was, of course, a massive popular literature on design and decoration of the domestic interior and this was directed predominantly at women as the moral guardians of the home. 28 After the 1866 Sanitary Act, householders' own hygienic efforts were supplemented by municipal disinfecting activities that entered domestic space. From the late 1870s in urban Britain, bacteriological experiments and technological know-how were harnessed to create highly mobile, city-wide systems of disinfection that deployed pressurised steam and a cocktail of chemicals to rid peoples' homes, clothes and belongings of dangerous microbes. Though municipal disinfection of homes was geographically variable, incomplete, and deployed both 'old' (fumigation) and 'new' (disinfecting) methods, public health officers were extremely confident by the early 1900s that they could eliminate most biological threats from the domestic environment. 29 Much of this confidence can be accredited to bacteriological research in the 1890s on tubercular dust (that is, the dried sputum of the tuberculosis patient). This research was readily grafted onto existing anxieties about the accumulation of dust and dirt in the over-adorned Victorian domestic space. 30 It was a common trope of hygienists that dust was a 'carrier' or 'common conveyer' of tuberculosis and that the tuberculosis bacillus 'lingers long in the dust of rooms, inhabited by careless tuberculous subjects'. 31 Eradicating this 'matter out of place' became a hygienic duty and conditioning the behaviour of these reckless individuals became a central plank of effective anti-tuberculosis campaigns. 32 Despite clarification from the early-1880s that tuberculosis was indeed a communicable disease, a prolonged period of institutional sequestration was not a viable option for the vast majority of sufferers due to the potential loss of earnings and social functioning. Domestic space had to be the main therapeutic site. If home-based interventions were to have any impact, as many patients as possible needed to be reached and as many risks as possible nullified. Under this rationale, the notification of tuberculosis was the only realistic way forward and a number of voluntary schemes were developed. 33 The first, in Brighton in 1899, was quickly copied elsewhere and by 1904 eleven other towns encouraged GPs to voluntarily inform the sanitary authority of tuberculosis cases coming under their care. 34 Public health officials and tuberculosis campaigners complained that voluntary notification only revealed a limited number of sufferers; it was thought that Sheffield's scheme routinely missed between 40% and 50% of all cases in the city. 35  Annmarie Adams discusses the ways in which doctors discredited architects' contribution to the healthiness of homes. See her Architecture in the Family Way: Doctors, Houses, and Women 1870e1900, Montreal and Kingston, 1996, 36e72. Architects such as Robert Edis and E.W. Godwin, Adams argues, were relegated to providing advice on decoration and furniture, precisely the aspects of middle-class homes that Carpenter was worried about. Also on Edis, see Neiswander, The Cosmopolitan Interior (note 25), chapter 3. 28 An American perspective can be found in G. Wright, Moralism and the Model Home: Domestic Architecture and Cultural Conflict in Chicago 1873e1913, Chicago, 1980, especially chapter 4. 29 Municipal governments did carry out cleansing operations, particularly during epidemics, but these usually focused on public spaces such as dirty streets, alleys and health administrators from Sheffield worked hard behind the scenes to alter the LGB's position. 36 In May 1903 negotiations took place with the LGB's medical officers (one of whom, Dr Theodore Thomson, just happened to be a former Medical Officer of Health for Sheffield 37 ) to draft a law that was acceptable to central government. 38 Sheffield's representatives argued that the public themselves did not see notification as problematic and witnesses attested that 'the dread of consumption amongst the poor' was 'very much greater than the dread of notification'. 39 Furthermore, interference with the future livelihood of the tuberculous patient was not an issue, because Sheffield's proposed law stated that 'no provisions contained in any general or local Act of Parliament relating to infectious disease shall apply to tuberculosis of the lung'. 40 This meant that patients could not be removed to hospital after notification (at least not without their consent). Sheffield did not operate a sanatorium of its own at this point. 41 Another aspect of Sheffield's law concerned the domesticated nature of the actions taken after notification. There were two elements to this: domiciliary education and disinfection. The city made it apparent that it possessed the wherewithal to carry out disinfection measures. The LGB's Theodore Thomson argued the public, as consumers of health services, had every right to benefit from disinfection if their property rates were being used to pay physicians to notify their illnesses. Thomson used the language of citizenship to maintain that compulsory tuberculosis notification should not be granted 'unless you have [disinfection] staff and appliances sufficient to deal with the problem': There is, in a case like this, as in very many other sanitary provisions, some interference with the liberty and possibly the comfort of the subject. I should not care to see a power given which conveyed that danger unless some adequate amount of benefit was to be obtained in return. 42 Sheffield had modern disinfecting apparatus, adequate staff and an efficient administration to deal with the potential workload that compulsory notification would generate. 43 The city's high-pressure steam disinfector had begun operation in 1888 and the annual number of houses disinfected leapt from around 30 in the mid-1880s to an average of more than one thousand by the early 1890s. 44 As well as disinfecting homes and possessions, the second prong of Sheffield's policy of domestication was to give patients intensive education in the home. The position of Sheffield's Medical Officer of Health John Robertson was that public lectures and blanket leafleting of the community about the dangers of tuberculosis did not, and would not, have any lasting impact. 45 In Sheffield and other cities with voluntary tuberculosis notification, patients and their carers already received verbal and written advice, in the domestic setting, about isolation, ventilation, disinfection and the disposal of sputum. A compulsory scheme meant that interventions could be targeted directly at people with active disease.
The House of Commons put compulsory notification of tuberculosis on trial in Sheffield for seven years. In 1910, the clauses were renewed for a further 10 years, as were those that had been given in the interim to the Lancashire towns of Bolton, Burnley and Oldham. 46 These local acts were granted on the understanding that patients would not be compulsorily sequestered in sanatoria, that people would be educated about prevention, and that adequate facilities existed to disinfect patients' homes. All the local laws were superseded by a national act in 1912.
In this discourse about tuberculosis at the turn of the twentieth century, the spatiality of 'home' and 'domestic' was expressed as both site and scale. The home was naturalised as a location for intervention. Three points can be made about this. First, it is intriguing that this deliberative re-siting had to happen at all. Hospitals, workhouse infirmaries, lunatic asylums and pertinently in this case, tuberculosis sanatoria, were increasingly seen as the most appropriate sites of health care for many kinds of patients. Of course, a lot of sick people were still cared for at home, but institutionalisation destabilised this tradition, necessitating a restatement about the value of domiciliary care. 47 Second, the domestication of state-sponsored disinfection activities provides a balance to the dominant view that responsibility for cleanliness in the home devolved solely onto housewives and mothers as popular knowledge about germs spread. 48 Whilst not disputing this parallel trend, it is also plausible to argue that at the same time the state actively sought heightened obligations in the domestic arena. Furthermore, it was recognised that certain aspects of domestic architecture, materiality, organisation and social relations presented a risk to the health of tuberculosis patients and their relatives. The potential return on the mitigation of these risks was very high, which meant that the home had to be made into a viable site of effective regulation. Domestic space needed to be thought of and reproduced as a scale through which interventions could be imagined and implemented.

Self-help and the diffusion of therapeutic space
The reluctance of Parliament to sanction the notification of tuberculosis partly helps to explain why, despite the mushrooming of private, public and voluntary sanatoria from the late nineteenth century, these institutions treated only a minority of people who had the disease in the early twentieth century. Worboys estimates there were 1500 sanatoria in-patient stays in 1900. By 1913 this had risen eightfold to 12,000 stays. This represented provision for less than 5% of all tuberculosis sufferers nationwide; or about 20% of patients with the active form of the disease. 49 The 'sanatorium benefit' included in the National Insurance Act of 1911 stimulated more provision. 50 From this date to 1920, the number of beds available for tuberculosis patients (excluding the Poor Law system) increased by about a factor of five, to almost 16,000. 51 The term 'sanatorium benefit' was somewhat misleading, because it also provided funds for care beyond the walls of sanatoria, including home treatment. Most notably, local authorities were required to provide a tuberculosis dispensary that served as a diagnostic out-patient centre with welfare functions. The dispensary's tuberculosis officer and a team of nurses worked on a case-by-case basis in conjunction with the patient's GP to determine the most suitable treatment. 52 Dispensary treatment rocketed after the National Insurance Act: there were 64 tuberculosis dispensaries in 1911; by 1920 there were 398. 53 Debate about the effectiveness of home treatment seems to have intensified in the aftermath of the 1911 act. Some commentators, such as Oscar Holden, a tuberculosis officer with experience in Birmingham and Southampton, warned that the continuing risk of infection by advanced cases living at home was a serious danger to the wider community. 54 Others were sceptical about the lack of moral support at home: anxious parents, relatives and friends made for bad advisors and it was impossible for them to be alert to all sorts of imprudent actsdkissing, visiting the pub, singing around the pianodthat might endanger the patient and their family. 55 On the other hand, some were convinced that many cases of tuberculosis could be successfully managed and cured at home, particularly with the additional level of monitoring offered by the dispensary system. 56 Despite quite vehement support for both sides, there was no clear and convincing evidence about the benefits of either approach. An uneasy consensus emerged that sanatorium treatment was most suitable for early cases that were actively infectious, whereas home treatment was more appropriate for cases that were not currently infective or infective advanced cases that were beyond salvation. 57 While precise details varied from place to place, a sanatorium 'cure' commonly included a combination of wholesome diet, exercise, graduated labour and plentiful fresh air. 58 The involvement of the adult patient in deciding the parameters of their sanatorium treatment was important. Sanatoria staff tailored treatments to provide an individualised regime that the patient could manage him-or herself. Despite continual dispute about the regimen's therapeutic effectiveness, contemporaries nevertheless believed that sanatoria and the open-air movementdwhich transferred most activities including sleeping, eating, schooling and rest from indoors to out 59 dhad the potential to 'revolutionise social, municipal and national life'. 60 Michael Worboys has gone so far as to suggest that the sanatoria-based 'attempt at "cultural control" was of equal, if not greater, significance than the betterknown Edwardian campaigns about motherhood and physical degeneration; indeed it may be artificial to separate them'. 61 Historian Flurin Condrau's view is that the sanatorium has been mistakenly written about as a 'façade behind which discipline, order and militaristic concepts of hygiene were used to control working-class sufferers', and that more subtle historical interpretations should include the integration of patient agency into the therapeutic narrative. 62 Whilst I broadly concur with Condraudat the very least, the notion of 'control' might be more appropriately thought of as 'regulation'dthe predominant historical concern with the discrete site of the sanatorium potentially underestimates the wide-ranging influence of its therapeutic reach. A complementary focus on domestic preventive therapydthe design of which was drawn up in the sanatoriumd clarifies how unsatisfactory the crude concept of 'control' really is. Furthermore, in the context of moral regulation, a rather complex set of practices of self-formation take shape in the domestic sphere that defy simple categorisation into projects articulated by the state and those performed by individuals on themselves. As Alan Hunt argues: Projects of moral regulation and ethical self-formation frequently come together in the complex and varied forms of interaction between governing others and governing the self . a significant dimension of moral regulation projects is that they are projects directed at governing others while at the same time they result in self-governing effects . We need have no fear that the term moral regulation refers only to projects to impose external moral codes, even though history is replete with just such endeavours; moral regulation is often directed at inducing projects of self-formation, manifest in ubiquitous incitements to 'self-control'. 63 Self-control through tuberculosis education was popularised from the 1880s. The inculcation of both preventive and curative behaviours in the domestic sphere was adopted as a credible tactic because so few non-pauper tuberculosis sufferers were ever likely to be admitted to local institutions. Publicly-and privately-funded leaflet campaigns for tuberculosis control emerged in Britain in the mid-1880s, initially in Lancashire (notably Oldham and Manchester). 64 These educational drives were conducted at the urban scale. Rhetorically, they identified transgressions in domestic and public space and codified appropriate forms of self-regulation: keep your home clean; ventilate it; disinfect furniture; maintain an unblocked chimney; destroy your sputum; practice open-air living; and stay away from close and crowded rooms, especially concert halls, theatres, and pubs. This is familiar historical ground. Yet, as we have seen in the case of Sheffield, some public health administrators grumbled about this dissipated technique of didactic intervention. 65 Lifestyles and behaviours were simply too slow to change, if they did at all. While leaflets and pamphlets had drawbacks, advice targeted directly at domiciled tuberculosis patients was also limited in that it was impossible for health visitors to monitor patients closely or reinforce the lessons on anything like a regular basis. 66 Nor did the various local prevention schemes give detailed advice on how to approach the disease therapeutically. Some enterprising doctors identified this gap in the market and produced self-help manuals for the home-based tuberculosis patient. Medical self-help books have a long tradition. 67 Those for consumptives that appeared at the beginning of the twentieth century were little different to many others that had gone before them in that they provided a fall-back mechanism for poor patients who were either unable or unwilling to avail themselves of medical attendance. 68 However, tuberculosis self-help manuals were also directed at patients who had undergone a period of sanatorium treatment and, it was presumed, wanted it maintained in a domestic setting. Even then, a sanatorium stay was not necessarily a guarantee that the patient had been given the information needed to survive. In 1909, Sheffield's Medical Officer of Health, Henry Scurfield, bemoaned that 'in many sanatoria, when the patient leaves he has not been educated', even in some basic measures such as the disposal of sputum. 69 These manuals were the product of a particular historical moment when sanatorium treatment was gaining credence as the most appropriate mode of therapy; at the same time, facilities did not exist to provide that treatment for all patients, and the chronic nature of the disease made the argument for long-term hospitalisation a tough one to make politically.
Essentially, the regime of home treatment replicated as far as possible that of the sanatorium. The key to success was a patient's self-knowledge of, and control over, his or her own body and its domestic surroundings. Bodily regulation was achieved by the constancy and repetition of physical conditioning: exercise, rest and diet were scrutinised as the patient undertook vigilant surveillance of her or his own temperature and weight. Patients were expected to eat, sleep and rest at prescribed times of the day and even to breathe in precise ways. 70 Body temperature synchronised the eatesleeperesteexercise rhythms of home treatment; body weight was used to gauge the patient's progress.
Normal temperature and weight were achieved through strict control over dietary intake (the type and amount of food to be consumed), exercise (suitable forms of recreation were suggested), 62 Condrau, Urban tuberculosis patients and sanatorium treatment in the early twentieth century (note 58), 204e205. See also S. Craddock, Engendered/endangered: and the timing and extent of rest periods. Experts expressed differences of opinion about these aspects of the regime, differences that depended partly on the stage of the disease and partly on the individual patient; no two patients were the same. 71 More important was the implementation of regularity and strict adherence to the set programme. Henry Hyslop Thomson wrote in his manual that: 'The more closely one day conforms to another, and the more strictly the patient adheres to the routine of treatment, from day to day, and from week to week, the more beneficial and effective will the result be'. 72 As such, disagreements over detail were overridden by the commonalities and the shared acknowledgement that some activities had a deeper moral purpose. Self-responsibility and strength of character were the key to concluding of a successful course of home treatment, be that complete cure or, more realistically, a prolonged period of capacity for work and the enjoyment of life. Noel Bardswell's guidance stressed that: Character or temperament, as in all other things, is a very large factor in success. The irresponsible, the undisciplined, and the despondent have nothing like the same chance of recovery as the cautious, the level-headed optimist, and the man of purpose. It is well for the patient to recognise frankly, from the first, that the fight for life and health is to be a hard one, with the odds against him . the odds can be levelled up by learning the principles by which consumption may be cured, and resolutely adhering to them . the happy-golucky consumptive, though perhaps the shorter-lived, is a happier man that the discontented hypochondriac. He is certainly the more contented companion. The mid-course between these two extremes should be aimed at. 73 These interlinking points about individual responsibility and determination constantly reiterated familiar tropes of self-help rhetoric. Thomson spoke of 'personal effort', 'intelligent effort', 'constant effort', 'unswerving allegiance to the rules' and 'personal endeavour'. 'In many cases', wrote Thomson, 'the consumptive holds in his hands the power of treating and curing himself . [he] . must intelligently order and supervise his whole method of living'. 74 Bardswell was sure that there would be 'little setbacks' and the regime involved 'much troublesome care and self sacrifice'. 75 But the most successful patients, argued Henry Warren Crowe, will be 'those who can form a resolution and steadfastly carry it out, and who are sufficiently master of their own surroundings'. 76 Nurturing such characteristics was intrinsically linked to the prevention of immoral behaviours. Bardswell did not just emphasise the benefits of exercise when he advocated taking a walk around the local park each evening; he also believed that it staved off the temptation to stray into the pub and fritter money away on alcohol. 77 According to Thomson, intemperance was the main predisposing cause of tuberculosis not because it corroded the liver of the habitual drinker, but because of 'the conditions of life to which it gives rise. The children of the drunkard are badly clothed, indifferently fed and poorly housed, and readily fall prey to the ravages of tuberculosis'. 78 As well as developing moral rectitude through bodily discipline, the patient had to comprehend the domestic conditions that mediated the risk of infection and predisposed their 'deviation from the normal healthy standard'. 79 Echoing the belief of Sheffield's public health officials, Thomson argued that the campaigns against poor ventilation, uncleanliness and inappropriate furnishings had made but a small dent on popular consciousness: there was still much 'ignorance and mistaken views as to what constitutes a healthy home'. 80 Crowe urged consumptives to study the direction of draughts through the house so that they might know where to position their bodies. 81 No detail was 'too trivial' if the patient was to become 'familiar with everything relating to himself and his surroundings'. 82 The many constituents of domestic spacedbeds, furniture, windows, floor coverings and peopled invariably were construed as problematic and risk-laden.
Awareness of the minutiae of domestic life was therefore exalted and this also had an explicit moral dimension. Intimate interactions with other family members represented an obstacle to the patient's progress. Of course, one of the main benefits of sanatorium treatment in the eyes of its promoters was isolation from meddlesome family and friends, which proved extremely difficult to replicate in the crowded domestic sphere. 83 As with other infectious diseases, the patient was expected to take sole occupancy of a separate room in the house whenever possible. 84 Even still, complete segregation was practically impossible, particularly for working men and women and housewives who moved in and  around the house out of necessity. 85 This feature of home treatment worried the writers of self-help manuals not only because the patient might continue to infect other family members, but also because the family could exert a corrupt influence on the stringent therapeutic regime. 86 Consequently, the routine of the patient was aimed at restricting the likelihood of contact. Consumptives with active disease 'should never be kissed on the lips'. 87 Retiring early to bed not only delivered much-needed rest, but it also 'removed the temptation to join the family circle in sitting up till a late hour'. 88 Clearly, these texts were not just about health but also about morality. The emphasis in the tuberculosis self-help manuals on discipline, self-control, responsibility and the suppression of intimacy reflects the important role of character and morality in the daily life of the domiciled consumptive patient. These ideals had their high-water mark in the late Victorian period and have been associated with a type of 'governmental self-formation' through which authorities and experts explicitly seek to shape individuals' conduct. 89 But the moment at which this tubercular self-help genre picks up was also the moment when the quest for 'character' shifted more towards subjectivity through self-discovery and the crafting of unique identity. Written from the standpoint of medical authority and expertise, yet emphasising individuality, selfquantification and bodily knowledge, these tuberculosis self-help manuals typify this transition. Indeed, it does not strike me as egregious to transplant to the early twentieth century Alan Hunt's argument that moral regulation today 'is more likely to be found in the guise of self-help texts or the discourses of "addiction" and "recovery". Yet such projects remain attempts at moral regulation in that they are concerned to effect changes in the conduct and ethical subjectivity of individuals'. 90

A material culture of consumption
In her book Household Gods, Deborah Cohen describes the complex, shifting relationship between domestic space and possessions, and what the two together signified about notions of the self at the turn of the twentieth century: Possessions offered a lifeline for coming to terms with one's own identity in a society so much in flux. From its origins in the 1890s, the idea of 'personality' was fundamentally intertwined with the domestic interior. Character, an older conception of the self, connoted a moral state. Personality was about earned distinctiveness, performance, and display. No place was more of a stage for the turn of the century British than their homesdeven if no one was else was watching. 91 More of the intricacies and subtleties of the transition from 'character' to 'personality' can be teased out by looking at the consumer culture surrounding tuberculosis. 92 It is worth stressing at this point that it was not as if the nurturing of moral character disappeared as a fundamental aspect of tuberculosis treatment. Well into the twentieth century, subsequent editions of the selfhelp manuals considered above (the third and, it transpired, final edition of Thomson's book was issued in 1928) were no less insistent on the importance of character than were the earlier versions. 93 It continued to be common to think of consumptives as having character flaws that made them vulnerable to behavioural lapses which the ownership of, or contact with, certain things might help prevent. Nonetheless, it is difficult to resist the general thrust of Cohen's argument where the materiality of tuberculosis is concerned.
One conduit through which household commodities were marketed and sold to tuberculosis sufferers was a section of the BJTB entitled 'Preparations and Appliances'. Medical and public health journals of the time carried direct advertising to supplement subscriptions and sustain print runs and circulation. Indeed, at the end of the nineteenth century, advertising constituted the largest revenue stream for prestigious medical journals. 94 As with other publications, however, the BJTB also provided editorial information about commercial products that it thought might be of interest to its readers. There is no direct evidence to substantiate this claim, but it seems likely that the 'Preparations and Appliances' section of the journal involved a form of indirect advertising known as 'puffing' (now commonly known as 'advertorials'); that is, the inclusion of an editorial item promoting the virtues of a product for which a payment was made by the advertiser. In the newspaper trade, a puff-piece commanded a higher rate than a regular advertisement because it carried the imprimatur of the newspaper itself.
By this date, the layout of direct advertising in most newspapers and professional journals gave the impression of a multitude of 85 According to Newsholme, this was especially true for poor patients: A. Newsholme, Four and a half years' experience of the voluntary notification of pulmonary tuberculosis, Journal of the Sanitary Institute 24 (1903) 253e260, 254e255. 86 Crowe, Consumption (note 70), 4. 87 Thomson, Consumption, its Prevention and Home Treatment (note 72), 23. 88 Thomson, Consumption, its Prevention and Home Treatment (note 72), 55. 89 Hunt, Governing Morals (note 5), 16e18, 157. I am aware that this emphasis on auto-regulation and self-government downplays the fact that the main caregivers in the home were in most circumstances women. In fact, these self-help texts rarely mentioned the role of a caregiver and the tuberculosis sufferer was either masculinised or referred to in gender-neutral terms as the 'patient' or the 'consumptive'. It is perhaps instructive here (if not directly comparable) that much recent research on the geography of caregiving has highlighted the neoliberal devaluation and depoliticisation of female care work in the privacy of the home. commodities jostling for space and attention. Advertisements were individually bordered and designed in an attempt to distinguish themselves from all the others on a congested page. In contrast to these sorts of pages at the front and back of the BJTB, however, 'Preparations and Appliances' was set in the journal's preferred typeface and column format. It looked no different to the main articles in the journal. In the BJTB's running order, it frequently appeared between the book reviews and 'Notes', which was a segment that made readers aware of conferences they might attend, research they should keep up with, health resorts that could be visited, and tuberculosis institutions that needed patients (these topics help indicate the specialist readership of the journal, of which I can trace no firm evidence). 95 In other words, 'Preparations and Appliances' was a sequential component in the BJTB's procession of tuberculosis commodification; an example of the way in which the power of private capital became institutionally entrenched.
Products appearing in 'Preparations and Appliances' were given a free promotional pass. Assertions claiming that a product 'only needs to be known to be extensively used', 96 or that it 'should gain an entrance to every home', 97 were just as common as the journal's assurances that it had tried and tested commodities extensively before recommending them. 98 Though the journal claimed that it vetted these products, it is not known what filtering criteria (if any) were used to include or exclude particular commodities. The author(s) praising these products were not identified; such anonymity applied a veneer of objectivity. Yet manufacturers' artwork was reproduced faithfully and the promotional language was never critical.
Readers were directed either to retail outlets where goods could be purchased, or provided with the name and address of the manufacturer to buy direct. The journal's British audience of tuberculosis activists (sanatorium administrators, nurses, dispensary staff, and public health personnel), family doctors and patients was undoubtedly familiar with some form of purchasing-atdistance, either in response to advertisements in newspapers and magazines or through mail-order catalogues that were touted by agents. This type of consumer behaviour was not confined to the middle class. Networks of mail-order agents were also used by working-class people, partly because their origins were in the culture of working-class savings clubs. 99 Mail-order shopping was boosted by the institution of the Royal Mail's parcel post in 1883. Just two years earlier the introduction of postal orders had given people without access to a cheque book a secure means of sending money. By World War One, £57 million worth of postal orders were issued and the General Post Office delivered more than 130 million packages each year. Much of this traffic was driven by the mailorder business. 100 Journal writers at the BJTB and elsewhere who generated copy about commodities inserted themselves into this burgeoning mail-order trade, more or less acting like those catalogue agents who were working steadily in communities across the country. 101 Though plying their powers of persuasion from a distance and in print, these publicists compiled and showcased inventories of potentially useful products and cajoled readers into contacting a manufacturer or retailer for further details, if not enticing them into an impulse purchase.
The motors of this consumer culture were rising incomes, the expansion of the middle classesdwho, by 1901, represented 25% of the national populationdand the ready availability of products through mass manufacture. 102 The purchasing power of both the working and middle classes increased, but the latter spent a smaller proportion of their incomes on housing and necessities such as food and heat. When the middle class's disposable income was expended on filling homes with possessions, the explosion of acquisitive behaviour abraded Victorian notions of religious restraint, particularly given the indelible influence of domestic space over individual character. One solution to this dilemma, argue Cohen and other historians of domestic material culture, was to bestow possessions with moral qualities. Household goods conferred domestic propriety and decency. Appropriate, well-designed furnishings raised the moral tone, whereas inappropriate fixtures and fittings indicated deceit or ugliness that should not be tolerated: 'By redefining consumption as a moral act, and the home as a foretaste of the heaven to come, the British middle classes sought to square material abundance with spiritual good'. 103 The right sort of mass-produced possessions and their appropriate arrangement in domestic space denoted morality, spirituality, distinctiveness and personality.
I do not claim that the BJTB's puff pieces tell us very much, if anything at all, about the motives and actions of tuberculous consumers. Rather, I want to suggest that 'Preparations and Appliances' was an interstice where a common tubercular 'language' of material consumption was fashioned, particularly for the middle-class patient who was more able to afford most of the goods on offer. The journal's readers were educated on how to visualise the domiciled tuberculosis patient. The things on display helped solidify the idea of the home-based patient in their minds. This language could be understood by sanatorium officials, public health activists, family doctors, patients and patient carers alike; not because it was specific or unique to the world of tuberculosis activism, but because it was ubiquitous. 104 The pages of BJTB revelled in a technology of possession that 95 T. Nevett, Advertising and editorial integrity in the nineteenth century, in: M. Harris, A.J. Lee (Eds), The Press in English Society from the Seventeenth to Nineteenth Centuries, sought to integrate tuberculosis patients into a contemporary consumer culture that everyone could recognise (if not partake of equally). 105 A bewildering multitude of commodities were determined as 'requisites' of both the sanatoria and the 'hygienic' home. Some of these objects were explicitly medical, but their portability served to unify the regimen of these discrete spaces. The thermometer is a good example. The 'Presto Thermometer' purportedly overcame the deficiencies of most other thermometers, which could be slow acting, indistinctly marked and difficult to adjust, if not defective altogether. The Presto model had a scale marked for a range of 12 C (94 Ce106 C) instead of the customary 16 C or 20 C; these more generously-spaced fractional divisions were easier for the patient to read. Markings above the 'normal' temperature were indicated in red. 106 Some items were specifically related to the practice of open-air living. Window tents made it possible to sleep close to an open window but protected the patient from the elements and the rest of the house from the bracing cold. Steel-framed awnings made from canvas were manufactured with the intention that the patient, lying in an extendable cot-like bed, would sleep with his or her head and shoulders completely outside the window frame. 107 Significantly, bed screens and shelters were shown at the first Ideal Home Exhibition in 1908. A screen protected the patient from the wind and direct sunlight, as well as providing privacy. These devices sought to simplify the mechanics of sanatorium therapy for the domesticated patient: they were easily legible, readily manoeuvrable, and had manageable dimensions. 108 One revealing aspect to the promotional images for many rest-related products is that patients tended to be reading (Fig. 1). Portrayal of an intellectually-stimulating behaviour shaped the common understanding of how a domiciled tuberculosis patient should look and what they should be doing. In this case, one possible visual chain message was that possession of a screen had a moral purpose because it allowed control of the immediate environment, which in turn facilitated character-building activities like reading. 109 Keeping the home free from dirt was hard when practicing the open-air life. Anything that helped prevent mud from crossing the threshold was a boon. The 'Major' boot cleaner used revolving cocoa-fibre brush mats, steel wire and an underfoot scraper to remove dirt. A hot air boot dryer delivered a regulated current of warmth up a tree-shaped funnel (Fig. 2). This was particularly helpful in the rainy British climate. Shoes dried more quickly (but not so quickly so as to scorch and shrivel them) thus enabling frequent walks without the uncomfortable sogginess of damp leather. 110 Given the iconic status tuberculosis activists granted to dust, the BJTB observed with some relief that because of contraptions such as these, 'at last it would seem that homes may be kept free from dust all the year round'. 111 Other types of equipment explicitly inculcated hygienic norms. The 'Beb' Bath, for example, could be used in the bedroom or on the sanatorium ward (Fig. 3). Moreover, it was marketed as affordable way of instilling bodily cleanliness, since it was on sale 'at the specially low price of 13s 6d for the working classes'. 112 How affordable these sorts of devices were is open to question. Thirteen shillings represented more than half of the average labourer's weekly earnings and a couple of shillings more than the average weekly wage for a working woman. 113 Portable disinfection spray pumps and cleaning equipment that were relatively cheap also delivered the 'gospel of germs' into the home. 114 Lightweight, with directional nozzles and long handles, these appliances could reach every surface and penetrate the darkest nooks and crannies.
As mentioned earlier, rest was a vital (if contested) feature of the sanatoria regime. Many commodities invited the home-based tuberculosis patient to become involved in middle-class leisure pursuits that complemented long periods of respite. 115 Bed rests, foot rests and telescopic reading stands such as the ReferReader (Fig. 4) were presented as an entryway into the market of goodsdsome luxurious, others less sodthat multiplied the contentment of modern life. 116 The Kumfee, which doubled up as a leg-rest and fire-screen, was 'an ingenious addition to the comforts of life which will be appreciated by invalids, luxury-lovers, and weary workers . appeals to both healthy and sick, and it is certainly an  economiser of energy and an increaser of comfort' (Fig. 5). 117 The DumbNurse provided 'the greatest comfort and convenience to patients, invalids, and, perhaps we might add, healthy luxurylovers'. 118 For the bed-ridden, the DumbNurse was a table, a backrest, and a reading stand (Fig. 6). Similarly, the 'Axis' portable bed table could be used for personal hygiene rituals such as washing and shaving, the serving of meals and as a table for writing, work or playing cards. 119 This kind of multi-functionality was equated with sophistication which, in turn, indicated luxury. Designers of these products were responding to ideas about social relations as well as potential profitability in the market. Multiple designs of the same product were aimed at consumers who were stratified by sex, age, social class, and purchasing power. Product variation also served other aims. Not only did it anticipate an increase in sales, but it also spread the risk for a producer who was unsure about the market for a particular item. Variety promoted fashion by leaving older products behind. Such novelty was commensurate with the notion of consumer choice. The proliferation of options for what were essentially similar products was an important consideration for consumers who were keen to express their individuality through possessions. 120 The novelty of design also applied to product naming. Manufacturers used portmanteau words (the blending of two words to create a new one, such as ReferReader and DumbNurse) and new spellings of old words (such as 'Kumfee') to differentiate their merchandise in a crowded market and to create product excitement. Each new version of a product represented yet another breakthrough or step forward. At the same time, the constant repetition of novelty and variety in media advertisements granted such developments the trajectory of predictability; rendering progress inevitable was a vital mechanism of modernity. 121 So it was that every few months, readers of the BJTB could expect to marvel at yet another tranche of innovative products that would improve the lives of domesticated tuberculosis patients.
The examples highlighted here are merely representative. Space precludes consideration of further products such as clothes, heating appliances, telephone mouthpieces, even plasticine . the list is a very long one. Suffice to say, the BJTB lost no opportunity to enlighten its readers of the chance of aligning themselves with the materiality of modern living. Taken together, tapping the mass consumer market and succumbing to fetishised novelty heralded the expression of individuality that characterised the so-called  'quest for personality'. 122 The BJTB noted that these 'numerous new inventions greatly facilitate the rational management of the sick and assist in the protection of the sound'. 123 This was another way of saying that the putative presence of these commodities in domestic space had the capacity to soothe the sickly body, normalise tubercular life, and produce a watchful self-carer. Just like the self-help manuals written by Crowe, Thomson and Bardswell, the selection, arrangement and interaction with these objects conditioned subjective identity. 124 They offered nothing less than a therapeutic toolbox for a materialised technology of the self that was deeply inflected with notions about the inherent morality of things.

Conclusion
Towards the end of his Advice to Consumptives, Noel Bardswell encapsulated his recommendations with this little pearl of wisdom: 'The best way, in short, of escaping consumption, is to live as if trying to cure it'. 125 In this sense one can interpret the rescaling and re-siting of the consumptive patient as essential ingredients in the emergence of a 'preventive therapy' for tuberculosis. Appropriation of domestic space transformed the sanatorium's 'rules of health' into 'rules for living'. The very title of Crowe's manualdConsumption: Treatment at Home and Rules for Livingdwas unambiguous on this point. 126 The term 'preventive therapy' also captures, but somewhat masks, what these experts sought to convey in terms of moral behaviour and to whom they were directing their efforts. The suppression of intimacy and avoidance of public houses made practical sense because it reduced exposure to infection. 127 But hygienists consistently reiterated the deeper moral purpose of these several forms of abstinence that were the minimum preconditions for creating a domestic environment in which tuberculosis could not flourish. This message was buttressed by an openly acquisitive approach that denoted all sorts of worthiness; not least, many things promoted homely pastimes that distracted the patient from potentially immoral behaviours and towards wholesome interests.
It is impossible to deny the contradictions of the message and the medium. In the best traditions of nineteenth-century public health reform, an obvious intended target of these policy interventions, language, and images was the reckless moral behaviour of those working-class sufferers who constituted the main body of domiciled patients. Yet some of the risks (over-furnished homes for example) and some of the opportunities for recovery (such as the accumulation of appropriate possessions) were articulated through Victorian middle-class mores. They were the product of middleclass ideas about the typical patient's family and the presumed centrality of domesticity. Furthermore, the readership of the texts is not entirely clear. On the one hand, the knowledge promulgated in a specialist serial such as the BJTB was more likely to be passed on by doctors and activists verbally than fall into the hands of patients and carers directly. On the other hand, Crowe's Consumption was affordably priced at 1s for the working-class patient. He wanted GPs to buy the book who could then sell it on to their consumptive patients, thereby delivering the sanatorium regime into the home. 128 Of course, the purchase and reading of a tuberculosis selfhelp manual was itself a moral form of consumerism, no matter the class of the patient. Who actually read the books, and to what extent the advice contained in them was acted on, are elusive questions at the moment. Perhaps these paradoxes and ambiguities are best read as the inevitable result of moral regulation exercised in a market of consumer goods that was not itself regulated very much.
Through the implementation of compulsory notification, disinfection, educational schemes, dispensary management and the home-based surveillance of patients and contacts, national and local government negotiated the legitimation and naturalisation of the home as a both a site and a scale of intervention. In this respect, these strategies can be seen as classics of their type: government administrations seeking ways to influence the self-conduct of individuals at a distance. It is important to emphasise that the formal power structures of the state prepared the ground on which the domiciliary self-regulation of tuberculosis patients gained traction.
This paper has shown that the production and reproduction of the domestic scale of moral regulation constituted a complex set of processes that were connected to wider social transformations in public health, consumer liberalism, subjectivity and governance of the self. 129 State activities emerged from existing infectious disease policies; medical experts and activists worked inside and outside of formal government in ways that happened to complement the aims of the state; and, not least, the market was a crucial arena in which moral persuasion and regulation were played out.