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Enhancing relational care through expressions of gratitude: insights from a historical case study of almoner–patient correspondence
  1. Giskin Day1,2
  1. 1 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
  2. 2 Faculty of Medicine, Imperial College London, London, UK
  1. Correspondence to Giskin Day, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London WC2R 2LS, UK;{at}


This paper considers insights for contemporary medical practice from an archival study of gratitude in letters exchanged between almoners at London’s Brompton Hospital and patients treated at the Hospital’s tuberculosis sanatorium in Frimley. In the era before the National Health Service, almoners were responsible for assessing the entitlement of patients to charitable treatment, but they also took on responsibility for aftercare and advising patients on all aspects of welfare. In addition, a major part of the work of almoners at the Brompton was to record the health and employment status of former sanatorium patients for medical research. Of over 6000 patients treated between 1905 and 1963 that were tracked for the purposes of Medical Research Council cohort studies, fewer than 6% were recorded as ‘lost to follow-up’—a remarkable testimony to the success of the almoners’ strategies for maintaining long-term patient engagement. A longitudinal narrative case study is presented with illustrative examples of types of gratitude extracted from a corpus of over 1500 correspondents’ letters. Patients sent money, gifts and stamps in gratitude for treatment received and for the almoners’ ongoing interest in their welfare. Textual analysis of letters from the almoner shows the semantic strategies that position gratitude as central to the personalisation of an institutional relationship. The Brompton letters are conceptualised as a Maussian gift-exchange ritual, in which communal ties are created, consolidated and extended through the performance of gratitude. This study implicates gratitude as central to the willingness of former patients to continue to engage with the Hospital, sometimes for decades after treatment. Suggestions are offered for how contemporary relational healthcare might be informed by this unique collection of patients’ and almoners’ voices.

  • cultural history
  • patient narratives
  • cultural studies
  • medical humanities
  • psychology

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • Correction notice This article has been corrected since it was first published online. The open access licence has been updated to CC-BY in order to comply with funder requirements.

  • Contributors GD is the sole author of this work. Supervisor contribution has been attributed in the acknowledgements.

  • Funding This work was supported by the Wellcome Trust, grant no 212792/Z/18/Z.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository.