Gratitude for treatment

Many former Sanatorium patients expressed gratitude to the institution they considered instrumental in restoring their health at a time when TB was often still deadly. To give a few of many examples:

I have enjoyed splendid health since taking your wonderfull [sic] treatment and must thank you always for it. I remain yours gratefully…26

Thank all at Brompton and Frimley for the kind help and treatment while I was there, and wish many others may be so well. Thanking you all.27

I often think what Brompton Hospital done for me also staff and my Subscriber’s letter.28 I must now thank one and all for restoring me to such fine health, going through last war and still A1 though crippled and wounded with stiff left leg since 1918…. I will now close and it gives me the greatest of pleasure to write these few lines on my health. Thanking once again Subscriber and Brompton Hospital for my health today.29

Along with being grateful for the treatment they received, there is also a sense of pride throughout the correspondence through former patients emphasising that they are keeping up the ‘lessons learned’ at Frimley. When asked to give an account of the work they were doing, if any, many stressed that they were keeping up Frimley habits by exercising out of doors:

I can do light duties and able to go [for] long walks when suitable weather…. After the good time I spent at Frimley I feel I know how to live to keep in good health.30

I think I have kept fit, because I was taught how to live at Frimley, and will always be very grateful for the care and attention I received there.31

It is also noticeable throughout the correspondence that expressions of gratitude are often mentioned in close proximity to mentions of ‘kindness’.

I am very grateful for all the kindness shown me by Dr Wingfield and sisters and nurses in the Sanatorium. Would you please convey my gratitude to them all and accept some for yourself, dear Madam. / Believe me still / Yours Gratefully…32

The extension of gratitude for treatment to whichever almoner was currently in post, as shown in the extract above, is typical for patients who were pleased to still be remembered. Appreciation was often recorded in the case books as ‘grateful letter from pt’, sometimes with the phrases of gratitude transcribed. The almoner also earned patients’ gratitude by being quick to offer advice if patients did report health setbacks. She arranged for patients with respiratory problems to be seen at Brompton, and generally did her best to direct patients to sources of help regardless of the nature of their ailments.

Relational gratitude

Along with thanks for treatment, correspondents most often expressed gratitude that they were still of interest to the Sanatorium.

I can assure you how much I appreciate your annual letters and is indeed a pleasure to me to give you all the information I can about myself and I have had a wonderful year.33

I should like to say how much I appreciate your keeping in touch with me after so long [26 years since discharge].34

I cherish grateful memories of the kind and wonderful treatment I received both at Brompton and Frimley, now 42 years ago. I thank you very much for your letter and it is nice to realise that you still have such kind interest in my welfare after so many years. Wishing you every success. / Believe me to remain ever yours gratefully / [sig.] / PS Will you please accept the enclosed £1 note as a small contribution to your gratitude box.35

Cherry notes that almoners were ‘often resented’,36 and Doyle says the almoner was often portrayed as ‘a heartless harridan’,37 but in the Brompton correspondence there is a marked absence of rancour aimed at the almoners. Indeed, one correspondent who abhorred the treatment regimen and considered Frimley to be ‘a blot on the medical escutcheon’ said, ‘My most pleasant memory is of my interview with yourself’.38 While the almoner herself was hardly ever the focus of ire, not everyone was pleased to hear from her. There are a handful of letters that request the almoner to exercise discretion because of the stigma that being a patient with TB still engendered, including the fear of ostracisation and even blackmail:

I am now married and my husband has a big dread of tuberculosis and any reference to my previous illness would cause serious domestic difficulties, in fact, he would leave me. […] also, lodgers in the house or other strangers might see the letters & serious consequences may result. I am not ungrateful, but I earnestly request that you do not send any more inquiries.39

I cannot help suggesting that the information sought for mainly statistical reasons should be obtained in person as correspondence is not always confidential and may cause serious trouble and inconvenience for when things are going okay we do not wish some people to know, whose tongues can put us to a disadvantage financially and socially.40

You must understand I am now married & should not like my wife to know of my stay at Frimley. There is nothing to be ashamed of I know, but it is just that feeling everybody should have in my position, so I hope you will not think too badly of me for not disclosing my address. […] Thanking you once again for the good you have done me in the past, also for your kind enquiries.41

These letters reveal the complexities of patients needing to negotiate their commitments to the almoner, fuelled in part by a sense of obligation set up by gratitude, and the fear of the implications of revealing to others that they once had TB. For this reason, the almoner often obtained health reports from relatives or friends of patients, or trusted patients to write of their own volition rather than being sent a reminder. Patients’ preferences for how correspondence should be handled were noted in the case books and underlined in red. It is perhaps the reliance on these case books, in which careful note was made of patients who asked for correspondence to be handled sensitively, that led Bryder to write, in her book on the social history of TB, that the Brompton almoner’s ‘extreme diligence was clearly unappreciated’.42 The letters themselves, however, are full of appreciation, even when patients were circumspect about the nature and value of her enquiries.

Donations of money, gifts and stamps

One of the most conspicuous ways in which patients expressed gratitude was through sending donations by postal order or cheque along with their letters to the almoner. The almoner always acknowledged donations with gratitude and sent a receipt. An example is an exchange with Mrs EFC, discharged from Frimley in 1910 but still sending annual reports of her health 30 years later. She typically sent 2 shillings and 6 pence (equivalent to about £5 today) with her letters, explaining, for example, it ‘may help in a small way for something sadly needed, it is from my sister and myself’.43 The almoner replied, ‘It is very kind of you and your sister to send a donation…. Your gift is much appreciated’.44 The last letter on file is from 1953 when the contribution sent has almost doubled to 5 shillings.

Some amounts donated by former patients of the Sanatorium were substantial. Mr AdSL, writing from Australia, gave a donation of £25 in 1928 (equivalent to about £1000 today). He asked the almoner for advice on what was needed, and the reply came back that the money could best be spent on comfortable chairs for the women’s recreation room at Frimley. He asked for his generosity to be recorded: ‘Could a small plate be placed on the back of one of the chairs indicating the purport of the gift, say, “from a one time male patient who had benefited by treatment here, with initials A.L.”?’45

Other gifts were also forthcoming. A grateful patient donated books to the Sanatorium library in 1951. A former patient gave a television to Frimley staff in 1956 and also offered the indefinite loan of one to any bedridden patient. A patient, writing 30 years after he was discharged in 1922, sent the almoner books of poetry along with a cheque ‘for cigarettes – not for Ministry’.46 The almoner replied:

Your donation is greatly appreciated and it has been placed in our fund from which we help patients in financial need – not in the Ministry funds! I am not quite sure about its use for cigarettes – they are not always permitted, but we have many patients with financial problems and it will be helpful for one of these.47

Some gifts were sent expressly to the almoner. One of Frimley’s earliest patients, Mr AGB (discharged in 1910), was a steadfast correspondent from New Zealand. He sent a calendar for the almoners’ office every year for 45 years until his death in 1955. His wife wrote:

As he was so ill in the Brompton Hospital in 1910 we were very thankfull [sic] that he lived to the age of 78. I am continuing to send the calendars as he did as a mark of appreciation of the Hospital’s care.48

Mr LB sent a booklet with pictures of Australian scenery some 46 years after he was discharged, and the almoner replied with a photograph of Frimley: ‘I hope that it serves to remind you of old times’.49

When the almoner requested news of the health of former patients during the Second World War in 1943, it came with a plea:

As the high rate of postage is likely to continue, I should be glad if you would kindly try and remember to send me your report next year by 1st February 1944, as this would be a help to us and save the hospital considerable expenditure.50

This correspondent was one of several patients who, with her health report, sent stamps to help the almoner with her work. The stamps were often accompanied by expressions of gratitude:

I am enclosing 2/6 in stamps wishing I could help more, again thanking Brompton and Frimley for all past benefits. Yours gratefully… 51

Donations were sometimes wryly seen as compensating for tardiness:

I enclose a book of stamps to make up for people like myself who do not forward their returns until they are applied for, and so cost the hospital stamps. Please don’t waste a stamp by acknowledging this.52

I am sorry I omitted to write to you earlier as requested. The matter was in fact borne in mind but I expect the necessity to “dig for victory” obsessed my mind. For which omission I fine myself ten shillings enclosed as a contribution to Hospital Funds.53

In 1947, the almoner sent some gifts of her own. There are some letters of thanks from patients for the ‘Christmas gift’: food parcels made up of donations from the Commonwealth as part of postwar relief efforts.

Entitlement and obligation

It would be naïve to assume that the gratitude so evident in the Brompton correspondence signifies an altruistic culture, unmotivated by any sense of obligation. The imperative to cooperate with the collection of health reports was made clear to patients, usually on discharge: ‘You will remember that when leaving the Frimley Sanatorium all patients are asked to keep in touch by sending a report once a year, to say how they are and if they are able to carry on their usual occupation’.54

Thomson has characterised the role of the almoner as poised between support and surveillance,55 which is consistent with Frimley patients being expected to comply with enquiries, often for the rest of their lives. When patients did not respond to the almoner’s enquiries, reminders were sympathetic but quite stern:

I am disappointed to have had no reply from you to my letters in recent years, asking for news of your health, and do hope that your failure to answer does not mean that you are ill and unable to write.…As you know, these reports of yours are of great value to our doctors in their research work, helping them to decide on the most successful and lasting forms of treatment. Their findings are applied for the benefit of our many new patients, and the reports of patients who keep well, are naturally of especial interest. I do hope therefore, that you will continue to cooperate with us in this work by sending me annual news of your health. You can feel that by doing so, you are making a very real contribution to the relief of suffering. I enclose a form for completion, also a stamped addressed envelope for your reply, and I do hope to hear from you soon.56

The moralising tone of this letter was consistent with the regimen at Frimley which was explicitly moral as well as physical.57 Good sanatorium patients were, according to Margaret Coltart, the Head Almoner from 1942, expected to show ‘self-discipline, and the particular brand of unselfishness needed in a community of ill people’, using the opportunity ‘to think and learn about human nature in themselves and other people, as well as how to look after their health’.58

Gratitude as a moral imperative dated back to the Hospital’s Standing Rules laid down in the 1840s in which patients were instructed to ‘return humble and devout thanks to almighty God, at their usual place of worship, for any relief or alleviations of suffering they may have received’.59 Also, patients were required to present a note of thanks to the Governor who had recommended them ‘on pain of being excluded from any future benefit from the Hospital’.60

Although the frequency of donations sent with the health reports to the almoner might suggest that one of the motivations for corresponding with patients was for the purposes of fundraising, the almoner was careful never to imply that a monetary contribution was expected from patients. One correspondent, writing in 1945, some 33 years after discharge, says, ‘Christmastime not auspicious for this sort of thing. Money tighter then. Enclosed please find ten shillings for Hospital with best thanks.’61 The almoner replies:

I…would like you to know that when we write to you, it is not for the purpose of obtaining a donation, but purely in order to obtain your health report and I should be very sorry to think that you send money gifts you cannot easily spare. We are, of course, very grateful for financial help, but the majority of our ex-patients simply send us the information for which we ask and that is all we expect of them.62

The insistence that no monetary contributions were expected is consistent with Gosling’s argument that almoners actively tried to counter the widespread impression that their role was merely to handle money.63 But Frimley patients had most likely internalised the message that generosity, no matter how token, was part of the legacy of their treatment under the voluntary hospital system. Figure 1 shows a poster from about 1934, now mounted on the wall in a corridor in the Royal Brompton Hospital as an item of nostalgia but also perhaps as a subtle exhortation to gratitude by current patients. The poster points out the cost of treatment, then paid for by subscriptions from benefactors, but asks patients to give what they could afford, ‘if only a few shillings’. In return, the patient could feel ‘satisfied that, by so doing, he is not only helping the Hospital, but, that he is not forgetful of the sufferings of others’. Most Sanatorium patients passed through the wards of the Hospital before being referred to Frimley, and a sense of financial obligation was almost certainly part of the culture64 in much the same way that charity fundraising efforts are prominent in many of today’s hospitals. The small amounts involved and the ways in which they are framed seem to support Gosling’s contention that money carried meaning for the patient in that it marked their ability ‘to do their bit’.65 These are small but symbolically significant acts of philanthropy, aimed to benefit the almoner’s work, rather than being retrospective payments for treatment.

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Figure 1

Poster from the Royal Brompton Hospital, c1934.

Acts of 1946 and 1947 establishing the National Health Service (NHS) as free at the point of use caused confusion about whether donations could still be accepted by the Hospital since the state, as one patient put it, was ‘soon to become the Fairy Godmother’.66 The Brompton, however, was recognised in legislation as a ‘teaching hospital’, which meant that, apart from the ownership of the building and equipment which was transferred to the state, the Hospital’s Board of Governors would retain control over the day-to-day running of the Hospital, and there would be ‘no interference with any future gifts to the Hospital, all of which would remain for the Board to spend at their discretion’.67 The ideological dissonance between the state’s discouragement of fundraising and the philanthropic impulse of past patients is encapsulated in a letter from 1952:

Now that you are under the government rule of the thumb, donations I take it don’t interest you now. However I am enclosing p.o. [postal order] for 10/0 to be used as you think best.68

The almoner replies:

I am grateful to you for your help with our research records… Thank you also for your kindness in sending a donation for our funds. Now that the hospital is nationalised we do not, of course, accept gifts towards its upkeep, but help is always welcome for the Almoners’ Fund, from which we help patients with many problems for which funds are not available from official sources.69

The drop-off in contributions after 1948 concerned the almoner who recorded in her January 1953 report that voluntary contributions had more than halved since the previous year. That contributions were considered to be a mix of gratitude and charity is evident:

Although this shows a decrease, it is encouraging to find even this number of patients feeling impelled to send thank-offerings and good wishes for other patients in trouble to get help from the almoners’ department.70

Gradually, the almoner’s role had transitioned from one of giving alms (deeming patients eligible for charitably funded healthcare) to accepting alms from patients. This uncomfortable position—along with the acceptance of paying patients and the shift to local council-funded healthcare and eventually the NHS—led to the term ‘almoner’ becoming anachronistic. In 1949, Miss Coltart proposed that the almoner’s department should be renamed the Social Service Department, because ‘much public ignorance remains as to what is the primary function of almoners’ work’.71 This is consistent with Gosling’s thesis that the introduction of the NHS authorised the reorientation of the profession to legitimise the disentanglement of financial and social work, although the two spheres were never entirely separable.72

Pelletier et al argue that linguistic features, such as the giving and giving back of thanks, frame communicative rituals in which autonomy and hierarchy are at stake.73 A close reading of exemplars of the almoners’ correspondence shows how semantic characteristics actively performed gratitude as a means of driving the ongoing gift relationship.

The almoners’ voice

From the 1920s through to the late 1950s, the authorial voice in the almoners’ correspondence is remarkably consistent. To read the letters is to imagine that they have been written by one person, familiar with each patient’s history and life circumstances. Figure 2 shows the construction of a typical almoner’s letter, showing how integral gratitude was to the almoners’ interactions with patients. The almoner makes frequent use of intensifying particles, often used at the expense of being concise (eg, thank you very much, most grateful). Jautz, in a study of thanking routines, finds that intensifiers, along with explicitly stating why one is grateful, lift ‘a mere token of appreciation to a situation-specific expression of one’s personal gratitude’.74 The almoner’s use of first-person singular (‘I’, ‘my’, ‘me’) also helped to personalise what was essentially an institutional relationship.

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Figure 2

Example of a typical letter from the almoner to a former patient.

The job title below the signature changes depending on the year of writing: Lady Almoner (up to 1942), Almoner (1942–1948), Acting Almoner (1948–1949), Frimley Almoner (1950–1959), and ‘Frimley Follow-up Department’ or ‘Follow-up Department “R”’ (1959–1963). This is the only clue, from a patient’s perspective, to a changing cast of record keepers, and it belies the concerted effort by many hands to maintain the work of follow-up alongside other duties. By the time Miss MS Coltart was senior almoner in the late 1940s, six other almoners were employed at the Brompton in various capacities along with a number of record clerks and typists.

One of the first signs of bureaucratic expediency came in 1939, when a form was sent with the almoner’s letter for former patients to fill out their details. The form asked for details of name and address (including a second address ‘which will always find in case of removal’), weight, if having a cough and whether any sputum, details of whether working or not and in what capacity, any special treatment, other information, doctor’s address, and insurer and insurance number if insured (for pre-NHS forms). The form was redesigned in 1940 to omit the request for insurance information and to place the request for any other information after the doctor’s address, allowing extra space for more information that might be helpful.

The form accompanied rather than replaced the almoner’s letter: the personal touch was still very much in evidence. Even so, the forms met with a mixed response. Most respondents seemed happy enough to complete the form, often adding chatty remarks in the space allowed for ‘Any other information you think might be helpful’. A few took exception. One of the first ex-patients to receive the form, having previously cheerfully responded to the almoner’s enquiries, now wrote: ‘I wish you to know I am an Englishman true born, & of good report, and refuse to acknowledge your right to enquire into my private affairs’. He still ended his letter with ‘With every good wish to the medical and nursing staff in their noble work’, before signing off with ‘Believe me, / Yours grossly insulted…’.75 Mr FF, writing in 1944, also took exception to the form, deeming it a ‘waste of time and supplies’.76 The almoner writes back: ‘I am very sorry if the fact you were sent a Frimley record form displeases you; but it is customary to send these forms to our ex-patients, and many of them prefer to fill in a form rather than write a personal note, or telephone or call at the hospital as you usually do. I will see to it that in future no form is sent with our usual enquiry’.77 And she did.

A letter dated 17 July 1957 from the almoner’s clerk, Kathleen Colgate, to the then Medical Superintendent of the Sanatorium reveals the administrative burden engendered by follow-up work.78 Since the previous 10-year block of statistics compiled in 1946, some 3000 extra patients had been added to the records, many of whom changed addresses in the 2-year interval between discharge and follow-up letters being sent out. The improvement in survival of new patients owing to chemotherapy meant that most patients were now available for 5-year follow-up, and the technical information required was much more demanding than merely the determining of whether patients were alive and able to work. The Almoner’s Report Book kept by Miss Coltart catalogues ongoing problems with retaining clerical staff and a burgeoning workload.79 The decision was made to step down follow-up work.

In 1958, letters from the almoner to earlier patients became a gentle ‘thank-you and goodbye’. Mr JS, a Frimley patient in 1909 whose correspondence over nearly five decades is filled with gratitude, was informed:

As modern methods of treatment have revolutionised the field of chest illnesses, we are no longer following up our earlier patients, but I shall always be pleased to hear from you and to see you if you come to London.… Many thanks for all the help that you have given by reporting for so many years for our research.80

More recent patients were still asked for reports of their health in 1959, but the letters had now begun to take on a corporate register, form and feel (Figure 3).

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Figure 3

Example of a typical letter from ‘Frimley Follow-up Department’ to a former patient.

A key difference between the requests for reports from 1944 (Figure 2) compared with 1959 (Figure 3) is the semantic switch from pleasure (glad, fit, hope, good, grateful, kind, help, appreciate) to one of encumbrance (‘time has come’, completion, records, questionnaire, regret). Whereas Miss Marx in her report in 1920 had written that ‘the very considerable time and labour expended is more than compensated for by [patients’] gratitude’,81 the burden of collecting data had come to outweigh their usefulness and no amount of gratitude from patients could compensate for this. Follow-up was discontinued in 1960.

Nostalgia for the voluntary hospitals and scepticism about the NHS were hard to shake. A retired nurse, treated at Frimley in 1925, writes bitterly in 1960:

I suppose I am fortunate to be here, but it is hard going. There is no mercy in the National Health Service. It was the worst thing that the late Aneurin Bevan did to kill the Voluntary Hospitals as such. Up here in Lancashire things are very different from London and the South. The people are hard and very callous.82

Gratitude as a frequently evoked emotion associated with the NHS83 was still some way off for those who had benefited from the voluntary hospital system.