A.J. Cronin is an almost forgotten British novelist who was wildly popular on both sides of the Atlantic just before and after World War II. A former doctor who put down his scalpel for a pen, Cronin tilted his pen at the British medical establishment in his novel The Citadel, demanding that British medicine become the science it was meant to be. The Citadel was published in 1937 and sold millions of copies. Respondents to a poll taken in Britain in 1938 voted it the most influential book after the Bible. Many hold that The Citadel paved the way for introduction of Britain’s National Health Service a decade later. Many doctors have stated that The Citadel inspired them to enter medicine.
The protagonist of The Citadel is Andrew Manson, a young Scottish doctor and a stand-in and mouthpiece for Cronin. The novel opens in 1924 as Manson begins his medical career in a mining community in Wales as an assistant to Dr. Page. The miners make contributions for medical care from their salaries, which allows them to sign up with one of several mine doctors. It turns out that Dr. Page is permanently bedridden after a stroke, and the good doctor’s wife exploits Manson horribly. Manson, meanwhile, finds that his medical training is inadequate when put to practice. Treatments memorized in medical school are ineffective. Fellow doctors treat symptoms or only some of them but fail to diagnose diseases and are not up to date. Medication is overprescribed because patients want to come away with a bottle. The public health official ignores a budding typhoid epidemic. Manson does manage to save a miner from commitment to an asylum, overruling an older doctor’s diagnosis. He saves a newborn through aggressive treatment. He befriends a like-minded surgeon, Phillip Denny. Denny becomes a second mouthpiece for Cronin. Denny believes that the medical establishment places too much upon the general practitioner, the physician who trots from house to house with his black bag. He describes a G.P. as a “dear old quack of all trades,” responsible for medicine, obstetrics, bacteriology, modern advances, and even a touch of surgery. Specialists are called in too late. Pathological analysis is rarely used.
When Mrs. Page’s mistreatment reaches its nadir, Manson leaves for a second mining community after marrying Christine, the local school marm. He’s employed by the Miners’ Association as one of four doctors. Compensation is based upon a capitation system; the more miners each doctor treats, the more he’s paid. The system inspires destructive competition. Doctors badmouth each other. They won’t even cooperate to form a rotation to respond to night calls. Manson’s fellow doctors yield to patient demands, whether for medication or a rubberstamp upon a certificate attesting that the miner is too ill to work. Meanwhile, the private doctor who owns the local, private hospital skims one-fifth of the salary of each of the Association doctors in exchange for Dr. Llwellyn’s help in treating the “bad cases” and admitting patients to his hospital. Continuity is lost because once admitted, the patient comes under Dr. Llwellyn’s exclusive oversight. Manson’s integrity causes him to butt heads with some of the miners. He won’t sign unwarranted certificates or prescribe unwarranted medicines. Manson manages to secure a small following after a miner suffers permanent injury because he disregards Manson’s advice. Manson also burnishes his credentials, studying and passing an examination and publishing a study of pulmonary disease in miners.
Manson’s paper earns him a place on the Coal and Metalliferous Mines Fatigue Board, whose very name conjures a stodgy, stale bureaucracy. The Board, as expected, behaves like a bureaucracy. It focuses on standardization of first aid kits at mines and places treatment of occupational mining disorders on the backburner. Manson meets another like mind in Dr. Hope, a young, irreverent bacteriologist, who bemoans being “sandwiched between commercialism and conservatism,” condemned to either become a tool of a pharmaceutical company or an operative in a government agency where change is glacial.
Manson leaves the Board to establish a practice in London, which he views as the gold standard of medical practice. He obtains admitting privileges at one of the more prestigious hospitals but is discouraged because the well-meaning doctor in charge is overly cautious about new treatments. Manson loses himself in London, enticed by the material opportunities that London offers. Those opportunities are chiefly comprised of rich, bored women who suffer from imaginary ills. Manson and his colleagues treat them with substances little better than water. If he’s not prescribing for people who have nothing wrong with them, Manson is becoming tempted by an offer to tout the non-existent therapeutic properties of an artificial food product. He has an affair with a socialite and becomes estranged from Christine, who is disgusted by Manson’s growing materialism and abandonment of his principles. Manson engages in a fee-splitting arrangement with a local surgeon and looks away when the surgeon recommends an unnecessary procedure. There are reasons that fee-splitting is unethical. It discourages a close scrutiny of a colleague’s competence. The inevitable happens, the surgeon is not very skilled, and as they say, doctors bury their mistakes. Manson repents. In collaboration with an American scientist, he effectuates a cure of a tuberculosis patient using a new therapy. Punishment happens, at least metaphorically. Manson returns to community medicine, this time in a team with Denny and Hope.
It’s clear that Cronin thought that the British medical system had become dysfunctional: ineffective, outdated, and susceptible to corruption. The Citadel advocates a medical revolution. However, although credited with paving the way for the NHS, The Citadel emphatically rejected socialized medicine. The aims of Cronin’s revolution were more modest. The Citadel prescribes improved training, mandatory continuing education, teamwork, and practice based upon science and evidence, steps that Cronin believed would end ineffective and unnecessary treatment, exploitation, and corruption. In Cronin’s mind, the “perfect answer” to the “hidebound G.P. system” was “group medicine.” “It comes between state medicine and isolated individual effort.” A bureaucracy “chokes individual effort.” Cronin ended up seeing some positives in the NHS, but also disparaged the new system as a “malingerer’s and hypochondriac’s paradise.”
As literature, The Citadel is comfort food. It’s melodramatic. It has a principled hero, a salt-of-the-earth wife (I was sure that Greer Garson would have been cast as Christine in the Oscar-nominated film, but Rosalyn Russell got the part), it has repeated collisions between good and evil, themes of sin, betrayal, punishment, and redemption, and a climatic stirring speech delivered when Manson defends his collaboration with an unlicensed scientist before the General Medical Council. We can’t always have profundity or superbly limned characters or expertly crafted sentences. Sometimes a good story and a little inspiration is enough.
The Citadel raises some interesting questions. Why did Cronin’s vision for a limited medical revolution morph into nationalized medicine? Was it possible that in Britain effective change could only be implemented from above?
The Citadel and the film that followed were also very popular in the United States. The Citadel won a “National Book Award” (for a few years prior to WWII, the American Booksellers Association awarded prizes. Booksellers simply voted for their favorite books. The award was reinstituted in 1950, with new criteria including limiting the prize to American authors). In 1937, it was the third best-selling novel in the United States, a year in which Gone with the Wind topped the charts for the second year in a row. The Citadel climbed to second place in 1938. The film was nominated for four Oscars. Why did The Citadel spark nationalization of medicine in Britain, but not the U.S.? Was the American practice of medicine more modern and scientific than in Britain? Were professional associations vigorous enough to self-police? Did the recent passage of New Deal social legislation silence demands for additional reform? Was American fear of big government too great? Was the medical lobby too strong? I’m sure the answer is very complex and would require years of comparative research but it would be great to hear what other people think.