The Citadel by A J Cronin — healthcare under the spotlight
The Citadel was a hugely popular novel when it was published in 1937. Demand was so high there were more than a dozen reprints issued within a year, a surprising feat for a book that largely focuses on issues of medical ethics and access to healthcare. The film version that was released a year later, starring Robert Donat ( a heart throb of the era) gave it an added boost in the popularity stakes.
Cronin based on his novel on his own experience as a doctor in the valleys of South Wales and later in Harley Street, London. His central figure is Andrew Manson, a newly-qualified doctor who arrives in the the small (fictitious) Welsh mining town of Drineffy in 1921 to take up a post of a medical assistant.
He is shocked by the conditions he discovers, but even more shocked by the attitudes of the town’s medical men. They are putting their patient’s lives at risk by their callous disregard for sound medical practices and unwillingness to try any new approaches.
Unable to make headway he escapes to a a new job as assistant in a miners’ medical aid scheme in the bigger coal mining town of “Aberalaw”. There he prospers, gaining a reputation as a caring and skilled doctor and recognition for his pioneering research into the relationship between dust inhalation of turberculosis. But once again he meets such strong opposition from a faction in the town, that he leaves Wales for London.
In the city he becomes seduced by the prospects for wealth and prestige by tending to well-heeled and influential members of society, putting aside all his ideals and principles. Until a disaster occurs which brings him to his senses.
Ups and Downs of A Doctor’s Life
My summary only barely touches on all the twists and turns in the life of Cronin’s doctor. Manson is a highly principled man who burns with the desire to see a change in medical practices. But he doesn’t have an ounce of sense about how to persuade people to his point of view. He repeatedly rushes ahead without considering the effect of his action, only to come up against jealousy, rivalries and complete opposition. He ends up moving from one post to another in search of his ideal system, only to end up more disillusioned.
As a work of fiction, The Citadel, has its flaws. I found it overly long and too full of dramatic “episodes”. I won’t go into details of these to avoid the book for other readers, but the sheer number of crisis moments in Manson’s life did push at the boundaries of credibility.
What kept me reading was the fact that the town of “Aberalaw” is actually based on the town of Tredegar, where I was born.
An Indictment of A Health System
Beyond the personal resonance I enjoyed learning more about the healthcare system in the early twentieth century. It was a bleak picture.
Patients who couldn’t afford prescriptions were often left to suffer. Those who scraped up some money, often got given drugs and treatments their doctor knew wouldn’t work but since the general practitioners relied upon prescriptions for an income there was no incentive to change. At the other of the scale were wealthy doctors and surgeons who behaved as members of a select club, passing cases to other medical men that they knew personally — without any regard for their capabilities.
Unsurprisingly the medical profession reacted with scorn to The Citadel. They shunned Cronin because they objected to his criticisms of their practices. They also censured the liberal attitudes he expressed through is protagonist.
In the end there was what you could class as a form of poetic justice. The Citadel — and especially its descriptions of a subscription based medical welfare system in “Aberalaw” — was credited with influencing one of the most significant health care reforms of the twentieth century: the foundation of a free-to-all National Health Service.
Sadly I bet few people have heard of Cronin let alone his connection to the NHS.
I read The Citadel as part of my second Classics Club list. it was the book chosen through the Classics Club spin back in March. I did manage to read it in time though I’m late getting this review done.
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I remember A J Cronin from being on my parents’ bookshelves. I really like the sound of The Citadel.
He was a big name when I was small – I’ve watched the film version a few times but never read the book
It’s interesting that despite the flaws you describe it sold so well, perhaps its criticism of the medical establishment struck a chord.
To be fair, there is more to it than the medical ethics part. I’m sure a lot of readers just enjoyed it as a man meeting and overcoming various problems….
Yours in the second review of this I’ve seen in the last few months and a reminder that I do need to find a copy to read. While Tredegar is where you were born, it’s just over Llangattock Mountain in the Bannau Brycheiniog where we’ve lived for the last decade, we pass by the town on a fairly regular basis, and I like what’s been done to the gardens around Bedwellty House.
It’s years since I was last in Tredegar; it was looking very sad then like so many of the valley towns. Good to hear that something has been done in part of the town at least
I haven’t been since a couple or more years before lockdown so hopefully it hasn’t gone any further downhill.
That book could work as a metaphor for all places where you can find this so called fortress mentality. The vocabulary and criteria they use to determine who’s in and who’s out, deviates of what is normal social practice.
that’s true, there are lots of vested interests in many walks of life with a clique that doesn’t welcome “outsiders”. The law professions would be another big culprit
I think AJ Cronin’s pretty well-known isn’t he? Or am I betraying my age? You haven’t exactly over-sold this, though, so despite its obvious interest, I think I may give it a miss.
Well I think he would be well known to people born in the 50s or earlier – but now not very much
I, well, I’m old and decrepit enough to fit the bill!
LOL
It seems to me that Cronin’s subject matter in The Citadel is just as relevant as when it was first written with our NHS currently being chipped away at from every direction.
Indeed it is very relevant – a very strong reminder of what people worked hard to achieve and we should fight to improve!
I wondered why the name Cronin was familiar to me, so I looked him up at WP, and he was such an astonishingly prolific author that it took me a while to get to the end of the list and find *lightbulb moment!* Dr Finlay’s Casebook!
My mother was an avid fan of the ensuing (B&W) BBC TV series, and not so long ago I came across a DVD collection of it, which I have since given to a Scottish friend of mine. Dr Finlay was an irascible, impulsive character (not unlike the vet Siegfried in All Creatures Great and Small, who also battles tradition and ignorance in the treatment of animals.) So I wonder whether there was someone in Cronin’s life who was like that in manner and personality, and he ‘got his own back’ by portraying him in his novel!
Oops, no Dr Finlay was the young doctor, open to new ideas and reasonable in every way (i.e. modelled on Cronin himself). It was Dr Cameron who was the crusty old guy who had to be jollied into making changes.
Dr Finlay – now there is a name from my past! I remember my grandmother loving that programme. I’d forgotten about Dr Cameron though – he was the older guy in the practice I think
The other book by him that you might have heard of is called The Stars Look Down
No, I don’t know that one, it’s only the Dr Finlay stories that I know.
it was a good film, not so sure how it would be in book form though
This is really interesting with everything happening in the medical fields; lots of wards/hospitals closing here in the U.S. with many nursing groups striking—yet many nurses have left the profession altogether but that does not seem so for doctors. I mean, I’ve not heard doctors leave the profession for something else.
I didn’t realise there were problems in the US health system so similar to the ones we are encountering here. We’ve had nurses go on strikes, then junior doctors and now it sounds like consultants are threatening to strike.
Really interesting review – thank you! Novels that do a lot of overt politicking aren’t always terribly successful as pieces of fiction – it sounds like this might fall into that category. I am still interested in reading it though, as such an important part of medical history in the UK.