A.J. Cronin: The Citadel

A.J.Cronin (1896-1981) was born in Scotland. He wrote over 30 books, several of which were filmed or televised, a recent example being Dr Finlay’s Case Book. He trained in various hospitals, finding himself a naval surgeon as World War One dragged on, and finally graduating from the University of Glasgow in 1919. He then moved to a mining town in South Wales. The Citadel, a tremendously popular book from 1937, is semi-autobiographical in its first sections. 

It is an episodic sort of novel, unified by the passage of one life over time, and with a trajectory through suffering into a kind of grace. It works as a forum for Cronin’s political, socialistic conceptions of medicine, and has been credited with stimulating the creation of the famed National Health Service of the United Kingdom.

‘I got the gig here. Set in- unless ye’d rayther swim’ 

The brand new Dr Andrew Manson arrives in a bleak Welsh mining town. His first case for Drineffy Haematite Mine and Ore Works is beautifully described, as only an author who has been ‘there’ can do. He soon meets one of his colleagues, Denny, a sarcastic and bitter drunkard who is nevertheless friendly and helpful, like his dog Hawkins: 

“Look here, Manson! I realise you’re just passing through on your way to Harley Street, but in the meantime there are one or two things about this place you ought to know. You won’t find it conform to the best tradition of romantic practice. There’s no hospital, no ambulance, no X-Rays, no anything. If you want to operate you use the kitchen table. You wash up afterwards at the scullery bosh. The sanitation won’t bear looking at. In a dry summer the kids die like flies with infantile cholera. Page, your boss, was a damn good old doctor, but he’s finished now, finished by overwork, and’ll never do a hand’s turn again. Nicholls, my owner, is a tight little money-chasing midwife. Bramwell, the Lung Buster, knows nothing but a few sentimental recitations and the Songs of Solomon. As for myself, I better anticipate the gay tidings- I drink like a fish. Oh! and Jenkins, your tame druggist, does a thriving trade, on the side, in little lead pills for female ills. I think that’s about all. Come Hawkins, we’ll go.” 

‘Denny at first had aggravated him intensely by his weary contention that all over Britain there were thousands of incompetent doctors distinguished for nothing but their sheer stupidity and an acquired capacity for bluffing their patients’ and he ‘…never failed in his derision towards this profession to which they belonged.’

Denny soon shows his true mettle when he takes the new doctor out at night to blow up the sewer contaminating a well and causing a paratyphoid epidemic with much child mortality, but which the authorities will do nothing about. A moat of sewage surrounds the councillor’s house, with the result that construction of a new sewer commences the following Monday.

 

Consider: Cronin uses humour to take the sting out of his story, which is one of almost inconceivable neglect of the workers in a powerfully class-driven society. 

After only 3 months on the job our restless hero questions the pharmacopoeia: 

‘And what about half, three-quarters of the other “remedies” in the pharmacopoeia? This time he heard the voice of Dr Eliot. lecturer in Materia Medica. “And now, gentlemen, we pass to elemi- a concrete resinous exudation, the botanical source of which is undetermined, but is probably Canarium commune, chiefly imported from Manilla, employed in ointment form, one in five, an admirable stimulant and disinfectant to sores and issues.”

Rubbish! Yes, absolute rubbish. He knew that now. Had Eliot ever tried unguentum elemi? He was convinced that Eliot had not. All of that erudite information came out of a book and that, in its turn, came out of another book, and so on, right back, probably to the Middle Ages.’ 

In a second mining town now, he learns about Gadge the dispenser: “He’s a miserable devil. But he knows his incompatibles.” The skilled Dr Llewellyn is one of a succession of people who rips him off, in this case by taking a fifth of his wage. Dr Urquhart, on the other hand, is a “good old type” of family doctor- shrewd, painstaking, experienced, a doctor sentimentalised by his patients and by the public at large, who had not opened a medical book for twenty years and was almost dangerously out of date. 

He has to amputate a miner’s forearm trapped under rubble way underground, with a lamp and on his belly in the water in a 2 ft high tunnel. Next he is ‘raving beautifully’ about worker’s rights and the antiquated financial structure of the profession:

“That’s how fees should be paid, Chris. No money, no damned bills, no capitation free, no guinea grabbing. Payment in kind. Do you understand? You get your patient right, he sends you something that he has made, produced. Coal, if you like, a sack of potatoes from his garden, eggs maybe if he keeps hens- see my point. Then you’d have an ethical ideal! By the way, that Mrs Williams who sent us the ducks- Leslie had her guzzling pills and physic for five stricken years before I cured her gastric ulcer with five weeks’ diet. Where was I? Oh, yes! Don’t you see. If every doctor was to eliminate the question of gain the whole system would be purer-“

“Yes, dear. Would you mind handing me the currants. Top shelf in the cupboard!” 

Consider: The fragment below demonstrates two things: the vision and influence of this book; and the considerable time it has taken for the profession to acquiesce. CME (Continuing Medical Education) has only recently been formalised: 

“Ignorance, ignorance, pure damned ignorance. There ought to be a law to make doctors keep up to date. It’s all the fault of our rotten system. There ought to be compulsory post-graduate classes- to be taken every five years.“ 

Dr Manson develops an interest in occupational lung disease, and ends up in London, where money, acquired at the expense of time for his wife, begins to work upon him as the canker it is. He meets his old friend Freddie Hamson and his two partners in medical scheming, and naively questions a new technology they are discussing: 

“I don’t think much of these lamps, you know. Did you see Abbey’s paper in the Journal on bogus heliotherapy. These Iradiums have got absolutely no infra-red content.”

Freddie stared, then laughed.

“They’ve got a hell of a lot of three-guinea content. Besides, they bronze nicely.”

 

Their old lecturer in Scotland had said “You know nothing, Mr Hamson. Your balloon-like mind is entirely filled with egotistical gas. But you’re never at a loss. If you are successful in cribbing your way through the nursery games known here as examinations, I prophecy for you a great and shining future.” 

Eventually Andrew Manson breaks his principles for money, injecting ‘Glickert’s Eptone’ into wealthy and gullible patients. He neglects serious cases among the poor in his practice for easy money from rich neurotics; and his wife Chris dispenses for him now, anything, like the poisons he used to rail against. She withdraws into herself: there is unhappiness creeping in to their lives because of the drive to money. 

Cronin next turns his scathing wit onto pompous surgeons whom he exposes as ignorant and fad driven, close enough to murderers:

“Ha!” said Sir Rumbold. “So you’ve been a victim too.” By the device of clearing his throat and placing his pince-nez upon his richly endowed nose, he gained the attention of the table. Sir Rumbold was at home in this position- for many years now the attention of the great British public had been focussed on him. It was Sir Rumbold, who, a quarter of a century before, staggered humanity by the declaration that a certain portion of man’s intestine was not only useless but definitely harmful. Hundreds of people had rushed straight away to have the dangerous section removed and, though Sir Rumbold was not himself amongst this number, the fame of the operation, which the surgeons named the Rumbold-Blane excision, established his reputation as a dietician. Since then he had kept well to the front, successfully introducing to the nation bran food, Yourghout, and the lactic acid bacillus. Later he invented Rumbold-Blane Mastication and now, in addition to his activities on many company boards he wrote the menus for the famous Railey chain of restaurants: Come, Ladies and Gentlemen, Let Sir Rumbold-Blane, M.D., F.R.C.P., Help You Choose Your Calories! Many were the muttered grumbles amongst more legitimate healers that Sir Rumbold should have been scored off the register years ago: to which the answer manifestly was- what would the register be without Rumbold?’ 

When a fake surgeon mate kills a patient Manson cries murder, and attains a sudden and painful new awareness of what he has sunk to. Corrupt, rich and falling, he is met and reassessed by two friends from his early idealistic days. At the same time, an ‘antidote to the poison of a facile success’ arrives...an appointment to the prestigious Victoria Chest Hospital. Here Doctor Thoroughgood, the chief consultant, is a good man but conservative, who gives all his patients cod liver oil and malt. Cronin paints the grey picture of an inefficient health system, manifest as such unhealthy hospitals as the Victoria, supposedly for TB and other chest complaints but located along the damp Thames, in the infested coal-smog of London. The new TB treatments are apicolysis, phrenicectomy, and massive intra-pleural injection for tuberculous empyema.  

Manson begins to shed his former patients, rather impatiently! 

“…But there’s nothing really wrong with you.”

“Dr. Manson!” she gasped, unable to believe her ears.

It was quite true. He realised, with cruel insight, that all her symptoms were due to money. She had never done a days work in her life, her body was soft, pampered, over-fed. She did not sleep because she did not exercise her muscles. She did not even exercise her brain. She had nothing to do but cut coupons and think about her dividends and her maid and wonder what she, and her pet Pomeranian, would eat. If only she would walk out of his room and do something real. Stop all the little pills and sedatives and hypnotics and cholagogues and every other kind of rubbish. Give some of her money to the poor. Help other people and stop thinking about herself! But she would never, never do that, it was useless even to demand it of her. She was spiritually dead and, God help him, so was he!

He said heavily:

“I’m sorry I can’t be of any further service to you, Miss Basden….”

 

The next issue Cronin takes on is that of who should and should not be on the medical register. Mr Stillman is from the US, an expert on TB alone, with no qualifications who is absolutely scientific, with no bedside manner at all, but who does successful partial pneumothoraces, and who saves his old friend’s daughter Mary. The London doctors get up a plot to ostracize Stillman and his rural clinic. Andrew is summonsed to the GMC for association with an unregistered practitioner, and he presents in court a list of the greats of scientific medicine who did not have medical degrees, including Louis Pasteur. 

A wonderful happy ending concludes one of AJ Cronin’s most enduring works.

References and Further Reading 

My copy of The Citadel is a 26th impression, 1948, published by Victor Gollancz of London 

Illich, I (1971) Deschooling Society

Illyich, I (1976) Medical Nemesis

updated: 22/03/2010