‘The Citadel’ by A.J. Cronin
Over the centuries many novels, short stories and poems have been written about doctors: their interaction with those who are ill, and with the communities they serve to improve overall health. Some of these books reflect the high standards and quality of the medical profession while others show doctors in a different, less favourable light. I first read The Citadel by A. J. Cronin about thirty years ago, having been brought up as a medical student on Dr Finlay’s Casebook, a BBC radio and TV series based on the novella Country Doctor by the same author. I enjoyed The Citadel enormously and re-read it perhaps ten years ago, and at that time marked up almost thirty passages of interest. On the present occasion the re-reading was more holistic and I was searching for broader messages in the text.
The Citadel has a particular emphasis on two areas. First, the work of the doctor in a poor community and how his work is transformed as the doctor moves to London and private practice. Second is the impact that the novel had on the delivery of health services in the United Kingdom. This is particularly important in terms of the content, geographical location and timing of the book and its translation into a film. This article will first briefly discuss the author, A. J. Cronin, then the basis of the novel, its wider impact and finally the more general issue of literature and medicine.
Archibald Joseph Cronin was born in Cardross, Dunbartonshire, in 1896. He subsequently moved to Glasgow and was destined either for the Church or medicine, and he chose medicine. He entered the University of Glasgow in 1914 with a Carnegie Scholarship and between 1916–17 he was abroad for naval service. He graduated in 1919 with honours. He gained a number of additional qualifications including a DPH, an MRCP and an MD on “The History of Aneurysm”. (This topic features in The Citadel when the main character, Dr Manson, is asked a question in his medical postgraduate examination on aneurysms, and gives the distinguished examiner a very learned reply.) Cronin trained in various hospitals in the West of Scotland, Dublin and in Tredegar, a mining town in South Wales. He was appointed as a Medical Inspector of Mines and reported on coal-dust inhalation and lung disease. He subsequently moved to London and private practice. In 1930 he was forced to take six months’ rest because of a duodenal ulcer and it was then that he wrote his first novel, Hatter’s Castle. It was an immediate success. He subsequently published The Stars Look Down, The Keys of the Kingdom, The Green Years and many more. The Citadel was published in 1937, with a film version produced in 1938; as will be noted, he used much of his professional career as a background to the book. Cronin died in 1981.
The Citadel begins as Dr Andrew Manson, a newly qualified doctor and a graduate of St Andrews/Dundee, arrives in a small Welsh mining village to take up his first clinical post as assistant to a general practitioner. The clinical cases are very real, from his first case of typhoid through to a broken arm in a pit collapse requiring an on-the-spot amputation in very cramped conditions. The men, as miners, have a company insurance policy and they can change doctors as they wish, which is fortunate: Dr Manson is often critical of the quality of the work of the other doctors in the town.
One of the most striking incidents in the novel relates to a typhoid outbreak. Dr Manson’s actions in this case are reminiscent of Dr John Snow, who in 1854 identified that the water pump in Broad Street Soho was the source of a cholera infection; Dr Snow removed the pump handle, a major action in public health management. In the novel, it is the sewer that is the source of the infection, but in spite of warnings, nothing is done about it. Dr Manson and a colleague decide to blow up the sewer using sticks of dynamite taken from the mines. They are successful and the sewer’s replacement begins the following week. He makes some remarkable diagnoses and treatments, such as the identification of myxoedema madness and resuscitating a newborn child.
Dr Manson is critical too of the system of care and the way in which the service is funded. He has an opportunity to move to a larger town and to work in a better environment, which he enjoys until some problems emerge: the doctors don’t cooperate, there is some concern about how ‘sickness certificates’ are signed off, and there are real health and safety issues. In the midst of this he begins a study of the lung conditions from which the miners suffer, and studies hard and long before successfully completing the Membership of the Royal College of Physicians.
One of the recurring themes in The Citadel is the competence, and incompetence, of doctors and their need to keep up to date. This includes botched operations and poor clinical skills. Dr Manson uses, but is also critical of, remedies that are ineffective and costly. He is concerned about the social conditions of the miners and the range and cost of medical services. He continues the research project on the effects of coal-dust on lung function, travelling back and forth to Cardiff for help, and eventually submits his research for an MD and is successful. This makes his name and he makes links with a wider range of people. One in particular, Mr Stillman, is a non-medical practitioner from the USA who has a new method of treating active tuberculosis. Despite these successes, Manson’s work has involved the use of animals in the research. This is frowned on by the Mines Committee, and he leaves.
The climax of the story begins when Manson is asked to see the daughter of an old friend. The girl has tuberculosis, and Manson has her admitted to hospital where the consultant examines her but the treatment provided shows no benefit. Manson recommends a special therapy but the other doctor disagrees; in spite of this, Dr Manson and the young patient agree that she will be admitted to a new, modern hospital, and be treated by Stillman, the unqualified doctor. The treatment is successful and the patient discharged. However Dr Manson’s London colleagues hear about this and refer him to the General Medical Council (GMC) to be investigated and potentially struck off the Medical Register.
He is brought before the GMC and cannot deny that he removed the patient from hospital, took her to Stillman’s clinic and assisted in the procedure to deal with the tuberculosis. The patient herself testifies that she is now well. Manson considers that, in spite of legal warnings, he should speak, giving a passionate defence of his actions which are central to the wider outcome of the book. He points out that when doctors qualify, they don’t have sufficient knowledge and skills: they do not undertake postgraduate educational programmes, they use ineffective and outdated remedies, the science base is limited and not in the front line, and they don’t work cooperatively. He is very negative about the fee system and the fee splitting between doctors, all done to make more money.
In particular Dr Manson highlights the lack of competence in many of the doctors. In this instance he has a particular colleague in mind who botched a major operation where the patient, a friend of Manson’s, died. He preaches idealism and a return to the values and ethical standards of the medical profession. This speech exonerates him and he has no sanctions imposed by the GMC. With two colleagues he decides to move to a small town in the Midlands to set up a team-based approach to clinical care.
Timing is critical when considering the impact of the book. The Citadel was a bestseller in 1937; the 1938 film received four Oscar nominations, and won the Best Picture Award from both the New York Film Critics Circle and the National Board of Review. After the Second World War, the Beveridge Report advocated significant changes to the welfare system and the establishment of a National Health Service. The Labour government which would take this forward included, as Minister of Health, Aneurin Bevan, a Welsh MP who would have been very familiar with the conditions in the mines set out in the book. In a recent review by S. O’Mahoney on this topic, the subject is considered in detail.1 He concludes that, while all the sentiments were there, Cronin was probably against State control, and indeed says so in the book.
What is clear, however, is that Cronin identified many of the issues in clinical practice which needed to be tackled in the succeeding decades, including better supervision of young doctors, postgraduate education programmes, an emphasis of ethical issues and team-based care. The funding of care was resolved by the establishment of the NHS, though what can be done within the NHS, and its affordability, remains an issue even today. He wanted to see a science-based, as well as an ethical, approach to care.
The book, however, had even wider ramifications. In 1944 the Goodenough Report on Medical Schools was published, and picked up Cronin’s point about doctors being inadequately prepared for practice. It had many recommendations, but the most relevant was to be the introduction of a compulsory pre-registration year where new graduates should serve, under supervision, in approved hospitals. One of the statements from the Goodenough Report is worth recording: ‘A properly planned and carefully conducted medical education programme is the foundation of a comprehensive health service’. This is undoubtedly a sentiment which Dr Manson would have supported. This was a major change, and was the beginning of structured and continuing education programmes. The Citadel had demonstrated its need.
In 1947, the GMC responded to this report, but not in full. The NHS was created in that same year, and had a profound effect on medical education. It provided the framework within which educational developments could be undertaken. Subsequently there was a series of reports from the British Medical Association and the GMC picking up the issues in The Citadel, for improvement in the education and training of doctors.2 The Todd Report on Medical Education (1957) covered the undergraduate area while the Christchurch conference (1961) covered postgraduate training, and set up regional postgraduate organisations. A. J. Cronin died in 1981; he must have been pleased at the way things had developed, as these developments answered most of the points in Dr Manson’s passionate defence to the GMC.
The ethical issues raised by Cronin were also not neglected. Most medical schools began teaching in this area, and societies and institutes of medical ethics began to spring up. Medical ethics is now firmly established as a field of study, and literature can provide a focus for its discussions.
The wider ramifications of books such as The Citadel are also worth considering as a resource for teaching and learning. In the 1980s, while teaching medical ethics with Professor Robin Downie (Professor of Moral Philosophy) in Glasgow, we introduced students to literature to emphasise the broader dimensions of medicine.3 These were poems, plays, stories and novels, all of which raised issues of the practice of medicine and health. They provided a forum for discussion and debate and encouraged reflection and the ability to articulate views. Thus literature can provide a focus for considering one’s own clinical practice and how personal views on clinical issues amongst doctors can vary. In addition, books, poems and plays can highlight issues related to the social determinants of health-poverty, employment and housing, and can demonstrate very effectively problems in lifestyle and their impact on well-being. For example there are some very powerful images created on issues of drunkenness and cigarette smoking, and the problems of HIV infection and its causation. Such texts can all be used to help the professions learn about such issues.
Works of literature can also be used to change public attitudes to health and illness-related behaviour. Stories can change lives and the power of the word can be significant. One possible scenario is the Contagion theory of behaviour change, which proposes that behaviour can be changed by the passing on (the contagion) of effective stories.
This process has widened into the arts and humanities generally and there are now numerous organisations and at least one journal covering this area. The use of theatre, dance, the visual arts and creative writing can all improve well-being and happiness.
The process of becoming a doctor is a complex pathway and requires not only science but humanity as well. The Citadel, with its references to specific issues, provided an impetus for change in the profession and how it was organised. In this respect it was an iconic book which changed public and professional thinking; it is certainly one which bears re-reading.
(c) The Bottle Imp