The Citadel by A. J. Cronin (1937)

Review by Sylvia D:

The Citadel is a powerful attack on the medical system in this country before the inception of the National Health Service in 1948. The vehicle for this attack is the career of Scotsman, Andrew Manson, who starts out as a newly qualified doctor’s assistant in the 1920s in the drab South Wales mining village of Drineffy where:

‘There’s no hospital, no ambulance, no X-rays, no anything.   If you want to operate you use the kitchen table’ – (p 19).

Manson finds that his medical training is inadequate, that as a GP he has to be family doctor, diagnostician, surgeon, dispenser, anaesthetist, that other doctors are often incompetent, that local conditions are unsanitary resulting in an outbreak of cholera in the village, and that fee structures are open to abuse. When he moves to be an assistant doctor with the Aberalaw Medical Aid Society, for instance, he finds that all the assistant doctors have to pay one fifth of their fees to the suave Doctor Llewellyn, the head physician and surgeon.

Manson is very idealistic and principled at the start of his career. One can sympathise with his refusal to issue sick certificates to miners who are quite fit to work, with his run-in with the district nurse and her antiquated remedies which do more harm than good and his desire to overcome resistance to vaccination but when it comes to showing up another doctor for mis-diagnosis and to reviving a stillborn baby that others have given up on he comes across as rather sanctimonious.

As his career progresses , Manson becomes interested in the relationship between the coal dust in the mines and lung disease but this results in even greater disillusionment; having completed his paper and submitted it successfully for an MD, he is recruited by the government’s Coal and Metalliferous Mines Fatigue Board. He is dismayed at the inertia of the Civil Service and at the way he is channelled into the fatuous personal projects of the Board Directors rather than being allowed to continue his research and at the way one of the Board Directors gets the recognition for his (Manson’s) paper on lung disease.

It is when Manson sets up in private practice in London that Cronin unleashes the full force of his attack. Manson is gradually seduced by the idea of material success and resorts to the same stock remedies, pointless operations and endorsing commercial products which have no medical benefit as so many other doctors did. Indeed, some of them went even further by making a lot of money from carrying out illegal abortions.   Cronin also attacks the hospital system which saw the less well off condemned to be treated in crumbling, ancient buildings, funded by penny collections and advertising displays, whilst those who could afford it opted for private clinics, usually unsuitable former houses that were badly converted and ill-equipped.

He paints a picture of a profession that has no qualms about milking wealthy hypochondriacal ladies. After visiting one woman who ‘spent her time equally between exclusive private hotels and West End nursing-homes’, his college friend, Freddie Ransom declares, ‘You’ve no idea what a gold mine that old woman has been to us. We’ve taken nuggets out of her’ – (p 304).

As Manson comes to recognise, this woman

‘had never done a day’s work in her life, her body was soft, pampered, overfed. 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 scold her maid . . . If only she would walk out of [the] 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!’ – (p 387).

There is quite a lot of social commentary like this in the book.

 

The Citadel is also a love story. Early in his career Manson marries Christine Barlow, the schoolteacher in Drineffy. She supports him through thick and thin, encourages him in his work and helps with his research into lung diseases. However, when they move to London she becomes distressed and alienated by his abandonment of his principles and his pursuit of wealth. I struggle with Cronin’s characterisation of Christine though. Granted that women had to give up their careers on marriage at the time but the portrayal of her as the meek, uncorruptible wife who is constantly making do and forever knitting feels patronising. I’m not sure this is what Cronin intended but when he gives her a miscarriage which makes her unable to have further children and then kills her off at a dramatic moment in the narrative, she does comes across rather as a literary vehicle than a fully developed character.

The novel comes to a dramatic end with the unnecessary death of one of Manson’s patients at the hands of someone he had thought was an eminent surgeon, his rejection of lucrative private practice and his decision to set up a medical co-operative with two friends, a surgeon and a chemist, who have stood by him. In the closing chapter Manson gives an impassioned speech about scientific advance and the short-comings of the medical profession when summoned before the General Medical Council for so-called unethical conduct.

This speech reflects what Cronin once stated in an interview,

‘I have written in The Citadel all I feel about the medical profession, its injustices, its hide-bound unscientific stubbornness, its humbug … The horrors and inequities detailed in the story I have personally witnessed. This is not an attack against individuals, but against a system’ – (from Wikipedia).

As Cronin states, The Citadel is semi-autobiographical but because it was written to convey a powerful message, which it has been argued contributed significantly to the founding vision of the NHS, it has several flaws as a work of fiction. However, it is an excellent social document and makes one very grateful for our modern medical system.

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