Literature Annotations


Cronin, A. J. (Archibald Joseph)
The Citadel


Genre Novel (402 pp.)
KeywordsArt of Medicine, Cross-Cultural Issues, Disease and Health, Doctor-Patient Relationship, History of Medicine, Human Worth, Individuality, Love, Marital Discord, Medical Ethics, Medical Research, Occupational Disease, Physician Experience, Poverty, Power Relations, Professionalism, Public Health, Society, Tuberculosis
Summary

In 1921, the twenty-four year-old Scottish medical graduate, Andrew Manson, takes up an assistant’s position in a small Welsh mining town. He is idealistic, but he quickly learns that his training is inadequate and that his hemiplegic employer will never return to practice. Manson must do all the work for a pittance and bad food. He befriends another assistant, the surgeon Phillip Denny, whose fatal flaw is devotion to drink. Together they solve the town’s problem with typhoid by blowing up the sewer.

Manson’s escape comes in a new job in a larger town and marriage to the equally idealistic Christine. She encourages him to continue his studies and to conduct research on the relationship between dust inhalation and tuberculosis. The results include higher degrees and international recognition, but they also bring about the wrath of the town’s antivivisectionists. To add to the gloom, Christine looses a much wanted pregnancy and the ability to have children.

The Mansons leave Wales for London, where Manson hopes to extend his research within a government agency. Quickly disillusioned by bureaucracy, he is lured into society practice and slowly abandons his ideals in exchange for prestige and wealth. Christine is increasingly unhappy, but his response is annoyance with her and an affair with a married woman. When one of his new associates botches an elective operation on a trusting patient, he realizes the colleague is nothing more than a society abortionist and that he and his new friends are little better.

He decides to sell his practice and renews contact with Denny to establish a group consulting practice "on scientific principles" in a carefully chosen Midland town. He also helps the tubercular daughter of an old friend to an unorthodox (but effective) pneumothorax in a clinic run by Stillman, an American who does not have an MD. Just as he and Christine have rediscovered joy in each other and their future together, she is killed in a freak accident. Only days later in the depths of grief, he is brought before the General Medical Council on charges of unprofessional conduct laid by his former associates. He acquits himself brilliantly and leaves with his old friend Denny for work in the Midlands.

Commentary

The overriding theme in this novel is Manson’s touching desire to "do something" useful. In every situation--as an assistant, in a solo mining town practice, as a medical bureaucrat, and as an illustrious private practitioner--he is brutally conscious that most of what he does makes little difference to the lives of his patients or the health of the public. Defeated by repeated disappointment, Manson loses his way when he forgets to cling to that desire; his redemption comes in its rediscovery (life as "an attack on the unknown, an assault uphill--as though you had to take some castle that you knew was there, but couldn’t see" [i.e. the citadel] p. 299) The symbolic reward is the restoration of his marriage. Christine’s death comes as a cruel punishment for his blind stupidity.

In each of Manson’s sticky situations, Cronin provides a clear enemy and a clear ally, but he makes it plain that no person is entirely bad nor good--even the enemies act out a sense of principle (albeit misguided). Instead, Cronin blames the organization of health services, the nature of doctor training, and the arrogance of the profession for the failure of medicine to improve the well-being of the population.

With irony, he features the perquisites attendant on medical meetings (p. 60-61), the total ineffectiveness if not dangerousness of the best paid doctors; the important contributions of those who were not physicians, such as Louis Pasteur (p. 395). Cronin’s critical eye extends even to the unquestioning practice of medical history, when he allows Manson to win his fellowship for noticing an error of attribution to Ambroise Paré when it should properly belong to Celsus (p. 165).

First printed in September 1937, the Citadel enjoyed more than a dozen reprintings before the year was out, and a relatively faithful adaptation was the basis for a successful feature film in 1938 (see film annotation of 0092). Cronin suffered ostracism by the medical profession for his liberal views, but his book is said to have helped pave the way for public acceptance of National Health Service in the following decade. For more on Cronin, see Dale Salwak, A. J. Cronin (Boston: Twayne Publishers, 1985) and J. A. Fisher, "A. J. Cronin--physician, author,"

Pharos. 1988 Fall;51(4):25-8.

PublisherRyerson
Edition1937
Place PublishedToronto
Alternate PublisherLittle, Brown
Alternate Edition1983 (paperback)
Place PublishedBoston
Annotated by Duffin, Jacalyn
Date of Entry 09/07/00
Last Revised 02/15/07