History of Medicine

DID A NOVEL HELP CREATE THE NATIONAL HEALTH SERVICE? 

         A.J. Cronin’s medically oriented novel of 1937, The Citadel, was one of the world’s greatest publishing successes of all time. The author, a physician himself, wove a tale of an idealistic and hard-working young physician at odds with a crusty, decaying British medical establishment. Over time, the novel sold millions of copies and was even popular (and allowed) in the Soviet Union and its satellites, probably because of its criticisms of British health services. Many cite the work as influential in the formation of the British National Health Service. 

First edition of Cronin's novel (Wikipedia)

        The hero of the novel, Andrew Manson, a young Scottish doctor with a Bachelor of Medicine (BM) degree, fresh out of school with no internship, takes work in a Welsh mining town. After an unhappy time there, Manson moves to another mining town, Aberalaw. In Aberalaw medical care of the miners is paid through funds in part deducted from the miners’ pay and in part contributed to by the mine owners. 

        While working in Aberalaw, Manson crams at night, earns an MD degree and acquires a membership in the Royal College of Physicians. He notices several miners coughing and laboring to breathe and begins a research project, including research on mice, to determine the role of inhaled particles. After being criticized for experimenting on animals, he leaves in anger and accepts a position on a government board that oversees safety in mines. But he is disillusioned by the laziness, neglect, and lack of progress shown by the board. Andrew then buys a private practice in London. Soon he is mesmerized by his high income and the swanky social circles he inhabits but in time is troubled by pandering to hypochondriacs for large fees, fee splitting, and the coverup of a botched surgery. There are more twists to the plot but eventually Manson and two others, one a skilled surgeon and one an American tuberculosis specialist, who is not an MD, depart London to set up a multispecialty group practice in a small middle-class town. Some former colleagues, angry and slighted, charge him with practicing with a non-physician and abducting a patient from a decaying TB hospital to receive a new and unproven treatment. In the finale, an impassioned speech, announcing his good intentions, saves Manson from losing his license. 

Scene from movie version starring Robert Donat (Wikipedia)

        Throughout the drama, the novel is quite critical of several aspects of British medicine of the time and is said to have been a driving factor in the introduction of the British National Health program. Was this so, and did Cronin advocate a National Health Service? 

        The novel is highly autobiographic. Cronin was born in 

A J Cronin (Wikipedia)

Scotland in 1896. Like Andrew Manson, Cronin received his medical education in Glasgow and began practice in a Welsh mining town as assistant to a general practitioner. Cronin next moved to Tredegar, a nearby mining town, given the name Aberalaw in the novel. As in the fictional Aberalaw, Tredegar’s distinction was a well-functioning medical system, financed by modest deductions from the workers’ pay and by contributions from the Tredegar Iron and Coal Company and other employers. It provided medical, including hospital, care for some 20-25,000 inhabitants. Cronin portrayed this type of practice, private and communal at the same time, as an optimal approach, as did his fictional hero, Andrew Mason. And, like Mason, Cronin studied in late hours to earn his MD and FRCP honors. 

Tregedar Cottage Hospital, taken 2017 (Wikipedia)

        Aneurin Bevin, the principle driving force behind the formation of the National Health Service, was born in Tredegar in 1897, one year after Cronin. His father, a miner who had embraced socialism, died of pneumonoconiosis. Aneurin worked in the mines, became active in labor politics, and attended college on a scholarship. He spent two years on the management committee of the Tredegar Cottage Hospital, where he had a close look at the medical system. He joined the Labor Party, remaining on its left wing. During WWII he criticized Churchill and Army leadership and felt that England should cultivate closer ties with Russia. 

     

Aneurin Bevan (Wikipedia)

   Bevin promoted the idea of national health care, funded on a tax-based model rather than private organizations. Bevin struggled with fierce resistance from the medical profession and the British Medical Association and eventually made concessions, such as higher pay for consultants and allowance of private practice alongside work in the NHS. As Minister of Health in the post-war Atlee government, he shepherded The National Health Care Act into law in 1946. 

         Although Bevin created a socialist framework for national health services, he may well have been influenced by his association with the similar, but private, scheme in Tredegar. Cronin’s direct influence on Bevin is probably slight, as no meeting is recorded. Cronin’s Andrew Mason praised the Tredegar system, but Cronin himself was silent on the program promulgated by Bevin and did not take part in the politics of health care. 

         In The Citadel and in other fiction, Cronin criticized the custom of beginning practice without hospital experience (such as an internship), urged more complete postgraduate medical education, and frowned on various practices such as fee-splitting as dishonest and unbecoming. And he portrayed public health officials as lazy and incompetent. This suggests a suspicion of governmental management in health matters and Cronin, through his fiction or elsewhere, never advocated a government-run health service. In The Citadel, Manson’s dream follows the lines of the Tredegar plan. While there is a connection between Aneurin Bevin, the miner’s life, and the hospital at Tredegar, Bevin’s ideological ties to socialist thought in his crusade for equal health care for all probably were the dominant factors in designing the NHS. 

         Apologies for missing June. I was traveling again. 

 SOURCES: 

 Dunn, Francis Gerard, A. J. Cronin’s Career and Fiction with Specific Reference to The Citadel and the Context of the Foundation of the National Health Service. MPhil(R) thesis, University of Glasgow, 2022. 

 McKibbin, Ross, “Politics and the Medical hero: A.J. Cronin’s The Citadel.” English Historical Review 2008; 123: 651-78. 

 Davies, Alan, A. J. Cronin, The Man Who Created Dr. Finlay. Alma Books, London, 2011. 

 Cronin, A J, The Citadel. Victor Gollancz Ltd., London. 1937. 

 Cronin, A J, “Dust Inhalation by Hematite Miners.” J Indust Hygiene 1926; 8 (7): 291-4. 

 Richardson, Ruth, “The Art of Medicine: A J Cronin’s Citadel.” Lancet 2016; 387 (June 4): 2284-5. 

 A full index of past essays is available at: https://museumofmedicalhistory.org/j-gordon-frierson%2C-md