Aj cronin and The Citadel: how a “middlebrow” novel contributed to the foundation of the nhs

AJ Cronin and The Citadel: how a “middlebrow” novel contributed to the foundation of the NHS

Seamus O’Mahony

Consultant Physician/Gastroenterologist

Cork University Hospital

Wilton

Cork

Ireland
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Introduction
AJ Cronin (1896-1981), an author little known to those below the age of fifty, was arguably the most successful novelist writing in English in the 1930s. His best known novel, The Citadel, was published in 1937¹. The book paints an unflattering portrait of British medicine in the inter-war years. It is widely thought that the book influenced the result of the 1945 general election in Britain, and the subsequent establishment of the National Health Service (NHS) by the Labour government in 1948². The Citadel anticipates such phenomena as evidence-based medicine and continuing medical education. This paper examines the influence of the novel and argues that although Cronin’s novel did significantly influence public opinion in Britain in favour of socialized medicine, the novel was never intended as propaganda for a state-controlled national health service. On the contrary, Cronin was against state control. Analysis of the novel is informed by recent biographical revelations about Cronin, and the blurring of the margin between fact and fiction in Cronin’s life and work is examined.
Brief Biography of Cronin
Cronin was born in Cardross, Scotland in 1896. His father was of Irish descent and Catholic; his mother’s family was Protestant. Cronin’s father died when he was 7, forcing Cronin and his mother to move in with her parents. Cronin excelled academically and at sports, and won a Carnegie Foundation Scholarship to study medicine at Glasgow University, where he graduated in 1919. He subsequently worked as a GP in South Wales, moving then to London, where he established a successful private practice. In his mid-30s, he experienced some form of crisis – ascribed to peptic ulcer in his autobiography³ – and sold his practice, with plans to write a novel. This he duly did, and the resulting book, Hatter’s Castle, was accepted by the first publisher he sent it to – Victor Gollancz – and was an immediate best-seller. He never returned to medical practice. The 1930s were his most productive and successful years; following the success of Hatter’s Castle, he wrote two more best-sellers, The Stars Look Down, and The Citadel. His novels were successfully adapted for film, and Cronin became a wealthy man. He spent much of the subsequent war years in America, and eventually settled permanently in Switzerland. Although he published several more novels until the early 70s, he never repeated the success of the 1930s.
Cronin’s novels have common themes: the struggle of poor catholic scholarship boys to overcome sectarian bigotry and make their way in the world, usually through academic achievement; idealistic young men (usually doctors or priests) losing their moral compass through the temptations of money and sex; Catholic themes of sin, guilt and redemption. He re-cycled these themes and plots in his less successful later novels. He is probably best known to the television generation as the author of the Adventures of a Black Bag stories, whose characters formed the basis for the hugely popular Dr Finlay’s Casebook TV series which ran from 1962 to 1971.
The Citadel: a Summary
The Citadel tells the story of Andrew Manson, an idealistic young Scottish doctor, modelled closely on Cronin himself. Manson takes up a post as a GP assistant in a Welsh mining town, Drineffy. He is shocked to learn that his principal, Dr Page, has been completely incapacitated by a stroke and will clearly never work again. His wife (sister in the second edition of the novel) attempts to conceal this fact, while exploiting Manson. He works for the miners’ medical-aid club, but increasingly dislikes this work. He becomes friendly with the cynical Denny, another assistant GP, who tells him that contaminated water has led to several deaths from typhoid in the town. The senior doctors show no interest in the problem, and Manson and Denny eventually blow up the old sewer, forcing the authorities to build a safe water supply. Manson marries a local schoolteacher, Christine, and impresses the townspeople with his medical skill. He correctly diagnoses and successfully treats hypothyroidism (“myxoedema madness”) in a man who suddenly become violent and who is on the brink of being committed to an asylum by the other doctors. He saves a baby’s life during a difficult delivery, and is rewarded with a large cheque by the baby’s father. Dr Page’s sister is angered by this gift, and Manson resigns. He moves to a better post in another Welsh town, Aberlaw, but soon runs into trouble. The head doctor expects to receive part of his salary, and he refuses to sign sick-notes for malingering miners. He studies hard for the Membership of the Royal College of Physicians (MRCP) examination, which he passes, impressing his examiner, the distinguished and sympathetic Sir Robert Abbey . He saves a miner’s life following a mine accident by amputating his arm. His wife become pregnant, but loses the baby: she is told she will never have children. . He becomes interested in lung disease caused by coaldust, and carries out research which leads to an MD degree. His enemies in the town accuse Manson of using animals for experiments without obtaining a licence from the Home Office. Although he is exonerated, he resigns his post. He is appointed Chief Medical Officer for the Mining Fatigue Board, but he soon discovers that the Board, controlled by the mine owners, is filled with place-men, apart from the honourable exception of Sir Robert Abbey. The employers want to distract him from his work on coal-induced lung disease, and he becomes bored, with little to occupy him. He befriends an idealistic young microbiologist, Hope, who also works for the Board. After less than a year, he resigns his post and buys a run-down practice in London. He struggles at first, but soon is busy and successful. He succumbs to the temptations of money and sex: he attracts rich neurotic private patients, and embarks on an affair. He befriends two unscrupulous society doctors, Hamson and Ivory, and abandons his high ethical standards, becoming wealthy from fee-splitting and exploiting rich neurotics. Both Christine and his old friend Denny try to persuade him back to his old ethical ways. (The significance of the title becomes clearer when Christine remonstrates with Manson: “Don’t you remember how you used to speak of life, that it was 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, on the top”.) He meets Stillman, an American scientist, who, although not medically qualified, has done ground-breaking work on tuberculosis. He finally comes to his senses following the death of a patient after a botched operation by the incompetent Ivory. Manson had referred the man to Ivory and had assisted at the operation. Ivory is also revealed to be an abortionist. Manson vows to practice honest, scientific medicine, and plans with his friends Denny and Hope to set up a new clinic together. He sells his practice, but tragedy strikes when Christine is run over by a bus. The vengeful Ivory reports Manson to the General Medical Council for referring a patient with tuberculosis (the daughter of his old friend Con Boland) to Stillman, who is not a medical doctor. He delivers an impassioned speech on the failures of British healthcare and the Council, which includes his old patron Sir Robert Abbey, exonerate him. He leaves London for a town in the Midlands, where he sets up a clinic with Denny and Hope.
British Health-Care in 1937
Geoffrey Rivett’s history of the NHS⁴ gives a clear picture of medical services in Britain in the decades before the foundation of the NHS. Following Lloyd George’s National Insurance Act of 1911, low-paid workers were insured against illness, with free access to general practitioners (GPs) and rights to sick-pay. Access to GPs worked through a “panel”, operated by Friendly Societies that paid the doctors poorly. Workers’ families, however, were not covered by this insurance, and poor families with sick children could rarely afford to visit the doctor. GPs were paid an annual capitation fee per panel patient, with the result that the doctors had little incentive to see these patients, and were accused of devoting more time and attention to fee-paying patients. Some occupational groups, however, such as the miners in Tredegar in South Wales, had a more comprehensive health-care provision covering the families also. Middle-class patients either paid a fee for each visit to the GP, or else took out private insurance to cover such fees. Some GPs were relatively wealthy (particularly those who, like The Citadel’s Dr Llewellyn employed other doctors), but many, if not most, had a modest income. Hospitals were a mixture of local authority-controlled former workhouses and more prestigious voluntary hospitals, which were frequently teaching hospitals. Many of the famous teaching hospitals were relatively wealthy, raising funds from investment and charitable donations, but by the 1930s, their investment income had fallen sharply. Hospital consultants earned their living by treating fee-paying patients outside the hospitals, mainly in private nursing homes, in which the consultants frequently had a financial stake. The quality of hospital care varied enormously, with relatively high standards in the London teaching hospitals, some of whom were internationally recognised. Access to specialist treatment was mainly a matter of geographical chance. Patients living in London were more likely to access such specialist services, while hospital care in provincial cities was mainly in local authority controlled municipal hospitals, where standards of care were frequently very poor.
Impact of The Citadel
The Citadel was an immediate success, selling over 150,000 copies in Britain in the first three months after publication, and 10,000 copies a week for the rest of the year⁵. It was equally successful in the US and in Europe, particularly in Germany and Russia. Readers in Communist Eastern Europe admired the technical modernisation and social criticism, while in Nazi Germany the book was regarded as useful anti-British propaganda⁶. The novel’s success was partly due to Victor Gollancz’s astute marketing of the book. Gollancz launched a major advertising campaign, and the book became a favourite of Book Clubs, including Gollancz’s own Left Book Club. Gollancz successfully sold the book as an exposé of corrupt institutions. A Gallup poll conducted in 1938, reported that The Citadel “impressed” more people than any other book except the Bible⁶. The BBC broadcast ten readings from the novel in 1938. It went on to become a successful film, directed by King Vidor, which won four Oscar nominations, including best actor (Robert Donat) and best picture. It was the most commercially successful film in Britain in 1939. The film’s producers were wary, however, of being seen to be critical of the medical profession, and the opening credits contained the following rather clumsily-worded disclaimer: “This motion picture is a story of individual characterizations and is in no way intended as a reflection of the great medical profession which has done so much towards beating back those forces of nature that retard the physical progress of the human race”.
Contemporary reviews of the book were not uniformly positive. Leonora Eyles, writing in the Times Literary Supplement accused Cronin of demonizing the entire medical profession: “All over the country today are county and municipal officers who care less for fees than for healing; in general practice are insignificant men and women living devoted, anxious lives with only fourteen days a year away from the clamorous telephone by day and night. In Harley Street are men who might stand by Lister without shame”⁷.
It is claimed, with some justification, that the book strongly influenced the result of the 1945 British general election, when the voters rejected the war hero Churchill in favour of the less charismatic social reformer, the Labour leader Attlee. This Labour government established the NHS in 1948. The seeds of the NHS were sown in Tredegar, home town of the NHS’s architect, Aneurin Bevan. Cronin spent three formative years in this town (“Aberlaw” in The Citadel). The Medical Aid Societies set up by the Miners’ unions in South Wales inspired Bevan to extend free health care to the entire nation. In Adventures in Two Worlds, Cronin says: “In actual fact this scheme can definitely be regarded as the foundation of the plan of socialized medicine which was eventually adopted by Great Britain. Aneurin Bevan, who was mainly responsible for the national project, and at one time a miner at Tredegar, and here, under the local aid organization, the value of prompt and gratuitous treatment for the worker was strongly impressed upon him.” Launching the NHS, Bevan said: “All I am doing is extending to the entire population of Britain the benefits we had in Tredegar for a generation or more. We are going to “Tredegarise” you”⁸. Bevan and Cronin are not known to have met, but, given their mutual connections with Tredegar and their fame, it would seem highly likely that they did.
It is difficult to quantify the influence of The Citadel. Cronin was no socialist: he complained that people who had free healthcare did not value it. Nevertheless, its timing – published in 1937 – was perfect. The 1920s and 30s were decades of scientific and social advance, yet British medicine was still essentially Victorian. The Second World War accelerated the process of change, and it is not surprising that when the war finally ended the British electorate unsentimentally ditched Churchill. The theme of The Citadel is the struggle of the idealistic young hero against the medical establishment, which is corrupt, venal, unscientific and self-serving. Private practice is shown to be a shabby, money-grabbing business, exploiting the rich and gullible. Quack treatments are commonplace, and most doctors are too lazy to keep themselves abreast of scientific developments. GPs are portrayed as ignorant drudges, peddling useless and outdated drugs (“no more than a poultice mixer or medicine slinger”). They rarely co-operate with other, interested only in protecting their own patch. Cronin almost prophesies the advent of evidence based medicine (“an absolute allegiance to the scientific ideal, no empiricism, no shoddy methods, no stock-prescribing, no fee-snatching, no proprietary muck, no soft-soaping of hypochondriacs..”) and continuing professional education. (“There ought to be a law to make doctors up to date ….compulsory post-graduate classes – to be taken every five years”). He had his doubts, however, about socialized medicine: “There is certainly value in the scheme (The Miners’ Medical Aid Society), but it also has its defects, of which the chief one, in Tredegar, was this – with complete carte blanche in the way of medical attention, the people were not sparing by day or night, in “fetching the doctor”. A malingerer’s and hypochondriac’s paradise”³.
Manson delivers a long speech to his friends Denny and Hope on the inadequacies of the hospital system, particularly in London. He seems to suggest some form of state control: “And what’s being done? Zero, absolute zero. We just drag on in the old, old way, rattling tin boxes, holding flag days, making appeals, letting students clown for pennies in fancy dress. One thing about these new European countries – they things done.” One assumes these “new European countries” are Hitler’s Germany and Mussolini’s Italy. The final chapter, when Manson, in a speech from the dock-style oration, addresses the General Medical Council, could be read on its own as a political manifesto, summarizing Cronin/Manson’s views on the failures of the system. “Go to the beginning: think of the hopelessly inadequate training doctors get ……. We ought to be arranged in scientific units. There ought to be compulsory post-graduate classes. There ought to be a great attempt to bring science into the front line, to do away with the old bottle-of-medicine idea, give every practitioner a chance to study, to co-operate in research. And what about commercialism? – the useless guinea-chasing treatments, the unnecessary operations, the crowds of worthless pseudo-scientific proprietary preparations we use – isn’t it time some of these were eliminated? The whole profession is far too intolerant and smug. Structurally, we’re static.” Cronin’s main argument, therefore, is not for the establishment of a state-controlled nationalised health service, but rather for education, training, and reverence for the scientific method.
For a 21^st century reader, his clinical details are unfamiliar: the radical, allegedly scientific treatments espoused by Manson for TB seem to us as ineffective as the quack patent medicines he rails against. Stillman, the charismatic American, is portrayed as achieving remarkable results in patients with pulmonary tuberculosis by inducing a pneumothorax in the infected lung. In little over a decade and a half after the publication of The Citadel, effective antibiotic therapy for tuberculosis would become available, and the idea of inducing pneumothorax to “rest the lung” strikes the modern medical reader as odd, although I am told that in many cases it was effective. I sympathised with the character of Dr Thoroughgood, the chest physician who although kind and hard-working is portrayed as irredeemably old-fashioned and outdated. “But in treatment, his tidy mind resented the intrusion of the new. He would have nothing to do with tuberculin, holding that its therapeutic value was still completely unproved. He was chary of using pneumothorax and his percentage of inductions was the lowest in the hospital. He was, however, extremely liberal in the matter of cod-liver oil and malt. He prescribed it for all his patients.” Ironically, Thoroughgood’s practice strikes the modern reader as more evidence-based than Manson’s or Stillman’s. The description of the botched operation by Ivory is unconvincing: exactly what sort of “cyst” did this patient bleed from? It is not clear how a polyclinic comprising a physician, a surgeon and a microbiologist would bring cutting-edge medical care (“our idea of specialised co-operation”) to a market town in the West Midlands.


Cronin the Writer: Fact and Fiction
In a recent biography⁵ (only the second) of Cronin, the author laments the fact that while contemporaries such as Graham Greene and Evelyn Waugh are fêted and are still read and in print, Cronin has all but been forgotten. There is a simple explanation for this: Cronin was a good writer, but not a great one. His skill was for narrative, combined with a sort of hectoring moral righteousness. He had a good ear for regional dialect, and the dialogue of the Welsh miners is convincing and authentic. The reasons for the success of The Citadel were threefold: (a) timing, (b) the novel’s accurate portrayal of a dysfunctional medical care system easily recognisable to its readers, and (c) Gollancz’s genius for promotion. On the week of its publication in 1937, Gollancz cheekily sent 200 copies to the British Medical Association, who were in annual conference in Belfast⁶. He ran regular newspaper advertisements, announcing ever-increasing sales of the book. But the fact remains that Cronin’s style is pedestrian – “serviceable”, according to one charitable commentator⁶. Exclamation marks are scattered throughout both the third-person narrative and dialogue. The book is full of antique 1930s slang – “by Jove!”, “dashed”, “confound it!” His characters, such as Manson’s wife, Christine, are two-dimensional and clichéd. (Manson’s mistress, Frances Lawrence, appears to have wandered in by mistake from a Noël Coward play.) Many key scenes, such as the blowing up of the infected sewer, the arm amputation in the mine and Christine’s miscarriage and death, are pure melodrama . He is almost completely humourless. Cronin’s attempts at light relief, such as the scene when Con Boland’s jalopy collapses, are simply embarrassing. Manson is tedious, opinionated, judgmental, self-righteous. He is given to sermonizing at great length – as was Cronin, particularly in Adventures in Two Worlds. In 1941, one John T. Frederick, writing in The English Journal on Cronin, asked: “Can a novel which is dull and graceless in style, devoid of humour, obvious and often clumsy in construction, frequently mediocre in characterization, yet deserve serious consideration as a work of fiction? Can a poor writer be a great novelist?”⁶
Cronin did not have a vocation for medicine; he found it dull and abandoned it without much regret. He himself admitted as much, when he told Victor Gollancz that Hatter’s Castle was “written in the Scottish Highlands during August, September and October of 1930 and represents a rather fumbling attempt, upon my part, to escape from the neat little pathways of medicine into the unconfined and, to my mind, infinitely more attractive pastimes of literary art”⁵. He later admitted to an American audience that the success of this book gave him the opportunity “to leave my practice which I hated and take up the job of writing which I love”⁵. His memoir, Adventures in Two Worlds, contains so many untruths and inconsistencies that it is now regarded as essentially a fictionalised impression of his life. His biographer makes it clear that it should now be read as a novel, and indeed, it rehashes many of the themes of his novels. Adventures in Two Worlds and The Citadel contain near-identical set-pieces, such as Manson/Cronin’s MRCP viva. His fiction is autobiography, and his autobiography is fiction. Many of the characters in The Citadel were immediately recognisable as the “real” persons on whom they were based: Mrs Hinde-Arnold, widow of Dr William Hinde, immediately recognized herself as “Blodwyn Page” . She threatened a libel action against Cronin and Gollancz; this was withdrawn following a formal written apology from Cronin, and a substantial revision of the character in the second edition of The Citadel, where Blodwyn Page is now the sister, rather than the wife of Dr Page, and is portrayed more sympathetically⁵. Dr Edwin Davies, chief medical officer of the Tredegar Medical Aid Society, and the model for “Dr Llewellyn” made a similar threat but withdrew⁵. Sir Robert Abbey is clearly based on Lord Dawson of Penn, the Royal Physician who famously expedited the demise of King George V. Chapter 18 of Adventures in Two Worlds is almost identical to chapter 10 (Part2) of the Citadel. Sir Robert Abbey in The Citadel become the “real” historical figure, Lord Dawson of Penn, in Adventures in Two Worlds, while the devious (and fictional) Dr Gadsby appears in both books. Ivory was based on Ivor Back, a fashionable surgeon, whose wife, Barbara, was one of Somerset Maugham’s closest friends¹⁰. This is a very modern, even fashionable, phenomenon: the blurring of the boundries between fiction and memoir. David Shields’s recent Reality Hunger is subtitled “a manifesto” for this blurring¹¹. Although Cronin is too middlebrow for the likes of Shields, who prefers his blurring to be more knowing and post-modern, his flexible approach to fiction and autobiography is right up Shields’s alley. “The books that most interest me sit on a frontier between genres”, writes Shields in Reality Hunger. Although Cronin’s biographer advises that Adventures in Two Worlds should be read as a novel⁵, most readers have consumed it as straight, factual autobiography. Surawicz and Jacobson, writing in Doctors in Fiction state that Cronin “practised in the Scottish mining town of Tannochbrae”¹². There is no such town; Cronin also describes in Adventures in Two Worlds working as assistant to a Dr Cameron. Dr Cameron, of course, is no more real than Tannochbrae, and Cronin recycled these places and characters for the Adventures of a Black Bag stories; these fictional places and characters formed the basis for Dr Finlay’s Casebook, the television series which made Cronin globally famous, although Cronin did not actually write the scripts. One suspects that laziness, rather than some form of playful literary post-modernism accounted for Cronin’s frequent recycling of plots and characters. (The “myxoedema madness” story is re-told in at least three books.) Cronin was most definitely not an experimental writer, and had little truck with modernism, let alone post-modernism. Cronin told his publisher that the book “will not be an autobiography but will be full of incident, tender, moving and dramatic, with just that medical flavour which readers love, a really warm and interesting book.”⁵ Despite this assertion, Gollancz marketed the book as an autobiography, mainly for commercial reasons.
And yet, some details of Cronin’s life are stranger and more singular than the events described in his “autobiography” and novels. Cronin’s abandonment of medicine, was, according to the recent biography, even more dramatic than described in Adventures in Two Worlds. Like Manson, he saved the life of a sick child (he performed a tracheotomy on a child about to suffocate from diphtheria). The child’s father was naturally very grateful, and invited Cronin to join an investment group which led to a profit of £80,000 for Cronin⁵. He thus became a wealthy man, and gave up medicine for ever. He could have lived comfortably even if he never wrote novels. The combination of this huge windfall and the massive sales of his books made him very rich. Interestingly, the “Cronin” in Adventures in Two Worlds is similarly advised to invest, but loses most of his money; the moral of the story, of course, is that money doesn’t make you happy. Cronin the writer never really struggled for success: his first novel was accepted by the first publisher he sent it to, and was an immediate best-seller. Cronin truly had the Midas touch, but he was never quite comfortable with his good fortune, and his later books are suffused with a sense of guilt, regret and self-loathing. His finest later work, The Judas Tree, is the best example of Cronin’s keen instinct for sin¹³. The hero, a once-idealistic Scottish doctor abandons the Spartan but straight road of medicine for an easy life of money and comfort, in exile in Switzerland. He betrays and abandons his innocent sweetheart, and even manages to do the same many years later to the daughter (by another man) of this woman. He cannot bear the guilt and hangs himself - from a Judas tree. Cronin had uneasy relationships with women, and in his novels the female characters are poorly realized. The recent biography of Cronin by Davies makes frequent reference to the “1976 autobiography”, which was never completed or published, and apparently deals mainly with his unhappy marriage and parallel relationship with Nan, the Cronins’ nanny and housekeeper⁵. This autobiography gives some clues in this regard. He married young, under the mistaken impression that his wife-to-be was pregnant, and regretted the decision to marry thereafter. The relationship was strained, exacerbated by his wife’s mental fragility and Cronin’s indifference to her. He maintained a long-running (apparently chaste) relationship with Nan. His wife eventually developed dementia and spent her remaining years in institutional care. After her death, Cronin and Nan lived openly as a couple. Nevertheless, in Adventures in Two Worlds, Cronin proudly boasted of his own marital bliss: “If I speak feelingly here, it is because of the happiness which my own marriage has brought me, a happiness due to that stroke of fortune which gave me a wife so finely moulded by her early training; so patient, self-sacrificing, and wise; above all, so completely staunch in every vicissitude of our partnership of thirty years that life without her would be unthinkable”.
Cronin’s life is thus of interest, as it provides the key themes for his fiction: the poor scholarship boy who overcomes bigotry and poverty to qualify as a doctor; the idealistic young doctor struggling against ignorance and a corrupt medical hierarchy; the disillusioned middle-aged man who despite his wealth and comfort, longs for the excitement and moral certainties of his life as a doctor; the devout Catholic who has betrayed his wife and his principles.
Cronin creative powers declined after the 1930s. He never repeated the success of the 1930s novels, Hatter’s Castle, The Stars Look Down and The Citadel. In a perceptive essay⁶, McKibbin concluded that Cronin was a good genre novelist, but nothing more. McKibbin places The Citadel firmly in the medical hero genre, and points out that Cronin probably drew inspiration from Sinclair Lewis’s Arrowsmith, the plot and themes of which share many similarities with The Citadel. The recent Davies biography⁵ portrays an author more concerned with royalty cheques than artistic inspiration. He lacked curiosity: despite living for many years in the US, he never used this experience for his fiction. He lived to the age of 84, yet his fiction draws little from the last 50 years of his life. Like Waugh, the post-war world horrified him, but unlike Waugh this horror did not inform his writing. His son Vincent told Cronin’s biographer that in old age his father “finally accepted his peers’ judgement of him as a middlebrow writer”⁵.
The term “middlebrow” is laden with snobbery and condescension. It is significant that the term was first used in the 1920s, the decade of Ulysses and The Waste Land : the decade which introduced the notion that “serious” literature, novels and poetry, had to make demands of the reader. Two English writers of the pre-modernist era, Kipling and Galsworthy, would now be classified firmly as “middlebrow” – and in Kipling’s case, “racist” is usually thrown in for good measure. Yet both were Nobel Laureates. It would be inconceivable nowadays for such popular, and populist, writers to be awarded this prize. Virginia Woolf famously used the term to dismiss those readers unmoved by her experimental fiction¹⁴: “We highbrows read what we like and do what we like and praise what we like”. A lowbrow is a person “of thoroughbred vitality who rides his body in pursuit of a living at a gallop across life”. Middlebrows, however, are “in pursuit of no single object, neither Art itself nor Life itself, but both mixed indistinguishably, and rather nastily, with money, fame power or prestige”. The term is widely used today by academics and cultural elitists to dismiss popular art, be it literature, music or painting. Raymond Williams, in Culture and Society, remarked: “there are in fact no middlebrows; there are only ways of seeing people and books as middlebrow”¹⁵. Some contemporary commentators, however, now cautiously use “middle-brow” as a term of approval, meaning art which is accessible, popular and unpretentious. This approval, however, is heavily laced with irony, and middle-brow culture is enjoyed as a “guilty pleasure”, something we shouldn’t be proud of admitting to. Cronin came from a long tradition of “middlebrow” fiction. He admired and drew inspiration from the previous generation of “popular” novelists (Bennett, Galsworthy, Maugham), and his social crusading is clearly influenced by Dickens. Cronin’s contemporaries included fellow “middle-brow” authors such as JB Priestley (b1894), Agatha Christie (b1890), Dorothy L. Sayers (b1893) and James Hilton (b1900). It is instructive to compare bestseller lists of today with those from the 1930s. While today’s lists are dominated by genre fiction (crime, fantasy, thriller, boy wizards), the US top-ten best-seller lists from 1936-8 includes George Santayana (The Last Puritan), Aldous Huxley (Eyeless in Gaza), Margaret Mitchell (Gone with the Wind ) Somerset Maugham (Theatre), John Steinbeck (Of Mice and Men), Virginia Woolf (The Years), Daphne du Maurier (Rebecca ), Sinclair Lewis (It Can’t Happen Here ) and Cronin’s The Citadel. Note the happy mix of “highbrow” and “middlebrow” authors. It would seem that in the 1930s, there wasn’t a sharp demarcation between “popular” and “literary” fiction. “Ordinary” readers consumed serious fiction in far greater numbers than is the case today, and many of these novels dealt with major social issues (Of Mice and Men, The Citadel). With cinema being the only competing art-form, the 1930s was a golden age of popular, serious fiction. A mass audience was entertained, informed and challenged. Books no longer occupy this central position in our culture.
Cronin was frequently labelled “middlebrow”: his obituarist in The Times in 1981 wrote: “his was middle-brow fiction of the most adroit and telling kind”⁵, and the Dictionary of National Biography calls him “a middlebrow writer par excellence”¹⁶. Cronin was acutely aware of these snobbish and lazy dismissals of his work: his biographer quotes him confiding to his friend, the Rev. McClelland: “to be provincial and bourgeois in these days of complexes and cocktail parties is a crime which is hard to live down. But I shall gang my ain gate…”⁵ He despised modernism and deliberate obscurity, maintaining that “in most ages great art has been simple and intelligible”⁵ In a speech to a literary gathering before the war, he mocked the work of Gertrude Stein by quoting randomly from one of her books.⁵ He viewed Freud’s work with similar distaste, and lamented the influence of psychoanalysis on modernist fiction “because it offers easy cuts to psychological profundity….it is to me, at least, a matter of amazement that such writing is tolerated, let alone revered. There always has been, of course, respect for the unintelligible in every art. To a certain mentality what cannot be understood must be fine: obscurity is the synonym for genius. But to others, myself among them, this thing is intricate, pitch-dark rigmarole..”⁵ His biographer has suggested that Cronin’s views on modernism as elitist hokum may have been coloured by his modest upbringing.⁵
Cronin is a “popular” writer in the sense that his stories are told clearly, using traditional techniques of plot and character development. He wrote for the “ordinary” reader, not the critics. The moral of the books is clear, there is no ambiguity. The major influences on his work were his experiences as a doctor and his Catholicism. His heroes are usually doctors or priests, but he is frequently critical of the medical establishment and the church. His doctors and priests are flawed, falling prey to temptation, wandering away from their vocation, but in the end, with “a twitch upon the thread” drawn back to the true path. The later novels usually feature a strong love-interest, and this may have led to some genre-confusion. By the 1970s, (when I first read them) the marketing of Cronin’s books was perplexing. The paperbacks had badly-drawn cover illustrations, frequently in the style of a trashy romantic novel. Cronin’s novels could, in later years, have easily fitted into the Romantic Fiction section. The books were not sold as serious books, in the way Gollancz had first marketed The Citadel. (Significantly, the dust-jackets of the novels in the 1930s announced the author as “Dr Cronin”). Despite this publishers’ neglect, Cronin was still a high-profile presence on television: The Stars Look Down was serialized in 1974, and The Citadel in 1960 and again in 1983. Dr Finlay dusted down his black bag for a new series in the 1990s. Two further television adaptations of The Citadel were made in Italy in 1964 and 2003, and at three Indian films were based on the novel: Tere Mere Sapne (Hindi, 1971), Jiban Saikate (Bengali, 1972) and Madhura Swapnam (Telugu, 1982). Most of the books are no longer in print.
Enduring influence of The Citadel
Did The Citadel really have such an influence on the foundation of the NHS? It is difficult to judge. Manson considers, then rejects, some form of nationalized health-care: “It’s the system, he thought savagely, it’s senile. There ought to be some better scheme, a chance for everybody – say, oh, say State control! Then he groaned, remembering Doctor Bigsby and the Mining Fatigue Board. No, damn it, that’s hopeless – bureaucracy chokes individual effort – it would suffocate me”. The book describes a severely dysfunctional medical system, was a massive international best-seller, was adapted into a successful film, and, published shortly before World War II, was perfectly timed. I think we can cautiously conclude that it did significantly colour the views of the millions who read the book and saw the film: the 1938 Gallup poll clearly identifies the impression The Citadel made on its readers. The book also inspired many young people to pursue a career in medicine, including such unlikely students as Giorgio Armani. Did Cronin intend the book to be a rallying call for a nationalised state-controlled health service? I have my doubts. Shortly before the book was published, he wrote to Victor Gollancz: “It’s the best you’ve ever read. Also don’t forget it has a thesis. There’s a purpose close behind me and it’s treading on my tale”. What exactly was the “thesis”? The clear thrust of the book is that doctors should practice scientific, evidence-based medicine, that they should maintain and update their skills and knowledge, that they should work in partnership with each other, that the divide between GPs and hospital doctors should be broken and that the profit motive should be taken out of medicine. Cronin was a man of his time, a typical progressive of the 1930s. He believed in science. World War II saw the triumph of science and technology, and the British public, exhausted and beggared by the long conflict were ready for change.
Pressure for reform of the health service had been brewing for some years by the time of the publication of The Citadel. Lord Dawson of Penn (who else?) had produced a report on health reform as far back as 1920⁴. Further reports appeared in the 1930s: from the BMA in 1930, and by the Political think tank Political and Economic Planning in 1937. The Second World War, however, was the catalyst that finally brought about change. Noel Annan observed in Our Age: “During the war people had observed the decencies of equal treatment…..As in war, no queue-jumping. Accept your rations”¹⁷. The speedy creation of an emergency medical service during the war showed that a national system of health-care could be eastablished, and with popular support, could and would work. The Beveridge report in 1942 famously declared war on the “five giants”: want, disease, squalor, ignorance, idleness. Following Labour’s victory in 1945, Clement Atlee boldly appointed Aneurin Bevan as Minister of Health. Bevan was born in Tredegar, and had started his working life as a miner. As we have seen, his experience of health care growing up in Tredegar made a profound impression on him. Bevan, a ferocious auto-didact, overcame a stammer to become an orator the equal of Churchill. He had charm, flair and energy. Bevan was politically very much a man of the Left, but knew he would have to compromise to achieve the goal of a nationalised health service. He overcame opposition from the BMA, and shrewdly engaged as his adviser Lord Moran, Churchill’s personal physician and quondam President of the Royal College of Physicians. Bevan gave generous salaries to hospital consultants – he famously “stuffed their mouths with gold” – and allowed them to continue private practice. GPs would work as independent contractors paid by the state. All GP, dental and hospital care would be free. The medical profession which had proved so resistant to change quickly became the greatest champions of the new service. AN Wilson – hardly a leftist – wrote of Bevan: “He deserves the laurel crown as the British politician who did least harm and most good”¹⁸.
The Citadel is thus a good bad book, or a bad good book, depending on one’s perspective. It is undeniably, however, a serious book. The prose is plodding, and it lacks wit, but only Cronin, with all his limitations as a writer, could have written it. It is difficult to conceive of a version of The Citadel written by Graham Greene or Evelyn Waugh. Re-reading The Citadel and Adventures in Two Worlds, I am struck by one thing: Cronin’s readability. The books, for all their faults, have this indefinable quality. He was undeniably a gifted story-teller. And Cronin appeals to our better nature. One finishes a Cronin book with a faintly warm, sentimental glow, feeling a slightly better person. Cronin’s books contain no ambiguity, no irony, no mockery. The Citadel is still worth reading today.
References

1. 
   Cronin AJ. The Citadel, London: Gollancz; 1937.
   
2. 
   Samuel R. North and South. London Review of Books 1995;17(12):3-6.
   
3. 
   Cronin AJ. Adventures in Two Worlds. London: Gollancz; 1952.
   
4. 
   Rivett GC. From Cradle to Grave, the first 50 years of the NHS. London: King’s Fund and www.nhshistory.net
   
5. 
   Davies A. A.J. Cronin: The man who created Dr Finlay. Richmond, Surrey: Alma; 2011.
   
6. 
   McKibbin R. Politics and the Medical Hero: A.J Cronin’s The Citadel. English Historical Review 2008;CXXIII(502):651-678.
   
7. 
   Eyles L. TLS, 14 August, 1937.
   
8. 
   www.60 yearsofnhsscotland.co.uk
   
9. 
   Frederick JT. A.J. Cronin. The English Journal 1941;30(9):701-709.
   
10. 
    Hastings S. The Secret lives of Somerset Maugham. London: John Murray; 2009.
    
11. 
    Shields D. Reality Hunger: a manifesto. New York: Knopf; 2010.
    
12. 
    Surawicz B, Jacobson B. Doctors in Fiction: Lessons from Literature. Oxford: Radcliffe; 2009.
    
13. 
    Cronin AJ. The Judas Tree. London: Gollancz; 1961.
    
14. 
    Woolf V. “Middlebrow”. The Death of the Moth and Other Essays London: Hogarth, 1942.
    
15. 
    Williams R. Culture and Society, 1750-1950. New York:Columbia University Press; 1958.
    
16. 
    Hodges S. “Cronin, Archibald Joseph (1896-1981)”. Oxford Dictionary of National Biography Oxford: Oxford University Press; 2004.
    
17. 
    Annan N. Our Age: The Generation That Made Post-war Britain. London: Weidenfeld and Nicolson; 1990.
    
18. 
    Wilson AN. After the Victorians: The World our Parents Knew. London, Hutchinson; 2005.