My research diary – The Citadel by AJ Cronin

20th October 2017

I’ve started reading the eBook I bought earlier. It is cited as being influential in the setting up of the NHS.

Published in 1937, I am hoping it will give me an insight to conditions before the 1940s. AJ Cronin knew what he was talking about:

“Born in Cardross, Scotland, A. J. Cronin studied at the University of Glasgow. In 1916 he served as a surgeon sub-lieutenant in the Royal Navy Volunteers Reserve, and at the war’s end he completed his medical studies and practiced in South Wales. He was later appointed to the Ministry of Mines, studying the medical problems of the mining industry.”

Cronin, A. J.. The Citadel (Bello) (p. 2). Pan Macmillan. Kindle Edition.

I also discovered that there is a 1938 film, so I watched it.

The story begins with a newly qualified doctor (Andrew Manson) arriving for his first assistant post in a mining community in Wales. The doctors’ sister (Blodwen Page) explains that the Mine has 3 doctors on its list, of which her brother is one. The miners have money deducted from their wages to cover medical costs. This money is paid to the doctors according to how many patients they have registered with them. But Andrew discovers that Dr Page is bedridden and he is expected to run the practice alone. The fees from the miners are given to Blodwen Page and Andrew works as a doctor on the salary of an assistant.

Dr Denny, the assistant  of a rival doctor, describes the conditions:

“There’s no hospital, no ambulance, no X-rays, no anything. If you want to operate you use the kitchen table. You wash up afterwards at the scullery bosh. The sanitation won’t bear looking at. In a dry summer the kids die like flies with infantile cholera.”

Cronin, A. J.. The Citadel (Bello) (pp. 13-14). Pan Macmillan. Kindle Edition.

After working for Doctor Page for a month, Andrew discovers the reality of healthcare in Britain:

“Denny at first had aggravated him intensely by his weary contention that all over Britain there were thousands of incompetent doctors distinguished for nothing but their sheer stupidity and an acquired capacity for bluffing their patients. Now he began to question if there were not some truth in what Denny said.”

Cronin, A. J.. The Citadel (Bello) (p. 28). Pan Macmillan. Kindle Edition.

Andrew and Denny discover an outbreak of Typhoid Fever, and they identify the source as being a well. The two of them advise all of their patients to boil the water before drinking it, and with treatment the epidemic comes under control. But their efforts to deal with the source come to nothing:

“It’s the main sewer that’s to blame. It leaks like the devil and seeps into half the low wells at the bottom of the town. I’ve hammered at Griffiths about it till I’m tired. He’s a lazy, evasive, incompetent, pious swine.”

Cronin, A. J.. The Citadel (Bello) (p. 21). Pan Macmillan. Kindle Edition.

There is an interesting section of the book which didn’t make the film. It is about a suspected case of madness. One of the miners had been:

“acting strangely lately, getting into trouble at the mine, losing his memory. He had turned quarrelsome and violent. ‘I don’t like it, Manson.’ Bramwell nodded sagely. ‘I’ve seen mental trouble before. And this looks uncommonly like it.’”

Cronin, A. J.. The Citadel (Bello) (p. 58). Pan Macmillan. Kindle Edition.

The patient had set upon his wife with a bread knife and Andrew receives a note asking him to attend as two signatures were needed to “certify a lunatic”. Andrew attends the patient and examines him:

“He went over to Emlyn and at first he hardly recognised him. The change was not gross, it was Emlyn true enough, but a blurred and altered Emlyn, his features coarsened in some subtle way. His face seemed swollen, the nostrils thickened, the skin waxy, except for a faint reddish patch that spread across the nose. His whole appearance was heavy, apathetic. Andrew spoke to him. He muttered an unintelligible reply. Then, clenching his hands, he came out with a tirade of aggressive nonsense, which, added to Bramwell’s account, made the case for his removal only too conclusive. A silence followed. Andrew felt that he ought to be convinced. Yet inexplicably, he was not satisfied. Why, why, he kept asking himself, why should Hughes talk like this? Supposing the man had gone out of his mind, what was the cause of it all. He had always been a happy contented man – no worries, easy going, amicable. Why, without apparent reason, had he changed to this!”

Cronin, A. J.. The Citadel (Bello) (p. 60). Pan Macmillan. Kindle Edition.

Andrew diagnoses thyroid deficiency and after successful treatment the patient is returned to his former self.

After a while Andrew has an argument with Miss Page over money. His frustrations about his assistant status lead him to give notice and leave the practice. He finds a post as a qualified doctor and applies for it. He is interviewed by a committee which is made up of medical experts and miners:

“About thirty miners filled the room, seated, and all of them smoking, gazing at him, with blunt, but not unfriendly curiosity. At the small side-table was a pale quiet man with a sensitive, intelligent face who looked, from his blue pitted features, as if he had once been a miner. He was Owen, the secretary. Lounging on the edge of the table, smiling good naturedly at Andrew, was Doctor Llewellyn. The interview began. Owen, in a quiet voice, explained the conditions of the post. ‘It’s like this you see, doctor. Under our scheme, the workers in Aberalaw – there are two anthracite mines here, a steel works and one coal mine in the district – pay over a certain amount to the Society out of their wages every week. Out of this the Society administers the necessary medical services, provides a nice little hospital, surgeries, medicines, splints, etcetera. In addition the Society engages doctors, Doctor Llewellyn, the head physician and surgeon, and four assistants, together with a surgeon dentist, and pays them a capitation fee – so much per head according to the number on their list. I believe Doctor Leslie was making something like five hundred pounds a year when he left us.’ He paused. ‘Altogether we find it a good scheme.’ There was a mutter of approval from the thirty committee men.’”

Cronin, A. J.. The Citadel (Bello) (pp. 96-97). Pan Macmillan. Kindle Edition.

Andrew accepts the job offer and the house that goes with it, on the understanding that he is engaged to be married. The miners prefer a married man attending their wives and daughters. Andrew proposes to his girlfriend and is able to take up the position of GP with immediate effect.

To be continued………….

Observations

If this is based in truth, it seems that the system is inadequate. The miners, or shall we say the end users, seem to have too much influence in the running of the practice. Andrews employer, Dr Page, is kept on as a GP despite the fact that he is unable to perform his duties. This is the result of his patients loyalty allowing him to stay on the company books. This in turn affects the status and pay of Andrew who is running the practice alone but not receiving the financial reward or professional recognition for doing so. There is also the possibility that Dr Page and his sister rely on the fees from the mining company and would not have the financial means to retire.

There are a lot of examples of incompetence by doctors and Public Health representatives. I have also picked up a sense that most of the GPs either don’t know or don’t care about the symptoms of their patients and are happy to fob them off with ineffectual remedies. There seems to be an attitude of “things have always been done this way, why change now?”. This distrust of new methods becomes more apparent later in the book.

Till next time.


As a footnote, the father in law of my Great Aunt was a doctor and surgeon from the late 1880s. He died in 1938. So I’ll see what I can find out about his career. The information I have at the moment suggests that he had a surgery in Yorkshire and also worked at the hospital. He left £21, 267 12s 11d to his daughter. The equivalent value is about £610,000. They were wealthy enough to have a governess, a cook and a private nurse (I’m not sure if she was just for the family or whether she also worked in the practice) and they could afford to go to Australia for a holiday (I think there were relatives there).

 

 

 

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