Arrowsmith and The Citadel

Two novels: Sinclair Lewis’s Arrowsmith (1925)[Reference 1] and A.J. Cronin’s The Citadel (1937)[Reference 2] describe the careers of idealistic young doctors. Both illustrate the frustrations of young men whose devotion to science is threatened in their era, with its roots in nineteenth century medical practice, roots that had not yet withered. Both novels are important to the history of health, in similar but different ways. Arrowsmith’s hero, Dr. Martin Arrowsmith, and The Citadel’s hero, Dr. Andrew Manson, show us problems that are relevant today. As Mark Twain is claimed to have said, “History doesn’t repeat itself, but it often rhymes.”

According to medical historian Charles Rosenberg, Arrowsmith was the first novel in which the hero was a scientist.[Reference 3] The travails of the novel’s hero, Martin Arrowsmith, illustrate the triumphs of modern medicine and public health, specifically those related to the germ theory. His progress through a series of career challenges was an inspiration for a generation of future doctors.[Reference 4] Although this 1925 novel is attributed to Sinclair Lewis, it was co-written with the bacteriologist Paul de Kruif. Before the publication of his previous novel Babbitt (1922), Lewis was already thinking about the possibilities of a new type of hero. His initial thoughts focused on Eugene Debs, who was so important to the American labor movement, but Morris Fishbein, editor of JAMA, pointed him to Paul de Kruif, who helped him create Martin Arrowsmith.[Reference 4]

As historian Charles Rosenberg put it, “Martin Arrowsmith’s professional biography is a record not only of a confused and easily misled young man toward emotional and intellectual fulfillment; it is a recapitulation in one man’s life of the development of medicine in the United States. Each stage of Arrowsmith’s career corresponds to a particular stage in American Medicine.”[Reference 3] Arrowsmith illustrates a history of the late-nineteenth to early twentieth-century embrace of scientific medicine. Martin Arrowsmith’s mentor, the European medical scientist Max Gottlieb is based on the scientific ethos of the German-born American physiologist and biologist Jacques Loeb.[Reference 3]

Sinclair Lewis would eventually receive the 1930 Nobel Prize in Literature, largely because of Babbitt (1922). Paul De Kruif would go on to write the hugely influential Microbe Hunters (1926), a collection of quickly-drawn portraits of important medical scientists. Many of deKruif’s brief biographies would become the basis for popular Hollywood films, such as “The Story of Louis Pasteur” (1936), “Dr. Ehrlich’s Magic Bullet” (1940), and “Madame Curie” (1943).

In contrast, A.J. Cronin, who wrote The Citadel (1937) needed no help with medical science. He was both a physician and a novelist. Each stage of hero Andrew Manson’s career as a physician employed in the care of coal mine workers increases his professional capacity. Through long hours of hard work, including spare-time scientific research, he builds his professional qualifications. He is frustrated with the organization that should — but fails — to realize its science-based responsibilities for its coal mine workers. So he creates a private medical practice that becomes financially successful but spiritually empty. Finally, influenced by his wife Christine’s constant grounding in doing what is simple and right, he sees that his proper work ought to be aimed toward a group medical practice that places science above commercialism, and the wellbeing of patients above the profits of a sclerotic medical system.

The Citadel is widely held as the model for the British National Health Service. Although many American presidents wanted a national health system, influential political bodies (representing doctors, hospitals, and pharmaceutical companies) were successful in opposing it.[References 5,6,7]In 1925, when Arrowsmith was published, the Great Depression had not yet occurred. In 1937, when The Citadel was published, the full weight of the Great Depression gave resonance to its economic arguments. Two years later, Hitler would invade Poland. The postwar Marshall Plan would provide financial support for the British National Health Service.[Reference 8] In 1948, when President Harry Truman was campaigning for election (he had succeeded FDR in 1945), he argued for the importance of a national health system, pointing out that more American lives had been lost to the lack of proper medical care than had been lost throughout World War II; he said “This is not socialized medicine. It’s plain American common sense!”[Reference 9] In our current political moment, Truman’s argument and The Citadel’s theme still have resonance.

Dr. Andrew Manson’s constant scientific research concern is the potential danger of coal dust inhalation in the mines. A.J. Cronin had already worked as a physician in coal-mining communities, and he had researched the correlation between coal dust inhalation and lung disease. The novelist’s concerns were well founded. The National Library of Medicine’s (NLM’s) name, or Medical Subject Heading (MeSH), for the disease is “anthracosis,” which the NLM defines as “A diffuse parenchymal lung disease caused by accumulation of inhaled carbon or coal dust. The disease can progress from asymptomatic anthracosis to massive lung fibrosis. This lung lesion usually occurs in coal miners, but can be seen in urban dwellers and tobacco smokers.” Our hero’s additional concern was the possibility that the disease might predispose its victims to tuberculosis. His concerns were prescient: A recent PubMed search using the strategy (“Anthracosis”[Mesh]) AND “Tuberculosis”[Mesh]) turned up more than 100 citations.

Both novels showcase the efficacy of scientific medicine as applied by their respective young heroes. Both novels are relevant today, when we must grapple with similar questions: How is scientific knowledge created? How can the public understand it? Who pays for scientific research and its application as useful pharmaceuticals? Today, as in the past, scientific knowledge and the politics of health are in conflict. As William Faukner once put it, “The past is never dead. It’s not even past.”

References

1. Lewis S. Arrowsmith. New York: Signet; 1988.
2. Cronin AJ. The Citadel. Boston: Back Bay Books; 1983.
3. Rosenberg C. Martin Arrowsmith: the scientist as hero. In: No other gods: on science and American social thought. Baltimore: Johns Hopkins University Press; p. 123–31.
4. Markel H. Reflections on Sinclair Lewis’s Arrowsmith: the great American novel of public health and medicine. Public Health Rep Wash DC 1974 2001;116(4):371–5.
5. Starr P. The social transformation of American medicine. New York: Basic Books; 1982.
6. Stevens R. In sickness and in wealth: American hospitals in the twentieth century. New York: Basic Books; 1989.
7. Fox DM. Power and illness: the failure and future of American health policy. Berkeley: University of California Press; 1993.
8. Judt T. Postwar: a history of Europe since 1945. New York: Penguin Press; 2006.
9. Blumenthal D, Morone JA. The heart of power: health and politics in the Oval Office. Berkeley: University of California Press; 2009.