My life in relation to the history of tuberculosis by Kenneth Citron MD FRCP
Kenneth Citron MD FRCP
I was born in 1925. At that time tuberculosis, TB, was a major killer in Britain. About 80,000 cases were diagnosed every year, and well over half of them died. There was no effective cure.
In 1943 I became a medical student at Guy`s Hospital London where there were many patients suffering from TB. Some of the lecturers there were short of breath due to lung damage from old TB. BCG vaccination was developed 20 years before but was not routinely given to medical students and so we were unprotected. The war ended in 1945. Several young doctors from Guy`s went to care for people in the liberated concentration camps. One doctor caught TB there and died of it soon after.
In 1948 I qualified in my final examinations and was the only one in my group of students to be awarded honours in medicine by the University of London. 1948 was an auspicious year, the start of the National Health Service about which we young doctors were very enthusiastic. I had the privilege of being awarded a House Physician post on the medical wards at Guy`s. When I finished this appointment I felt unusually tired. A friend of mine insisted that I had a chest X-ray. It showed that I had pulmonary TB. I was devastated because there was no certain cure. I thought my promising career was finished. I resisted advice to have an Artificial Pneumothorax which when working in chest clinics I had seen cause grave complications.
In 1946 a small supply of streptomycin arrived from USA. The British Medical Research Council undertook a controlled trial in pulmonary TB. It was a ground-breaking study. Bradford Hill`s statistical analysis was the gold standard for future studies. The committee consisted of Phillip D`Arcy Hart and Guy Scadding. Dennis Mitchison did the Microbiology and John Crofton coordinated the clinical side. These men, together with Wallace Fox, were world leaders in the fight against TB. I knew them well. They all had long active lives surviving into their 90s, Dennis to 100 and Phillip to 107. The study showed that streptomycin cured 10% of TB patients but 90% failed and developed resistance to the drug. This triggered the search for other antibiotics which given together with streptomycin would prevent resistance.
I elected to try rest, relaxation and good food and sea air in a flat in Broadstairs under the devoted care of my mother in order to build up my natural resistance. After one year of this treatment I appeared to have recovered and started light medical work. It was this personal experience that stimulated my professional interest in TB.
In 1953 I was appointed a Registrar at the Royal Brompton Hospital. I was fortunate to be attached to the firm lead by Guy Scadding, a brilliant and kind physician who had developed the academic and research activities of the hospital work. He was my inspiration and had a major influence in stimulating my medical enthusiasm.
The Brompton had been founded as a charitable institution in the 19th century for the treatment of consumption (TB). At that time TB killed a third of the population aged under 50 years in the UK, and consumptive patients were not admitted to General Hospitals. My work in the Brompton in 1953 consisted mainly in the care of tuberculous patients. The Brompton Sanatorium was situated near the pine woods at Frimley. I found my visits there emotionally moving and unforgettable seeing so many young people whose lives hung in the balance. Treatment consisted of bed rest, fresh air, gradual mobilization and strict self-discipline. Many patients had remissions and suffered relapses and spent their lives in and out of sanatorium care. One did not speak of cure. Having TB was a lifelong occupation Artificial pneumothorax (AP) was a popular treatment at that time consisting of injecting air around the lung to collapse and rest it. There were no available studies to show this was effective. Working in AP Clinics I observed that serious complications were frequent. Major surgery to remove diseased lung was usually ineffective and often mutilating. During the 1950s new anti-TB drugs were discovered; PAS, isoniazid, pyrazinamide and rifampicin.
I was appointed consultant respiratory physician at Brompton in 1959. Much of my work thereafter was devoted to research in TB and developing TB services worldwide:
- In the 1970s I was chairman of the Research Committee of the British Thoracic Society doing trials of various durations and drug combinations for TB therapy in the UK. I became involved in worldwide studies with Wallace Fox, director of the Medical Research Council Tuberculosis. It was difficult to get patients to take unpleasant drugs for years. We observed multiple drug resistance emerging among patients who did not take their drugs regularly.
- I was involved in international studies of various regimens finally reducing the duration to 6 months, either self-administered or given intermittently under supervision.
- I travelled widely including India, Africa Hong Kong helping to set up TB services. TB was becoming a 3rd world problem.
- I became advisor to the Department of Health and was particularly involved with the BCG scheme started in the early 50s and shown to be highly effective.
The MRC TB unit was disbanded in the 1980s. I argued strongly against this because TB remained a major world killer and UK should continue to contribute to defeating it. In the 1990s it was thought likely that TB would be eradicated from UK. TB was becoming a forgotten disease. In 1993 the World Health Organisation declared TB to be a global emergency compounded by the HIV Aids epidemic and widespread multiple drug resistance. In HIV infected people TB frequently caused death within 3 months of infection. In UK TB rates began to rise particularly in cities and among immigrants.
The charity TB ALERT was founded in 1998 by Sir John Crofton, Peter Davis myself and others to raise awareness of the threat of TB in UK and worldwide and assist in its control.
I retired as a physician at the Brompton in 1990 but remained busy in TB teaching and research. Between 1992 and 1994 I worked with the homeless on the streets of London in association with the charity Crisis. I surveyed them for TB and found a TB rate 200 times that of the general population. In a survey of London boroughs done later after publication of the report I found that control measures were woefully inadequate. In 2018 there has been a great increase in homelessness in London.
I remember my discussions with my friend Sir John Crofton who had succeeded in virtually eliminating TB from Edinburgh, previously a high prevalence city. We thought it feasible that eventually TB could be eliminated worldwide. I am now 93 years old but I remain enthusiastic and hope that new research and effort will eventually defeat once and for all this great scourge of human kind.