b.25 June 1900 d.30 July 2006
CBE(1956) BA Cantab(1922) MB BChir(1925) MRCP(1926) MA(1926) MD(1930) FRCP(1936)
Philip Montagu D’Arcy Hart’s life spanned the entire twentieth century and his work contributed to many of the transformations in medicine and medical research that characterised that century. He became a skilled physician before the second world war at a time when therapeutic interventions were extremely limited; he then developed a considerable reputation for pioneering epidemiological research and clinical trials, at a time when such a career was comparatively rare; and after his first retirement in 1965 from the directorship of the MRC’s Tuberculosis Research Unit he devoted his considerable intellectual energies entirely to laboratory work on the tubercle bacillus. He continued to work until the age of 102, and published his final paper when he was 104.
Hart came from a family prominent in politics and finance. His father, Henry D’Arcy Hart, was a qualified barrister who became an artist, and his mother was the Honourable Ethel Montagu, daughter of Samuel Montagu, later the first Baron Swaythling, a former Liberal MP and founder of a merchant bank. After attending Gibbs Preparatory School in London and Clifton College in Bristol, Hart went up to Gonville and Caius College, Cambridge, and finished his medical training at University College Hospital London (UCH). After qualification in 1925 he served as house physician at UCH to Wilfred Trotter [Munk’s Roll, Vol.XI, p.582], and gained the MRCP the following year. In 1930 he won the Horton Smith prize for his Cambridge MD.
In the 1920s Hart’s professor of medicine, Sir John Rose Bradford [Munk’s Roll, Vol.IV, p.391], taught that there was only one disease, scurvy, that could be cured medically. This encouraged Hart to try his hand at research and he joined the medical unit at UCH, which had recently been established by the Rockefeller Foundation. He spent a year, from 1934 to 1935, in the United States at the Rockefeller Institute on a Dorothy Temple Cross fellowship, and returned to UCH as a consultant physician, which also brought the possibility of a lucrative private practice. In 1932 Hart wrote a Medical Research Council (MRC) report on tuberculin testing in man, and the noted UCH cardiologist Sir Thomas Lewis [Munk’s Roll, Vol.IV, p.531], who was a member of the MRC, subsequently suggested that he investigate coal miners’ diseases. This was the pivotal point in Hart’s career between clinical practice and medical research. He was offered a three year fellowship, but Lewis protested to the MRC that it was inappropriate to offer a short contract to a man with a profitable clinical career ahead of him. The MRC immediately offered Hart a rare staff position, which he accepted. His departure from UCH was, he always believed, never forgiven, and even in his final years he would comment on the fact that he had never been invited back to give a lecture.
Thus in 1937 Hart began an association with the MRC that lasted for 65 years. From 1948 until 1965 he was director of the MRC’s Tuberculosis Research Unit (TRU), and upon retirement he worked at the MRC’s National Institute of Medical Research (NIMR) until 1993, after which he continued to work there informally as an attached worker until 2002.
In 1936 the MRC was asked by the Home Office and the Mines Department to investigate chronic pulmonary disease among coalminers, particularly in the south Wales coalfields. There was increasing dissatisfaction that coal face workers in anthracite fields were frequently incapacitated by a lung disease, pneumoconiosis, for which they were not compensated, although rock workers who contracted silicosis were. The MRC’s committee on industrial pulmonary disease proposed a large-scale clinical and radiological examination of coal miners and Hart supervised the medical investigations.
The medical phase started in 1937. A mobile X-ray van travelled up and down the valleys, and Lord Nuffield presented a Morris Minor car to the team. A number of novel problems emerged during the course of the study. One investigation of the relationship between tuberculosis (TB) and pneumoconiosis involved volunteers being tested for TB, for which they were paid a ‘half crown’ (2/6d., 12.5 pence). Those who tested negative had to be re-tested, for which, understandably, they expected a further half-crown, which had not been included in the original budget. An urgent call from Hart to the MRC resulted in a sack of half-crowns being put on an overnight train to Swansea, which ensured the successful completion of the study. A further incident occurred during wartime, when the Morris Minor car broke down. Hart successfully hitched a lift from two Welshmen who needed some persuading that the mysterious stranger they had found was indeed an English doctor working on lung diseases, rather than a German spy parachuted into the Welsh valleys. Once satisfied with his explanation, they generously gave him a bar of chocolate, a rare wartime treat.
The three MRC reports from the study changed the diagnostic criteria of pneumoconiosis and were successful in getting compensation for sufferers, which Hart considered a particularly important triumph. Such work reinforced Hart’s interest in what was becoming known as ‘social medicine’. During the Spanish civil war he had been an active member of the British-Spanish Medical Aid Committee, which supported the republican government. Archie Cochrane’s [Munk’s Roll, Vol.VIII, p.95] autobiography recounts a harrowing triage session at the Escorial Hospital when his friend, the Bloomsbury writer Julian Bell, was brought in severely wounded and he desperately sought advice. Hart, who was visiting the unit, agreed that the wound was severe and Bell’s case hopeless. Virginia Woolf, Julian’s aunt, describes in her diary how Hart, ‘a nice sensitive thin man, an enthusiast’, visited her in Bloomsbury to tell her of Julian’s death. Hart belonged to the Socialist Medical Association for many decades, and served as their refugee secretary during the second world war. In 1939 an informal club called the Committee for the Study of Social Medicine was established, of which Hart was also the secretary. Members included Jerry Morris, Richard Titmuss, John Ryle [Munk’s Roll, Vol.IV, p.595], Max Rosenheim [Munk’s Roll, Vol.VI, p.394], Archie Cochrane and Tom Garland, all of whom became significant figures in post war medicine. They undertook a number of surveys, but unfortunately a bomb during the second world war destroyed the committee’s records, and they decided to disband.
In 1943 the MRC was asked by the Therapeutic Research Corporation, a wartime consortium of British pharmaceutical companies, to conduct a trial of patulin, a seemingly promising treatment for the common cold. A committee was appointed with Hart as secretary, and a trial was designed that treated patients with either patulin or a control (placebo) solution. By rotating allocation to one of two placebo groups and two patulin groups, Hart ensured that neither the patient nor the medical staff knew which ‘treatment’ had been administered. This, and other features of the patulin trial makes it the first well-controlled, multicentre trial conducted under the aegis of the MRC. No beneficial effect of patulin was discerned.
In 1946 the MRC established the Tuberculosis Research Unit, and Hart was appointed director. He also became secretary of another MRC Committee. This was to investigate streptomycin as a TB treatment. Discovered in the USA in 1944, streptomycin had been rapidly accepted without any large scale testing. In post-war austerity, the British government was anxious not to waste dollars on an inadequately evaluated drug. Hart was joined by Marc Daniels, Austin Bradford Hill [Munk’s Roll, Vol.IX, p.234] and Guy Scadding [Munk’s Roll., Vol.XI, p.501] to organise a now celebrated randomised control trial to assess the effects of streptomycin on pulmonary TB. Undoubtedly Hart’s previous experience of the patulin trial influenced the design and conduct of the streptomycin trial, which concluded that streptomycin was indeed a more powerful TB therapy than anything previously available. However, follow up of the patients in the trial revealed the development of bacterial resistance to the drug, and TB was eventually treated successfully only after drug combinations had been introduced.
Later assessments of new treatments have reflected the measures taken to control biases adopted for the streptomycin trial. Hart himself continued to develop the statistical design and analysis of such controlled trials. Work at the TRU and the Chemotherapy Centre, Madras, under the direction of Wallace Fox, also established, against the conventional wisdom of the time, that out-patient chemotherapy for TB could be as effective as hospitalisation, even in malnourished populations.
From 1950 Hart developed and supervised on behalf of the MRC extensive TB vaccine trials, involving almost 60,000 school children. The final report in 1963 provided strong evidence that both BCG (Bacillus-Calmette-Guérin) and vole bacillus vaccines substantially reduced the incidence of TB. In 1954 Hart was a founder member of the Acid Fast Club (after an histological staining technique to identify TB bacilli). Members of the club successfully agitated to convert the journal Tubercle, then a repository for largely uninformative case reports, to a journal for serious scientific research papers. Hart also served on the WHO’s first expert tuberculosis committee from 1947 until 1964.
After his first ‘retirement’ in 1965, Hart shed all his administrative and committee responsibilities and, as an external grant holder at the National Institute for Medical Research, turned entirely to laboratory studies on mycobacterium. He pioneered investigations into cellular mechanisms, such as the stimulation of the macrophage lysosomal system in response to infective agents, and developed new light and electron microscopic techniques to visualise and study the bacterium. In 1993 Hart became an attached worker at the NIMR and continued working there until 2002.
A dry wit made Hart an excellent speaker, although he was increasingly afflicted by deafness. At the College he delivered the Milroy (1937), Mitchell (1945), and Marc Daniels (1967) lectures, in addition to being awarded the Weber-Parkes prize in 1951. In 1941 he married Ruth Meyer, a gynaecologist some years younger, and their son, Oliver Simon, became professor of economics at Harvard University. Both his wife and son survive him.
E M Tansey
[The Independent 24 August 2006; The Times 16 August 2006; Brit.med.J.,2006,333,449; The Guardian 30 August 2006; The Lancet 2006,333,449; Journal of the Royal Society of Medicine Oct 2006; James Lind Library www.jameslindlibrary.org]
(Volume XII, page web)
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