Through a glass, darkly
ARTHUR FERGUSON MACCALLAN (1872-1955) : TRACHOMA PIONEER
Arthur Ferguson MacCallan in 1923
The cover shows MacCallan at Menouf camp, 1904
Ophthalmia in Egypt
Ophthalmia (a term relating to the inflammation of the conjunctivae; this includes trachoma, a contagious disease caused by bacterial infection), had blighted the people of Egypt and the Holy Land for many centuries. In his 1923 Ophthalmic Report, Arthur recorded that, even then, over 95 per cent of the Egyptian population (some 13 million people) were affected by various forms of eye disease. He also estimated in the early 1900s that between 7 to 10 per cent of the population were blind in one or both eyes.
The Cassel Trust Fund
The initiative to address the plague of ophthalmia had its roots in early 1900 when Sir Ernest Cassel (1852-1921), the financier and philanthropist, became involved with the construction of the first Aswan Dam (1898-1902). Recognising the extent of ophthalmia among the vast workforce, in 1902 he established a Trust Fund of £40,000 to ‘teach the principles of ophthalmic surgery to Egyptian surgeons’. This Trust Fund, sufficient to build between six to eight permanent ophthalmic hospitals at that time, was managed by a committee under the Chairmanship of Lord Cromer (1841-1917), the British Consul in Egypt (1883-1907). As a first step, this committee decided to establish an experimental travelling ophthalmic hospital (TOH) similar to those which had been used so successfully in Russia and Hungary. As someone was required to manage this initiative, the committee approached Moorfields for a suitable candidate.
In 1902, MacCallan was practising at the Royal London Ophthalmic Hospital (Moorfields). MacCallan had been educated at Charterhouse (1886-1891), Cambridge University (1891-5) and qualified as a medical practitioner. From there he went to St Mary’s Hospital (1895-1900). He was then appointed as House Surgeon at Moorfields (1900-03). In 1903, he resigned from Moorfields, through exhaustion, but was retained as an unpaid chief clinical assistant. A chance remark, overheard by one of the ward Sisters, led to MacCallan being approached, then appointed as the Travelling Ophthalmic Inspector. Arthur was delighted! He later wrote that this ‘glorious opportunity seemed to transcend even my dreams’. He arrived at Port Said in July 1903.
MacCallan operating in the desert, Menouf, 1904
MacCallan’s initial inspection and first TOH
MacCallan’s first task was to familiarise himself with local conditions; to do this he toured the Nile Delta to assess the extent of ophthalmia amongst the local population. This provided him with a first-hand insight as to the extent of the plague of ophthalmia in Egypt. Later that year, the first TOH was established at Menouf in the Nile Delta and, in January 1904, began treating patients, ‘free for the poor’. MacCallan’s volume of work was enormous and was conducted in harsh conditions, including heat, sand, flies, lice and ‘mosquitoes as big as sparrows, very bony and strong’. During the first quarter of 1904, he treated 6157 patients and performed 615 operations. These operations were mostly for malposition of the eyelids as a result of trachoma or as the result of badly performed operations by quack-doctors. Where anaesthetics were required, opium, cocaine or chloroform were used; in some cases, where anaesthetics were unavailable, patients might still insist that the appropriate operation be performed, so great was their desire for the restoration of their sight. This was, of course, the era before antibiotics. So successful was the first TOH, and so great the demand for treatment, that in 1904 Cassel funded a second TOH which was initially based at Fayum. These TOHs were also to play a critical role during the Great War, discussed below.
Developing an ophthalmic strategy for Egypt
These early investigations and experiences led MacCallan to conclude that ophthalmic resources in Egypt were just ‘a drop in the ocean’. To address this, he developed a bold long-term strategy for ophthalmic care. First, he planned to ‘create a stable central ophthalmic administration’ which included training of doctors in ophthalmic surgery. Second, that at least one permanent ophthalmic hospital should be established in each of Egypt’s fourteen provinces. Third, in order to reduce the incidence of ophthalmia, particularly in schools, it was essential to introduce an educational programme in ophthalmic hygiene. Fourth, the TOH scheme should be extended throughout the country as it would bring substantial economic benefits.
Results of the ophthalmic campaign
MacCallan attacked this huge challenge with determination and a clear vision as to what was needed to ease the suffering of the local population. His seminal work on trachoma included research (MacCallan Classification), surgery and medication (relief/cure), hygiene education (prevention) and securing increased funding (sourced from Government, local councils and wealthy individuals) for developing the hospital infrastructure. Over the next twenty years, he established twenty-three ophthalmic hospital units, including five TOHs, attending to 1.5 million patient visits and performing 76,000 operations. Furthermore, he trained some 100 surgeons to resource the expanding hospital network. MacCallan also founded the Memorial Ophthalmic Laboratory, Giza (now known as the Memorial Institute for Ophthalmic Research (MIOR), Giza), which he considered ‘the coping stone of my work’. It is a testament to MacCallan’s foresight and determination that almost all of the permanent hospitals (e.g. Fayum) and the MIOR continue to play a pivotal role in ophthalmic care and research in Egypt today.
Through sheer determination and focus, MacCallan achieved his self-imposed goals. Indeed, in November 1923, he wrote that the hospital infrastructure ‘form a unique organisation in the medical history of the world’. However, he was too well aware that so much more needed to be done to avoid ‘the incredible misery which is caused by the ravages of various forms of ophthalmia’.
Reconstruction of the St John of Jerusalem Ophthalmic Hospital
During the Great War, under MacCallan’s leadership, the TOHs were converted for military use in 1915 to treat the sick and wounded from the military campaigns at the Suez Canal, Gallipoli and Salonika. The largest ‘hospital under canvas’ was initially based in Alexandria with 200 beds; in October 1915 this moved to Giza and was expanded to 650 beds. The Director of Medical Services, Egypt Command, officially described MacCallan’s hospitals as ‘a model of what a war hospital under canvas should be.
In 1916, the Military had no further need for the ophthalmic hospitals so MacCallan returned to research, teaching and building hospitals. However, he was still to be required by the Military as, in 1918, he was ordered by General Allenby, who was in charge of the British Egyptian Expeditionary Force in Palestine, to inspect the St John of Jerusalem Ophthalmic Hospital and make recommendations for its reconstruction. This hospital had been occupied by the Turkish army to store ammunition and badly damaged by them on their retreat from Jerusalem in 1917. According to Sir Ronald Storrs, then Military Governor of Jerusalem, he found the hospital ‘in a pitiful state’.
MacCallan’s expert credentials in constructing and administrating ophthalmic hospitals were well recognised. By 1917, he had been instrumental in building thirteen permanent hospitals in Egypt. This had given him huge experience negotiating with professional engineers, qualified architects and draftsmen required to construct an efficient, bespoke, ophthalmic hospital. He was also well versed in dealing with Provincial Councils and their planning processes.
MacCallan left Cairo on 22 February 1918 travelling to Jerusalem by train; lorry, overcrowded with Australian troops; a Ford car regularly overheating until he arrived at Fast’s Hotel outside the City wall. He stayed in Jerusalem for four days, liaising with the Military Governor and making plans for the reconstruction of the St John of Jerusalem Ophthalmic Hospital. Twelve months later, in February 1919, Allenby opened the reconstructed hospital.
The renovated St John of Jerusalem Ophthalmic Hospital was captured on canvas in David Bomberg’s 1927 painting. In 1940, MacCallan was invested as an Officer of the Order of St John in recognition of his services to ophthalmology.
The MacCallan Classification of the stages of trachoma
MacCallan is best known within the international ophthalmic profession for developing the world-famous MacCallan Classification of the stages of trachoma; from 1905, he used this for his own internal analysis. In 1936, he published his seminal work, Trachoma. In 1952, the World Health Organisation (WHO) adopted the MacCallan Classification as its then standard. While the WHO grading system has subsequently been redefined, the MacCallan Classification acted as a foundation on which others could build.
Recognition of MacCallan’s work in Egypt
In recognition of the moral significance of MacCallan’s dedicated commitment in battling the plague of ophthalmia, the Egyptians accorded him the rare privilege, particularly as a foreigner, of dedicating a commemorative bust in his honour. This was unveiled in 1931 and remains on display inside the MIOR. The Egyptians shared the sentiment expressed by Lord Cromer in December 1914 when, in a letter to MacCallan, he wrote: ‘I regard the campaign against ophthalmia as one of the most important and useful works undertaken in Egypt’.
Recognition of MacCallan’s work today
There has recently been a revival of interest in MacCallan’s work, particularly given resonance by the current WHO initiative to eliminate trachoma worldwide. In 2014, the International Coalition for Trachoma Control (ICTC) inaugurated the ICTC MacCallan Medal, to celebrate their tenth anniversary. Then, in 2018, the National Centre for Translation (NCT), part of the Egyptian Ministry of Culture, requested permission to translate Light out of Deep Darkness into Arabic. This is a rare honour, recognising MacCallan’s significant contribution to Egyptian society over a century ago. The publication date is scheduled for late 2019.
Thus, MacCallan’s exceptional skills, his pioneering spirit, his humanitarian campaign for the relief of suffering and his many accomplishments, continue to resonate with, and be recognised by, the international medical and ophthalmic profession today.