Editorial Arthur Ferguson MacCallan: trachoma pioneer in ...
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Arthur Ferguson MacCallan: trachoma pioneer in Egypt 1903–1923 Michael MacCallan Arthur Ferguson MacCallan CBE, MD, FRCS (1872–1955) was an ophthalmic surgeon who undertook his pioneering work in Egypt between 1903 and 1923 ( figure 1). i He became a world authority on trachoma; the MacCallan Classification of Trachoma, initially published in 1908, was the first grading system used to stand- ardise the diagnosis of trachoma and was later adopted by the WHO. He also estab- lished the ophthalmic hospital infrastructure consisting of travelling and permanent hos- pitals, along with the training of surgeons. This fight to eliminate trachoma continues, with the WHO setting a target date for the Global Elimination of Blinding Trachoma by 2020 (‘GET 2020’). As a contribution to achieving this goal, the International Coalition for Trachoma Control (ICTC) inaugurated the ‘ICTC MacCallan Medal’ ii in 2014. By naming this award after Arthur, it recognises his pioneering spirit and accomplishments which continue to reson- ate with the profession today. The seeds of Arthur’s work were sown when the highly contagious eye-disease trachoma, which had existed in Egypt for centuries, was imposed on the Europeans due to the return of the British and other combatants’ troops to their respective countries after Napoleon’s invasion and subsequent defeat in Egypt (1798–1801). In Britain, this led to the opening, in 1805, of the dispensary for Curing Diseases of the Eye and Ear (‘Moorfields’) to treat the disease. Britain’s further involvement in Egypt increased from 1882, to protect its interest in the Suez Canal, but it was not until the late 1890s, during the construction of the first Aswan Dam, that the financier and philanthropist Sir Ernest Cassel became so shocked at the extent of ophthalmia among the vast workforce iii that, in 1902, he established a trust fund of £E40 000 (equivalent to £4 million today) with the objective of teach- ing ‘the principles of ophthalmic surgery to Egyptian surgeons’. The trustees decided to establish a first, experimental, travelling ophthalmic hospital (TOH) as had been used successfully in Russia. In 1903, Arthur, aged 31 years, was working as an unpaid ophthalmic surgeon at Moorfields. By a stroke of good fortune, which ‘transcended even my dreams’, he was offered the position in Egypt to operate that TOH and teach the Egyptian doctors the appropriate surgical skills. Arthur arrived in Cairo in July 1903. He rapidly concluded that hospital doctors had little knowledge of eye treat- ment but that success of the TOH scheme would be assured, given the potential overwhelming demand for treatment. The first TOH, at Menouf, was opened to patients in January 1904 ( figure 2). Initially, some of the fellaheen were suspi- cious of Arthur’s motives. However, these prejudices were soon overcome by the empathy, skill and professionalism, by which Arthur organised and treated his patients; they could literally ‘see’ the ben- efits of his operations. Demand for treat- ment grew rapidly thereafter. Arthur’s volume of work was enor- mous. During the first 3 months of 1904, at Menouf, he treated 6157 patients and performed 615 operations. Where anaes- thetics were required, opium, cocaine or chloroform were used; in some cases, where no anaesthetics were available, patients might still insist on treatment so great was their desire for sight. This was also the era before antibiotics. Working conditions were harsh with the heat, sand, flies, lice and ‘mosquitoes as big as spar- rows, very bony and strong’. This combin- ation of work and the environment put great strain on Arthur personally and he admitted that ‘the work is now very onerous’ and ‘I don’t know how long I shall be able to stand this sort of life’. Nevertheless, he persevered, recognising the overwhelming need by the population for professional treatment. Indeed, so suc- cessful were the results from the first TOH that, in 1904, Cassel provided the funds for a second one, initially estab- lished at Fayoum. The high incidence of ophthalmia led Arthur to conclude that the availability of treatment at that time was just ‘a drop in the ocean’ even with the second TOH. Thus, a bolder, long-term plan was needed. To address this, Arthur planned to ‘create a stable central ophthalmic administration with the best possible clin- ical and scientific teaching adjuncts’, along with establishing a permanent ophthalmic hospital in each of Egypt’s 14 provinces. Over the next 20 years, Arthur worked tirelessly to achieve his self-imposed goals. Arthur is probably best known among the international ophthalmic profession for his research into and ‘classification of the stages of trachoma’. His initial find- ings were published in 1908 and then further developed in his books Trachoma and its Complications in Egypt (1913) and Trachoma (1936). In 1952, the WHO adopted MacCallan’s Classification as the standard. He was also instrumental in founding the major ophthalmic research establishment at Giza, then known as the Memorial Ophthalmic Laboratory, iv which was formally opened in 1926 ( figure 3) and which is still operational today. Arthur stated that ‘this laboratory was envisaged by me many years before- hand. I got the site, the money for the building, arranged the endowment, and designed the interior, with all detail’. He believed that this Laboratory was ‘the coping stone of my work’. However, in order to treat the numer- ous patients with trachoma and other eye diseases, funding was required. To under- take this successfully, Arthur recognised that it was essential to involve the govern- ment in plans to create and develop an ophthalmic hospital infrastructure. This was achieved when, in 1905, the Egyptian Government took over the administration of the Cassel Fund and started providing funding. Arthur was delighted and noted that ‘the national importance of the Correspondence to Michael MacCallan, 15 Queen’s Gate Gardens, London SW7 5LY, UK; [email protected] i Source: Light out of Deep Darkness: A biography of Arthur Ferguson MacCallan by Michael MacCallan, privately published in 2013. ii This award recognises a current practitioner’s outstanding contribution in eliminating trachoma. iii At that time, it was estimated that some 90% of the population suffered from ophthalmia, with many operations being performed by ‘quacks’. iv Now known as ‘The Giza Memorial Institute for Ophthalmic Research’. MacCallan M. Br J Ophthalmol May 2015 Vol 99 No 5 577 Editorial on November 12, 2021 by guest. Protected by copyright. http://bjo.bmj.com/ Br J Ophthalmol: first published as 10.1136/bjophthalmol-2014-306527 on 26 March 2015. Downloaded from on November 12, 2021 by guest. Protected by copyright. http://bjo.bmj.com/ Br J Ophthalmol: first published as 10.1136/bjophthalmol-2014-306527 on 26 March 2015. Downloaded from on November 12, 2021 by guest. Protected by copyright. http://bjo.bmj.com/ Br J Ophthalmol: first published as 10.1136/bjophthalmol-2014-306527 on 26 March 2015. Downloaded from
Transcript of Editorial Arthur Ferguson MacCallan: trachoma pioneer in ...
Arthur Ferguson MacCallan: trachomapioneer in Egypt 1903–1923Michael MacCallan
Arthur Ferguson MacCallan CBE, MD,FRCS (1872–1955) was an ophthalmicsurgeon who undertook his pioneeringwork in Egypt between 1903 and 1923(figure 1).i He became a world authorityon trachoma; the MacCallan Classificationof Trachoma, initially published in 1908,was the first grading system used to stand-ardise the diagnosis of trachoma and waslater adopted by the WHO. He also estab-lished the ophthalmic hospital infrastructureconsisting of travelling and permanent hos-pitals, along with the training of surgeons.This fight to eliminate trachoma continues,with the WHO setting a target date for theGlobal Elimination of Blinding Trachomaby 2020 (‘GET 2020’). As a contribution toachieving this goal, the InternationalCoalition for Trachoma Control (ICTC)inaugurated the ‘ICTC MacCallan Medal’ii
in 2014. By naming this award after Arthur,it recognises his pioneering spirit andaccomplishments which continue to reson-ate with the profession today.
The seeds of Arthur’s work were sownwhen the highly contagious eye-diseasetrachoma, which had existed in Egypt forcenturies, was imposed on the Europeansdue to the return of the British and othercombatants’ troops to their respectivecountries after Napoleon’s invasion andsubsequent defeat in Egypt (1798–1801).In Britain, this led to the opening, in1805, of the dispensary for CuringDiseases of the Eye and Ear (‘Moorfields’)to treat the disease. Britain’s furtherinvolvement in Egypt increased from1882, to protect its interest in the SuezCanal, but it was not until the late 1890s,during the construction of the first AswanDam, that the financier and philanthropist
Sir Ernest Cassel became so shocked atthe extent of ophthalmia among the vastworkforceiii that, in 1902, he established atrust fund of £E40 000 (equivalent to £4million today) with the objective of teach-ing ‘the principles of ophthalmic surgeryto Egyptian surgeons’. The trusteesdecided to establish a first, experimental,travelling ophthalmic hospital (TOH) ashad been used successfully in Russia. In1903, Arthur, aged 31 years, was workingas an unpaid ophthalmic surgeon atMoorfields. By a stroke of good fortune,which ‘transcended even my dreams’, hewas offered the position in Egypt tooperate that TOH and teach the Egyptiandoctors the appropriate surgical skills.Arthur arrived in Cairo in July 1903.
He rapidly concluded that hospitaldoctors had little knowledge of eye treat-ment but that success of the TOH schemewould be assured, given the potentialoverwhelming demand for treatment. Thefirst TOH, at Menouf, was opened topatients in January 1904 (figure 2).Initially, some of the fellaheen were suspi-cious of Arthur’s motives. However, theseprejudices were soon overcome by theempathy, skill and professionalism, bywhich Arthur organised and treated hispatients; they could literally ‘see’ the ben-efits of his operations. Demand for treat-ment grew rapidly thereafter.Arthur’s volume of work was enor-
mous. During the first 3 months of 1904,at Menouf, he treated 6157 patients andperformed 615 operations. Where anaes-thetics were required, opium, cocaine orchloroform were used; in some cases,where no anaesthetics were available,patients might still insist on treatment sogreat was their desire for sight. This wasalso the era before antibiotics. Workingconditions were harsh with the heat, sand,flies, lice and ‘mosquitoes as big as spar-rows, very bony and strong’. This combin-ation of work and the environment putgreat strain on Arthur personally and he
admitted that ‘the work is now veryonerous’ and ‘I don’t know how longI shall be able to stand this sort of life’.Nevertheless, he persevered, recognisingthe overwhelming need by the populationfor professional treatment. Indeed, so suc-cessful were the results from the firstTOH that, in 1904, Cassel provided thefunds for a second one, initially estab-lished at Fayoum.
The high incidence of ophthalmia ledArthur to conclude that the availability oftreatment at that time was just ‘a drop inthe ocean’ even with the second TOH.Thus, a bolder, long-term plan wasneeded. To address this, Arthur plannedto ‘create a stable central ophthalmicadministration with the best possible clin-ical and scientific teaching adjuncts’, alongwith establishing a permanent ophthalmichospital in each of Egypt’s 14 provinces.Over the next 20 years, Arthur workedtirelessly to achieve his self-imposed goals.
Arthur is probably best known amongthe international ophthalmic professionfor his research into and ‘classification ofthe stages of trachoma’. His initial find-ings were published in 1908 and thenfurther developed in his books Trachomaand its Complications in Egypt (1913)and Trachoma (1936). In 1952, the WHOadopted MacCallan’s Classification as thestandard. He was also instrumental infounding the major ophthalmic researchestablishment at Giza, then known as theMemorial Ophthalmic Laboratory,iv
which was formally opened in 1926(figure 3) and which is still operationaltoday. Arthur stated that ‘this laboratorywas envisaged by me many years before-hand. I got the site, the money for thebuilding, arranged the endowment, anddesigned the interior, with all detail’. Hebelieved that this Laboratory was ‘thecoping stone of my work’.
However, in order to treat the numer-ous patients with trachoma and other eyediseases, funding was required. To under-take this successfully, Arthur recognisedthat it was essential to involve the govern-ment in plans to create and develop anophthalmic hospital infrastructure. Thiswas achieved when, in 1905, the EgyptianGovernment took over the administrationof the Cassel Fund and started providingfunding. Arthur was delighted and notedthat ‘the national importance of the
Correspondence to Michael MacCallan, 15 Queen’sGate Gardens, London SW7 5LY, UK;[email protected]
iSource: Light out of Deep Darkness: Abiography of Arthur Ferguson MacCallan byMichael MacCallan, privately published in2013.iiThis award recognises a current practitioner’soutstanding contribution in eliminatingtrachoma.
iiiAt that time, it was estimated that some 90%of the population suffered from ophthalmia,with many operations being performed by‘quacks’.
ivNow known as ‘The Giza Memorial Institutefor Ophthalmic Research’.
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struggle against ophthalmia has thus beenrecognised and must henceforth take itsplace amongst the measures essential tothe prosperity of the country’. The firstpermanent ophthalmic hospital wasopened at Tanta (1908); further hospitalswere constructed over the years funded bya combination of local and governmentfinance and, in many cases, generous
donations of land and money fromwealthy individuals.The TOHs continued to play a vital role
in treating patients around the country. In1904, for example, the two TOHs treatedpatients at Menouf, Fayoum, Damietta andCalioub. Their mobility, and the effectivetreatment received by patients, led to theTOHs being a powerful ‘roving
advertisement’ for the essential work beingdone, resulting in significant donationsfrom the public. Given the flexibility of theTOHs, these ‘hospitals under canvas’ wereused to great effect in 1915, during WorldWar I, when they were commissioned bythe military to treat the sick and woundedfrom the campaigns at the Suez Canal,Gallipoli and Salonica. The largest tent
Figure 1 Arthur, the Pioneer, Menouf Camp, 1904, with Saladin.
Figure 2 Mat huts at Menouf. These replaced canvas tents in summer.
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camp contained 650 beds; this was initiallyestablished in Alexandria and then movedto Giza for the winter of 1915. Arthur wascommended by Surgeon-General Ford thathis hospital was ‘a model of what a warhospital under canvas should be’.
Two other areas addressed by Arthur werealso essential to the successful achievementof his goals. First, he organised the trainingof ophthalmic surgeons to staff the hospi-tals; by 1923, the members of the EgyptianOphthalmological Society had increasedfrom 17 to 96. Second, Arthur believed that‘the most important work carried out wasthe institution of ophthalmic treatment in allGovernment Primary Schools throughoutEgypt’. Given that trachoma was highly con-tagious, particularly in the close environ-ment of the family unit or schools, Arthurdedicated much effort in educating peopleon the benefits of personal ophthalmichygienev and so prevent the spread of thedisease. Indeed, one of his first professionalcalls in 1903 was to the headmaster ofMenouf School with the offer of inspectingthe pupils for ophthalmia and offeringappropriate treatment.
The tangible results of Arthur’s effortsover 20 years led to a significant growthin the number of patients treated (3397 to
133 750: 40×), and operations per-formed, (1268 to 76 035: 60×). OnArthur’s departure in 1923, there were 23operational ophthalmic hospital units,including five TOHs and two plannedhospitals. As important, however, was thefact that Arthur established robust founda-tions for the ophthalmic hospital infra-structure to develop after his departure.By 1937, there were 63 permanent oph-thalmic hospitals, 15 travelling hospitalsand treatment centres in 38 governmentschools. Many of these hospitals are oper-ational today with the Fayoum ophthalmichospital celebrating its centenary in 2015.Arthur bore the mantle of ambassador in
promoting and ensuring the implementa-tion of his self-imposed goals. Over theyears, he persuaded both the governmentand local notables to provide significantfunding and other support for the develop-ment of the ophthalmic hospital infrastruc-ture. Arthur successfully achieved his goalswhile recognising that much still remainedto be done. In 1931, Arthur’s colleaguesfrom the Egyptian ophthalmic service dedi-cated a commemorative bust to honour hisillustrious career and accomplishments;this may still be seen today at the GizaMemorial Institute for OphthalmicResearch. It is touching to note that, whenthe bronze bust was imported into Egypt in1930, the Ministry of Finance agreed towaive the customs duty in recognition ofthe ‘moral significance’ of Arthur’s workover 20 years. This sentiment remains to
this day, as witnessed by the ‘ICTCMacCallan Medal’. Arthur’s pioneeringspirit continues to inspire, and resonatewith, today’s profession as they continuethe fight to eliminate blinding trachoma.
Competing interests None.
Provenance and peer review Commissioned;internally peer reviewed.
Open Access This is an Open Access articledistributed in accordance with the Creative CommonsAttribution Non Commercial (CC BY-NC 4.0) license,which permits others to distribute, remix, adapt, buildupon this work non-commercially, and license theirderivative works on different terms, provided theoriginal work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
To cite MacCallan M. Br J Ophthalmol 2015;99:577–579.
Published Online First 26 March 2015
Br J Ophthalmol 2015;99:577–579.doi:10.1136/bjophthalmol-2014-306527
Figure 3 Memorial Ophthalmic Laboratory, Giza, 1925.
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vThis emphasis on hygiene (clean hands, facesand towels) continues today as part of theWHO—endorsed SAFE strategy (‘F’—facialcleanliness).
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Project (31370893), Research Fund for the Doctoral Program of Higher Educationof China (20115503110002), Basic Research Program of Chongqing(cstc2013jcyjC10001), Chongqing Key Laboratory of Ophthalmology (CSTC,2008CA5003), National Key Clinical Specialties Construction Program of China,Key Project of Health Bureau of Chongqing (2012-1-003), Chongqing Science &Technology Platform and Base Construction Program (cstc2014pt-sy10002) andFund for PAR-EU Scholars Program.
Competing interests None.
Patient consent Obtained.
Ethics approval The Ethics Committee of the First Affiliated Hospital of ChongqingMedical University (permit number: 2009-201008). This project was registered inthe Chinese Clinical Trial Registry (registration number: ChiCTR-CCC-12002184). Allexperimental steps obeyed the principles of the declaration of Helsinki. This researchadopted the case–control method.
Provenance and peer review Not commissioned; externally peer reviewed.
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Correction
MacCallan M. Arthur Ferguson MacCallan: trachoma pioneer in Egypt 1903–1923. Br JOphthalmol 2015;99:577–9. The Provenance and peer review statement should read:Commissioned; externally peer reviewed.
Br J Ophthalmol 2015;99:1154. doi:10.1136/bjophthalmol-2014-306527corr1
1154 Gao X, et al. Br J Ophthalmol 2015;99:1150–1154. doi:10.1136/bjophthalmol-2014-306163
Laboratory science
