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‘Family-Centred Care’ in American Hospitals in Late-Qing

Michelle Renshaw

Today, patients’ families in the West are regaining the access to hospitals that they lost when hospitals emerged as the primary site for medical treatment, research and training at the beginning of the twentieth century. In China, however, families were never excluded from American mission-run hospitals, in fact, they were indispensable. Families were in the waiting rooms, consulting rooms, wards and operating theatres. They provided more than reassurance and comfort: they fed and nursed their sick relatives, acted as advocates and middlemen and may even have lowered the incidence of cross-infection, the scourge of the contemporary hospital in the West.

Inspired by the consumer-led movements of the 1960s, and encouraged by research from psychologists who wrote about ‘maternal deprivation’ of institutionalised children, American parents had started to campaign against restrictions on visiting their children in hospitals.1 In Massachusetts they formed ‘Children in Hospitals’, an organisation which, in 1973, started to conduct and publish bi-annual surveys of visiting hours in the state’s hospitals. It is unlikely they could have foreseen their activism leading to the widespread adoption of an entirely new approach to patient care that pertains in American hospitals today.2 This new policy approach goes by the name of ‘family-centred’ care. Developed originally with children in mind, one of the first concrete moves in its direction was legislation passed in Massachusetts in 1980 requiring hospitals to institute twenty-four-hour family access to paediatric wards.3 Today it is a well-developed system with an agreed set of principles and protocols.4 Over the years it has extended its reach and is increasingly being adopted by hospitals for the aged as well as for adults in acute care hospitals.5 Like fathers wanting to be present at the birth of their child – including those carried out by caesarean section – family members are expecting to be present even during invasive and emergency procedures.6 55

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The cornerstone of the family-centred policy – emphasised in many hospital advertisements – is a belief that ‘health care providers and the family are partners, working together to best meet the needs of the child.’7 Of course, neither the idea nor the practice of families caring for their sick is new and, before the advent of hospitals for other than the very poorest of them, patients were routinely cared for at home with occasional visits from a physician. What is new in America is the idea that the family should take on a significant, if not central, role in patient care within the hospital setting. But, there have been manifestations of the American hospital from which the family was never excluded – those established by Protestant missionaries in nineteenth-century China, for example. There, the presence of family and friends was commonplace well into the twentieth century and continues in the Chinese successors of these hospitals today.8 So, the questions addressed in this chapter include: what economic, political and cultural factors operated in China to distinguish the American hospital in China from its counterpart at home, particularly in relation to the presence of patients’ family and friends? To what extent and in what capacities were these ‘visitors’ involved in the actual operation of mission hospitals? What were the possible consequences of the families’ involvement, so far as outcomes were concerned, for the Chinese patients, their families and for hospital staff? Lacking first-hand contemporary accounts by either Chinese patients or their families, this chapter relies upon annual reports published by a wide range of hospitals operated by various missionary societies and articles in missionary journals, particularly those written for and by medical missionaries. For the history of hospitals and present-day practices in America, secondary sources are used. Background: When the first of the Protestant medical missionaries arrived in China in the mid-1830s what few public hospitals there were in America had been established primarily to serve the poor.9 Those who could afford it were still treated at home by a physician and cared for by family members. The state of medical knowledge, practice and technology – before anaesthesia and the germ theory – meant that specialised equipment and nursing were not deemed to be necessary; the middle or upper-class home was thought to provide a perfectly adequate environment in which to care for the sick. So it would have been considered unremarkable when the first American medical missionary, , arrived in Canton, the warehouse he chose for his hospital, in 1835. Equally unremarkable was the fact that he had no nurse; caring for the forty in-patients he could accommodate was undertaken by their relatives, friends or servants.10

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Following Parker, Protestant medical missionaries established themselves in China, slowly at first until the rate picked up from the 1880s to reach a peak after the Boxer Rebellion in 1900 of almost twenty new arrivals per year for the following five years. By the end of 1905, some 450 medical missionaries had arrived in the country since 1869.11 In 1906, according to the China Medical Missionary Association, there were 241 dispensaries and 166 mission hospitals operated by 207 male and 94 female medical missionaries.12 Much was changing, however, in hospitals in America throughout this period. Anaesthetics such as ether and chloroform, discovered in the 1840s, enabled surgeons to contemplate more radical, particularly abdominal, surgery with its attendant danger of infection. In the 1860s, Lister pioneered the performance of antiseptic surgery and, in the 1870s and 1880s, Pasteur’s and Koch’s experiments established the germ theory of disease. The causative agents of wound infections were identified and the idea of aseptic surgery was advocated and eventually universally adopted. Sanitation studies influenced the design of hospitals and the need for trained nurses was recognised. Both general and specialised hospitals were opened to cater specifically for the middle-classes and trained medical personnel – physicians, nurses, surgeons and technicians – largely usurped the role of the family in caring for the sick. Medical missionaries kept abreast of these changes, via study trips home and reading medical journals, and were quick to assimilate much of the new knowledge and implement many of the techniques. The economic and cultural conditions in China, however, were such that the development of mission hospitals did not completely mirror the changes taking place in hospitals at home. In the dispensary In America, free-standing public dispensaries, which had arisen in the late eighteenth century, gave way to the emerging hospitals as the principal sites for physicians to learn, practise diagnosis and advance their careers.13 However, no study of mission hospitals in China can avoid discussing the operation of dispensaries; it was through these out-patient institutions that the vast majority of Chinese continued to come into contact with Western . Dispensaries always preceded the building of mission hospitals; large numbers of patients could be catered for at little cost and the missionary could start work as soon as he or she had acquired sufficient Chinese language. It also provided a way to break down barriers because it was easier to persuade potential patients to visit a physician than to enter a foreign hospital. After all, the set-up of a public dispensary – a doctor sitting in a room, examining and questioning a patient and prescribing medicine – 57

Michelle Renshaw - 9789042026322 Downloaded from Brill.com09/23/2021 06:20:13PM via free access Michelle Renshaw had been familiar to Chinese people since at least the Tang Dynasty (618–907 AD).14 In 1906, medical missions reported that only 3.7 per cent of the 913,200 new and returning patients treated during the year had been admitted as in- patients.15 The rest had been seen in dispensaries, by missionaries who periodically travelled throughout the countryside proselytising and holding ‘clinics’ wherever people gathered at fairs and markets or in their homes. But the hundreds of thousands of patients who were treated in dispensaries did not come alone: they were invariably accompanied by friends or relatives. For example, when the Methodist Episcopal Mission (South) (MEM(S)) Women’s Hospital at Suzhou opened in 1887, the ‘number of friends [coming to the dispensary was] usually double that of patients’.16 Similarly, the Southern Presbyterian Mission (SPM) reported in 1905 that their out- patients at Qingjiangbu in Jiangsu, were invariably accompanied by ‘at least one friend’.17 Understandably, children would have been accompanied when visiting the dispensary but so too were most women and many men. As Elizabeth Reifsnyder, the physician-in-charge of the Margaret Williamson Hospital (est. 1885) at Shanghai observed in 1887, ‘[a]t home the woman is a free moral agent, so far as going to the dispensary is concerned… here, the husband invariably comes with the wife, the father with the daughter, and it is the father, too, very often [who] brings the baby, or comes with it and the mother or nurse.’18 As the medical missionaries’ stated ‘prime’ purpose in establishing dispensaries and hospitals was ‘to propagate the Christian religion and make it a power in the hearts and lives of these people’, they welcomed the opportunity to influence patients’ families and friends.19 In addition to introducing them to the Gospel by preaching in waiting rooms, missionaries also sought to persuade the Chinese of the ‘superiority’ of Western – which the missionaries equated with ‘Christian’ – ‘scientific’ medicine. So, patients and visitors were encouraged to observe medical consultations and minor procedures carried out in the dispensary. When their turn came a patient might enter a separate examination area, partitioned off but often remaining in full view. Many doctors advocated this arrangement and designed their dispensaries so that patients who were still waiting and any friends or relatives who had accompanied them could see what the doctor was doing.20 They hoped that this would inspire confidence, allay fears and prevent rumours from arising. To this end, one doctor went so far as to call patients into the consulting room in groups of ten at a time. They would sit on a bench until being called individually to take a chair next to his desk to be examined.21 The large number of people who thereby became familiar with dispensaries associated with missionary hospitals would presumably have 58

Michelle Renshaw - 9789042026322 Downloaded from Brill.com09/23/2021 06:20:13PM via free access ‘Family-Centred Care’ in American Hospitals in Late-Qing China come to view the foreign-run hospital as a ‘public’ space where both patients and visitors were welcome. It was so common for visitors to crowd Parker’s hospital that on one occasion, in 1838, he was only able perform a potentially dangerous operation by seizing the opportunity afforded when, ‘during the time of the attempted execution of an opium dealer, and the consequent riot… all was quiet at the hospital’.22 In the wards Up until the 1870s, American hospital patients had, according to Rosenberg:

[H]oped and expected to find relatives and friends a source of emotional support in strange and threatening surroundings. Their visitors had smuggled in food and drink and paid little attention to stipulated visiting hours.23 But the physical conditions within American hospitals were transformed with the advent of trained nurses to replace untrained staff or the convalescent patients who were required to help care for others. By the early- twentieth century a new-style regime had become firmly established and ‘the patient became subjected to a routine which was in the main unnatural and largely determined by the nurse and her needs.’24 The familiar photographs of hospital wards with highly polished wooden floors, two rows of iron- framed beds arranged facing into a central aisle, tightly tucked white sheets, patients either in bed or sitting in a chair next to it and attendant nurses in starched uniforms and caps began appearing in hospital reports.25 There may have been visitors in these hospitals but, presumably, hospital administrators who wished to paint their hospital in the best possible light considered it imprudent to have them appear in photographs. Along with the emergence of the trained nurse and the ordered ward came a tightening of rules and regulations devised to try to govern the behaviour of patients and their relatives. Thus, visiting hours were restricted and limits were placed on the number of visitors a patient could have at any one time. Family and friends, however, thought that bringing food for a patient was the one caring task they could continue to perform and hospital rules were written in an effort to control this aspect of the patient–visitor relationship: generally, they forbade bringing in any food for patients, even going to the extent of searching visitors before they were allowed in.26 Medical missionaries on the other hand, were not in a position to institute rigid rules for either patients or their visitors. In the 1830s, Peter Parker’s lack of even untrained nurses meant that he alone was responsible for ‘[t]he prescribing, the principal part of the labor of administering the prescriptions, and the supervision of house patients by day and night’.27 Sixty 59

Michelle Renshaw - 9789042026322 Downloaded from Brill.com09/23/2021 06:20:13PM via free access Michelle Renshaw years later, in 1902, another missionary, operating in Shandong, explained to his patients, ‘we have no staff of nurses; if you are going to need attendance, you must bring some one from your home.’28 Mission hospitals in China in 1910, according to Jefferys, of the American Episcopal Mission’s St Luke’s Hospital at Shanghai, were ‘far more homey and far more human than eleven-tenths of our rule-trodden institutions in the dear homeland, and it suits the Chinese patients very well indeed.’ He advised medical missionaries that they would save themselves ‘endless trouble’ and their patients ‘endless ingenuity’ if they were to limit their ‘rules to the bare necessities and extend [their] elasticity to the utmost degree short of, and sometimes past, the breaking point’. His patients ‘could smoke and talk all night’ and friends could come and go, or not go, as they pleased.29 By the turn of the twentieth century in America trained nurses had come into their own: the number of students enrolled in professional nursing schools had increased from a mere 323 in 1880 to 11,164 in 1900 with graduates increasing from 157 to 3,456 per annum.30 But in China, according to a survey of sixty hospitals undertaken in 1904, some 80 per cent were operated by a single physician. In 1923, 69 per cent of mission hospitals in China were ‘one-man’ hospitals with a single physician and ‘his or her Chinese helpers’; a further 18 per cent were described as ‘two-man’, which meant they had two doctors and a foreign nurse; and only 8 per cent had more than two foreign-trained physicians.31 So far as nursing staff were concerned, Balme and Stauffer found in 1919 that 34 per cent of the hospitals did not have a trained nurse on the staff; a further 26 per cent of hospitals had but one trained nurse. They summed up the situation thus: ‘in one third of all these hospitals there is no sort of skilled nursing whatever, and in 60 per cent of them there is no more than can be attempted by a single graduate nurse.’32 The lack of nursing staff in China was due to a confluence of forces: lack of money to employ foreign-trained nurses; the Chinese custom of family members taking an active role in caring for the sick; and the reluctance of Chinese women to be attended by a man. There were few Chinese women trained as nurses and the small corps of trained nurses was overwhelmingly male. As late as 1918, there was a widespread belief among physicians and nurses that it was not yet appropriate for Chinese women to nurse men.33 In America, once trained nurses were in place, under certain circumstances – in cases where the patient was ‘dangerously ill’ for example – a hospital would allow a friend, relative or nurse to accompany a patient.34 The privilege was not generally extended to patients in wards.35 In China, the situation was very different. Margaret Polk of the MEM(S) hospital at Suzhou, one of the relatively few women who contributed regularly to the China Medical Missionary Journal and spoke at medical conferences, 60

Michelle Renshaw - 9789042026322 Downloaded from Brill.com09/23/2021 06:20:13PM via free access ‘Family-Centred Care’ in American Hospitals in Late-Qing China commented in 1901, ‘two or three servants’ frequently accompanied private patients and family members – husbands, sons, daughters, sisters, fathers and mothers – attended patients in wards.36 This led to the chronic overcrowding which characterised mission hospitals. In 1906, Arthur Peill, of the London Missionary Society (LMS) Roberts’ Memorial Hospital in Hebei, proposed restricting in-patient numbers to the number of beds in the wards ‘instead of allowing them to pack in like sardines as heretofore’. He had tried to solve his problem two years earlier by building a ‘commodious and very convenient inn’,37 but his wards had remained ‘very full’. One day he had found 103 people in quarters intended for 50; of these, 75 were actual in-patients and the rest were ‘so called “nurses”’, that is, family and friends.38 Another doctor, writing in 1912, described the situation in hospitals’ wards in China:

[B]esides the patients are to be found their relatives, with one and all practicing their natural unhygienic habits. Any attempt of nursing is done by the relatives or glorified coolies and is of the most primitive and disgraceful character.39 Things were much the same in 1919 when Gibson declared that:

[N]o more can be tolerated wards which are dirty and disorderly, patients who are clad in their own ‘questionably clean garments’ and cared for by their own ‘questionably capable’ friends or hirelings.40 Peill announced his intention to tackle the overcrowding in his hospital by appointing ‘regular nurses… men chosen for their Christian character and reliability, to act as ward evangelists, to do dressings, and be responsible for the cleanliness and order of the wards’.41 Even if Peill and his fellow medical missionaries had had the appropriate staff, it would have still been necessary to allow patients’ families to accompany them into hospital. They were keen to admit as many patients to hospital as they could because it was universally believed that in-patients offered the maximum opportunity to influence the Chinese with respect to religion. Patients could be persuaded to both enter and stay longer when they would not be separated from their family and friends. When Balme conducted his survey in 1919, 37 per cent of hospitals required that all patients be accompanied while a further 51 per cent allowed family, friends or servants to live in with patients. In other words, 88 per cent of hospitals had to be able to accommodate friends and family. In the early days, as Balme explained, it had been a matter of cultural sensitivity: it had been ‘neither easy nor polite to induce patients to come into the hospital unless they were allowed to bring their friends to live with them.’42 John A.

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Anderson, who was working in Western Yunnan in 1901, went further: he rather liked his patients to bring their friends or servants with them. It helped to keep the patients from being homesick, and it brought more people under the influence of the Gospel.43 It would seem that some patients were extremely well catered for, at least in terms of the number of attendants. A little girl of eight years whom Parker operated on in 1838 to repair a hare-lip was apparently the ‘the idol of her wealthy parents’ and had four people in ‘constant attendance’ for the ten days she was in hospital. At the other end of the age scale, a 56-year-old former ‘district magistrate’, was attended by two or three servants, his ‘personal servant’ being described as being ‘as old as himself, with a flowing jet black beard… unwearied in his attention to his blind master’.44 Sixty years later, the fact that patients were still being routinely accompanied in hospitals excited no particular comment. Josephine Bixby, bringing her readers’ attention to the lack of space in her hospital, described a room ‘scarcely large enough for two’ having to accommodate three women. What she does not say is that it actually had to hold at least six – each patient had at least one attendant.45 The practice of requiring or allowing all patients to be accompanied, while extremely common, was not universal. Lillie Saville at Beijing was a rare exception among medical missionaries: she appears to have succeeded in her quest to rid her hospital of live-in visitors. In preparation for introducing clinical training for Chinese nurses, she reported in 1906 that she had ‘almost entirely abolished the heretofore prevalent practice of allowing mothers and friends to live with the patient in the hospital’.46 Family and friends: multiple roles Important as reassurance, companionship and even nursing were to patients, the responsibilities of family and friends went much further. They were so ubiquitous and commonplace in these mission hospitals, however, that many writers of hospital reports appear to have considered their roles unworthy of detailed attention. As we have already noted, some of these reports included sweeping generalisations that decried Chinese family members’ perceived ineptitude, ignorance or lack of hygiene. Others welcomed and, indeed, expected family and friends to participate in caring for patients. Naturally, in some instances, attendants used the methods of traditional Chinese medicine; for example, Parker described a servant, alarmed at her mistress’ vertigo which had been brought on by a dose of laudanum, ‘engaged in pinching the patient’s nose and violently rubbing the temples with green ginger, which she had first masticated’.47 On another occasion a pregnant woman who had been accidentally shot was brought to the hospital. She was attended by a Chinese nurse and midwife; the nurse 62

Michelle Renshaw - 9789042026322 Downloaded from Brill.com09/23/2021 06:20:13PM via free access ‘Family-Centred Care’ in American Hospitals in Late-Qing China swathed the new-born ‘hand and foot [with its] face only remaining exposed’ and fed it its first food which was ‘a little paste prepared from cakes composed of sugar and rice flour, with which fare the little one seemed quite satisfied’. Parker was told that ‘this is the common nourishment, the infant not being put to the breast for one or two days.’ He tells us that the Chinese midwife made:

[A] great objection to the application of cold water to the abdomen to produce contractions of the uterus, and to stop the haemorrhage, and, on being asked what means the Chinese adopted, the reply was, we ‘let the patient alone’.48 In such passing asides one can glean something of the variety and depth of the families’ involvement in the life of the hospital and sometimes, the missionary’s attitude towards his patients and their customs and beliefs. Since Peter Parker made frequent mention of family members in his published cases, much of the remainder of this chapter relies upon his reports. His hospital was not unique, however, and all of the relevant events he described had their parallels in other mission hospitals for at least the next sixty years. When he first opened the hospital in Canton, Parker had anticipated difficulty ‘in receiving females as house patients’ because, he noted, it was ‘regarded as illegal’ for a woman to enter the foreign factories area where he was situated. The difficulty, though, had proved more imaginary than real. Women whose condition meant that they should remain in hospital had been ‘attended by some responsible relatives, – wives by their husbands, mothers by their sons, daughters by their brothers.’ He found it ‘truly gratifying to see the vigilance with which these relatives’ duties have been performed.’49 In 1839, for example, when the first death occurred following surgery in his hospital, he reported that the ‘husband was asleep by the patient’s side’.50 The attendance statistics Parker quotes seem to bear out his observation that women were not deterred from consulting him. He does not tell us how many of the 925 patients he saw in the first three months of operation in 1836 were admitted as in-patients, but we do know that 270 of them were female. An analysis of Parker’s statistics reported between 1836 and 1849 reveals that the rate of admission for patients suffering from obviously ‘female’ complaints accelerated over that time.51 By allowing relatives and servants to live-in with patients, Parker had access to, and thus the opportunity to influence, Chinese women as well as men. Friends and family acted as advocates on behalf of their sick relatives. Parker decided after his first three months to try to limit his workload by

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‘nominally’ closing the doors to new patients for one month. In this, he failed. He estimated that at least one third of the 358 new patients who had managed to gain admittance did so by ‘importunity and the combined influence of their friends’.52 Equally, a family’s desire to protect their relative could frustrate the physician’s desire to admit a patient. In the experience of Dr Margaret Polk, women would often be surrounded by ‘people whose unreason will prevent her yielding herself to treatment’. Frequently she had had to turn away from:

[A] case begging to be relieved after trying to reason with the father-in-law, the mother-in-law, two or three of the older sisters-in-law, the woman’s own family, and last but no means least in a Chinese family, the servants.53 Family members could also be valuable sources of information about the course of the patient’s illness and any past treatment. It was relatively common for the literati to provide Parker with a written patient history which might include their understanding of the cause of the illness. Less often, it seems, family members sought to be actively involved in deciding the treatment regimen. One such was the father of a 22-year-old woman who suffered from cataracts. In a note, he requested that Parker ‘couch the cataract’ or at least adopt a ‘quick and easy method of cure’ because it was going to be inconvenient for her to have to stay in hospital.’ He stressed that if this course was followed but the cure was not successful and ‘she should not be able to see’ he would still be ‘satisfied’.54 From Parker’s arrival in 1836, in contrast to America and Britain, most Western medical practices in China were weighted in favour of surgical, over medical, cases.55 There were two reasons for this. Firstly, Western medical therapeutics were not demonstrably more efficacious than traditional Chinese. Secondly, surgery was ‘almost without tradition in China’56 and missionaries believed that ‘the superiority of scientific surgery [was] more easily demonstrated to the Chinese than that of scientific medicine’.57 But surgery was risky and, to safeguard his reputation, Parker always required at least one family member or friend of the patient to consent before he would operate. His insistence on this policy was demonstrated when a 23-year-old man presented in November 1839 with an arm in such a state that Parker – and the colleagues he consulted – decided that his only chance of life was to have it amputated at the earliest possible opportunity. As the young man’s friends were not present to give permission, the operation was delayed until the next morning when consent could be obtained.58 Whenever Parker was persuaded to take into the hospital any patient whose prognosis was poor, he required, in addition to consent to operate, someone to indemnify the hospital in the event of the patient’s death. Such

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Michelle Renshaw - 9789042026322 Downloaded from Brill.com09/23/2021 06:20:13PM via free access ‘Family-Centred Care’ in American Hospitals in Late-Qing China a case occurred during the first half of 1836 when a 13-year-old girl was brought in suffering from extreme ascites. He told her friends that if they insisted on leaving her at the hospital, instead of taking her home, they must be ‘satisfied’, after he had done his best to help, if she should die in the hospital. They agreed: she stayed, and was relieved of her abdominal swelling.59 Frequently, before a patient was admitted to the hospital, physicians would require them to name a ‘middleman’ who could act as an intermediary and, if necessary, on the patient’s behalf. Duncan Main, who had established his Church Missionary Society (CMS) Hospital in Hangzhou in 1885, insisted upon having an intermediary whose role included taking care of the patient’s clothing when it was exchanged for hospital garments. Many medical missionaries went so far as to require all in-patients to find a ‘local man to go surety for them’. This was firstly to cover burial costs in case no one would ‘come and claim the body’; secondly, to compensate the hospital for the loss of any property the patient might steal – the physician-in-charge of the CMS hospital at Ningbo recommended this practice because he believed that the ‘police are of little use’; and thirdly, to guarantee any unpaid fees.60 The requirement would not have struck Chinese patients as odd because it was common, in a society based on reciprocal relationships, for transactions to be effected through contacts. The roles of family and friends of Chinese patients were not limited to acting as companions, advocates, intermediaries or nurses: they were often also responsible for the patient’s nutrition. They collected fuel and brought, prepared and cooked patients’ meals. Just as the doctor referred to earlier was unable to provide his patients with nursing neither could he provide them with food: ‘[W]e have not money to feed you. You must bring your own grain.’61 This meant that the type of hospital rules so common at home could not be applied to diet in the hospitals in China. Some doctors wished they could be. It was, said one, a ‘very important thing with people who are so prone to over-eat, under-eat, to eat dead or half decayed food rather than see it thrown out, and to eat at any and all hours of the day or night.’62 A few tried. One doctor, in 1899, despaired of his Chinese patients who ‘almost invariably… refuse to take beef tea, or milk, or chicken broth... [t]hey prefer nothing, or peanuts, or raw pears, or pig’s stomach, and all sorts of sweetmeats and smuggle them in and eat them.’63 One of Parker’s patients was found five days after her arm had been amputated ‘with a bowl of oily sausages, which she was devouring even without rice.’64 Apparently, it did her little harm as her wound healed and she was discharged a month later. It was probably fortunate for them that the majority of patients in missionary-run hospitals ate Chinese food prepared by their own family 65

Michelle Renshaw - 9789042026322 Downloaded from Brill.com09/23/2021 06:20:13PM via free access Michelle Renshaw members. Had this been the case in the MEM(S) hospital at Suzhou, in the 1890s, Anne Fearn’s young patients might not have died. She acknowledged that it was her ‘desire for cleanliness… and anxiety to provide only the best foods [that] inadvertently were responsible for bringing two dread[ed] diseases into the compound, tuberculosis and beriberi.’ By providing the more expensive polished rice, the hospital had:

[U]nknowingly taken away the very vitamins they needed because, aside from their… three bowls of rice, they ate little else save a flavouring of cabbage, pork, chicken, or fish. First one girl and then another was sent home to die.65 In China, the role of the family in providing food to patients has rather more significance than it might in another setting. Dietetics had always been an integral part of Chinese medicine and moreover, knowledge of the role of diet in medical treatment and recuperation was not confined to medical practitioners but was widespread among all classes of society. Foods were classified in the same way as drugs were and could be prescribed – or proscribed – according to their supposed interaction with the person, their disease, their temperament, the season, and so forth, to re-establish ‘balance’, that is, health. ‘Warming’ foods could be used to compensate for problems classified as ‘cool’, ‘cool’ foods to help reduce heat symptoms and foods classified as ‘strengthening’ recommended following trauma, surgery or birthing.66 Medical missionaries were aware of the place of dietetics in Chinese medicine and one, Daniel MacGowan, thought that just as ‘the materia medica of China has merited and received attention from foreigners, their materia alimentaria [was] worth investigating’. He had observed that ‘culinary and dietary regulations abound’, particularly ‘selecting edibles for the same meal that are not incompatible’ because ‘articles which when taken separately are wholesome become noxious when in combination, so much so that such cases are classed among poisons.’67 The advantage to the patients’ psychological health is self-evident. They would not only have had evidence that their family cared about them, they would also have believed that the specific foods chosen would benefit them. The family would have also felt better, as Anderson puts it, ‘when they could do nothing else, as was all too often the case, they could at least make the patient feel that family, neighbors, and community cared and were acting to help.’68 But Margaret Polk’s complaint would be familiar to those in today’s hospitals wanting to introduce a ‘family-centred’ approach who encounter resistance from professional staff. As she put it, ‘women… usually bring two or three servants, which not only complicates the relations with the patient but complicates the housekeeping arrangements.’69 At Anne Fearn’s hospital

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‘another factor contributing to our disorganisation was the special kitchen we were forced to maintain for our Mohammedan patients, who brought along special food and their own cooks to prepare it.’70 One hospital thought it worth the extra work and expense to take control of the provision and preparation of food but the patients obviously disagreed and, in 1888, the in-patients had had to be allowed ‘to return their custom of bringing their own food and cooking for themselves’, resulting in ‘its constant attendant – perpetual untidy wards’.71 As well as parents accompanying children, some children accompanied their parents. They were not always there in the capacity of carer but because the parent had no choice. In 1922, a woman suffering burns brought her ‘daughter and little boy with her’ to the Baptist hospital at Ningbo because ‘their home was burned and they didn’t have any place to stay’.72 Some, though, were there in a caring capacity, for example, a 54-year-old man whom Parker treated for ‘cataract of both eyes’ was attended by ‘his son twelve years of age, and two servants’.73 Another patient, an apparently ‘amiable’ 43-year-old woman, on whom Parker operated for cancer of the breast, came with her 12-year-old daughter.74 One father particularly impressed Parker. Lew Akin was 12 years old when her father signed the ‘usual indemnity’ for Parker to remove a seven-pound tumour from her hip: the ‘strength of [the father’s] natural affections’ was demonstrated by his ‘vigilance in his attention to his only child, continually, day and night’. Akin’s father, along with other ‘spectators’, was in the room when Parker operated but the ‘unsightly wound that presented as the integuments retracted ten or twelve inches apart, the incision being about ten inches, was too much for [him] to witness without tears’. He left the room but the girl’s cries, when Parker stitched the wound, ‘soon recalled him’.75 It was not unusual for family members to be present in the operating room in mission hospitals (such as in Figure 3.1, overleaf). The most obvious reason for allowing them in was to comfort the patient in an alien, frightening, painful and often dangerous situation. In 1837, Parker performed what he described as the ‘first instance of the extirpation of the female breast from a Chinese’. The patient was a courageous 48-year-old woman, a maker of artificial flowers, who had had a ‘cancerous breast’ for six years. It seems her family was equally brave, both her husband and her son being present during the ground-breaking operation. She endured the procedure with ‘the fortitude characteristic of her sex’ while her family ‘commanded their feelings remarkably, and spoke cheerfully to their suffering friend.’76 When Parker performed a similar operation on a 26-year- old woman, the ‘several European and Chinese witnesses’ included her ‘devoted mother and sister [who] on seeing the poor sufferer as she fainted, all covered with her blood… could not refrain from weeping.’ 77 67

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Figure 3.1

A Family Witnesses an Orchidectomy

Having been summoned to sign an indemnity for the hospital, the wife and son of the patient look on. The British doctor’s assistant weighs the diseased testicle which has been removed under anaesthetic.

Source: Dianshizhai Hua Bao, Vol. Chen, No. 3 (1888), 14. Reproduced with permission of the Library, School of Oriental and African Studies, London University.

Family were not the only people who witnessed operations. When Parker made an incision to remove a fist-sized hydatid cyst from the breast of a 62- year-old money-changer he ‘unluckily’ opened the cyst and he and the ‘bystanders [were] spattered with its foul contents, which resembled dark venous blood’.78 Parker was happy to accommodate this level of scrutiny of his work as he felt sure that it would serve to overcome ‘prejudice’ and lead to a wider acceptance of Western medical techniques and thereby to more Chinese coming under the influence of his Christian mission.

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Benefits to missionaries and consequences for patients Observing operations did more than reduce Chinese anxiety about what medical missionaries were doing. Parker thought it was also the best form of advertising. As he put it, ‘few operations could exhibit in a stronger light their confidence in foreign surgery’ than the one he had just performed for breast cancer.79 Simple procedures, such as separating the eyelids of a little girl of seven years, provided the opportunity to demonstrate his skill to larger numbers. He used a pair of curved scissors and the:

[F]ine black eye, which had neither seen nor been seen for seven long years, was in a moment unhooded [which] impressed the spectators more than a successful treatment of half a dozen pulmonary affections would have done.80 In the first year of operation, Parker had received 2,152 patients but estimated that ‘not less than 6,000 or 7,000’ Chinese had visited his hospital:

They have witnessed the operations, and have seen the cures. They are from nearly all parts of the empire; they carry with them the intelligence of what they have seen and heard. Consequently, from provinces more remote applications are made, new and anomalous diseases are presented, and the desirableness is daily increasing.81 When anti-foreign sentiment was high and rumours of foul deeds – such as Western doctors stealing the eyes of children to make or to use in photography, and extracting ‘the fetus and placenta from pregnant women for medicinal and alchemical purposes and for sorcery’82 – were rife, it was essential that they welcomed visitors and acted as openly as possible. Without first-hand accounts from patients or their families it is difficult to be certain about the psychological benefit of having their family and friends care for them. But, if the recent research carried out in American hospitals is any guide, it would have been considerable for both patients and their families.83 From Parker’s and others’ accounts, we know that the mission hospital in China in the nineteenth century was a safer place for a patient undergoing major surgery than a hospital in America or England. An analysis of the results of the 144 surgical cases Parker published between 1835 and 1849 reveals a low death rate from amputation of a limb (5.6 per cent) and removal of tumours (3.2 per cent).84 By contrast, when Lister arrived at Glasgow Infirmary in 1860 ‘eight out of every ten amputations died [and] pyaemia almost always followed a compound fracture’.85 Half a century later another physician, J. Thomson, was to write about the ‘remarkable recuperative power’ of the Chinese after surgery, often major. According to him, it was ‘unanimously testified by all who have had 69

Michelle Renshaw - 9789042026322 Downloaded from Brill.com09/23/2021 06:20:13PM via free access Michelle Renshaw to deal with them’ and his experience in Hong Kong had confirmed the ‘generally received opinion [that] recovery and convalescence are very much more rapid and complete in the average Chinaman than in the average Englishman’. To illustrate, he provided details of four of his patients who had recovered ‘in circumstances that one can scarcely believe would have been other than fatal in Europeans’.86 To what extent, if at all, Chinese powers of recuperation could be attributed to the presence of family in the hospital is debatable. But one can conjecture from the vantage point of present-day knowledge. Firstly, in Western hospitals of that period, death following surgery was mainly due to the high rate of infection and cross-infection associated with hospitals. As Robert Liston, a contemporary of Parker’s, described the situation at Edinburgh in 1835:

No patient was admitted with a breach of surface, an ulcer, or a wound of any kind, without suffering erythema or erysipelas; and scarcely a single operation was performed, seldom even bloodletting, without the same results.87 In contrast, Parker records having seen erysipelas in only nine of the 32,600 patients who entered his hospital in the fourteen years to 1849.88 Similarly, John Kerr, who succeeded him at the Canton Hospital, met his first case of erysipelas in 1874, after twenty years of practice in China, and Thomson had never had an instance following an operation. Given that these medical missionaries agree that most of their Chinese patients who submitted to surgery did so only after prolonged illness, treatment by Chinese physicians and healers, and often as a ‘last resort’ – not the best case scenario for success – their recovery rate is even more remarkable. Could it have been the fact that friends and family were providing the nursing that contributed to the comparative safety of Chinese patients? Liston described the ‘foolish practice of washing every sore indiscriminately… with the same sponge’ in British hospitals, with the result that ‘a patient with a putrid sore, or labouring under an attack of erysipelas, soon became the means of spreading erysipelas throughout the ward.’ In a mission hospital in China, this was less likely to happen where all patients had their personal attendants.89 Also, knowing the patient intimately and being with them constantly would surely have improved the quality of observation above that of a harried, overworked nurse.90 Further, the surgical success rate would have been enhanced by the widespread policy, discussed earlier, of reluctance to operate on anyone without good prospects of recovery. Family and friends were instrumental in the implementation of that policy. The physician in charge of the LMS

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Michelle Renshaw - 9789042026322 Downloaded from Brill.com09/23/2021 06:20:13PM via free access ‘Family-Centred Care’ in American Hospitals in Late-Qing China hospital at Xiaogan attributed the fact that no death had occurred in his hospital during 1902 to this approach. In the first instance, if he considered a patient to be a poor risk he would try to dissuade him or her from proceeding with the operation. But ‘should he still beg for it’ the physician would insist that he send for some friends or relatives to talk it over with them before deciding. ‘Much talking and arguing’ would ensue with the physician calling in ‘friend after friend’ until, usually, the patient concluded that the ‘advantages to be gained by operation [were] too small to warrant the risk’. If this failed and the patient insisted that the operation proceed the hospital had made it ‘sine qua non that there shall be one or more friends present at the operation, in order to see fair play.’ The plan, apparently, worked ‘splendidly. There is afterwards no suspicion that we have plucked out an eye or mysteriously extracted blood or “virtue” or what not. The Chinese are wonderfully suspicious and inventive and we need on that account to do everything quite openly.’ This vigilance did not end when the operation was concluded because after the patient was placed in a ward the physician demanded that a ‘friend shall remain with him until all danger of a relapse is past’.91 Conclusion In the United States today, family members might not think it necessary to be observers in hospitals to be assured that the physician is not removing organs to use in some arcane medicine, nevertheless, ‘vigilance’ is the term used by researchers to describe the role of family members who accompany patients in hospitals. ‘Vigilance’, in this context, has been defined as ‘the close protective involvement of family members with hospitalised relatives’.92 It is manifest as a ‘commitment to care’ involving wanting to protect the patient, acting as the patient’s advocate, watching for any changes, monitoring treatment, providing company and reassurance and demonstrating love. In a study of the ‘day-to-day experience of vigilance’, Carr and Fogarty report observing family members in a range of caring activities including feeding and bathing patients, moving them from bed to chair, providing exercises to increase mobility as well as providing ‘general comfort’.93 As the concept and practice of family-centred care spreads from paediatric to adult wards, acceptance is growing among health professionals and research suggests that it enhances the hospital experience and outcomes for both patient and their families. For children, these outcomes have included being less anxious, recovering and being discharged earlier and requiring less pain medication.94 Their parents experience less stress and ‘procedure related’ anxiety and feel that their presence has helped the child.95 In some hospitals, relatives of adult patients have been able to help with feeding, washing and allaying patient fears and have, themselves, felt useful 71

Michelle Renshaw - 9789042026322 Downloaded from Brill.com09/23/2021 06:20:13PM via free access Michelle Renshaw and more confident about being able to care for the patient when they return home.96 Patients have told of feeling ‘comfort, strength, and support’ because family members were present; they felt that their family had acted as their advocates and, by interpreting and explaining information, had helped them to ‘understand, cope with, and reframe painful and stressful events’.97 There is no reason to suppose that these benefits would not have accrued to patients and their families in mission hospitals in China where, as has been shown, the involvement of families was even more extensive and included being responsible for the patient’s nursing and diet as well as being present for all procedures. It is somewhat ironic that the practice of families accompanying their relatives to hospital, being so enthusiastically embraced in Western hospitals, is now under threat in China. As China moves away from centralised planning to a regionalised, privatised market economy, few Chinese still have access to the free, or low cost, medical care they enjoyed before 1980. Costs have been shifted from the government to individuals, so that 90 to 95 per cent of total hospital income is now derived from ‘direct user charges’ and less than 15 per cent of the population is covered by medical insurance.98 Hospitals charge patients on a fee-for-service basis and separate fees cover such things as registration, the bed, laboratory tests, scans, food, nursing, operations, treatments and drugs. Families unable to meet these multiple expenses have no option but to accompany and cook and care for their sick relative. In 1998, an American medical student who spent time in a teaching hospital in the remote city of Jiamusi, in the Heilongjiang Province, described the infectious diseases ward as having: ‘five nurses, and 20 to 30 patients whose family members usually cared for them’.99 But smaller families – as a result of China’s one-child policy – and many elderly people – rising due to the increase in life expectancy, with more now living alone as workers are able to move between cities – are combining to put pressure on the diminishing number of offspring available to provide care for the growing number of aged parents and grandparents. A colleague from Beijing tells me that today the greatest concern he and his friends have is not being able to raise the money if their parents need to be hospitalised: ‘If they can raise the money to cover the medical expense [but] do not come to see them, even once, that is fine – [their parents will say] their children are still good.’100 Notes 1. For a summary of the history of hospital visiting policies, see A.W. Giganti, ‘Families in Pediatric Critical Care: The Best Option’, Pediatric Nursing, 24, 3 (1998), 261–6: 261–2. See also H. Hendrick, ‘Children’s Emotional Well- Being and Mental Health in Early Post-Second World War Britain: The Case of Unrestricted Hospital Visiting’, in M. Gijswijt-Hofstra and H. Marland 72

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(eds), Cultures of Child Health in Britain and the Netherlands in the Twentieth Century (Amsterdam: Rodopi, 2003), 213–42. 2. For a comprehensive summary of the development of family-centred care in America, including a review of the literature, see B.H. Johnson, ‘Family- Centered Care: Four Decades of Progress’, Families, Systems, and Health, 18, 2 (2000), 137–56. For a cross-cultural perspective, see L. Shields and J. Nixon, ‘Hospital Care of Children in Four Countries’, Journal of Advanced Nursing, 45, 5 (2004), 475–86. 3. Johnson, op. cit. (note 2), 139. 4. American Academy of Pediatrics Committee on Hospital Care, ‘Policy Statement: Family-Centered Care and the Pediatrician’s Role’, Pediatrics, 112, 3 (2003), 691–6. 5. See J.M. Carr and P. Clarke, ‘Development of the Concept of Family Vigilance’, Western Journal of Nursing Research, 19, 6, December (1997), 726–40: 726. 6. For example, see K.S. Powers and J.S. Rubenstein, ‘Family Presence During Invasive Procedures in the Pediatric Intensive Care Unit: A Prospective Study’, Archives of Pediatric and Adolescent Medicine, 153 (1999), 955–8; T.A. Meyers et al., ‘Family Presence During Invasive Procedures and Resuscitation: The Experience of Family Members, Nurses, and Physicians’, American Journal of Nursing, 100, 2 (2000), 32–43; D.J. Eichhorn et al., ‘During Invasive Procedures and Resuscitation: Hearing the Voice of the Patient’, American Journal of Nursing, 101, 5 (2001), 48–55. 7. Cincinnati Children’s Hospital Medical Center, Family-Centered Care Philosophy and Core Concepts, 2005, http://www.cincinnatichildrens.org/ about/fcc, accessed 26 January 2009. 8. Medical missions to China were predominately sponsored by British and American Protestant churches. For new medical missions established between 1890 and 1910, American out-numbered British, two to one. M. Renshaw, Accommodating the Chinese: The American Hospital in China, 1880–1920 (London: Routledge, 2005), 11. 9. There were only three in 1810, a number that had increased to 129 by 1873, of which a third were for the mentally ill. See J. Bordley and A.M. Harvey, Two Centuries of American Medicine (Philadelphia: W.B. Saunders Company, 1976), 57; C.E. Rosenberg, The Care of Strangers: The Rise of America’s Hospital System (New York: Basic Books, 1987), 118–9; G. Rosen, ‘The Hospital: Historical Sociology of a Community Institution’, in E. Freidson (ed.), The Hospital in Modern Society (London: Free Press of Glencoe, 1963), 1–36: 25. 10. ‘Walks About Canton: Extracts from a Private Journal’, Chinese Repository, 4 (1835), 44–5. 11. Renshaw, op. cit. (note 8), 11. 73

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12. C.J. Davenport, ‘Secretary and Treasurer’s Report for 1906’, China Medical Journal, 21, 3 (1907), 146. 13. Many dispensaries lived on as out-patient departments of hospitals. See, P. Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), 182–4. 14. Renshaw, op. cit. (note 8), 113–14. 15. The survey was carried out by the China Medical Missionary Association, ‘Medical [Mission] Statistics for 1906’, China Medical Journal, 21, 3 (1907), Endpaper. 16. ‘Letter to the Editor: Woman’s Hospital in Soochow’, Chinese Medical Missionary Journal, 1, 2 (1887), 73. 17. ‘Hospital Reports: Tsing-Kiang-Pu (Qingjiangbu) Hospital’, Chinese Medical Missionary Journal, 19, 1 (1905), 32–4: 33. 18. E. Reifsnyder, ‘Methods of Dispensary Work’, Chinese Medical Missionary Journal, 1, 2 (1887), 67–9: 69. 19. ‘Why Medical Missionaries are in China?’, Chinese Medical Missionary Journal, 14, 4 (1900), 278–80: 279. 20. Renshaw, op. cit. (note 8), 95–6. 21. O.L. Kilborn, Heal the Sick: An Appeal for Medical Missions in China (Toronto: Missionary Society of the Methodist Church, 1910), 189. 22. P. Parker, ‘Ophthalmic Hospital at Canton: The Ninth Report, Being for the Quarterly Term Ending December 31st, 1838’, Chinese Repository, 7 (1839), 569–88: 577–8. 23. Rosenberg, op. cit. (note 9), Ch. 12, 286–309. 24. R. Hawker, ‘A Day in the Life of a Patient’, Nursing Times, 12 June 1985, 43–4: 44. 25. Sisters of Mercy, Annual Report of St John’s Hospital and Training School for Nurses: October 1913–September 1914 (St Louis: 1915), 18–19. 26. R. Hawker, ‘Rules to Control Visitors, 1746–1900’, Nursing Times, 21 March 1984, 49–51: 50. 27. P. Parker, ‘Ophthalmic Hospital at Canton: Third Quarterly Report, for the Term Ending on the 4th of August, 1836.’ Chinese Repository, 5 (1836), 185–92: 185. 28. A.P. Peck, ‘The Development of the Medical Department of a Mission Station’, Chinese Medical Missionary Journal, 16, 1 (1902), 13–15: 14. 29. W.H. Jefferys and J.L. Maxwell, The Diseases of China (Philadelphia: P. Blakiston’s Son & Co., 1910), 7. 30. United States Bureau of the Census, Historical Statistics of the United States, Colonial Times to 1970, bicentennial edn (Washington: U.S. Department of Commerce, 1975), 75–6. 31. J.H. Snoke, ‘Administration of Mission Hospitals in China’, China Medical Journal, 37, 10 (1923), 860–6: 862. 74

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32. One-hundred and ninety-two hospitals provided information with reference to nurses: H. Balme and M.T. Stauffer, An Enquiry into the Scientific Efficiency of Mission Hospitals in China, paper presented at the Annual Conference of the China Medical Missionary Association (Peking, 1920), 31. 33. Paper read to Biennial Conference of the Nurses’ Association of China, Fuzhou: E.J. Haward, ‘Is China Ready for Women Nurses in Men’s Hospitals?’, Chinese Medical Missionary Journal, 33, 2 (1919), 174–7: 177. 34. In America, most educated nurses were employed by families who worked for them, both at home and when they went to hospital, as ‘Private Duty Nurses’. Student nurses provided hospital labour: E. J. Halloran, personal Communication, 2 December 2005. 35. See for example, ‘Rules for Companions to Patients’ in Sisters of Mercy, op. cit. (note 25), 21. 36. See, for example, M.H. Polk, ‘Women’s Medical Work’, Chinese Medical Missionary Journal, 15, 2 (1901), 112–19: 114. 37. A.D. Peill, ‘Roberts’ Memorial Hospital, T’sang-Chou’, Chinese Medical Missionary Journal, 18, 2 (1904), 99–100: 100. 38. A.D. Peill, ‘Hospital Reports: Roberts’ Memorial Hospital, T’sang-Chow’, Chinese Medical Missionary Journal, 20, 1 (1906), 44–7: 44. 39. W.A. Tatchell, ‘The Training of Male Nurses’, China Medical Journal, 26, 5 (1912), 269–73: 269. 40. D.M. Gibson, ‘The Old-Time Hospital and Assistants’, China Medical Journal, 33, 5 (1919), 475–6: 475. 41. Peill, op. cit. (note 37), 15. 42. Balme and Stauffer, op. cit. (note 32), 15–16. 43. ‘Medical Discussions in Shanghai: Following Dr Polk’s Paper on “Women’s Medical Work’’’, Chinese Medical Missionary Journal, 15, 4 (1901), 299–300: 299. 44. P. Parker, ‘Ophthalmic Hospital at Canton: The Eighth Report Including the Period from January 1st to June 30th, 1838’, Chinese Repository, 7, 2 (1838), 92–106: 94–5. 45. J.M. Bixby, ‘Kieh-Yang Hospital Report’, Chinese Medical Missionary Journal, 19, 6 (1905), 261–3: 262. 46. L.E.V. Saville, ‘Hospital Reports: London Mission Women’s Hospital, Peking, Annual Report, 1905’, Chinese Medical Missionary Journal, 20, 4 (1906), 188–91: 188. 47. Parker, op. cit. (note 22), 582. 48. This was the first baby born at the hospital: P. Parker, ‘Twelfth Report of the Ophthalmic Hospital at Canton: From 21st November, 1842, to December 31st, 1843’, Chinese Repository, 8, 6 (1844), 301–20: 305.

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49. P. Parker, ‘Ophthalmic Hospital at Canton: First Quarterly Report, From the 4th of November 1835 to the 4th of February 1836.’ Chinese Repository, 4, 10 (1836), 461–73: 462. 50. Parker, op. cit. (note 22), 571. 51. Parker, op. cit. (note 49), 463. Parker recorded but did not report numbers of female patients, see M. Renshaw, ‘The Nineteenth Century Hospital: Europe’s Gateway to Death – China’s Safe Haven?’ (Honours, University of Adelaide, 1998), 25–7. 52. P. Parker, ‘Ophthalmic Hospital at Canton: Second Quarterly Report, from the 4th of February to the 4th of May, 1936’, Chinese Repository, 5, 1 (1836), 32–42: 32. 53. Polk, op. cit. (note 36), 141. 54. Parker, op. cit. (note 52), 37. 55. As Rosenberg pointed out, in relation to antebellum hospitals in America, many ‘surgical’ patients were admitted but few operations undertaken. Treatment more often consisted of ‘diet and rest, the regular changing of dressings, and the healing powers of nature’, Rosenberg, op. cit. (note 9), 28. 56. I. Veith, The Yellow Emperor’s Classic of Internal Medicine: Translated with an Introductory Essay (Berkeley: University of California Press, 1972 [1949]), 2. 57. Kilborn, op. cit. (note 21), 197. 58. P. Parker, ‘Ophthalmic Hospital in Canton: The Fourth Quarterly Report, for the Term Ending on the 4ht [sic] of November, 1836’, Chinese Repository, 5, 7 (1836), 323–32: 229–31. The patient was seated in a chair, ‘supported around the waist by a sheet’ and less than a minute after the ‘application of the scalpel… the arm was laid upon the floor’. Po Ashing, was as far as Parker knew, ‘the first Chinese… who has ever voluntarily submitted to the amputation of a limb.’ 59. Ibid. 60. Twenty-Sixth Annual Report: CMS Hospital, Ningbo (Ningbo: C.M.S. Medical Mission, 1912), 198. 61. Peck, op. cit. (note 28), 14. 62. Bixby, op. cit. (note 45), 263. 63. ‘Hospital Reports’, Chinese Medical Missionary Journal, 13, 1 and 2 (1899), 56–7. 64. Parker, op. cit. (note 22), 578. 65. A.W. Fearn, My Days of Strength: A Woman Doctor’s Forty Years in China (London: Robert Hale Ltd., 1940), 64–5. 66. For discussion of Chinese Traditional Medicine and dietetics, see, E.N. Anderson and M.L. Anderson, ‘Folk Dietetics in Two Chinese Communities, and its Implications for the Study of Chinese Medicine’, in Arthur Kleinman et al. (eds), Medicine in Chinese Cultures: Comparative Health Care in Chinese and Other Societies (Washington: U.S. Department of 76

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Health, Education and Welfare, 1975), 143–76. See also, ‘Legacy of China’, Part 3 of Louis E. Grivetti, ‘Nutrition Past, Nutrition Today: Prescientific Origins of Nutrition and Dietetics’, Nutrition Today, 26, 6 (1991), 6–17. For a more general study of the place of food in Chinese culture, see K. C. Chang and E.N. Anderson, Food in Chinese Culture: Anthropological and Historical Perspectives (New Haven: Yale University Press, 1977). Linda Koo has demonstrated the extent of lay knowledge and use of food to prevent and treat disease in Hong Kong in 1981, see L.C. Koo, ‘The Use of Food to Treat and Prevent Disease in Chinese Culture’, Social Science and Medicine, 18, 9 (1984), 757–66. For a recent case study, see also E.N. Anderson, ‘Fishing People’s Medicine: Variations on Chinese Themes’ (2002), http://mcel.pacificu.edu/aspac/papers/scholars/anderson, accessed 26 January 2009. 67. D.J. MacGowan, ‘Report on the Health of Wenchow for the Half-Year Ended 30th September 1881’, in Customs Gazette: Medical Reports, No. 22 (Shanghai: Imperial Maritime Customs, 1881), 14–50: 45. 68. See Anderson, ‘Fishing People’s Medicine’, op. cit. (note 66). 69. Polk, op. cit. (note 36), 114. 70. Fearn, op. cit. (note 65), 65. 71. ‘Report of the Mission Hospital and Dispensary, Taiwanfu, Formosa’, Chinese Medical Missionary Journal, 2, 1 (1888), 94–5: 94. 72. H.N. Smith, ‘Nurses Training School’, Hwa Mei Hospital (Ningpo, China) Report for 1921 (Shanghai: American Baptist Foreign Missionary Society, 1922), 11–14: 12. 73. Parker, op. cit. (note 49), 469. 74. P. Parker, ‘Ophthalmic Hospital at Canton: Seventh Report, Being That for the Term Ending on the 31st of December, 1837’, Chinese Repository, 6, 9 (1837), 433–45: 439. 75. P. Parker, ‘Ophthalmic Hospital at Canton: The Sixth Quarterly Report, for the Term Ending on the 4th of May, 1837’, Chinese Repository, 6, 1 (1837), 34–40: 38–9. 76. Parker, op. cit. (note 74), 437–8. She was discharged five weeks later. 77. P. Parker, ‘The Fourteenth Report of the Ophthalmic Hospital, Canton, including the Period from 1st July 1845, to 31st December, 1847’, Chinese Repository, 17, 3 (1848), 133–50: 136, 137. 78. Parker, op. cit. (note 48), 307. 79. Parker, op. cit. (note 74), 438. 80. P. Parker, ‘Ophthalmic Hospital in Canton: The Fifth Quarterly Report, for the Term Ending on the 4th of February, 1837’, Chinese Repository, 5, 10 (1837), 456–62: 461. 81. Parker, op. cit. (note 58), 332.

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82. P.A. Cohen, History in Three Keys: The Boxers as Event, Experience, and Myth (New York: Columbia University Press, 1997), 165–6. 83. J.M. Carr and J.P. Fogarty, ‘Families at the Bedside: An Ethnographic Study of Vigilance’, Journal of Family Practice, 48, 6 (1999), 433–8. See also Giganti, op. cit. (note 1); Powers and Rubenstein, op. cit. (note 6); Meyers, op cit. (note 6); and Eichhorn, op. cit. (note 6). 84. Renshaw, op. cit. (note 51), 57–62. 85. R. Traux, Joseph Lister: Father of Modern Surgery (London: George G. Harrap & Co. Ltd, 1947), 56. 86. J.C. Thomson, ‘Surgery in China (Continued)’, Chinese Medical Missionary Journal, 6, 2 (1893), 69–79: 70. 87. R. Liston, ‘Clinical Lecture on Erythemia and Erysipelas’, Lancet (1835), 324–31: 325. 88. Renshaw, op. cit. (note 51), 62. 89. Liston, op. cit. (note 87), 325. 90. There are too many other contributing factors for a direct comparison to be made between the infection rate in a missionary hospital in China, which more closely resembles the ‘cottage’ hospital found, by Simpson in 1872, to be a safer place for patients, and a major ‘teaching’ hospital in the West where all patients were ‘material’. For example, see Rosenberg, op. cit. (note 9), 122. The fact that post-mortem examination and dissection were forbidden in China until 1913, I contend, would also have contributed to the low rates of cross-infection in hospitals. Renshaw, op. cit. (note 51), 67–9. 91. ‘L.M.H., Hiau-Kan Annual Report’, Chinese Medical Missionary Journal, 17, 3 (1903), 124–5. 92. Carr and Fogarty, op. cit. (note 83), 433. See also Carr and Clarke, op. cit. (note 5). 93. Carr and Fogarty, ibid., 435. 94. American Academy of Pediatrics, op. cit. (note 4), 692–3. 95. Powers and Rubenstein, op. cit. (note 6), 958. 96. E.J. Garton, ‘In Praise of Open Visiting’, Nursing Times, 11 October 1979, 1747. 97. Eichhorn, op. cit. (note 6), 53. 98. Q. Meng et al., ‘The Impact of Urban Health Insurance Reform on Hospital Charges: A Case Study from Two Cities in China’, Health Policy, 68, 2 (2004), 197–209: 198. 99. S. Eigles, ‘Medicine in China and the U.S.: Observations from an American Medical Student’, Oberlin Alumni Magazine, Spring (1998), http://www.oberlin.edu/alummag/oampast/oam_spring98/medicine.html, accessed 7 January 2009.

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100. My thanks to Zhang Dapeng whose first-hand account helped me understand the situation in China today.

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