A Medical History of Hong Kong: 1842–1941 [1 ed.] 9789882370784, 9882370780

Citation preview

A Medical History of Hong Kong 1842–1941

By Moira M. W. Chan-Yeung

THE CHINESE UNIVERSITY PRESS

A Medical History of Hong Kong: 1842–1941   By Moira M. W. Chan-Yeung © The Chinese University of Hong Kong 2018 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from The Chinese University of Hong Kong. ISBN: 978-988-237-078-4 The Chinese University Press The Chinese University of Hong Kong Sha Tin, N.T., Hong Kong Fax: +852 2603 7355 Email: [email protected] Website: www.chineseupress.com Printed in Hong Kong

To my teachers, colleagues, and students

This page intentionally left blank

Contents

Foreword 

/ vii

Preface / ix Acknowledgements / xiii Chapter 1  The Reluctant Birth of Medical Services in Hong Kong / 1 Chapter 2  Diseases of Venus: Prostitution and Its Control / 31 Chapter 3  The Chinese Hospital (Tung Wah): Its Rise, Decline, and Rebirth / 55 Chapter 4  Western Medicine: A Hard Sell in Hong Kong / 81 Chapter 5  The Inconvenient Truths: Sanitation in Hong Kong / 107 Chapter 6  The “Great Dying”: Bubonic Plague / 133 Chapter 7  Plague: A Breeding Ground for Improvements in Public Health / 157 Chapter 8  Women’s Medicine: Maternal and Infant Health / 181 Chapter 9  The Three Great Killers: Malaria, Smallpox, and Beriberi / 205 Chapter 10  A Century of Development and Achievement / 225

Appendices  Appendix 1 Medical and Public Health   Development Timeline, 1796–1941 / 253 Appendix 2 Governors, Administrators, Secretary of State for the   Colonies, and Heads of Medical Services, 1841–1941 / 265 Notes / 271 Glossary / 305 Bibliography / 309 Index / 319

Foreword

It is widely recognized that the health statistics in Hong Kong are among the best in the world. In 2015 infant mortality was 1.5/1,000 live births and the expectancy of life at birth was 81.4 years for males and 87.3 years for females. Much of the credit must be given to the healthcare system in Hong Kong. The government bears the responsibility for community health and preventive medicine through the Department of Health. It also provides curative care for most of the population through the Hospital Authority. But the rosy picture that we see today did not happen overnight. It has evolved over many years and many generations through the process of trials and errors, strife and reform ever since 1842 when Hong Kong became a British colony. Some of these changes were planned in response to a pressing need or came about through a desire to improve the future health of the population. But most were unplanned and adopted in haste in response to epidemics or social and political crises. The founding of the Alice Memorial Hospital in 1887 and the establishment of the Hong Kong College of Physicians for the Chinese, the forerunner of the Faculty of Medicine at the University of Hong Kong are examples of the former while the sanitary reforms and the development of public health after the devastating bubonic plague in 1894 are examples of the latter. This book is not just a chronological history of the medical and health system of Hong Kong between 1842 and 1941. It also gives a critical and dispassionate analysis of the different cultural, social, and political factors which prompted the government and the public to consider change and implement reforms with far reaching effects. It also teaches us that racial discrimination, social inequity, and mutual distrust are always obstacles to social progress including healthcare. Rosie T. T. Young December 2016

This page intentionally left blank

Preface

There have been many books written about the history of the individual medical or health institutions of Hong Kong, mostly to celebrate their anniversaries. One of the more comprehensive books on the medical history of Hong Kong, Plague, SARS, and the Story of Medicine in Hong Kong, published in 2006 by the Hong Kong Museum of Medical Sciences Society, marked the 10th anniversary of the Museum. Focusing on several topics, including infectious diseases, hospitals in Hong Kong, the Bacteriological Institute, health care issues, and medical education, it covered the period from 1842 to 2006. More recent books provide well-illustrated stages of development of different areas of medicine: orthopaedic surgery (Repair, Reconstruct and Rehabilitate—Half a Century of Orthopaedics in Hong Kong), emergency medicine (From “Casualty” to Emergency Medicine—Half a Century of Transformation), surgery (Healing with the Scalpel: From the First Colonial Surgeon to the College of Surgeons of Hong Kong), and medicine (Sapientia Et Humanitas: A History of Medicine in Hong Kong), published by the Hong Kong Academy of Medicine Press in 2004, 2006, 2010, and 2011 respectively. However, until now no study of the history has contextualized developments in medicine, health, and sanitation within the local and global political, social, and economic changes in Hong Kong. The development of medicine and sanitation in the Crown Colony of Hong Kong during the first half century of British rule is a fascinating history, providing a lens through which we might view important social, economic, and political changes in Hong Kong. This book tells the story of how the medical and sanitation policies of the Hong Kong colonial government reflected changing political values and directions from the time Hong Kong became a British colony in 1842 up to the start of the Second World War. In the beginning of British rule, the hands-off policies of colonial administration were based on principles of segregation and non-interference in Chinese affairs. When it was jolted awake by the widespread horror of the bubonic plague, the government

x   |   P reface

reacted with draconian intervention measures that led to an emptying out of half the population. Finally, in consultation with the Chinese leadership, the government learned strategies of friendly persuasion, public education, and propaganda campaigns to promote Chinese acceptance of Western public health policies and practices. This book also details how, during the first few decades of British rule, the administration’s laissez-faire policies, differing sanitary habits, and mutual mistrust of the Chinese people and the colonizing British led to a sorry state of public health in Hong Kong. In an unequal society, it was impossible to implement regulations that could be applied equally and impartially to members of two races. Not until the horror of bubonic plague, which struck Hong Kong in 1894 and continued to rock the colony at almost annual intervals over the following thirty years, did the government move to conduct sanitary reforms and develop public health measures to prevent the spread of infectious diseases. Each chapter of this book examines different turning points in Hong Kong’s medical history, while also showing how much the mingling of cultural values with both politics and history bleeds into this story. The chapters are arranged by theme and sometimes go over the same chronological periods. Chapter 1 narrates the story of how, shortly after the cession of Hong Kong to the British in 1841, severe epidemics of malaria partitioned the city of Victoria into east and west, separated by military barracks. This separation led to the aggregation of the Chinese in the Tai Ping Shan area, a breeding ground for the subsequent eruption of bubonic plague. It also describes the destructive effects of opium on physical, socio-political, and economic health of the population in China while the very same poisonous substance benefiting the financial health of the colony. Chapter 2 recounts how, while completely ignoring the prevalence of venereal diseases among the indigenous Chinese population, the government used medical interventions in brothels to protect those who served in Her Majesty’s Army and Navy from venereal diseases. Chapter 3 examines the establishment in 1872 of a Chinese hospital, Tung Wah Hospital, where impoverished Chinese were treated exclusively with traditional Chinese medicine. At a time when traditional Chinese medicine and Western medicine struggled for ascendance in Hong Kong, the Chinese elite, encouraged by the government, built this hospital with a grant and funds raised among the wealthy Chinese. After the

P reface   |   x i

devastation of the bubonic plague, the introduction of Western medicine into Tung Wah Hospital helped foster its gradual acceptance in the Chinese community. Chapter 4 tells how the members of the London Missionary Society founded Alice Memorial Hospital in 1887 and helped encourage acceptance of Western medicine through collaboration with local medical practitioners and westernized Chinese elite to provide free care to the poorer citizens. They also facilitated the establishment of Western medicine by founding the Hong Kong College of Physicians for the Chinese, the forerunner to the Faculty of Medicine, at the University of Hong Kong. Chapter 5 analyses the reasons that led to the unsanitary conditions in the densely populated Tai Ping Shan district. It explains the dismal failure to carry out recommendations of Osbert Chadwick, a metropolitan expert in sanitary engineering and son of British reformer Edwin Chadwick. The squalor and overcrowding in Tai Ping Shan, the Chinatown of Hong Kong, became the epicenter of the 1894 bubonic plague epidemic. Chapter 6 describes how the colonial administration used harsh, repressive measures in vain attempts to control plague, and the resulting Chinese exodus that left the colony’s economy in tatters. It took thousands of lives and millions of lost revenue before the government and the people would engage actively in sanitary reforms. Chapter 7 explores the sequelae of the plague epidemics: sanitary reforms and development of public health, the appointment of the first medical officer of health, the reorganization of the Sanitary Board and the Medical Department, and the founding of the Bacteriological Institute. Another milestone was the founding of the Chinese Public Dispensaries which provided free Western medical care and carried out the government’s public health measures, including birth and death registrations, public health education, and dissemination of propaganda material for public health measures. Staffed by Chinese doctors with programs on antenatal and infant welfare clinics and the government midwives, these highly successful dispensaries increased the acceptance of Western medicine in the Chinese community. Chapter 8 addresses the ways in which the missionaries and the Chinese elite together tackled the problem of high infant mortality in Hong Kong, by establishing the Alice Memorial Maternity Hospital,

x i i   |   P reface

a midwives’ training program, as well as antenatal and infant welfare centers in the Chinese Public Dispensaries. Aiming to avoid confrontation with the traditional midwives, the government created a parallel system of training in midwifery and the provision of popular free midwives’ services attached to the Chinese dispensaries. Chapter 9 examines the colony’s three great killers apart from plague—malaria, small pox, and beriberi—and the extent to which advances in Western medical science benefitted the people of Hong Kong. Finally, Chapter 10 assesses the status of medical and sanitary services, and the health of the population in Hong Kong after one century of British rule. Despite the haphazard way medical and sanitary services in Hong Kong developed before the Second World War, many factors contributed to Hong Kong’s entry into the ranks of “developed” countries by 1970: the establishment of public health measures and their acceptance among the Chinese; a reasonable supply of Western-trained local doctors and nurses; legislation on sanitary and health matters; and the government’s provision of medical care to the poorer Chinese. Even though most of the physical structures of hospitals were destroyed during Japanese occupation between December 1941 and August 1945, Hong Kong was able to rebound. Today its health indices are among the best in the world. This book draws on a wide array of archival material and scholarly literature, the details of which can be found in Bibliography.

Moira M. W. Chan-Yeung December 2015

Acknowledgements

I wish to express my gratitude to Dr. Shiu Man Hei, Dr. Kenneth Suen, Professor Rosie Young, and the late Professor Sir David Todd for their encouragement and most valuable advice in the preparation of the manuscript. I am especially indebted to Professor S. C. Tso for his careful reading of the manuscript and his insightful comments, Professor Y. W. Fung for his advice and suggestions, Professor Angela K. C. Leung for her information on smallpox vaccination and beriberi, and Dr. Elizabeth Sinn for her support and inspiration. My sincere appreciation goes to the late Dr. Sue Ann Cairns for her invaluable editing, Anne DyBuncio and Stanley Yeung for their help with preparation of graphs, and Miranda Ho for her secretarial assistance. Finally, I would like to gratefully acknowledge Hong Kong Museum of Medical Sciences, Alice Ho Miu Ling Nethersole Hospital, Tung Wah Group of Hospitals, and the Hong Kong Museum of History for permission to access to their archives and to reproduce photographs, and the staff of Special Collection of the Hong Kong University Library and Hong Kong Public Records Office for their unfailing assistance.

This page intentionally left blank

1. The Reluctant Birth of Medical Services in Hong Kong

The Founding of the Colony: Eyeing the Advantage On 26 January 1841, Royal Navy Captain Charles Elliot, Plenipotentiary and Superintendent of Trade, ordered the British flag to be raised at Possession Point, Hong Kong, which the British Foreign Secretary, Lord Henry John Palmerston, famously described as “a barren island with hardly a house upon it.” An unmistakable new energy animated the island with a population of about 7,500 Chinese residents, mostly fishermen and farmers living around the Aberdeen area, with a minority residing in Chek Chue (Stanley). Hundreds of mat-sheds gathered along the beach west of Cantonment Hill with its gentle sloping banks on the northern side of the island. Hong Kong, an apparently unpromising and lonely outpost, had been ceded to Britain at the Convention of Chuenpi (Chuanbi) after the First Opium War of 1839–1842. The process was confusing, and although a satisfying agreement briefly, it was to be the undoing of negotiators on both sides. The senior Chinese official responsible for the negotiation, Qishan (Keshen), was challenged with impeachment for giving up territorial rights to the “barbarians.” On the British side, Elliot was judged as stepping outside his mandate. He had been instructed by Palmerston to take Zhoushan (Chusan), a group of islands off the coast of Zhejiang province. He chose Hong Kong instead, believing its excellent harbor would support the British trading community in Guangzhou (Canton) while also serving as a base for the British navy.1 For his insubordination, Elliot would soon be replaced. Despite confusion surrounding the cession of Hong Kong that left in doubt whether sovereignty had really been yielded, Elliot proclaimed the full right of the British crown to administer the island as a British dominion, and offered protection to its residents. He then hurried to

2  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Guangzhou to arrange for the reopening of trade. Once that was settled, he returned to Macao (Macau), anxious to create a trading settlement in Hong Kong. Having no idea that he had been pushed aside, Elliot announced the appointment of Captain William Caine, of Her Majesty’s 26th regiment of infantry, as Chief Magistrate of the island pending Her Majesty’s further pleasure, in first issue of the Hong Kong Gazette, on 30 April 1841.2 On 7 June, he further announced by public notice his intention of disposing by public auction four types of lots: marine, town, suburban, and bazaar. The same day he blithely proclaimed Hong Kong a free port, inviting merchants to resort there to trade.3 All Chinese trade was to be exempted from any charge or duty of any kind to the British government. British traders from Macao seized upon this opening. Taking advantage of free trade promised by Elliot, they flocked to Hong Kong.

Victoria: A Kind of Gold Rush Town The sovereignty of Hong Kong had not been confirmed and the British government had given no indication that the settlement would be permanent. Nevertheless, Mr. A. R. Johnston, Deputy Superintendent of Trade, whom Elliot appointed to take charge of the government, organized the first land sale as ordered on 14 June 1841, a week later than planned. British traders, such as Jardine Matheson, jostled for land auction, drawn to Hong Kong as a place to store their goods for China trade and by the lure of British protection and free trade. The total number of lots sold that day was 404: 39 marine lots, 75 town lots, 22 suburban lots, and 268 bazaar lots.4 Johnston then hired hundreds of Chinese laborers to construct a major thoroughfare, Queen’s Road, which would stretch from Sai Ying Pun in the west to Wan Chai in the east. With the laborers came the hawkers, and soon seller stalls were consolidated into bazaars. Construction proceeded at a feverish pace. By August 1841, the land office and the post office were humming, the jail and the magistracy were almost completed, and ships clustered in the harbor. Elliot’s replacement, Sir Henry Pottinger, who arrived in Hong Kong in August 1841,5 also saw the potential for Hong Kong as a naval base that should not be abandoned. A military man chosen to replace Elliot because of his decisiveness and experience in battle, Pottinger hurried north, taking the expeditionary force up the China coast and occupying

T he R eluctant B irth   |   3

the Zhoushan Islands. He returned to Macao and moved the headquarters of the Superintendent of Trade to Hong Kong, enthusing in a letter home: “Within six months of Hong Kong being declared to have become a permanent Colony, it will be a vast Emporium of commerce and wealth.”6 Pottinger went north again the following June, up the Yangtze River, reaching and seizing Nanking by 5 August 1842. When the Treaty of Nanking was signed in 1842, he secured the cession of Hong Kong, and the opening up of Guangzhou and four additional ports: Xiamen (Amoy), Fuzhou (Foochow), Ningbo, and Shanghai, at which British subjects and British consuls could reside.7 On 26 June 1843, when the Nanking Treaty was ratified, Pottinger became the first Governor and Commander-in-Chief of Hong Kong. The town was to be called Victoria. Concerned by the indiscriminate building, Pottinger immediately established the Lands Committee to investigate claims regarding “allotted” locations of ground, and to define the locations already sold or otherwise granted.8 Figure 1.1  Painting of Pottinger’s house in 1845

Wikimedia Commons photo

By 1842 the Armed Forces had already chosen land for its two encampments in Hong Kong. The eastern encampment was situated on Cantonment Hill, called the “Artillery,” and later “Victoria Barracks,”

4  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

and is now occupied by part of the Hong Kong Park; it left a strip of land between the hill and the sea, now known as Admiralty. The western encampment was located in the area now called Sai Ying Pun. The Navy had laid claim to “Navy Bay” lying east of Belcher’s Battery. Anticipating the conflict that might arise between defense and commerce, Pottinger gave wide powers to the Lands Committee with the following mandate: to select public landing places, to define the limits of cantonments, to fix the extent of ground to be reserved for a naval depot and dockyard, and to select a watering place with a running stream of clean water.9 The City of Victoria developed around the Central district, bordered on the north by the Queen’s Road and the nearby Victoria Harbor (Figure 1.2). Most of the European buildings stood near the Police Station, but construction rapidly extended both east and west. The central area was almost exclusively European from the present Garden Road to Aberdeen Street, and uphill from the harbor to Hollywood Road. Buildings of all kinds were constructed, including a post office, a jail, a record and land office, other government offices, private residences, and markets.10 Figure 1.2  The City of Victoria was divided by the Cantonment Hill (the barracks) and the Government Hill (the government offices) into East (Wan Chai) and West (Central) in 1843

Source:  Adapted from maps of Victoria in 1880s, on the front pages of the book by Tsai, J. F., Hong Kong in Chinese History. Community and Social Unrest in the British Colony 1842–1913 (New York: Columbia University Press, 1993), front page xvi.

T he R eluctant B irth   |   5

The Chinese were encouraged to supply food and other necessities of life, and built mat-shed huts on the hillside to the west of the main part of town, extending to the waterfront. In August 1841, the Lower Bazaar was formed in the area later occupied by Jervois Street and Bonham Strand. The Chinese were allowed to settle in what was known as the Upper or Middle Bazaar, located on the other side of Queen’s Road opposite the Central Market. Completed by March 1842, the Upper or Middle and Lower Bazaars formed the first “Chinatown” in Hong Kong, and was positioned for the convenience of the denizens of the city.11

A Pall Descends: “Hong Kong Fever” in the Town of Victoria Victoria seemed to be thriving when early in July 1842, a fever epidemic descended on the Colony. Merchants and troops fell under a pall as sickness that started in the 26th Regiment began spreading quickly to other regiments: the 39th, then the 55th, and the 98th, which had returned to Hong Kong from the expedition.12 The death toll climbed. In the 98th Regiment alone there were 53 deaths in July, 70 in August, 40 in September, 55 in October, and 38 in November. Out of 905 soldiers, 256 died (28.3%)—40 from malignant fevers, 195 from cholera, acute dysentery, and diarrhea, and the balance from other causes.13 Still stationed on board the steam frigate Queen near Shanghai when the outbreak occurred, Pottinger blamed the illness on excessive drinking and exposure to the hot sun.14 A military court inquiry was launched, but nothing was found to substantiate Pottinger’s wild claim. Instead, the Court came to a different conclusion—that the disease was related to the climate and locality. Since all who stayed for any length of time at the West Point Barracks contracted disease, the location was deemed most unhealthy.15 The fever outbreak and the conclusion of the court of enquiry greatly influenced the subsequent development of the city. To ensure the prosperity of his young Colony, Pottinger had wanted to situate the entire length of the Queen’s Road along the waterfront, with streets radiating from it, for shops, warehouses, and dwelling houses.16 However, because of the conclusion that West Point was unhealthy, Major General Commanding Land Forces in China, A. F. Saltoun, sought to relocate all the soldiers from there to Cantonment Hill, consolidating the defense position and accommodations for all officers and troops. Such a strategy

6  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

would require taking over the strip of land between the foot of the hill and the sea for building more barracks, effectively dividing the City of Victoria into two portions; Wan Chai to the east, and the Central District to the west.17 Dreaming of the Colony’s future prosperity, Pottinger’s priorities differed from those of Saltoun, who was most concerned with the health of the troops. The “battle” for the narrow strip of land at the base of the Cantonment Hill began with Pottinger’s missive to Lord Stanley, Secretary of State for the Colonies: “I think that carrying out those plans will interfere very much with the increase in prosperity of Hong Kong as an Emporium of Trade which was, I believe, the sole, or, at least, the chief object to secure its cession….”18 He and Saltoun each submitted proposals to Lord Stanley and the Parliament. Meanwhile, by June 1843, the fever, soon to be called “Hong Kong fever,” began to claim its victims in the West Point Barracks.19 Confident of his success, Saltoun suggested that Pottinger should warn people who were living in that strip of land of the possibility of it being taken over by the military. In July, among a total of 408 admissions to hospital, 294 were suffering from fever with 25 deaths from fever, and 14 from other diseases. All but two of the nine officers in the detachment suffered from disease, and two died. This was enough for Saltoun, who then removed all men from the West Point Barracks to “Cantonment Hill.”20 In his long awaited reply, which took six months to arrive, Lord Stanley indicated that he did not intend to let the young Colony suffer.21 This answer was an empty victory for Pottinger, as both the Army and the Navy, disregarding what Lord Stanley had said, had requested land to build a hospital outside the Cantonment Hill. When the Army requested land by the sea parallel to the Five Gun Battery, Pottinger could not refuse, knowing the important role that the military would play in the defense of the Colony, and he gave this prime real estate away with great reluctance. For its part, the Navy requested land on higher grounds.22

Tai Ping Shan—“Chinatown” of Hong Kong Victoria continued to grow so rapidly that by the middle of 1843 the central district had run out of land for development. On the east, development was restricted by the “Government Hill” and the military cantonment. The only direction available for expansion was westward,

T he R eluctant B irth   |   7

where a large number of Chinese houses in the Upper Bazaar blocked the development of streets and drainage. The government took over the land of the Upper Bazaar for transformation into the European commercial area, and moved the Chinese lot-holders to another area—Tai Ping Shan— uphill and south of Queen’s Road, from approximately Gough Street in the east, to Possession Street in the west, and Caine Lane and Rutter Street in the south.23 This became the second “Chinatown” of Hong Kong (Figure 1.3). Figure 1.3  Map of Victoria showing Upper (or Middle) Bazaar, Lower Bazaar, and Tai Ping Shan district in 1843

Source:  Adapted from maps of Victoria in 1880s, on the front pages of the book by Tsai, J. F., Hong Kong in Chinese History. Community and Social Unrest in the British Colony 1842–1913 (New York: Columbia University Press, 1993), xvi.

The resumption of Upper Bazaar was carried out in a way that flagrantly violated the rights of property ownership. This takeover was documented by Evans in 1970, and will be summarized briefly here. On 22 January 1844, the lots of the Upper Bazaar went on sale, and the Chinese lot-holders learned only after the fact that their lots had been sold

8  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

out from under them. Sometime after the lots had been sold, Pottinger appointed a committee to consider where the Upper Bazaar lots should be relocated and on what terms. Although the Chinese petitioned to remain, they were told that the certificates that they had received in 1842 were only temporary since the Treaty had not been ratified until 1843. The committee recommended that if the Chinese moved to Tai Ping Shan, which would be leveled with streets marked out, they would have their arrears of rent excused and would enjoy a “rent holiday” for a period of five years, as well as $50 compensation.24 Pottinger approved the first two of the committee’s recommendations, but vetoed the monetary compensation; partly because some of the residents were unauthorized squatters, and also because others kept brothels and gambling houses which he wanted to remove.25 However, Pottinger did nothing to carry out the committee’s recommendations before he left Hong Kong in May 1844. John Davis, an authority on China who succeeded him,26 immediately encountered problems. Since the possession date of the Upper Bazaar lots was only two months away, Davis’s first problem was to remove the disgruntled Chinese residents of Upper Bazaar to Tai Ping Shan. No work had been done to level Tai Ping Shan or to mark out the streets, and Davis immediately directed the work to be done, without even ordering an estimate. He also published a notification that the Upper Bazaar lot-holders should remove themselves by 25 August so that the purchasers could take possession on 31 August.27 This was the beginning of Tai Ping Shan, a place for the poor Chinese. In sum, to prevent epidemics of malaria among soldiers, the government gave away the Admiralty area to the military and limited the eastward expansion of the city. Expansion westward was carried out by forcibly taking over the land occupied by the Chinese in the Central district and removed them to the Tai Ping Shan area. Half a century later, the government would again appropriate Tai Ping Shan district occupied by the Chinese, destroying and rebuilding it completely, as a solution to the plague epidemic. It is difficult to imagine what Victoria would have become, absent the havoc wreaked by the Anopheles mosquitoes in its early years.

T he R eluctant B irth   |   9

Class and Racial Divide As the population in Hong Kong swelled to 15,000 by March 1842, the stage was set for overcrowded conditions and squalor associated with gold rush towns. The first census in 1854 showed the total population to be 55,715, with 40,517 males and 15,198 females. Europeans only accounted for 2.4%, Chinese 97.1%, and the balance were Indians and others.28 There was a clear class divide between the Europeans and the Chinese. Apart from soldiers and sailors in the Navy, along with some adventurers who kept the taverns busy, the Europeans were mostly in the civil service, merchants and their families, and merchant sailors. The Chinese were laborers, stone cutters, builders, coolies, prostitutes, hawkers of every description, jugglers, fortune-tellers, and actors belonging mostly to the lower social class.29 Elliot’s policy had also set the pattern for segregation of the Chinese in Hong Kong. When he proclaimed the British right to govern Hong Kong, he also declared that its inhabitants would be “secured in the free exercise of their religious rites, ceremonies, and social customs.” The natives would be governed in accordance with “the laws, customs and usages of the Chinese (every description of torture excepted),” implying that the British system of administration would not be applied to the native people of Hong Kong. The government would not interfere with the Chinese way of life.30 Under government policy, which encouraged Chinese and Europeans to live in separate parts of the city, the Chinese were despised and treated with contempt, ostensibly because of unreliability and involvement in crime. According to Lethbridge, however, the disrespectful attitude toward the Chinese cannot be wholly attributed to racism and ethnocentricity. He suggests that class snobbery was also a crucial factor, as many British had been accustomed to treating the lower classes of servants in Britain as badly as they treated their Chinese servants, rickshaw coolies, chair bearers, night-soil porters, and other menial workers.31 The Reverend George Smith, later Bishop Smith, came to the Far East between 1844 and 1846 and visited Hong Kong several times. He considered the island, a reputed base for pirates and thieves, unworthy of missionary efforts for the Church Mission Society. The Chinese, he wrote, were “the lowest dregs of native society that flocked to the British settlement in the hope of gain or plunder.” The Reverend Smith found

10  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

their moral and social character to be totally different from that of the people in the cities of northern China. He did not think much of his own countrymen either, owing to their “moral improprieties and insolent behavior,” and the frequent scenes in the streets that brought discredit upon the British.32 The Colony failed to attract a higher social class of Chinese in the beginning since it was against the law in China to migrate to another country. The Taiping Rebellion, which began in 1850, caused tremendous upheaval in southern China, sending many refugees to Hong Kong. By the end of 1860 the population in Hong Kong, which fell just short of 100,000, included the wealthier and better educated Chinese who had fled seeking a better and more secure place for their families to live. As Hong Kong was developing into a staging post for Chinese emigration, the need for laborers overseas and the reliance of Hong Kong as a transshipment center provided much of the economic activity in its formative years. The increasing emigration also generated re-export of Chinese goods to support the expanding Chinese communities overseas, laying the foundation for entrepot trade in Hong Kong.33

British Governance and Questions of Justice After signing the Treaty of Nanking, Pottinger set up a small local government in Hong Kong with just a handful of administrators. One does not have to go far exploring the streets of Hong Kong today to find major streets that memorialize several of Pottinger’s appointments: A. R. Johnston, Assistant and Registrar to the Superintendent; LieutenantColonel Malcolm (an exception), officiating Colonial Secretary; Charles Stewart, Treasurer; Major William Caine, Chief Magistrate; J. R. Morrison, Chinese Secretary; and Lieutenant William Pedder, Harbor Master. Pottinger also appointed Johnston, Morrison, and Caine to the Executive Council and the Legislative Council, to assist him in governing according to the Hong Kong Charter.34 In those days, Britain expanded its empire in order to facilitate trade. In administering a colony, the governor followed a set of basic instructions laid down in the Colonial Regulations, the “Directions to Governors for general guidance by the Crown through the Secretary of State for the Colonies.” The Secretary of State for the Colonies, who acted formally in the name of the Crown, had complete authority to prescribe what should

T he R eluctant B irth   |   1 1

be done in any colony, and to supervise and control all the actions of the local administration, except for matters of defense and foreign policy. The governor was bound to carry out all such instructions or risk the possibility of dismissal. In reality, the Secretary of State for the Colonies and the Parliamentary Under-Secretaries, who were politicians, never held this portfolio for long. Furthermore, few would be able to grasp the complexities of administering 50 colonies in different parts of the world to give coherent, effective direction (Appendix 2 Table 2). The Secretary of State for the Colonies relied on career civil servants who might have been better informed, but were usually inundated with hundreds of papers from numerous colonies that had piled up on their desks. The governors should have been able to assess the local situation, but as they often moved from colony to colony (Appendix 2 Table 1), they were not around long enough to familiarize themselves with the local scene, let alone Chinese customs, values, and practices in Hong Kong.35 The governors had free reign to govern as they wished, as long as they appeared to follow the Colonial Regulations, and generated adequate local revenue to defray government expenditures. Since governors were tasked with balancing the budget, Governor Davis was in a particularly unenviable position, as Captain Elliot had declared Hong Kong to be a free port. Davis was caught between irreconcilable demands. The home government required that the colonial revenue be raised to defray all its expenses in public works and other local services. On the other hand the few hundred English merchants believed that the home government should bear all the expenses with a grant, while demanding utmost freedom from government interference. During the first few years, the Colony had failed to develop into a “mart” of the Far East for a variety of reasons: rampant piracy in nearby waters around Hong Kong, the opening up of several treaty ports in other parts of China, and wealthy Chinese merchants finding it more advantageous to be at Guangzhou. The revenue collected was small but the expenditures great, due to the large number of necessary public works (Table 1.1).36 The deficits in the initial years were made up by a grant from the British Parliament. To balance the budget, Governor Davis passed a series of revenue generating bills to keep the government afloat. He raised the rate of maintenance of a police force, imposed licenses for the sale of liquor and tobacco, and farmed out the monopoly of the retail opium

12  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Table 1.1  Revenue, expenditure, total expenditure (%) on medical services, police, and public works from 1845–1860 Budget in sterling pound (£) Year

Total expenditure (%)

Population Revenue Expenditure Balance Medical Police Public works

1845

23,748

22,240

66,730

-44,490

1.2

14.8

20.2

1846

22,450

27,820

60,590

-32,770

1.2

19.6

44.2

1847

23,872

31,100

50,960

-19,860

1.4

20.9

34.5

1848

21,069

25,070

62,310

-37,240

1.4

14.4

27.8

1849

28,913

23,620

38,990

-15,370

2.4

17.6

10.9

1850

33,243

23,530

34,310

-10,780

2.4

19.8

3.8

1851

32,983

23,720

34,110

-10,280

2.2

20.8

4.7

1852

37,058

21,000

34,760

-13,760

2.1

18.3

14.2

1853

39,017

24,700

36,410

-11,710

2.0

18.5

16.1

1854

55,714

27,040

34,610

-7,570

1.4

20.4

15.1

1855

72,607

47,970

40,810

7,160

0.8

19.5

24.2

1856

71,730

35,500

42,420

-6,920

0.9

23.3

20.3

1857

77,094

58,840

65,490

-6,650

0.6

15.4

22.9

1858

75,503

62,480

62,980

-500

1.1

13.4

29.3

1859

86,941

65,230

66,110

-880

1.6

15.4

22.7

1860

94,917

94,180

72,390

21,790

2.1

13.5

27.3

Note:  A deficit exists in almost all years between 1845 and 1860. The expenditure on public works dropped to below 5% in 1850 and 1851, during the years of Governor Bonham’s administration Source:  Hong Kong Blue Books, 1845–1860.

trade in the Colony. The ordinances, particularly the one concerning opium monopoly, evoked fierce opposition from the British merchants, but also became the foundation of the Colony’s fiscal system. Davis’s attempt to impose a registration system and a poll tax on all inhabitants in Hong Kong met with stiff resistance from both Europeans and Chinese, with the registration eventually confined to the Chinese and the poll tax dropped completely.37 Despite his hard work in the challenging, formative years of the Colony, Davis was the most unpopular governor among the locals in early Hong Kong, heartily disliked by both the Chinese and the Europeans by the time he left office.

T he R eluctant B irth   |   1 3

The Colony’s Treasure Chest—Opium Monopoly By farming out the monopoly of opium trade to the highest bidder, Davis was able to reduce the government’s deficit compared to previous years. The monopoly of the opium farmer was protected as it was a criminal offense to be found in possession of prepared opium unless it had been purchased from the farmer. Davis set the trend of generating a significant proportion of the government’s revenue from opium trade and solved the financial problem for the future colonial governments. Figure 1.4 shows the revenue from farming out the opium monopoly and the proportion of government revenue derived from the opium monopoly between 1886 and 1913.38 It accounted for almost 30% of the government’s total revenue between 1904 and 1906. Figure 1.4  Revenue from government farming out opium monopoly in HKD and as a percentage of total government revenue, 1886–1913

Source:  Norman Miners, Hong Kong under Imperial Rule, 1912–1941 (Hong Kong: Oxford University Press, 1987), 212.

Until the British started importing opium, foreign trade with China always resulted in deficit with vast amount of silver flowing into China. The European traders could not get enough tea, silk, and porcelain from China but the Chinese were self-sufficient and had no interest in woolens, furs, or spices. The trade situation reversed after the British East India Company secured a monopoly on opium which was sold to

14  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

British merchants in Calcutta in 1773. The opium from India was very popular in China, rich and poor Chinese alike gathered in opium dens called divans to smoke the drug, and millions of Chinese—government officials, merchants, coolies, and servants, became addicted and subdued. As the Chinese consumption of opium grew rapidly, the Emperor Jiaqing became alarmed and banned opium trade in 1799, but the ban could be easily circumvented by the greedy and corrupt Chinese local officials who were involved in a smuggling network. The First Opium War was the result of the action of Viceroy Lin Zexu, who seized 20,000 chests of opium from the British in Guangzhou and dumped them into the trenches by a river, mixed them with lime and flushed them out to the sea. The British led an expeditionary force to blockade Guangzhou. Because of the superior British naval power, the Chinese finally agreed to sign the draft treaty—the Convention of Chuenpi—in 1841. This was replaced by the Nanking Treaty in 1842, with the cession of Hong Kong and the opening up of five treaty ports as mentioned before. No sooner had peace been negotiated than the insatiable British merchants began the Second Opium War in 1856 to legalize opium trade, to expand coolie trade, and to again access to all of China. The Second Opium War ended in 1860, with the removal of all residual restraint on the trafficking of opium as China began cultivating poppy, and the cession of Kowloon to the British. Opium trade flourished while other business failed to prosper in the young Colony. All major foreign firms dealt in opium trade. Davis reported to the Secretary of State on 13 May 1844 that he was unable to recommend any local resident as an unofficial member of the Legislative Council because “almost every person possessed of capital who is not connected with government employment is employed in opium trade.”39 In 1868, Governor Richard G. MacDonnell estimated that the total amount of opium imported annually into Hong Kong from India averaged about 80,000 chests (about 160 pounds of opium per chest, one pound equals 12 taels), valued at £11 million. Of these, 63,000 chests were sent north along the China coast to various treaty ports, 4,000 to 4,500 chests to non-treaty ports, 10,000 chests to Macao, and the remaining consumed by the local Chinese. Any colonial official, who considered curbing the opium trade, realized that an attempt to control the influx of opium would be blocked by the government of British India.40 The smoking of opium does not involve burning as in the case of

T he R eluctant B irth   |   1 5

tobacco. Prepared opium is indirectly heated to temperatures that cause active alkaloids, chiefly morphine, to vaporize. Opium users traditionally “smoked” the drug in a specially-designed pipe (Figure 1.5) with a glass porcelain or metal bowl and a long stem usually made of bamboo, although ivory, silver, or even jade, were also used. Smokers would lie on their sides to prevent falling as they relaxed and dozed after inhaling the heated vapor of opium (Figure 1.6). There was a great deal of controversy in those early days on the health effects of opium. Dr. P. B. C. Ayres, Colonial Surgeon, reported year after year in his annual reports on the harmlessness of opium if smoked in moderate amounts. Under his observation and experimentation on the Chinese prisoners in gaol, opium smokers did not experience any withdrawal symptoms on deprivation.41 It appears to me that the opium smoker suffers much less from the enforced privation of the accustomed luxury at once than the tobacco smoker. Many of them make no complaint at all. There is no particular symptom caused by the deprivation, which is common to all…. Yet according to statements made by the Anti-opium League, they ought to have suffered tortures, but then it is the custom of the Anti-opium League to repeat and believe all the yarns they hear, and not take very much trouble about verifying them…. I am still of opinion that there are few subjects concerning which so much nonsense has been talked, or so many false impressions [have] been disseminated as about opium smoking which from all I can gather seems in itself a most harmless practice…. I contend that opium smoking has no effect whatever on the opium smoker.…42 Dr. Ayres reported that smoking only large amount of opium could lead to addiction and that tobacco smokers suffered more effects of withdrawal when deprived compared to opium smokers. It is well known now that opium is a narcotic and smoking even a small amount can lead to addiction. Chronic opium abuse results in changes in behavior, and damage to the heart, liver, lungs, and brain. Because of the high cost of the drug and the consistent need to use it, even a gainfully employed worker might be ruined by the habit as he would spend nearly everything he earned on his habit. With no savings sometimes he could not afford even poor-grade opium and withdrawal symptoms kicked in. Many

16  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Figure 1.5  An opium pipe, an opium lamp, spare pipe-bowls, and other implements lie arranged on a layout tray; a second opium pipe rests nearby

Photographed by Steven Martin, via Wikipedia

Figure 1.6  Opium smokers in a Chinese opium den

Wikimedia Commons photo

T he R eluctant B irth   |   1 7

suspected that Ayres himself was an opium user. While he was derided for his defense of opium smoking, the five successive governors during Ayres long-serving years, and those who served after Ayres’s departure, cited his remarks to uphold their opium policy. In 1908 under international pressure, British India undertook to reduce her export of raw opium to China over a period of 10 years, and China on her part also started to reduce the acreage of opium growing. The Colonial Office issued an order to close all opium divans in Hong Kong over a period of two years. 43 With a great deal of reluctance Governor Frederick Lugard ordered all 192 opium divans in Hong Kong to be closed in stages completed by March 1910.44 He successfully negotiated a compensation of £9,000 in 1910–1911, and £12,000 in 1911–1912 and 1912–1913, from the British government for the loss of revenue from the opium farm which was let at HK$1,185,200 per annum.45 The work of the Anti-opium League culminated in Hague International Opium Convention, during which an agreement was reached in January 1912 to control the production and distribution of raw and prepared opium, to take measures for the gradual and effective suppression of the internal trade in and use of prepared opium, and to prohibit its import and export.46 Because the British and all colonies all signed the agreement, Hong Kong was threatened with insolvency. Governor May, with the support of the Legislative Council, proposed to, and accepted by, the Colonial Office that the Hong Kong government should set up its own monopoly for the preparation and sale of opium. The government monopoly would maintain a strict control over the use of opium so that the abuses could be checked.47 The prepared opium was only for local consumption and not to be exported to China. Under the government operation, the price of opium had escalated from $6.5 per tael in 1913 to $10 per tael in 1914. The revenue from opium monopoly shot up to over $3.5 million in 1914 constituting 34% of the government revenue, increasing in subsequent years to more than 40% before its eventual decline (Figure 1.7).48 Opium monopolies in all Eastern colonies including the one in Hong Kong, continued to make profits right up to the outbreak of the Pacific War, despite the strong pressure for closure of the colonial opium monopolies from the Foreign Office, the Home Office, the League of Nations, International Labor Office, numerous philanthropic societies in Britain and the United States. During the last year of operation 1940–

18  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Figure 1.7  Revenue from Hong Kong government’s opium monopoly in HKD and as a percentage of total government revenue, 1914–1940

Source:  Miners, Hong Kong under Imperial Rule (1912–1941) (Hong Kong: Oxford University Press, 1987), 232.

1941, the Hong Kong government made greater profit than the previous few years because of the massive influx of refugees from the mainland as a result of the Sino-Japanese War. Most of the time the Colonial Office tenaciously defended the financial interests of the colonies against other government departments in Britain frustrating efforts to implement opium control. Hong Kong’s official role as a base for the supply of opium to China ended only in 1943 when the British government, under pressure from the United States, had decided to adopt the policy of total prohibition of opium smoking in its Eastern territories. The prepared opium monopolies run by the colonial governments would no longer be reestablished after British rule was restored.49

Health and Sanitation in the Young Colony From “Hong Kong Fever” to Syphilis Hong Kong proved to be an unhealthy place, especially for Europeans. The malaria outbreaks during the summer of 1842 and of 1843 affected not only the troops, but also the European civilian population as 10% of them succumbed to the 1843 epidemic.

T he R eluctant B irth   |   1 9

Although malaria was only one of the causes of death, it had always been considered the reason for the unhealthiness of Hong Kong at that time. By 1843, the fever that became widely known as “Hong Kong Fever,” was closely identified with the unsanitary conditions, as well as the lifestyle and cultural practices of the Chinese, who lacked knowledge of modern sanitary measures. The Colonial Surgeon, Dr. William Morrison, reported in 1848 that the fevers usually started in May, increased in June and July, continued during August, and subsided in September. The average duration of the disease was about 56 hours, and death generally occurred about the third day, but often only a few hours after admission. This disease was called febris remittens, and described as congestive and malignant.50 Table 1.2 shows the mortality rate of the Europeans compared with the native population.51 These numbers may not be entirely accurate, as there was no proper census and no death registration at that time. They nevertheless suggest a remarkably high number of European deaths as compared with the native population—although it is likely that the preference of the Chinese to die in their own villages gave rise to a deceptively low death rate. In 1852 for example, it had been estimated that a total of 1,020 (2.7%) Chinese residing in Hong Kong died, but only 258 (0.7%) of them died in the Colony, while the rest returned to their villages. On the other hand, it may also be that generations of living in the environment might have equipped the Chinese with immunity to prevalent infectious diseases such as diarrhea, dysentery, and malaria. It is also possible that the Chinese habit of drinking tea prepared in boiling water might have helped ameliorate the poor water quality. Dr. Francis Dill, the Colonial Surgeon, recorded the ten most common types of diseases among 501 patients whom he saw that year: ague (acute fever) 14.6%, diarrhea 14.2%, remittent fever 11.9%, dysentery 10.1%, venereal diseases 7.2%, liver diseases 7.2%, ulcers 5.8%, wounds and accidents 5%, catarrh 3.2%, and rheumatism 3.2%.52 The cause of acute fever was unclear, but remittent fever was likely malaria. Venereal diseases occupied the fifth place. The mortality rate of the police officers, which was composed of 40% Europeans with the balance Indians and Chinese, ranged from 2.8% to 9.4% during this period. Their high sickness rates meant that adequate manpower to deal with the rampant robberies and crimes in the Colony was often lacking.53 From 1845 to 1860, the prevalence of diseases and

20  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Table 1.2  Population and deaths, total and Europeans only, 1845–1860* Year

1845 1846 1847 1848 1849 1850 1851 1852 1853 1854 1857 1858 1859 1860

Europeans (excluding troops) Deaths Population % mortality

40 75 81 125 65 89 67 67 66 NA 126 110 70 51

731 990 603 642 656 585 617 1,005 776 1,344 1,411 1,462 1,034 1,592

5.47 7.57 13.43 19.47 9.91 15.21 10.86 8.42 9.42 NA 8.93 7.52 6.76 3.20

Total population+ Deaths Population % mortality

NA NA 140 227 104 125 255 258 268 NA 888 546 406 280

NA NA 21,069 20,980 28,913 33,243 32,983 37,058 39,017 55,715 77,094 75,503 86,941 94,917

NA NA 0.66 1.08 0.36 0.38 0.77 0.69 0.68 NA 1.15 0.72 0.47 0.29

Note:  * There were no returns before 1845 and 1854–1856 in the Colonial Surgeon’s Report; + The total population included Westerners (Europeans and Americans), Chinese, and Indians. The Chinese accounted for the majority of the population, and Indians only a minority. NA=not available. Source:  Hong Kong Blue Books, 1842–1860.

mortality of the military troops were also high. In 1850, the mortality of the troops was so high (23.9%) that the police force had to be sent to guard the naval stores.54 This pattern of disease with prominence of fevers would change less than two decades later. In the Colonial Surgeon’s annual report of 1862, Dr. Murray described the type of diseases that brought the patients into the Government Civil Hospital: syphilis 20%, fevers 17%, accidents and wounds 11.5%, diarrhea and dysentery 7.5%, and smallpox 3.5%.55 Syphilis, a venereal disease, now topped the list—the epidemic would beleaguer Hong Kong for the next century.

Ad Hoc Sanitation Town planning in the early days was limited to the use of land and marking up streets, with little thought given to sanitation. Necessities were met on an ad hoc basis. During the 1843 fever epidemic, when Hong Kong lost about 10% of its European population, including the

T he R eluctant B irth   |   2 1

Chinese Secretary, J. R. Morrison, son of Robert Morrison, Pottinger set up a Public Health Committee to enforce “a rigid system of attention to Sanitary Rules.” He then removed himself to Macao with other wealthy merchants.56 After the regiment moved out of the West Point Barracks in Sai Ying Pun because of an outbreak of fever in the summer of 1843, the flooring was exposed and found rotten, having been built on pools of water.57 In many other areas that were also subject to flooding, puddles of stagnant water gathered on uneven grounds after rainstorms, nurturing the growth of mosquito larvae. Though the cause of the fevers was not clearly understood then, the association between stagnant water and the outbreaks of fever had long been known. The Public Health Committee therefore recommended drainage of four different areas. Pottinger, being criticized for his escape to Macao during the outbreak, vigorously pursued a comprehensive program of drainage as recommended.58 As there was no sanitary department, he instructed Major Caine, the Superintendent of Police, to set up a permanent body of men to ensure that all drains, sewers, and water courses, as well as the streets and lanes, be cleared of filth, stones, and rubbish.59 Pottinger was determined to construct sewers and road drains along existing streets. The new drainage system was built by untrained laborers, including prisoners, and was rapidly destroyed by the heavy rainstorm in the summer of 1845. This presented the next governor with yet another urgent problem. Devoting his energy to clearing the city of swamps, Governor Davis dealt with the drainage problem much more successfully than his predecessor. Unlike Pottinger, he was on friendly terms with Aldrich, the Commander of the Royal Engineers, and had engaged the Royal Engineers to construct a “catch water drain” along the base of the hill above the town to conduct water into proper channels, rather than allowing it to spread over the surface of the ground and fill the paddy fields.60 By 1845 the complete survey of the island had been completed and Davis, again with the help of the Royal Engineers, built the Pok Fu Lam “highway” cutting through the old West Point Barracks to Aberdeen, connecting the island from north to south.61 The clearing of swamps and improved drainage, in addition to the building of roads, brought about a reduction of mortality of the troops from 10% in the previous year to 6% in 1846. This led Dr. Dill, Colonial Surgeon, to conclude confidently in his annual report of 1846: “I am fully persuaded that this place is now

22  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

the healthiest British settlement east of the Cape of Good Hope and this I ascribe wholly to the great improvement in the way of drainage, roads, and suitable dwelling.”62 Alas, he sang praises for the infant Colony too soon, as he himself succumbed to an illness about one month after he completed the report.

The Luxury of a Water Supply Davis worked to ensure a water supply for the local population, which had relied on mountain streams for their water, by constructing tanks and wells. The Royal Engineers brought water from the ravine west of Albany to the summit of Caine Road, between Arbuthnot and Old Bailey Road. From there, water was directed via a stone channel into four culverts and 16 tanks, then transported into town by iron pipes.63 Despite these innovations, many residents still had to drill wells to supplement their water supply. The Chinese population in Tai Ping Shan continued to depend on water from streams running down from the peak. The Water Lane in Tai Ping Shan used to be a stream running down to the sea, which the Chinese used for consumption and disposal of household waste. In dry weather, water had to be carried from quite a distance from their residence. For poor people, fresh water was a scarce, expensive luxury.

Development of Early Medical Services Once the British Armed Forces, under the administration of the War Office, took possession of Hong Kong, they promptly erected the Naval and Military Hospital. Thrown up hastily, the hospital to look after their sick and injured was destroyed by the first typhoon of the season. During the malaria epidemic of 1842, two unseaworthy ships, Moira and Salaiman, served as hospitals, but Moira caught fire and Salaiman leaked. Patients were transported back to the barracks.64 HMS Minden, which arrived on 7 June 1843, was the first hospital ship fitted appropriately for this purpose.65 Other ships also served as hospitals for the Army. Later both the Army and the Navy had their own hospital on the island, and in 1873, the Navy bought the Seamen’s Hospital to be the Royal Navy Hospital. For the sick and injured in the Armed Forces, facilities were now

T he R eluctant B irth   |   2 3

superb with a salubrious environment and plenty of qualified medical personnel. At one time there were 12 medical officers in the garrison to serve 5,000 soldiers. The military could certainly afford to share one medical officer with the Governor Bonham’s administration as a part-time Colonial Surgeon.66 Medical services for civilians in Victoria were in the hands of private doctors. For the Europeans, there was no shortage of needy Scottish doctors who had immigrated to the colonies in search of opportunities and fortunes. 67 The Chinese trusted their own traditional Chinese medicine practitioners, with knowledge handed down over centuries. Skeptical of Western doctors and medicine, they had little use for their services. The destitute were simply left to their own devices.

The Colonial Surgeon’s Appointment: Not a Job to Wish for The real beginning of government medical and health services in Hong Kong was marked by the appointment of the Colonial Surgeon. While leaving all health matters in the hands of the local administration, the Colonial Office recruited medical professionals into service in the colonies. The requirements were modest: age between 23 and 30 years, preferably single, and in possession of medical and surgical qualifications. Specialized training was not required.68 In Hong Kong, the Colonial Office did not agree to a permanent appointment of a Colonial Surgeon until 1847, satisfied that private and missionary doctors could be employed instead. The Colonial Surgeon was responsible for the health of the governor, civic administration, and the whole population. His duties were similar to that of the director of medical and health services. Because of frequent exposure to illnesses, his job was very hazardous. Dr. Alexander Anderson, appointed in 1843 by Governor Pottinger as the first Colonial Surgeon,69 retired after one year in service because of poor health and died shortly thereafter.70 Dr. Francis Dill, who succeeded Anderson, died after just two years of service. Dr. William Morrison, who was appointed the following year,71 was a little more fortunate, as he made it through six years on the job before he succumbed. Governor Samuel Bonham then appointed Dr. J. Carroll Dempster as part-time Colonial Surgeon, to be shared with the military as a cost-saving measure.72 Although the health status of the Colony would have earned a failing grade, Governor Bonham’s tight-fisted fiscal policy persisted almost until the end of the next administration,

24  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

when Dr. William A. Harland, who was employed by the mercantile community in charge of the Seamen’s Hospital, became a full-time Colonial Surgeon.73 Six months after his appointment, the Colony lost Dr. Harland to a heart attack. It was not until the appointment of Dr. John I. Murray in 185974 that the Colony enjoyed continuous medical care from the same doctor until 1872 when he, too, was compelled to retire because of ill health (Table 1.3). Table 1.3  Colonial Surgeons in Hong Kong, 1843–1897 Colonial Surgeon Anderson, Alexander

Year of tenure 1843–1844

Known reason for termination Sickness followed shortly by death

Dill, Francis

1844–1846

Death

Young, Peter (Acting)

1846–1847

Morrison, William

1847–1854

Death

Dampster, J. Carroll (half-time) 1854–1858 Menzies, Edward (Acting)

1858

Chaldecott, T.A. (Acting)

1858

Harland, William

1858–1859

Death

Murray, John Ivor

1859–1872

Retirement due to ill-health

McCoy, R. (Acting)

1872–1873

Ayres, Philip Bernard C.

1873–1897

Retirement

Source:  Colonial Surgeon’s Reports 1843–1897 in Hong Kong Blue Books, 1843–1897.

This rapid turnover of Colonial Surgeons due to disease or death reflects the inadequacies of Western medicine at the time, and could hardly inspire confidence of the community toward the medical system. The next stage of development of medical services, a proper government civil hospital, would take many years.

The Government Civil Hospital Before the establishment of the Government Civil Hospital, there were two hospitals in Hong Kong: the Medical Missionary Society Hospital, founded in 1843 by the London Missionary Society but closed in 1853, and the Seamen’s Hospital, erected in August 1843 in Wanchai (where the Ruttonjee Hospital is currently situated), on the promise of a donation from Heerjeebhoy Rustomjee. 75 Unfortunately, Rustomjee became insolvent before the completion of the hospital and it had to be paid for

T he R eluctant B irth   |   2 5

through public subscription of $6,000, along with additional funds from William Jardine, a British merchant.76 The Seamen’s Hospital, which functioned as a private hospital for European seamen, with expenses paid by their employers, accommodated up to 50 inpatients. It ran at a loss for years and was finally bought by the Royal Navy in 1873 to become the Royal Navy Hospital. Dr. Anderson’s very difficult first year might have contributed to his ill health and subsequent demise. His responsibilities included looking after the sick in the civil service, the police force and their respective families, the prisoners in jail and, theoretically, the rest of the civilian population in the Colony. Appointed during the summer of 1843 at the height of the epidemic of “Hong Kong Fever,” he found traveling long distances to see many patients in different parts of Hong Kong exhausting. Every Colonial Surgeon was required to have, in addition to his own medical instruments, his own transport, a horse at first, and later a private sedan chair carried by Chinese coolies or a private rickshaw. After the Seamen’s Hospital was built, Anderson was able to admit some of his patients. Being a private hospital, it admitted officers for HK$1.50 and seamen for $0.75 per diem for board and lodging, including medicine and medical attendance (for comparison: the price of one pound of rice was $0.03 and an unskilled laborer’s day wage was $0.15/day in 1845, Hong Kong Blue Book, 1845). While the government would reimburse the total cost of hospitalization of the senior civil servants, lower grade civil servants did not have such a privilege. Policemen and their families would have part of the cost of hospital stay deducted from their pay.77 Because of the high prevalence of diseases among policemen and lower grade civil servants and their families, Anderson applied to the governor twice for a hospital to be built for them. Pottinger was sympathetic, suggesting to the Colonial Office that instead of building another hospital, he would give the same sum of money as Rustomjee ($12,000), to enlarge the Seamen’s Hospital, and a monthly grant of $200 to cover the cost of medicine, furniture, and other necessities.78 Governor Davis, who succeeded Pottinger, was also very supportive of the idea, but Treasury’s reply to his application amply epitomizes the policy of the British Government at that time, and for decades to come—it was the business of charity, not the government, to look after the sick of the lower classes. Depending on the amount of revenue and private donations, they might, just might, contribute some small portion.

26  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

But although the expenses of the institution ought, in their Lordship’s opinion, to be left to be provided for by private benevolence and good management, they concur in opinion with Lord Stanley that it would be a proper act of liberality for the Colonial Government to contribute a reasonable sum towards their erection of a suitable building for the Hospital, and the amount so to be contributed should depend partly on the state of the Colonial revenue…. 79 Despite a “positive” response from the Colonial Office, the first government hospital did not appear until long after the death of Anderson and his successor Dill. Although Davis had imposed taxation on urban properties, Hong Kong had not been able to balance its budget in its early years. In 1854 the home government stopped any more parliamentary grants to the Colony.80 In the meantime, sick policemen were admitted to the Military Hospital with $0.24 per diem deducted from their pay.81 In 1848, the year that “Hong Kong Fever” struck the Colony with a vengeance again, Dr. Morrison, the Colonial Surgeon, convinced the Governor, Sir George Bonham, that it was essential to have a place for the reception of the sick. There was also the problem of not being able to fill the prescriptions of many of his patients. Drugs had to be purchased from the Seamen’s Hospital and the government was paying for the cost of medications for private patients. Morrison carefully calculated the cost of sending patients to the Seamen’s Hospital and the cost of medications for all his patients, compared with that of renting a house as a temporary hospital with the government running its own dispensary. He convinced the governor that the government could have its own hospital for the same cost. In 1850 the first Government Civil Hospital was established, in a rented two story bungalow. The governor asked only for sanction from the Colonial Office after its establishment.82 In 1859, the government paid $2,000 to purchase another house (where Tsan Yuk Hospital is today) as the government hospital.83 It was a two storied building with verandas on its north and south sides, adapted into a hospital by pulling down the partitions to allow a free flow of air through the wards. Water had to be carried into the building, and it lacked water closets and baths. The sewerage and drainage of the building was defective, and in winter months when the windows had to be closed, there

T he R eluctant B irth   |   2 7

was poor ventilation. However unsuitable this building was as a hospital, Dr. Murray, expressed great satisfaction in his annual report of 1860 that the small hospital had beds and bedding, hospital clothing, surgical appliances, and other requisites. He had “no hesitation in pointing to this Establishment as equal to anything of the kind out of Europe.”84 As the work of the Colonial Surgeon was obviously too much for one person, in 1861 a Superintendent of Government Civil Hospital, Dr. C. Scott, was at last brought in to help on a half-time basis.85 In addition, a European apothecary was hired for the dispensary. The Government Civil Hospital was originally intended to treat accidents, as well as members of the police force and lower grade civil servants, but its mandate gradually extended to admit seamen on the order of the Harbor Master, destitute patients by order of the Colonial Secretary, the Colonial Surgeon, or the Police Superintendent, and paying patients by the order of the Colonial Surgeon. Although the hospital was supposed to be for all residents in the Colony, unless they were in the police force, Chinese were rarely admitted into Government Civil Hospital, deterred chiefly by the expense of one dollar a day as well as their distrust of Western medicine. The reforms of Florence Nightingale had not yet reached the Crown Colony of Hong Kong in the 1860s and 1870s. The Government Civil Hospital was served by two European and one Chinese ward-masters, who had no training. European positions were often filled by discharged solders, seamen, or any European looking for a job. They seldom held a post for more than a few months at a time. If they were good men, they soon found something better, while others were discharged for drunkenness or neglect of duty. The “nursing staff ” was composed of untrained Chinese coolies, also continually changing, headed by the Chinese ward-master: a skilled dresser who also served as an interpreter and a postmortem assistant.86 The hospital meals were prepared in a broken-down brick building with the cook room on the ground floor, and the Chinese ward-master and cooks living on the floor above. Dr. Ayres, Colonial Surgeon, sounded desperate in his review of the condition of the Government Civil Hospital after taking up his appointment: Under these conditions, the superintendent, Dr. Charles J. Wharry, with the assistance of the apothecary, Mr. Botelho, and the Chinese ward-master, Mr. Cheun A Lok, the only members

28  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

of his staff on whom he could rely, had to run the working of the hospital which no one entered as a patient except under compulsion or dire necessity.87 In 1871 there was a plan to build a new hospital that would accommodate at least 100 patients, but a prohibitive cost estimate of more than $100,000 meant that the plan had to compete with more urgent priorities in public works for the budget.88 In 1874, after the hospital was wrecked in a typhoon that blew off the roof and veranda, patients were moved into an empty hotel on Hollywood Road with very poor facilities. The government planned to move the Government Civil Hospital back into its old site, where the new Lock Hospital had been built for treating venereal diseases in prostitutes,89 but nothing much was done until 1879 when the hotel was destroyed by fire. At that point, the government had no option but to move Government Civil Hospital patients into the Lock Hospital, which had empty beds due to improved venereal disease control among the prostitutes.90 Land was difficult to find and there was no other building fit for the purpose of a hospital, so the government decided to take over the Lock Hospital for good, expanding it into the permanent Government Civil Hospital, and building a new smaller Lock Hospital nearby. Such a plan would save the government $60,000, a considerable amount at that time.91 The plan did not materialize for years, mostly because of the inefficient administration of Governor Hennessy, which left all plans related to hospital building suspended. When Sir William Henry Marsh took over as the Colony’s Administrator in 1882 after the departure of Hennessy, he began the process of building a small Lock Hospital.92 In 1883, Ayres, having to attend his patients in three different buildings, reported: “At present the work of this Establishment is carried on in the Old Lock Hospital (old site of Government Civil Hospital), the New Lock Hospital which had just been completed, and the Old Temporary Lock Hospital (the old school house…)” making his life difficult. 93 The discord between Ayres and Dr. C. J. Wharry, Superintendent of Government Civil Hospital, also contributed to the delay. When Dr. J. M. Atkinson replaced Wharry who retired in 1887, the work on Government Civil Hospital (Figure 1.8) moved ahead. In 1890, Atkinson was joined by an Assistant Superintendent of Government Civil Hospital, Dr. J. Lowson. This eased the burdens of both Ayres and Atkinson, and made life much more pleasant for all concerned.94

T he R eluctant B irth   |   2 9

In 1889, when six French Sisters of Mercy joined the nursing staff, the Government Civil Hospital had its first female nurses, and the nursing standard at the hospital improved significantly. Unfortunately these nurses did not meet the requirements of the doctors, and trained English nurses, recruited from England, arrived in Hong Kong in 1890 for the first time.95 By 1893, after waiting for 20 years, and three years before his retirement, Ayres was finally able to enjoy working in a hospital of reasonable standard and with a team of well-trained doctors and nurses from England. Little did he realize that in a year, he and his team would be battling a terrible epidemic of plague. Figure 1.8  Government Civil Hospital c1910



Photo courtesy of Hong Kong Museum of History

This page intentionally left blank

2. Diseases of Venus: Prostitution and Its Control

For more than a century after the birth of the Colony, an epidemic that did not discriminate between Europeans and Chinese ravaged Hong Kong. This epidemic of venereal diseases, primarily syphilis, popularly known as “the great pox” in England or grosse vérole in France; and gonorrhea, known as “the clap,” flourished in a city with a high male to female ratio, where high poverty rates among the Chinese on the mainland led desperate parents to sell their daughters into prostitution. The government instituted ordinance after ordinance aimed at licensing and regulating brothels, and implemented periodic medical examination of inmates in brothels for foreigners, but the brothel inmates who serviced the Chinese were spared, due to the prohibitive costs of conducting periodic examinations, as well as opposition from the Chinese. The epidemic did not subside until the introduction of penicillin, the availability of condoms, and the provision of free diagnosis and treatment after World War II.

Diseases of Venus Although it had been known for centuries in Europe that syphilis and gonorrhea were both sexually transmitted diseases, the two were commonly confused as they often occurred together in the same infected person. The physicians at that time recommended avoidance of intimate contact with women infected by the disease—particularly prostitutes. These admonitions for abstinence, however, were not often heeded.

Syphilis Elaborating on the idea of what he called “contagion,” based on the transmission of clinging and imperceptibly small “seeds of disease,” the

32  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Italian physician and poet Girolamo Fracastoro coined the term syphilis in his epic poem “Syphilis sive morbus gallicus” (Syphilis or the French Disease) in 1530.1 In 1495, after King Charles of France sent an expedition to besiege Naples, the first recorded outbreak of syphilis occurred among the French troops. In their ranks were many mercenaries—including Spanish soldiers who had been crew members returning from the voyage to the Americas carrying some non-venereal tropical bacteria. In the new environment, these organisms, which mutated into a more deadly form, led to the horrible syphilitic disease that swept across Europe. The pustules that covered the bodies of sufferers caused the flesh to fall from their faces and their bones could be suppurated to the marrow, inducing horrendous pain. Most of the afflicted would die within a few months, but if they survived, the resulting disfiguration of their faces marked them as social pariahs and sexual deviants. The quick spreading of this disease from Naples northward to France, Holland, and England, eastward to Central Europe, then from Central Europe to India, China, Japan, and eventually to the rest of the world,2 was helped along by benighted social views on masturbation. Almost any teenager today would know that masturbation is a safer sexual practice than unprotected intercourse with prostitutes, but for a long time even physicians used to stress the dangers of masturbation. Until the 1950s, Hong Kong newspapers emphasized these dangers as part of a sex education program. These views originated in medical contributions such as L’Onanisme, published in 1760 by a Swiss physician named S. A. A. D. Tissot. He announced the consequences of solitary sex: retarded growth, gonorrhea, fainting fits, epilepsy, and diluted male seeds needed for procreation. He further claimed that masturbation would cut down the richness of blood and lead to “sensible diminution of powers, of the memory, and even of the understanding … the organs of generation are hereby enfeebled; other symptoms would include bloody urine, loss of appetite, headaches. From this other horrors would follow.”3 These kinds of claims encouraged men to think that it was better for them to turn to prostitutes rather than solitary masturbation. In the early part of the twentieth century some advances in the detection and understanding of syphilis were made. Treponema pallidum, the organism responsible for syphilis, was discovered by Fritz Schaudinn and his colleagues in Berlin in 1905. While not perfect because of some false positive results, the Wassermann test to detect syphilis infection, that

D iseases of V enus   |   3 3

was developed one year later, was also viewed as a major advance. More specific tests for detecting of T. pallidum came later. In the early days the treatment for syphilis usually involved strict dieting, blood-letting, sweating, and purging. Mercury was administered in various ways, by mouth, by rubbing it on the skin, and by injection. A more drastic method of mercury treatment was to enclose the patient in a box with his or her head sticking out. Mercury was then placed inside the box and a fire started under the box, causing the mercury to vaporize,4 hence the expression “A night in the arms of Venus leads to a lifetime on Mercury.” Those who endured this 20- to 30-day treatment developed sweating, salivation, and sore gums—signs of mercury poisoning. In 1910, a more effective drug, Salvarsan, containing arsenic, was developed for the treatment of syphilis. These measures were used until after World War II, when penicillin was discovered and became readily available.

Gonorrhoea Gonorrhoea, a name coined by Galen in the second century, commonly presents in women with vaginal discharge, lower abdominal pain, or pain on intercourse, while in men it presents as urethritis, a condition associated with discharge and burning sensation on urination. Less commonly, gonorrhea may cause skin lesions and joint infection; very rarely the settling of the organisms in the heart may cause endocarditis (infection of the heart valves). The causative agent for gonorrhoea, Neisseria gonorrhoeae, was discovered by Albert L. S. Neisser in 1879. Diagnosis of gonorrhoea is based on the demonstration of the organism by smear or by culture of urethral or vaginal discharge, or more recently by PCR (polymerase chain reaction) testing methods. The most consistently used medication for treatment of gonorrhea in the 1850s were cubebs, an Indonesian variety of pepper and balsam of copaiba, extracted from a South American tree. In 1919, Mercurochrome-220 was found to be effective against N. gonorrhoeae, and was administered by injection of 1% mercurochrome in a 50% glucose solution via the urinary meatus or orifice. After 1937, cures in 80% of cases became a reality with a three-week course of sulfa drugs. The discovery of penicillin led to rapid cure of the disease in almost every case.5

34  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Brothels, Prostitution, and Venereal Diseases Prostitution: A Booming Business In Hong Kong’s early days, in a city filled with many more men than women, prostitution flourished. In 1844, two years after Hong Kong’s cession to the British, of the approximately 20,000 Chinese living in the city, there were only 315 families. In fact, the 32 brothels outstripped the number of private houses. In 1877, the first Police Magistrate, Charles May, declared that only about one sixth of Chinese women in the Colony lived with one man either in marriage or concubinage, and that the rest were prostitutes. A long-time physician in Hong Kong, Dr. Pang Uishang, estimated that only 25% of Chinese women were “respectable” in the 1860s and 1870s.6 Even if this number is slightly exaggerated, the indisputably high rate of prostitution is not difficult to understand. Due to the prohibitive cost of accommodation and the “corrupting” influence of a town established by “foreign devils,” Chinese men were reluctant to bring their wives and children with them, preferring to leave them in the care of relatives in their native villages. Also, Chinese migrants failed to see prostitution as evil. It was just a necessary service for a place with a high male to female ratio, an imbalance that persisted until the Second World War (Figure 2.1).7 For lonely men in a frontier town, where the controlling norms of village gossip were lacking, the moral principles and standards that they were expected to maintain in their home villages were no longer relevant.8 Figure 2.1  Male to female ratio of population in Hong Kong, 1847–1940

Source:  Hong Kong Blue Books and Hong Kong Sessional Papers, 1847–1940.

D iseases of V enus   |   3 5

Chinese prostitutes were very different from European prostitutes, who were usually quite low on the social scale, and commonly seen as “fallen women” or victims of seduction. In China, few could be called “fallen women” as the majority were owned by professional brothel keepers or traders of women in Guangzhou or Macau. Because of poverty, their parents or relatives had sold them to be brought up as the property of their keepers for the profession, and trained in various accomplishments suited to brothel life.9 After being in the trade for a number of years, there was a good chance that their fate could improve in one of several ways: 1) by becoming the second, third, or fourth wife of a wealthy man; 2) by being redeemed and espoused by an honest devoted but poor man; 3) by saving up sufficient money to redeem herself and in turn to become a brothel keeper or manager for wealthy capitalist or speculators; or 4) by buying and selling girls to act as prostitutes or concubines.10 The rule of segregation between the Chinese and the Europeans in early Hong Kong also applied to the brothels, with some brothels that serviced Chinese only and others for foreigners. The Chinese brothels were subdivided into three classes according to the social status of the customers they served: the wealthy, the well-to-do, and the poor. The brothels for foreigners were usually patronized by the lowest class of foreigners, mostly soldiers and the seafaring merchants; they employed women of similarly low social standing. Higher class foreigners did not frequent brothels as members of the upper and middle-class tended to keep “protected women.” Yet another class of prostitutes, who called themselves washerwomen or boatwomen, carried on their trade in the harbor, where prostitution was virtually impossible to control. Less stigma attached to Chinese men, even married men of high social standing, than to European men who visited brothels. Prostitutes were, not uncommonly, romanticized and glorified as beautiful, heroic, talented, and virtuous. They occupied a social niche that was not exclusively based on sexual servicing. The first class Chinese brothels in the 1870s were places for merchants and rich shopkeepers to entertain friends. Prostitutes provided the customary social and entertaining element at parties in restaurants. During the evening the prostitutes sat behind the chairs, one each for the host and his guests. A regular scale of charges was levied on these services, which ended with the dinner and did not include other services after dinner. According to the Report of Commissioners ordered by the

36  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Governor, Sir John Pope Hennessy, in 1878 to enquire into the workings of the 1867 Contagious Diseases Ordinance, this class of brothels would seem to be “absolutely free from disease.” The second class brothels were similar to the first class, except entertainment was on a less grand scale. In third class brothels, emphasis was usually on sex rather than entertainment.11 A brothel keeper in Hong Kong was invariably a woman who had been a prostitute herself. Her difficult life did not render her more compassionate towards her wards, whom she purchased and exploited to the fullest degree. Personal hygiene was at a minimum, with no chance for the woman to wash between clients; sometimes she received up to five or six clients each day. Not even the medical profession recommended the use of condoms.12 When a woman fell ill, she would still be forced by the keeper to carry on working, transmitting the disease to the next client. Sometimes ailing women would be sent back to China for traditional treatment. When they finally developed late stages of syphilis, business sense trumped any notion of compassion and the unfortunate women would be pushed out of the brothels and left to die on the street.13 The impoverished social situation was highly favorable to the maintenance of prostitution: the old Chinese law of inheritance neglected daughters in favor of sons, the universal practice of buying and selling females as prostitutes or as mui tsai whose “adoptive” parents treated them as servants and some sold them into prostitution—all contributed to the booming business of prostitution in Hong Kong.

Unwanted Business Spin-Offs: Venereal Diseases By the 1850s, Hong Kong had become known as a center not only for prostitution, but also for high rates of venereal diseases. Although accurate statistics are hard to come by, it is clear that venereal diseases accounted for a very high percentage of hospital admissions among Europeans in the army or navy, as well as among merchant seamen. In 1855, the Rear-Admiral wrote to Sir George Bonham, the Governor of Hong Kong, complaining that a large number of the crew of the HMS Winchester had come down with venereal diseases, and requesting that the Governor apply some kind of regulation on prostitution. Later that year, the Rear-Admiral wrote again, reporting that one third of the crew suffered from syphilis.14

D iseases of V enus   |   3 7

In 1857, Dr. J. C. Dempster, Colonial Surgeon, noted in his annual report that every sailor admitted into the Seamen’s Hospital with fever or bowel problems also had venereal disease, as did almost all prisoners in the jail, whether they were Chinese or European. He had never witnessed such an appallingly high prevalence of venereal diseases in other cities where he had served.15 Dr. P. B. C. Ayres, Colonial Surgeon, noted the scourge of this disease among the local population: It is a daily occurrence to see Chinese in the streets of Hong Kong horribly scarred with syphilitic disease, with nose and eyes completely gone. Prisoners come into the Gaol who, when stripped, reveal most horrible scars and deformities, the result of syphilis in its worst form … Anyone can see miserable little wretches of Chinese children about the streets of Victoria suffering from congenital syphilis. One Chinese doctor tells the Commission that he has been in practice 23 years in Hong Kong that he treats over 1,000 cases of syphilis a year.16

Laws to Regulate Prostitution and Their Agenda The various ordinances relating to prostitution over the course of the first century of British rule reflect the changing policy of the colonial government and the Colonial Office, shifting societal attitudes towards prostitution, and the rising status of women in Western society. While at first glance the laws to regulate prostitution may seem to have been a socially progressive measure, they were in fact discriminatory and self-serving. The government spent time and energy working to enact ordinances in order to protect Her Majesty’s troops and sailors, unconcerned with a Chinese population that constituted the vast majority of Hong Kong, except for those Chinese prostitutes who served the Europeans. Laws aimed at detaining infected prostitutes for treatment were not enacted to protect the women themselves, but their European clients. In addition, the government made money from the business of prostitution through taxation. Under the Venereal Diseases Ordinance of 1857,17 brothels were taxed at HK$4 per month per establishment, and HK$1.5 per prostitute. In addition, foreign seamen required health certificates upon departing Hong Kong that were taxed at $0.5 per certificate.

38  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Venereal Diseases Ordinance of 1857 The first Venereal Diseases Ordinance, enacted in 1857 in Hong Kong for “checking the spread of venereal diseases,” mandated the registration and inspection of brothels, compulsory medical examination of the inmates, and the punishment of prostitutes who communicated the disease to their clients. It also required the segregation of diseased prostitutes in the aptly named Lock Hospital until they were cured. It is believed that the name for the Lock Hospital, which opened in 1858 for women with venereal diseases, was derived from the practice of locking up the diseased prostitutes while they were infectious so that they could receive treatment. In the 1850s the causative bacteria had not yet been identified and effective antimicrobial agents had not yet been discovered. It is unclear what type of treatment was offered at the Lock Hospital, which was funded by the license fees of the brothels and prostitutes. The number of women treated in the Lock Hospital was 124 in 1858, soaring to 280 in 1862, and remaining at around that level until 1868.18 Mr. Henry Labouchere, the Secretary of State for the Colonies at that time, approved the 1857 Ordinance that limited the localities of the brothels. The law asked for punishment of those who kept brothels where disease was found, but not of the infected women.19 Not having been consulted on this Ordinance, the Chinese community, as might have been expected, opposed it immediately. Chinese women and the Chinese community detested medical examinations by foreign doctors so much that it would not be possible to apply the Ordinance to the inmates of Chinese brothels. As the ratio of brothels for Chinese compared to brothels for foreigners was about 110 to 40, with more than four times as many prostitutes for Chinese as for Europeans, the objective of the Ordinance “to check the spread of venereal diseases” could never be met in the general population.20 From its enactment, the 1857 Ordinance was later shown to have been a source of injustice, abuse, and corruption.21 Nevertheless Dr. J. I. Murray, Colonial Surgeon, reported that the Ordinance had been effective in reducing the prevalence of syphilis in the police force from 31% in 1862 to 16.7% in 1869, and the percentage of patients admitted to the Government Civil Hospital with syphilis had declined from 25.2% in 1859 to 15.8% in 1869.22

D iseases of V enus   |   3 9

Contagious Diseases Ordinance of 1867 A more draconian ordinance, the Contagious Diseases Ordinance of 1867, was enacted by the Legislative Council and approved by the Colonial Office. Conferring upon the Registrar General and the Superintendent of Police the powers to authorize break in and entry, without a warrant, to any house suspected of being an unlicensed brothel, and to arrest the keeper. It also gave judicial power to the Registrar General. In unlicensed brothels, the brothel keeper and the prostitutes were both targeted for punishment, a departure from the principle laid down by Labouchere of not punishing the brothel inmates. The Ordinance also gave the Governorin-Council the power to fine or imprison all prostitutes found outdoors in the streets, harbor, or elsewhere.23 There was a great deal of discussion as to whether the Ordinance should apply to all the brothels, including the Chinese ones. However, such a widespread application of the Ordinance would require too much costly infrastructure—twice the number of medical staff, and four times the number of hospital beds for periodic medical examination and treatment. Seeking to avoid the detested medical examination all the Chinese brothels would close their doors and the number of unregistered or “sly” brothels would skyrocket in different parts of the town.24 In the end, economic and political considerations determined that while all the brothels had to be registered, the requirement for medical examination would be applied only to brothels for foreigners. The priority was the protection of soldiers and sailors in Her Majesty’s service.25 Under the 1857 and 1867 ordinances, brothels were allowed in certain designated districts; the ones that catered to European clients were separate from those that catered to Chinese clients. Brothel keepers in all districts were required to give regularly updated lists of their inmates to the Registrar General and to display these lists in their brothels. Inspectors had authority to examine these brothels at any time. Infected prostitutes found on periodic medical examination were admitted to the hospital and treated until “cured,” and those found to be disease-free would be granted certificates of good health which they could display. Meanwhile, in England, military and naval officials were also struggling with the most effective methods of protecting men from venereal diseases. Seven years after the 1857 Venereal Diseases Ordinance was passed in Hong Kong, the Contagious Diseases Act was passed

40  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

in England, aiming to provide healthy women for soldiers based in 18 garrison towns around the country. Unlike the law in Hong Kong, there were no compulsory regular medical examinations in this or subsequent amendments to the Act.26 It did not escape the notice of ethical people in Victorian society that laws like the Contagious Diseases Act were unfair and discriminatory, punishing the prostitutes but not the men who gave them the disease. If the disease itself was not punishment enough, the women found to have the disease were fined or imprisoned, while the men carried on freely. In Hong Kong, ordinances that forced women who serviced foreign clients to have periodic medical examinations were also racially discriminatory. Women found to have the disease were then committed to the Lock Hospital at a time when the etiology of the venereal diseases was unknown, and when there was no test to confirm the diagnosis, not to mention the lack of truly effective treatment. Dr. Ayres claimed that he only admitted women to the Lock Hospital if they had vaginal discharge associated with symptoms and signs of inflammation, presence of sores, purulent discharge from the urethra or orifices of the Bartholin’s glands—not just any woman with vaginal discharge.27 There is no record as to how he treated his patients in the Lock Hospital, though it seems that silver nitrate had been used frequently to “touch” the chancre of primary syphilis to “prevent secondary syphilis.”28 The use of mercury was not mentioned. There is no indication of when Dr. Ayres considered a patient “cured,” but presumably, in the case of syphilis, he inferred a cure when the chancre healed and the disease became quiescent—before the development of the next stage of the disease. After the enactment of the Contagious Diseases Ordinance of 1867, the percentage of diseased women discovered through periodic medical examinations dropped progressively (Figure 2.2).29 The hospital stays for those found to have the disease were getting shorter, and the symptoms were milder. Despite its shortcomings, it appeared that the program had been successful in reducing the amount and severity of disease among the inmates of the brothels for foreigners. Among the police force, the frequency of venereal diseases decreased further from 16.7% in 1869 to 6.6% in 1878. The reduction in the prevalence of syphilis was particularly striking. 30 In fact, the program had been so effective in reducing diseases among the prostitutes that in 1878 when the Government Civil

D iseases of V enus   |   4 1

Hospital was burned down, the Lock Hospital, which had many empty beds, gave up its premises and moved its patients to an old school and two adjacent private houses rented by the government. In 1879, the government decided that the Lock Hospital would become the permanent Government Civil Hospital, and to erect a smaller building as the new Lock Hospital.31 Figure 2.2  Percentage with venereal diseases among prostitutes, * troops, and the navy, 1867–1877

Note:  *Percentage of prostitutes found to have disease on weekly medical examination. Source:  For prostitutes: Colonial Surgeon Report 1867–1877 in Hong Kong Blue Book, 1867–1877; for troops: Kennedy to Earl of Carnavon, 4 January 1875, CO 129/170, #1, 13; for navy men: Report of the Commissioners 1879, 33.

Among the troops, the percentage with venereal diseases also shrank, from 51.1% in 1861 to 11.3% in 1867, falling further to around 6% in 1874, but increasing again to 11.8% in 1877 (Figure 2.2).32 The percentage in the navy with venereal diseases, however, grew from 17.9% in 1871 to 25.8% in 1877.33 The lack of effectiveness of the 1867 Contagious Diseases Ordinance in protecting naval men could be explained by their unrecorded visits to unlicensed brothels or brothels in other cities, or the boatwomen in the floating population. This overall reduction in the rates of venereal diseases appears to be a positive outcome of the implementation of the 1867 Contagious Diseases Ordinance in Hong Kong, but it came at great social and personal

42  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

cost. Scandals, abuses, and corruption abounded when the inspectors of brothels, heady with power, zealously suppressed unlicensed brothels and tracked down hundreds of women to prosecute them. Many women were terrified at the prospect of a degrading punishment. They risked their lives in efforts to escape by running into another house or trying to flee onto adjacent rooftops. Some even fractured their arms or legs, or suffered worse consequences. On the night of October 17, 1877, two women who were trying to escape fell from a roof and died.34 These scandals triggered Sir John Pope Hennessy, Governor of Hong Kong, to form a commission to inquire into the workings of the 1867 Contagious Diseases Ordinance. The inquiry was carried out over a period of months by three people: Thos. C. Hayllar, one of Her Majesty’s Counsels for the Colonies who chaired the commission, the Reverend E. J. Eitel, a sinologist, and W. Keswick, an unofficial member of the Legislative Council. They produced a highly critical report published in 1879.

Holes in the Laws: The Report on the Workings of 1867 Contagious Diseases Ordinance The scandal of the two women who died trying to escape arrest was only one of many that the commissioners discovered. They found the practices by which prosecutions were secured under the ordinances of 1857 and 1867 highly inappropriate and illegal: often brought about by paid informers, by entry into premises without warrants, and through the use of marked money. In some cases, women who were not prostitutes were ordered to undergo medical examinations, and on occasion, these examinations revealed that they were virgins. Clearly, the ordinances made it easy for inspectors of brothels to engage in illegal practices that led to abuses. Although the commissioners found a decrease in the number of women for medical surveillance in 1877 compared to 1866, they did not see this decline as a sign that the Ordinance was effectively stamping out prostitution. Assuming that prostitutes had left to conduct business in unlicensed brothels, they concluded that the Ordinance had been ineffectual in suppression or termination of unlicensed houses and unregistered prostitutes. They also concluded that, while there appeared to be reduction of venereal diseases among troops and among the police, there had been no improvement in the rates of these diseases among sailors in the

D iseases of V enus   |   4 3

Navy.35 These findings led them to recommend the abolition of the 1867 Contagious Diseases Ordinance. The commissioners proposed that the licenses granted in future be strictly limited to brothels for foreigners and that Chinese brothels should not be in any way subject to government supervision. Women were not to be punished for infecting men with venereal diseases, and their feelings and prejudices about examination and treatment should be taken into consideration. They urged that their recommendations be the basis for amendments to the Ordinance.36 The report was signed by two commissioners, Hayllar and Eitel, but not by Keswick, who found the other two commissioners’ condemnation too sweeping. He considered that the abuses that had occurred, while serious, were an inevitable byproduct of working with the lowest classes of both Europeans and Chinese. He believed that the spread of venereal diseases had been checked by the licensing and medical examination of women, as well as by the segregation of diseased women. He conceded that there should be no requirement for medical examinations of the inmates of Chinese brothels, but argued that Chinese brothels should continue to be registered for the purposes of law and order—and also for sanitary reasons. Despite objections from the Colonial Surgeon and the medical officers of the Army and the Navy, the liberal and progressive Hennessy accepted the recommendations of the 400-page report without any comment. After he submitted it to the Earl of Kimberley, the Secretary of State for the Colonies, extensive discussions took place in the Colonial Office. Kimberly studied the report, examined its evidence and carried out some more investigation himself. He took almost two years to reply to the Governor, unable to accept the recommendations in the report because of the differing opinions of the commissioners.37 Kimberley agreed with Keswick that registration and supervision of all brothels should continue for the protection of inmates and for sanitary reasons, and that medical examination should be applied only to inmates of brothels for Europeans. He also suggested a certificate of registration rather than a licence be issued, and that penalties for women with venereal diseases should be dropped. The practice of entry into unregistered houses without a warrant for the purpose of proving the house to be a brothel should not be allowed to continue, but some such power might be necessary in case of emergency for the suppression of serious offenses. He requested that Hennessy come up with a draft of an ordinance that would include these reforms.

44  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

It was most unusual for the Secretary of State for the Colonies to overrule the advice of the Governor, as the “man-on-the-spot” was expected to know the local situation better. Hennessy, an Irish Catholic and a reformer, was distrusted in the Colonial Office and among the British in Hong Kong for his humanitarian reforms in abolishing harsh punishments against Chinese criminals and his “pro-Chinese” policies. He had lifted the ban that forbade Chinese people from buying lands, constructing buildings, and operating businesses in the Central District. He allowed Chinese immigrants in Hong Kong to become naturalized as British subjects, and appointed the first Chinese member, Ng Choy, to the Legislative Council.38 In 1882 Hennessy went on leave. He was subsequently appointed Governor of Mauritius and did not return. The Contagious Diseases Ordinance Amendments of 1882 were forwarded to the Colonial Office by Sir William Henry Marsh, the Colonial Administrator. As instructed by the Secretary of State, the amended Ordinance replaced the word “licence” with the word “registration.” The amendments also featured protection against brothel slavery. Before entering a brothel as a prostitute, a woman had to be brought before the Registrar General, who would have a respectable Chinese gentleman with him, to ensure that she understood what she was doing, and that even though she had been purchased, she was still a free agent in Hong Kong (Figure 2.3).39 Inmates who left the brothel business would report to the Registrar General and their names would be removed from the registry. Inspection of Chinese brothels would be carried out periodically and inmates were to know that they were free and protected.40 The Registrar General, J. Russell, also introduced a system of photographs to avoid the substitution of one prostitute for another who was not registered. Each woman needed two photographs—one to be kept on her person, the other to be kept in the Registrar General’s office.41 Periodic medical examinations were still required for inmates in brothels for foreigners.42 Moral reformers in England were decrying the Contagious Diseases Act, as they considered the licensing of brothels by the state implied official recognition of immoral behavior. The reformers also objected to the implicit double standard in the Act, as women, but not men, were compelled to submit to demeaning medical examinations.43 Finally in 1896, after a long hot campaign, Parliament repealed the Contagious Diseases Act and abolished licensed prostitution. In Hong Kong, resistance

D iseases of V enus   |   4 5

Figure 2.3  Notice to a prostitute indicating that she was a free agent in Hong Kong. If forced into doing anything against her wish, she could go to the authorities

Source:  Halifax, Secretary for Chinese Affairs, Public Brothels in Hong Kong, 23 April 1923, Enclosed in Stubbs to Devonshire, 7 July 1923, CO 129/480 #235, 263.

to abolition came in the form of arguments about the distinctive nature of Chinese culture, which regarded prostitution differently.44 The colonial administration was anxious not to upset the Chinese elite. It listened to the views of its advisors on Chinese affairs, who included both coopted Chinese unofficial members of the Legislative Council and others who were presumed to be familiar with the sexual habits of its native population because of their long residence in the Far East.45 Despite protests from Marsh, who claimed that this ordinance was the only means of controlling the spread of venereal diseases, preventing the proliferation of brothels in respectable areas of the city, and protecting young girls from being forced into brothel slavery, the Secretary of State instructed the colonial government to follow the example of the home government.46 At the insistence of the Secretary of State, in 1889 a bill entitled the “Protection of Women and Girls Ordinance” was introduced in the Legislative Council in Hong Kong to repeal the Contagious Diseases Ordinance of 1867. However, all other regulations such as the requirement for the registration and inspection of the brothels were re-enacted, although these regulations were not forwarded with the 1889 Ordinance when it was sent to the Colonial Office in England for confirmation. When the Secretary of State discovered this deliberate disregard of his directives, he immediately instructed Governor Des Voeux to repeal the

46  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

1889 Ordinance and to enact a new one in 1890, rejecting compulsory periodic medical examinations. Despite the changes in the ordinance, the inmates of the brothels for Europeans continued to report to the Lock Hospital for examinations even though they were informed by the Colonial Surgeon and Registrar General that their attendance was not legally required.47

The View from Afar: The 1894 Ordinance to Abolish Legalized Prostitution In Britain, moral reformers had found a cause they could embrace. They were determined to end the practice of legalized prostitution not only in England, but also in its colonies. Under pressure from these societies, the Secretary of State agreed that the 1890 Ordinance should be repealed and the whole system of prostitution control be abolished. In 1894, the bill to abolish legalized prostitution was passed in Hong Kong, carried through only by the official members of the legislature, with unanimous opposition from the unofficial ones. The results were predictable—the incidence of venereal diseases in the garrison climbed. In 1897, over 50% of the troops in Hong Kong underwent treatment for venereal diseases. In Singapore it was not different.48 Supported by the China Association in London and its branches in Hong Kong and Singapore, the governors of Hong Kong and Singapore appealed to the Colonial Office to reintroduce the legal system of control. Bowing under public pressure, the Secretary of State, Joseph Chamberlain, decided that it was impossible to sanction the re-enactment of the contagious diseases legislation in any form. Understanding, however, the situation in the colonies, he sent the Governor of Hong Kong, Sir Henry Blake, a confidential dispatch on 11 May, 1899. Since the Law for Protection of Women and Girls in Hong Kong already made it an offense for brothel keepers to compel those with venereal disease to continue working, Chamberlain was prepared to accept an amendment to empower a magistrate to close down any brothel if an application was made by the Superintendent of Police or the Registrar General.49 This discretionary power would allow the Hong Kong government to reintroduce zoning of certain parts of the city as areas where brothels were tolerated, although this was not spelled out in the paper laid before the House of Commons.

D iseases of V enus   |   4 7

On receiving this letter, Sir Henry Blake, an exceptional governor who did much to control plague in Hong Kong, at once took the hint. He immediately accepted the Secretary of State’s proposal to draft an ordinance that would include all the suggestions. He added, “It appears to me that an ordinance on the lines suggested by you ought to give complete power to deal with the questions and I will take care that the provisions of the ordinance when passed shall be enforced.”50

Off the Radar: Extralegal System of Control and Its Dismantling As there were no longer any laws regarding the licensing of brothels, the subject of prostitution and brothel control disappeared from the dispatches between the Colonial Office and the Hong Kong government from 1899 to 1920. However, even without legalization, the government essentially had control over brothels, as it was empowered to close down any brothel at the request of the Superintendent of Police or Registrar General. During this period, a system of regulation with registration and medical examination had been restored extralegally by the Hong Kong government in collusion with the Colonial Office. In 1921, a commission from the National Council for Combating Venereal Diseases, consisting of Mrs. C. Neville-Rolfe and Dr. R. Hallam, arrived in Hong Kong. The Governor, Sir Reginald Stubbs, who was known to be direct and outspoken, advised the commissioners that he would not welcome such a visit, being dubious about a woman speaking on the subject of venereal diseases in Hong Kong. He suggested that the government departments, the Medical Faculty of the University of Hong Kong, which had opened since 1912, and the local medical associations refuse to meet with them. At first this small commission was denied assistance, but eventually the Governor relented and gave them a small private office and permission to meet with representatives from the Army, Navy, Chamber of Commerce, different government departments, the bishops of the Anglican and the Catholic Church, and some women’s organizations. The commissioners were able to convene with the Chinese Chamber of Commerce and to approach the Chinese through the Secretary for Chinese Affairs.51 Throughout the commissioners’ visit, Governor Stubbs maintained

48  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

an atmosphere of secrecy around the subject. He would not permit the press to advertise any meeting dealing with venereal diseases. Despite all these barriers, the commissioners managed to organize a meeting attended by more than 450 Chinese people. They also showed a film and taught a number of women interested in health education about venereal diseases. Before leaving Hong Kong, the commissioners met with Governor Stubbs a second time. Having seen the enthusiastic response of the public to the commission, the Governor said he “saw no reason against carrying into effect the provisions for free diagnosis and treatment or to a careful campaign of public entertainment and to the opening of a Port Clinic immediately.” He also promised to add a venereal diseases officer to the government staff and arranged for his payment from the government budget. In response to a group of enthusiasts who wanted to form a branch of the Council locally to continue the work, Governor Stubbs demurred, preferring to have an official organization chaired by the Principal Civil Medical Officer for the propaganda and educational activities. The commissioners made some very useful recommendations which would form the framework for managing venereal diseases in Hong Kong. Its chief goals were to provide the following: 1. free diagnosis and free treatment for venereal diseases funded by the private sector and the government; 2. a number of easily accessed free clinics for diagnosis and treatment among hospitals and Chinese Public Dispensaries throughout Hong Kong and Kowloon (see Chapter 7); 3. a number of government laboratory facilities for free diagnosis; 4. a specialist in venereal diseases with expertise in treatment and control who could supervise the workings of the clinics and hospital facilities for such treatment; 5. an extensive public health education campaign on venereal diseases and their transmission in organizations such as the YMCA, YWCA, Seamen Institute, and in schools, to lessen the taboo associated with these diseases; 6. recreational facilities for seamen; 7. appropriate information on venereal diseases to groups such as doctors, nurses, midwives in the community, as well as parents and teachers;

D iseases of V enus   |   4 9

8. a clear prohibition of women to access ships in the harbor except by permit; and 9. enforcement of the brothel and solicitation laws and local ordinance (the Public Health Ordinance), and abolishment of the brothels. In addition to dealing with venereal diseases and prostitution, the commissioners sent a confidential report to the Colonial Office, in which they described the uncooperative attitude of the Governor and the surprisingly enthusiastic support that they had from the Chinese community. In their highly critical report, they emphasized that the government had done nothing to improve the standard of health for the native population. Despite 60 years of British rule, they added, the status of public health in Hong Kong was still in its infancy. They stressed the very high infant mortality rate in Hong Kong, which in 1918 amounted to 31% of all deaths, and that the government had made no attempt to teach Chinese midwives elementary personal or infant hygiene.52 The National Council for Combating Venereal Diseases was the first semi-official British organization to express an interest in the health of the native population. The report highlighted not only the existence of an extralegal system of regulation of prostitution and the lack of facilities for treatment of venereal diseases in Hong Kong, but also the lack of provision of public health measures. These findings, transmitted to the Colonial Office and to the British public for the first time, became a rich source of material for parliamentary questions. The conservative, patriarchal, and uncooperative approach of Governor Stubbs to the Council’s visit probably contributed to public pressure in Britain for medical and health reforms in the Colony. The report of the commissioners was sent to Governor Stubbs, who then set up a committee to refute its more extreme findings. Stubbs strongly supported the established system of regulation of prostitution, and consented to providing free outpatient treatment of venereal diseases at government hospitals. The redoubtable Mrs. Neville-Rolfe was relentless in ensuring that the recommendations were being carried out. 53 Concerned with issues including infant mortality, tuberculosis, mui tsai, brothels, and venereal diseases in the Crown Colonies of Hong Kong and Singapore, a deputation of members of the British Parliament led by Lady Nancy Astor met with the Secretary of State for the Colonies. To avoid public agitation

50  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

over these issues, the Secretary of State agreed to form a committee to work on them.54 Most of the issues identified by the deputation had never been addressed seriously by the government of Hong Kong, which had always maintained a laissez-faire policy in social welfare, claiming that it did not wish to upset the ancient customs of the local people.55 Over the years within the Chinese community, a group of elite, who had received Western education from abroad, emerged. They supported proposals for public education, the provision of decent lodging houses for seamen, and the removal of brothels. The government, however, chose to listen to the views of the conservative group.56 The visit of the commissioners of the National Council for Combating Venereal Diseases and Lady Astor’s parliamentary deputation led the Colonial Office to investigate the brothel situation in Hong Kong in 1923. The Hong Kong government openly described its system of regulation, quite unconcerned or unaware that an identical system of control had been abolished 30 years earlier by the Secretary of State for the Colonies.57 There were, in 1923, a total of 296 registered brothels (43 for Europeans, 4 for Indians, and 249 for Chinese) with 3,093 inmates.58 The brothels were concentrated in three areas permitted by the government: 1) Lyndhurst Terrace and the vicinity for foreign women and for Europeans; 2) Sampan Street (Spring Garden Lane) mainly for Japanese; and 3) Shek Tong Tsui (part of Kennedy Town) for Chinese only (Figure 2.4). To control the kidnapping trade, each woman who went into a brothel was seen and registered by the Secretary for Chinese Affairs or one of his representatives and received a card with her name and address. A police inspector was assigned the sole duty of ensuring that the provisions of the Women and Girls Ordinance were observed, to note any irregularities in the brothels, and to make it easy for the inmates to register complaints or grievances. In fact this system of control was exactly what the Colonial Office had asked them to discontinue 30 years earlier. At that time the average rate of venereal diseases in the Hong Kong garrison over a period of five years (1918−1922) was 69 per 1,000 (6.9%). Only a small proportion of cases were from registered brothels; the majority were from outside sources.59 This rate of 6.9% was only slightly higher than the rate in the civil population in England. On the other hand, the prevalence of venereal diseases among the Chinese male population was estimated to be at least 27% and possibly 40% in the

D iseases of V enus   |   5 1

Figure 2.4  Location of brothels: 1) Lyndhurst Terrace—for Europeans; 2) Sampan Street, Japanese district—for Japanese; 3) Shek Tong Tsui, Kennedy Town—for Chinese

Source:  Modified from maps of Victoria in 1880s on front pages of the book by J. F. Tsai, Hong Kong in Chinese History: Community and Social Unrest in the British Colony 1842–1913 (New York: Columbia University Press, 1993), xvi.

coolie population, as reported by the Government Civil Hospital.60 These diseases were common among Chinese merchants and shop-keeping classes, who contracted them at the brothels at Kennedy Town where the inmates did not have to undergo medical examinations.61 When Sir William Peel became the Governor of Hong Kong in 1930, he examined the problem of prostitution and sent his views to Lord Passfield, the Secretary of State for the Colonies. Peel stressed that the abolition of brothel regulation would be opposed by the military and naval authorities, senior government officials, and the leading members of the Chinese community who sat on the District Watch Committees and knew the community well. Abolition would lead to an increase of “sly” brothels and streetwalkers, and inevitably a greater number of venereal diseases, and would render international traffic of women impossible to control.62 Peel’s views were supported by the Permanent Under-Secretary and officials in London. Although Peel wanted to wait and see the effects of complete abolition of prostitution in Singapore first, events were moving quickly on the international scene. A commission of the League of Nations investigating international traffic of women and children was about to visit the Far East. Lord Passfield instructed the Governor to close down all the brothels: those for Europeans immediately, and those for the Chinese

52  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

in incremental stages, after consulting the Chinese leadership in the community.63 In June 1935 the last Chinese brothel in Hong Kong closed its doors. Sure enough, by 1938, the prevalence of venereal diseases among sailors and soldiers in the garrison had increased to 24% from the low of 7% in 1922. The number of new cases of venereal diseases treated at clinics swelled from 3,533 in 1932 to 8,573 in 1939. Soon a large number of “sly” brothels masquerading as dancing academies, bath houses, or massage parlors sprang up in different parts of Hong Kong. During the occupation from December 1941 to August 1945, the Japanese, like the British before them, had a system of regulation of brothels and prostitutes to benefit their own soldiers. When British rule was restored after the war, there was no further regulation of prostitution. In summary, the 1857, 1867, and other ordinances to regulate prostitution and brothels in Hong Kong, and later the extralegal system of control of prostitution, ostensibly to prevent venereal diseases in the Colony, had been designed to provide “clean women for the use of the soldiers in British Army and sailors in the Royal Navy,” rather than to check the spread of venereal diseases in the Chinese community or to preclude the exploitation of women. Although the British repealed the Contagious Diseases Act in England in 1886, the same law lingered in Hong Kong long after 1886. In a most unconventional move, the Colonial Office had overruled the advice and objections from the governors on several occasions— in 1889, 1890, and 1893— insisting on the abolition of legalized prostitution. Although the Government of Hong Kong finally repealed the Contagious Diseases Ordinance in 1894, it colluded with the Colonial Office, and put in a system of extralegal control that lasted for more than 30 years. These measures helped reduce the incidence of venereal diseases in the British army and navy to around 7%, but it was a different story among the Chinese population, where it remained high, between 27% and 40%. When pressure from the British public and the Colonial Office made it necessary to dismantle the extralegal system in 1931, despite protests from the Governor and all levels of government, the incidence of venereal diseases in the military climbed again. The story of the epidemic of venereal diseases in Hong Kong, marked as it is at times by moral and political indifference, as well as selective blindness and self-interest, does not follow the steady line of

D iseases of V enus   |   5 3

Figure 2.5  Incidence of venereal diseases (no. of cases/1,000 population) in Hong Kong after World War II, 1950–2013

Source:  Medical and Health Department Annual Reports, Hong Kong Government, 1951–2011.

enlightened progress we might like to imagine. The epidemic, which had lasted for over a century in Hong Kong, finally sputtered to an end after the Second World War, through prevention via condom use, extensive public health education and propaganda, and the institution of free clinics for diagnosis and treatment (Figure 2.5).64 These measures together with the wide availability of penicillin after the war all contributed to a marked reduction of the conventional venereal diseases.

This page intentionally left blank

3. The Chinese Hospital (Tung Wah): Its Rise, Decline, and Rebirth

The Chinese tradition of families caring for their sick at home changed for many with the opening, in February 1872, of Tung Wah Hospital. Its story mirrors the struggle between traditional Chinese medicine (TCM) and Western medicine in Hong Kong, with far-ranging cultural, social, and political implications. In it we can read the tensions of competing power interests between the Chinese and British communities in Hong Kong, the human and medical costs of misplaced priorities in its early years, and the colonial administration’s changing policy on the governance of Chinese community in Hong Kong.

The Rise of an Influential Chinese Gentry Most Chinese immigrants who came to Hong Kong in the early years were laborers from a lower socioeconomic class, seeking opportunities to make a better living. Elsewhere in China it was not the official administration, but members of the gentry class, who tended to look after local community affairs. In Hong Kong, however, with no one to mediate between the Chinese and the colonial administration, ordinance after ordinance to control the Chinese was passed. The Chinese, however, most of whom did not speak English, could not possibly understand these ordinances.1 Some of these Chinese immigrants became wealthy; they could communicate with the British and were able to act as middlemen for the administration. Loo Aking, a former outcast Tanka boatman, helped the British during the First Opium War by supplying their fleet with much needed provisions. He was rewarded with a large section of land in Hong Kong, and became very prosperous handling the opium monopoly, as well as operating a gambling establishment, several brothels, and a market for the residents. Tam Achoy, who had come to Hong Kong in 1841 from

56  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Singapore, worked as a foreman in a government dockyard. He became very well-off after being granted land and business privileges by the Hong Kong colonial government. He bought properties and acquired extensive sea frontage, as well as becoming a building contractor. Using part of their wealth strategically, the two built the Man Mo Temple (Temple of Literacy and Martial Valour) on Hollywood Road. These two patrons of the Temple became gentrified leaders among the Chinese and acted as judges for the local community.2 Soon other Chinese men who had acquired considerable wealth became respectable in the eyes of the Europeans. When a written protest of levying of ground rents was sent to Governor Davis in 1848, it was signed by 72 people, 27 of whom were Chinese building contractors, landowners, and merchants.3 By the end of the 1850s, Chinese who knew the English language and culture of the two races, called compradors, had become affluent on their own, and indispensable to the British merchants. As a result of the turbulence caused by the Taiping Rebellion in the South China community, kaifong (neighborhood) leaders, who were prominent merchants and shopkeepers of their neighborhoods, began to emerge in the second decade of the Colony’s existence. These civicminded and status-seeking citizens set themselves up as a public body to manage public affairs. Among them were affluent merchants from Guangzhou who had moved to Hong Kong with their families seeking stability and peace. The Chinese community welcomed them for their offers of alms, money, and social services, for the poor. At that time, each district in the city had a shrine dedicated to the earth god who protected the community from misfortunes and diseases. The kaifong leaders formed a committee to run the shrines, including the Man Mo Temple.4 The members of the Man Mo Temple Committee were responsible for both religious and civil matters in the district. Their judicial function was conferred by the British magistrates who would send complainants to the Temple authorities for dispute arbitration. 5 As trade began to flourish in Hong Kong in the 1860s, large merchant establishments known as “hongs” began to appear. The Man Mo Temple Committee was soon dominated by well-heeled merchants from Nam Pak Hong, 6 including merchants from dozens of trading firms in various native districts.7 As the Nam Pak Hong merchants became gentrified, they asserted their superiority and control over the Chinese community. There were 178 traders in Hong Kong according to the 1871

T he C hinese H ospital ( T ung Wah )   |   5 7

census; by 1881, the number had burgeoned to 2,770. They were affluent merchants from different parts of southern China, including Teochew, Fukienese, and Punti Cantonese, who used their resources to promote their power and influence. Emerging as the elite group, these men formed business connections with the British, who conferred upon them authority and social advancement.8 Well-to-do merchants could also gain recognition by joining the District Watch Committee. As early as 1842, the Hong Kong government had established a police force, initially consisting of mostly Europeans and Indians. Because the Europeans had high rates of sickness and mortality, the government began to hire Chinese.9 This police force was so corrupt and inefficient that Chinese trade houses and neighborhoods were compelled to employ their own guards. The District Watch Force, formed after the kaifong leaders petitioned the government in 1866, was supported by subscription from the Chinese community. It consisted of private watchmen and guards already employed by the merchants and shopkeepers, and was supervised by the District Watch Committee, a committee of Chinese merchants under the control of the Registrar General.10 Neither the District Watch Committee nor the Man Mo Temple Committee had been recognized by the government, and therefore were not prestigious enough to satisfy status-seeking Chinese merchants. The establishment of the Tung Wah Hospital met the desires of the Chinese directors for recognition by the government, while also answering to the social and medical needs of the poorer Chinese.

The Founding of Tung Wah Hospital The drama of the founding of the Tung Wah Hospital has been elegantly told by Elizabeth Sinn in her book Power and Charity and it will be briefly summarized below.11

Kwong Fook I Tsz A time-honored Chinese custom was to transfer the dead or their memorial tablets12 back to their native villages. But there was no provision for Chinese migrants who were far from home, and had no common

58  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

ancestral hall or temple to serve the dead. In early Hong Kong, there was a need for such an ancestral hall to receive the deceased’s tablets, awaiting transfer to their native villages. In 1851, several Chinese petitioned the government for a piece of land to build such a common ancestral hall in Tai Ping Shan. The petition was granted and the Kwong Fook I Tsz (Figure 3.1) was erected from funds raised in the community. Once constructed, it became much more than a place to store tablets. In June 1866, after an Inspector of Nuisance discovered coffins with bodies in the I Tsz, an inquiry was launched, during which Dr. I. Murray, the Colonial Surgeon, found that people were sent there to die. Hearing this, Governor R. G. MacDonnell realized that since the Government Civil Hospital was not used by the Chinese, who deeply mistrusted Western medicine, the Chinese needed their own hospital. He approved a proposal from a group of Chinese government clerks and school teachers, headed by Leung King Ham, to have a hospital built for the Chinese.13 Figure 3.1  Kwong Fook I Tsz

Photo courtesy of Tung Wah Museum

T he C hinese H ospital ( T ung Wah )   |   5 9

Despite Governor MacDonnell’s approval, the project collapsed. Influential Chinese community members obstructed the group’s efforts in fund raising, likely because they thought that such a worthwhile project should be undertaken by themselves. 14 While this scandal soon died down, it was to be replaced by a much bigger one three years later. Alfred Lister, the acting Registrar General, detected the atrocious situation in the I Tsz, and submitted a report that graphically depicted the horrors of the conditions for the sick, including those near-death being housed in the same rooms as the already deceased: One, apparently dying from emaciation and diarrhoea, was barricaded into a place just large enough to hold the board on which he lay, and not high enough to stand up in, and other room contained a boarding on which lay two creatures halfdead, and one corpse, while the floor, which was of earth, was covered with pools of urine. The next room contained what the attendants asserted to be two corpses, but on examination one of them was found to be alive…. And other rooms contained miserable and emaciated creations, unable to speak or move, whose rags had apparently never been changed since their admissions … 15 Newspaper reports on the I Tsz inhumanity resulted in an enormous uproar. After ordering another inquiry, Governor MacDonnell revived the old proposal of establishing a hospital for the Chinese, in order to deflect unfavorable publicity. He offered a grant of HK$10,000, later increasing it to HK$15,000.16 Influential Chinese, probably ashamed of the scandal, started a subscription campaign for a Chinese hospital and in no time had raised over HK$30,000.17 The government then approved a site for the hospital. In 1870, the government passed an ordinance to establish “a Chinese Hospital to be supported by Voluntary Contribution and for erecting the same into an Eleemosynary Corporation.”18 The board of directors, who was given considerable powers, would include no fewer than six and no more than twelve directors. Even though the term of office was for only one year, the directors were eligible for re-election. To check the board’s power, the Government would have the authority to order the Registrar General, the Colonial Surgeon, or any other qualified person to inspect

60  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

the premises at any reasonable time, and to intervene and even declare the abolition of the hospital, if necessary, should any extraordinary circumstances or abuses arise. An annual statement of accounts was to be submitted to the government. The ordinance would thus protect the interests of both sides.

The Hospital Committee The Tung Wah Hospital was a “society” consisting of a large number of members, governed by a hospital committee. Any Chinese who contributed HK$10 or more to the hospital could become a member. The number of members recorded in the 1873 annual report was 870,19 growing to 4,814 in 1907.20 The hospital was managed by a directorate of elected representatives at three levels: zongli (director), xieli (assistant director), and zhishi (assistants to zongli and xieli).21 The board of directors represented the highest authority of the hospital. The founding directors of the hospital formed the hospital committee for 1870 and 1871.22 The directors of the hospital were elected from candidates nominated by kaifong of all eligible districts and guilds. The hospital would send invitations to the nominees and post their names in the hall of the hospital for the public to view and to elicit possible objections. The slate of candidates was inevitably small, and it is likely that everyone involved knew before the election who would be chosen to serve. According to Lethbridge, the election was merely a window dressing, a formalized charade, but its main function was an important one sociologically—to create an opportunity for the order of social and economic superiority to be recognized by the community.23 The zongli and xieli were expected to donate substantial sums, depending on their ranking order, toward the philanthropic work of the hospital. The three principal directors had to be chosen from among the richest members of the community. Each committee was expected to donate more than the previous committee, and to further enlarge the scope of the activities of the hospital. In 1875 the hospital recorded revenue of over HK$40,000. The sources were donations from members of the directorate, local companies, Chinese residents, employees or passengers of various ships sailing to or from different countries, Chinese communities abroad, and various local theatre groups; rents collected from properties owned by

T he C hinese H ospital ( T ung Wah )   |   6 1

the hospital, and interests and investment income from the endowment fund; and drugs as gifts to the hospital. The expenditures of HK$33,972 for that year included salaries for the staff, hospital meals, purchase of food and drugs, coffins, burial expenses, payment of rates and rents for the properties and their insurance, maintenance and repair, and various miscellaneous projects. All the items of income and expense were meticulously documented in the annual reports.24 Businessmen with acumen and expertise necessary to manage the business activities of the hospital and investment of its endowment were recruited to the committee. Using the endowment fund, the hospital was able to acquire properties, and by the end of the century, these acquisitions had become a major business operation of the hospital. There was a striking absence of anyone with medical expertise to run the medical affairs on the Tung Wah hospital committee. Looking at the membership of the hospital committee, one would not have even known that it was managing a medical institution.

The Rise of the Hospital (1872–1882) In February 1872 the Hospital was formally opened with much fanfare. In attendance was Governor MacDonnell, who announced a further endowment of HK$100,000, a legitimate use of the gambling fund.25 Designed to impress the public, the compound of the Hospital was imposing and the meeting hall grand, rivaling those at the yamen compounds in China. In the grand hall, there was an altar with incense burners and vases placed before a scroll with an inscription honoring the patron deity, Shennong. Isabella Bird, a celebrated, independent-minded travel writer of the nineteenth century, visited Tung Wah Hospital in the company of Governor Hennessy in 1882. Her glowing description of this imposing hospital could hardly be more different than the earlier grim description of the I Tsz: The Tung Wah Hospital consisted of several two storied buildings of granite, with large windows on each side, and a lofty central building which contained the directors’ hall, the accommodation of six resident physicians, and the business offices. The whole was surrounded by a well-kept garden,

62  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

bounded by a very high wall. The entrance was grand with a flagged pavement; each flag consisted of a slab of granite twelve feet long by three broad.... The hall ... was lofty and very handsome, the roof being supported on massive pillars. One side was open to the garden. It had a superb ebony table in the middle, with a chair massive enough for a throne for the chairman, and six grand carved ebony chairs on either side … The wards held twenty each, and were divided into wooden stalls, each stall containing two beds. Partitions seven feet high ran down the centre. The beds were matted wooden platforms and the bedding white futons or wadded quilts, which were washed once a week. The pillows were of wood or bamboo. Each bed had a shelf above it with a teapot upon it in a thickly wadded basket, which kept the contents hot all day. A ticket, with the patient’s name upon it, and the hours at which he is to take his medicine, hung above each person … 26 Although Tung Wah Hospital was not a religious institution, it did have a patron deity, Shennong.27 Members of all ranks of the hospital were required to be present in the grand hall between 5 a.m. and 7 a.m. on the 1st and 15th day of each month, to worship the patron saint and to show that they were pure, upright, and honest. No outsiders were allowed to worship in the hospital. The directors, doctors, secretaries, and stewards, as well as servants had to sign two declaration forms of loyalty and faithful service before assuming their positions, as a form of sacred oath. One form was burned before the patron saint at the beginning, and the other at the end of their term of service.28

Medical Activities as a Charitable Mission The Tung Wah Hospital was initially staffed by three TCM practitioners, later increasing to eight. One of the practitioners was a vaccinator. Only Chinese doctors were employed in the hospital and, to ensure their good working habits, contract terms were for just three months at a time. They received salaries of HK$27.6 per month with room and board, and were allowed to conduct private practice outside the hospital.29 The hospital had a charitable mission, and would accept destitute, as well as paying patients. For room and board, the upstairs wards charged

T he C hinese H ospital ( T ung Wah )   |   6 3

HK$0.18, while those downstairs HK$0.075 per day, but the poor did not have to pay. Fearing that the poor and sick would overwhelm the hospital, the board of directors required that patients obtain a doctor’s confirmation that they were sufficiently ill to be admitted, as well as a security from a shop or one of the directors. Even with this added measure, the hospital became inundated with sick and destitute patients, and repatriating them became a major undertaking. Medical records of Tung Wah Hospital of the early days are not found in the hospital archive, but Isabella Bird gives us a glimpse of what the medical practices of the hospital’s staff appeared to her: The doctors never bled, leeched, blistered, or applied any counterirritants in cases of inflammation. They performed operations such as removing cancers and tumors, but they did not perform amputations. While chloroform was not used as an anesthetic for operations, other drugs were employed to put the patients into a profound sleep during the operations. These drugs possessed few side-effects, as the patients reportedly awoke an hour or two afterwards with neither headache nor vomiting. Bird was amazed at what she found in the hospital kitchen—150 earthen pots on 150 earthen furnaces. Each earthen pot was used to brew Chinese herbs for a different patient, under the superintendence of eight cooks. The doctors gave powdered rhinoceros’ horn, sun-dried tiger’s blood, powdered tiger’s liver, spider’s eyes, and many other unusual, yet traditional materials, and of course, ginseng was used frequently as a tonic. The composition of their medicine was always a secret. Bird found that wounds, dressed with musk, lard, and ambergris and covered with a piece of oiled paper, were invariably deplorably dirty and not cleaned, and gangrened feet were treated regularly with musk and tiger’s fat. Figure 3.2 shows some of the drugs and food items purchased by the hospital in 1878.30 These included ginseng, dried white lizards, tiger bones, lard, ambergris and others. In TCM some foods are used as medicine. The women’s ward was very clean and comfortable, but nursing was minimal. A woman in death-agony was not attended. Great attention was paid to cleanliness and ventilation, but the staff did not appear to use disinfectants. Dry earth was used as a deodorizer, and sandalwood was burned to disperse any bad odor. All windows were opened at both the top and bottom, to create air currents. Considering the great numbers of festering wounds, the freedom from smells was remarkable. While Bird commented that there was “much to admire in this hospital—the humane

64  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Figure 3.2  Some of the food and drugs purchased by Tung Wah Hospital in 1878  

 

Photo courtesy of Tung Wah Museum

T he C hinese H ospital ( T ung Wah )   |   6 5

arrangements, the obvious comfort of the patients, and the admirable ventilation and perfect cleanliness of the beds and wards,” she also added that “the system adopted was one of the most antiquated quackery. The mortality in this hospital was very large, not only from the nature of the treatment, but because Chinamen who had no friends in Victoria went there when they were dying, in order to secure that their bodies should be sent to their relations at a distance.” She concluded that the surgery and medicine in Tung Wah Hospital were of the most “antiquated and barbaric description,” untouched by European science.31 The high mortality rates of Tung Wah Hospital were also reported by the Colonial Surgeon in his annual reports, as shown in Figure 3.3. Year after year the mortality of Tung Wah Hospital hovered around 50%. The overall mortality in the Government Civil Hospital was between 5% and 6%, and among the few Chinese who were admitted to Government Civil Hospital, mortality was only 6% to 7%.32 Figure 3.3  Mortality (% deaths) of patients admitted to Tung Wah Hospital and to Government Civil Hospital for European and for Chinese, 1875–1896

Note:  * TWH=Tung Wah Hospital; GCH=Government Civil Hospital Source:  Colonial Surgeon Reports from 1875–1896, Hong Kong Sessional Papers, 1876– 1897.

While it was true that Chinese people did not usually go to hospital until they were close to death, it is also true that the failure to use antiseptics and the use of non-sterilized materials such as lard, musk, and ambergris to treat open wounds must have also encouraged infection, septicaemia and in many cases, even death. Moreover, housing the patients

66  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

with infectious diseases and open infected wounds with other patients was conducive to the spread of infections. Despite its high mortality rates, there was no shortage of patients, and the numbers grew over the years. In 1875, there were 882 inpatients and 45,685 outpatients, and in 1882, the numbers were 1,434 and 67,158, respectively. This remarkable growth attested to the popularity of the hospital.33 The hospital was intended to train Chinese to be practitioners of Western medicine under the auspices of Governor Hennessy, who was eager to promote Chinese culture and also to introduce Western knowledge. After the initial two years of a five-year course of study, better students would be sent to the Government Civil Hospital to learn Western medicine. It was hoped that doctors trained in both TCM and Western medicine would eventually serve China.34 The scheme, for a variety of reasons, was not realized. In contrast to a Western method of training that emphasizes free dissemination of knowledge, Chinese practitioners traditionally were reluctant to share their medical knowledge with their colleagues. Tung Wah Hospital ran a successful vaccination program, partly because Chinese in both south and north China had accepted Jennerian vaccination, brought to them by Dr. Alexander Pearson in the early nineteenth century. At Tung Wah so many people were vaccinated each year that the Colonial Surgeon, Dr. P. B. C. Ayres, decided to leave the main job of vaccination of the Chinese community to the hospital. The vaccination program did much to prevent severe epidemics of smallpox in the local community. Ayres often marveled that the Chinese were farsighted enough to see the benefits of vaccination, which was not at all compulsory, while many educated people in Europe were questioning its benefits.35 Even though Ayres appreciated the vaccination program, he had been very critical of other treatments that patients were receiving at Tung Wah Hospital. In his report for the year 1873 Ayres wrote: “The treatment of surgical cases shows an amount of ignorance which is much to be deplored. Seeing that the institution was endowed with such a large sum of money by the Colonial Government I think that the directors might be asked to set apart one ward of their Hospital for the treatment of patients by foreign doctors.”36 In the following year he was even more disparaging: “This institution at present hardly deserves the name of Hospital in the ordinary acceptance of the word. It does good as a refuge of the destitute

T he C hinese H ospital ( T ung Wah )   |   6 7

… and in time when their inveterate dislike of European improvements is overcome, may do much more good than it can now.”37 Ayres’ reports of these defects to the Registrar General and the Governor were ineffectual. Realizing the government’s reluctance to interfere, he gave up trying, as can be seen in the brief four to six lines he would write about the hospital in the annual reports for subsequent years. Although the English press criticized Tung Wah Hospital for balking at the acceptance of Western medical treatment, the directors claimed that the Chinese had no desire to expose themselves to forms of medical care they were not used to. Meanwhile in Guangzhou, patients were flocking to the Guangzhou Missionary Hospital, where Dr. Peter Parker performed eye surgery and removed tumors, or to Dr. John Kerr’s Hospital, where thousands were being treated with Western medicine. It is not clear why patients in Hong Kong clung to the prejudice against Western medicine for so long, or whether the directors of Tung Wah Hospital simply wanted to maintain their hold on the Chinese population.

Philanthropic Activities The hospital developed extensive philanthropic activities, providing free room, lodging, and medical services to all those in need. While it requested that patients pay for drugs, those who could not afford medications would be given to them for free. Those who died without relatives, or whose relatives were poor, would be given coffins and buried at the Hospital’s expense.38 It also repatriated shipwreck victims, coolie-emigrants abducted abroad, and women and girls who had been kidnapped for prostitution or other immoral purposes. When there were large numbers of deaths from natural disasters such as fire or typhoon, the hospital offered a place for the remains of the victims, erected an appropriate memorial, and conducted religious rites to appease the spirits. Over the years, it raised huge sums in relief of various disasters in China, such as the 1877 floods in Shanxi province. It received awards of plaques from the Governor of Shanxi and from the Emperor Guangxu, greatly enhancing its prestige in the eyes of the Chinese public.39 The hospital also served the overseas Chinese communities throughout the Pacific region. These communities often sent money, letters, and other personal effects to the Hospital for distribution to their native villages in mainland China. When Chinese died overseas and

68  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

their remains were shipped to Hong Kong, the hospital committee used funds from their coffin depository to transfer the remains to the native villages for burial. They also performed the same service for those who died in Hong Kong and whose surviving family members wished them to be buried in China. Because of the extensive services provided, the Chinese communities both at home and overseas subscribed readily and generously to its fund-raising campaigns.40 After the merger of the Tung Wah Hospital and the Man Mo Temple, the hospital committee took over the responsibility of managing the Chung Wah School, which was attached to the Man Mo Temple. Over time, the hospital managed more and more free schools that provided poor children with a traditional Chinese primary education. Modern methods of education were also introduced, and eventually middle school education was offered. Figure 3.4  Tung Wah board of directors wearing Qing official robe and headgear in the assembly hall of the hospital in 1885

Photo courtesy of Tung Wah Museum

Political Activities Membership in certain Chinese community organizations was the most effective method of acquiring prestige in Hong Kong in the 1860s and 1870s. Since membership of the Tung Wah hospital committee was

T he C hinese H ospital ( T ung Wah )   |   6 9

by “popular vote” of the Chinese community and provided a badge of respectability, the government regarded the committee as a “mouth piece” of the people. Governor MacDonnell was present during the hospital’s opening ceremony and the two successive governors, Kennedy and Hennessy, had endorsed it, conferring upon it the recognition lacking in other Chinese institutions, such as the Man Mo Temple. With prestige, wealth, and moral authority acquired through its charitable work, the work of the Tung Wah hospital committee extended beyond its medical and philanthropic activities to include management of Chinese public affairs. The hospital became the most important civic center for the Chinese, where members of the community could bring forth any matter of public interest for discussion. The committee also played a quasi-legal role, arbitrating civil and commercial disputes among Chinese, who had no use for the British Magistrate’s court, as they did not understand either the English language or their laws.41 The hospital committee approached the government on behalf of the Chinese community on medical issues such as vaccination, post mortem examination, and exemption from amputation, but they most often presented non-medical issues. These included brothels, marriage laws, adultery, registration of companies, bankruptcy laws, and the Night Pass law, which had created great ill-feeling among the Chinese law-abiding residents. By bringing these issues to the government, the committee fulfilled a need of the Chinese community to be heard, and to have their concerns heeded. At the same time, its directors were able to realize their own desires to be influential and admired in the community. Another important way that the hospital committee served the Chinese community was by addressing issues associated with emigration in the port of Hong Kong. They persuaded Governor Kennedy to take action on abuses such as the kidnapping and sale of men, women, and children. Three ordinances were passed in 1873, and, as a result of the petition of four prominent merchants to the Governor, permission was granted to found a society to prevent kidnapping and to protect victims. The Po Leung Kuk (Society for the Protection of Women and Children) was formed in 1878.42 To solve problems arising from emigration to different parts of the world, the Chinese mandarins in Guangzhou and their diplomatic staff often worked with the hospital committee, which frequently hosted visiting Chinese officials, taking advantage of their extensive overseas

70  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

connections. The Commissioner of Customs in Guangzhou observed “that the Tung Wa Hospital was hand in glove with the Prefect of Canton” and “really managed all Chinese matters in Hong Kong.”43 Alarmed by the potential that the committee might use political influence over the Chinese population in the Colony, the Secretary of State for the Colonies, Sir Michael Hicks Beach, sent a confidential dispatch to Governor Hennessy, instructing him to restrict the functions of the hospital committee.44 But Hennessy did not take the warning seriously. By 1882, the hospital had reached the zenith of its reputation and power, having acted as a bridge to champion many Chinese causes with the government. However, these valuable political gains came at the expense of the hospital’s medical work. The mortality remained at around 50 percent, unacceptably high from the standpoint of Western medical doctors. That same year, Isabella Bird found the hospital to be a kind of curiosity, untouched by major breakthroughs in Western medicine that had greatly reduced surgical mortality rates, such as the advances of the “germ theory” of disease, and the introduction of disinfectants to hospitals. Despite the increase in demand, there was no plan for expansion. With terrible overcrowding, the hospital’s sanitation deteriorated from lack of proper supervision. Tung Wah Hospital, the first Chinese hospital, lacked knowledge of how to run it effectively, and its directors were too stubborn and too proud to employ the Western methods which would have helped reduce the mortality rates of the patients it purported to serve.

The Sickening Descent of the Hospital From its opening, the English press had taken every opportunity to attack Tung Wah Hospital and its committee, eager to expose and exaggerate its defects, even though their real antagonism was related to its non-medical activities. The two communities were especially polarized by the issue of the Night Pass, which the hospital committee had raised. When the activities of community hall next to the Man Mo Temple were moved into the great hall of the Hospital at the merger of the two organizations, the suspicion of the foreign community that the committee was arrogating too much power, even functioning as an unofficial government for the Chinese community, seemed to be confirmed.

T he C hinese H ospital ( T ung Wah )   |   7 1

To deflect criticism of conducting nonmedical activities, the hospital committee petitioned Governor Kennedy in 1875 to build a City Hall on the Chinese Recreational Ground close by. Although the Governor agreed, the Surveyor General, Mr. J. M. Price, objected because the ground was meant for recreation, not for a civic building. When Hennessy replaced Kennedy as Governor, he instructed Price to prepare the deed for the Chinese to build the City Hall on the Chinese Recreational Ground, but when Hennessy left his post, the hospital lost its strongest supporter. Sir William Henry Marsh, who took over the administration after Hennessy’s departure, rescinded Hennessy’s decision. 45 Hostile to the hospital committee and wary of its political power, Marsh worked to restrict its influence and helped bring about its gradual decline. With Hong Kong having such close geographical and economic ties to China, the Chinese elite in Hong Kong found at times that they were serving two masters, and vulnerable to the political influence of officials in China. As many elite had Chinese official degrees, the Chinese officials treated them as subjects under their jurisdiction, and at times made unreasonable demands on them. The colonial masters regarded such connections with suspicion. During the Sino-French War in 1884 the colonial officials suspected that some leading Chinese, who were closely connected to the mandarins in Guangzhou, had been the instigators of unrest. When a riot broke out, Marsh stationed British troops in the great hall of Tung Wah Hospital, humiliating the elite by making a show that British authorities were determined to use force to exert control when necessary.46 One might wonder why the British authorities tolerated the hospital committee’s presumption of power for so long. In fact, the colonial administration, which had been monitoring its activities, assumed that, with no military force and no authority to collect tax, the committee had no genuine power. In addition, it had been providing important services to the community, at no expense to the government. It also furnished the government with advice and information concerning the governance of the Chinese and the maintenance of law and order. There was a certain symbiosis: the hospital committee required governmental support and the government needed the approval of the elite to enhance their legitimacy in the eyes of the Chinese community. By the late nineteenth century, however, membership on Tung Wah hospital committee was no longer the only route to social recognition in

72  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

the Chinese community. New avenues for social advancement opened up for aspiring individuals, especially the younger, westernized ones who had been educated abroad. More and more Chinese who had been naturalized to become British citizens were appointed by the colonial government to serve on various official boards such as the Sanitary Board and the Commission of Peace. These members served in an advisory capacity and under the government’s control, cooperating with the government to bring about sanitary reform or to mediate labor strikes. In this way the government co-opted the Chinese elite, giving them the trappings of status but no actual power.47 It was time for a shift in the center of gravity in Hong Kong’s medical history.

The Turning Point A turning point in the history of Tung Wah Hospital, and in the history of medicine in Hong Kong, came with the devastating bubonic plague in 1894. When Dr. James Lowson, the Assistant Superintendent of the Government Civil Hospital, discovered that undiagnosed advanced cases were not being isolated from other patients in Tung Wah, a veil was lifted on its insanitary conditions and general lack of medical expertise. In his report on the plague, Dr. Lowson condemned the hospital as a hotbed of medical and sanitary vice that would have been abolished if it had been a Western institution. It was clear that it had remained in Hong Kong purely for political reasons. He asserted that the hospitals he had visited in China were generally far superior to the overcrowded and filthy Tung Wah Hospital, which lacked cleaning and disinfecting processes to prevent the spread of diseases from patient to patient. Situated in the center of a densely populated area, it posed a tremendous danger to public health. He claimed that he was unable to speak about the hospital in a calm and collected manner because of the disgrace and danger it represented to Hong Kong.48 Although only an edited version of Lowson’s report was sent to the Colonial Office, the Secretary of State for the Colonies heeded Lowson’s proposal for improving the medical services in the Colony, and he asked for Governor William Robinson’s input. Robinson replied that Lowson’s scheme would involve nothing short of abolishing Tung Wah Hospital, which he was not prepared to do.49 In 1895 Robinson ordered

T he C hinese H ospital ( T ung Wah )   |   7 3

a commission to investigate the workings of the hospital. Chaired by J. H. Stewart Lockhart (Registrar General), it also included Ho Kai, J. C. Thomson, C. P. Chater, and T. H. Whitehead. The last two were unofficial members of the Legislative Council. Many witnesses were called, and, as expected, medical experts denounced the Tung Wah hospital committee. Lowson submitted further evidence of the poor sanitation in the hospital, underlining the lack of knowledge of the Chinese doctors, who placed so many at risk by not isolating patients with infectious diseases.50 The hospital was grossly mismanaged and utterly filthy and had far too small a staff to care for it. There was not even a doctor regularly on duty. Dr. J. M. Atkinson, the Superintendent of Government Civil Hospital, reported that Chinese doctors with no surgical knowledge were allowed to carry out operations. He believed that 90% of surgical patients lost their lives by being treated in Tung Wah Hospital. As it had failed to carry out the objects and purposes for which it was created by providing proper treatment of the indigent sick, it should therefore be abolished.51 Francis Clark, Medical Officer of Health, noted the inadequacy of latrines and bathrooms in the hospital, and the lack of light and ventilation in the surgical wards because the verandas were used for storage of lumber, rubbish, woodwork, baskets, and clothing. Clark believed that the whole problem was one of management, and that someone under the Colonial Surgeon should be responsible for overseeing the day-to-day operation to keep it in sanitary conditions and to ensure the emptying of night soil every day. He suggested the appointment of a European steward to ensure proper ventilation of the wards, proper sewage drainage, and that servants did not live in the basements.52 The assessment of Hugh McCallum, Secretary of the Sanitary Board, was more considered, as he recognized the grander role of the hospital in the life of the Chinese community. He found the drainage arrangements defective and the conservancy arrangements for the patients rather primitive, but as these problems were being attended to, he believed that once completed, the sanitation of the hospital would be placed on a satisfactory footing.53 The commission concluded that Tung Wah Hospital had in many respects fulfilled the primary purpose for which it was established, but had failed in other equally important aspects. It had completely superseded the old I Tsz and had rendered excellent service as a poor house and refuge for

74  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

the sick and destitute. It had promoted vaccination, given the sick a better chance of recovery than they could have had in their own houses, and enabled thousands to die in relative ease and comfort. At the same time it had also performed a considerable amount of charitable, benevolent, and other meritorious work. However, it had not been “the really good, well conducted hospital to be used for the relief and cure of the sick and destitute Chinese” that Governor MacDonnell had envisioned and that the then Secretary of State, Lord Granville, had approved and sanctioned. To avoid further humiliating the hospital directors, the commissioners wisely laid the blame on successive Registrars General and Colonial Surgeons, for their failure to exercise “continuous inspection, frequent supervision, and regular and systematic control over the management of the Hospital.”54 They made several constructive recommendations to improve the hospital. To meet the growing population, which had doubled from 1872 to 1896, it needed to be enlarged. Accommodations for those who were brought there to die should be separated from those who were brought there for treatment with the hope of being cured. For purposes of separating the sick from the dying, the infectious from the non-infectious, and for tracking diseases, deaths, and causes of deaths, a Chinese resident doctor trained in Western medical science was required and paid for by the government. This resident doctor should be under the close and constant supervision of the Visiting Surgeon, or of some other competent medical officers. There should also be a resident European superintendent, with training in sanitation, to ensure that all necessary precautions and all rules as to cleanliness and ventilation would be observed. This officer should not be permitted to interfere with the management or the treatment of the patients, or to give orders, but would be required to observe and report, so that the government could intervene at the first sign of any neglect, or any non-conformity to government rules and by-laws. The hospital would be required to gradually replace some of the current doctors with Chinese doctors who had been trained in Western medical science, so that patients would be given the option of choosing Western medicine if they desired.55 Governor Robinson, who had been harshly criticized by both the Chinese and English communities during the epidemic of plague of 1894, now took a very strong stand. He demanded that the hospital change its policy of exclusive use of TCM and undertake the reforms suggested

T he C hinese H ospital ( T ung Wah )   |   7 5

by the commissioners. Meeting with the new directors of Tung Wah Hospital to deliver the commission’s recommendations, he pointedly remarked how a number of the directors of the hospital were in the habit of consulting Western trained doctors. Why then should not the poor have the same choice? Then he waved his stick: It had been hinted to me that there may be opposition to these appointments I propose to make.... If I discover anyone trying to stir up trouble and by misrepresentation creating bad feeling, I will take prompt steps to deal with the person.56 The government appointed Dr. J. C. Thomson to supervise the sanitary arrangements of the hospital and Dr. Chung King-ue, a Chinese doctor trained in Western medicine, as the resident surgeon. Patients were to be given the choice of either TCM or Western medicine.57 An administrative advisory board for the hospital was also established. Within a very short period of time Thomson made remarkable improvements in the sanitation of the hospital. Patients with infectious diseases were isolated. The surgical wards were properly ventilated and well lit, and new flooring was installed in the wards. Doctors and servants were given proper accommodations. Chung, who treated many patients during the first few months, created two registries: one for all patients admitted with a diagnosis, and another for all dead bodies brought in. Dead bodies were not accepted until relatives of the diseased had answered relevant questions and a diagnosis reached. No post mortem was carried out without the approval of the family.58 More and more patients opted for Western methods of treatment once the higher survival rate of those who had chosen this approach became common knowledge. Figure 3.5 shows the percentages of inpatients treated with TCM and Western medicine in the years from 1897 to 1920.59 During this period the mortality of patients who chose Western method of treatment was consistently 10% to 15% lower than those treated with traditional Chinese medicine (Figure 3.6). By 1915, the number of patients who chose Western medicine surpassed those treated with TCM. From 1896 onwards, the hospital committee focused on providing medical care, greatly expanding its medical services to serve the changing needs of the population, and founding more clinics and subsidiary hospitals. In 1890, it established the Kennedy Town Clinic, which became

76  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Figure 3.5  Percentage of inpatients treated by TCM and by Western medicine in Tung Wah Hospital, 1897–1920

Source:  Colonial Surgeon Annual Reports 1897–1920 in Hong Kong Administrative Reports, 1897–1920.

an anti-plague clinic in 1899. In 1902, a new Tung Wah Hospital was built. In 1909 the New Street Anti-plague Clinic was established, while the Kennedy Town Clinic became an anti-smallpox clinic. In 1911 Kwong Wah Hospital (Figure 3.7) was established in Kowloon, and in 1929 Tung Wah Eastern Hospital was added to the group.60 In 1919, the maternity wards in Tung Wah Hospital and Kwong Wah Hospital were expanded to cater to the needs of the female population. In the meantime the hospital committee continued its philanthropic activities in relief work and in provision of free education and senior citizen’s homes. The Tung Wah group of hospitals held annual fund-raising campaigns to defray its expenditures, but economic depression in 1935 brought the fund raising campaigns to a standstill. By 1938, when the deficit mounted to HK$150,000, the chairman of the committee appealed for government assistance. The government agreed to support the hospitals with an annual grant and would be responsible for any future deficit if hospital committee would form a separate medical committee and delegate to it all medical administration matters. The establishment of the medical committee led to the modernization of medical services and enabled this group of hospitals to keep pace with rapid advances in Western medical sciences. In summary, Tung Wah Hospital was born out of a unique Chinese concept of public welfare, tending to the needs of the old and the young,

T he C hinese H ospital ( T ung Wah )   |   7 7

Figure 3.6  Mortality (% deaths) of inpatients treated by TCM and by Western medicine in Tung Wah Hospital, and in Government Civil Hospital, 1897–1920

Note:  * TWH=Tung Wah Hospital; GCH=Government Civil Hospital Source:  Colonial Surgeon Annual Reports 1897–1920 in Hong Kong Administrative Reports, 1897–1920.

Figure 3.7  Kwong Wah Hospital building now occupied by Tung Wah Museum

Photo courtesy of Tung Wah Museum

78  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

housing the poor and the sick, providing free coffins and free burials for the dead, and offering monetary relief to victims of disaster, both locally and in mainland China. Its sense of mission was far-ranging, and did not stop with the patients it treated in the hospital, or even with the lifespan of its patients. Its philanthropic work extended beyond Hong Kong to overseas Chinese communities, and it invested much in the repatriation of the remains of people who had died, back to their home villages and cities. The wealth and prestige of the hospital committee empowered the hospital to oversee the public affairs of the Chinese and to mediate with the Hong Kong government. Thus the hospital satisfied the desire of the wealthy Chinese for social status and public recognition, and provided the Chinese community, for the first time, with a voice that would be heard by the government. At the same time, the colonial administration was able to use Tung Wah as a communication channel with the Chinese majority in Hong Kong. Later, as the hospital committee became involved directly with the Chinese officials in Guangzhou, assuming a quasi-political status, British fears of an imperium in imperio in Tung Wah led the colonial administration to use the crisis of the bubonic plague of 1894 to step in. Some people view the forced acceptance of Western medical practices in Tung Wah Hospital as cultural, social, and political imperialism. While I agree that the government exploited the crisis of the bubonic plague to curb the power of the hospital committee, I would also argue, as a physician, that ultimately the hospital and Chinese patients in Hong Kong were beneficiaries of the commission’s scathing report. The British government maintained its historical position of not interfering with Chinese customs, reacting only when the health of the Europeans was threatened. But non-interference was unconscionable when basic principles of sanitation were completely violated in a hospital that could easily have been the site of an epidemic outbreak. From the perspective of the Colonial Surgeon trained in Western medical practice, neglect of sanitation and hygiene in a hospital within the city under his jurisdiction could not be ignored. Since the 1990s there has been a dramatic increase in interest in TCM, reflecting a changing political scene. In general, most people in Hong Kong rely on Western medicine for treatment of acute illnesses, accidents, and conditions that require surgery and consult TCM practitioners for treatment of chronic illnesses and for maintenance

T he C hinese H ospital ( T ung Wah )   |   7 9

of health. Neither Western medicine nor TCM is perfect and the two systems may complement each other well. How can we continue to work to integrate the two systems and provide more choices for patients? Of course, as Elizabeth Sinn has warned us in her book, we cannot be overly optimistic that real merging between practitioners of the two systems in Hong Kong could happen any time soon. 61 The basic premises and philosophies of TCM and Western medicine and the prevailing sociocultural backgrounds of the practitioners of the two systems are so different, that it would be challenging for them to understand each other and work together. Still, we can imagine that, like a couple in an arranged marriage, they might, given time and patience, move into a productive, even harmonious relationship.

This page intentionally left blank

4. Western Medicine: A Hard Sell in Hong Kong

While Western medicine and traditional Chinese medicine (TCM) may now be found as treatment options in China and Hong Kong as well as in the West, this phenomenon is relatively recent. At the time that Hong Kong was ceded to the British, it is not difficult to understand why Chinese distrusted Western medicine, preferring TCM, which had been part of their culture, their customs, even their identities for thousands of years. It did not help that they found the few Europeans they had contact with to be arrogant and barbaric, with bizarre, indecipherable customs. In the mid-nineteenth century, unfounded and unproven theories in the West blamed illnesses on imbalances of fluids or humors—black bile, yellow bile, phlegm, and blood—as postulated by Galen. Although Western medicine of the time had a few effective medications such as quinine for malaria, digitalis for heart failure, colchicine for gout, and metals such as mercury and antimony for treatment of venereal diseases,1 most treatments derived from humoral theories were harmful to the patient. To be a surgeon in Western medicine before the 1870s meant bloodletting—someone wielding a lancet or some elaborate “scarificator,” a f iendish look ing device with multiple blades that would cut simultaneously into the skin. At that time treatment consisted of getting rid of bad humors. To treat fevers, the physician would let blood by using leeches, cupping, or venesection, and purge using laxatives or something stronger. Thus Western medical therapeutics would make the patients anemic through bloodletting, deplete them of fluid and electrolytes by purging, and poison them with heavy metals. To the Chinese, blood was vital to impart the energy and strength needed for recovery, and the practice of using emetics and purgatives seemed detrimental to patients’ constitutions. They also viewed Western medical practices such as surgical amputations, and removals of tumors or bladder stones, as utterly barbaric.

82  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

By the latter part of the nineteenth century, when European doctors, such as Dr. P. B. C. Ayres, came to Hong Kong, a series of major scientific breakthroughs had transformed Western medicine. The invention of the stethoscope by René Laennec in 1816 had already improved the accuracy of diagnosing various heart and chest diseases. The widespread use of microscopes in medical research by great scientists such as Louis Pasteur and Robert Koch had led to the discovery of bacteria responsible for various infectious diseases, such as Bacillus anthracis in anthrax (1876), Mycobacterium tuberculosis in tuberculosis (1882), and Vibrio cholerae in cholera (1883). In 1867 the introduction of antiseptic techniques that greatly reduced surgical mortality, and the use of anesthetics that enabled surgery to be carried out painlessly, were other important milestones in the history of Western medicine. Then in 1895 came the invention of x-ray technology by Wilhelm Roentgen in Germany, rendering ready confirmation of clinical diagnosis. (See Appendix 1 for the timeline of development of Western medicine) Added to these innovations were the discovery and availability of new medications such as opium and morphine for pain, and the wonder drug, aspirin, for fever and pain. Further advances in medicine led to the identification of tetanus bacilli as the causative agent for tetanus by Dr. Shibasaburō Kitasato at Koch’s laboratory in 1889 and the development of diphtheria antitoxin by Dr. Alexandre Yersin and colleagues at the Pasteur Institute in 1890. A short time later, these two medical scientists would discover the plague bacillus during the 1894 epidemic in Hong Kong. With the establishment of the British Medical Association in 1856 and the General Medical Council in 1858, professionalization and regulation of medical practice had begun. By the end of the nineteenth century, physicians had become respectable in the eyes of the public, and Western medicine had become institutionalized with the founding of the first medical schools. Although Western medicine had come a long way in a relatively short time, TCM had been stalled in a state of arrested development. Thus it is not surprising that doctors such as Ayres viewed TCM, which had failed to develop after the Tang dynasty, as quackery. A speech given by Dr. James Cantlie, the Dean of the Hong Kong College of Medicine, at its first graduation ceremony on 23 July 1892, illustrates a condescending attitude toward Chinese culture and beliefs, as well as a sense of innate European superiority:

W estern M edicine   |   8 3

We have taught them without pecuniary reward or extraneous help and freely we hand our offering to the great Empire of China, where science is yet unknown, where ignorance of our own medieval times is current, where the astrologer stalks abroad with the belief that he is a physician, where the art of surgery has never been attempted, and where thousands of women suffer and die by the charmed potions of the witchcraft practices of so called obstetricians.2 Cantlie, of course, does not acknowledge Chinese discoveries such as the compass, gun powder, paper making, and printing, and that the great Chinese physician, Hua Tuo, performed surgery under anesthesia during the Warring States period (three to four centuries B.C.E.). It is also likely that many important discoveries in China had been erased by time due to the ancient custom of guarding esoteric knowledge rather than passing it on to pupils. The tradition of protective secrecy in China has a long history. Leading medical doctors in China seldom passed on their knowledge to others, not even their own sons, and any knowledge that was transmitted was highly selective and partial.

Traditional Chinese Medicine The history of Chinese medicine can be divided into four periods, reaching back nearly five millenia.3 The ancient period (2697–1122 B.C.E.) began with the legendary Huangdi (Yellow Emperor), who was credited with the Chinese medical classic Neijing (Inner Classic). The second period (1123 B.C.E.–960 C.E.), commencing with the Zhou dynasty and ending with the Tang dynasty, was the most progressive. Chinese physicians’ emphasis on observations and on the careful recording of the manifestations of diseases placed this period in a more scientific framework. Dieticians were appointed at royal courts during the Warring States period, and during the Han dynasty a Chinese physician described the clinical signs of leprosy: swelling of the eyebrows, loss of hair, difficult and hoarse respiration, and areas of anesthesia. Another physician recognized diabetes as a disease that occurred in those who had made a habit of eating sweet and fatty food, and Zhen Quan noted an excess of sugar in the urine of diabetic patients.4 A Tang

84  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

physician, Sun Simiao, suggested that for diabetic patients “three things must be renounced, wine, sex, and eating salted, starchy cereal products,” claiming that cure would occur without drugs if this regimen were followed.5 In the Tang and Song dynasties, proper medical schools were established and the examination of medical practitioners was conducted on a larger scale. Also during the Tang dynasty, Buddhism entered China from India, introducing Indian therapeutic measures and medical education was available only at the imperial college, from which students graduated to serve as court physicians. In the Song dynasty medical schools also sprung up in other parts of the country. When medicine entered the third period (961–1800 C.E.) after the Tang dynasty, it showed gradual decline partly because of a lack of system of centralized control and training, and also because different schools of thought had emerged. In the Ming and Qing dynasties, medical instruction was not properly supervised, and Chinese medicine deteriorated further.6 Anyone could call himself a doctor—there was no registration, no code of practice, and no ethical code.7 TCM, with its deep ancient roots, did not easily make room for Western medicine, but the arrival of Western medical missionaries in China initiated the fourth, more modern period (1801–1936 C.E.). We can well imagine the great reserves of faith and determination necessary for these missionaries to carry their message to China and Hong Kong.

The Framework of TCM TCM, grounded on the law of “five elements”—metal, wood, water, fire, and earth, which interact with each other—goes back to the fourth century, and is based on a very different way of envisioning the body than that found in Western medicine. The five main zang, or organs of the body are classified according to the five elements: metal for the lungs, wood for the liver, water for the kidney, fire for the heart, and earth for the spleen. The zang’s functions are to manufacture and store essential substances. The six fu organs: stomach, small intestine, large intestine, gall bladder, urinary bladder, and the san jiao or “triple burner,” receive and digest food, absorb nutrients, and transmit and excrete waste material.8 The organ which TCM refers to does not always correspond to the same named anatomical structure of Western medicine. For example, the term “kidney” in TCM has the following physiological functions: 1)

W estern M edicine   |   8 5

stores essence and dominates reproduction, growth, and development; 2) produces marrow and manufactures blood and controls the brain and bones; 3) dominates water metabolism; 4) receives qi; and 5) opens to the ear. TCM is based on the concept that the cosmos is composed of ethers of heaven and earth which are yang with attributes of bright, light, and male, and yin, which are dark, heavy, and female. The ethers (yin and yang) and the five elements also symbolically represent aspects of nature. From correspondences between the ethers and the five elements, the Chinese formed theories based on complex sets of relationships between the human body and the physical environment, and between humans and life events. According to these theories, an individual’s physical and psychic characters are determined by the movement of cosmic ingredients, with the elements acting on the ethers, with additional attributes of hot (yang) and cold (yin) that reflect the human constitution. In their natural state, the relationship among phenomena is one of balance and harmony. When imbalances among these elements occur, diseases develop. As both the cosmos and human society are in constant flux, with people being born, maturing, marrying, and dying, these transitions are seen to create metaphysical instabilities. These instabilities in turn affect internal balance in the human body. Some people have cosmic balances that clash with those of people they are connected with in their immediate environments. Thus the Chinese compared the horoscopes of prospective bride and groom to avoid these clashes.9 Another fundamental concept of TCM is the qi, which represents the life energy or “vital breath,” and is analogous to the Greek concept of “pneuma.” The acquired qi comes from food and air and forms the essential qi that nourishes the heart and lungs and promotes the function of blood, vessels, and respiration. The other type of qi circulates in the skin and muscles, nourishing the subcutaneous tissues and defending the body from exogenous pathogens. Qi is excreted in the lungs and kidneys.10 A practitioner of TCM would make a diagnosis based on a fourstep process: 1) inspection; 2) listening and smelling; 3) inquiry; and 4) palpating the pulse. He would take note of the patient’s facial expression, general appearance, the color and luster of the skin, and the state of the patient’s tongue. Believing that there is a close connection between the tongue and the functioning of the internal organs, Chinese practitioners place a great deal of significance on changes in its color, mobility, and

86  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

coating. After feeling the pulse and interpreting the findings on palpation together with the patient’s clinical history, the TCM doctor would make the diagnosis and prescribe treatment in the form of a list of herbs. The patient would give the prescription to a dispenser, who would collect and carefully weigh each of them, wrap them up in paper, instruct the patient to boil the contents with so many bowls of water, and simmer together in one bowl before drinking. The medicine would be taken once a day, with the patient expected for a follow-up visit the next day.11 Thousands of herbs have been used in Chinese medicine, and many of the active ingredients have been identified, including ephedrine from mahuang, for treatment of asthma; iodine-rich seaweeds, for treatment of thyroid enlargement; salicylic acid or aspirin, for rheumatism; chaulmoogra seed or its oil, for leprosy; and artemisia, for malaria. There are three types of TCM practitioners: herbalists, who specialize in the use of herbs for internal medical care; acupuncturists, who treat illnesses by inserting needles into certain points of the body; and bonesetters, who treat sprains and contusions.12 Acupuncture and the related moxibustion are two of the most ancient therapeutic techniques of TCM. In acupuncture, needles are implanted at different depths at a great variety of points on the surface of the body, along a highly complex pattern of twelve regular channels and eight “extra” ones. The channels and collaterals have both afferent and efferent potential. Stimulation of an “acu-point” can affect the internal organs, and imbalance in the internal organs can be detected at the superficial acu-points. The proper selection of points is the key to acupuncture therapy.13 TCM was almost completely replaced by Western medicine with the founding of the Republic of China in 1911, although the change of regime in 1949 to People’s Republic of China led to its revival. It is common knowledge that since the Cultural Revolution, the use of acupuncture to address problems such as chronic pain has gained many adherents in the West. Many herbs known to be effective have now been subjected to extensive research for their active ingredients, and they have been purified and their effects assessed using Western scientific methods.

W estern M edicine   |   8 7

“Healing Bodies and Saving Souls”— The Interweaving of Western Medicine and Christianity The introduction of Western medicine into China is a story of faith, charity, and dedication of missionaries, particularly medical missionaries, coming from Europe and North America. The missionaries attempted to introduce Christianity to China by packaging it with medical services. Even though Christianity arrived in China as early as 635 C.E., and intermittently thereafter, it had never really taken root until the arrival of Robert Morrison in 1807. After seven years of living between Guangzhou and Macau, and encountering much hostility in these places, Morrison had converted only one person. But he was indefatigable. Mastering the language, he translated the New Testament into Chinese, and published an English-Chinese dictionary. While in Macau, he and Dr. John Livingstone of the East India Company, started a dispensary. They invited a Chinese medical practitioner, Dr. Lee, to work with them in the clinic, and it seems that both Western medicine and TCM were offered.14 Morrison then went to Malacca and established the Anglo-Chinese College, hoping that the students would be influenced by Christianity and become preachers of the gospel. Although Western medicine lacked therapeutic agents at that time, surgery, which was seldom carried out by TCM doctors, could produce dramatic results in the hands of Western doctors. Dr. Peter Parker, the first medical missionary to reach Guangzhou from the United States in 1838, started the first mission hospital in China, which became the wellknown Ophthalmology Hospital. Dr. Parker had used his surgical skills to treat the prevalent eye diseases, which had not been treated effectively by TCM doctors. By extracting cataracts, Parker performed an apparent miracle by enabling the blind to see again. He also performed surgeries to repair hernias, and remove bladder stones as well as huge disfiguring tumors.15 The Chinese began to flock to his and similar hospitals run by Western missionary doctors such as William Lockhart and John Kerr. Parker was regarded by many as Hua Tuo, the legendary Chinese physician. Another important medical missionary, Dr. William Lockhart, arrived in Macau in 1839 under the auspices of the London Missionary

88  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Society, and worked initially in Parker’s hospital in Guangzhou, learning the Chinese language while he was there. In 1842, on his way to Zhoushan, he passed through Hong Kong, and was asked by the London Missionary Society to supervise the building of the Medical Missionary Society Hospital. After completing the hospital, the London Missionary Society sent him to Shanghai to establish another hospital. Before leaving China, he also founded the Peking Missionary Hospital, which became the well-known Peking Medical College.16 A few non-missionary doctors hired by the East India Company also helped introduce Western medicine into China. Dr. Alexander Pearson, who brought cowpox vaccination, left behind a vaccine institute in China on his departure in 1832. Dr. Thomas R. Colledge, who performed eye surgeries and improved the sight of innumerable patients,17 established a Medical Missionary Society in China in 1838, where he aimed at not only healing the sick and educating native youths in Western medicine, but also bringing the gospel of Christ to China.18 Most of the missionaries and medical missionaries targeted China as their destination after the First Opium War in 1841, which led to the opening of the treaty ports for trade. They considered Hong Kong to be only a convenient first port of entry. One might expect that the high rate of surgical successes in China would have resulted in the rapid rise in popularity of Western medicine, but in fact the Chinese clung tightly to TCM, perhaps for a reason that might seem counter-intuitive. Because Western medicine was given freely to the poor, and not used by wealthy people, Dr. Patrick Manson argued that it was seen as having less value than TCM, for which people had to pay. An avid proponent of private medicine, who practiced for more than two decades in China, Manson claimed that the preference for indigenous medicine was due less to Chinese pride or prejudice, and more to what he deemed to be the “pernicious effects of charitable medicine.”19 The situation in Hong Kong, however, gradually changed. The Chinese elite, in collaboration with missionaries, founded the Alice Memorial Hospital, which provided free Western medical care, and the Hong Kong College of Medicine, which was the precursor of the Faculty of Medicine of the University of Hong Kong, was established. Together with Patrick Manson, James Cantlie, and other European local private doctors, the Chinese elite and the missionaries brought Western medical education to Hong Kong, popularized Western medicine and ensured its position as mainstream medicine.

W estern M edicine   |   8 9

Western Medical Services Medical Missionary Society Hospital (1843–1853) The first hospital to provide Western medicine service for civilians in Hong Kong, the Medical Missionary Society Hospital, was built on Morrison Hill next to the Morrison Society School, and financed by the London Missionary Society.20 When Lockhart left Hong Kong, he handed over the administration of the hospital to Dr. Benjamin Hobson, another medical missionary, who was instructed by the Society to move the facilities from the hospital in Macau to the new one in Hong Kong.21 The Medical Missionary Society Hospital, with 42 beds at that time, offered free medical services to the Chinese, along with proclamations of the gospel. Having been trained in a scientific discipline and believing that TCM had no scientific basis, Hobson wanted to give China and Hong Kong a rational system of medicine. He offered his young assistant, Chan Apun, instructions on physics, chemistry, physiology, various diseases and operations of the eye. Hobson had the support of local medical colleagues and during the first meeting of the China Medico-Chirurgical Society on 13 May 1845, the president expressed the hope that one day a proper medical school would be established in Hong Kong.22 After Apun passed an examination conducted by a group of local doctors, 23 Hobson asked the Committee of the Medical Missionary Society for permission to recruit boys for a preparatory medical course, so that they could observe the treatment of diseases in the hospital. In 1846 he used a home leave to raise funds for a medical school. Returning to Hong Kong with about £300 to start the school, Hobson’s hopes were dashed. Local doctors who had expressed interest in the project had either moved away or died, and the principal of the Morrison Education Society School had taken all the bright students to the United States for further education.24 Unable to realize his dream of opening a medical school in Hong Kong, Hobson used the money he raised to open a hospital in Guangzhou, and to further the education of Chan Apun. Despite his disappointment in Hong Kong, he used his mastery of the Chinese language to write six medical books that would help to advance Western medical education in China.25 Hobson’s books, with their attractive illustrations and detailed anatomical diagrams, were widely distributed and eventually used in Japan as well.26 In Hong Kong, Hobson was succeeded by Henri Hirschberg

90  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

in 1848, and the Medical Missionary Society Hospital flourished under Hirschberg’s management.27 Operating a hospital which offered Western medicine, even though it was free, proved to be a rather precarious endeavor in China or Hong Kong at that time, as after one or two mishaps or treatment failures, or one or two deaths, patients would rapidly disappear. In 1853 the Medical Missionary Society Hospital closed its doors. It is unclear whether it was due to lack of doctors or lack of patients.28 In one of his biographical papers, Manson wrote about how high the stakes were around his treatment of a scrotal tumour, and how anxious the hospital in Xiamen was for his success in surgical treatment: “Should one patient die after this operation, this combined with the disturbing effects of these rumours would have been almost fatal to the reputation of the Hospital.”29 In 1857, the Roman Catholic Church opened the St. Francis’ Hospital in Wan Chai, which was forced to close its doors after only one year.30 It would not be until almost thirty years later that the London Missionary Society would provide medical services in Hong Kong again, prompted by the arrival of Dr. William Young from Canada.

Alice Memorial Hospital A serendipitous convergence of several circumstances and various people with common interests marked the real introduction of Western medicine into Hong Kong: the establishment of Alice Memorial Hospital and the founding of the Hong Kong College of Physicians for Chinese. Governor Hennessy first proposed a medical school to train doctors in Western medicine in Hong Kong during a speech day at the Central School in 1878. He suggested that preclinical work should be carried out in the Central School, and the clinical work at the Tung Wah Hospital. This proposal was ignored by most of those in the European community, whose wealth and support would be required to make this into a reality.31 However, it did pique the interest of a wealthy Jewish merchant, Emanuel R. Belilios, who created a scholarship fund for Chinese students to study medicine in Hong Kong. Imagining that Tung Wah Hospital, which was providing only TCM, would be encouraged to introduce Western medicine and train medical students, he was disappointed when the hospital was not ready for this progressive change, and the scholarship fund remained funded, yet unused.

W estern M edicine   |   9 1

However, the arrival of Dr. William Young from Canada in 1881 marked a change.32 Struck by the amount of diseases and medical neglect he saw among the deprived Chinese, Young contacted the London Missionary Society and formed a small Medical Mission Committee with three local businessmen. The committee, chaired by an accountant named Henry William Davis, opened a dispensary in one of the rooms of Tai Ping Shan Chapel of the London Missionary Society.33 The Nethersole Dispensary, named after Davis’ mother, was opened on 4 October, 1881. Although the clinic operated only from 7 a.m. to 8:30 a.m. two days a week, 927 patients attended the clinic during its first three months, receiving free medical services from Young. In addition to demonstrating the great need for such a dispensary, its popularity showed that the poorer Chinese had no prejudice against Western medicine, as long as it was effective and free of charge. Encouraged by the clinic’s success, the committee requested that the London Missionary Society send a full time doctor and build a hospital.34 The following year, 1882, was not a propitious one for raising funds for a charity hospital. Young left for Canada, and during the fall of that year, the economy of Hong Kong collapsed from overspeculation in land and property.35 The chances for a new hospital seemed rather remote until Dr. Ho Kai and his new wife, Alice Walkden, arrived from England. Ho Kai, the son of the Reverend Ho Fuk-tong, was sent by his father to study in England at the age of 13. A brilliant scholar, Ho Kai read medicine at the University of Aberdeen, and graduated at age 20 in 1879. He had the foresight to study law in Lincoln’s Inn after getting his medical degree, and was called to the bar in 1881. The following year, after marrying Alice Walkden in London, he returned to Hong Kong to set up a medical practice. Much to his annoyance, he could not make a living as a doctor. No Chinese would pay to see a Western doctor, and no European would consult a Chinese doctor in Western medicine. Thoroughly westernized after years abroad, Ho Kai, who had his queue cut off and adopted a Western style of clothing (Figure 4.1), turned to his other skill and set up a law practice. He became deeply involved with community affairs shortly after his return. He was approached by the Medical Missionary Committee about establishing a charity hospital to provide Western medical care to the poorer Chinese. Trained in Western medicine, he viewed Tung Wah Hospital’s stubborn resistance to adopting Western science as a symbol of Chinese conservatism and obstruction

92  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

to progress. His motives were probably Figure 4.1  Sir Kai, Ho Kai mixed, as he was likely shrewd enough to see that supporting such a hospital would strengthen his position in both the Chinese and the European community without having to become one of the directors of the Tung Wah Hospital, which was then at the peak of its prestige and power. He enthusiastically supported founding a charity hospital.36 Buoyed by the interest of Ho Kai Wikipedia photo and a small group of Chinese Christians, the Medical Missionary Society recruited several prominent members in both the Chinese and the European communities to the committee.37 The Medical Missionary Society Committee decided that the London Missionary Society would make a contribution up to HK$14,000 from the sale of its Queen’s Road Chapel for the acquisition of a site for the hospital. In return, the Senior Missionary of the London Missionary Society in Hong Kong would be a member of the managing committee. In February 1884, the Medical Missionary Society Committee announced a plan—the building of a charity hospital for the poor—that immediately sparked lively debate in Chinese and European press. The proposed hospital, while treating patients without distinction of race, creed, or nationality, was to be a non-conformist Protestant institution controlled by the local London Missionary Society. The European community appeared to be widely split over the issue, with some vigorously attacking the proposal and others strongly supporting it. The religious bearing of the proposed hospital was not well received by the public, as they wished to see the hospital free of all missions or denominational aid in any way. Some local doctors questioned why the London Missionary Society should be in charge of building the hospital.38 There was also the huge challenge of finding enough funds to build the hospital.39 In 1884 the money problem was solved with the untimely death of Ho Kai’s wife, Alice Walkden. Ho Kai generously offered to pay for building the hospital in memory of his wife.40 He agreed that the hospital should be under the control of the London Missionary Society, and if it one day decided to exit from Hong Kong, the Society would arrange for the property to continue to be a hospital. Mr. Belilios munificently

W estern M edicine   |   9 3

donated the scholarship fund towards the hospital, setting out the condition that it should be open to all creeds and nationalities, with no special preference shown to Christians. With the finances settled, local doctors consented to provide medical services free of charge, even though the London Missionary Society had intended to send out a missionary doctor to take charge of the hospital. A site was purchased on the northeast corner of Hollywood Road and Aberdeen Street for HK$22,000, of which HK$14,000 was paid for by the Society and the rest by public subscription, including HK$5,000 from Belilios. Opened on 16 February 1887, the Alice Memorial Hospital (Figure 4.2) would provide medical consultation, medicine, and accommodation free of charge (except a small charge for food) for the sick of all creeds and nationalities.41 The constitution stated that the London Missionary Society would manage the hospital, but that all local doctors were welcome to practice in it.42 Figure 4.2  Alice Memorial Hospital in the 1890s

Photo courtesy of Alice Ho Miu Ling Nethersole Charity Foundation

The dedicated local doctors who donated their services to the impoverished Chinese soon found that they were also donating their time to medical teaching.43 The Hong Kong College of Medicine for Chinese was established shortly after the opening of the Alice Memorial Hospital, with Dr. Patrick Manson (Figure 4.3) as the Dean. Manson arrived in Hong Kong from Xiamen (Amoy) in 1883, to set up private practice with Dr. William Hartigan. After graduating from

94  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Aberdeen University in Scotland Figure 4.3  Sir Patrick Manson in 1866, Manson had worked as a port surgeon for the Imperial Chinese Customs Ser vice in Takow (now K aohsiung) of For mosa (now Taiwan), and after four years he moved across the Strait of Taiwan to Xiamen. There he had gained wide recognition for his discovery of the role of the mosquito in the life cycle of the filaria worm, which causes elephantiasis in humans.44 Manson would further distinguish himself after he left Hong Kong by work ing with Ronald Ross to unveil the full life cycle of plasmodium, the malaria parasite, in female Anopheles Wellcome Collection photo mosquitoes. This discovery, as well as his founding of the London School of Tropical Medicine and Hygiene, helped him earn his knighthood. An ardent believer of private medicine, Manson was nonetheless attracted to the proposal for a charity hospital. He had set up a dispensary for his private practice in Xiamen, while at the same time running a small medical school that trained Chinese assistants in a mission hospital where he worked. After two decades in China he wanted to leave a legacy, and since he had long desired to bring Western medicine to China, and to protect the interests of his profession, a school for training Chinese in Western medicine seemed a good fit for him.45 Despite his reservations about mission medicine,46 he needed the mission hospital, Alice Memorial Hospital, as a teaching hospital, and also as an avenue for him to treat patients. Whatever Manson’s motives were, Hong Kong has benefited enormously from the College of Medicine for Chinese and the sustained presence of Western medicine practitioners in the community. It seems highly plausible that Manson, who was already famous when he reached Hong Kong, was invited to the governor’s house where he could expound on his idea of a medical school in conjunction with the

W estern M edicine   |   9 5

establishment of the Alice Memorial Hospital. After laying the foundation stone of the Alice Memorial Hospital in 1886, acting Governor Marsh wrote to the Secretary of State for the Colonies, expressing his hope that a medical school would be attached to this hospital. At that time the Central School (now Queen’s College) in Hong Kong had been educating students in English, but most needed to go outside Hong Kong to pursue study for a professional degree. Marsh also noted that “the study of Western medicine and surgery by Chinese would be a new departure and may have important results in promoting good feeling between us and the Chinese.”47 The medical staff included William Hartigan, Manson’s partner; Gregory Jordan, the nephew of the powerful financier Paul Chater, and a part-time Port Health Officer in Hong Kong; and the Canadian doctor, William Young.48 They were soon joined by Dr. James Cantlie (Figure 4.4), who arrived in Hong Kong in July 1887.49 Cantlie, a graduate of Aberdeen University and a respected teacher of anatomy and surgery, had pioneered in the first aid and preventive medicine movements before joining Manson in Hong Kong. He would receive knighthood for his contributions to first aid medicine and for his provision and organization of ambulance services during the First World War. Cantlie would also become well known for rescuing his Hong Kong College Figure 4.4  Sir James Cantlie of Medicine student and the founder of the Republic of China, Dr. Sun Yat-sen, from imprisonment, when Sun was held by the Chinese legation in London and threatened with expatriation to China. Without Cantlie’s help, the history of China would have unfolded very differently. Dr. John C. Thomson, the f irst medical superintendent appointed by the London Missionary Society, took up his duties in the hospital in 1889. From 1887 to 1892 the number Wellcome Collection photo of inpatients increased from

96  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

533 to 875 per year, while the number of outpatients grew from 7,685 to 9,064 per year.50 There were originally five wards for housing 80 patients, and five more beds were added. Even then the hospital was constantly overcrowded and expansion became necessary.

Alice Memorial Affiliated Hospitals Mr. Davis had never been satisfied with a small dispensary in Tai Ping Shan to be named after his mother. He had always wanted to honor his mother with something more substantial, and envisioning a hospital, he created the Nethersole fund of HK$7,000, which he later increased to HK$10,000.51 When the trustee of the Alice Memorial Hospital applied to Davis for the funds to build a hospital on London Missionary Society’s land at Bonham Road, near Breezy Path, Davis agreed immediately, requesting that the new hospital to be under the same management. The Nethersole Hospital,52 (Figure 4.5) opened in September 1893, had 35 beds for women and children, at which point the Alice Memorial Hospital became a men-only facility.53 The Nethersole Hospital only briefly relieved the congestion at the Alice Memorial Hospital, and the government agreed to allocate land on Breezy Path next to the Nethersole Hospital for two more hospitals: Alice Memorial Maternity Hospital in 1904 (the story of its founding will be told in Chapter 8) and Ho Miu Ling Hospital in 1906. Ho Miu Ling, Ho Kai’s sister who married Ng Choy, the first Chinese to be appointed to the Legislative Council, generously offered to pay for the construction of the second new hospital, which Governor Matthew Nathan opened on 20 July 1906. To help with the diagnosis of diseases, the first X-ray machine in Hong Kong was installed in the Alice Memorial Hospital in 1904.54 By 1921, the site of the Alice Memorial Hospital on Hollywood Road had become increasingly unsuitable for a hospital. It was demolished and rebuilt in 1929 next to the Nethersole Hospital, which in turn was also demolished and re-erected in 1938. By 1939 all four hospitals, with a total of 126 beds, were situated next to each other, and in 1954 they were incorporated under one name: the Alice Ho Miu Ling Nethersole Hospital (Alice Hospitals).55 Ho Kai remained as Chair of the Finance Committee of the Alice Hospitals until his death in 1914. He and his group of influential Chinese friends were very much involved in fund-raising. Having been educated in

W estern M edicine   |   9 7

Figure 4.5  The Nethersole Hospital on Breezy Path, 1893

Photo courtesy of Alice Ho Miu Ling Nethersole Charity Foundation

the West, they believed in Western medicine and were eager to promote it. They were also welcomed by the government as alternative leaders to the Tung Wah Hospital Committee in the Chinese community. The London Missionary Society played a major role in popularizing Western medicine among the Chinese in Hong Kong. It employed Chinese doctors, such as Chung King-ue, whose good reputations gained the confidence of the public. In 1896 the government appointed Chung to introduce Western medicine into Tung Wah Hospital, responding to the severe outbreak of bubonic plague that had wreaked such havoc in Hong Kong two years earlier.

Western Medical Education Hong Kong College of Medicine for Chinese In 1836 the handful of medical missionaries who had come to Guangzhou saw that TCM was not alleviating the high rates of disease among the impoverished Chinese, and that unhealthy living conditions were breeding grounds for disease. They wanted to provide Western medical care to

98  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

people living in poverty, but had met a wall of resistance and understood that the Chinese themselves had to be the ones to practice Western medicine among their own people before the resistance could be eased. Although only a few Chinese such as Kwan Ato, the star pupil of Dr. Parker, had received medical training, the stage was set for the introduction of Western medical education in China. The sponsorship of Grand Viceroy Li Hongzhang proved to be the tipping point for the eventual establishment of the first medical college in China—the Beiyang Medical College in Tianjin in 1881. Although there was much doubt as to whether the Chinese would overcome their resistance to Western medicine, the Grand Viceroy’s support carried much sway. Li Hongzhang, who greatly admired Manson, thinking that the doctor had cured the “cancer” of his tongue (actually a large abscess which was incised and drained) became the patron of this next important venture—the establishment of Hong Kong College of Medicine for Chinese. The Grand Viceroy’s official support of Western medicine and Governor Des Voeux’s acceptance of the office of president were vital to the founding in 1887 of the Hong Kong College of Medicine,56 which was to be operated on a shoestring budget, unsupported by an endowment fund. With no premises of its own, the college was headquartered in the Alice Memorial Hospital which designated certain rooms for lectures and demonstrations, and allowed the teachers and students to use the wards for clinical instruction. A grant from the directors of Tung Wah Hospital helped with the purchase of necessary books, models, and other teaching appliances. While the fee was initially fixed at HK$60 a year, many of the students were admitted free, and the fee was eventually reduced to HK$40. There were also several scholarships with values ranging from HK$40 to HK$100, available for up to five years.57 The control and management of the college was vested in a court consisting of the rector, who was elected by the general council and the students conjointly every two years; the rector’s assessor, nominated by the rector; the standing council of the college; a representative of the Alice Memorial Hospital; and the secretary, appointed by the court, who supervised the senate, which consisted of lecturers at the college. The court dealt with matters concerning courses of study, arrangements for professional examinations, and discipline at the college. Although important people in the colonial administration served as successive

W estern M edicine   |   9 9

rectors over the years,58 the college was unable to obtain a government grant to match the generous offer of Belilios of HK$40,000 for the college to have a building of its own.59 The lecturers included Manson who taught medicine; Cantlie, surger y; Har tigan, g ynecolog y and obstetrics; J. C. Thomson (superintendent of the Alice Memorial Hospital), pathology; G. Jordan, public health; P. B. C. Ayres (Colonial Surgeon), anatomy; J. M. Atkinson (superintendent of Government Civil Hospital), physiology; and Ho Kai, forensic medicine. Several others also contributed, teaching basic sciences such as botany, chemistry, and physics. More volunteer faculty were added later, including Francis Clark, the first Medical Officer of Health, and R. M. Gibson, superintendent of the Alice Memorial Hospital, as well as various medical officers of the Army and the Royal Navy.60 The five year curriculum, taught in English, was not dissimilar to the curriculum one finds in medical schools a century later. It was modeled after Aberdeen University, the alma mater of Manson and Cantlie, and the Charing Cross Hospital Medical School in London. Year 1: physics, chemistry, botany, materia medica, anatomy, physiology, and clinical observations; Years 2 and 3: anatomy, physiology, pathology principles of medicine, surgery, and midwifery; Year 4: medical jurisprudence, public health, and practical surgery; Year 5: medicine, surgery, and midwifery. Independent examiners, unconnected to the College, conducted professional examinations in their respective fields of expertise. Each student who satisfied all of the examiners would be awarded the diploma of Licentiate of Medicine and Surgery of the Hong Kong College of Medicine for Chinese. In 1884 the Medical Registration Ordinance, which did not apply to TCM practitioners, was enacted to regulate the qualifications and to provide registration of practitioners in medicine and surgery.61 Only those whose qualification satisfied the requirement of the General Medical Council in Britain were allowed to practice in Hong Kong. The college’s application to the General Medical Council in England, requesting recognition of its license, was rejected on the ground that the training failed to meet requirements of the British General Medical Council; specifically, it did not have an anatomy school or laboratories.62 Without the license being recognized for registration, graduates could not engage

100  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

in private practice in Hong Kong. There were also no government positions for them. In the first few years Hong Kong lost all the licentiates to Singapore and other parts of Southeast Asia, whose demand for Western medicine practitioners seemed inexhaustible.63 One of the two first graduates in 1892 was Dr. Sun Yat-sen, who scored a 71% average on all subjects and was the most celebrated licentiate of the college. After graduation, Sun practised in Macau for only two years, devoting all his time afterwards to the revolution.64 In 1923 when he returned to address students at the Hong Kong University, he claimed that his experience of the security of law, order, and freedom from corruption while he was studying in Hong Kong contributed to his revolutionary ideas. He finally decided to give up “curing men’s bodies” for the greater cause of “curing his own country.”65 More jobs opened up for the licentiates after the plague of 1894— in the Tung Wah Hospital, where the government decided to introduce Western medicine, and still later in the Bacteriological Institute and in the Chinese Public Dispensaries that had sprouted up in different parts of Hong Kong and Kowloon.66 After Manson and Cantlie left Hong Kong, and the loss of almost all graduates to other parts of the world, the enthusiasm for the college waned when there was no increase in resources. Unless it received more funds to meet all the requirements of the British General Medical Council, the future of the college was bleak. In 1900, the court of the college asked the government for an annual grant of HK$2,500 in order to pay the lecturers, HK$100 for three month sessions and HK$150 for five month sessions. With this grant-in-aid, all qualified students would be bound to serve the government for three years after graduation, at a salary not exceeding HK$50 a month for private practitioners, and HK$100 for those without private practice. Also they would have to agree not to take any other employment within that period, unless the government granted them special permission. During epidemics of plague and smallpox, the government would be able to use senior students to help with vaccination, and other types of work. Senior students could also assist with house-to-house visitations during epidemics. While this had been done in the past on an ad hoc basis, this agreement would be systematized and rendered permanent. Using students and fully qualified licentiates in this manner would help the government to secure better and more reliable health and disease statistics.67

W estern M edicine   |   1 0 1

After the government approved the grant, the college was able to continue on a firmer footing. In 1902, the admission of students of other nationalities boosted the college’s morale, and its name was changed. It was now simply the Hong Kong College of Medicine, as the tag “for Chinese” was dropped. In 1905, the college made plans to have its own campus. It requested the government for two sites in Tai Ping Shan district, with an estimated value of HK$21,650, so that it could erect a building that would contain lecture rooms, laboratories, a library, and some offices, as well as a detached dissecting room and anatomy lecture room.68 The estimate for the total cost of construction was HK$45,000. The college would raise an endowment fund for the faculty through public subscription, and the government would be asked to increase its annual grant to HK$5,000. A donation of HK$20,000 for the construction of the buildings from Mr. Ng Li-hing, a merchant, prompted the government to grant the two sites to the college free of charge. The buildings were never erected, however, as the college itself was to be absorbed into a much bigger scheme—the University of Hong Kong—and would become one of its first three faculties, the Faculty of Medicine. During the f irst decade of the twentieth century, medical practitioners ran small medical schools in Scotland and England out of a sense of public duty. Colleges offering a restricted range of subjects began to merge, creating new universities that offered a range of disciplines.69 In Hong Kong there was no other college for the College of Medicine to merge with, and the university had to start from scratch. The Hong Kong College of Medicine had admitted 128 students and graduated 51 since its establishment. Some of the graduated students went into private practice after more training elsewhere, while others joined the government and government-assisted hospitals, filling posts as district medical officers and medical officers in charge of clinics. In addition to Dr. Sun Yat-sen, Dr. Li Shu-fan, and Dr. C. Y. Wang (the first Chinese Professor of Pathology of the University of Hong Kong) were among its most notable graduates.70 Thus the Hong Kong College of Medicine pioneered medical education and provided a solid foundation for the Faculty of Medicine of the University of Hong Kong.71

102  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Faculty of Medicine, The University of Hong Kong By 1908, planning to construct the Hong Kong College of Medicine buildings had reached an advanced stage. Mr. Hormusjee N. Mody, a local Parsee merchant, stockbroker, and philanthropist, approached Governor Frederick Lugard with an offer of HK$150,000 to build a university, and another HK$30,000–50,000 towards an endowment fund, provided that the government was willing to offer an adequate site. The Governor found one site that was acceptable to Mody—at the junction of Pokfulam Road and Bonham Road, and Mody asked his architect to prepare drawings of the buildings.72 Although the idea of having a university in Hong Kong had been debated among the local intellectuals for more than a decade, it was Lugard who forged ahead with the proposal and brought it to fruition during his administration, despite numerous difficulties.73 He wanted an “imperial” university in Hong Kong to serve both Hong Kong and China, to disseminate British culture and language, and to increase British prestige and influence in the Far East. He was hopeful that Chinese doctors trained in Western medicine would take their skills into China.74 When Mody made this most generous offer Lugard immediately conferred with the rector and the court of the Hong Kong College of Medicine. They concluded that the college would need to be merged into the university for the project to succeed. The court of the college endorsed the proposal, and Lugard agreed that should the university project came to fruition, the endowment of the chairs in the faculty of medicine would have priority over any other faculty, and that existing students would be admitted as undergraduates of the university. The college would help with the building of an anatomy school. An agreement was signed on 13 March, 1908, between the court of the college, the Governor, and Mr. A. H. Rennie, who represented Mody. The following conditions were specified in the agreement: 1) the date on which the university would be declared open, and that the college would be dissolved, merged into the university, and its property transferred; 2) the designation of members of the court as life members of the court of the university; and 3) the offering of lectureships of the university to lecturers of the college, insofar as funds would allow and according to their lecture subjects continuing as part of the curriculum.75 Lugard convened a meeting of the principal members of the

W estern M edicine   |   1 0 3

Legislative Council to consider Mody’s proposal and to appoint a subcommittee to report on the basic operational requirements for establishing three academic faculties. The subcommittee reported that building should not commence until there were sufficient funds raised for endowing the three faculties. The building that Mody’s architect had designed would cost a great deal more than HK$150,000, but since Mody was anxious to see the scheme take shape in his lifetime, he agreed to pay for the cost of construction, whatever it might be. However, he was not willing to spend money on buildings that would be used for other purposes if the university failed to materialize because of insufficient endowments. He left his offer open for 6 months, as of January 1, 1909. To raise funds for the endowment, Ho Kai took charge of approaching the Chinese community, while Lugard worked hard among the British community locally and elsewhere in China and in England. Lugard accepted a private donation of HK$200,000 from the Viceroy of Guangzhou. The John Swire group of companies also donated £40,000. Together with donations from the local community, the total amount raised of around HK$1.2 million as endowment fund enabled the laying of the foundation stone of the university on 16 March, 1910, although money was still needed for the endowment, for the construction of residences for the staff and students, and the provisions for equipment and furnishing.76 The cost of construction of buildings to accommodate the three faculties: medicine, engineering, and arts, totaled HK$365,000, and Mody gladly honored his commitment. For his generosity, Mody was bestowed the Knight Bachelor.77 Meanwhile in England there was widespread popular support for the project. In a report in the Times on 3 July, 1909, one correspondent reflects an enthusiasm that is undergirded by a certain imperialistic self-interest: From the British point of view the scheme is equally commendable, for it is surely of the utmost importance that, at a time when undoubtedly the leaven of new ideas is formulating all over China, the rising generation from which so much is expected should be brought into close contact with the best aspects of British life. British influence may no longer be paramount in the Far East, but the supremacy of the English tongue is as yet untouched…. English must serve as the one common medium of Western learning until China has evolved a literature of her own on the lines of Western thought. But

104  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

unless we bestir ourselves, the advantage will be lost to us in the same way as so many other advantages have been lost to us in the field of diplomacy and of commercial enterprise.78 The University of Hong Kong was incorporated in 1911 and officially opened in 1912 with Sir Charles Eliot, an accomplished scholar, linguist, and colonial administrator, as its first Vice-Chancellor. Dr. Gregory Jordan was appointed as its first Pro-Vice-Chancellor, in recognition of his services to medical education. Governor Lugard was involved in every stage to ensure a successful merger of the College of Medicine into the university. He also reviewed the curricula from a number of universities in England and in India, discussed the course work and examinations with officials of the London University, and obtained a commitment from them to provide examinations through their external degrees system. This relationship with London University was written into the University Ordinance in order to guarantee the quality of the degrees of the Hong Kong University.79 The first Dean of the Faculty of Medicine was Francis Clark, an esteemed teacher at the college for many years. Since the curriculum was designed according to the requirements of the General Medical Council in England, and the quality of the medical degree had been ensured, the degree to be conferred by the Faculty of Medicine was recognized by the council in England as equitable and reciprocal with those in the United Kingdom, effective 1 April, 1913.80 This was a major step forward for the Faculty of Medicine, and quite a remarkable feat, as Chinese graduates would, in theory, be licensed to practice not only in Hong Kong, but in England as well.

Training of Nurses Nursing care for patients was very limited in the early days. In the Government Civil Hospital, there were untrained ward-masters to supervise the so-called “nursing” performed by coolies. After many years of complaints from the Colonial Surgeon, the government finally agreed to appoint five French sisters from the Roman Catholic Church as nurses in 1888.81 They were replaced by trained English nurses a year later.82 The training of Chinese nurses began first in the Alice Hospitals. In 1891, Mrs. H. Stevens of the London Missionary Society, the first fully

W estern M edicine   |   1 0 5

qualified nursing sister, was appointed matron of the Alice Memorial and Nethersole Hospitals. She began training Chinese nurses on an informal basis soon after her arrival.83 In 1893, she pioneered a formal two-year training program that allowed student nurses to work in the wards immediately after recruitment, while attending lectures before and after work. The demand for private nurses among the European elite was particularly great, and there was a profound shortage of nurses for many years. In 1896, the Government Civil Hospital began to take in probationers for training, hoping not to have to depend on English nurses from home. As part of the celebration of the Diamond Jubilee of Queen Victoria, a nursing institute was proposed to be built together with the Victoria Hospital for Women and Children, with the goal of training up to five probationers at a time, and to eventually replace the nurses from England.84 Although it had only six students, the Tung Wah Hospital initiated a training school for nurses in 1927. The Hong Kong Sanatorium and Hospital, founded in 1922 as the Yeung Wo Nursing Home, also started its own training school for nurses in 1927 with three probationers.85 Other hospitals in the Tung Wah Group commenced training schools for nurses, in order to meet the expected increasing demand in the future. Professionalization of nurses took place in 1931 with the passage of the Nurses Registration Ordinance. A Nursing Board was formed to exercise jurisdiction over the nursing profession, and all training schools for nurses were required to be approved by the Nursing Board before their commencement.86 The training of midwives was also initiated by the Alice Hospitals, where Western sciences and medicine were first taught, and the first hospitals in Hong Kong to initiate training of nurses for the community. In summary, the establishment of the Alice Memorial Hospital arose as a result of the merging of different interest groups: the missionaries, the westernized Chinese elite, the European philanthropists, and the local private doctors in Hong Kong, in a common desire to provide free Western medical services to the underprivileged Chinese, and to promote Western medicine. Its establishment was an important milestone in the history of medicine in Hong Kong. The founding of the Hong Kong College of Medicine, which became the Faculty of Medicine in the University of Hong Kong, established Western medicine as the mainstream medicine in Hong Kong for the next century.

106  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Although personal motives for those involved in bringing Western medicine to Hong Kong were often a mix of self-interest and altruism, in both the British and Chinese communities, and cultural prejudices sometimes made their presence felt, the present status of Hong Kong medicine is an enviable one. With the state-of-the-art medicine that owes its origin to Western medical missionaries and philanthropists from both England and Hong Kong, and TCM that Hong Kong also acknowledges, patients now have the luxury of choice of effective medical treatments.

5. The Inconvenient Truths: Sanitation in Hong Kong

Good health depends on good sanitation and a clean living environment. In an urban environment, decent sanitation requires an adequate supply of clean, unpolluted water and food, high-quality drainage and sewerage, efficient removal of solid waste and refuse, and housing that provides adequate ventilation and light. In the Middle Ages, most cities were magnets for diseases. Human waste was flung into the streets to mingle with that of dogs and horses. Rats, mice, and other vermin burrowed through most human habitat.1 Until the nineteenth century little was done in England or anywhere in Europe to promote public health. There was practically no medical education, and therefore no knowledge of the causes of diseases or their remedies. Not until the great epidemics of cholera that swept Europe in the 1830s and reached England in the 1840s, did the concept of health and disease change, along with recognition of the importance of sanitation. Severe outbreaks in 1832, 1849, and 1854 stunned and alarmed England, rousing it to take the first steps in administrative sanitary reform.2 In 1842, a lawyer named Edwin Chadwick published the Report on the Sanitary Conditions of the Laboring Population of Great Britain. It described the incredibly overcrowded and unsanitary living conditions of the vast majority of working men, as well as the high correlation between poverty and death rates. Chadwick’s revelations shocked the conscience of the middle class, motivating them to clean up this serious national evil. In a number of large cities the public took independent action and formed Metropolitan Health of Towns Associations to carry out sanitary reforms. In 1848, the first Public Health Act in England established a Board of Health to coordinate the activities of the local boards, which were responsible for providing clean water and adequate drainage. Subsequent legislation in 1866 and 1872 made local councils responsible for the disposal of sewage and rubbish, the provision of street lighting, and improvements in the quality of new housing. Government

108  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

intervention and legislation led to great improvements in sanitation and living conditions for the lower social class.3 In Hong Kong, development of sanitation during the first half century of colonial administration lagged far behind those in England. When Osbert Chadwick, son of Edwin Chadwick, visited Hong Kong in 1882, he was appalled by the Colony’s unsanitary condition and made recommendations for sweeping reforms. The government’s response was inadequate, and by 1894 the Colony’s overcrowded and unsanitary conditions had led to the disastrous plague that would ravage the population for the next 30 years.

Decades of Neglect (1842–1882) In the early 1840s, as the city boomed, sanitation was not even an afterthought. During the 1850s, a continual flow of Chinese leaving unrest on the mainland for opportunities in the Colony resulted in a critical shortage of accommodations. Overcrowding, widespread poverty, lack of building construction standards, exploitation of indigent and illiterate families, and shortage of satisfactory water supplies and other public utilities gave rise to an intolerable unsanitary condition in Hong Kong, especially in the Tai Ping Shan area, where most Chinese lived. Colonial Surgeons had repeatedly drawn attention to the unhealthy state of the Colony, warning of impending epidemics in their annual reports. While they were concerned with the limited water supply and faulty sewage and drainage system of the city as a whole, their main focus was on the unsanitary conditions in Tai Ping Shan. Certainly, the Colonial Surgeon’s annual reports were read by the governor and the Secretary of State for the Colonies in London. Why then was nothing done to improve the situation? It is worth remembering that the first Public Health Act was not passed in England until 1848, and in the early years of the Colony’s existence, the state of sanitation in England was not radically different from the situation in any of its colonies. Thus early colonial governments saw no need for reform. Moreover, Tai Ping Shan was not the only place in Asia with such filth in the nineteenth century.4 Most of the major cities in China were mired in the same unsanitary state as Hong Kong. While sanitation had advanced in England considerably by the 1870s,

T he I nconvenient T ruths   |   1 0 9

the unhygienic environment in China and Hong Kong remained. Most Chinese rationalized that this environment did them no harm, and as they had lived this way for centuries, they did not know any better. The governors in Hong Kong would hide behind the excuse that they did not want to interfere with the age-old customs of the Chinese, whom they did not wish to distress, when most of the time there simply was no money available to effect change. The Chinese also used the same reason to resist changes that would cost them financially. Moreover, why should they spend money to improve sanitation for the benefit of foreigners? It is true that foreigners did not have quite the same immune resistance as the Chinese. For the Chinese to reach adulthood in the nineteenth century, they had to be immunological elite, surviving an assortment of assaults from childhood illnesses such as smallpox, measles, diphtheria, and a multiplicity of gastrointestinal infections. While foreigners who had never been exposed to a similar sort of hostile environment would more likely succumb to these diseases, the Chinese, having developed immunity, were often resistant to them. Nevertheless, exposure to epidemics of diseases such as bubonic plague or to organisms that had undergone genetic mutation such as influenza virus could still cause havoc. Clearly the Colony did not fulfill Governor Pottinger’s forecast that it would become the “Emporium of the Far East” during its first two decades. After the third governor, Governor Bonham, was told to retrench and balance the budget, 5 no major public works were accomplished during his term (Table 1.2 of Chapter 1). Once the entrepot trade began to flourish during Governor Robinson’s administration (1859–1865) and the revenue improved, funds remained scarce, as the home government insisted that the Colony pay its share of military expense—£15,000 in 1865, a sum increased to £20,000 per year in 1891, despite vigorous objections from the merchants in the Colony.6 Very few Europeans or Chinese were interested in settling permanently in Hong Kong, or had developed any pride in the city. Nor did they appreciate any government interference in their lives, particularly when it required payment of taxes. They imagined themselves as sojourners coming to Hong Kong to take advantage of the facilities offered by British, hoping to earn money and then return to their own villages to end their days. Even the richer, propertied Chinese in Hong Kong did not, as a rule, settle in Hong Kong with their whole families.

110  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

The first or principal wives remained at the home of their ancestors in their native village. Except for the successive Colonial Surgeons, very few demanded or even cared about improvements in sanitation. Colonial Surgeons could do little more than just embed their complaints in their annual reports, and these were often edited before submission to the Colonial Office. In fact, the Colonial Surgeons had no real power. In 1845 the basic annual salary of a Colonial Surgeon was around £600 (about one eighth of the governor),7 one of the lowest in the colonial administration—reflecting what the Colonial Office thought of them and how they were exploited at that time.8 Salary increases for the colonial medical officers were not automatic, but awarded at the pleasure of the governor. The medical officers could supplement their salaries in private practice, but such a privilege was at the discretion of the imperial administration. Yet, despite the harsh working conditions, relatively low pay compared with similar jobs in England, and high mortality, there was no shortage of applicants due to the glut of underemployed practitioners. Medicine was such a popular calling in Britain that the profession could not assimilate all its members in the domestic market. The oversupply of medical practitioners meant that few would be prepared to do anything that would displease the imperial administrators. In addition, the Colonial Office had no master plan for health and sanitation, and administration and policy were left in the hands of the incumbent local governor. The wide variance of policies is revealed in the range of responses of the different governors to the urgent warnings of their Colonial Surgeons, concerning the tremendous overcrowding and unsanitary conditions in the Tai Ping Shan district.

Governor Sir John Bowring’s Response: A Pernicious Double Standard In 1854 the Colonial Surgeon, Dr. J. Carroll Dempster, examined the streets, lanes, and houses in Tai Ping Shan and was alarmed not only by the presence of open drains, but also by the unhygienic conditions of the densely packed houses. He bemoaned the faulty drainage and sewerage in the Colony: I must express my regret that Hong Kong should present so much filth and so many nuisances, the more especially as its

T he I nconvenient T ruths   |   1 1 1

site in many respects well adapted for Drainage and Sewerage. In carrying out my assertions it will be only necessary for me to report on the Taiping-sheng district. The Lanes (certainly not streets) are in a most objectionable state, containing almost invariably cowsheds, pigsties, stagnant pools—the receptacles of every kind of filth, all which nuisances have remained unheeded for a considerable time. In this District are two large open Drains, which at all times are most offensive.... The great want of Privies and suitable Depots for dirt, is observable everywhere the Native population reside. Dempster warned that diseases thrived in overcrowded dwellings where cleanliness, ventilation, and drainage were neglected. The lack of sanitary measures, he cautioned, would lead to development and spread of diseases.9 Dempster’s report of 1854 caught the attention of the Secretary of State for the Colonies who sought advice from the General Board of Health in England. The Board of Health then forwarded guidelines for improvement in sanitation to Governor Sir John Bowring, the incumbent governor.10 Bowring’s response was dismissive, asserting that “he was not prepared to confirm the strong opinion expressed in the Colonial Surgeon’s report.” He avowed that the City of Victoria was remarkably clean and healthy compared with most Chinese cities and with the rural population in the orient.11 Bowring also enclosed the report of C. G. Cleverly (Surveyor General), suggesting it was pointless to do anything. His assurance that sewerage was not necessary in Tai Ping Shan, as the night soil (excrement) was manually removed every day, and that any improvement in drains would be tampered with, shows a striking double standard—one for “civilized communities” and a different one for the Chinese: … to provide a system of sewerage (and such as is adapted in the better parts of this Town) ... would be attended with injurious effects and would totally frustrate the object, for the drains would most assuredly become choked either by carelessness, want of water to flush each house connecting drain, intentional damage, or absolute robbery of the various appliances to a perfect system of Sewerage …

112  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Cleverly’s remarks betray a sense of class entitlement that he carried with him to Hong Kong. In suggesting that it would be as impossible to compel the low, dirty class of residents in Tai Ping Shan to keep clean as it was difficult to force servants of their private homes to keep their premises clean, he was likely expressing the feelings of the majority of the Europeans who employed Chinese as their coolies and domestic servants.12 Thus, while the rest of the city gradually enjoyed a better system of drainage, sewerage, removal of refuse, and paving of roads, Tai Ping Shan residents were deprived of proper sanitation, and even clean water. The government justified its inaction by citing Chinese customs, Chinese incorrigibility, and Chinese carelessness or criminality as excuses. Even though Bowring finally appointed an Inspector of Nuisances in 1859 to deal with the sanitation problems including drains, water supply, and scavenging, this small concession was too little, too late. With only one person attending to sanitation, and with the ongoing lack of funding, problems would remain unresolved.

Governor Sir Hercules Robinson: Water First Dr. John I. Murray, Colonial Surgeon, echoed Dempster’s opinion throughout his years of service. In 1859 he remarked that because Hong Kong was basically a hilly island, most dwellings were located on the hill slopes, and technically it could be effectively drained. He saw the barrier to good sanitation as more of an administrative than an engineering problem. The city had adequate laws to safeguard the sanitation of dwellings, but the lack of enforcement of the laws had resulted in deteriorating, unsanitary conditions.13 The new Governor, Sir Hercules Robinson, dissented from “several of Murray’s conclusions and (could) not approve altogether of his report of 1859.”14 But Robinson did attack the problem of water shortage with ingenuity. Up to this point, people in the city had obtained their water from nearby streams or wells, but these sources were unable to support the rapid growth of the population. Robinson offered a reward of £1,000 to anyone who could provide a workable solution, allocating a budget of £25,000 for the project. S. B. Rawling, a Royal Engineer, won the award with his proposal to construct a dam across the valley of Pok Fu Lam to collect rainwater. Although the reservoir was completed in 1863, there was inadequate funding for

T he I nconvenient T ruths   |   1 1 3

its construction, and its small size and poor system of water distribution rendered it ineffective.15 In 1862, following a cholera outbreak, Robinson appointed a Sanitary Committee composed of the Colonial Surgeon, the Surveyor General, Medical Officer of the Military, and two other individuals. The Committee produced an 88-paragraph report of useful recommendations one year later, including reconstruction of public dust bins, provision of public privies, and improving night soil removal methods, sewerage, and drainage. The Surveyor General, Cleverly, who was on leave when the report came out, claimed that the recommendations were too impractical and expensive to implement. Cleverly repeated his stereotypical claims about the dirty habits of the Chinese, and re-articulated his belief that the connection of house drains in Tai Ping Shan district to existing drains would cause blockage. He thought that most of the recommendations regarding drainage and sewerage were superfluous and wrong,16 and the report of the Sanitary Committee was shelved.

Governor Sir Richard G. MacDonnell: No Vital Statistics Murray continued to report on the unhealthy conditions of the Colony in his annual reports. The next Governor, Sir Richard G. MacDonnell, tried to be more proactive, and immediately made plans to improve Tai Ping Shan by paving the streets, improving surface draining, and linking dwellings with the main drainage. Regrettably, in a climate of economic recession, he was unable to do much more than introduce an Order and Cleanliness Ordinance in 1866, which prohibited the keeping of pigs and similar animals in dwelling houses without a license. The law was not enforced, as Dr. P. B. C. Ayres, the next Colonial Surgeon, would discover. Government works expenditure under MacDonnell was further reduced by an increase of contributions to military expense to £20,000 every year. In 1867 he had to postpone work on water storage and distribution improvements from the Pok Fu Lam reservoir because of a lack of funds.17 While MacDonnell encouraged the Chinese elite to build the first Chinese Hospital in Hong Kong, when the Colonial Office asked MacDonnell to gather statistics on births, deaths, and marriages, vital information for health planning, he demurred, reluctant to arouse Chinese suspicions.18

114  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Governor Sir Arthur Kennedy: Censor the Report Governor Arthur Kennedy, an excellent administrator, took great pains to cultivate Chinese good will, and was the first governor to invite the Chinese to various functions at the Government House. His administration was characterized by a program of public works aimed toward improving the water supply. Using the criteria that an individual needs at least 15 gallons of water per day, he calculated that the entire population of Hong Kong would need a total of 1,800,000 gallons per day, only about one third was available at the time.19 Kennedy authorized a project to build a larger conduit from Pok Fu Lam reservoir, to be completed in 1877, to supply the central and western districts.20 The new Surveyor General, J. M. Price, proposed a more far-sighted scheme of bringing water from Tai Tam reservoir via a tunnel through the hills. He was asked to modify it because of a prohibitive estimated cost of £350,000, and a less costly version was recommended at £136,400. The proposal was further pared down to £50,000, so that at least the first phase of the project could be constructed under the present budget. As a result, the increase in water supply was only a fraction of the original plan. Although Price also suggested repairing the faulty drainage system,21 Kennedy did not pursue the recommendation due to lack of funds. After conducting a series of inspections accompanied by Price, Ayres reported on sanitation in Hong Kong at the end of his first year in office.22 He found that although at first glance the town of Victoria appeared cleaner than most Asian towns, beneath the surface it would be difficult to find a filthier place. Much to his alarm, he found pigs being kept by the hundreds in residential houses all over the town, and pigsties under the beds on the second and third floors and even in kitchens. The government had granted many people licenses to keep their pigs, even though the upper floors of their dwellings were constructed of thin boards, and wide interstices between the boards allowed the pig urine to drop to the floor below. Ayres often found five to ten families living in one house, which he determined “would not be considered fit to put pigs in by any decent person.” The construction of Chinese tenement houses made them impossible to clean. The ground floor tenants could not wash their floors because they were mud, and the walls could not be whitewashed because they were generally bare bricks. The floors above, constructed

T he I nconvenient T ruths   |   1 1 5

of rough quarter planks, could not be washed without half drowning the inhabitants below. The meagerness of the water supply meant that personal cleanliness was neither possible nor affordable: women of the lowest class rarely washed themselves and men washed only their exposed parts. Washing of clothes was carried out once or twice a month at most, and usually once every several months­—usually in the kitchen, but sometimes not at all. Ayres also reported that many houses in Tai Ping Shan had wells either in the main rooms or in the kitchens on the ground floor. These wells were invariably only one or two feet away from the house drain or downspouts, and raw sewage would filter through the earth and mix with the water in the wells. In some cases, the water smelled or tasted so bad that it was not used for drinking, but in others, where there was no smell, it was used for drinking, washing vegetables for sale in the markets, washing clothes, and preparing food. Ayres warned that every necessary condition existed in Tai Ping Shan “for the development of cholera or fevers of a typhoid character; if the seeds are once sown, they will have a fair start,” and that “… the houses of the lower classes whose filthy habits are well known … or in future years these plagues will be endemic in the Colony, and probably end in an epidemic of unenviable renown….” Ayres’ 1874 report was censored by the Colonial Secretary, who deleted the offensive sections on sanitation before sending it to the Colonial Office. This experience convinced Ayres to be less explicit and less forthcoming in subsequent reports in the years to come.

Governor Sir John Pope Hennessy: Romanticize the Chinese House Bucket The next Governor, Sir John Pope Hennessy, believed in the principle of equal treatment for all peoples, as laid down in the Hong Kong governor’s instructions since 1866. His more sympathetic attitude towards the Chinese inspired him to improve their marginalized status, and he had the advantage of serving at a time when Hong Kong’s trade was flourishing, and revenue showed a surplus in most years. As he was popular with the Chinese because of his pro-Chinese policies, he could have certainly improved sanitary conditions in Tai Ping Shan, but he was not able to accomplish much. He proved to be a poor administrator, and although he

116  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

was capable of articulating principles, he was impossible to work with, quarreling with many in his administration, from the Colonial Surgeon to the Registrar General and the Surveyor General. He was also distrusted by the Colonial Office. His reluctance to delegate, wanting to do everything himself, destined him to achieve very little. Governor Hennessy regularly consulted Chinese leaders on all important issues, and his genuine respect for the Chinese people and their traditions could blind him from seeing the severity of the sanitary problems at hand. He complained to the Earl of Kimberley, the Secretary of State for the Colonies, about Ordinance 8 of 1856, “Buildings and Nuisance Ordinance,” requiring water closets for dwellings that was copied almost entirely from certain Sanitary and Building Acts in England. Since Chinese householders were not consulted on this Ordinance when it was being framed and passed, some of its provisions were entirely unsuited to the Colony. He believed that the Chinese house-bucket scheme, especially when combined with a dry earth method, was far better than a system of water closets and house privies, which did not follow Chinese customs.23 To support his claim about the superiority of the house-bucket and the dry earth system in China, Hennessy quoted the work of Dr. John Dudgeon24 of Beijing, The Diseases of China: Their Causes, Conditions, and Prevalence, Contrasted with Those of Europe: “Much that is recommended at home in the way of ventilation, water supply, and disinfection of privies is rendered in China unnecessary. All the advantages claimed for the dry earth system are gained here free of expense to the individual or public. The industrious and frugal habits of the Chinese and even their poverty, thus work to their advantage (all sanitary measures more than repay their cost), for it compels them to utilize all excrementitious matter.... China, par excellence, the country of bad smells, and yet, as we have seen, the people do not seem to suffer from them.” As relatively progressive as he was, Hennessy had a form of selective blindness, believing deeply in the inherent difference between the resilient Chinese and the less adaptable British. Hennessy had a medical degree from Ireland, but he traded medicine for politics shortly after graduation, perhaps realizing the inadequacies of Western medicine in those days. He subscribed to Dudgeon’s views that the unsanitary habits of the Chinese did not give rise to diseases, and to that point, the fact that Hong Kong had been spared from any severe epidemic would seem to support his claim. However, Hennessy had

T he I nconvenient T ruths   |   1 1 7

overlooked the degree of congestion in Tai Ping Shan, which was different from any other part of China, where dwellings were only one story high, even in the cities. Once an infectious disease occurred it would spread rapidly in Tai Ping Shan, becoming an epidemic simply because so many people were packed together in so small a confined space, without the slightest heed to proper sanitation. Hennessy refused to interfere with ancient Chinese customs until he had an argument with General E. W. Donovan, 25 Commander of British troops in China and Hong Kong. Objecting to an ordinance which would extend the area in which Chinese houses could be built, Donovan denounced the filthy, unsanitary conditions of the Chinese houses. He referred to Ayres’ original 1874 report, which had not been sent to the Colonial Office, but had somehow surfaced and caused considerable alarm in the Colonial Office. Donovan then requested Dr. W. A. MacKinnon, Surgeon General of the Army Medical Department, to investigate the sanitary situation in Hong Kong. In his report of 1880, MacKinnon condemned the Colony’s dirty condition, remarking that while the conditions of Victoria had shown gradual improvement since 1866, it deteriorated considerably with the departure of Sir Arthur Kennedy, whose sanitation policy had been completely reversed by Governor Hennessy. Adding that the health of the garrison depended on that of the surrounding population, MacKinnon argued that the situation should be investigated by a medical commission appointed not by Hennessy, but by the Secretary of State of War and Secretary of State for the Colonies. MacKinnon believed that the remedy was entirely in the governor’s hands, and that all he needed to do was to renounce Chinese doctrines in matters connected with public health, resuming the sanitary policy of his predecessor, especially the long delayed project to increase the water supply.26 Apparently Hennessy had canceled instructions by Kennedy’s administration to the Inspector of Nuisance, asking the Inspector to instead follow the advice of Dr. Eitel, a German pastor, scholar, and sinologist with no training in sanitary matters, and his Chinese colleagues. 27 The Tai Tam water project had also been stalled when Hennessy reacted to the Chinese complaints of its high cost.28 Hennessy had plans to set up a separate sanitary department to work directly under him, to bypass his Colonial Surgeon and Surveyor General.29 Mackinnon’s report, which caused quite a stir at home, came at

118  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

the same time as Hennessy’s disagreement with his Colonial Surgeon and Surveyor General, who emphasized the need for water closets and a closed drainage system for Hong Kong, to include the Tai Ping Shan district.30 Deciding it could no longer ignore the situation, the Colonial Office sent Osbert Chadwick, an engineer, to assess sanitation in Hong Kong and to advise on how best to remedy the situation. Hennessy was instructed not to make any changes or enact sanitary legislation until after Osbert Chadwick’s visit.

Osbert Chadwick’s Blueprint for Sanitary Reform While Edwin Chadwick helped usher British sanitation out of the Middle Ages into the modern era, his son, Osbert Chadwick, did much to improve sanitation in the city of Victoria. His report would form the blueprint for sanitary reform in Hong Kong.31 The city of Victoria that greeted Osbert Chadwick in 1882 had already developed a significant entrepot trade. It stood on a strip of land extending about 3¾ miles long, and less than one-half mile wide on the northern foot of the island mountain, with the heart of town stretching one mile west of City Hall. Seagoing and river steamers of all sizes were anchored in the harbor, along with sailing vessels and junks, while alongside the wharf was a dense mass of boats and barges—a scene of great activity. The streets running up the slopes of the hill at right angles to the shore line were far too steep for wheeled vehicles, and people were transported on chairs carried by coolies, or by rickshaws. Burdens of all sizes and weights were carried by men. At that time Victoria contained 130,000 of Hong Kong’s total population of 160,000. The majority were Chinese. The Europeans lived on higher grounds, with those in the upper class having retreated to the Peak district where the Chinese, unless they were servants, were not allowed. The Europeans lived graciously in great mansions and shady arboretums, separated from the Chinese below. The majority of lower class Chinese crowded into the Tai Ping Shan district where the water supply was provided only by mountain streams or public hydrants and the sewerage and drainage were faulty, yet the Chinese continued to pour in, willing to live under the British flag. Although there was little intercourse between the two communities, by 1882 both were flourishing, each vitally dependent on the other economically.32

T he I nconvenient T ruths   |   1 1 9

Figure 5.1  Hong Kong waterfront in the 1880s, around the time of Chadwick’s first visit

Photographed by John Thomson, via Wikimedia Commons

Osbert Chadwick conducted a very thorough study of sanitation in Hong Kong. He carefully selected the average working class houses for inspection, in order to form an accurate assessment of conditions. He avoided the worst and the most objectionable ones, and was considerate and sensitive about native customs and beliefs. Having formed a general opinion of the defects of existing conditions and the remedial measures that would be advisable, he then explored the attitudes and feelings of the local Chinese, so that the proposed measures, based as much as possible on the time-honored Chinese customs, would be acceptable to them. He drew up a series of questions and submitted them to important Chinese institutions: Tung Wah Hospital Committee (representing the moneyed and house-owning interests), the two associations of Chinese medical practitioners, (the members of which though educated, were not wealthy), the Roman Catholic Church, and the Hakka Christian Churches. He also sent the questionnaires to individuals, and although we do not know how many questionnaires were sent out, two hundred questionnaires were returned. On the whole, it seems that Chadwick was pleasantly surprised to find that the Chinese showed no evidence of obstruction or apathy toward sanitation. They recognized its importance for health, and some of the questionnaires included thoughtful remarks on sanitation. Chadwick consulted with medical experts in Guangzhou, the Tung Wah Hospital and the hospital committee, and interested members of the medical corporations, and formulated his

120  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

recommendations with respect to his understanding of the sanitary habits of the community.33 His report, presented in detail below, shows the state of sanitation in Hong Kong and just how defective it was.

Unlivable Housing Chadwick found considerable overcrowding in the Chinese tenement houses. They had been hastily thrown up in the cheapest way, to accommodate as many people as possible, without consideration for adequate ventilation, lighting, or disposal of human waste. The narrow street frontage of these houses was only 13 to 16 feet, but the setback from the street was large, from 30 to 60 feet. When a site was level, the houses were often built back-to-back, with no lane or space between them. When the ground was sloping, there would be a lane or gully at the back, often not more than five feet away, and frequently this lane would be at or near the level of the first floor of the houses in front. Sometimes the ground floor in front was completely open to the street and used as a shop or workshop, doubling as a sleeping room for the shopkeeper or his assistants. In the other back-to-back houses, only the ground floor was ventilated, with smoke escaping by “smoke holes,” usually about four or five feet square on the first floor. Chimneys were rare. The tenement houses were constructed with one main room and a kitchen or cookhouse, either in front or at the back (Figure 5.2). The upper floors were divided by wooden partitions into cubicles about 9 feet long and 10 feet wide. Each of these could house either an individual or an entire family. These cubicles would not extend to the full height of the story, but were about 7 feet high. The average number of inhabitants per house was 16, but it was often more. Each floor was leased separately from the owner, and sublet again to individual lodgers. The total space per head, as estimated by Chadwick, was 437 cubic feet, or an area of about 50 square feet. This calculation included the whole domestic accommodation, with a ceiling height of eight and one-half feet. When the calculation was limited to sleeping room only, the total space per individual was 139 cubic feet (16 square feet). Each floor had two windows in front, and the cookhouse would also have a window through which smoke could escape. All the floors were dark and unventilated. To dispose of kitchen waste water, a drain led from the sink in the cookhouse to the public sewer. Some houses had

T he I nconvenient T ruths   |   1 2 1

independent drains running out under the floor to the street in front. More often the drain ran from cookhouse to cookhouse, under the party walls of adjacent tenements, until it reached the end of the row, or was brought out under one of the houses to the front. Because they had no convenient way of getting rid of rubbish, the upstairs lodgers would stuff it in the down pipe. This would choke it, causing it to leak, and saturating the walls with the filthy fluid that often blocked the house drain.34 Figure 5.2  A model of a Chinese tenement house with two floors

Courtesy of the Hong Kong Museum of Medical Sciences Note:  The model shows the longitudinal section of the second floor which is partitioned into five cubicles and a loft on top, accommodating at least six families. Partitions are incomplete and only the front cubicle has windows. The bottom or ground floor, the longitudinal section of which is not shown, has the living room and the cookhouse. Pigsties are under the beds which also store pots for human excreta.

Manual Removal of Excreta and Rubbish Unlike Europe, where proper water closets were connected to town drains, in Hong Kong only the relatively wealthy Chinese houses had latrines in them, and these were only for men. Women and children of all classes used pots, generally kept under beds, while working class men used public latrines. In coolie houses there was frequently a total absence of any provision for this purpose. Human excreta were disposed

122  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

of manually through the ancient practice of the Chinese “pail system” or bucket system. In public buildings the use of dry earth or decomposed granite had been partially introduced. In the city of Victoria, there were 25 public latrines with 565 seats. The number of seats in each latrine varied from 2 to 51, and although these latrines were built and owned by private persons as businesses, the government supervised their construction and management, levying a tax of HK$0.60 per seat per annum. The latrine owner derived his profit from the sale of the manure collected, and from fees paid by those using them. Chadwick found the location and construction of existing latrines deplorable and so crowded together that maintenance and improvements were nearly impossible. The night soil from the latrines was removed daily in covered tubs by a government scavenging contractor. It was taken to collecting junks that conveyed it to Lap Sap Wan or Gin Drinkers Bay, on the west side of town, and then transported to Guangzhou or other parts of China. The scavenging contractor also collected rubbish, which he simply threw on the beach. He derived his profit from the commercial value of the manure collected, and from the fees paid to him by the latrine proprietors—the City of Victoria paid nothing out of public funds to the scavengers who were providing the waste removal for the government.35

Faulty Public Drains or Sewers The public sewers were built as drains to carry off storm water rather than as sewers to remove sewage from habitations. They were constructed on an as-needed basis, not according to any master plan, to convey the storm water from the ravines, and the surface water of the streets and houses, via the shortest and most direct line to the harbor, into which they discharged their contents through large openings without built-in tide flaps. The result was a most offensive smell along the whole harbor front at low tide. Since there were no manholes, when a sewer had to be examined or repaired, the street surface had to be dug up.36

Inadequate and Inequitable Water Supply The City of Victoria depended on rain for its water supply. In the dry season, water came from mountain streams. After 1863, when Pok Fu

T he I nconvenient T ruths   |   1 2 3

Lam reservoir was completed, the 6 gallons (27.3 liters) provided daily for each individual was barely enough for drinking and cooking. Chadwick also noted a striking injustice in the distribution of the water supply. Most of the houses with piped in water belonged to Europeans, but a uniform rate of 2% of the assessed annual rental was levied on all tenements in the city, regardless of whether they received piped in water or not. No extra charge was levied on closets, baths, gardens, or even fountains—luxuries that only the wealthy could afford. Those who had no service had to obtain water from the public street hydrants, where the supply was intermittent. The users either carried the water themselves or paid water carriers, about one dollar for 120 to 200 buckets, according to the distance or height that the water needed to be transported. In the morning the water carriers assembled with their buckets around the street fountains, waiting for the water to be turned on. Outsiders had little chance to compete with the professional water carriers, and often the supply was shut off before all could get their turn. Those who carted water by themselves were the poorer people, and when they did not succeed in filling their buckets, they would have to seek water elsewhere, usually a long way off.37

Questioning the Myth of Chinese Healthiness Osbert Chadwick also addressed the widely held belief that the Chinese were immune to diseases despite the unsanitary conditions they lived in. He believed that this statement was not evidence-based for good reasons: no vital statistics had been kept in Hong Kong or China, most people died without seeing a Western doctor, and the causes of death were not accurately noted. The apparently low mortality rate was misleading, as most Chinese returned to their native villages to die once they became sick or when they grew old. Chadwick speculated that one reason Hong Kong escaped the epidemics that had afflicted nearby Chinese cities may have been that the settlement was only 40 years old, and the subsoil beneath the city might not have been sufficiently saturated with filth to make it a “hotbed for disease and a breeding ground of filth poison.” It is, in fact, more likely that Hong Kong’s reprieve from ravaging epidemics was purely due to luck. While there was no official registration of births and deaths in Hong Kong, and no cause of death was recorded on death certificates, Chadwick

124  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

found that the published death rates of 26 to 30 per 1,000 among Chinese in Hong Kong in the 1880s were higher than those reported in London (approximately 21 per 1,000 in 1881).38 He estimated that the mean age at death for those over the age of 20 was 43 in Hong Kong and 55 in England. When those who died before the age of 20 were included in the calculation, the mean age of death for the whole population was 18.3 in Hong Kong compared to 29 in England. The health of the population in Hong Kong was decidedly poor, and reform was urgently required.

Chadwick’s Bold Recommendations Osbert Chadwick’s report featured sweeping recommendations to reduce overcrowding, including the provision of open spaces at the rear of the buildings, prohibition of cocklofts and earthen floors, provision of a window in every habitable room, and 600 cubic feet of unobstructed air for each adult. He advocated the reconstruction of the drainage system, an increased water supply, requisition and rebuilding of the public latrines, provision of public bath houses and laundry, building of new markets and improvement in the scavenging system.39 He added that the Chinese viewed the subject of sanitation with intelligent attention and that he had seen no evidence of obstruction or apathy. The principal objection that the Chinese raised was a fear of a tax burden and a “squeeze” by public officials. Noting what he saw as the docile character of Chinese people, Chadwick suggested that once they saw that the government had an earnest, firm determination to enforce cleanliness, there would be little or no obstruction—especially if the orders of government were promulgated in the time-honored custom of posting a proclamation to alert people, and then carrying out the changes with as minimal interference as possible with their social customs. Chadwick ended the report with a warning: … that my report would show the necessity for strong and complete measures of sanitation, and I trust that they will be undertaken for the immediate benefit of public health without waiting for the necessity to be demonstrated by the irresistible logic of a severe epidemic. The report marked a turning point in the history of sanitation in Hong Kong, as his call for reform altered the attitudes of subsequent

T he I nconvenient T ruths   |   1 2 5

governors and their officials. But would a shift in sentiment be enough to forestall the severe epidemic Chadwick warned about?

The Prelude to Disaster 1882–1894 The extensive sanitary reforms Osbert Chadwick proposed would require a large and costly program of public works, some sacrifice on the parts of the landlords, and a strong leadership to push through the reforms, as well as maintain continuity of management. Unfortunately, Hennessy had already left and the rapid and frequent changes in administration that followed was not what the Colony needed to implement the vital sanitary reforms during this crucial period.40 Governor Sir George Bowen arrived in Hong Kong in March 1883. After carefully studying Chadwick’s report he visited every part of Hong Kong, including the infamous Tai Ping Shan, which previous governors had likely avoided. Not only did he agree with Chadwick’s findings and recommendations, he also admitted that the unsanitary state of the Colony was due to neglect and incompetence of previous administrations.41

Bureaucracy Clogs Sanitation Progress To carry out sanitary reforms and to be responsible for all sanitary affairs in Hong Kong, Chadwick recommended the establishment of a Sanitary Board. The members of the board were to formulate policies for the Sanitary Superintendent, but the board itself would have no statutory power. On the insistence of the Colonial Office, Marsh, while acting as the Colony’s administrator before the arrival of Bowen, set up a Sanitary Board composed of three officials as recommended by Chadwick: Surveyor General, Registrar General, and Colonial Surgeon. He also appointed a Sanitary Inspector, Hugh McCallum, to carry out the much needed sanitary reforms.42 In May 1883, Governor Bowen introduced a draft Order and Health Amendment Ordinance officially constituting the board. The three officials were to be members ex officio, and there were to be not less than two other members nominated by the governor. The ordinance proposed wide powers to deal with unsanitary

126  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

houses, inspection of premises, compulsory disinfection, and removal of persons who were sources of disease. As expected, it was met with strong opposition in the Legislative Council and had to be withdrawn. The Sanitary Board accomplished nothing by the time Bowen left office in 1885, but in 1886 Marsh strengthened the board by adding four unofficial members to represent ratepayers: Dr. Patrick Manson, Dr. Ho Kai, A. P. MacEwen, and N. T. Ede.43 At the end of the year, the Sanitary Board had prepared an eight-part draft of the long-delayed Public Health Ordinance to introduce necessary sanitary reforms.44

The Neutered Public Health Ordinance of 1887 There seemed to be a real chance to instigate change with the eight-part Public Health Ordinance of 1887.45 Part I dealt with the constitution of the Sanitary Board, and was the first time in the history of the Colony that popular election would not be confined to British nationals. It would consist of four officials: the Surveyor General, Registrar General, Superintendent of Police, and Colonial Surgeon, and not more than six additional members, four of whom (two being Chinese) were to be appointed by the governor, and two elected by ratepayers. The Public Health Ordinance conferred the power to make, alter, amend, or revoke bylaws with regard to 26 different sanitary measures, including drains, privies, light, and ventilation of dwelling houses, scavenging and removal of night-soil, protection of water supply, and prevention of overcrowding. The board would have authority to order the sanitary staff to enter premises to inspect nuisances, and to serve notice on the author of the nuisance to abate, remedy, or remove such nuisance. Part II dealt with measures to be taken against epidemic diseases such as proclamation, disposal of the dead, house to house visitation, destruction and disinfection of infected articles, and compulsory vacating of houses, as well as other measures for prevention and mitigation. In Part III, regulations were provided for owners of houses with respect to the construction of drains and sewage systems. Part IV to Part VIII consisted of building ordinances with regulations for construction such as the recommended sizes or capacities of windows, basements, kitchens, sub-soil drainage, privies, water closets, and space in front of and behind the buildings. A new building would have at least one window to every room to ensure proper light and ventilation. A clear

T he I nconvenient T ruths   |   1 2 7

area between a building and the hillside was required in order to allow the laying of subsoil drainage, and the basement of a building was not to be against the hillside, with a distance of at least four feet maintained between them. Every adult would be provided 300 cubic feet of air space (half of Chadwick’s recommendation). Property owners were concerned, after reading the draft ordinance, that they would lose money on their unsanitary properties if regulations for decent housing were enforced. They demanded compensation, which neither the Colonial government nor the Sanitary Board opposed in principle—in fact, Sir Gordon Cameron, the Administrator, felt that compensation should be liberal, as it was previous administrations’ negligence that allowed such unsanitary buildings to develop.46 The strong Chinese opposition, represented by Ho Kai on the Legislative Council, was cloaked in the language of Chinese custom and tradition, and an apparent concern for the poor whose rents would likely be raised—but was really based on the fear of financial losses for vested interests. Improving the standard of housing without compensation to the landlords would cut down on available space and would drive up rents, which the poor could not afford. Ho Kai submitted his Memorandum of Objections, indicating that “the ordinance made the mistake of treating Chinese as if they were Europeans” because the Public Health Ordinance was based on the one implemented in England. The ordinance would cost millions of dollars for landowners with property in the Colony and public confidence would be shaken to its foundation. He then used the often quoted claim that there were wide constitutional differences between a native of China and one from Europe, alleging that the lawmakers did not allow for the diversity of habits, modes of living, and a host of other distinctions between the two races. The Chinese should be governed as much as possible in accordance with their manners and customs, and government officials should respect their religious and cultural differences, and meet their peculiar requirements, as promised when the Colony was founded. Arguing from the economic rather than public health standpoint, Ho Kai asked rhetorically why millions of dollars had to be spent simply for the sake of an unproven theory that the Chinese would require sanitary regulations to promote their health and welfare. It was not for the benefit of the poor to have small rooms narrowed even further in order “to provide for a privy, a superb kitchen and a sumptuous backyard of 10 feet

128  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

wide, while at the same time wicked landlords would be charging a higher rent for the improvements.”47 Ho Kai, a physician as well as a barrister, had put aside his knowledge of medical sciences, sided with the Chinese who opposed making costly improvements, and argued for the need to move slowly, avoiding interference with traditional culture. In essence he wanted to leave the Chinese in festering slums. What happened to the man who gave such generous support to the Alice Hospitals and the Hong Kong College of Medicine for the Chinese? In protecting the interests of the landlords and opposing improvements in housing, Ho Kai helped to perpetuate the continual overcrowding and unsanitary conditions of the Chinese population. By prioritizing financial interests over the pressing health concerns, perhaps he wanted to win the confidence of the Chinese—the poor as well as wealthy property owners. In September 1887, a neutered Public Health Ordinance was passed. William G. Cameron, the Administrator, was so eager to pass the Ordinance that he decided to leave out all of the contentious clauses affecting properties; in particular, the requirements for compulsory backyard space and ventilation would be left for a future ordinance, but the demand for a minimum of 300 cubic feet of airspace remained. Further, the Sanitary Board had no power to impose penalties directly; a magistrate was to be given power to make orders for the inspection of overcrowded premises. A notice had to be given in writing not less than six hours before inspectors could enter into a premises for inspection. When a nuisance was found, notice for its abatement and compliance with the law had to be served first. If the owner was incompliant, the case had to be brought before a magistrate who would then issue a summons.

Housing and Sanitary Reforms After the Public Health Ordinance was enacted in 1887, many Chinese and property owners continued to express strong objections to making changes to buildings. Forty-seven thousand Chinese, who were actually not so docile, signed a petition to protest the much weakened Ordinance, which had already been accepted by the British home government. Despite the petition, Governor Sir William Des Voeux was able to pass the Buildings Ordinance, reinstating the regulations that had been omitted in the Public Health Ordinance of 1887. The more contentious clauses

T he I nconvenient T ruths   |   1 2 9

dealing with ventilation and space for backyard still had to be omitted and left for a later ordinance—the Crown Lands Resumption Ordinance of July 1890. Des Voeux thought the best way to avoid dissension was to use the power of resumption to effect sanitary improvement, with compensation being settled by a board of arbitrators. His intention was to resume and rebuild the Chinese area over a twenty year period. The Secretary of State finally agreed to the Resumption Ordinance which gave property owners the compensation that they wanted.48 Figure 5.3  Improved design of a Chinese house with windows in front and at the back. Note the narrowness of the house

Source:  Hong Kong Administrative Reports, 1893, M44

In the meantime the Sanitary Board had appointed a committee to conduct a two-year inquiry into overcrowding. Their report, issued in October 1890, showed just how bad things had become. Many blocks of buildings were found to have 1,500 people per acre; one even had 3,235 per acre. In total, 745 houses were reported to have serious overcrowding. Des Voeux agreed to apply the clauses of the 1887 Public Health Ordinance regarding overcrowding and to pass an amending act to deal with tenants

130  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

of overcrowded houses as recommended by the committee but he did not follow through. Nothing was done to improve overcrowding during his administration. Instead of building dwelling houses to relieve overcrowding for the Chinese in the newly reclaimed area as he originally intended, Des Voeux allowed developers to build large godowns and blocks of office buildings. He should be responsible for not seizing the opportunities to implement the much needed housing reforms.49 In 1883 Governor Sir George Bowen set in motion various sanitary reforms that had been recommended by Chadwick and accepted by the Executive Council,50 which could be carried out immediately. These included reorganization of the sanitary staff, separation of contractors for night soil removal and for dry garbage removal, establishment of public latrines, improvement in town sewers and water distribution, enactment of bylaws to regulate public markets, and new ordinances to control water supply and buildings. The Chinese did not object to any of the above sanitary reforms as long as they did not intrude into their privacy or incur increases in taxation. The Colonial Office even accepted Bowen’s suggestion to issue a loan to defray expenses for the public work associated with improvement of sanitation, as some of these works would generate revenue, including increasing the water supply, building a new central market, and starting the reclamation of Causeway Bay so the city could expand eastwards.51 Chadwick supported the costly Tai Tam water project that involved building a reservoir on the southeast side of the island with a storage capacity of over 312 million gallons, with water traveling via a tunnel through the hills to the north. After much delay, the project was finally approved following the great drought in the summer of 1886, when Hong Kong had to bring in water by boats from the mainland.52 Chadwick recommended a system of drainage that separated sewage from storm-waters. The system would allow town sewage to be carried to the sea for disposal in the tidal current, permitting only a limited amount of rainfall into the sewage drains for flushing and cleaning.53 Chadwick was invited to Hong Kong again in 1890 when he was temporarily appointed to the Executive Council, to ensure that the improvements in the water supply, drainage, and sewers were carried out properly. During his second visit he worked with the City Engineer to lay out water mains for the upper zone of city, and to start work on sewage for the high level

T he I nconvenient T ruths   |   1 3 1

districts where the rich lived. Planned work on the lower level districts and Tai Ping Shan had yet to be carried out when he left.54 Indeed, during the years following Chadwick’s first visit, about HK$1 million was spent on the sewerage system. Other public works, including a new central market, new dust bins, animal depots, latrines, laundries, and other miscellaneous works cost a further HK$660,000. Other significant improvements focused on food handling, reorganization of scavenging, and reclamation of pestilent swamps at Causeway Bay and Yaumati. In addition, schemes to link up the east and the west by a road on the seaward side of the Admiralty and by a military road were also completed. As a result of these improvements, the streets in the European districts were clean, and their houses had increased water supplies and efficient drainage. The sanitation and the health of the Europeans improved, and the wealthy and the privileged led healthy, gracious, and leisurely existences. Not so far away in Tai Ping Shan, the situation was utterly different. In fact, Colonial Surgeon Ayres, after an 1893 house inspection, sounded desperate about the lack of progress: The floors were reeking with filth. The drainage was very bad, the smell abominable. In some of the houses were dark holes in which there were quantities of decomposing and putrid meat, fat and bones and one of them filled with maggots. The stench was unbearable. I found [these houses] in the same condition I had reported twenty years ago.55 In summary, despite Chadwick’s report independently citing evidence of the pressing need for radical reform, the following decade was marked by bureaucratic procrastination and frequent change of governors, with no decisive action dealing with the unsanitary and overcrowding conditions in Tai Ping Shan district. A Sanitary Board was appointed but there were endless disputes over its power and scope; a public health ordinance was passed but the vital regulations to reduce overcrowding were removed; more careful insertion of subsidiary clauses was followed by yet another study on housing and overcrowding. The collective indifference of the Europeans and the wealthy Chinese, the resistance of the property owners, the European and Chinese sojourner’s attitude of disinterest, and the numbing effects of decades of warnings

132  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

about impending disasters which did not materialize led to little being done to ameliorate overcrowding and unsanitary housing. It would take the plague of 1894 to strike Hong Kong before a critical mass of influential people would be jolted awake. Plague started in Tai Ping Shan, where over 50% of all cases would occur, then it became recurrent, punishing Hong Kong nearly every year for the next 30 years. The people of Hong Kong would pay dearly for their neglect, their indifference, their prejudices, and their lack of foresight. The cost for not investing in a healthy living environment would be not only millions of dollars, but also thousands of human lives.

6. The “Great Dying”: Bubonic Plague

No disease in human history has evoked such horror, panic, and fear as the plague. Of course it is dreaded for the pain and suffering it inflicts, but it is especially abhorred for the high mortality rate that follows in its wake. The first recorded epidemic, the Justinian Plague, was named after Emperor Justinian I, and devastated the Byzantine Empire during the sixth century, reportedly killing as many as 50 million people. Known as the “Great Dying,” the second pandemic occurred during the fourteenth century. German physician-historian J. F. C. Hecker named it the “Black Death” in 1932, due to the dying patient’s skin turning black from excessive subcutaneous bleeding and gangrene of the extremities. Traveling from Asia to Europe, the disease arrived at the Sicilian port of Messina in October 1347, then spread north throughout Europe, reaching Moscow in 1351. The first wave of plague killed about one quarter to one third of the population, while many more succumbed in outbreaks in later years.1 The third pandemic began in the mid-nineteenth century in Central Asia. After killing millions in China and India, it then spread worldwide, reaching Hong Kong in 1894, where it became endemic over the next 30 years. We now know that plague is caused by Yersinia pestis (previously known as Pasteurella pestis), and that the bacteria infect humans through flea bites. The fleas are often found on rodents such as rats and mice, and when their rodent hosts die, the fleas seek out other prey, whether other rodents or humans. The bacteria, which form aggregates in the gut of infected fleas, are harmless to the flea, and allow it to spread the disease. The bacteria are regurgitated with the ingested blood into the bite site of a rodent or human host, the bacteria then rapidly spread to the regional lymph node and multiply. The swollen lymph nodes are called “buboes”— hence bubonic plague. Bubonic plague can progress to septicemic plague (bacteria in the blood stream) and also to pneumonic plague (when it

134  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

settles in the lungs). These diseases can then spread even more rapidly, directly to other people by the droplet route. The incubation period is two to five days after a person’s exposure to the bacteria. The patient develops high fever of up to 104°F with severe headache and swollen lymph nodes, commonly found in the armpits, upper femoral, groin, and neck region. The patient may develop convulsions or become delirious and lapse into coma, and their fingers, toes, lips, and nose may turn black from gangrene. Other symptoms include shortness of breath, hematemesis (vomiting of blood), cough, and extreme pain caused by the decay or decomposition of the skin while the patient is still alive. Until the nineteenth century, physicians’ attempts to understand plague amounted to little. Astrologists believed that plague was the result of a rare event in the constellations, while others saw it as an act of God to punish the wicked. All agreed that it was contagious, and victims along with their families were isolated. With the discovery of microscopy and the advancement of “germ theory” in the late nineteenth century, medical scientists were eagerly looking for the microorganisms which caused the disease. The 1894 plague epidemic which descended on Hong Kong challenged that era’s frontline researchers to unravel the mystery of this disease.

The Plague of 1894 Plague first appeared in China in the Province of Yunnan during the Mohammedan Rebellion (1857–1878) as part of the third great pandemic in 1866. 2 The disease became endemic in this mountainous district 4,000–5,000 feet above the sea. In June and July of 1885 plague raged in Yunnan, heralded by the ominous signs of rats dying in the streets. First reported in Beihai in 1882 by Dr. J. H. Lowry of the Chinese Maritime Customs Service,3 plague erupted again in the middle of March of 1894. It seemed to follow the trade route from Yunnan to Beihai and then onto Guangzhou,4 for in late March 1894 plague assaulted Guangzhou, initially in the poorer district near the South Gate. By April, the disease was ransacking Guangzhou, killing 200 to 500 each day. The Chinese doctors in Guangzhou estimated that the mortality was 80% and the number of deaths from the 1894 outbreak was estimated to be around 50,000.5

T he “ G reat D ying ” : B ubonic P lague   |   1 3 5

Hong Kong was fortunate to be spared of any serious epidemic before 1894, but for that very reason it was vulnerable to a worse one. Government officials found reasons to avoid dealing with the serious overcrowding found in the Tai Ping Shan neighborhood, where povertystricken Chinese lived in poorly ventilated and poorly lit houses, with no provision of water or latrines. The density of the population had reached 840 per acre, higher than any other town in the world at that time. Hong Kong had also become a great emporium, with hongs and godowns (business houses and warehouses) filled with stores and infested with rats. Moreover, because of its intimate intercourse with ports of coastal China, where river steamers carried between four and five thousand passengers each day, it was a clearing house not only for emigration, but also for infectious diseases. One final factor conspired to exponentially increase the likelihood of an impending disaster. Each year the Chinese merchants in Hong Kong held an annual Chinese New Year parade where hundreds of thousands of Chinese came from Guangzhou to watch. Thus, when the epidemic of plague reached Guangzhou in 1894, it simply continued its march to Hong Kong.6 Dr. P. B. C. Ayres, Colonial Surgeon, heard rumors of an epidemic of plague in Guangzhou, and on 4 May 1894, he sent Dr. J. Lowson, the Assistant Superintendent of the Government Civil Hospital, to investigate. Lowson visited hospitals in Guangzhou and realized the gravity of the situation after conferring with local doctors. On 8 May, the day after he returned to Hong Kong, he diagnosed the first case of plague and isolated the patient.7 It was no longer possible to stifle public speculation. The following morning, spread across the front page of the Hong Kong Telegraph, was the announcement, “A fatal disease, somewhat similar in its effects to the ‘black fever’ which has carried off thousands of the natives of Canton during the past month … has, we regret to learn, made its appearance among the Chinese residents in the Taipingshan district.”8 The government swiftly denied the presence of plague in the city, informing the press that the deaths in the Tai Ping Shan district were from diarrhea, phthisis (tuberculosis), and bronchitis. But in Chinese circles, the occurrence of plague could not be so easily denied. On 10 May, Lowson was instructed to go to Tung Wah Hospital to find out whether cases of plague existed in the hospital. He identified 20 patients in different parts of the hospital with the telltale buboes, bleeding on the skin, and other signs of the advanced stage of plague. Despite

136  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

these obvious signs, the Chinese doctors had not recognized the plague or isolated the patients. Lowson reported to Ayres that all the plague victims in the hospital came from the Tai Ping Shan neighborhood— Market Street, Tank Lane, and Ladder Street. He and Ayres informed the Registrar General, J. H. Stewart Lockhart, about this grave situation, and an emergency meeting of the Sanitary Board was called that afternoon.9 It became obvious that none of the members of the Sanitary Board had any experience dealing with the crisis of an epidemic—let alone with such a deadly one as plague. So far only the Chinese in Tai Ping Shan had been affected, but if unchecked, the disease would spread to the European community, to which the majority of the Sanitary Board members belonged. To be on the safe side, they adopted drastic measures to curb the disease: identifying patients by house to house visits, isolating them on the hospital ship Hygeia, thoroughly disinfecting and cleaning clothing and furniture in the house with Jeyes fluid (a disinfectant with cresol, phenol, and terpineol), and assigning a special ground for burying the dead. Ho Kai, a member of the Sanitary Board, pointed out that many Chinese would object to be sent to the Hygeia, but no one in the meeting listened to him, nor did anyone anticipate just how intense those objections would be. The Sanitary Board appointed a permanent committee to deal with the situation more effectively.10 As Ho Kai predicted, patients and their families objected to being transferred from Tung Wah Hospital to the Hygeia, which the Chinese regarded as an object of terror. The Hygeia’s appearance was ominous— it had no foredeck or afterdeck, jutting forbiddingly out of the water, especially after dark, and rumors about the ship abounded. Some claimed that the Hygeia was not a real hospital, but a form of sinister laboratory where Western doctors cut up Chinese children, using their livers to produce a “cure for the plague.” It was even averred that officers would visit every school, examine every child, and send to the Hygeia anyone having just one boil or pimple. These rumors were probably started by the Chinese doctors who were hostile towards the arrogant foreign doctors.11 Most of the Chinese schools were soon closed, and in those that remained open, attendance had fallen by 60%.12 The Chinese doctors from Tung Wah Hospital were asked to treat the patients in the Hygeia, but they were unwilling to go. Because of the growing number of patients, the Kennedy Town Police Station was soon converted to a hospital. In the meantime house to house visits had begun, supervised by Lowson and the

T he “ G reat D ying ” : B ubonic P lague   |   1 3 7

Superintendent of Police and assisted by the sailors of the Royal Navy’s Victor Emmanuel. Those found to have the disease were immediately sent to the Hygeia and their houses were cleaned, disinfected, and whitewashed. Dead bodies were removed to another boat destined for a special burial ground.13 The governor had to call upon the Royal Engineers and King’s Shropshire Light Infantry to help with the highly undesirable job of disinfection, since there were so many houses to be cleaned. These dwellings were filthy, and many houses contained heaps of rubbish and filth, with vermin of all sorts found everywhere.14 Many blamed the epidemic on the prolonged dry winter season, with insufficient rain to wash away the dirt. But when rain finally came on 17 May, rather than showing signs of abating, the plague gathered force and swept through Tai Ping Shan with ferocity, leaving a trail of deaths. On 19 May the 24-hour death tally was 34, escalating on 2 June to 78, and on 7 June to 107. Hong Kong was officially declared an infected port—a leper in the international community, and ships were no longer permitted to enter the harbor.15

Fear, Anguish, and Paranoia The Chinese already had frightening mental pictures of the foreign surgeon as a ruthless demon, armed with steel, who delighted in slashing up the human body—a practice condemned by Confucian ethics. They hated the intrusive house to house visits and the house cleaning which they regarded as an invasion of family privacy. Although accustomed to a more or less arbitrary and despotic rule outside their homes, they were used to being much more masters within their own houses than Englishmen. Even though they were prepared for the “squeezing” of individuals in proportion to their wealth, they resented, above all, government interference into what they considered their private affairs.16 To avoid the intrusion of house cleaning and disinfection, cases of plague went unreported, and victims were moved from house to house to evade the search parties. The draconian measures to check the plague were being executed without any publicity or public education ahead of time among a population that was normally suspicious. Fear and paranoia among the Chinese mounted. In a climate of mutual distrust, it took little to escalate to violence, and in Tai Ping Shan a riot almost exploded.17

138  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

On 20 May 1894, the Chinese blockaded houses to be visited and stoned the sanitary officers, prompting the intrusive visits to be called off. The plague patients in Tung Wah Hospital also resisted transfer to the Hygeia. Feeling that the Tung Wah Hospital Committee could no longer protect them from the Western doctors, patients’ relatives and friends besieged the hospital. The hospital committee members considered that they had to maintain their respect of Chinese wishes. Lau Wai-chuen, who was a member of the Sanitary Board as well as the chairman of the hospital committee and comprador of Hongkong and Shanghai Bank, was caught in the middle.18 The following day, a large meeting was held at Tung Wah Hospital, chaired by Lau, and attended by the Superintendent of Police, F. H. May, and Ayres. Lau requested that plague patients be allowed to go to Guangzhou if their relatives so desired. The Superintendent of Police responded that the officials in Guangzhou would not allow plague patients to go there. As the Chinese present were dissatisfied with the answer, Lau suggested that he would prepare a petition for Guangzhou, signed by all leading firms of the Colony. In the meantime, Lau’s hong was ransacked by a gang, and when he left the hospital he was surrounded by a howling mob and required a police escort to his residence.19 That same day Governor Sir William Robinson held an emergency conference attended by the Colonial Secretary, Treasurer, Colonial Surgeon, Superintendent of Police, Ho Kai, J. J. Frances (chairman of the permanent committee of the Sanitary Board) and Lau Wai-chuen, to determine what steps should be taken next. Insisting on the absolute necessity of house to house visits, the Governor announced that the Tung Wah Hospital Committee needed to cooperate in order to prevent the spread of disease. He issued a proclamation addressed to the Chinese explaining the objects of the preventive measures and asking them to cooperate with the government. 20 As a seeming compromise, the government announced that the plague patients would no longer be sent to the dreaded Hygeia, but to the Glassworks Factory at Kennedy Town. There they would be treated by Chinese doctors under the management of Tung Wah Hospital. This apparent concession was an attempt to conceal the fact that the Hygeia, the Government Civil Hospital, and the Tung Wah Hospital had all reached full capacity, and that the government needed another place to house patients. On 23 May, a deputation of leading Hong Kong Chinese, including

T he “ G reat D ying ” : B ubonic P lague   |   1 3 9

the Tung Wah Hospital directors, pleaded for a relaxation of plague measures adopted by sanitary authorities, requesting that 1) house to house visitation be ceased; 2) sick persons be allowed to return to their own country; 3) the Hygeia patients be sent to the Glassworks Hospital; and 4) all future sick patients be sent to the Glassworks Hospital. Although he conceded that the future sick could go to the Glassworks Hospital, the intransigent Governor said no to all the other requests, adding that it would be too dangerous to transfer moribund patients from the Hygeia to the Glassworks Hospital. After meeting with the deputation, the Governor issued another proclamation that all plague cases should be isolated and treated in a hospital free of charge, all the dead buried, and the premises where the cases came from disinfected and cleaned. The people were required to report plague cases and cooperate with the government.21 Now the Tung Wah Hospital Committee which had always been the “voice” for the Chinese community, was in a very untenable position, unable to provide relief for the anguished community. The media did its share to heighten the tension between the two communities. The Daily Press editorial comments illustrated the haughtiness typical of the European community: Splendid illustration of the intelligence and perspicuity, to say nothing of the gratitude, of these so-called representatives of the local community! But fortunately the government had reached the end of its tethers in the matter of concessions…. Another editorial appeared to blame the poor for the poverty and overcrowded conditions that made them vulnerable to the epidemic: … all due to the vast influx of filthy mendicants and coolies … all huddled together … reeking with filth, many of them disease. The only solution was to “purify” the island by expelling the infected.22

Evasion and Confrontation The Chinese did not need to be expelled, as about 1,000 a day began leaving the Colony of their own volition. As the numbers of cases of plague and death climbed exponentially, the Chinese left Hong Kong by steamers, boats, and junks. As summer neared, the departure of almost

140  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Figure 6.1  A plague hospital (probably the one converted from the Police Station in Kennedy Town)

Photo courtesy of Hong Kong Museum of Medical Sciences and donor Mrs. Francis Ashbourner Note:  A hospital ward of the plaque hospital showing a long room with bare floor boards, and patients lying on the floor on reed mats on each side of the room and a walkway in between.

half the population, between 80,000 and 90,000 people, left the once bustling city a near ghost town. Meanwhile placards posted all over Guangzhou warned people against going to Hong Kong, where women and children were being cut up and having their eyes scooped out by foreign doctors. Foreigners were hurling people’s furniture out of windows, which they sloshed with detergents and disinfectants. Rage against the foreigners was boiling over. If the foreigners were burning houses in Tai Ping Shan in Hong Kong, then the people would take revenge by burning foreign consulates and hongs in Canton. By 25 May foreigners no longer felt safe in Guangzhou. The British Consul in Guangzhou applied to the Viceroy of Guangdong and Guangxi, Li Hanzhang, brother of the Grand Viceroy Li Hongzhang, to issue a proclamation to calm the public. The Viceroy responded by proclaiming that the governor of Hong Kong had decided to move the Chinese patients from the Hygeia, the great cause of offense, to the

T he “ G reat D ying ” : B ubonic P lague   |   1 4 1

Glassworks Hospital or to the Tung Wah Hospital. He also gave orders to arrest the disseminators of rumors and placards.23 The announcement that the Governor had ordered the removal of patients from the Hygeia was not true at all, as Robinson had never made that decision. To make room for the European patients as the Kennedy Town Hospital and the Government Civil Hospital could accommodate no more patients, Lowson had shipped all the Chinese patients out of the Hygeia.24 In a misguided attempt to cool off tensions, Robinson decided on a show of force. In this already chaotic and desperate time, Robinson ordered the Commodore to anchor the fully armed gunboat, Tweed, opposite to the Tung Wah Hospital and train its cannons on it. Robinson also offered a handsome reward for any information that would lead to the arrest of the author of the “disgraceful” placards.25 These steps stopped the placards locally, but the Tung Wah Hospital directors were further humiliated, and any negotiation was now impossible. The death toll continued to climb. On 1 June, 1894, there were 59 new cases and 53 deaths; on 3 June, 81 new admissions and 54 deaths, as well as 18 dead bodies removed from the Tai Ping Shan district. As more and more Chinese left for Guangzhou or the mainland, business hongs lost their clerks, chair coolies left their employers without warning, and many domestic servants applied to employers for wages due, so that they could join their families on the mainland.26 The 800 workers of the China Sugar Factory crossed over to Kowloon to start their walk to Xiamen— a journey of 180 miles. The Hong Kong Rope Works shut its doors. As Hong Kong’s harbor emptied out, the Europeans stopped clamoring to get rid of the filthy coolies, and instead began to worry about a bleak scenario where they would have to wash and iron their own clothes and pull their own rickshaws. They realized that they needed the underclass, which had cushioned their lives with relative comfort. Behind the scene, the Tung Wah Hospital Committee had probably worked hard to gain the Viceroy Li’s support for allowing Hong Kong patients to go to Guangzhou. On 3 June Robinson received a strange offer through Viceroy Li from the directors of the Benevolent Hospital at Guangzhou. It said that any sick Chinese subjects who wished could go to Guangzhou, and in case of death, have their corpses sent to their native villages in specially prepared junks. Robinson could not understand why

142  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Guangzhou authorities would agree to accept any more plague patients when they already had more than they could handle.27 Robinson also received requests from several compradors, who employed a large number of clerks, asking that they might be allowed to have the sick sent to Guangzhou. In exchange, they would promise to remain in the Colony; otherwise they would leave at once, thus placing the banks and houses of business in an even more precarious position. By 12 June, all plague hospitals were overflowing with patients. The Glassworks Hospital had 200 patients, which was double its capacity, and the newly completed Pig and Sheep Depot had been converted to a temporary hospital. Robinson was faced with a very grim choice: either cling to his policies and end up with the economy of the city in ruin and more dead to be buried, or accede to the wishes of the Chinese. After serious consultation with the Executive Council, Robinson agreed to the transfer of the sick to Guangzhou based on the following conditions: 1) the patients wanted to go; 2) they were fit enough to travel; 3) their sickness had been reported to the police; 4) they had been seen first in one of the local hospitals; and 5) the junks were properly equipped to transport the patients. Suitable junks were prepared for this purpose, and 170 such patients were transferred. Surprisingly, only eight died while making the journey.28 More drastic measures came from the Sanitary Board. Thousands were displaced as a new bylaw closed the infected houses that medical officers had condemned as unfit for habitation.29 House to house visits were carried out in a rough, insensitive manner. Even the conservative Hong Kong Daily Press expressed sympathy on 16 June: We understand that many unfortunate people have during the last two nights been compelled to sleep in the streets owing to being peremptorily turned out of their houses. The Sanitary Board have issued a notice which is posted on the door of every condemned house and intimates that the occupants are to remove within 24 hours after the posting of the notice. It appears that some thick-headed officials have insisted upon the poor people being evicted as soon as the notice is posted which is directly opposed to the specific terms of the notice, and the consequence has been that whole families with their goods and chattels have been left to spend the night as best they

T he “ G reat D ying ” : B ubonic P lague   |   1 4 3

could with no roof to their head but the not too friendly sky. In George Lane, several such cases occurred and one whole family including women and children had to bivouac in the miserable thoroughfare all night.… It is very unfortunate that the supervision of this important matter has to be left to a staff which though on the whole fairly reliable, contains some members who have no respect for the miserable people they are dealing with and neither tact, discretion or common kindness.’30 The abrupt dislocation of people escalated tensions in Hong Kong and spilled over into Guangzhou, arousing anger and anti-foreign feeling. Two American missionary women were attacked. Viceroy Li immediately sent soldiers to protect the foreign settlement. The Viceroy, who could not understand Robinson’s way of handling the plague, telegraphed Zongli Yamen in Beijing, complaining about how Chinese plague patients were being treated in Hong Kong.31 Matters had now reached the national level, and the Yamen Ministers approached the British Minister in Beijing with an unusual request—while they did not wish to interfere with the policy of Governor Robinson, they suggested that the Tung Wah Hospital Committee issue a notification to the people explaining the objectives of the sanitary measures. The British Minister in Beijing, N. R. O’Conor, who felt that the anti-plague measures in Hong Kong should have factored in native customs and biases, wired Robinson with a request that he consider modifying the extreme regulations.32 Having the Yamen Ministers intervened in this way demonstrates the importance of Tung Wah Hospital at this time. Although Robinson was disturbed with this criticism from Beijing, he cunningly turned the situation around to his advantage. He sent for the directors of Tung Wah Hospital and told them that the Zongli Yamen Ministers were extremely anxious about the public agitation that the scandalous placards and malicious reports had stirred in Hong Kong. Suggesting that the Tung Wah Hospital Committee issue a notification that would calm the public, he told the directors that this notification would only be credible if they plainly stated that they had personally observed kind and humane treatment of Chinese patients in the European hospitals, and that any reports to the contrary were absolutely false. Furthermore, the committee would need to submit their proclamation to him through the Protector of Chinese for his approval. The Tung Wah Hospital

144  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Directors, who had opposed the sanitary measures that had been taken, must have felt humiliated to be used in this way. The proclamation read: The Tung Wa Hospital of Hong Kong having learned that placards and wild rumours been profusely spread and published through Canton, which have excited the minds of the people, and almost created serious disturbances, puts up this notice in order to allay suspicion, for the Hospital is well acquainted with Western doctors, who have always treated patients of all classes with the greatest care and kindness and compassion; moreover great harmony now prevails between the Western and Chinese doctors in the treatment of the patients. The rumours current in the streets and the placards published there are all false and forged. Let everyone be careful to be in no degree misled by these rumours. This notice is for general information. 18th day 5th moon 20th year of Kwong Su [Guangxu Emperor] [lunar calendar]33 These empty words failed to change the opposition of the Chinese to the government’s sanitary measures. Even the Colonial Office commented that Robinson had practically dictated the proclamation which was supposedly issued by the Tung Wah Hospital. By 20 June 1894, about six weeks after the first reported case in Hong Kong, the epidemic had finally begun to ebb. Robinson wrote a long letter to the Marquess of Ripon, the Secretary of State for the Colonies, describing the dire effects of plague in Hong Kong. After weeks of sending only telegrams that dryly listed the number of cases and deaths, Robinson finally had some good news he could tell the Marquess— Japanese scientists in Hong Kong had identified the bacillus that was causing plague. Then he delivered the more sobering news that every branch of business was imperiled by the epidemic. In the shipping and transportation sector, most countries had imposed quarantines on Hong Kong ships. Thousands of Hong Kong migrants to Strait Settlements were stranded because steamers refused to take them.34 Merchants, whose merchandise was left on their hands beyond the contract time, had to ask bankers for funds to tide them over, and bankers bought and sold fewer bills. Ramifications were far-reaching: the sugar refinery was crippled from lack of ready labor; ordinary men found their food costs had gone

T he “ G reat D ying ” : B ubonic P lague   |   1 4 5

up by 30 to 50%; and public revenue decreased greatly. In short, the plague had inflicted an unprecedented calamity on commerce and trade for Hong Kong.35 Robinson did not, incidentally, emphasize the greater tragedy of the large number of deaths among the Chinese poor. To entice people to return to Hong Kong, Governor Robinson reassured property owners that should the government resume any property in Tai Ping Shan, the owner would be paid a sum based on proper assessment. Finally on 3 September, Hong Kong was declared clean.36 The final returns for the 1894 epidemic were a staggering 2,679 cases with 2,552 deaths, a mortality rate of 95.3%.37 No doubt the total number affected was much higher, likely around 5,000, as more than 80,000 fled Hong Kong during the epidemic and some certainly had carried the disease with them. People must have let out a sigh of relief towards the end of the year, imagining that the plague would go away forever. However, this turned out not to be the case. Every year for almost three decades the plague would keep raising its ugly head in Hong Kong. Figure 6.2  Replica of a Hong Kong plague medal 1894  

Photo courtesy of Hong Kong Museum of Medical Sciences and donor Mr. Keith Poon Note:  The medals were awarded by the colonial authorities on behalf of the Hong Kong community to nurses, civil servants, policemen, Royal Navy personnel, and members of the King’s Shropshire Light Infantry who rendered assistance during the bubonic plague of 1894.

146  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

The Race to the Prize— Discovery of the Plague Bacillus When Governor Robinson sent out a desperate plea to the international community for help with work on the plague, he received responses from the world’s two finest bacteriologists, Professor Shibasaburo Kitasato and Dr. Alexandre Yersin. These two would unlock the mystery of plague that had been puzzling the medical profession since the Middle Ages. The one positive result of the 1894 epidemic in Hong Kong was the discovery of the plague bacillus. For many years the etiology of the plague was shrouded in mystery. In the nineteenth century, the long-held miasma theory that claimed a connection between poisonous vapors and disease was being displaced by a contagion theory of disease. In 1862, the French chemist and bacteriologist Louis Pasteur, a proponent of the “germ theory,” found that bacteria could be removed from milk by boiling and then cooling it—the process known as pasteurization, applied in the dairy industry. In 1885, Pasteur produced the first rabies vaccine. Another giant in this field at that time, Robert Koch of Germany, isolated the anthrax bacilli (Bacillus anthracis) in 1875. By 1882, Koch established a proof that tuberculosis was caused by bacteria, Mycobacterium tuberculosis. Having formulated the most modern laboratory techniques in the field of Figure 6.3 microbiology, Koch was no doubt Professor Shibasaburo Kitasato the world’s preeminent bacteriologist wh e n t h e o u t b re a k o f p l a g u e occurred in Hong Kong. To crown his career, he discovered the cholera bacillus (Vibrio cholerae) in 1884. Kitasato (Figure 6.3) had worked in Koch’s laboratory for six years, distinguishing himself through his work on tuberculosis and by isolating the tetanus bacillus. Before he returned to Japan in 1891 as a national hero, the German government had awarded him the title of professor, the first such honor bestowed on a Photo courtesy of The Kitasato Institute foreign scientist.

T he “ G reat D ying ” : B ubonic P lague   |   1 4 7

Kitasato, confident of his success, left Japan for Hong Kong with a team of five, including the renowned pathologist Professor Aoyama Tanemichi of the Tokyo Medical School, another bacteriologist, Dr. Tohiu Ishigama, and three experienced assistants. On 12 June 1894 the team arrived in Hong Kong with trunks filled with laboratory equipment. Yersin (Figure 6.4) was Swiss by Figure 6.4  birth but received training in France Dr. Alexandre Yersin as a bacteriologist and a physician. He worked in the Pasteur Institute and participated in the development of the anti-rabies serum. After discovering the diphtheria toxin (produced by the  Corynebacterium diphtheriae bacillus) in collaboration w i t h E m i l e R o u x , Ye r s i n d i d something unthinkable for a young talented researcher—he left the institute and France in 1890 to work as a ship’s doctor. He would later obtain permission from the French government, in addition to a grant, Wellcome Collection photo to explore the dark interior of its new colony, Indochina (Vietnam), during leave from that position.38 For Yersin the trip to Hong Kong from Hanoi was not assured, because his previous petition to the French Governor to study plague in Yunnan had been denied. When he heard that plague broke out in Hong Kong, he immediately applied to the French Governor and appealed to Paris to be the Pasteur Institute’s official researcher in Hong Kong. After several weeks of anxious waiting and bureaucratic wrangling, Yersin finally obtained permission. He left for Hong Kong with two assistants and arrived three days after Kitasato, on 15 June, carrying the most important arsenals for a bacteriologist: his microscope and an autoclave. Kitasato received a very warm welcome from Lowson who, according to Kitasato, “put everything needful at our disposal in the most friendly spirit.” Aware that opening up the bodies of the dead was anathema to the Chinese, even for the sake of science, and could lead to rioting and stone throwing, Lowson arranged not only for the Japanese team to have a laboratory at the Kennedy Town Hospital, but also to

148  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

have unclaimed corpses for postmortem examination. Two days after his arrival, Kitasato found bacilli in the blood sample from a postmortem subject. He inoculated a mouse, which died two days later, but because the postmortem was done 11 hours after the death of the patient, he had questions about the significance of this finding.39 He saw the same bacillus in the blood of another patient, but still had his doubts. Lowson, however, had a clear certainty, writing in his diary on 14 June, “Kitasato discovered bacillus. Kitasato and Aoyama to dinner—good chaps.”40 Lowson’s diary entry the next day recalled: “writing most of the morning” and by the end of the day he had “wired Lancet,”41 one of the most prestigious medical journals in Britain, then and now. His telegram reported that Kitasato “had succeeded in discovering the bacillus of the plague,” but Lancet cautioned that there were “as yet no means at our disposal for forming a judgment.”42 No one met Yersin when he arrived on 15 June. Although Ayres had been looking forward to his visit, Lowson did not offer any help. In fact, all Yersin received was obstruction. Lowson informed him of the news that Kitasato had already found the plague bacillus, and provided no space to use as a laboratory. Yersin was forced to build a mat-shed near the Kennedy Town Hospital as his “laboratory.”43 Lowson’s different attitudes toward the two bacteriologists were understandable: Lowson had tried to isolate the plague bacillus himself without success, and he resented the fact that he had to look after plague patients “for which no fame is secured and leaving so little time to look to the more purely scientific side.” He also needed to justify why he had failed to make a discovery: “I can only say that after a day of twelve to eighteen hours’ hard and exciting work in the trying heat of a Hong Kong summer, none of the men who had to bear the brunt of medical supervision, and who had to look forward to a prolonged mental strain, were much inclined to start work with the microscope by gaslight.”44 Lowson felt that assisting Kitasato, the most celebrated bacteriologist next to Koch, was an honor, and if Kitasato discovered the plague bacillus, he, Lowson, would be greatly appreciated. In contrast, assisting Yersin no doubt probably seemed a waste of time, especially when Lowson firmly believed that Kitasato had already isolated the plague bacillus. Moreover there is little love lost between British and French. Nevertheless, Lowson introduced the Frenchman to Kitasato on 16 June,45 just as the Japanese team was completing a postmortem

T he “ G reat D ying ” : B ubonic P lague   |   1 4 9

examination. Yersin was astonished to learn that while the Japanese took samples of blood and from various organs, they did not touch the buboes, the most distinctive feature of the disease. He became skeptical of Kitasato’s approach and thought that the goal may have not yet been achieved. Kitasato was interviewed by the press on 20 June,46 and mentioned his finding of the bacilli in the blood of patients, but did not mention the buboes. For the next five days Yersin waited anxiously for a cadaver to use for a postmortem examination. Each day he was greeted with news that “no autopsies will be carried out today” and was instead given blood samples. He was unable to find bacilli to confirm Kitasato’s findings, and upon discovering that Lowson had all the cadavers reserved for Kitasato, began to explore an alternate way of getting what he needed. The hospital mortuary was guarded 24 hours a day by naval conscripts. Knowing that with the right inducement, soldiers and policemen could be made to bend the rules, he slipped some money to the mortuary guard and snuck in with a scalpel. Gingerly he removed the lid of one of the coffins, excised the bubo of a corpse, slid the lid back, and dashed out.47 In his anxiety and excitement, he did not even register the gruesome look of the cadaver, the fetid odor, or the ghostly surroundings. He had put himself at great risk. If word got out among the Chinese that he had desecrated the bodies of their relatives, he would be lucky to leave Hong Kong alive, and if he did, his career and his future at the Pasteur Institute would likely be over. From the smear of the pus of the bubo, Yersin saw many little rods with rounded ends. He took more smears and prepared cultures which he would inject into mice and guinea pigs. He returned to the mortuary, and once again the sentries let him in without asking questions. He excavated two more buboes and returned to his workbench. The inoculated animals died after two days, and the same bacilli could be isolated from their lymph nodes. Thus the bacillus that Yersin found passed the criteria of Koch’s postulate to be the culprit for plague.48 He informed the British authorities of his findings on 23 June 1894,49 and Lowson entered in his diary, “Frenchman got his bacillus.”50 Kitasato also found his bacillus to satisfy Koch’s postulates and reported his findings in scientific journals. On 4 August, the Lancet confirmed that “Dr. Kitasato has discovered and described a specific plague bacillus.” The slides sent to Britain by Lowson and Kitasato were reproduced in the Lancet on 11 August and in the British Medical Journal

150  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

one week later. Kitasato was quoted in an editorial in the 11 August 1894 issue of the Lancet as having written, “The organism, which is a bacterium resembling the bacilli found in the haemorrhagic septicemia, except that the ends are somewhat rounded, when stained lightly appears more like an encapsulated diplococci, but when more deeply stained, it has the appearance of an ovoid bacillus. When, however, it is focused more accurately, it is still possible to see the diplococci form.” This was Kitasato’s first recorded description of his bacillus. Both journals commented on the diverse morphology: in addition to the small bacilli, the predominant form was an encapsulated diplococcus. On 18 August 1894, the journals published reports of Yersin’s letter to the French Académie des Sciences claiming the discovery of “the bacillus of the Chinese plague.”51 Yersin described the characteristics of his bacillus in his original paper as follows: The pulp of the buboes always contains masses of short, stubby bacilli, which are rather easy to stain with aniline dyes and are not stained by the method of Gram. The ends of the bacilli are colored more strongly than the center. Sometimes the bacilli seem to be surrounded by a capsule. One can find them in large numbers in the buboes and the lymph nodes of the diseased persons. They are seen in the blood from time to time but less abundantly than in the buboes and in the lymph nodes, and only in very serious and rapidly fatal cases…. Microscopic examination of the cultures reveals true chains of short bacilli interspersed with large spherical bodies … As the cultures get older, swollen and abnormal forms become more common, and these do not stain easily.52 The Lancet commented that “there must be some misapprehension here, as Professor Kitasato is such an accurate and reliable observer that we cannot conceive that he has rushed into print without having first satisfied himself as to the accuracy of his observations and experiments.”53 It is recognized now that the bacillus is as Yersin described, “a small oval bacillus, Gram negative, non-motile and non-sporing, staining heavily at both ends but lightly in the centre with Giemsa or Wayson’s stain.” The bipolar staining is regarded as almost diagnostic. On culture it becomes pleomorphic, altering its shape.

T he “ G reat D ying ” : B ubonic P lague   |   1 5 1

Before he left Hong Kong for France, Yersin traveled to Guangzhou where he found the layout of the plague hospitals and medical treatment far superior to those in the Hong Kong. In early August he left the Colony alone for Paris—to prepare a vaccine against the plague bacilli as a method of preventing the disease. After leaving Hong Kong on 20 July, and unaware that in the coming years his reputation would be gradually chipped away, Kitasato received a hero’s welcome from a proud nation at home. That year, Lowson spent the whole of September away from Hong Kong, enjoying a most cordial welcome from his friend Kitasato in Japan. He stayed in a suite at the Imperial Hotel in Tokyo, and was showered with valuable gifts.54 The first one to cast some doubt on Kitasato’s findings was Dr. Aoyama Tanemichi, who had survived an attack of plague in Hong Kong after nicking his finger during an autopsy examination of a plague patient.55 In his paper “On the Plague Epidemic in Hong Kong in the Years 1894 to 1895,” Aoyama wrote, “As the bacilli present in the blood differ in size and staining properties by the Gram method, I think they are not the same as those present in the glands. When the streptococci are broken from their chains and are liberated, they may produce the appearance of the blood bacilli … I think Kitasato’s bacilli need to be considered as streptococci circulating in the blood.”56 Much debate followed the publication of these articles. The consensus was that Kitasato did discover the plague bacillus, however, some expressed reservations about the imprecision of his description, and it appeared that his first cultures were contaminated by pneumococci which are diplococci. Many questioned why someone like Kitasato, who had already made a name for himself, would rush to publish. In a recent article in the Lancet, Professor Tom Solomon, after reviewing Lowson’s diary, posited that it was the young and energetic Lowson who rushed the publication and contributed his slides. By pushing Kitasato to publish prematurely, Lowson was probably responsible for Kitasato not being recognized as the first to discover the plague bacillus. In 1944 the bacillus was given the name Yersinia pestis.57 Although the bacillus responsible for the disease had been identified, and the association between the epidemic in rats and the epidemic in men was well established, it was still not clear how the disease was transmitted from rats to humans; the 1894 epidemic in Hong Kong was not the end of the story. Plague continued to erupt in many parts of the world—Japan,

152  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

India, countries in the Middle East, Africa, Europe, Russia, and in the United States. In 1898, another Pasteurian Dr. Paul-Louis Simond, working in a town called Cutch-Mandvi, north of Bombay, India, found that fleas, Xenopsyllax cheopis pulex irritans (Figure 6.5), from healthy rats had no plague bacilli in their intestines, while those from a dead rat had their intestines bloated with plague bacilli. The intermediary host between rat and man had finally been established.

Figure 6.5   The flea Xenopsyllax cheopis pulex irritans responsible for transmitting the plague bacillus

National Institute of Allergy and Infectious Diseases photo

Plague Epidemics 1895–1929 Table 6.1 shows the number of cases and deaths from the plague that befell Hong Kong from 1894 to 1931. It is striking that the incidence fluctuated widely from year to year. Initially appearing to be worse in alternate years, after 1898 the pattern becomes less clear. The mortality remained high, however, varying from 82% to 100%.58 Far from turning a blind eye, Governor Robinson had erred on the side of caution, intervening quickly and with much force. After submitting his last update on the progress of 1894 plague to the Colonial Office, he lost no time in organizing various enquiries towards improving the medical and sanitary services, and on the workings of the Tung Wah Hospital. The following year, Hong Kong enjoyed a respite as there were just 44 plague cases,59 In 1896, however, the plague returned with a vengeance.60 The Governor had apparently learned his lesson. During the plague epidemic of 1896 and in subsequent years, house to house visits were still carried out, but now they were done with a great deal of consideration for the residents. In 1896, patients were sent to Kennedy Town Hospital, and their contacts were sent, at the government’s expense, to stay for 10

T he “ G reat D ying ” : B ubonic P lague   |   1 5 3

Table 6.1  Number of cases and deaths from plague, 1894–1931 Year 1894

Cases (N) Not known*

Deaths (N)

Year 1913

Cases (N) 408

Deaths (N)

2,552

2,146

2,020

386

1895

45

36

1914

1896

1,204

1,078

1915

144

139

1897

21

21

1916

39

39

1898

1,320

1,175

1917

38

35

1899

1,486

1,428

1918

266

251

1900

1,087

1,034

1919

464

426

1901

1,651

1,562

1920

138

120

1902

572

515

1921

150

130

1903

1,415

1,251

1922

1,181

1,071

1904

510

493

1923

148

136

1905

272

256

1924

0

0

1906

893

842

1925

0

0

1907

240

198

1926

0

0

1908

1,073

986

1927

0

0

1909

135

108

1928

4

2

1910

25

23

1929

2

2

1911

260

253

1930

0

1912

1,857

1,768

1931

0

0 0

Note:  * The number of total cases was estimated to be around 5,000. Over 80,000 fled Hong Kong and some must have carried the disease with them and died in China. Source:  Colonial Surgeon Reports, 1894–1929; Hong Kong Sessional Papers and Administrative Reports, 1894–1929; G. H. Choa, The Life and Times of Sir Kai Ho Kai (Hong Kong: The Chinese University Press, 2000), Appendix VI.

days on “marriage boats”—large roomy junks anchored in the vicinity of Stonecutters Island. Later, because of the great number of plague patients, sheds were erected in the city to accommodate the contacts while their houses were being cleaned, disinfected, and whitewashed. A search team visited and inspected each of the 3,200 houses occupied by impoverished Chinese about once every 10 days, from 25 February until the end of the epidemic in 1896. Although most of the Chinese people were more ready than before to submit to these intrusive visits, some still tried to avoid isolation and disinfection by removing patients and corpses from Hong Kong without the knowledge of the authorities. To allay their fears, Robinson decided to let Chinese take them to Guangzhou under

154  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

the conditions outlined in 1894. Believing that this move would calm the people and discourage concealment of cases, he was determined to prevent the general exodus of the population and their cash. During these epidemics Robinson had come to realize the appalling poor sanitation, the overcrowding, and the absurdly high rents that the majority of his subjects had to pay for dreadful accommodations. In his report to Joseph Chamberlain, the Secretary of State for the Colonies, he wrote, “The housing of the working class in Hong Kong is an important question, the consideration of which should be no longer delayed.” In 1896, he proposed a typical bureaucratic method for approaching thorny problems—the appointment of a commission to enquire into and report on these houses.61

A War on Rats: The 1902 Sanitary Commission By 1901, after four successive years of plague cases reaching well over one thousand each year, the people of Hong Kong had reached the point where they would spare no expense to stamp out the disease. A petition with 1,000 signatures of merchants, bankers, professional people, traders, artisans, and others was sent to Chamberlain, complaining of the government’s failure to prevent the recurrence of plague every year.62 Chamberlain dispatched a commission of two experts to Hong Kong: Professor W. J. Simpson, an authority on plague and infectious diseases, and Mr. Osbert Chadwick, who had been to Hong Kong on two occasions in the past, to find out how to prevent the recurrence of plague.63 Simpson arrived in Hong Kong in December 1901 and declared war on rats. He proposed Ordinance 1 of 1902, in order to prevent the spread of plague infection by rats.64 The preventive measures included: 1. S u r ve i l l a n c e o f r a t s : e m p l oy i n g m e d i c a l o ff i c e r s t o bacteriologically examine the rats which were found dead or alive by the rat-catchers, to identify where the infected ones came from, and to bring special measures to these localities; 2. Destroying all the rats in a locality before plague was imported, so that plague would become a manageable disease—rats would be killed by laying down poison, using traps, pouring crude carbolic acid down the rat runs, and hiring professional rat catchers; and 3. Preventing the import of rats at the wharves and landing stages.

T he “ G reat D ying ” : B ubonic P lague   |   1 5 5

In relation to human plague, he suggested early detection of cases, contact tracing, and giving Haff kine’s prophylactic serum (an anti-serum to plague bacilli) to people who were likely to be exposed to plague. 65 Simpson seemed to find the Haff kine serum protective against plague. He also suggested that a Chinese private hospital be built for treating plague patients.66 When plague made its dutiful annual appearance in 1902, it at least arrived a little later, and the numbers—572—were down to about a third of those in the previous year. Before he left, Simpson sent a second memorandum with his thoughts on the reasons for the stubborn persistence of plague, and more details on proposed preventive measures.67 He noted that since Hong Kong, West River, and Guangzhou are so closely interconnected, with so many people traveling between them, quarantine of all passengers was impossible. There was no notification of diseases in China, and it was hard to know where to apply preventive measures. Hong Kong’s numerous wharves and godowns were infested with rats, which were particularly difficult to eradicate. A constant supply of incoming ships likely brought in new populations of infected rats. Simpson believed that these godowns contributed to the endemicity of plague. The overcrowding and the unsanitary buildings in which the poor Chinese lived also attracted rats. Simpson suggested compulsory notif ication of disease and extermination of rats, and that the government should obtain information of infection in small towns and villages in China. Medical officers should board incoming ships to inspect, looking for sick people and rats. The government should also prevent dead bodies from being thrown out into the streets, and communicate better with the people by using, for example, posters. A special team of trained plague staff should be employed for disinfection and house-to-house visits. 1902 proved to be a very costly year for Governor Sir Henry Blake. The total expenditure for plague related activity was HK$303,000 (5.1% of total expenditure), the highest for all years. Simpson had hired a huge staff of rat catchers and six Japanese doctors to come to Hong Kong to look after patients. Although the doctors were supposed to be fluent in Cantonese language, it turned out that only three could speak the language and the rest had to be sent back.68 Governor Blake conducted an experiment of his own the following year: he identified a city block next to Tai Ping Shan at high risk for

156  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

plague and supervised careful disinfection of the houses on the block. When cases appeared, he arranged for patients with plague to be treated by doctors of their choice, in their own home or in a small building that he rented as a local hospital. This small neighborhood hospital won the approval of the Chinese, and four small district plague hospitals were later established. The results of his experiment seemed to show that cases appeared in disinfected buildings as often as in buildings that had not been disinfected, suggesting that other factors had led to the spread of plague.69 Nevertheless, he had established a tradition of regular cleaning of all houses (it was “cleaning the Tai Ping floor” in Cantonese literally, which means cleaning up the environment) twice a year, supervised by sanitary inspectors, until after the Second World War. Plague continued to scourge Hong Kong year after year, with more cases some years, and fewer in others. Finally, in 1929, the last two cases of plague in Hong Kong were reported. Even though large numbers of rats persisted, they were not infected. There are many parallels with what happened in Hong Kong and one noted example occurred in the 1900– 1920 plague epidemic in San Francisco.70 There have been speculations as to why the plague disappeared from Europe in the second pandemic. One theory suggests that the flea-bearing Black Rat (Rattus rattus) was displaced by a bigger Brown Rat (Rattus norvegicus) which was not as prone to transmit the germ-bearing fleas to humans, due to a different ecology.71 Others have postulated that the disappearance could be due to development of herd immunity, or possibly genetic changes in the rats. Since the transmission involved not just the rats but also fleas, the dynamics must be rather complex. We can be thankful that while this too remains a mystery, the absence of its return means that solving it no longer demands haste.

7. Plague: A Breeding Ground for Improvements in Public Health

The horrifying plague epidemic of 1894 was a turning point in the history of medicine and public health in Hong Kong. At last the government and people were jolted awake, and gradually began devoting significant resources to improve public health. Plague outbreaks recurred almost every year for about thirty years. With commerce disrupted by quarantine, imports and exports reduced, and immigration suspended, the people of Hong Kong, especially those in the mercantile community, became anxious. Quarantine measures and international isolation threatened Hong Kong’s bright future as a major trading center in the Far East. Although disease prevention measures such as surveillance of plague in rats, their elimination, and regular cleaning and disinfection of houses, no doubt contributed to the final disappearance of plague from Hong Kong, these measures, together with improvements in sanitation, came with both high direct and indirect costs. Europeans and wealthy Chinese merchants had finally come to realize that Hong Kong’s economy was a kind of eco-system, and that their interests were tied to the health of the poorer Chinese. Businessmen and landlords were at odds—businessmen knew that healthier people meant a healthier economy, while landlords, the majority of whom were Chinese, opposed sanitation measures that would reduce their rental profits. Most legislation concerning unsanitary properties went into limbo, stalled by the objections of landowners and their representatives on the Legislative Council. Only the relentless persistence of plague forced a shift in the attitude of property owners, who began to realize that overcrowded, unhygienic dwellings were all too hospitable to the disease that threatened Hong Kong’s prosperity. The governor of Hong Kong and officials in the Colonial Office came to see that the previous laissez faire policy and neglect of the poorer Chinese had worked against their own interests.

158  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Near the end of 1894, as the plague epidemic was dying down, Hong Kong was in financial distress. The British government had doubled the Colony’s annual military contribution from £20,000 to £40,000, due to increased defense obligations. With a depreciation of the silver dollar, all sterling payments increased. Thus all salaries had been raised to compensate for losses on sterling remittances, and to keep pace with the increased cost of living. The extraordinary public works necessary to fight plague and the day-to-day preventive measures had already overwhelmed the Colony’s financial resources. Governor Sir William Robinson was still determined to do all he could to prevent the recurrence of plague, with its trail of financial devastation as well as death. He wrote, “I am of the opinion that neither effort nor expenditure should be spared to render it as little liable as possible to visitation of disease such as it experienced last year.”1 Over the following two decades, most public works funds were allocated for making improvements in water supply, sewerage, drainage, and for building public facilities such as latrines, baths, laundries, markets and animal depots.

Water Supply and Sanitary Reform Tapping into the Water Supply With no natural source of water, it was a continuing challenge to provide sufficient water for Hong Kong’s growing population. Since Chadwick’s first visit, the government had been tackling the problem of water shortage, and by 1894, the completion of Tai Tam water works and improvements in the distribution system throughout the city had increased the water supply. In Kowloon, works to supply water to Yaumati, Tsim Sha Tsui, and Hung Hom were also nearing completion. Even so, in order to have adequate water for sanitation, especially during the dry season, Robinson approved two costly water projects, one to raise the height of the dam of Tai Tam water works by 10 feet to increase water storage, and another to build a new impounding reservoir in Wong Nai Chung Gap.2 The estimated total expenditure on water works from 1882 to 1901 amounted to HK$2,130,983.3 These improvements still fell short of the city’s thirsty demands. During his third visit in 1902, Chadwick had observed that water needed

P lague : A B reeding G round for I mprovements in P ublic H ealth   |   1 5 9

to be transported by boats from the mainland during the dry winter, and that population growth had constantly outpaced the water supply. Chadwick investigated every part of the island for possible water sources, laying down a comprehensive blueprint for the development of sources and distribution of water for the next few decades. First, Chadwick advocated increased gathering-grounds with appropriate storage, identifying Tai Tam Tuk as the most suitable site. Second, he proposed universal meterage for supplying water efficiently and equitably, and to prevent waste and extravagance. Third, he suggested, in addition to meterage, the installation of a rider main system, which would allow the water supply for houses to be turned off without affecting the continuous flow of water in the principal mains, to prevent contamination during periods of water shortage.4 Lastly, he recommended that both Kowloon and the newly leased New Territories should be carefully examined for catchment areas and reservoir sites so that the government could reserve the land for future use.5 By 1918, the reservoirs and their catchment areas covered every possible drainage and storage site, taking up about one third of the island’s surface and constituting the most highly developed water catchment system on earth.6 Despite Chadwick’s foresight, epic events in China during the twentieth century had produced an enormous influx of refugees to Hong Kong, far beyond what anyone could have expected. In the 1920s more reservoirs had to be built in Kowloon and the New Territories. After the severe drought in 1929 when water had to be purchased and shipped from China, the government made long-term plans to solve the problem of water shortage. The Aberdeen Reservoirs were built to supply about 2 million gallons of water each day. In 1930, a cross-harbor underwater pipeline was constructed to bring water from the mainland to Hong Kong.7 To augment the water supply to the island, a second cross-harbor pipeline was constructed in 1935, running parallel to the first, and transferring 3.5 to 4.5 million gallons of water daily. In 1937, the first pipeline was found to be seriously eroded and it was replaced by one capable of transferring 9 million gallons each day from the New Territories and Kowloon to the island. The catchment areas of Tai Tam and other reservoirs were increased and plans were made to build Shing Mun Reservoir. Table 7.1 shows the reservoirs built in Hong Kong before the Second World War. 8 Despite additional water from Dong jiang,

160  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

China, and large scale reservoirs being built after the Second World War, rationing remained a way of life into the 1980s. The water shortage problem was finally resolved in 1989, when Hong Kong negotiated with China for 1,100 million cubic meters of water per year, providing for 70% to 80% of Hong Kong’s water supply.9 Table 7.1  Reservoirs and related waterworks in Hong Kong, 1842–1940 Site Hong Kong Island

Kowloon

Total capacity

Reservoir and related works Pok Fu Lam Reservoir

Year completed 1863

Tai Tam Reservoir

1888

Tai Tam Dam raised 9 feet

1897

Wong Nai Chung Reservoir

1899

Rider Mains installed

1902

Tai Tam Byewash and Intermediate Reservoirs

1904, 1907

Two Aberdeen Reservoirs— Upper and Lower

1931, 1935

Tai Tam Tuk Reservoir, Pumping Station and Mains

1917

Kowloon Reservoir

1910

Shek Lei Pui Reservoir

1925

Kowloon Byewash Reservoir

1931

Jubilee (Shing Mun) Reservoir

1939

5,970 million gallons

1940

Note:  Cross harbor pipeline was laid in 1930. Source:  “Hong Kong’s Water Supplies: 1960: A Year of Decision,” Hong Kong Annual Report, 1960, 3–10.

Sewerage, Drainage, Scavenging, and Public Facilities In his 1882 report Chadwick had outlined a separate drainage and sewerage system for Hong Kong. Returning in 1890 at the government’s request to ensure that the main drainage and sewerage had been laid down properly, he saw that the work had been going on steadily but slowly. By 1894, the surface drainage in the City of Victoria, the Peak, Tsim Sha Tsui, Yaumati, and Hung Hom had improved, but all of the houses, especially those in Tai Ping Shan district, required re-drainage and had yet to be connected to the main sewers. After 1894, the pace of the work on drainage and sewerage finally accelerated.

P lague : A B reeding G round for I mprovements in P ublic H ealth   |   1 6 1

When Chadwick retur ned in 1902 as one of the Sanitar y Commissioners and inspected the drainage and sewerage in Hong Kong, he was able to reassure the people that the sewerage work had been carried out generally in accordance with the principles that he had laid down in 1890. Some claimed the separate system of sewerage and drainage that he had recommended had not worked properly, but he pointed out that no sewer would work well or flush adequately when each person had fewer than 7 gallons of water each day; the estimated minimum amount required for proper sewer drainage of sewers was about 15 gallons. On the whole he also found scavenging was efficiently performed.10 Figure 7.1 shows the impact of improvements in drainage, sewerage, and general sanitation in Hong Kong after 1882 on the death rates from enteric fever (typhoid, a water-borne or a food-borne disease), which is associated with poor sanitation. While there was a sharp increase in the incidence of deaths due to enteric fever from 111/100,000 in 1873 to a peak of 579/100,000 in 1882, thereafter it decreased to below 50/100,000 in the late 1890s, and dropped further in the 1930s to below 20/100,000.11 One serious remaining problem was lack of proper accommodation for the disposal of human excreta. Since 1894, a number of public latrines Figure 7.1  Deaths from typhoid fever per 100,000 population, 1874–1936

Source:  Colonial Surgeon’s Annual Report or Medical Officer of Health Annual Report, 1874–1936; Hong Kong Sessional Papers or Hong Kong Administrative Reports, 1874–1938.

162  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

had been erected in different parts of Hong Kong, especially in places such as the Central Market and the Slaughter House, where large numbers of men were employed. In 1900, ten public laundries were built and managed by the Sanitary Board.12 Chinese houses had no latrines, except for a handful of wealthy homes, and night soil continued to be disposed of manually until well into the 1980s, when all of the older buildings had been rebuilt or rehabilitated, and water closets installed.

Housing—A Health Issue Too Resumption of Tai Ping Shan District Governor Robinson set up a Housing Committee to determine what to do with the area in Tai Ping Shan that he had cordoned off, after declaring its houses unsanitary for human habitation. In 1894 half of the cases of plague arose from this area, where 417 old, dark, badly drained, and poorly ventilated houses occupied only 6.25 acres.13 The Housing Committee recommended that the government should resume possession of the land and compensate the property owners14—costs that came to HK$763,000 once the arbitration process was completed. The houses in this area were demolished and cleared, streets were re-marked, and lanes were set aside for public use (Figure 7.2). Drains and water mains were constructed before the lots were sold and houses rebuilt.15 Instead of putting all the resumed land up for auction, Governor Blake sensibly allocated one open space in the most crowded area of Tai Ping Shan for a public garden. Despite the cost, the Colonial Office could see the wisdom of implementing this proposal.16 This first public garden for the Chinese was named after the Governor—Blake Garden.

Unsanitary Dwellings The Sanitary Board returned some of the houses that it had closed outside Tai Ping Shan during the epidemic to their owners. Others remained closed, and vigorous debates followed as to what constituted an unsanitary dwelling.17 In 1896, Governor Robinson ordered a commission to further define and classify unsanitary properties, and to determine the full extent of the problem.18

P lague : A B reeding G round for I mprovements in P ublic H ealth   |   1 6 3

Figure 7.2  Tai Ping Shan resumption, houses leveled and streets remarked

Photo courtesy of Hong Kong Museum of Medical Sciences

After inspecting many houses, the commissioners concluded 19 that only 18% of the Chinese houses could be considered in good, sanitary condition. It classified unsanitary properties into four general categories: 1) back-to-back houses; 2) houses fronting on narrow streets that were less than 15 feet in width, with ground floors cubicles that should be disallowed; 3) houses with insufficient open spaces in the rear; and 4) houses abutting the hillside. If legislation to improve lighting and ventilation to render these houses sanitary were enacted, the commissioners stated that it would not be necessary to resume a large number of houses. The commission found two levels of overcrowding: 1) overcrowding in dwellings—the occupation of a domestic dwelling by a greater number of persons than the floor space and cubic feet allowed by Ordinance 15 of 1894 (not less than 300 cubic feet of air space or 30 square feet floor space per person); and 2) overcrowding of dwellings or “surface overcrowding”—too many houses built on a small area. There were 7,042 Chinese dwellings with 18,800 floors in the city, with an average of 23 persons per house. Assuming the dimension of a Chinese tenement was 40 × 15 feet and each house had two floors, each person had about 50 square feet of floor area. But many dwellings

164  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

accommodated three or four times that number. While only 745 Chinese houses were found to be overcrowded—mostly in divans and common lodging houses—surface overcrowding existed to an alarming extent in the city, far greater than the most densely populated districts in any other metropolis then. After deliberating on the commission’s findings, the Sanitary Board drafted a unanimous recommendation: an Insanitary Properties Ordinance to reduce the degree of surface overcrowding in the city. This ordinance, sanctioned by the Legislative Council in 1899, would make it possible for the energetic Francis Clark, the first Medical Officer of Health in Hong Kong, to close a number of unsanitary properties within a short period of time.20 The fight to clean up overcrowded and unsanitary houses was still far from over, and when Chadwick returned for the third time in early 1902, he found the degree of overcrowding in the city even worse than the first time he had visited twenty years ago. In 1901, the population in Hong Kong was 283,975, with only 9,560 non-Chinese. The average number of persons per acre had increased from 117 in 1897 to 129 in 1901. In the Tai Ping Shan district, population density had multiplied from 400 per acre in 1882 to 700 per acre in 1901. Of the Chinese population, the majority, 178,810, lived in the City of Victoria, with the kind of overcrowding that breeds squalor and disease. Chadwick proposed that the floor space allowed for each person should be increased from a level of no less than 30 to 50 square feet.21 Beginning in 1887, bills were proposed to reduce overcrowding and to correct the design of Chinese dwelling houses, but resistance, especially from landowners, was fierce. Chadwick had suggested that the only way to reduce overcrowding and the number of unsanitary properties was to resume possession and reconstruct these areas extensively.22 The unofficial members who sat on the Legislative Council would likely vote against such a costly move, since the government would have to pay full market price for the resumed land, and the subsequent construction of sanitary buildings would require further investment to recoup the value of the land. Chadwick warned darkly, “no amount of external sanitation would absolutely avoid the recurrence of epidemics, so long as a large proportion of the dwellings were unsanitary and overcrowded.” During Chadwick and Simpson’s visit in 1902, a fire destroyed 40 houses in an area below the Tai Ping Shan area. They saw their chance, and immediately proposed

P lague : A B reeding G round for I mprovements in P ublic H ealth   |   1 6 5

that the governor resume the burned area and rebuild more sanitary houses.23

The 1903 Public Health and Buildings Ordinance Chadwick and Simpson drafted a comprehensive bill at the request of Governor Blake, the Public Health and Buildings Ordinance, in the hope that it might obviate the need for further sanitary legislation for the next few years. On 27 July, 1902 the Bill was read for the first time in the Legislative Council, but was quickly withdrawn because it had no provision for compensation.24 A revised ordinance was re-introduced in October 1903, and it included an outline of principles for compensation. Several compromises still had to be made before this ordinance was enacted by the Legislative Council. One of them was the reduction of the standard, from 50 square feet of floor area and 600 cubic feet of air space to be provided for each adult as recommended by Chadwick and Simpson, to 30 square feet and 400 cubic feet respectively. It had been calculated that if Chadwick and Simpson’s standards were applied, about 50,000 people would be displaced. As there were no empty houses in Victoria to receive the displaced population, the ordinance would have become untenable, without the government stepping in to provide public housing on a huge scale. Another compromise related to the abolition of windowless cubicles in existing buildings, because structural changes necessary to comply with this regulation proved to be impossible in most of the buildings.25 In the ensuing decades, because of a continual influx of refugees fleeing from political instability on the mainland, regulations concerning buildings in the Public Health and Building Ordinance of 1903 had to be relaxed again and again, as there was no commensurate increase in the housing supply.26 In Hong Kong, overcrowding remained a kind of Gordian knot, bound up with the rapid, continual increase in population, the scarcity of land, the engineering difficulties, and the high cost of site formation for the erection of buildings on Hong Kong’s steep hillsides. Even though the part of Kowloon south of Boundary Street had been ceded to Britain under the Convention of Peking in 1860, it remained largely undeveloped. The area was used by British troops for military defence, and by civilians who had means and leisure for hunting. The rest of Kowloon and the

166  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

New Territories that were leased to the British for 99 years remained semirural well into the 1950s. Housing development in Kowloon did not take place until after the turn of the twentieth century, when the KowloonCanton Railway, the Kowloon Wharf, and later the Kai Tak Airport were constructed. At first the houses built on the Kowloon Peninsula were much less crowded, but it too became congested after the Second World War, as another influx of refugees poured in. With Hong Kong housing left to the private sector, the mismatch between supply and demand led to astronomical rents for terrible accommodations. In Chinese tenement houses, for example, many families of up to seven or eight lived in cubicles without windows. It was only in the aftermath of the fire in Shek Kip Mei during Christmas of 1953 that the government finally decided to address the problem of overcrowding and unsanitary dwellings by providing public housing for workers and low-income groups.

Reorganization of the Medical Department The plague of 1894 led not only to the reorganization of the Sanitary Board, but also to the reorganization of the Medical Department, and later, indirectly, to the founding of the Bacteriological Institute and Chinese Public Dispensaries. After repeated complaints of a shortage of medical staff from the Colonial Surgeon, Governor Robinson appointed a committee of five members, chaired by Deputy Inspector General Mr. T. H. Knott, to investigate the workings of the Medical Department. The department’s staff at that time consisted of the Colonial Surgeon, Superintendent, and Assistant Superintendent of the Government Civil Hospital, Health Officer of the Port, Inspector of Immigrants, and Surgeon of the Gaol. Although there were nominally five medical officers in the Colony, the Health Officer of the Port and the Surgeon of Gaol were private practitioners who worked part-time for the government, and were unable to help during the plague epidemic. Medical staff coverage was grossly inadequate for an epidemic, and certainly not for the plague epidemic of 1894.27 After the enquiry, the committee recommended the appointment of a Medical Officer of Health, attached to the Sanitary Board and

P lague : A B reeding G round for I mprovements in P ublic H ealth   |   1 6 7

independent of the Medical Department, to advise on the formation of policies consistent with those in place in England. Governor Robinson, realizing the importance of having someone with special training in sanitary science, followed the Medical Committee’s recommendations and appointed Dr. Francis Clark as the first Medical Officer of Health in Hong Kong—a significant step because this was the first time that the government formally recognized the importance of public health. The Governor recommended that the Medical Department have at least five full time doctors, a principal civic medical officer and four assistants, to undertake medical as well as sanitary work. The post of the Sanitary Superintendent could be dispensed with and his salary used to hire an additional physician if circumstances warranted the change.

A Sanitary Board in Need of Cleansing Except during the plague epidemic, when the real work was performed by a permanent committee, the Sanitary Board was better at talking in circles than at deciding on courses of action. Dr. Ayres had complained about the long, rambling discussions that usually went nowhere at the board’s fortnightly meetings. Whenever it appeared that the mercantile community and the general public would be seriously inconvenienced, the Sanitary Board would relegate the issue to the future for further consideration. 28 It was inevitable that the Sanitary Board would be criticized and even blamed for the unsanitary conditions that led to the plaque epidemic of 1894. The Chamber of Commerce was also dissatisfied with the board’s lack of effective administration.29 The Sanitary Board consisted of four officials: the Surveyor General, Registrar General, Captain Superintendent of Police, and Colonial Surgeon, and six unofficial members, four of whom (two being Chinese) appointed by the governor, and two elected by ratepayers. Thus the board had an unofficial majority and an elected element. The board depended entirely on government funds. It had no real power because any bylaws that it proposed had to be sanctioned by the Legislative Council before they could be enacted. Mr. Francis, the chairman of the permanent committee of the Sanitary Board and an unofficial member, had resigned after the 1894 plague. When Governor Robinson appointed Dr. Francis Clark as Medical

168  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Officer of Health and placed him on the Sanitary Board, other leading unofficial members also resigned, protesting the appointment of yet another official member. By 1895 the board was in a state of collapse.30 Governor Robinson thought that the Sanitary Board had been a failure and should be abolished, and that a stronger sanitary authority with real executive power was required. Although abolishing the Sanitary Board would eliminate the only elected representation, Robinson believed that the Legislative Council would be able to respond to the community’s wishes on sanitation and related matters.31 Joseph Chamberlain became the Secretary of State for the Colonies in 1895, and agreed with Robinson that the government should have direct control over sanitation. Before the Sanitary Board was abolished, he wanted the Legislative Council to have the opportunity to debate the issue. More interested in health than his predecessors, Chamberlain was concerned that combining the two departments, Medical and Sanitary, might reduce the number of medical staff too far. He had other duties in mind for the Medical Department, including the regular inspection of all non-governmental hospitals, provision of medical services in Kowloon, and training of local Eurasian nurses to work under the English nurses.32 Robinson conducted a plebiscite among members of the Imperial and Civil Services in the British community, and was surprised to find that 331 voted for an unofficial majority and only 31 for an official majority to serve on the Sanitary Board. Even then, Robinson insisted on setting up a Sanitary Board consisting of only government officials, but Chamberlain disallowed such a move, as it would remove ratepayers’ input on public spending. The European ratepayers, who were responsible for generating a significant portion of the government’s revenue, and yet had no input in the policy of the government, had demanded the creation of a municipal council during the constitutional reforms of Bowen’s administration in 1883–1885. Bowen had rejected the proposal, given that the vast majority of ratepayers were Chinese (647 vs 83), it would be all but impossible to prevent the Chinese from outvoting the Europeans on issues such as sanitation, water supply, and police, when their views were different from the Europeans.33 In the end the Sanitary Board’s constitution remained unchanged, and the Medical Officer of Health, Francis Clark, became the Sanitary Board’s chief executive officer. He was to be entirely independent of the control of the Medical Department—a model similar to that in England.34

P lague : A B reeding G round for I mprovements in P ublic H ealth   |   1 6 9

The 1903 Organization Chadwick and Simpson also addressed the constitution of the Sanitary Board in their draft of the Public Health and Buildings Ordinance in 1902. They advocated that the Sanitary Board be chaired by a Sanitary Commissioner, who should be the head of the Sanitary Department and have expertise in sanitation, though not necessarily trained in medicine. Such an appointment would seek to prevent haphazard improvisations of emergency measures and the need to enlist untrained men during an epidemic. The unofficial members of the Legislative Council strongly opposed assigning great powers to a Sanitary Commissioner rather than to the Sanitary Board, and considerable changes had to be made before the 1903 Public Health and Buildings Ordinance was enacted. In its final form the ordinance did not mention a Sanitary Commissioner and the governor was given power to appoint both the chairman and the vice-chairman of the Sanitary Board. Faced with an unexpected large deficit in 1902 instead of a surplus, as in previous years, Governor Blake objected to appointing a Sanitary Commissioner. He had no wish to increase expenditures for sanitation and the commensurate increase in taxation necessary to cover it.35 Governor Blake asked Dr. J. M. Atkinson, the Principal Civic Medical Officer (retitled Colonial Surgeon), who had both a medical degree and a diploma of public health, to take over the administration of the Sanitary Department. Justifying that the interests of the Colony would be better served by bringing the medical and the sanitary services under one administration, the Principal Civic Medical Officer would become the ex officio president of the Sanitary Board and the head of the Sanitary Department. Although Simpson was comfortable with Atkinson taking up such a position, he requested that Atkinson be relieved from most of his clinical duties in order that he could give sufficient attention to sanitary matters. He also warned that, in the future, another Principal Civic Medical Officer might not have the necessary qualifications to be in charge of sanitary matters.36 In 1903, the Sanitary Board handed over the administrative control of the Sanitary Department to the Principal Civic Medical Officer.37

170  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

The 1908 Reorganization The 1903 administrative arrangement did not last long. It was heavily criticized by the press for its handling of the 1903 Public Health and Buildings Ordinance. There were complaints about officers entering houses during daytime hours without warning, and even into women’s quarters, and about irregularities of contractors striking bargains with inspectors and clerks of the Sanitary Department.38 To investigate these allegations, Governor Nathan appointed a commission comprised of wealthy merchants, who were all unofficial members of the Sanitary Board.39 It is puzzling that the Governor should appoint members of the Sanitary Board as commissioners—a clear case of conflict of interest. Although the commissioners were charged with inquiring into the workings of the Public Health and Buildings Ordinance, as well as corruption in the Sanitary and Public Works Department,40 they devoted part of their investigation to the 1903 Public Health and Buildings Ordinance itself, which was outside their mandate. They ignored the Public Works Department and focused instead on the workings of the Sanitary Department. The commissioners found widespread corruption among the subordinate staff in the Sanitary Department, and brought formal charges against 14 British inspectors. Five were convicted and dismissed from their jobs, while the charges against the remainder were dropped because of insufficient evidence. There were complaints of harsh administration of the sanitary laws by the sanitary staff, but no specific instances were brought forward. The report came out when Dr. Atkinson was on leave, and it disturbed him greatly. He criticized it as unjudicial, often vague, overly sweeping, and not based on evidence. He regretted that the whole staff had been stigmatized because some inspectors had demeaned themselves by accepting bribes. Atkinson had been overwhelmed by the demands of his clinical work at the Victoria Hospital, where he was the only clinician,41 and it is hardly surprising that he had overlooked irregularities in the Sanitary Department, having administrative responsibilities of two relatively large departments while singlehandedly heading a hospital. In 1908, a cadet officer was appointed as the Head of the Sanitary Department, and ex officio president of the Sanitary Board, accountable to the governor for the expenditure of the funds voted by the Legislative Council. The Sanitary Department, supervised by the Medical Officer of Health, became the executive arm of the Sanitary Board.42 For the next

P lague : A B reeding G round for I mprovements in P ublic H ealth   |   1 7 1

three decades, the Sanitary Department was divorced from the Medical Department, and the Sanitary Board had little medical input.43 Medical officers, despite their efforts to become involved, were unable to enforce sanitation rules, and they confined themselves to dealing with the sick and running the government hospitals.

The 1936 Scheme and Creation of the Urban Council In 1929, Dr. A. R. Wellington became the first Director of Medical and Sanitary Services. A public health expert with previous experience in Asia, Dr. Wellington was also appointed to the Legislative Council and became the official advisor to the government on all matters of public health, medicine, and sanitation. In 1930 he proposed that all government public health activities other than scavenging, conservancy, and public works be placed under the control of the Director of Medical and Sanitary Services. The plan was referred to the Sanitary Board, but it still took several years before reorganization finally took place in 1936. The Sanitary Board was replaced by the Urban Council, with an expanded range of services. The Medical Department and the Sanitary Department were combined, with the Director of Medical and Sanitary Services taking over responsibilities for the urban health officers, the veterinary surgeons, and the sanitary inspectors, as well as becoming the vice-chairman of the Urban Council. The responsibilities of the Urban Council, Medical, Sanitary, and Public Works departments were clearly defined. 44 The Medical Department assumed responsibilities for the operation of government hospitals and dispensaries, inspection of Chinese and subsidized hospitals, bacteria research, detection and control, quarantine and prevention of diseases, registration of births and deaths, vaccination programs, venereal disease clinics, school health program, and first-aid centers.45 The Sanitary Department benefited greatly from medical input in creating and implementing vital public health policies in Hong Kong.

Bacteriological Institute The Bacteriological Institute is a major legacy of plague, and provided a great impetus to public health development in Hong Kong. After several years of having a surplus in his budget, the forward-looking Governor Sir

172  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Henry Arthur Blake (Figure 7.3) created the Bacteriological Institute in 1901. Tired of depending on metropolitan experts, Blake had wanted a bacteriologist to carry out research on plague and other infectious diseases in Hong Kong, and was prepared to build a bacteriological institute for this purpose.46 The job description for the bacteriologist, accordingly, had an important investigative component—most unusual in a resource- and cash-strapped colony that had only primitive facilities for medical care. Dr. Patrick Manson, who Figure 7.3   became a medical advisor of the Governor Henry Arthur Blake Colonial Office, enthusiastically suppor ted this proposal. He fo u n d a p r o m i s i n g yo u n g investigator, Dr. William Hunter, to be the bacteriolog ist, who astutely requested the most upto-date equipment for research.47 The equipment, salary, and travel expense came to the relatively large sum of HK$40,000, which the governor hoped to cover with the estimated surplus of HK$47,000 in 1902. The Hong Kong Leg islative Council did not quibble about any expense needed for prevention of the Wikimedia Commons photo plague. Arriving around the same time as Simpson and Chadwick in 1902 and assisting them with the investigation of plague in rats, Hunter began his remarkably productive but short career in Hong Kong. He supervised the construction of the Bacteriological Institute. Completed in 1906, it boasted four laboratories on the top floor, an animal house for making vaccines, and a dormitory for the staff. The clinical work included postmortem examination of all the bodies in the public mortuary to determine causes of death, bacteriological examination of clinical samples sent to the institute, and regular examination of the quality of water and milk. The institute was the place to examine all the rats collected daily by rat catchers for the plague bacilli, and it also produced vaccines against smallpox, cholera, and other infectious diseases for local use when necessary.48

P lague : A B reeding G round for I mprovements in P ublic H ealth   |   1 7 3

The Chinese would not allow postmortems unless required by law, but Hunter was performing 1,600 to 1,700 autopsies each year, an average of about five each day. Where did the bodies come from? The Chinese, who associated death with bad luck, had dumped bodies on the streets or in the harbor. During the epidemics of plague, to avoid being isolated as contacts and to prevent houses from being disinfected, ill people without relatives were being thrown out onto the streets and left to die, or their bodies were simply dumped after death. From April to September 1907, Hunter, who was charged with determining the cause of death and to exclude foul play, performed autopsies on 874 “dumped” bodies. Table 7.2 shows the prevalence of the causes of death in Hong Kong that year according to those findings. Since causes of death were based on autopsy findings for the first time in the history of Hong Kong, they are presented here, even though the figures are likely to be biased, as the postmortem examinations were carried out on a non-representative population sample. Table 7.2  Number of postmortem examinations from April to September 1907 Causes Number (%) General 364 (41.6) Local 233 (26.7)   Nervous system 6 (0.7)   Circulatory system 10 (1.1)   Respiratory system 180 (20.6)   Digestive system 32 (3.7)   Genitourinary system 5 (0.6) Death by violence 46 (5.2) Miscellaneous (still births, decomposed bodies) 231 (26.4) Total 874 (100) Source:  W. Hunter, Report for the year 1907, in Lugard to Elgin, 12 October 1907, CO 129/341 #258, 464–540.

Hunter divided the causes of death into general and local, and as expected, the majority died from infection. During that year, there were two epidemics, smallpox and plague, which accounted for most of the deaths in the “general” disease group (Table 7.3). Among the “local” disease group, infection also appeared to be the major cause of death; for example, deaths from respiratory diseases (N=180) were due mostly to bronchopneumonia and pneumonia (N=145), and tuberculosis (N=11)— conditions due to infection.49

174  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Table 7.3  Deaths from general diseases, from April to September 1907 Causes Number 112 Marasmus* Small pox 77 Plague 59 Beriberi 49 Tuberculosis 26 Malaria 20 Septicemia, pyema 17 Diphtheria 1 Measles 1 Syphilis 1 Cellulitis 1 Total 364 Note:  * The term marasmus had been used for almost any cause of death. Hunter probably used the term when he was unable to find the cause of death, since he did not have the benefit of a clinical history of these “dumped” bodies. Source:  W. Hunter, Report for the Year 1907, in Lugard to Elgin, 12 October 1907, CO 129/341 #258, 464–540.

Dealing day after day with rats, dead or alive, and their fleas, must have been gruelling work. During those same six months, 23 of the 19,500 rats examined had plague bacilli. These examinations were carried out by graduates of the Hong Kong College of Medicine. With the arrival in 1906 of Dr. C. M. Heanley, an assistant bacteriologist, the work was extended to include examination of rat fleas. Heanley found Xenopsyllax cheopis pulex irritans, the species that carry the plague bacillus, on the rats. During his brief career in Hong Kong, Hunter completed several research projects in addition to his clinical work. In 1905, three years after arriving in Hong Kong, he published four original articles and three case reports. The original studies included plague in cats, probably contracted from devouring infected rats; the incidence of diseases in Hong Kong; the spread of plague by insects; and the prophylaxis and prevention of plague.50 Although this output may seem modest to us today, one must take into account that he started from scratch—from supervision of the building of the laboratory, and had also taken on a very heavy clinical load. To accomplish what he did, he must have worked long hours, day after day.51 Despite his high profile position, Hunter’s temporary appointment

P lague : A B reeding G round for I mprovements in P ublic H ealth   |   1 7 5

needed to be renewed every three years, and did not seem to be leading to the permanent position that he had been hoping for after his first five years. With publications in prestigious journals, the Lancet and the British Medical Journal, his work was beginning to gain recognition at home. His Certificate of Laboratory Instruction for those trained in this laboratory received recognition as fulfilling the conditions for the Diploma of Public Health from some universities in England,52 and by the Committee of Management in the Colonial Office.53 It must have been devastating for him to learn that even his reappointment was in question, in part because Blake had been replaced by Governor Matthew Nathan, who had less interest in health issues.54 Hunter’s appointment was finally renewed, but he died suddenly shortly after, in 1909, at only 35 years of age. The cause of death was not revealed. The telegram from Governor Lugard to the Colonial Office was terse and cryptic: “Regret to inform you of the death of Hunter Bacteriologist.”55 Hunter’s death remains a mystery to this day.56 We might question the wisdom of hiring a young, promising investigator in such an unsophisticated place as Hong Kong then, and the denial of a permanent position after he had proven himself against all odds. It is possible that his special status within the Medical Department, with facilities and a mandate for research, earned him few friends among government medical officers such as Lowson, who complained of having to work up to 18 hours a day during the plague without the opportunities for research that might bring honor and glory. Blake had great foresight in founding the Bacteriological Institute, which was not only a government laboratory for routine work, but also a place for research and public health work. The Bacteriological Institute remained until after World War II, at which time its name was changed to the Pathology Institute. The institute continued to provide public health services in the prevention of diseases, surveillance program for plague and other diseases, vaccine production, and good quality water and milk for the community. In 1960 the Pathology Institute was relocated to a new facility at Sai Ying Pun Polyclinic, but vaccine production continued at the old building site until 1970s. The building was declared a protected monument in 1990 and was turned into a museum under the auspices of the Hong Kong Medical Sciences Society in 1996. (Figure 7.4)

176  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Figure 7.4   Hong Kong Museum of Medical Sciences, previously the Bacteriological Institute

Photo by author, 2014

The Chinese Public Dispensaries Towards the latter part of the nineteenth century it became clear in Britain that the control of epidemics depended on public health measures, and that birth and death records with causes of death were needed to estimate the extent of diseases, as well as the effects of preventive measures. From there it was a short step to recognizing the implications of Hong Kong’s lack of proper registration records for births and deaths. The early roots of the establishment of the Chinese Public Dispensaries can be found in response to the problem of an excessively high infant mortality rate in Hong Kong, a problem that the Secretary of State for the Colonies pointed out to Governor William Robinson in 1892. Hong Kong lagged behind other colonies such as Ceylon and the Straits

P lague : A B reeding G round for I mprovements in P ublic H ealth   |   1 7 7

Settlements, where registration of births and deaths were already in place, and causes of death readily available.57 Wanting to avoid scaring the Chinese, and spending as little of his scarce resources as possible, Governor Robinson proposed a gradual approach—first obtaining accurate causes of death from Tung Wah Hospital and the two convents,58 and later from the Chinese communities. His scheme to introduce such registration, which was proposed by Dr. Ayres, involved the government’s hiring of licentiates from the Hong Kong College of Medicine to work in various dispensaries located in different parts of Hong Kong. Their primary responsibility would be to obtain causes of death and to issue death certificates, and their secondary responsibility would be to provide free Western medical treatment to patients. The licentiates, who became the Chinese Medical Officers responsible to the Medical Officer of Health, would be allowed to collect fees from those who could afford to pay. This shrewd scheme of exploiting the cheap labor of the licentiates, who otherwise would not be able to practice medicine locally, allowed the government to obtain the necessary information on the causes of death and at the same time be able to provide medical services to a large section of the community at almost no expense. The outbreak of plague in 1894 interrupted the implementation of this proposal. Interestingly, in 1905, the scheme was carried out by the Chinese elite, not the government. The motivation was not primarily the registration of births and deaths as originally planned, but a response to the public health problem created by the growing abandonment of dead bodies on the streets, caused by fear of intrusion of Sanitary Department staff for cleaning and disinfection. Two Chinese members of the Sanitary Board, Fung Wa-chun and Lau Chu-pak, working with the blessing of the Registrar General, approached Tung Wah Hospital for permission to open two offices under their auspices. Each was staffed by a licentiate of the Hong Kong College of Medicine, who saw sick persons and dispensed treatment. In the case of a dead infant, the licentiate would obtain permission to remove the body to the office to ascertain the cause of death before proper disposal and the family received one dollar as a reward. A similar office was opened in Kowloon City by the district elders and was well supported by the community.59 Soon after their establishment, these offices severed their connection with Tung Wah Hospital and called themselves Chinese Public

178  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Dispensaries. A central committee of nineteen people was formed to take over all responsibilities of the dispensaries, while local committees were established to manage each of the dispensaries located at Yaumati, Hung Hom, and Kowloon City. In 1907, two more dispensaries were established in the City of Victoria: the West Point (or Western) and the East Point (or Eastern) Dispensary.60 The expense of building the dispensaries and their operation came from the Chinese elite. The Registrar General paid the doctors and other dispensary personnel, in addition to the rents of buildings out of an annual HK$2,000 grant. The local committees were responsible for purchase of drugs and other miscellaneous expenses.61 The work of these dispensaries was twofold: 1) medical work carried out by doctors—treating patients in the clinic, referring them to a hospital for further treatment when necessary, issuing death certificates, arranging for collection and burial of corpses, and vaccinations; and 2) educational work performed by the local committee with the assistance of many “street committee men,” well-known in their own neighborhoods, who would discourage their neighbors from “dumping” bodies. These men also disseminated knowledge about the close connection between rats and plague, and distributed thousands of rat traps for the Sanitary Department. Their garnering of the cooperation of the mass of the population made wholesale poisoning of rats possible.62 The Chinese Public Dispensaries are a great success story, and the number of cases they treated increased dramatically over the years: in 1908 there were 24,353 new cases seen in the six dispensaries, and by 1911 the number of cases treated had already climbed to 68,566.63 The educational program turned out to be popular and effective, and the number of dead bodies dumped declined markedly, from 1,068 in 1905, to 268 in 1910.64 During the summer of 1911, the Chinese Public Dispensaries Committee employed sanitary workers to visit houses in the Central District to stop all rat-runs with cement and glass. Through public health measures such as the introduction of Western methods of hygiene to impoverished Chinese to prevent outbreaks of infectious diseases, the work of the dispensaries likely contributed to the final disappearance of plague epidemics. The dispensaries eventually became popular outpatient clinics, providing free Western medical services for people across the social spectrum. With Western-trained midwives attached to them, these clinics offered maternal and infant services which helped reduce the unacceptably high infant mortality (see

P lague : A B reeding G round for I mprovements in P ublic H ealth   |   1 7 9

Chapter 8). After the Second World War, the government took over all the Chinese Public Dispensaries, operating them as public outpatient clinics.

Other Lessons from Plague Epidemics The highly effective public hygiene education program did not stop with the role served by the Chinese public dispensaries, but also included the Colony’s general education policy. Governor Blake helped integrate hygiene instruction into the school curriculum. To make it more appealing to the students, there was a hygiene competition among schools every year.65 To ensure quality instruction, some teachers from the schools received hygiene training from England.66 One of the most lasting effects of the plague was a shift in awareness—of the government, and of those in the Chinese and British communities as well. The plague epidemics forced the government to realize, however belatedly, that it could no longer ignore the local population, and must take them into account with respect to its policymaking. People also recognized the extent to which the Chinese and the British communities were interwoven. The well-being of the Europeans as well as the wealthy Chinese depended on the labor of the low-income group, who in turn needed jobs. The government learned that education and persuasion carried out by the locals themselves was much more effective than drastic legislation or repressive measures. Recognizing that the sanitary measures served their own interests, not just the interests of Europeans, most Chinese became more compliant, and the twice a year “Cleaning up the Environment” campaign became a custom that continued well into the first decade after the Second World War. To their surprise, the Europeans discovered that the Chinese were not a dirty race: the free public baths were always full of people enjoying the luxury of fresh water. As Chadwick had said, “It was unjust to condemn them as a hopelessly filthy race till they had been provided with reasonable means for cleanliness. It was the duty of the government to see that the means were provided for.” Once the government got serious about sanitation, when the sewers were properly connected and working well, when water closets became mandatory, Hong Kong’s “Chinatown” no longer emitted the pungent smell that ruined its reputation. Public education, courses of hygiene in schools, and reliable and regular

180  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

scavenging and refuse removal services led to cleaner streets and a cleaner environment for everyone to enjoy. Just as severe outbreaks of cholera launched sanitation out of the Middle Ages in England fifty years earlier, the horrific outbreaks of plague propelled sanitary reforms and public health in Hong Kong into the modern era.

8. Women’s Medicine: Maternal and Infant Health

By the time the twentieth century was underway, the colonial administration had realized that the colony’s closeness to China meant that its fortune was inextricably bound with what was happening in the mainland. China became a republic in 1912. After the First World War, the Chinese were angry, feeling betrayed by the Allies, with whom they had sided during the war, but who had then turned around and transferred the rights of Germany in the Shandong Province to Japan. This betrayal unleashed swells of protests by students, workers, teachers, and other urban intellectuals across China on 4 May 1919. 1 The outpouring of nationalism that swept through China leapt across the border into Hong Kong, manifesting as strikes and boycotts. Although the First World War did not adversely affect Hong Kong’s trade, the strikes and boycotts in the decade following the 1919 protests certainly did. During a protest against the killing of a Chinese worker by a Japanese foreman, and students by British police in Shanghai, British soldiers killed Chinese workers in Shameen (now Shamian) when they left Hong Kong on foot. The ensuing strike and boycott lasted over one year, and led to the collapse of the economy.2 From then on, instead of taking native workers for granted, the colonial administration knew they had to deal with them directly in the future to prevent similar confrontations.3 The government also felt sufficiently pressured to start spending a higher percentage of its revenue on social services such as education and medical and sanitary services, to improve the quality of life for workers. After the First World War the attention to social services was also fed by a certain kind of humanitarian zeitgeist in Europe, where several organizations had been established to improve social welfare and health, especially of indigenous people in the colonies. Across the ocean in Britain, social reformers, such as Mrs. C. Neville-Rolfe, were concerned with prostitution and venereal diseases in the colonies as well as at home. Her report on venereal diseases and their control in Hong Kong ultimately

182  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

led to the abolition of extralegal regulation of prostitution (though not of prostitution per se). She also reported on the high infant mortality and highlighted the primitive status of public health in the Colony. National organizations such as the National Council for Combating Venereal Diseases, international organizations such as the League of Nations, and the British home government, all exerted pressure on Hong Kong government to improve the health of indigenous people. The most glaring deficit in the health care system, made obvious by exceedingly high infant mortality rates, was the lack of medical services for women and children. Women’s issues were rising in the public’s consciousness, even in China, where prior to the twentieth century Confucian thought had relegated women to an inferior role, shuttering them in the household, and poor parents sold their daughters as mui tsai to “adoptive” parents who treated them like servants, at times selling them into prostitution. The birth of the Republic of China was bringing changing social values. While the thousands of missionaries, who had come to China after the First Opium War with the opening of treaty ports, had made few inroads with their agenda of Christian conversion, they had nevertheless greatly influenced Chinese cultural attitudes toward women. They saw education of women and abolition of foot-binding as the key to emancipation of women in China. They formed anti-foot-binding societies to eradicate a practice that kept women completely under the control and at the disposal of men.4 The missionaries’ concepts of individuality, equality, and humanitarianism challenged traditional Chinese cultural denigration of females.

Medical Services for Women and Children in the Nineteenth Century Until the late nineteenth century there were no provisions or facilities for medical care for Chinese women, for childbirth, or for infants in Hong Kong. More well-off European women were attended to by their private physicians or midwives in their own homes, and poor European women used the Government Civil Hospital. Chinese women did what they had done since ancient times, having their confinement at home attended by their older female relatives or by traditional Chinese midwives, wan po. With no formal education, a wan po would learn midwifery and delivery

W omen ’ s M edicine   |   1 8 3

from an oral tradition that was passed down from one generation to another, and from attending childbirths with another wan po.5 Like their counterparts in the West before the late nineteenth century, they knew nothing about sepsis as a cause of maternal and infant mortality. Towards the end of the nineteenth century, however, some facilities for medical services for women, including Chinese women, were beginning to open up in Hong Kong. As early as 1884, Colonial Surgeon Dr. P. B. C. Ayres had noted that a few Chinese women being brought into the Government Civil Hospital died in labor after Chinese midwives had made unsuccessful attempts to treat them.6 He suggested that women in difficult labor should be attended at the Tung Wah Hospital by doctors of Western medicine, not at the Government Civil Hospital, which had no space or staff to deal with them.7 In 1890, Ayers finally introduced confinement beds at the Government Civil Hospital, hiring a Chinese nurse trained at the Missionary Hospital in Guangzhou. In April 1897, a maternity hospital annex was added to the Government Civil Hospital, and in that year there were 20 confinements with three deaths—Chinese women who were admitted in moribund condition, reluctant to go into such a hospital until they were at death’s door.8 When the Alice Memorial Hospital opened in 1887, sponsored by the London Missionary Society and the Chinese elite, it had a ward of 19 beds set aside for women. The pressure for more beds led to the establishment of the Nethersole Hospital in September 1893, which had 35 beds for women and children. Although some Chinese women were admitted for confinement, the number was very small.9 Until the twentieth century, having a baby could be a dangerous affair for a woman not only in China, but indeed in any part of the world. The estimated maternal mortality rates in England, for example, for 1,000 live births were 10.5 in 1700–1750, 7.5 in 1750–1800, and 5.0 in 1800–1850.10 Mothers could die from a number of causes: puerperal pyrexia (fever following giving birth), which usually starts 3 to 10 days after giving birth; severe bleeding before, during, or after giving birth; or convulsions due to toxemia.11 Even a woman who did survive the ordeal of childbirth could easily lose her baby in its first year of life, as the rate of infant mortality in Europe ranged from 100 to 250 per 1,000 births before 1900.12 In Hong Kong, infant mortality rates among Chinese were strikingly worse than those of Europeans. In 1885, 31% of all deaths among the

184  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Chinese were infants under the age of one, while among the Europeans, the number was 9.9%.13 Accurate data on births and deaths were not available at that time, even though the Colonial Office had requested as early as 1867 such data from the whole population in Hong Kong. The colonial administration had been cautious about pushing this agenda for fear of arousing suspicion among the Chinese, who had defied any type of registration—and also, as might have been expected, because of the government’s reluctance to spend the money to set up the infrastructure for registration.14 The high infant and maternal mortality rates would have remained unchanged for Chinese women if it were not for the foundling scandal that rocked Hong Kong in the late nineteenth century.

The Foundling Scandal, 1886 In November 1866, J. H. Stewart Lockhart, the acting Registrar General, found that infant deaths from the two local convents, one French and one Italian, were shockingly high; an average of 92.5% and 79.8% respectively from 1880 to September 1886.15 Dr. W. Hartigan, who investigated the problem for the Sanitary Superintendent, found that 69% and 50% of the deaths in respective convents were caused by tetanus neonatorium (convulsion). The other common causes were fever, “consumption,” and diarrhea. Hartigan’s account of the conditions of the Tai Ping Shan area where the infants came from describes the filth and neglect that the infants were left in: … anyone who has visited the Chinese dwellings in that locality will know the abominable state of dirt, want of ventilation and overcrowding in which the natives live…. Always filthy, generally puny, their cloths saturated with soil and stinking; their bodies emitting a horribly fetid odor, which is without exaggeration … overpowering; their eyes filled with purulent discharge, their foreheads, cheeks and abdomen seared with the cauterizing cash [sic]; the umbilicus, if attached, smelling foully and bathed in foetid pus, or if detached, giving out a dirty greying purulent discharge; the genitals and anus inflamed and most with muco-pus, whilst eczematous eruption spreads over the nates.16

W omen ’ s M edicine   |   1 8 5

It is hard to imagine that any infant could have survived in those horrid conditions. Hartigan also reported cramped quarters of convents where the wards were ill ventilated, too cold in the winter, and suffocating in the summer. An overpowering odor arose from the cots, where several infants would be lumped together. In the orphanage, the children were exposed to unhygienic conditions almost as bad as the ones they had been rescued from, not through any fault of the nuns, but because of lack of resources. Some infants were already dead by the time they were brought in; others, half dead, died shortly afterwards. Dr. O’Brien examined these children in the convents and had established that nothing could be done to save them. Dr. Ayers testified that the infants he saw were so malnourished and close to death that they were virtually hopeless cases. The low survival rate of 10% for infants in orphanages was comparable to the survival rate of infants in European orphanages. Ayers also commented that he found many dead, abandoned infants, mostly female, on the hillside, who likely did not even make it as far as the convents.17 The investigation cleared the convent sisters of all suspicion of wrongdoing, but this incident highlighted the high infant mortality rates, and it also raised the specter of female infanticide, an association that Westerners frequently made with Chinese culture at that time.

Questioning the Morality of High Infant Mortality Dr. Clark, the first Medical Officer of Health, reported that 20% of the total deaths in 1896 were infants under one year old. Among the nonChinese, the infant mortality rate was reported as 147/1,000 registered live births while among the Chinese it was 745/1,000.18 The high mortality rate among the Chinese was probably overestimated because many Chinese did not comply with the 1872 ordinance for registration of births and deaths. If they registered at all, it would usually be after the infant had reached one month of age, according to the traditional Chinese custom, and mostly for boys, not girls. To correct for the under-reporting of births, a revised calculation for infant mortality factored in those who were registered at birth plus the number of dead infants under the age of one month from the convents, along with those collected by the police from the streets and the harbor. Table 8.1 shows that from 1895 to 1906, the number of infant deaths under the age of one year was higher than the

186  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Table 8.1  Births and infant deaths (under age of one year) per 1,000 births in Chinese and non-Chinese 1895–1906 Non-Chinese Chinese Infant Infant Infant Births Births N * deaths N deaths/1,000 N corrected deaths N

Infant deaths/1,000**

Year

Births N

1895

232

27

116

1,195

2,000

1,519

759

1896

285

42

147

978

1,515

1,069

745

1897

243

29

120

1,125

1,582

938

593

1898

243

34

139

963

1,605

1,012

630

1899

204

26

128

852

1,501

1,273

848

1900

261

32

122

678

1,485

1,378

928

1901

240

31

129

848

1,410

1,261

894

1902

234

46

196

966

1,569

1,115

796

1903

285

31

108

749

1,244

1,038

832

1904

263

20

76

942

1,514

1,137

784

1905

301

36

119

988

1,728

1,501

872

1906 293 46 157 1,028 1,614 1,577 979 Note:  * Corrected—registered number of births plus the number of infants of one month old and under that died in the various convents or were found by the police in the streets or in the harbor; ** The number of corrected births was used in the calculation. Source:  Medical Officer of Health, Report to the Sanitary Board, Hong Kong Sessional Papers, 1896 to 1907.

total number of births before correction in most years—a clear indication that a large number of births was unregistered.19 Despite such corrections, the calculated Chinese infant mortality remained far too high. When Clark looked for the cause of the disparity in mortality rates of infants between the Europeans and Chinese, he ended up pointing his finger at the unscientific methods that the traditional Chinese medicine (TCM) practitioners were using. On many dead infants, he often saw tell-tale burn marks all over the heads, arms, and legs, a common remedy used for treating fever and diarrhea by the Chinese. He considered these signs physical evidence of malpractice, and called for the prompt removal of TCM practitioners.20 Clark also targeted Chinese wan po and argued for legislative control over them in 1895 when twelve deaths from puerperal fever were reported. Clark recommended the registration of all Chinese midwives

W omen ’ s M edicine   |   1 8 7

and TCM practitioners in the colony. He even drafted the bill, but it was never presented on the advice of the Registrar General, who sought the opinion of Ho Kai and Wei Yuk, two prominent unofficial Chinese members of the Legislative Council. Claiming that the bill was premature, the legislators urged instead the government to start a training school for local midwives,21 because the 14 midwives qualified in Western methods at that time could not possibly meet the demand. Again, cost was a factor. Wan po charged 50 cents to HK$1, while fees for midwives who used Western methods ranged from HK$5 to HK$15. If forced to pay such fees, most Chinese would have to do without any assistance whatsoever. Despite Clark’s efforts, no action was taken and a training school for midwives was not started. The Colonial Office also noted the high infant mortality in Hong Kong, but took no action. Clark did not give up. In 1900, he observed that the infant mortality rates had soared to 928/1,000, and although this unbelievably high rate was most likely due to unregistered births, Clark blamed Chinese parents for their neglect, and even invoked the horror of infanticide: The Chinese unfortunately do not regard infanticide as a crime, and it can hardly be expected therefore that they will appreciate the criminality of this neglect of our infant population, unless it is occasionally brought home to them by the strong arm of the British law.22 As patronizing as Clark sounds here, his reference to “our infant population” suggests that the attitude in the colonial administration was changing. Clark pressed again for registration of Chinese midwives. He also wanted to have the 1896 Births and Deaths Registration Ordinance amended to allow for postmortem examinations in any cases where the cause of death was not certified. The Chinese members of the Legislative Council, who considered the idea of postmortem examinations anathema, strongly opposed the bill. As usual the press seized upon this story of disaster with glee. Ignoring the statistical bias in Clark’s report, the Daily Press hailed Clark’s report as “a fearless, unexaggerated, dispassionate and impartial record of unremitting honest effort.” In highly colored language that recalls Social Darwinism, the journalist claims that Clark’s figures gave “clear proof that the pinch of poverty combined with the stress and aggravated intensity of the fierce struggle for bare existence has practically annihilated what little

188  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

altruistic sense Chinese parents possess, even in respect of male infant lives. The figures given are appalling in their dread eloquence, and seem almost incredible.”23 British cultural, moralistic judgments in the late nineteenth and early twentieth centuries viewed this high infant mortality rate as an index of social evil.24 Once the story appeared in the British press, the colonial government was under pressure to act.

Development of Medical Services for Women 1903 Enquiry into the Causes of Infant Deaths In 1903 Chamberlain, the Secretary of State for the Colonies, responded by requesting an enquiry into the causes and possible remedies for the high infant mortality. 25 The committee of six 26 that Governor Blake appointed reported in March of the following year that about 50% of the infants died of trismus or lockjaw, 33.8% from marasmus attributed to malnutrition, unhealthy, and overcrowded Chinese dwellings. The other infants died from respiratory disorders and convulsions.27 Trismus usually starts from the third to the fifth day after birth, when the infant gives up sucking and its cry becomes muffled and feeble. On the sixth and seventh day, their jaws become clenched together and no food can be given by mouth, owing to the rigidity of the muscles of the jaw. Any stimulus will induce the child into convulsions, and death occurs soon after. Trismus is now known to be due to tetanus bacilli infection and most cases arose from applying a sealing-cord powder to the umbilicus. Chinese tradition held that the navel is the “gate of life,” a site of interaction between internal fetal poison, derived from the mother, and external influences. It was believed that the navel should be kept warm and dry using a sealing-cord powder (Figure 8.1); the most simple form was composed of burnt ashes of red cotton cloth, finely ground cow’s dug or human hair, rouge and dragon bones, but more common ingredients were earth or manure.28 In 1926, Dr. C. Y. Wang found that 8 out of 121 samples of sealing-cord powder contained live tetanus bacilli. He advocated the prohibition of the sale of sealing-cord powder and education for mothers regarding the proper dressing of the cord.29

W omen ’ s M edicine   |   1 8 9

Figure 8.1  A package of sealing-cord powder

Photo courtesy of Hong Kong Museum of Medical Sciences and donor Mr. Keith Poon Note:  Sealing-cord powder for applying to the navels of newborns. Some powder might be contaminated by tetanus bacilli.

The committee recommended education in basic hygiene of infant rearing for the poor Chinese people, as well as more systematic registration of births and deaths. They also suggested that since most Chinese women were reluctant to go to the Nethersole Hospital for their confinement, however desirable, a free maternity charity should be established to allow poor people to be attended to in their own homes. The committee also suggested the incentive of a HK$2 bonus to encourage mothers or midwives to register births within one month. Furthermore, they said that female visitors should be employed and paid HK$2 to verify the accuracy of each registration. Convents should register each child admitted, and a proper death certificate be issued for each death therein. Each police station should keep a register of births and deaths so that midwives need not travel long distances just for the purpose of registration. After the inquiry, the question of training Chinese midwives was addressed. Of the 33 Chinese midwives who were practicing in Hong Kong in 1904, only 6 used Western methods of delivery. The Colonial Administrator, F. H. May, suggested that money would be better spent training Chinese midwives at the soon-to-open Alice Memorial Maternity

190  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Hospital, than it would by paying midwives and female visitors to report births. An annual training program for six Chinese midwives was launched in 1904. As the demand for trained midwives grew, it became necessary to open a larger school.30 In 1911, a new addition to the Alice Hospitals, a training institute for nurses and midwives, which could accommodate up to 24 students, was established at the Alice Memorial Maternity Hospital behind the Ho Miu Ling Hospital.31

Hospitals for Women and Children As more women started using hospital facilities, the Alice Memorial and Nethersole Hospitals were terribly overstretched, and as the Government Civil Hospital was also flooded with far too many patients, there was a pressing need for a hospital that could treat women and children— including the Chinese majority. When public proposals to commemorate Queen Victoria’s Diamond Jubilee in 1897 were solicited, a favored proposal came forward for a hospital for women and children. The need was obvious.32 The Victoria Jubilee Hospital (Figure 8.2) was not planned as a maternity hospital, but attached to it was a proposal for a training institute for private nurses—much in demand by Europeans—who were required to have midwifery qualifications. The hospital would be under government control and open to “all ranks, classes, creeds and races.”33 Two sites were considered: one close to the Sisters’ Quarters at the Government Civil Hospital, and the other above Bonham Road. In the end, the Victoria Jubilee Hospital was erected in 1903 on Barker Road, the Peak, where Chinese were forbidden. Even though contributions to the Jubilee fund came from Her Majesty’s loyal Chinese subjects, Chinese women were left out in the cold. It is hard to say how the decision came about, or whether people raised objections; presumably Chinese women were not expected to go to a hospital staffed by European male doctors offering Western medicine. Admittedly, Chinese women continued to distrust Western medicine, especially when delivered by European male doctors. It would take a Western lady doctor, Dr. Alice Sibree, to popularize the Western method of delivering babies among Chinese women.

W omen ’ s M edicine   |   1 9 1

Figure 8.2  Victoria Jubilee Hospital for women and children

Wikimedia Commons photo

The Lady Doctor and the Changing Paradigm of Maternal Care Dr. Alice Sibree’s story and the establishment of Alice Memorial Maternity Hospital, provide a window into the struggle of women in the medical profession at that time. The Chinese elite recognized that the only way to give their women the benefits of Western medicine was to have a woman doctor, even if she was a European. When the prominent Chinese member of the Legislative Council, Ho Kai, was asked for help, he went into action. Within one month he had collected HK$8,500 from his friends, enough to build a maternity bungalow. Chinese subscribers placed a condition on the use of the fund—a lady doctor must be appointed to look after the hospital’s maternity patients. Politics immediately came into play during the long negotiation, and as is so often the case, the primary question was one of money. Would it be the London Missionary Society or local subscribers who would pay the salary of the lady doctor? Dr. R. M. Gibson, who had succeeded Dr. T. Burton as the Medical Superintendent of Alice Memorial Hospital and Nethersole Hospital in 1897,34 took every opportunity to increase its

192  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

power.35 In 1898 he dissolved the hospital committee, which consisted of Ho Kai, the medical staff, and the missionaries. The committee members did not raise any objections, and afterwards Gibson and the London Missionary Society District Committee ran the hospital.36 Unable to work with local doctors who attended the hospital on an honorary basis, Gibson proceeded to discontinue their services. As a result he was constantly overworked, having to look after all the patients in two hospitals himself. Gibson suggested that the London Missionary Society and local Chinese subscribers share the expense of the lady doctor’s salary equally, but at that time the society wanted local district committees to be responsible for their own funding and administration. The Chinese subscribers finally guaranteed the whole salary, a sum of HK$2,000 per annum, on two added conditions—that she be available to treat the wives of the subscribers in their own homes, and that she learn Cantonese during her first year, so that she could easily introduce Western health care and hygiene to Chinese women. Since Gibson had his own missionary fervor about bringing Western medicine to more Chinese in Hong Kong, he was obliged to accept the Chinese subscribers’ conditions—as much as he disliked the idea of having a lady doctor working in the Alice Hospitals. Alice Memorial Maternity Hospital (Figure 8.3) opened in 1904, 37 Figure 8.3  Alice Memorial Maternity Hospital

Photo courtesy of Alice Ho Miu Ling Nethersole Charity Foundation

W omen ’ s M edicine   |   1 9 3

and the lady doctor, Dr. Alice Sibree, arrived to take charge. Having graduated from the University of Edinburgh, she was well trained in general medicine and in diseases of women and children. She had the qualifications that the London Missionary Society District Committee had outlined in its terms of appointment: training in midwifery, and diseases of women and children. Other terms of appointment included: willingness to attend to cases in their own homes, to train native women in Western methods of delivery; to work exclusively among women and children; and to act under the Medical Superintendent. The terms defined not only her duties, but also her subordinate role under Gibson.38 When the London Missionary Society in London asked questions, Gibson’s reply was glib. He said that he did not think the lady doctor was a subordinate and that she should have the full status of a missionary.39 It was unclear on what basis Sibree agreed to the appointment, but these terms remained a source of friction in her relationship with Gibson for the duration of her five year contract. Sibree, whose father was a missionary, was well connected in the hierarchy of London Missionary Society. Although her annual reports to London suggested that she gradually acquired more work, privately she complained to the Joint Foreign Secretary of Society that she was often left idling. On average there were only about 1.5 deliveries a week, and the women in Chinese subscribers’ families did not request her services.40 She was excluded from any general medical work in the Alice Memorial and Nethersole Hospitals.41 Whether they were doctors, students, or patients, the Chinese would not accept a female doctor.42 Gibson, who seemed to have subscribed to the general prejudice at that time that women’s health was inferior to men’s, did not even permit her to work at a Sham Shui Po clinic, citing her health as a reason, even though Sibree was perfectly healthy.43 When Gibson could no longer withstand the pressure that was coming from London, he reluctantly allowed her to run two weekly clinic sessions for women and children. Women were denied access to clinical training at the University of Edinburgh in the 1870s. Although they finally gained access to clinical teaching, they were then barred from graduation. The Lancet constantly attacked the efforts of women to become doctors, and when the British Medical Association decided to exclude female practitioners in 1878, an editorial on 17 August exposed the predominant male sexist view of the role of women:

194  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Again “the woman question” in relation to the practice of physic and surgery, is forced upon us by the wise decision of the British Medical Association to exclude female practitioners … the gracelessness of the passion which a well-meaning but misguided young woman assumes when she undertakes the practical study of medicine, and waiving the question of female personal and social disabilities for the vocation of physician and surgeon, there is the all-important issue of natural and constitutional fitness … the ministry of women is one of help and sympathy. The essential principle, the key-note of her work in the world is aid; to sustain, succour, revive and even sometimes shelter, man in the struggle and duty of life, is her peculiar function. The moment she affects the first or leading role in any vocation she is out of place … If women undertake the duties of physicians and surgeons, we shall presently feel the want of nurses….44 Feeling rusty with medicine and unhappy with her lack of work, Sibree wanted to return to England to be married before the end of her five year contract. However, when Ho Kai and Ts’o Seen-wan, who were responsible for raising the funds for her salary, suggested that she should take over the maternity work at Tung Wah Hospital and remain in Hong Kong, she decided to stay.45 During the remainder of her contract term, maternity work in Alice Memorial Maternity Hospital increased steadily, and in 1909 she and her trainees delivered 235 hospital births and 1,381 domiciliary births.46 Sibree was also responsible for the midwives training program at Alice Memorial Maternity Hospital, supervising government midwives who carried out deliveries in Hong Kong, Kowloon, and the New Territories. She also acted as the medical officer of Po Leung Kuk.47 The government midwives program for domiciliary deliveries allowed Sibree to advise mothers on nutrition and general care of babies during the first year of life. By 1907, three years after the program had started, there were six government midwives attached to the Chinese Public Dispensaries, and they attended to 578 confinements.48 As Sibree became more fluent in Cantonese she was able to reach out to the Chinese ladies, rich and poor alike, in their own homes and actively engaged in missionary work. She networked so successfully within the

W omen ’ s M edicine   |   1 9 5

Chinese and medical communities that by the end of her contract term she had become quite busy, and the Chinese elite had been won over. They demanded that the next lady doctor should be on the regular staff of the Alice Hospitals, acting as visiting surgeon to Po Leung Kuk, and, if necessary, to take charge of female patients under Western treatment at the Tung Wah Hospital.49 Sibree returned to Hong Kong a year later, but not to the Alice Memorial Maternity Hospital. 50 After leaving the London Missionary Society, Sibree was married in 1910 to Mr. C. C. Hickling (Manager of Taikoo Sugar Refinery). She set up a private practice and became the supervisor of government midwives, despite Gibson’s objections. Although he wanted her in the Alice Memorial Maternity Hospital, she chose instead to develop maternity service in secular settings: Wan Chai Maternity Hospital and Tsan Yuk Hospital. She became the Acting Medical Officer of Health and the Assistant Medical Officer in charge of Chinese hospitals in 1918.51 In 1919 she was awarded a MBE (Member of the Order of the British Empire) for her wartime services. Sibree’s conflict with the patriarchal Gibson, which the community was well aware of, must have proven quite stressful at times. Although Gibson positioned himself as “protective” of the so-called weaker sex, it is obvious now, as it was to many then, that he was defending the expansion of his medical mission, and primarily his own role and prospects in the future Hong Kong medical school. Bound by her upbringing as a daughter of a missionary, not to mention her own gender conditioning, Sibree was unable to directly confront the irascible Gibson. Instead, she took her complaints directly to her pastoral support at the London Missionary Society. Her detractors, the London Missionary Society District Committee, charged her with lack of initiative and adaptability, yet once she left the Society, she was able to achieve her full potential as a medical doctor. The discord between Gibson and Sibree that led to her resignation resulted in discontinuity of maternity services in the Alice Hospitals after 1909, and secular agencies filled the gap. Although two female doctors served brief stints at the Alice Hospitals, it was another 16 years before the London Missionary Society was finally able to find a long-term replacement in Dr. Annie Sydenham, who supervised maternity services at the Alice Hospitals until her retirement in 1954.52

196  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

How Chinese Public Dispensaries Nurtured Two Maternity Hospitals The Wan Chai Maternity Hospital was established by the Chinese Public Dispensaries Committee, which sponsored nine dispensaries in different parts of Hong Kong and Kowloon. Although these were set up initially to encourage registration of births and deaths and to discourage the dumping of bodies, the free outpatient clinics for the poorer Chinese turned out to be extremely popular. They quickly became places where not only dead infants were brought in, but also live infants for treatment. In 1907, 2,721 children under 5 years of age were brought in with various problems for therapy, and by 1911 that number had nearly tripled to 7,892.53 Western medicine was clearly becoming more widely accepted. A committee of nineteen members working closely with the Registrar General managed the Chinese Public Dispensaries. One of the members was Ts’o Seen-wan, who joined Ho Kai and Wei Yuk as leaders of the Chinese community upon his return with a law degree from England.54 In 1910, he became a member of the Chinese Public Dispensaries Committee and was elected chairman of the Western Public Dispensary in 1911. Ts’o took a kindly interest in the career of Sibree, whose medical expertise impressed him. He was also astonished by her ability to speak Cantonese so soon after her arrival, while Gibson and most of the other Western doctors had never managed to master the language. When Sibree returned in 1910 to start her private practice, she proposed that a maternity hospital be built with midwifery training, as the six training places in Alice Memorial Maternity Hospital were far from adequate. Her proposal was turned down as the government had already committed to the establishment of the Training Institute for Nurses and Midwives at the new Alice Memorial Hospital. In 1919, Ts’o and the Chinese Public Dispensaries Committee started an experiment, converting the Wan Chai District Plague Hospital into a maternity hospital as there were very few cases of plague. Ts’o invited Sibree to take charge of the hospital—an excellent decision, as even in its first year the hospital handled 194 cases.55 Sibree continued to administer the hospital until her untimely death in 1928. Buoyed by the success of the Wan Chai Hospital, the Chinese Public Dispensaries Committee asked the government to grant a piece of land

W omen ’ s M edicine   |   1 9 7

for a larger venture in the more congested area of Sai Ying Pun, adjacent to the Western Dispensary. 56 The Registrar General enthusiastically supported this proposal, and after a successful fund raising campaign through which Ts’o raised HK$20,000 from the local community, Tsan Yuk (Encourage Birth) I Un (Hospital) was opened on 17 October, 1922. It could accommodate 28 patients and had living quarters for nursing staff and six trainee midwives. The hospital also organized a training school for Chinese midwives. While Sibree gave part-time support, the rest of the hospital staff was Chinese. Tsan Yuk was the first hospital practicing Western medicine where the most senior staff—the doctor in charge, Dr. H. Y. Chiu, and the matron, Miss S. C. Leung—were Chinese. Patients in the general ward paid a fee of 20 Hong Kong cents per day while those in private rooms were charged HK$1 to HK$2.57 By the end of its first year Tsan Yuk had handled 436 cases, while the Wan Chai Maternity Hospital handled 814 cases, indicating that the Chinese community appreciated such services and that there was increasing demand for them. Figure 8.4  Queuing up in front of Old Tsan Yuk Hospital at Western Street

Photo courtesy of the Department of Gynecology and Obstetrics, The University of Hong Kong

As Tsan Yuk Hospital is situated in one of the most densely populated areas in Hong Kong, it was always full (Figure 8.4). The hospital worked closely with the kaifong Committee and various guilds from the Western part of the island, which had donated generously to the building of the hospital.58

198  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Modernization of Women’s Medicine The training of midwives had resulted in some improvement in infant and maternal mortality rates which, nevertheless, remained high towards the end of the 1910s. In 1922, the Rockefeller Foundation agreed to endow three professorships; medicine, surgery, and obstetrics, at the University of Hong Kong.59 Because of the poor facilities for obstetrical care in the Government Civil Hospital, the chair for obstetrics was not endowed until 1924, when 25 beds for obstetrics were made available at the Government Civil Hospital. R. E. Tottenham, the assistant master of the renowned Rotunda Hospital in Dublin,60 was appointed as the founding chair of obstetrics in the University of Hong Kong. He transferred his teaching base from the Government Civil Hospital to Tsan Yuk Hospital in 1926, where, at the invitation of Sibree and Ts’o Seen-wan, he rearranged and modernized according to the model used by the Rotunda Hospital. Tottenham introduced forceps delivery and Caesarean section for women with difficult labor due to vaginal stricture or eclampsia, and conducted research into the common causes of maternal mortality in Hong Kong; eclampsia and beriberi complicating pregnancies.61 Tottenham retired after 10 years, by which time his work had led to lower maternal mortality rates (0.4% in 1934), and admissions to the Tsan Yuk Hospital had climbed steeply. Instead of being dreaded, Western medicine for women became a necessity for Chinese women.62 Tottenham was succeeded in 1935 by a brilliant young doctor, William Nixon, who resisted protests from nursing staff and introduced incompletely milled rice into the diet of pregnant beriberi patients in Tsan Yuk Hospital, and cured the disease. Despite his short term of only two years, Nixon revolutionized women’s medicine in Hong Kong by founding the Eugenics League, later renamed the Family Planning Association, which provided local women with contraceptive means to space their pregnancies in order to improve family health. He also promoted antenatal care and monitored blood pressure of women during pregnancy to reduce eclampsia.63 Nixon was followed by Dr. Gordon King who contributed a great deal not only to women’s medicine in Hong Kong, but also to the survival of the medical school during the war. Tsan Yuk Hospital became a center for teaching and pioneering research in women’s diseases. By 1933, Tsan Yuk Hospital had grown too large to be operated

W omen ’ s M edicine   |   1 9 9

by the Chinese Public Dispensaries Committee, a voluntary agency, and the committee offered the hospital as a free gift to the government. This was a timely move for the government, taking over a highly functional hospital that had been successfully promoting maternal and child health in the community. In recognition of how generously the Chinese elite had contributed to medical services in Hong Kong, as well as the hospital’s value as a training ground for students of medicine, nursing, and midwives, the government decided to take over the hospital unconditionally.64 The government’s contribution to medical services for Chinese women and children had been minimal to that point: a grant of HK$2,000 for all the dispensaries, and financial support for training of six Chinese student midwives at the Alice Memorial Maternity Hospital. Taking over Tsan Yuk Hospital, with an annual budget of HK$20,000, represented the first time that the government became financially responsible for an institution purely for the Chinese.

More Institutions with Maternity Services As noted above, the government employed six midwives, trained in Western methods, attached to the six dispensaries to provide for domiciliary services. In 1924, the midwives in different parts of Hong Kong, including the New Territories, delivered 869 babies. The Tung Wah Hospital and Kwong Wah Hospital, which was established in Kowloon in 1911, began to provide maternity services in 1919, as Chinese women increasingly used hospital settings for their confinement. By 1922, there were 1,734 confinements in the two hospitals. St. Paul’s Hospital, founded by the sisters of St. Paul de Chartres, had 10 rooms for maternity cases, and private hospitals such as the Hong Kong Sanatorium and Hospital and the Matilda Hospital also provided maternity beds. Table 8.2 shows the number of hospital beds in Hong Kong for maternity cases in 1936.65 There were six antenatal and infant welfare centers: Government Infant Centers in Wan Chai and Kowloon, Tsan Yuk Hospital Infant Centre, Tung Wah Hospital Infant Centre, Alice Memorial Hospital Centre, and Military Infant Centre. That year the center in Wan Chai handled a huge caseload of 24,618 attendances, while the one in Kowloon had 18,000.

200  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Table 8.2  Number of maternal beds in Hong Kong in 1936 Sponsoring agency Government

Name of institution No. of beds Government Civil Hospital 21 Victoria Jubilee Hospital 26 Kowloon Hospital 34 London Missionary Society Alice Memorial Maternity Hospital 12 Chinese Public Dispensaries Wan Chai Maternity Hospital 31 Tsan Yuk Hospital 46 Tai Po Dispensary 5 Tung Wah Group of Hospitals Tung Wah Hospital 24 Kwong Wah Hospital 59 Tung Wah Eastern Hospital 14 Private Matilda Hospital 8 Hong Kong Sanatorium and Hospitals 6 War Memorial Hospital 6 French Mission St. Paul’s Hospital 9 Canossian Mission Canossa Hospital 2 St. John Haw Par Hospital in Cheung Chau 34 Ambulance Association and also in other parts of Hong Kong Total 337 Source:  Medical and Sanitary Department Report of 1936, Hong Kong Administrative Reports, 1936, M67.

Women’s Medicine—Women’s Domain? In the late nineteenth century, as the position of women had begun to shift in Chinese society, influenced in part by the widely publicized suffragette movement, women began claiming the right to be educated and to participate politically. Chinese families began to allow their daughters to pursue education and career. Nursing and midwifery seemed ideal choices, since these occupations, focused on women and children, were socially acceptable. The Alice Memorial Hospital had begun to train Chinese girls in nursing as early as 1891, and very soon thereafter, training programs were established in other hospitals. The Nurses Registration Ordinance, passed in 1931 in Hong Kong, legitimized this career by professionalizing it.66 With the establishment of maternity hospitals and maternity units in different hospitals, training of more midwives became necessary, and programs began in the Tsan Yuk Hospital, Tung Wah Hospital, Kwong

W omen ’ s M edicine   |   2 0 1

Wah Hospital, and Tung Wah Eastern Hospital and Government Civil Hospitals separately. There was no shortage of Chinese girls who wished to take up midwifery as a career. The government’s support of Tsan Yuk Hospital followed on the heels of the decision to admit female students to the University of Hong Kong in 1922. Eva Ho Tung, daughter of Sir Robert Ho Tung was the first female medical graduate in 1927. 67 Administrators had finally come to understand that there had been much wasted human capital in the Colony, and that now it was time to invest. Young women could channel their energy into productive work as professionals. Professionalization of midwives by registration took place in 1910. The Midwives Ordinance of 1910 stipulated that “No one whose name is not on the Midwives registrar may practice midwifery habitually for gain or describe herself as one specially qualified to carry on the work of a Midwife.”68 Unless the girls had already completed a course in general nursing, training in midwifery meant studying for two years to qualify for an examination, practice observation, and learning new skills, not simply absorbing through osmosis what had been passed down through the generations. The traditional Chinese midwives, wan po, were permitted to practice only until 1937, at which time it would become illegal for them to continue without registration. By 1938, the total number of midwives on the register had climbed to 765 when another 250 wan po signed up.69 By 1941 the traditional freelance midwives could no longer practice in Hong Kong. In 1930, all midwives had to receive training when they learned, among other things, about antisepsis, which had been shown to reduce puerperal fever. They also had to spend one month living with a government midwife in an outlying center. In 1940, government midwives attended 3,704 births mainly in the outlying areas and in domiciliary settings.70 The increasing professionalization of obstetrics and gynecology led to much better training of doctors and nurses in the field of midwifery and maternal and child health. In 1941 there were 17 women doctors, of whom 12 were graduates of the University of Hong Kong. With few other options, these women gravitated towards obstetrics and gynecology practice in the pre–Second World War years. Women’s medicine in Hong Kong was brought about by men such as Ho Kai and Ts’o Seen-wan, who were responsible for the founding of the Alice Memorial Maternity

202  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Hospital and the Tsan Yuk Hospital respectively, and advanced by men such as Professors Tottenham, Nixon, and King, who modernized Tsan Yuk Hospital, adapted Western methods for local use, and reduced maternal and infant mortality before the Second World War. It was only in 1957 that women’s medicine came into the women’s domain when Professor Daphne Chun, a Hong Kong University graduate and the first Chinese woman doctor, became the head of the Department of Obstetrics and Gynecology at the University of Hong Kong, followed by her successor Professor Ma Ho-Kei, who became world recognized for her research in gynecological oncology, especially gestational trophoblastic diseases.71 As we look back at the question of the high maternal and infant mortality rates that had catalyzed many of these improvements in maternal and infant medical care, we may wonder what was accomplished in measurable terms before the Second World War. Did the growing medical services for mothers and infants improve the chances for any given infant to live into adulthood? The answer is a definite yes, but with qualifications. Accurate data on population statistics and maternal deaths from child birth were not available before the Second World War. Due to a combined actual increase from the ever blooming population and an apparent increase in registration of births, records show that the crude birth rate per thousand population increased from 4.2 in 1908 to 34.9 in 1938. From 1929 to 1939, rates of Chinese infant mortality showed a progressive decline from 663 to 335 per 1,000 live births (See Chapter 10, Table 6; current infant mortality is about 2 per 1,000 live births). While much of the apparent reduction in infant mortality might still be accounted for by better registration of births, actual improvements in infant mortality rates must also have occurred due to better obstetrical care, antisepsis and improved hygiene in home deliveries, together with education of mothers caring for babies. It is not until the introduction of antibiotics after the Second World War that we see a dramatic plunge in maternal and infant mortality rates, but without the infrastructure already in place, the reduction in mortality might not have been that dramatic, even with the use of antibiotics. In summary, the colonial government’s response to high infant mortality in the Chinese was painfully slow in the beginning. Unlike plague, the problem of high infant mortality did not translate into poor economic news for the Colony. Although missionaries introduced

W omen ’ s M edicine   |   2 0 3

Western medicine into China and the Colony, this changing paradigm for Western medicine, including maternal and infant health care, was financially supported for many years by the Chinese elite, and not by the government. The government dragged its feet, fearing provocation of the Chinese population by passing legislation that might trespass on Chinese traditions and customs. Of course it was also concerned with overextending its limited budget. When the Colonial Office pressured it to act, it sidestepped a risk of confrontation with the traditional customs by creating a parallel system of Chinese midwives trained in Western methods. Its decision to take over the management of Tsan Yuk Hospital, however, was uncharacteristically swift. In assuming that responsibility the government was responding to pressure not only from the Colonial Office, but also from the British Parliament and the public. The colonial government’s decision to begin social reforms to reduce high infant mortality signaled a cultural and political shift. The need for effective governance meant that the colonial government had to scrap its old policies of laissez-faire and segregation, and integrate the Chinese in its policies.

This page intentionally left blank

9. The Three Great Killers: Malaria, Smallpox, and Beriberi

In the late nineteenth century, Hong Kong was not haunted only by plague, malaria, and smallpox, beriberi, which masquerades as an infectious disease, was also a major killer. While malaria accounted for 8% to 10% of deaths, beriberi, which was listed among infectious diseases in government annual reports up to the 1920s, accounted for 5% to 12% of all deaths annually, and smallpox killed over 50% of its victims whenever it stuck. With advances in medical science, a fair amount was already known about the etiology of malaria, smallpox, and beriberi, and it is possible to assess the effectiveness of preventative and treatment measures that were put in place in Hong Kong. Tuberculosis, another great killer, accounted for about 10% to 20% of all deaths, but it will not be addressed here, since effective therapeutic agents were not available until after the Second World War.

Malaria—An Ancient Foe Malaria, one of the most successful parasites ever known, has been on the world stage of infectious diseases for a long time. The description of the classical symptoms of malaria can be found in the Neijing, Chinese medical writings attributed to Emperor Huangdi in 2700 B.C.E., in Vedic writings from 1600 B.C.E., and in writings of Hippocrates, who described the characteristics of the disease in the fifth century B.C.E. The name malaria, or “mal air” for “bad air,” was first used in Italy in the seventh century, when the disease was prevalent in the swamps near Rome. Some people believed that the Romans lost their empire to the Visigoths, Huns, and Vandals, because their soldiers were sick with malaria and that malaria shaped the course of history and empires.1 In Africa, millions died from malaria, and those who survived carried it to the New World on slave ships. Malaria made Africa and other tropical countries the “white man’s grave,” conquering many soldiers with imperialistic dreams.

206  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Some treatments for malaria also have ancient roots. A common herb known as qinghaosu was used by Chinese herbalists to treat malaria for more than two thousand years. What is old sometimes does become new again: the earliest recorded use of this herb dates back to 200 B.C.E. in the Fifty-Two Prescriptions unearthed from the Mawangdui Han dynasty tombs, and its anti-malarial use was first described in Zhouhou Beiji Fang (The Handbook of Prescriptions for Emergencies), edited in the fourth century by Ge Hong (265–313 C.E.). Also known as artemisinin, when combined with another anti-malarial drug, qinghaosu is now standard treatment worldwide for Plasmodium falciparum malaria,2 and it provides the most rapid action of all current drugs against the parasite. Long before the malaria parasite was identified, natives of Peru and Ecuador had discovered a potent remedy against these fevers, when they found that the bark of the cinchona tree, when dried and crushed into powder, could provide a “miraculous” cure. When the Jesuit missionaries brought this powder back to Europe in 1632, it became an instant hit. The active compound, quinine, was subsequently identified and successfully manufactured. It was used extensively until the 1940s when it was replaced by other drugs. In 1943, chloroquine was synthesized in the United States, followed shortly thereafter by mefloquine. Although these drugs were effective against the malaria parasite, resistance to them developed. Despite the gains international medical communities have made on many fronts in the fight against malaria, the development of drug-resistant parasites and insecticide-resistant mosquito vectors have thus far made the goal of eradication of malaria unattainable. The signs and symptoms of malaria typically begin eight to twenty five days after a bite from an infected mosquito. The initial symptoms are a flu-like illness followed by headache, shaking, chills and fever, and joint pain. Classically there is a cyclical occurrence of sudden chills followed by shivering, then fever and sweating, occurring every second day (tertian fever) in P. vivax and P. ovale infections, and every third day (quartan fever) in P. malariae and P. falciparum infections. However, P. falciparum infection can give continuous fever, and when there are infections with multiple malarial parasites, the characteristic fever pattern is lost. Severe malaria is usually due to P. falciparum infection, which can cause cerebral malaria, giving rise to convulsions, retinal damage, abnormal postures, or coma. Anemia occurs as a result of hemolysis (lysis of red cells) and hemolytic jaundice can occur. Death results from respiratory failure or renal failure

T he T hree G reat K illers   |   2 0 7

when hemoglobin from lysed red blood cells leaks into the urine, or from encephalopathy from cerebral involvement. Splenomegaly (enlarged spleen) and hepatomegaly (enlarged liver) may also occur. Sickle-cell trait3 and glucose-6-phosphate dehydrogenase deficiency,4 far more common among Africans than any other races, carry protection against falciparum malaria. In 1880 a French army surgeon named Charles Louis Alphonse Laveran, stationed in Constantine, Algeria, was the first to discover the malaria parasite in patients’ blood. It was still unclear how the parasites got into the blood, and it took another nineteen years before Ronald Ross, a British officer in the Indian Medical Service, working with Patrick Manson, was able to solve the mystery of transmission of the malaria parasite. 5 Ross studied malaria in birds and found that mosquitoes, anopheles species, could transmit malaria parasites from bird to bird. In 1899 a group of Italian investigators, led by Giovanni Battista Grassi, demonstrated the complete life cycle of the malaria parasites P. falciparum, P. vivax, and P. malariae, and solved the missing link of transmission of malaria parasites in humans.6 Even though cases of malaria had been reported in China since ancient times, it was not clear whether malaria was endemic in Hong Kong already in 1841 when it was ceded to the British, or whether British soldiers who landed on the island that summer had already experienced malarial fevers when exploring other tropical areas. If so, they should have looked warily at the stagnant pools of water and the swampy areas on the island in the hot summer—perfect breeding grounds to host the mosquito larvae. Although there was a minor epidemic that summer, the severe outbreak of fevers the following summer reduced the population of Hong Kong by 10%, the soldiers in the garrison by 25%. The epidemic of 1842 and of 1843 led to the removal of Western Barracks from Sai Ying Pun to current day Hong Kong Park and the subsequent formation of a “Chinatown” in the Tai Ping Shan district where the poor Chinese aggregated—an area which would become the epicenter of the 1894 plague epidemic due to serious overcrowding and insanitary conditions. While we are now quite sure that the fevers were due to malaria, the etiology was unknown then. Many attributed the fevers to miasma at that time, the result of environmental exposure to gases of decomposing vegetation arising from swamps and marshes. Up to 1888, Colonial Surgeons in Hong Kong reported different types of fever: intermittent

208  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

(tertian), remittent (quartan), and continuous fever in their annual reports; the term malaria was only used from 1888 onwards.7 Having become an endemic disease, malaria was a regular unwelcome summer visitor and its degree of virulence appeared to be related to the amount of summer rainfall. In the late 1880s and early 1890s, the incidence of malaria in the civilian population was around 400/100,000, with a 50% death rate of approximately 200/100,000. 8 The prevalence of fevers, presumably malaria, was particularly high in the Western District, and in 1888, Governor Des Voeux appointed a commission to investigate the etiology of these fevers. The commissioners found that the houses in the Western District stood at the base of a steep hill where there was a large amount of tropical rainfall and no subsoil drainage, a condition conducive to growth of mosquito larvae. The commissioners recommended improving drainage and carrying out excavations only during the dry winter months, as new excavations for housing development were frequently associated with fatal forms of remittent fever. They also recommended reforestation with Blue Gum, a variety of eucalyptus tree from Australia, which grows rapidly and has a drying effect on the subsoil.9 When mosquitoes were discovered to be the vector for the disease, Governor Blake immediately ordered studies of the mosquitoes in Hong Kong. Charles Ford of the Botanical and Afforestation Department carried out the first study in 1899, collecting 185 specimens which he forwarded to the British Museum for identification. Nine different species of Culex mosquitoes were identified, but no Anopheles, the mosquito that transmits the malarial parasites.10 The second study, which began on 1 October 1900, was more systematic. Dr. John C. Thomson obtained the cooperation of the police force to collect 12 mosquitoes each week for one year from each of the 36 police stations in Hong Kong, Kowloon, and the New Territories. He received 31,350 mosquitoes during the year and found that on average, 96.3% of the mosquitoes belonged to Culex genus and 3.7% to Anopheles genus. He identified three species of Anopheles mosquitoes: Anopheles sinensis; and two new species: Anopheles maculatus and Anopheles fatigans, and determined that the distribution of mosquito species was different in various districts. Shek O, Tai Po, Tung Chung, and Lamma had higher percentages of Anopheles mosquitoes than other areas.11 The government used this information to put in place an anti-malaria program which included eliminating the breeding grounds by training

T he T hree G reat K illers   |   2 0 9

(channeling) the water courses in and near the City of Victoria, Kowloon, and the New Territories, especially in locations with a high percentage of Anopheles mosquitoes. A team of sanitary inspectors, foremen, and coolies cleared brushwood, removed water receptacles from wastelands in the neighborhood of dwellings, and poured oil on pools. They also redirected nullahs for proper drainage, and converted ravines into wellpaved nullahs. The government started a hygiene program in schools and a student hygiene competition every year, and the Chinese Public Dispensaries Committee conducted special lectures on malaria prevention in each district. Quinine was also distributed free from the Chinese Public Dispensaries and from schools, for prophylaxis and treatment.12 In 1901, Captain Johnston, who had worked with Ronald Ross, came to Hong Kong and taught the local doctors how to examine blood smears for malaria parasites to make a definitive diagnosis.13 One sanitary superintendent made a recommendation that Europeans could better protect themselves from contracting malaria by keeping a prescribed physical distance from the presumably dirty Chinese. His recommendation was that Europeans build houses at least 400 to 500 yards away from native dwellings—the maximum distance that Anopheles mosquitoes could travel.14 Clearly this suggestion conforms more to his prejudice than to scientific data, and this kind of thinking about the disease reinforced the racial segregation in Hong Kong. More resources were freed up to fight malaria when plague finally disappeared from Hong Kong after 1929. In 1930, the Malaria Bureau, headed by Dr. R. B. Jackson, was established to coordinate all anti-malaria activities in the Colony. While conducting a general mosquito survey of Hong Kong, the bureau investigated the prevalence of malaria and other mosquito-borne diseases: filariasis, yellow fever, and dengue fever, none of which were found then in Hong Kong. With the help of the Bacteriological Institute, the bureau examined blood films for malaria parasites and worked with the Public Works Department to improve drainage throughout Hong Kong. It identified two more species of Anopheles mosquito that were responsible for malaria transmission in Hong Kong, Anopheles minimus and Anopheles jeyporiensis.15 As a result of these measures and continual urbanization, as well as improvements in drainage and the environment, the mortality from malaria in Hong Kong dropped from 203 in 1901 to 35/100,000 in 1937 (Figure 9.1), accounting for 8% to just 1% of all deaths in the respective

210  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

years.16 From 1900 to 1910, many cases of malaria came from the New Territories, mostly associated with the building of the British Kowloon– Canton Railway. When the Railway was completed, the number of malaria cases declined.17 Among the British troops the rate of hospital admissions for malaria also dropped from 256/1,000 in 1906 to 84/1,000 in 1913.18 Figure 9.1  Deaths from malaria per 100,000 population in Hong Kong, 1901–1938

Source:  Medical and Sanitary Reports 1901–1938, Hong Kong Sessional Papers or Hong Kong Administrative Reports, 1901–1938.

Since there were no preventative measures in place during the Japanese occupation, malaria slammed Hong Kong again during the latter part of Japanese Occupation and after World War II. Its severity prompted the government to employ a large scale aerial spraying of dichlorodiphenyltrichloroethane (DDT) in 1946 to kill mosquitoes and flies in certain areas of the Hong Kong, Kowloon, and the New Territories.19 Hong Kong still has about 20 to 40 cases of malaria each year, but most of them are imported. The threat of malaria is far from over on a global level, as after thousands of years it still remains the world’s most pervasive infective agent in at least 91 different countries. Despite many advances in diagnosis and treatment, an estimated 300 to 500 million clinical episodes of

T he T hree G reat K illers   |   2 1 1

malaria, and 1.5 to 2.7 million resulting deaths, occur globally each year. Especially susceptible are children in sub-Saharan Africa and India where insecticide resistance is high.

Smallpox The earliest credible evidence of smallpox is found in the mummies of Egyptians who died around 3,000 years ago.20 From Egypt the disease spread to India, where it was endemic for 2,000 years. In China, one finds the first description of this disfiguring disease in the writings of Ge Hong in the fourth century: Recently there are persons suffering from epidemic sores that attack the head, face and trunk. In a short time they spread all over the body. The sores have the appearance of hot boils containing white matter. While some of these pustules are drying up a fresh crop appears. Patients who recover are disfigured with purplish scars, which do not fade until after a year.21 In Europe, a smallpox epidemic was described as far back as 581 C.E. Waves of European exploration and colonization brought the unwelcome gift of the disease to other parts of the world. It was smallpox, not the Spanish Army, which conquered Mexico for Spain. An epidemic of smallpox from 1518 to 1548 killed 18.5 of 25 million people in Mexico, who had no smallpox immunity, almost wiping out the Aztec civilization.22 There are three forms of smallpox virus which is an orthopoxvirus: Variola major, or true virulent smallpox; Variola minor, or alastrim, a milder form; and Variola vaccinae, cowpox. Long before the discovery of the virus, it was recognized that if a person contracts one of these forms, he or she receives immunity, and at least temporary protection against the other two forms. This method of prevention forms the basic principle of vaccination. Inoculation against smallpox was introduced in China between 1000 and 1100 C.E. Several methods of inoculation anticipated future, much more precise vaccination methods. These included blowing powdered smallpox scabs or placing a pledget of cotton impregnated with smallpox

212  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

scabs into the nose of a child, or wearing the unwashed undergarment of a child with smallpox for 2 to 3 days. Great care was taken to work with material from mild cases so as to avoid a severe reaction, but it was not foolproof, and severe reactions did sometimes occur. These methods of inoculation must have offered a reasonable degree of protection, as they were used for centuries.23 Since the Chinese had been familiar with the idea of smallpox prevention, it did not take long for British physician Edward Jenner’s method to become accepted in southern China in the early nineteenth century. Jennerian vaccination reached China through Dr. Alexander Pearson, a surgeon of the East India Company in 1805, and even before Pearson’s arrival, D. F. X. Balmis, from Manila, had already been vaccinating residents in Macau. Pearson practiced vaccination regularly in Macau and wrote a pamphlet about it, which was translated to Chinese. Pearson initially inoculated children of the poorer class at his own expense. Seeing its high degree of effectiveness, increasing numbers of Chinese were lining up for vaccination, and Pearson needed help. In 1806, he began employing Chinese assistants and training them in the vaccination technique. Pearson’s most celebrated student, Yao Hochun, called A-Hequa by the foreigners (and nicknamed Dr. Longhead due to the extraordinary length of his head), published a most influential book on vaccination in 1817. He drew on the methods described in Pearson’s pamphlet, but he explained them in terms that his readers could easily understand, using the language of acupuncture to name the meridian points on the arm where incisions were to be made. His explanation of pustules as manifestations of liberating “foetal toxin” in children was framed in the terms of traditional Chinese beliefs. He further recommended traditional herbs for care after the scarification. By couching what would have seemed intrusive—making incisions and introducing something foreign into the body—in familiar, traditional concepts and language, A-Hequa helped the Chinese people accept vaccination. He and his descendants made a fortune later, when vaccination became his “family business” for several generations.24 Vaccination was done by arm-to-arm transmission. Problems that might arise from this technique included the risk of loss of potency of the vaccine lymph (the fluid inside the blister of the smallpox lesion), and

T he T hree G reat K illers   |   2 1 3

the risk of transmitting other diseases, such as leprosy and syphilis. In addition, the Chinese often balked at having their child’s lymph removed for fear of the child losing vital energy. Continuous vaccination had to be done throughout the year to obtain fresh lymph. Since the Chinese disliked vaccination in summer and winter months, sometimes the vaccinator ran out of fresh lymph. As stored lymph often lost potency, at times fresh lymph had to be brought in from elsewhere at great expense. There was a sliding scale of fees, as a vaccinator commonly charged a fee of 50 Hong Kong cents or HK$1, while the poor were vaccinated for 10 or 25 Hong Kong cents, and the children who provided the lymph received 25 Hong Kong cents. Sometimes the Chinese vaccinators received sponsorship from local merchants to perform vaccinations for the poor. Unlike areas such as Shanghai, which kept relying on traditional methods of inoculation, a rapid and smooth acceptance of the new vaccination program in the Guangzhou area can be traced to the combined efforts of merchants, Chinese and British, missionaries and native vaccinators.25 In 1828, Jennerian vaccination was also introduced successfully to Beijing. By the time Pearson left China in 1832, his great work was firmly implanted. Figure 9.2  Deaths from smallpox per 100,000 population and the number of vaccinations in Hong Kong, 1901–1938

Source:  Medical and Sanitary Reports 1901–1938, Hong Kong Sessional Papers or Hong Kong Administrative Reports, 1901–1938.

214  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

In Hong Kong, Colonial Surgeons had started reporting smallpox in 1858, but epidemics did not truly begin until 1879. Smallpox became endemic during the latter half of the nineteenth century and first half of the twentieth century, with intermittent epidemics, as shown in Figure 9.3.26 There were only short reprieves, as the epidemics usually occurred in the winter months starting towards the end of the year and carrying on into the summer of the following year. As most of the Hong Kong population came from southern China around the Guangzhou area, and must have heard about vaccination or perhaps even been vaccinated themselves, it is not surprising that a traditional Chinese medicine doctor was hired as a vaccinator at Tung Wah Hospital’s founding. Several vaccinators were later employed as vaccinations grew into the thousands each year. The program became so successful that when Dr. Ayres arrived, he felt that there was no need for him to mount another vaccination program for the Chinese. He only vaccinated the family of civil servants.27 The potency of the lymph for vaccination, which Ayres obtained from Britain, was sometimes lost during the long transit period. Because the supply of lymph was depleted during the 1887–1888 epidemic of smallpox, the Sanitary Board recommended that a vaccine institute be established, overseen by the Colonial Veterinary Surgeon. In the fall of 1890, the government extended the leave of the Colonial Veterinary Surgeon Mr. Ladd in Japan, so that he could learn about methods for cultivating lymph in that country. The following year Governor Des Voeux approved the proposal, and the Vaccine Institute was erected in 1891.28 Ladd used what he learned to successfully produce lymph for smallpox vaccination for local use, and at times there was even enough for export to other countries. In 1906, the Vaccine Institute became incorporated into the new Bacteriological Institute, and in the 1920s, vaccines against typhoid, paratyphoid, and cholera were also produced as well as meningococcal antiserum.29 Since the 1887–1888 smallpox epidemic, nearly all hospitals offered vaccinations, and in 1890 an ordinance was passed to ensure that all infants were vaccinated before they reached six months of age.30 Yet in July 1916, Dr. W. J. Woodman, Acting Medical Officer of Health, was alarmed to notice a large number of smallpox patients. Since cases of smallpox were rare in the summer months, Woodman anticipated a severe epidemic during the coming winter months. He asked the Tung Wah Hospital and the Chinese Public Dispensaries to mount a vaccination campaign as soon as possible. He also communicated with Ts’o Seen-wan, chairman of the

T he T hree G reat K illers   |   2 1 5

Chinese Public Dispensaries, who along with the staff, helped persuade people in the community to comply with Woodman’s requests: that all cases of smallpox be reported to the Medical Officer of Health, and when a case of smallpox had occurred in a house, all inmates of the house be vaccinated, and a notice be placed on the door. The uncomplaining response of the Chinese community to the preventive measures for the smallpox epidemic was radically different from their reaction to the measures imposed for the 1894 plague epidemic. The 300,000 vaccinations carried out during that winter was twenty times that of previous years.31 While there were around 3,000 to 4,000 cases of smallpox, only 1,307 (less than one third) died in the 1916–1917 epidemic.32 All signs pointed to the efficacy of vaccinations. In 1917, among smallpox patients admitted to Tung Wah Hospital, the medical officer found that death occurred in 65.6% of the unvaccinated but only in 5.4% of the previously vaccinated, and among those vaccinated who did develop the disease, it was mild.33 Public health education efforts were bearing fruit. The colonial administration had learned from past experience not to impose public health measures from above without consulting the local Chinese elite for help, as they were respected by the community. The compliance with the public health measures this time around was smoothed by having the support of well-recognized kaifong members, organization of public health education by the Chinese Public Dispensaries, and widespread awareness of the ravaging effects of the disease. Although the most effective measure to eradicate smallpox was prevention through vaccination, it was also necessary to find ways to isolate patients who had contracted the disease in order to keep it from spreading. Over the years smallpox patients had been isolated in several smallpox hospitals, the first one was converted from the Stonecutters Island jail. When the Government Civil Hospital was damaged by a typhoon and had to move to a hotel in 1874, smallpox patients were installed in the undamaged portion of the partly destroyed hospital. In 1879, smallpox patients were housed in an old building on Hollywood Road, and Chinese smallpox patients went to Tung Wah Hospital, which eventually ran out of space for patients with infectious diseases. In 1908, Ho Kai, Wei Yuk, and other members of the Chinese community applied to the government for a piece of land to build a smallpox hospital for the Chinese, near the Tung Wah Hospital.34 In 1910, as the number of plague patients decreased, it was decided to convert the

216  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Tung Wah Infectious Disease Hospital in Kennedy Town into a smallpox hospital, treating patients using TCM. Because the vaccination program had become so effective that the hospital had no patients and had fallen into disrepair by 1935. When a huge influx of refugees arriving from mainland China in 1937–1938 brought another wave of smallpox victims, the now dilapidated Tung Wah Smallpox Hospital was unable to accommodate these patients (Figure 9.3). The government was forced to erect temporary structures in the Government Infectious Disease Hospital to house them.35 Again, vaccination was the main defense. In 1937–1938, over one million vaccinations were administered to the local residents and the refugees from the mainland escaping from the Sino-Japanese War. With the lymph made locally, the vaccination program became more extensive, and after World War II, vaccination campaigns continued year after year as part of the World Health Organization program. When the border between Hong Kong and mainland China was closed, control of epidemics became easier. The last case of smallpox in Hong Kong occurred in 1952, and in 1979 Hong Kong was declared smallpox free (Figure 9.4). Smallpox vaccination was then deleted from the immunization schedule of all clinics and hospitals.36 We can at last celebrate that the efforts of countries united under the World Health Organization have resulted in the eradication of smallpox around the globe. Figure 9.3  Remains of the arch and foundation stone of Tung Wah Smallpox Hospital in Kennedy Town

Wikimedia Commons photo Note:  The hospital was built in 1910 and demolished after the Second World War.

T he T hree G reat K illers   |   2 1 7

Figure 9.4  Declaration of smallpox free status in Hong Kong in 1979

Source:  S. H. Lee, Department of Health. Infectious Disease Surveillance (Hong Kong: Government Printers, 1994), 43–45.

Beriberi Technically, beriberi is not an infectious disease, but its appearance among inmates of prisons, camps, asylum, armies, and ships who shared close quarters gave a false impression that it was contagious. For a long time it was listed in the category of infectious diseases, even after 1906, when Hong Kong’s own bacteriologist, Dr. William Hunter, and others definitively established that it was not.37 This disease, which was very common in Hong Kong before the Second World War, accounted for 5% to 10% of all deaths each year. Unlike familiar nutritional deficiency diseases such as scurvy, pellagra, and rickets, it is the only one that was commonly found in Hong Kong. Beriberi, caused by a deficiency of

218  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

thiamine or vitamin B1, thrived, as most poor Chinese relied on polished rice as their staple food, while vitamin-rich fresh meat and vegetables were only taken in small quantities. Beriberi had been described in medieval Chinese and Japanese medical texts, under the term kakke, and in Europe by Dutch and English physicians in the West Indies from the mid-seventeenth century onwards.38 In his book on tropical diseases, Patrick Manson vividly describes common symptoms of muscle weakness and lassitude often associated with beriberi:39 The visitors (to hospitals in South East Asia) may be struck with the thinness of the patients’ calves, the flabby state of the gastrocnemii, and by the fact that if, whilst making the examination, he should handle these and the neighboring muscles somewhat roughly, the patient may call out in pain and try to drag the limb away … Some are so trifling that they are up and moving about with more or less freedom; others are so severely smitten that they lie like logs in their beds, unable to move a limb or even a finger. Some are atrophied to skeleton; others are swollen out with dropsy and some show just sufficient dropsy to conceal the atrophy the muscles have undergone. The short paragraph above implicitly classifies three types of beriberi patients: the atrophic type, associated with polyneuritis; the “dropsical” form, associated with edema and heart failure, and the third type, a mixture of the two. While the disease could be readily diagnosed based on its classical manifestations, its etiology remained a mystery until the turn of the twentieth century. While Manson saw beriberi as a disease of unknown etiology, there were at that time several theoretical speculations—including the possibility of an infectious cause. However, when Dr. Hunter carried out a meticulous examination on all the inmates of Po Leung Kuk affected by beriberi in 1905, he was unable to find a specific organism or a primary lesion where the microorganism might have entered the body. Experimentally, he failed to induce the disease in healthy animals when he transfused them with large quantities of blood from patients with beriberi.40 Other investigators agreed with his findings. An infectious cause was ruled out.

T he T hree G reat K illers   |   2 1 9

In the late nineteenth and early twentieth centuries, the spread of this disease across many Asian countries coincided with the growth of mechanized rice-milling. One theory posited that rice consumption led to rice poisoning—but no specific poison was found. The other theory, formulated by F. J. Van Leent in 1879 from his experience in the East Indies Navy, was a bit closer. Van Leent theorized that the cause of the disease was a deficiency in the rice diet due to its very low content of protein and fat. When native sailors were given a European diet, the incidence of beriberi decreased. A few years later, Kanehiro Takaki, a Japanese naval doctor, changed the diet of the Japanese Navy, which had a large number of sailors suffering from beriberi, to a European style of diet, and obtained the same result as Van Leent. However, both investigators found that it was not possible to change the diet of the patients for good, as many went back to the monotonous white rice diet after they recovered from the disease.41 In 1886, Christiaan Eijkman was sent by the Dutch government together with Professor C. A. Pekelharing, University of Utrecht, to investigate the cause of beriberi in Batavia.42 A timely opportunity arose for Eijkman when an epidemic of polyneuritis, with similar features as those seen in humans, broke out in the chicken house at the laboratory in Batavia. Eijkman was fortuitously offered a natural animal model to study the disease. After a thorough investigation of the chickens for an infectious cause, none was found. Then the disease suddenly cleared up. Further enquiry revealed that the chickens had been fed cooked white rice from the hospital kitchen for several months before the epidemic appeared. When the cook left and his successor gave the chickens the old diet of rough rice, there was no further occurrence of disease. From a series of experiments in 1897, Eijkman was able to conclude that the antineuritic principle in the husk of the rice had been removed by mechanized milling. A controlled trial that Eijkman subsequently carried out with Adolphe Vorderman, another Dutch physician and scientist, feeding white rice to half the 300,000 prisoners in East Indies, and rough rice to the other half, confirmed these preliminary findings. The incidence of beriberi was found to be 300 times higher in those fed with polished rice. The antineuritic principle, which confers protection against beriberi in minute doses, was isolated sometime between 1910 and 1913. In 1929, Eijkman and Sir Frederick Hopkins shared the Nobel Prize for Physiology/Medicine for their discoveries that some foods contained “accessory factors,” which

220  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

were necessary for the functioning of the human body, in addition to proteins, carbohydrates, fats, and salt. Although it is now generally accepted that beriberi is due to thiamine or vitamin B1 deficiency, the initial reception to the findings of Eijkman and Vorderman was far from favorable. The Dutch government had to retreat from its initial policy of banning white rice in state institutions due to complaints from rice merchants, prisoners, and others. Even though other investigators from British India subsequently confirmed their findings,43 outbreaks of beriberi continued to occur among laborers, prisoners, and asylum inmates in Hong Kong, Singapore, and Saigon. As David Arnold, a historian in the United Kingdom, has analyzed, the beriberi problem was not easy to solve for several reasons, mainly because the value of rice export in rice-producing countries created vested interests for many involved parties. First, there was a continuous growth in the number of rice mills in Burma, Thailand, India, and other rice growing countries in the early twentieth century, which had replaced the handpounding method completely by 1930s. White rice had replaced all other types of rice exported from rice growing countries. Second, the tastes of the populations in countries such as China and Japan, where rice is the staple diet, had changed for good. It had become a source of family and a national pride to serve white rice. Third, because it reduced the bulk by 35%, milling rice made it cheaper to transport. Because white rice was relatively cheap and readily available, it became the exclusive diet of institutional groups, even in garrisons and on ships.44 White polished rice was not the only culprit in the etiology of beriberi as those whose diet was centered on manioc meal and flour, or those who ate mainly white bread before the adoption of enrichment procedures, were also susceptible to this disease. It has been estimated that from Hong Kong’s population of 350,000 in the late 1890s and early 1900s, there were 10,000 cases of beriberi annually,45 but it is unclear how the numbers were derived. The mortality from beriberi in Hong Kong from 1901 to 1938 is shown in Figure 9.5.46 Taking the mortality rate of 50% from the disease, the number of cases of beriberi in Hong Kong could not have been more than 1,500 annually in the early 1900s, although those with mild symptoms probably did not consult doctors. In the majority of countries where the disease was endemic or epidemic, mortality was low, less than 5%, but among the Chinese in Sumatra, native Javanese, and Filipinos, it was as high as 60% to 70%.

T he T hree G reat K illers   |   2 2 1

Figure 9.5  Deaths from beriberi per 100,000 population in Hong Kong, 1901–1938

Source:  Medical and Sanitary Reports 1901–1938, Hong Kong Sessional Papers or Hong Kong Administrative Reports, 1901–1938.

Hunter investigated deaths from beriberi in Tung Wah Hospital from 1896 to 1904, and found that, among 3,118 beriberi patients, of which 2,912 were men and only 206 were women, the mortality rate was 49% for men, and 35.4% for women. Mortality was highest among patients in older age groups, and the disease usually affected the working class.47 He believed that the high mortality was due to patients unwilling to go into hospitals until they were moribund. Dr. R. M. Gibson of Alice Memorial Hospital also reviewed all the cases of beriberi seen in the hospital from 1888 to 1899. Of the 1,864 beriberi patients who had attended the hospital, 1,547 were seen as outpatients and 317 as inpatients. As with the Tung Wah Hospital series, the vast majority were men of the coolie class. The overall mortality of patients in Gibson’s series was 20%, half of that in Tung Wah Hospital. Gibson found a seasonal pattern to the disease, with the highest number of patients admitted from May to September. He related how the Chinese treated the disease: change of residence or leaving the country for a while, change of diet, taking potatoes instead of white rice, avoiding greasy food, eating vegetables and fruits, and drinking mulberry tea. Gibson recommended that his patients eat more beans and fat pork to increase the percentage of protein and fat in the diet.48

222  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

As those were the days before the discovery of thiamine, it is reasonable to think that the beans and the fat pork probably provided some thiamine. It seems that Gibson’s regimen was superior to that at Tung Wah Hospital, but still not good enough, as 20% of patients died. By 1910, it was generally accepted that consumption of white rice as the staple diet without a sufficient intake of other food produced beriberi. Francis Clark, Medical Officer of Health, advised that fresh fish should be given to supplement the rice diet, and if fresh fish was not available, then beans could be the alternative.49 Nevertheless, large number of deaths from beriberi continued in Hong Kong. As the disease carried considerable economic and political implications, the Far Eastern Association of Tropical Medicine had focused on it as a central concern in a series of ten congresses held in Asia between 1910 and 1938. Providing a platform for research on tropical diseases, as well as a clearing house for information exchange and professional expertise across tropical and sub-tropical regions in south and south-east Asia, the association played a prominent role in evaluating the evidence for the white rice vitamin deficiency as the etiology of beriberi, and also helped assess measures to eradicate the disease. At the inaugural meeting in Manila in 1910, Clark put forth a resolution stating that since there was then “sufficient evidence” to show that beriberi was associated with the continuous consumption of white rice as a staple diet, the government must act. He believed “the resolution would enable us to take early steps to protect natives under our care from a disease which is responsible for much suffering and many deaths.” Although the resolution provoked some dissent, the claim that beriberi was a “disorder of nutrition principally caused by a diet of which overmilled rice forms the staple” became a doctrine repeated at subsequent congresses.50 The hardworking Clark, one of the best Hong Kong Medical Officers of Health despite his cringe-making paternalism, now tackled the beriberi problem in an international forum, hoping that the recognition of the cause of beriberi would spur the local governments to act. Clark’s resolution made little difference to the beriberi problem in Hong Kong, as there was no reduction in the mortality from beriberi in the 1910s and 1920s. The challenges that Arnold identified for eradicating beriberi clearly applied to Hong Kong, where no one, including coolies, would have been eager to trade a familiar luxury—shimmering, fragrant

T he T hree G reat K illers   |   2 2 3

white rice heaped enticingly on the bowl—for rough or parboiled rice which was difficult to find in the market. In the 1930s, beriberi was common among pregnant women in Hong Kong, as pregnancy required increased thiamine. Impoverished Chinese women had even less meat or fresh vegetables in their diet than men, although for a month before delivery, they omitted vegetables for small portions of fish, beef, and pork, and after delivery they reverted back to the usual polished rice diet. W. C. W. Nixon, Professor of Obstetrics and Gynecology at the University of Hong Kong, pioneered the study of beriberi and obstetrical complications, replacing white polished rice with the incompletely milled rice for patients with beriberi in the Tsan Yuk Hospital, despite objections from the nursing staff. He also introduced thiamine injections for patients with beriberi, providing rapid symptomatic relief.51 Even after World War II, beriberi was still making appearances in Hong Kong, although not to the same extent as before the war. By the 1960s it had disappeared from hospital wards, except among chronic alcoholics. Not being an infectious disease, it was no longer under surveillance; thus there is no record of its mortality in the annual medical reports after the war. The improved standard of living among the working class in the 1950s and 1960s meant that workers could afford a diet that included fresh meat, vegetables, and a variety of other products where thiamine could be found. If a case of beriberi occurs in Hong Kong now, it will certainly be a curiosity.

This page intentionally left blank

10. A Century of Development and Achievement

Hong Kong, which had been under British administration for almost a full century, was doing very well economically in the years leading up to World War II. Having recovered from the doldrums of the Great Depression in the early 1930’s, the city had grown prosperous, raking in profits from its flourishing entrepot trade. The city’s economy had also diversified into various industries: fireworks, canning, knitting and dyeing, shipbuilding, manufacturing of cement and machine tools, and sugar refining. Despite the Sino-Japanese War on the mainland, and the steady march of the Japanese Army towards Guangzhou that brought thousands of refugees to the city daily, the Hong Kong government was enjoying a healthy surplus for 1937 and 1939. On Christmas day of 1941, darkness shrouded Hong Kong. The city had fallen to the Japanese Imperial Army. Its infrastructure, including Medical and Health Department that had taken a century to build, lay in shambles. To help us to appreciate the depth of struggle that the medical profession of Hong Kong had gone through in order to transform the health of the population from one associated with a developing region during the postwar years to one associated with a developed region by the late 1960s and early 1970s, a bird’s eye view of the overall development of medical and health services preceding the Japanese occupation will be helpful.

Government Medical and Health Services Hong Kong’s medical and health services developed over the first century of British rule in response to economic, social, and political influences, rather than being planned according to any social philosophy, ideology, or from a system with deliberate formulation, implementation, and evaluation. In the beginning, the colonial government had no wish to provide medical and health services to the Chinese population in Hong

226  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Kong. Any initial medical service development had been catered to the need of its own people: the colonial administration, the civil servants, the police force, and the European businessmen. The government’s role in providing medical care can be traced to the appointment of its first Colonial Surgeon during the 1843 malaria epidemic, and the establishment of the first hospital, Government Civil Hospital, in 1849. The Lock Hospital was established in 1858 for women who were found by the Colonial Surgeon to have venereal disease when he conducted weekly medical examination on inmates of brothels that catered for foreigners. The main aim was to protect the army and navy personnel and other Europeans. In 1861 the Government Civil Hospital acquired a part-time superintendent and in 1868 a private practitioner was hired on a part-time basis to perform Port Health work. By 1871, the workload in Government Civil Hospital had become so overwhelming that a full-time superintendent was employed, followed later by an assistant superintendent. When the 1894 plague epidemic arrived there were only five doctors in the Medical Department. Two of them were part-time doctors who could not work extra hours because of their private practice, one was on leave (Dr. Atkinson) and only two doctors, Dr. Ayres and Dr. Lowson, were working full time. With such limited resources, most plague patients at the hospital were simply left alone to die without treatment or care. The government also tried to wash its hands of the responsibility for the Colony’s sanitation, rationalizing that “the people were clever enough to manage their own affairs.”1 Presumably, since the Chinese and the Europeans had different views on this issue, this non-interfering approach was considered a form of cultural sensitivity. However, the underlying reason for the government’s lack of involvement was the usual one—a very limited budget. There was also no political will to enforce the sanitary regulations that existed, and the Sanitary Board, established in 1883, had no real power. The 1887 Public Health Ordinance that was drafted was so vigorously opposed that it had to be greatly diluted until a much watered down version was finally passed. It would cost thousands of lives and millions in lost revenue before the ravages of the bubonic plague motivated the government and the community toward sanitation reform. After the 1894 plague epidemic, the government began to improve sanitation and pay attention to public health in the Colony. It appointed the first Medical Officer of Health as the executive officer of the

A C entury of D evelopment and A chievement   |   2 2 7

Sanitary Board, and gave a new title to the Colonial Surgeon: Principal Civil Medical Officer. For a brief period between 1903 and 1908, the Principal Civil Medical Officer headed both the Medical and the Sanitary Departments. After 1908, the Medical and the Sanitary Departments were separated. A cadet officer was appointed to be in charge of the Sanitary Department and the Sanitary Board, while the Medical Officer of Health remained as the executive officer of the Board. For the next twenty to thirty years, the lack of medical input to the Sanitary Board thwarted its progress. In 1929 Dr. A. R. Wellington was appointed as the Director of Medical and Sanitary Services. He proposed reorganization of the Sanitary Board, and the Sanitary Department to be recombined with the Medical Departments, but it was only in 1936 that the reorganization was approved. The Sanitary Board, now renamed the Urban Council, had an expanded mandate.2 By 1938 the Medical and Sanitary Department had grown into a relatively huge enterprise (Table 10.1) with a total staff of 1,026 in five major divisions: administrative, investigative, chemical, health, and medical divisions.3 For all the services it provided, the Medical and the Sanitary Departments received about 10% of the total government budget in the late 1930s.4 Some of the public works expenditure was also related to medical and sanitary work.

A Shape-Shifting Medical Division The Medical Division oversaw and managed a number of government hospitals in Hong Kong. In response to changing patient needs and social influences, many of these hospitals were small and adaptable. All smallpox hospitals were temporary, hastily created to respond to smallpox epidemics. During the epidemics of plague, several temporary “hospitals” were opened to isolate the patients from their families; they were the Kennedy Town Hospital (previously a police station), the Kennedy Town Glassworks Hospital, the new Pig and Sheep Depot, and the Hygeia, the hospital ship. Once the plague epidemic had spent its terrible power, the several small district hospitals that had been opened to care for local plague patients were able to close. Only the Kennedy Town Hospital became an infectious diseases hospital.5 A maternity hospital was annexed to the Government Civil Hospital, and the Victoria Hospital for Women and Children was built on the Peak in

228  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Table 10.1  Structure of medical services in Hong Kong in 1938 Division Administrative Division

No. of Staff 52

Investigative Division Bacteriological Institute Malaria Bureau Chemical Division Health Division Urban Branch

10 5 92 4

Port Health

41

Fumigating and Disinfecting Bureau

1

Venereal Diseases Branch

8

Maternal and Child Welfare Branch

11

School Hygiene Branch

8

Chinese Hospitals and Dispensaries Branch

19

Medical Division Clinical Branch (General)

Total

18 8

859 29

Nursing Staff (General)

234

Nursing staff (Mental Hospital) Kennedy Town Hospital (Infectious Disease branch) Tsan Yuk Maternity Hospital Stewards Pharmacy Branch Radiology Branch New Territories Branch Lai Chi Kok Temporary Chinese Hospital Miscellaneous*

8 7 22 3 18 11 13 74 440 1,026

*

Note:  It is unclear the categories of miscellaneous staff of 440 consisted of. Source:  Medical and Sanitary Department Report for 1938, Hong Kong Adminstrative Reports, 1938, M81–84.

1897 to commemorate the Diamond Jubilee of Queen Victoria, as the needs for confinement of women increased. In 1919, the district plague hospital in Wan Chai took on a more auspicious identity as a maternity hospital. As more and more people began to reside in Kowloon, and the New Territories came under British administration, the government built a general hospital, Kowloon Hospital, to provide medical services for the residents in 1925.

A C entury of D evelopment and A chievement   |   2 2 9

By 1938 the earlier hospitals—Government Civil Hospital, Lock Hospital, the lunatic asylum, smallpox hospitals, and district plague hospitals—had been replaced or absorbed. The former Lock Hospital was renamed the Women’s Hospital, treatment of venereal diseases was absorbed into the work of the Government Civil Hospital while the lunatic asylum became the Victoria Mental Hospital in 1929. After half a century of existence, the Government Civil Hospital maintained just 250 beds for the throngs of patients seeking care. Seeing that the need for a replacement was long overdue, Governor Cecil Clementi ordered the Director of Public Works and the Principal Civic Medical Officer to prepare a plan for the reconstruction of the Government Civil Hospital. The strategy would be to build the hospital in a quieter quarter, away from the busy, bustling Victoria harbor. Sai Ying Pun had become too overcrowded and the clamor of vessels and ocean-going ship traffic in the harbor did not create the healing ambience preferred for a hospital. Pressure for expansion also came from the University of Hong Kong. The Government Civil Hospital had been serving as an ad hoc teaching hospital, but was too congested to be suitable for teaching. In 1922 the Rockefeller Foundation offered HK$750,000 to the university, divided into three equal endowments for chairs of medicine, surgery, and obstetrics. Among the stipulated conditions were improvements in university facilities by the government.6 Several sites were proposed for the new hospital with its 500 beds. After much debate, the hilly site in Pok Fu Lam, close to the university, was chosen. Members of the District Watch Committee questioned this semi-rural location, and members of the Faculty of Medicine objected that patients would not go to such an isolated site, but the site’s health benefits of sun, fresh air, sea breezes, and a clean and quiet environment trumped all other potential drawbacks.7 The financing for such a huge undertaking showed the conservative bent of fiscal policy at that time; the all too common refrain of balance the budget carried the day. The Secretary of State for the Colonies instructed that the building cost be paid out of the budget rather than from a loan, as it had done for building the Shing Mun Reservoir. The thinking was that the government could make a profit from the water supply, but a hospital was clearly a liability.8

230  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Figure 10.1  Queen Mary Hospital 1937

Photo courtesy of the Department of Gynecology and Obstetrics, the University of Hong Kong

The Great Depression had set in when construction of the hospital began in 1932, and the Queen Mary Hospital project came under regular review every year. When completed in 1937 the new, improved hospital that would be the main teaching hospital of the University of Hong Kong was, according to Dr. Wellington, an embarrassment. The Queen Mary Hospital (Figure 10.1)—the flagship hospital of Hong Kong—contained many deficiencies, with non-essential, yet desirable items left out because of inadequate funding. Before he retired, Dr. Wellington organized a Technical Committee for the Reorganization and Improvement of Official Hospital and Clinical Facilities that recommended another 2,500 hospital beds, as well as increased outpatient and welfare services. Although this proposal was approved by the Colonial Office and the Hong Kong government, the start of World War II interrupted this forward momentum.9 During his tenure, Dr. Wellington had greatly improved the standard of medical and health services, especially in hospital care. He was succeeded by Dr. Percy Selwyn Selwyn-Clarke who, until he was imprisoned by the Japanese in 1943, made significant contributions to improving the health of thousands of prisoners-of-war, internees, and others by improving sanitation, and containing infectious diseases.

A C entury of D evelopment and A chievement   |   2 3 1

Investigative Division: Tracking Mosquitoes to Bombs The Investigative Division had three major activities: those carried out in the Bacteriological Institute, the Malaria Bureau, and the Government Analytical Laboratory.10 The Bacteriological Institute provided both routine and research work, performing diagnostic services for the whole Colony consisting of examinations of blood, urine, stool, and other body secretions for bacteria, parasites, and helminthes (worms), wherever appropriate. Parasitic infestations such as malaria and ameba (Entamoeba histolytica) were common in those days, as were helminthic infestation, such as ascaris, clonorchis, trichuris, ankylostoma, enterobius, and fasciolopsis. Many patients had multiple infestations. The Institute performed serological tests for syphilis and prepared vaccines for smallpox, cholera, and rabies, and anti-meningococcal serum. It was also responsible for surveillance work including examination of rats for plague bacilli, and regular examination of water and milk for bacterial contamination. The Malaria Bureau was responsible for anti-malaria work and public education, practical hygiene, and recorded the numbers of cases and deaths from malaria each year. Its staff worked extensively to reduce mosquito larvae breeding grounds by removing stagnant pools of water and channeling or draining with nullahs. The bureau also identified the species of mosquitoes in different parts of Hong Kong and the New Territories, and investigated complaints of mosquito nuisance in various areas. The Government Analytical Laboratory provided a consultation service for the community. It performed analytical work related to legal cases such as murder, forgery, armed robbery, counterfeit coins, forged notes and materials; bombs and explosives; pharmaceutical samples; food and drug samples; dangerous goods; and biochemical examinations of samples from the medical department and the university. The fees that were charged went directly into the treasury.

Health Division: Taking Prevention Seriously The plague of 1894 forced the government to acknowledge the interdependence of human and economic health in the Colony, and recognize the importance of preventing diseases before epidemics could break out. The government responded by appointing a Medical Officer of

232  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Health to implement preventive measures. Vector-borne diseases such as plague, malaria, and dengue fever; water- and food-borne diseases such as cholera and typhoid; air-borne droplet diseases such as tuberculosis and influenza; and sexually transmitted diseases—all called for different preventative strategies. Despite the absence of plague since 1929, vigorous anti-plague measures continued into the 1950s, including destruction of rats, abolition of rat refuges in ceilings and paneling, rat surveillance for plague bacilli, and twice yearly “Cleaning up the Environment” events. To prevent water-borne diseases, a clean, adequate supply of water, proper night soil and refuse disposal were necessary. These measures fell short of standard when Hong Kong had to cope with the massive influx of refugees just before the Second World War. In May 1938 the cholera epidemic that had spread in the Far East came to Hong Kong, reaching a peak in July, and disappearing the following January. The Health Division had responded effectively, implementing several measures: isolation of the sick; disinfection of homes of the infected; quarantine of shipping; inspection of trains; mass inoculation with antitoxin; and mass education on how to avoid infection, where to obtain inoculation against cholera, and what to do with a suspected case. It was virtually impossible to prevent the spread of air-borne diseases carried by droplets or particles in overcrowded Hong Kong, where people were literally coughing and sneezing on each other while huddling together in the confined spaces of tenement houses and in refugee shelters. Smallpox, which had been under control, broke out in November 1937, and reached its peak in March 1938. Again, effective measures were ready: over one million free vaccinations were performed that winter in hospitals and dispensaries using locally produced vaccine lymph, and active cases were kept in isolation in the smallpox hospitals. Although this virulent epidemic killed 2,327 persons, due to the massive vaccination campaign it ended just four months later.11 The Health Division was also responsible for Port Health administration. Although there was no quarantine for immigrants in Hong Kong, the International Sanitary Convention of 1920 called for close observation when ships arrived from an infected port. The Port Health Medical Officer examined passengers on board at one of the two quarantine anchorages. In 1938, because of the prevalence of epidemics in Hong Kong, about 1.1 million persons were medically examined on

A C entury of D evelopment and A chievement   |   2 3 3

arrival, an average of about 3,000 a day. Port Health officials routinely inoculated people against cholera, and, unless they carried a valid certificate proving that they had been vaccinated in the previous five years, arriving passengers were also vaccinated against smallpox. Before they left Hong Kong, emigrants were examined and vaccinated if necessary. The Fumigation Bureau was established to disinfect ships and rid them of rats, and to issue a deratization certificate after the process.12 Venereal diseases control also fell under the auspices of the Health Division. Since regular medical examinations were limited to prostitutes serving only foreigners, the incidence of venereal diseases among the Chinese in Hong Kong remained high, whether legalized prostitution was in place or not. At the recommendation of the National Council for Combating Venereal Diseases, whose commissioners visited in 1921, the colonial government established social hygiene centers at different hospitals and clinics in Hong Kong, Kowloon, and the New Territories to provide free diagnosis and treatment of venereal diseases.13 Not until after World War II did effective medications become available for treatment of venereal diseases. Efforts to reduce infant mortality had led to the development of maternal and infant services at the beginning of the twentieth century— also the responsibility of the Health Division. Antenatal and infant welfare work was also carried out in hospitals, dispensaries, and health centers. Sixteen midwives stationed in different dispensaries provided free services to the poor, and visited mothers after delivery to teach them how to care, feed, and wash their babies.14 Infants brought in at that time invariably had health troubles, mostly infection, feeding problems, and malnutrition.15 Mothers were advised on feeding and personal hygiene, and for those who could not breastfeed, the Society for the Protection of Children provided free milk powder. Although school inspection had been carried out since the 1910s, in 1925, the Health Division introduced a formal school hygiene program. Assisted by two Chinese health officers, a health officer inspected schools and examined more than 100,000 school children in three groups of schools: government schools, grant-in-aid schools, and private schools. The officers found the most common health problem at that time to be dental caries, followed by myopia, with those in government schools receiving eye glasses. Trachoma was also common.16

234  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Non-governmental Medical Services: Filling the Gap Voluntary Organizations By 1939, the bulk of inpatient and outpatient care for the Chinese was being provided for by voluntary organizations supported by funds raised from local Chinese. Tung Wah Hospital, founded by Chinese elite in 1872, provided only traditional Chinese medicine (TCM) at first. After the 1894 plague epidemic, the government applied pressure to introduce Western medicine into Tung Wah Hospital. Over time the hospital expanded to establish two other hospitals (Kwong Wah Hospital and Tung Wah Eastern Hospital) as well as a number of clinics to provide various types of inpatient and outpatient services to the Chinese community. The Chinese Public Dispensaries, established in different parts of Hong Kong, filled an important gap in Hong Kong health care. A different group of Chinese elite, under the leadership of Ts’o Seen-wan, formed the Chinese Public Dispensaries Committee, so that outpatient services, midwifery, antenatal and infant care services offering Western medicine could be given free of charge to the Chinese community. In 1919 they turned the Wan Chai Plague Hospital into a maternity hospital, and its popularity led to the founding of another maternity hospital, Tsan Yuk Hospital, in 1922 in Sai Ying Pun. In addition to London Missionary Society’s Alice Hospitals, which provided free Western medical services to the deprived Chinese, the Roman Catholic Church had established a number of small hospitals in Hong Kong such as the St. Francis Hospital, St. Paul’s Hospital and the Canossa Hospital. St. John Ambulance also founded a hospital in Cheung Chau, a small island off Hong Kong, and a number of dispensaries for outpatient services. (Tables 10.2 and 10.3)

The Private Sector: Traditional Chinese Medicine (TCM) The private sector had always contributed significantly to the medical care of the people in Hong Kong. In the 1930s, unless they were sick enough to be sent to one of the hospitals, most Chinese with health complaints had

A C entury of D evelopment and A chievement   |   2 3 5

a few choices. For Western medicine, they could consult a Chinese doctor trained in Western medicine in the private sector, or a doctor in one of the dispensaries run by the Chinese Public Dispensaries Committee or in a government clinic for free. Even though the government provided a number of outpatient clinics, the waiting time was often long and the hours limited that some of the poor working class could not afford to take the time off work to see a doctor in a government clinic. Most Chinese, however, preferred to consult a TCM practitioner for their health complaints either in the private sector or in one of the Chinese hospitals (Tung Wah Group of Hospitals) which provided free consultations but charged for drugs. At the onset of British rule, TCM was used by the Chinese exclusively, and remained popular in the Chinese community despite the government’s lack of formal recognition of TCM doctors. As there was no registration, and as it was also difficult to define who was a TCM doctor, it is unclear how many TCM doctors were practicing at that time. The sick could also consult herbalists with no medical training, or they might seek advice from shops that sold Chinese medicine.17 There were those who practiced acupuncture and also bonesetters who treated sprains with massage, dislocations and fractures with splints, and internal injuries with medications.18 Even before the Second World War Hong Kong was a hub for the trade of Chinese herbs and patent medicine. Numerous patent medicine producers in Hong Kong offered many different herbs and drugs to the people. In 1930, TCM practitioners organized a Chinese Medical Society, publishing a local journal of Chinese medicine to share their experience and to learn from each other. The merchants who ran import and export businesses of Chinese herbal medicine had also organized themselves in 1926, and founded the Chinese Pharmaceutical Merchants Association with three hundred members.19 Many ordinary people regularly drank herbal teas and soups for “maintenance” of health rather than as treatment for diseases; this practice has persisted to this day. It was not until after the British handover of Hong Kong to the Chinese in 1997 that the government began to regulate TCM to ensure that practitioners were meeting professional standards. The Chinese Medicine Council of Hong Kong was established in 1999 to provide medicinal and professional standards for TCM practitioners, who were required to register with the council.20

236  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

The Private Sector: Western Medicine For the European population in Hong Kong’s early days, health care was a different story. Except for the relatively poor Europeans, who were obliged to seek out the Government Civil Hospital, most Europeans relied on the services of European private doctors. The Naval and Military Hospitals that opened in 1843 had hired doctors from England, some of whom later started private practice when they retired from military service. The Seamen’s Hospital hired some of these doctors to treat civilians as well as merchant seamen. The oldest private medical practice in Hong Kong, “Drs. Anderson and Partners,” was initially established as “Adams and Henderson” in 1868.21 Dr. William Stanley Adams, a graduate of University of Glasgow, was appointed as a part-time salaried Port Health Officer and the resident surgeon to the Seamen’s Hospital, and Dr. James Orr Henderson, also from University of Glasgow, became an Honorary Medical Health Officer part-time to a convict hulk (ship) off Stonecutters Island. When Dr. Adams retired after 20 years, his replacement, Dr. Gregory Jordan, renamed the practice as “Adams and Jordan.” Jordan had worked in hospitals in Vienna and in Paris before arriving in Hong Kong where he was welcomed by his wealthy uncle, Paul Chater, who would become a Hong Kong financier and philanthropist. For over 20 years, Jordan held the job as Port Health Officer (part-time). This hard-working, outgoing man was consumed by work that kept pouring in: examination of crews, treatment of passengers, and issuance of certificates and bills of health. In 1924 Dr. Anderson joined the practice, and the practice was expanded to include other doctors such as Charles Forsyth and Pierce Grove. Anderson later renamed the practice “Drs. Anderson and Partners.” In 1998, “Drs. Anderson and Partners” changed its name to Quality HealthCare Medical Services Limited, a huge enterprise with doctors practicing both Western medicine and TCM. Jordon was not the only doctor in the medical limelight then. He had a formidable competitor in Dr. William Hartigan, who became even more challenging when he was joined by Dr. Patrick Manson in 1883. When Manson left in 1889, he handed over his practice to Dr. James Cantlie. It was Cantlie who proposed the curriculum of the College of Medicine along the same lines as the University of Aberdeen and the Charing Cross Hospital. The energetic Cantlie headed a flourishing practice and taught

A C entury of D evelopment and A chievement   |   2 3 7

science, medicine, and surgery at the Hong Kong College of Medicine. As a surgeon, he perfected the technique of draining liver abscesses, a method devised by Manson. He founded the Peak Hospital for Europeans, and introduced private nursing to Hong Kong.22 The Matilda Hospital was opened in 1907 on Mount Kellett, staffed by private practitioners to provide Western medicine to missionaries, teachers, and other westerners of limited means. In the 1880s, the European medical doctors in Hong Kong were a very active group. Some were also researchers such as Manson and Cantlie, while others were able practitioners with a keen interest in keeping abreast of the latest scientific and medical developments in Europe. In addition, the government had recruited a number of doctors such as James Lowson, John Atkinson, John Bell, and Francis Clark who contributed frequently to The Lancet and the British Medical Journal. Manson provided the leadership to advance professional development locally and in 1886 he formed the Hong Kong Medical Society which became the Hong Kong Branch of the British Medical Association. In 1889, there were eighty members who met regularly to discuss medical advances.23 Throughout the latter part of the nineteenth and the first half of the twentieth century, there was no shortage of doctors from Scotland, Ireland, and England coming to Hong Kong to set up practices or join in partnership with other senior doctors. As Western medicine became more popular, their practices were not limited to treating Europeans but also included care for the Chinese. Although Hong Kong had 51 graduates from its own College of Medicine before it became the Faculty of Medicine of the University of Hong Kong, the college’s license was not recognized, and most graduates left Hong Kong to practice in other parts of Southeast Asia. Later some licentiates entered government service to become Chinese medical officers working in the Chinese Public Dispensaries, while others went to further their training in the United Kingdom before returning to serve Hong Kong. One such graduate who contributed greatly to private medicine was Dr. Li Shu-fan an avid tiger hunter who lived a colorful life. After studies in Edinburgh, Li served briefly as the Minister of Public Health under Dr. Sun Yat-sen. Returning to Hong Kong in 1926, he set up his private practice and headed the Yeung Wo Nursing Home which was founded in 1922 by a group of leading Chinese doctors who were

238  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

practicing Western medicine.24 Among them were Drs. Wan Man-kai, Ho Ko-tsun, Kwan King-leung, Ma Luk, Jeu Hok, and Wu Tin-po. The Nursing Home had been operating at a loss for a number of years; Dr. Li Shu-fan reorganized the Home with his brother Li Shu-pui and renamed it the Hong Kong Sanatorium and Hospital in 1935.25 Li Shu-fan retired from medical practice in 1958 but remained, until his death in 1966, as chairman of the board and medical superintendent of Hong Kong Sanatorium and Hospital. He left a sizable piece of land to the Faculty of Medicine of the University of Hong Kong, which named a building for preclinical studies after him.

Medical Facilities Available The colonial government relied heavily on the charitable organizations to provide medical services for the Chinese community before the Second World War. In 1938 there were 2,538 hospital beds in Hong Kong (Table 10.2), approximately 2.53 beds per 1,000 population. The government contributed only 34% of all hospital beds, while charitable organizations supported 55% and the rest came from the private sector. This “tripartite” provision of inpatient services continued for several decades even after the Second World War. When Dr. Wellington was appointed head of Medical and Sanitary Services in 1929, all hospitals were regularly inspected by medical officers to ensure the state of hygiene and standard of treatment up-to-date. In 1935, the government began providing the Tung Wah Group of Hospitals an annual grant, marking the beginning of subvented services. Most hospitals, government or charitable, ran outpatient clinics. The great demand for outpatient services led to the establishment of more outpatient clinics in the government hospitals and government dispensaries in the New Territories. Venereal diseases clinics were set up to provide free treatment. There were also nine Chinese Public Dispensaries in different parts of Hong Kong and Kowloon. A list of the outpatient facilities offering Western medicine that existed in Hong Kong in 1937 can be found in Table 10.3.

A C entury of D evelopment and A chievement   |   2 3 9

Table 10.2  Hospitals in Hong Kong in 1938 Controlling authority Government

Year of founding 1937 1925 1894 1891 1922 1938 1938

Military Navy Chinese Tung Wah Group

1872

Hospital

No. of beds Queen Mary Hospital 546 Kowloon Hospital 140 Infectious Disease Hospital (Kennedy Town) 26 Chinese Lunatic Asylum Mental Hospital 32 Prison Hospital in Stanley 59 Tsan Yuk Hospital 60 Tai Po Maternity Ward 5 Lai Chi Kok (Cholera) Hospital Lai Chi Kok (Relief ) Hospital Female Prison Hospital in Lai Chi Kok Leper Colony Combined Military Hospital, Kowloon Military Hospital, Bowen Road Naval Hospital, Wan Chai Royal Navy Hospital Tung Wah Hospital 451

1911 1929 1902

Kwong Wah Hospital Tung Wah Eastern Hospital Tung Wah Infectious Diseases Hospital Alice Hospitals

Canossian Mission French Mission Caritas Group

1887 1893 1904 1906 1929 1898 1937

St. John Ambulance Private Private

1934 1907 1922

  Alice Memorial Hospital   Nethersole Hospital   Alice Memorial Maternity Hospital   Ho Miu Ling Hospital Canossa Hospital St. Paul’s Hospital Precious Blood Hospital, Sham Shui Po, Kowloon Haw Par Hospital—Cheung Chau Matilda Hospital Yeung Wo Nursing Home

London Missionary Society

325 260 60 126

18 110

50 50 94 2,538 Note:  * Blank—not available. The Director put the total number of beds as 2,538. Source:  Annual Medical Report of 1938, Hong Kong Administrative Reports, 1938, M85.

240  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Table 10.3  Freestanding outpatient facilities offering Western medicine in Hong Kong in 1938 Sponsoring authority Government

Name Tai Po Dispensary Un Long Dispensary Lady Ho Tung Welfare Centre, Fanling Sai Kung Dispensary Tai O Dispensary Ruttonjee Dispensary Chinese Public Central Dispensary   Dispensaries Committee Western Dispensary Eastern Dispensary Aberdeen Dispensary Kowloon City Dispensary Shamshuipo Dispensary Shaukiwan Dispensary Stanley Dispensary Yaumati Dispensary Source:  Medical Annual Report for the Year 1938, Hong Kong Administrative Reports, 1938, M43–44.

Despite TCM not being recognized and even actively discouraged by the government, it remained popular among the Chinese. Table 10.4 shows the number of in- and outpatients who attended government hospitals, Chinese hospitals, and Chinese dispensaries (excluding those for maternity, mental problems, and venereal diseases) and the type of treatment (Western medicine or TCM) received in 1936.26 It is clear that the Chinese hospitals, supported by donations and fund raising from the Chinese community, provided the bulk of the medical care for the people in Hong Kong. It appears that the Chinese chose the option that seemed most fitting for them. In the Chinese hospitals, they frequently chose Western medicine, with its significantly lower mortality rates than TCM for inpatient care, but for milder health problems requiring only outpatient care, more sought TCM treatment. These findings suggest that for milder ailments and outpatient care, TCM would not likely be displaced by Western medicine.

A C entury of D evelopment and A chievement   |   2 4 1

Table 10.4  Total in- and outpatient attendances in government hospitals, Chinese hospitals, and Chinese public dispensaries in 1936 Hospital/public dispensaries

Inpatients Western

Outpatients

TCM

Western

TCM

5,875

0

103,266

0

644

0

0

0

3,367

0

62,502

0

0

0

474,827

0

Tung Wah Hospital

7,157

4,984

34,748

170,584

Kwong Wah Hospital

9,135

4,436

48,106

182,813

Tung Wah Eastern Hospital

4,081

2,650

36,569

62,849

Government hospitals Government Civil Hospital Victoria Hospital for Women and Children Kowloon Hospital Chinese public dispensaries Chinese hospitals

Total 30,259 12,070 760,018 416,246 Source:  Medical and Sanitary Department Report of 1936, Hong Kong Administrative Reports, 1936, C56.

Manpower Before Hong Kong had its own medical school, all doctors practicing Western medicine were medical graduates from Britain, Europe, or Japan and other parts of the world. When the Hong Kong College of Medicine became the Faculty of Medicine of the University of Hong Kong in 1912, the curriculum followed closely those recommended by the General Medical Council in England so that the medical degree would be accepted for registration. The colonial government amended the Medical Registration Ordinance of 1884 to ensure that graduates of the university were recognized for licensure to practice medicine in Hong Kong, marking the beginning of a medical system we know today.27 Most of the local medical graduates settled into lucrative private practice as there was a great demand for Chinese doctors trained in Western medicine which had been popularized by the Chinese Public Dispensaries and the London Missionary Society hospitals. However, there were a few who used their skills to serve the poor and distinguished themselves in the government medical service, such as Dr. G. H. Thomas.28

242  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

Table 10.5 shows the number of doctors qualified to practice in Hong Kong by year before the Second World War. The first list of qualified medical practitioners appeared in the Hong Kong Gazette in 1904 and yearly thereafter.29 In 1904, there were 18 qualified medical practitioners in Western medicine, 12 from the United Kingdom and the rest from Japan, Canada, and Germany.30 As expected in 1941, the total number of qualified medical practitioners had grown to 310: 198 were Hong Kong University graduates, while 66 were from the United Kingdom, and 46 from other countries. The latter category mainly consisted of Chinese graduates from Canada and Japan, with a few from Europe.31 In the decades leading to the Second World War, medical graduates outside Hong Kong played an important role in providing medical care. Table 10.5  Total number of doctors qualified for practice in Hong Kong by year Year

Total registered

United Kingdom HKU graduates graduates

Other countries graduates

1904

18

0

12

6

1905

21

0

14

7

1915

38

3

25

10

1925

117

40

62

15

1935

233

159

61

13

1941 310 198 66 46 Source:  Hong Kong Government Gazette, 1904, 1905, 1915, 1925, 1935, 1941, see note 29 for details.

Of the 310 registered doctors in 1941, 10.9% were practicing in hospital or university settings and 76.1% were in private practice, as indicated by their work addresses. The remaining 12.9% did not provide their work addresses, and their practices remained unknowable. In 1937 the number of doctors practicing Western medicine per 1,000 residents was 0.31, a very low rate compared to the present day standard (around 2.8/1,000 in Western countries in 2011). In 1941 there were 483 registered female and 37 registered male nurses, as well as 810 registered midwives in Hong Kong. These numbers were far from adequate to serve the large population. One may ask the question why there were only 198 Hong Kong University medical graduates practicing in 1941 when the University had been in existence for almost three decades. During this period, 3,628

A C entury of D evelopment and A chievement   |   2 4 3

medical students were enrolled, but only 490 graduated (13.5%). A large number of students failed the first and the second degree examination and had to leave. Before the Second World War, many students came from China, the Straits Settlements, and at one time a few from Russia. Most external students returned home after graduation. Only about one quarter of the medical graduates were local although a few external students started their practice in Hong Kong after graduation.32 Governor Sir Frederick Lugard, the founding chancellor of the university, had intended to create an “imperial” institution believing that the university should serve not only the Chinese in Hong Kong but also those from the mainland and to disseminate British culture and language expanding the influence of Britain in the Far East.

Population’s Health Status: The Vital Importance of Vital Statistics There are many reasons why it is challenging to make definitive statements about the health and changes in health status over time of Hong Kong’s population before the Second World War, but a primary one is the lack of systematic record keeping, especially in the nineteenth century. In order to assess the health status of a population, there has to be an adequate system for tracking the following: the total number of people; sex and age distribution; the number of births and deaths each year; the age at death and the cause of death. Other important parameters include infant mortality (defined as the number of infants dying before the age of one for every thousand live births), maternal mortality (the number of women dying per thousand births), and life expectancy from birth. Although the Hong Kong government had reported on the population since 1845, proper census gathering principles were not followed until 1881, at which time a proper population census was conducted in Hong Kong every 10 years except for the years between 1931 and 1961. In between the census, population figures were based on estimates. It is also difficult to obtain accurate information on Hong Kong’s shifting population at different times. One huge problem was the porous border between Hong Kong and China, which was completely unrestricted until 1952. The first census in 1881 coincided with Qingming (Ching Ming or Grave Sweeping Festival) when thousands returned to the

244  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

mainland and the population was grossly underestimated.33 Many Chinese returned to their native village in the mainland to celebrate Chinese New Year and other festivals, and some even commuted between Hong Kong and their native villages.34 In a few major events such as the 1894 plague epidemic, half the population of Hong Kong had gone to the mainland. Many Chinese returned to their ancestral village when they developed serious illness for treatment, and to be buried there if they died. Tung Wah Hospital often repatriated patients with beriberi and other illnesses to Guangzhou for treatment. Thus the death and disease rates of Chinese were likely to be underestimated. Knowing that the Chinese were suspicious of any k ind of registration for fear of it being used in head counts for taxation, the Hong Kong government had shied away from implementing legislation on registration of births and deaths. For many years the total number of deaths of Chinese infants below the age of one was higher than the number of live births each year for the whole population (Table 10.6).35 This anomaly arose because many Chinese women returned to their native village to give birth, and when the infant died in Hong Kong, there would be a death without a birth. Most Chinese did not register births until the infants reached one month old, and they did not usually bother with registering girls.36 Thus it appeared that Chinese women gave birth to twice as many boys as girls. Population statistics from Hong Kong before the Second World War were unreliable. The practice of many Chinese with health problems returning to their native village to die and be buried there so that their tablets could be in the ancestral hall generated a falsely low mortality rate for the Chinese. Their apparent healthiness was highly misleading. Towards the 1930s the work of educating the public by the Chinese Public Dispensaries improved the compliance to registration for births and deaths markedly. The population increase in the late 1930s was due to the influx of refugees from the mainland. By 1937 the population of Hong Kong had grown to just over one million; the many refugees fleeing the Sino-Japanese War swelled it to around 1.7 million before the Japanese occupation. The crude birth rate had increased to 25/1,000 in 1936—probably still an underestimation, but much higher than the rate of 4 to 5/1,000 at the beginning of the twentieth century. The crude death rate remained at around 20 to 25/1,000, similar to those in the early twentieth century, high by more contemporary standards, which ranged from 6.1 to 4.6/1,000

A C entury of D evelopment and A chievement   |   2 4 5

Table 10.6  Population, births, overall deaths, and infant deaths, 1921–1939 Births+ Birth Deaths+ Death Infant* C. infant C. infants Year Population (N) /1,000 (N) /1,000 deaths% Deaths* (N) deaths/1,000 1921

625,166

3,618

5.8

11,880

19.0

31.7

3,728

NA

1922

638,300

3,904

6.1

14,569

22.8

28.9

4,216

NA

1923

667,900

4,414

6.6

15,536

23.3

29.5

4,556

NA

1924

695,500

4,143

6.0

15,553

22.3

30.4

4,698

NA

1925

725,100

3,654

5.0

14,991

20.7

31.4

4,671

NA

1926

710,000

4,041

5.7

12,516

17.6

27.3

4,238

NA

1927

740,300

7,500

10.1

14,761

19.9

31.6

4,637

NA

1928

766,700

9,309

12.1

14,735

19.2

29.5

4,338

458

1929

802,900

10,233

12.7

17,565

21.9

38.6

6,777

663

1930

838,800

11,134

13.3

16,268

19.4

38.2

6,180

557

1931

849,751

12,443

14.6

18,797

22.1

39.6

7,443

617

1932

900,796

13,597

15.1

19,829

24.7

35.1

6,916

525

1933

922,643

15,362

16.6

18,161

22.0

37.3

6,782

455

1934

944,492

20,886

22.1

19,766

20.9

34.7

7,094

347

1935

966,341

25,037

25.9

22,133

22.9

35.2

7,784

316

1936

988,190

27,383

27.7

26,356

26.6

37.6

9,924

372

**

1937

1,281,982

32,303

25.2

34,635

27.0

37.6

11,620

376

1938

1,478,619** 35,893

24.3

38,818

26.3

34.3

12,001

343

1939

**

26.7

48,317

27.6

34.1

15,678

335

1,750,256

46,675

*

Note:  Infants under the age of one year. Census took place on 1921 and 1931 and the population in between were based on estimation. ** The figures were based on estimated population due to refugees pouring into Hong Kong (See Medical and Health Annual Report, 1941). Birth and death/1,000 were crude rates. C=Chinese. N=Number. Chinese infant death rates between 1921 and 1927 were not given because of the gross under-registration of births. NA=not available; +=Chinese and non-Chinese. Source:  Annual Medical Reports or Medical and Sanitary Reports, Population, Birth rates, Death rates, 1921–1939, Hong Kong Administrative Reports, 1921–1939.

between 1961 and 2010. Infant mortality appeared to account for 30 to 40% of all deaths, but because the Chinese persistently failed to register births, the infant mortality rate for the Chinese remained artificially high. In 1929, it was 663/1,000 but decreased in 1937 to 376/1,000, due to increased registration of births and better maternal and infant care.

246  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

To be able to compare the causes of death with other populations, or to assess the effects of intervention on the same population, standardization of classification of diseases is necessary. The first widely used system was devised by William Farr, an English public health official, after the inaugural International Statistical Conference at Brussels in 1853. It was later called the International List of Causes of Death. Dr. Atkinson, who became the Superintendent of the Government Civil Hospital in 1887, introduced this system in his annual report of admissions and deaths of the hospital. In 1893 Jacques Bertillon, a French physician, introduced a similar system in France. A number of countries and cities had since adopted the Bertillon Classification of Causes of Death, which was based on the principle of distinguishing between general diseases and those localized to a particular organ or anatomical site. In 1898, a synthesis of English, French, German, and Swiss classifications led to a proposal by the American Public Health Association to adopt its use in the United States, Canada, and Mexico. Thus in 1900, the first international conference to revise the International Classification of Causes of Death (ICD-0) took place; further revisions would be made every ten years thereafter.37 The Medical and Health Department in Hong Kong also adopted the ICD in the annual reports soon after it had been instituted internationally, indicating that the medical officers in Hong Kong were keeping up with advances in public health. In his annual medical and sanitary reports, Dr. A. R. Wellington, published a “death clock,” showing the percentage of total deaths due to different diseases for the year (Figure 10.2). For as long as he published these results and probably for decades before his time, infections accounted for more than 60% of deaths: approximately 40% from infections of the lung (bronchopneumonia, pulmonary tuberculosis, bronchitis, pneumonia), 15% from infections of the gut (diarrhea and infantile diarrhea), and the balance from systemic infections. The death clock shown below is for the year 1936—before the assault of various epidemics in Hong Kong as a result of the deluge of refugees from the mainland before the Second World War.38 The number of cases of communicable diseases each month was usually charted in the annual reports by Colonial Surgeons or Medical Officers of Health. Physicians in the nineteenth century believed that climate—temperature, rainfall, and humidity—had considerable influence on the cyclical occurrence of diseases. Hong Kong’s position just below

A C entury of D evelopment and A chievement   |   2 4 7

Figure 10.2  Dr. Wellington’s “death clock” showing % deaths due to various diseases, 1936

Source:  Wellington, A. R. Medical and Sanitary Report 1936, Hong Kong Administrative Reports, 1936, M35.

the 22.5° latitude in the northern hemisphere, within the northern limits of the tropics and immediately south of the great land mass of China, subjects its climate to great influence by the direction of the prevailing winds. When the northeast monsoon blows from November until April, the weather is dry, cool, and invigorating. From May to October, the season of the southeast monsoon, the air is highly charged with moisture and the climate is hot and muggy. July, August, and September are the typhoon season, which is often accompanied by torrential rains. There are seasonal cycles for various communicable diseases. Plague, for example, usually started in April or May and ran out of steam by August. Malaria usually caused its greatest damage in the hot and wet summer months while epidemics of smallpox, influenza, and cerebrospinal meningitis usually occurred in the cool, dry winter months. Figure 10.3 shows the number of cases of different infectious diseases that occurred in each month of 1938.39 In addition, in the summer months the usual endemic diseases, malaria and dysentery, and throughout the year, tuberculosis, raged (not shown). It is difficult to imagine how frightening such lethal epidemics of smallpox, cerebrospinal meningitis, cholera,

248  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

and diphtheria following one another in quick succession would be in present day Hong Kong, or indeed anywhere, especially if there were no antibiotics, antitoxins, or other cures available. Figure 10.3  No. of cases of various infectious diseases by month in 1938

Note:  CSM-cerebrospinal meningitis; endemic diseases such as malaria and tuberculosis were not shown in this figure. Source:  Medical and Sanitary Report for the year 1938, Hong Kong Administrative Reports, 1938, M15–19.

As in many parts of the world, communicable diseases and infections accounted for at least 60% to 70% of all deaths in Hong Kong during the first half of the twentieth century. Antibiotics were not discovered until 1935, when the first sulfur drug was used and then, after World War II, when penicillin became widely available. In 1936, heart diseases accounted for just 3% of all deaths, and cancer was also uncommon as a cause of death because infection tended to kill off most people before the non-communicable diseases had a chance to develop or diagnosed by the physicians. Further, diseases related to obesity such as diabetes were uncommon, and sleep apnea (frequent episodes of stoppage of breathing at night time associated with fall in oxygen levels in the blood) was unheard of. The pattern of causes of death from various diseases in Hong Kong in the late 1930s is similar to those in what are referred

A C entury of D evelopment and A chievement   |   2 4 9

to as “developing” countries today. Of course, most countries in the world would still be in the category of “developing” if it were not for the wonderful discovery of antibiotics, although drug resistance to many antibiotics continue to develop from widespread overuse.

Hong Kong Medicine: From Sickness to Health The development of medicine and health care in Hong Kong reflects the changing social, political, and cultural scenes under British rule during the first century, and often came about more as an emergency response than as a carefully thought out, farsighted plan. Hong Kong had been ceded to the British at the height of imperialism, and the policy of the colonial government was to do as little as possible to keep the Colony under law and order in order to further trade, while at the same time not antagonizing the natives. Thus the government, constrained by a limited budget, rarely took a stand on sanitary or health issues, especially when the two races were so different in their attitudes to sanitation. Another obstacle to health and sanitation reform was the sojourner attitude of inhabitants, European and Chinese alike. The propertied class, mostly Chinese, held out against any sanitary reforms that would have cost them economically, until the unsanitary state in Hong Kong led to the visitation of bubonic plague, and the government and the people were forced to confront its devastating effects. Ironically just as the great epidemics of cholera brought sanitation practices in Britain out of the Middle Ages, the bubonic plague ultimately led to changes that transformed Hong Kong’s reputation as one of the most unhealthy cities to one of the cleanest in the Far East. The horrors of plague marked the beginning of a progressive political change. The colonial government moved away from total segregation to gradual assimilation of the local Chinese in its policy making; from laissez-faire remoteness to repressive intervention—and finally to one of consultation, friendly persuasion, and education in public health matters. Throughout the late nineteenth century, the government’s budget for medical services had been less than 4% of its expenditures, depending on voluntary agencies to provide the bulk of medical care to the poor. The London Missionary Society, the Chinese elite, and local private

250  |  A MEDICAL HISTORY OF HONG KONG: 1842–1941

practitioners of Western medicine helped ensure that Western medicine would be an integral part of Hong Kong by founding the Hong Kong College of Medicine, now the Faculty of Medicine, the University of Hong Kong. By establishing public dispensaries to provide free medical care, public health education and propaganda, the Chinese elite helped ease the acceptance of Western medicine and Western hygiene measures in the Chinese community. The success of the midwives trained in Western methods in markedly reducing infant and maternal mortality further popularized Western medicine. Revelations of the squalid conditions and the lack of public health measures in Hong Kong after the First World War had stirred the social conscience of people in the metropolitan government. In response, they applied pressure on the colonial government to improve Hong Kong’s medical and health services. During the interwar years, the Medical and Sanitary Departments had expanded and evolved into a more mature institution; essential services for sanitation and health were firmly established. Medical services became more available to the population in three different settings: a private fee-based medical service, the government hospitals and clinics, and the charitable organizations, religious or non-religious, which were free or charged only a nominal fee. The establishment of effective health programs to prevent the epidemics of infectious diseases such as plague, malaria, smallpox, and cholera happened over decades. After various reorganizations and planning, a satisfactory administrative structure for the Medical and Sanitary Departments had developed before the Second World War, remaining more or less intact until the late 1980s. In retrospect, it seems remarkable that any of the medical infrastructure framework survived the ravages of the Second World War. Many of the physical structures became dilapidated and were partly destroyed. Many medical personnel died, or were interned as prisonersof-war, or dispersed into southern China. The population was weakened from malnourishment and living in overcrowded conditions where the threat of epidemics lurked. For a few decades after the Second World War, Hong Kong had to cope with population explosion from massive influx of refugees from the mainland as a result of civil war and postwar baby boom. Yet the health status of the Hong Kong population rose steadily from one associated with a developing region after the war to one of a

A C entury of D evelopment and A chievement   |   2 5 1

developed region by the end of 1960s and early 1970s. At present, the life expectancy (females at 87.32 and male 81.24 years in 2016) of its citizens is one of the highest in the world. Further, the infant mortality rate is lower than that of the United States or the United Kingdom, while the health care cost is lower than most of the developed world. How did Hong Kong population health status reach a level that it could rival those in any advanced economy? With economic growth from the 1950s to the 1970s, chances of infection were lowered through progressive improvements in sanitation, water supply, and housing, coupled with increased immunity conferred by better nutrition. The discoveries of many new antibiotics also served to dramatically reduce the mortality from infections that had been the major killers. Advances in medical technology and improved diagnosis and treatment also considerably lowered the mortality from chronic, non-communicable diseases, even cancers. These improvements would not have been possible without the relatively well-established public health system and public health legislation before the war, the dedication of the officers in the Medical and Health Department, and the medical doctors, registered and “unregistrable” (refugee doctors from the mainland),40 who participated in the difficult task of postwar renewal, re-building, and rehabilitation. Other important factors include the perseverance of the few Medical Faculty members of the University of Hong Kong who had the challenging mission of ensuring that the university would keep turning out the much needed medical graduates, and the diligence of the staff of the nursing schools for training the desperately needed nurses. Finally we can all salute the people of Hong Kong for their tremendous patience and endurance during the difficult postwar decades, as they labored under grueling conditions, to build a healthy community that their children and grandchildren could take pride in.

This page intentionally left blank

1843

1842

Long used ether as a general anaesthetic

Medical Missionary Society Hospital established; Seamen’s Hospital opened; first Colonial Surgeon appointed

Military and naval hospital built and destroyed by typhoon Edwin Chadwick published Report on the Sanitary Conditions of the Labouring Population of Great Britain

Cession of Hong Kong to Britain

The 1840 Act to extend the practice of vaccination to be given free of charge

1840

1841

1836 Registration Act—new system of national registration of marriages and deaths

1836

Public health in Britain

Severe outbreak of cholera in Britain

Laennec invented stethoscope

1816

Medical development in Hong Kong

1832

Jenner discovered cowpox vaccination

1796

Year Advances in Western medicine

Medical and Public Health Development Timeline, 1796–1941

Appendix 1

Outbreak of fevers; Public Health Committee formed

Outbreak of fevers (likely malaria) and 10% of population died

Public health in Hong Kong

Kwong Fook I Tsz built

Medical Missionary Society Hospital closed

1851

1853

1854

Government Civil Hospital first established in a rented bungalow

1850

John Snow discovered contaminated water responsible for severe outbreak of cholera in London—Broad Street Outbreak

Vaccination Act of 1853 made vaccination against smallpox compulsory for all children

Severe cholera outbreak

1849

Public health in Britain

First Public Health Act of 1848 passed, General Board of Health created

Semmelweis discovered prevention of puerperal fever

Lock Hospital began in make-shift premises; Hong Kong branch of China Medico-Chirurgical Society founded

Medical development in Hong Kong

1848

1847

1845

1844

Year Advances in Western medicine

Cont’d Appendix 1 Davis established opium monopoly; Tai Ping Shan founded

Public health in Hong Kong

2 5 4   |   A ppendix 1

Lister published “Antiseptic Principle of the Practice of Surgery” based on Pasteur’s work

Koch and Pasteur established “germ theory” of disease

1870

Pasteurization of milk began

1867

1864

1863

1862

1859

Government Civil Hospital established on Inland Lot 24

Contagious Diseases Act of 1864 enacted

Public Health Act 1858; local health boards created

General Medical Council in England established; Virchow proposed theory of cellular pathology in disease

1858

Lock Hospital opened

Pasteur identified germs as a cause of disease

1857

Contagious Diseases Ordinance of 1867 enacted

Pok Fu Lam Reservoir completed

Venereal Diseases Ordinance of 1857 enacted

Florence Nightingale returned Buildings and Nuisance Ordinance from Crimean War and enacted promoted her ideas on nursing

British Medical Association founded

Public health in Hong Kong

1856

Public health in Britain John Simon appointed Central Medical Officer

Medical development in Hong Kong

1855

Year Advances in Western medicine

Cont’d Appendix 1

A ppendix 1   |   2 5 5

First cholera vaccine developed; Government Civil Hospital built at Neisser isolated Neisseria the site of the Lock Hospital gonorrhoea, causative agent in gonorrhoea

Laveran discovered malarial parasites in blood

Pasteur developed the first anthrax vaccine

1879

1880

1881

Nethersole Dispensary started

Manson discovered mosquitoes as vectors for filariasis

1877

1875 Great Public Health Act— required each town council to provide sewers, clean water, and a medical officer

Report of Commission on the Workings of 1867 Contagious Diseases Ordinance

Government Civil Hospital wrecked by typhoon and moved into the Lock Hospital

1874

Koch identified Bacillus anthracis, organism responsible for anthrax

Seamen’s Hospital became Royal Navy Hospital; Ayers appointed as Colonial Surgeon

1873

1875

The Public Health Act 1972 Births and Deaths Registration established sanitary authorities Ordinance of 1872 in both urban and rural areas

Tung Wah Hospital opened

Public health in Hong Kong

1872

Public health in Britain Public Health became recognized as a separate discipline of medicine

Medical development in Hong Kong

1871

Year Advances in Western medicine

Cont’d Appendix 1

2 5 6   |   A ppendix 1

Hong Kong Medical Society established with Manson as president

Alice Memorial Hospital and Hong Kong College of Medicine for Chinese founded; Sun Yat-sen one of its first students

Manson left Hong Kong; James Cantlie became dean of College of Medicine

1886

1887

1889

Kitasato isolated tetanus bacilli as causative agent of tetanus

European Lunatic Asylum established

1885

Medical Registration Ordinance of 1884 enacted

1884

Koch isolated Vibrio cholera responsible for cholera

Patrick Manson arrived in Hong Kong

Koch isolated Mycobacterium tuberculosis responsible for tuberculosis; Pasteur developed a rabies vaccine

Medical development in Hong Kong

1883

1882

Year Advances in Western medicine

Cont’d Appendix 1

The Infectious Diseases Notification Act—compulsory notification of infectious diseases

The Disease Prevention Act 1883 passed, giving Metropolitan Asylum Board powers to isolate and treat people suffering from infectious disease

Public health in Britain

Protection of Women and Girls Ordinance introduced

Public Health Ordinance 1887 enacted

Sanitary Board formed

Chadwick’s first visit and submitted his report

Public health in Hong Kong

A ppendix 1   |   2 5 7

Yersin and Kitasato identified plague bacillus

Roentgen discovered x-rays for medical imaging

First vaccine developed for typhoid fever

Ross discovered mosquitoes as vectors for malaria; first vaccine developed for plague

Simond discovered flea as vector for plague bacilli

1894

1895

1896

1897

1898

Cholera, smallpox, diphtheria included as notifiable diseases

Public health in Britain

Francis Clark appointed first Medical Officer of Health; reorganization of Medical Department and Sanitary Board

Bubonic plague epidemic, recurrent until 1929; ordinance passed to abolish legalised prostitution; completion of Tai Tam Water Works

Chadwick’s second visit; Vaccination Ordinance of 1890 enacted

Public health in Hong Kong

St. Paul’s Hospital opened

Founding of London School of Report of Commission of Enquiry Tropical Medicine and Hygiene on Insanitary Properties by Patrick Manson

Protection of Women and Girls Ordinance enacted

Tung Wah Hospital Enquiry Report Contagious Diseases Birth and Death Registration and introduction of Western Ordinance repealed in England Ordinance 1896 enacted medicine to the hospital

Nethersole Hospital opened; Nurses Training School in Alice Memorial Hospital established

1893

Medical development in Hong Kong

Chinese Lunatic Asylum built; Vaccine Institute founded

Emile Roux and Yersin discovered antitoxins and developed diphtheria vaccines

1891

1890

Year Advances in Western medicine

Cont’d Appendix 1

2 5 8   |   A ppendix 1

Chinese Public Dispensaries established in Yaumati, Hung Hom, and Kowloon City

Treponema pallidum (causes syphilis) isolated

Wassermann test developed to detect syphilis

1905

1906

Establishment of Ho Miu Ling Hospital; Bacteriological Institute completed

Alice Memorial Maternity Hospital opened; arrival of Alice Sibree; midwives training began; first diagnostic x-ray system in Alice Memorial Hospital

1904

Victoria Jubilee Hospital for Women and Children built

1903

Einthoven discovered electrocardiography (ECG)

Tung Wah Infectious Diseases Hospital built; William Hunter appointed Government Bacteriologist

Landsteiner discovered blood groups

1902

1901

The 1906 Education (provision of meals in schools) Act

Midwives Act—training of midwives

Midwifery training first established

Public Health and Buildings Ordinance of 1903 passed; Principal Medical Civic Officer in charge of Sanitary Department; enquiry into causes of Infant deaths

Sanitary Commission headed by Chadwick and Simpson

Crown Land Resumption Ordinance 1900 enacted

Public health in Hong Kong

1900

Public health in Britain Extralegal system of controlling prostitution began

Medical development in Hong Kong

1899

Year Advances in Western medicine

Cont’d Appendix 1

A ppendix 1   |   2 5 9

Medical degree from HKU recognized by General Medical Council, Britain

1913

1915

Tuberculosis became a notifiable disease

National Insurance Act 1911 to provide unemployment benefits, sick pay, and medical expense

Hong Kong College of Medicine dissolved

Beginning of First World War

HKU opened; Faculty of Medicine established

1912

1914

Kwong Wah Hospital founded; HKU incorporated; training institute for nurses and midwives in the Alice Hospitals

1911

Dental Registration Ordinance enacted

Midwives Ordinance of 1910 enacted and Midwives Board established; all opium divans closed; Kowloon Reservoir completed

Hong Kong University (HKU) laid its foundation stone

1910

Salvalsan “606” for treatment of syphilis

Licentiates of College of Medicine Medical examination of school Reorganisation of Sanitary Board authorized to sign death certificates children and separation of Sanitary Department from the Medical Department

1908

Public health in Hong Kong

1907

Public health in Britain

Medical development in Hong Kong

West Point and East Point Chinese Public Dispensaries opened

Year Advances in Western medicine

Cont’d Appendix 1

2 6 0   |   A ppendix 1

First vaccine for tetanus and BCG vaccine developed

Fleming discovered penicillin

Berger discovered electroencephalography

1927

1928

1929

Tung Wah Eastern Hospital opened; new Alice Memorial Hospital built on Bonham Road

Tsan Yuk Hospital supervised by HKU Obstetrics Unit

1926

First vaccine for pertussis developed

Kowloon Hospital opened

Tsan Yuk Hospital and Yeung Wo Nursing Home opened

1925

1923– First vaccine for diphtheria 1924 developed

Banting and Best discovered insulin

1922

Hong Kong Chinese Medical Association formed

1920

Mellanby discovered vitamin D deficiency as cause of rickets

Wan Chai Maternity Hospital opened

1921

Influenza epidemic of 1918, estimated 50 million killed; Ministry of Health Act 1918

Public health in Britain

The Public Health (tuberculosis) Act of 1921

Housing Act and policy of slum clearance

End of First World War

Medical development in Hong Kong

1919

1918

1917– 1918

Year Advances in Western medicine

Cont’d Appendix 1

Last two cases of plague

National Council for Combating Venereal Diseases Commissioners visited Hong Kong

Completion of Tai Tam Tuk Reservoir; Influenza and smallpox epidemic

Public health in Hong Kong

A ppendix 1   |   2 6 1

1939

Cerletti and Bini discovered electroconvulsive therapy

1938

Lai Chi Kok Hospital opened

Queen May Hospital completed; Government Civil Hospital became an infectious disease hospital

First vaccine for typhus developed

1937

Government took over Tsan Yuk Hospital

The Hong Kong Eugenics League established and family planning began

First vaccine for yellow fever; steroid used for rheumatoid arthritis

First sulfur drugs discovered

1936

1935

1933

1932

The Emergency Medical Services created

The Public Health Act 1936 replaced all previous legislative public provisions relating to public health matters

Tuberculosis became a notifiable disease; Shing Mun Reservoir completed

Epidemics of smallpox, cholera, cerebrospinal meningitis

Urban Council formed taking over some sanitary services from the Sanitary Department; Medical and Sanitary Departments combined

Last brothel closed its doors

Nurses Registration Ordinance enacted

Public health in Hong Kong

1931

Public health in Britain Cross-harbor water pipeline; Shek Lei Pui Reservoir completed; Malaria Bureau established

Medical development in Hong Kong

1930

Year Advances in Western medicine

Cont’d Appendix 1

2 6 2   |   A ppendix 1

Crude penicillin available

Public health in Britain

Beginning of Second World War and fall of Hong Kong

Medical development in Hong Kong

Public health in Hong Kong

Source:  1) “Timeline of Medicine and Medical Technology,” Wikipedia, https://en.wikipedia.org/wiki/timeline_of_medicine_and_medical_ technology; 2) “Medical Advances Timeline,” infoplease, www.infoplease.com/ipa/A0932661.html; 3) “Public Health Timeline,” British Library, http://www.bl.uk/learning/histcitizen/21cc/publichealth/background/timeline/publichealthtimeline.html. All accessed on 20 January 2018.

1941

Year Advances in Western medicine

Cont’d Appendix 1

A ppendix 1   |   2 6 3

This page intentionally left blank

Appendix 2 Governors, Administrators, Secretary of State for the Colonies, and Heads of Medical Services, 1841–1941

Table 1  Governors and administrators of Hong Kong, 1841–1941 Name

Governor*/ administrator 

Start date

End date

Sir Charles Elliot

Administrator

26 January 1841

12 August 1841

Alexander Robert Johnston

Acting Administrator

22 June 1841

December 1841

Sir Henry Pottinger

Administrator

12 August 1841

26 June 1843

Alexander Robert Johnston

Acting Administrator

June 1842

December 1842

Sir Henry Pottinger

砵甸乍

26 June 1843

8 May 1844

Sir John Davis

戴維斯

8 May 1844

18 March 1848

William Staveley

Administrator

18 March 1848

21 March 1848

Sir George Bonham

文咸

21 March 1848

13 April 1854

Sir John Bowring

寶靈

13 April 1854

5 May 1859

William Caine

Administrator

5 May 1859

9 September 1859

Sir Hercules Robinson

羅士敏

9 September 1859

15 March 1865

William Thomas Mercer

Administrator

15 March 1865

11 March 1866

Sir Richard Graves MacDonnell

麥當奴

11 March 1866

11 April 1872

Henry Wase Whitfield

Administrator

11 April 1872

16 April 1872

Sir Arthur Kennedy

堅尼地

16 April 1872

1 March 1877

John Gardiner Austin

Administrator

1 March 1877

22 April 1877

Sir John Pope Hennessy

軒尼詩

22 April 1877

7 March 1882

Malcolm Struan Tonnochy

Administrator

7 March 1882

28 March 1882

Sir William Henry Marsh

Administrator

28 March 1882

30 March 1883

Sir George Bowen

寶雲

30 March 1883

21 December 1885

Sir William Henry Marsh

Administrator

21 December 1885 25 April 1887

William Gordon Cameron

Administrator

25 April 1887

6 October 1887

Sir William Des Voeux

德輔

6 October 1887

7 May 1891

Sir George Digby Barker

Administrator

7 May 1891

10 December 1891

Sir William Robinson

羅便臣

10 December 1891 1 February 1898

2 6 6   |   A ppendix 2

Cont’d Table 1 Governor*/

Name

administrator 

Start date

End date 25 November 1898

Sir Wilsone Black

Administrator

1 February 1898

Sir Henry Arthur Blake

卜力

25 November 1898 21 November 1903

Sir Francis Henry May

Administrator

21 November 1903 29 July 1904

Sir Matthew Nathan

彌敦

29 July 1904

20 April 1907

Sir Francis Henry May

Administrator

20 April 1907

29 July 1907

Sir Frederick Lugard

盧吉

29 July 1907

16 March 1912

Claud Severn

Administrator

16 March 1912

24 July 1912

Sir Francis Henry May

梅含理

24 July 1912

12 September 1918

Claud Severn

Administrator

12 September 1918 30 September 1919

Sir Reginald Edward Stubbs

司徒拔

30 September 1919 19 March 1925

Claud Severn

Administrator

19 March 1925

Sir Cecil Clementi

金文泰

01 November 1925 01 February 1930

Thomas Southorn

Administrator

01 February 1930

09 March 1930

Sir William Peel

貝璐

09 May 1930

17 May 1935

Thomas Southorn

Administrator

17 May 1935

13 September 1935

Norman Lockhart Smith

Administrator

13 September 1935 01 November 1935

Thomas Southorn

Administrator

01 November 1935 12 December 1935

Sir Andrew Caldecott

郝德傑

12 December 1935 16 April 1937

Norman Lockhart Smith

Administrator

16 April 1937

28 October 1937

Sir Geoffry Northcote

羅富國

28 October 1937

06 September 1941

Norman Lockhart Smith

Administrator

06 September 1941 10 September 1941

Sir Mark Young

楊慕琦

10 September 1941 25 December 1941

*

01 November 1925

Note:  Chinese names were given to the Governors. Source:  Information in this table was modified from “Governor of Hong Kong,” Wikipedia, accessed on 5 January 2016, https://en.wikipedia.org/wiki/Governor_of_ Hong_Kong.

A ppendix 2   |   2 6 7

Table 2  Secretary of State for the Colonies, 1841–1941 Name

Start date

End date

Political party

Lord John Russel

30 August 1839

30 August 1841

Whig

Lord Stanley (Later Earl of Derby)

3 September 1841

23 December 1845

Conservative

William Ewart Gladstone

23 December 1845

27 June 1846

Conservative

The Earl Grey

6 July 1846

21 February 1852

Whig

Sir John Pakington

27 February 1852

17 December 1852

Conservative

The Duke of Newcastle

28 December 1852

10 June 1854

 

Sir George Grey, Bt

12 June 1854

8 February 1855

Whig

Sidney Herbert

8 February 1855

23 February 1855

Whig

Lord John Russell

23 February 1855

21 July 1855

Whig

Sir William Molesworth

21 July 1855

21 November 1855

Whig

Henry Labouchere

21 November 1855

21 February 1858

Whig

Lord Stanley (later 15th Earl of Derby)

26 February 1858

5 June 1858

Conservative

Sir Edward Bulwer-Lytton

5 June 1858

11 June 1859

Conservative

The Duke of Newcastle

18 June 1859

7 April 1864

Liberal

Edward Cardwell

7 April 1864

26 June 1866

Liberal

The Earl of Carnarvon

6 July 1866

8 March 1867

Conservative

The Duke of Buckingham and Chandos

8 March 1867

1 December 1868

Conservative

The Earl Granville

9 December 1868

6 July 1870

Liberal

The Earl of Kimberley

6 July 1870

17 February 1874

Liberal

The Earl of Carnarvon

21 February 1874

4 February 1878

Conservative

Sir Michael Hicks Beach

4 February 1878

21 April 1880

Conservative

The Earl of Kimberley

21 April 1880

16 December 1882

Liberal

15th Earl of Derby

16 December 1882

9 June 1885

Liberal

Frederick Stanley (16th Earl of Derby)

24 June 1885

28 January 1886

Conservative

The Earl Granville

6 February 1886

20 July 1886

Liberal

Edward Stanhope

3 August 1886

14 January 1887

Conservative

The Lord Knutsford

14 January 1887

11 August 1892

Conservative

The Marquess of Ripon

18 August 1892

21 June 1895

Liberal

Joseph Chamberlain

29 June 1895

16 September 1903

Liberal Unionist

Alfred Lyttelton

11 October 1903

04 December 1905

Liberal Unionist

2 6 8   |   A ppendix 2

Cont’d Table 2 Name

Start date

End date

Political party

The Earl of Elgin

10 December 1905

12 April 1908

Liberal

The Earl of Crewe

12 April 1908

03 November 1910

Liberal

Lewis Vernon Harcourt

03 November 1910

25 May 1915

Liberal

Andrew Bonar Law

25 May 1915

10 December 1916

Conservative

Walter Long

10 December 1916

10 January 1919

Conservative

The Viscount Milner

10 January 1919

13 February 1921

Liberal

Winston Churchill

13 February 1921

19 October 1922

Liberal

The Duke of Devonshire

24 October 1922

22 January 1924

Conservative

James Henry Thomas

22 January 1924

03 November 1924

Labour

Leo Amery

06 November 1924

04 June 1929

Conservative

The Lord Passfield

07 June 1929

24 August 1931

Labour

James Henry Thomas

25 August 1931

05 November 1931

National Labour

Sir Philip Cunliffe-Lister

05 November 1931

07 June 1935

Conservative

Malcolm MacDonald

07 June 1935

22 November 1935

National Labour

James Henry Thomas

22 November 1935

22 May 1936

National Labour

William Ormsby-Gore

28 May 1936

16 May 1938

Conservative

Malcolm MacDonald

16 May 1938

12 May 1940

National Labour

The Lord Lloyd

12 May 1940

08 February 1941

Conservative

The Lord Moyne

08 February 1941

22 February 1942

Conservative

Source:  “Secretary of State for the Colonies,” Wikipedia, accessed on 28 January 2016, https://en.wikipedia.org/wiki/Secretary_of_State_for_the_Colonies.

A ppendix 2   |   2 6 9

Table 3  Heads of medical services in Hong Kong, 1843–1941 Year

Title of head of service

Name

1843–1844 1844–1846 1846–1847 1847–1854 1854–1858 1858 1858 1858–1859 1859–1872 1872–1873 1873–1897 1897–1912

Colonial Surgeon Colonial Surgeon Colonial Surgeon Colonial Surgeon Colonial Surgeon Colonial Surgeon Colonial Surgeon Colonial Surgeon Colonial Surgeon Colonial Surgeon Colonial Surgeon Principal Civil Medical Officer (in charge of both Medical and Sanitary Department) Principal Civil Medical Officer (in charge of Medical department) Principal Civil Medical Officer (in charge of Medical department) Director of Medical and Sanitary Services (in charge of both Medical and Sanitary Department) Director of Medical Services (Medical and some of the services in the Sanitary Departments combined). Urban Council created in 1936 to deal with the remaining sanitary and other services Director of Medical Services (in charge of Medical Department)

Anderson, Alexander Dill, Francis Young, Peter (Acting) Morrison, William Dampster, J. Carroll (half-time) Menzies, Edward (Acting) Chaldecott, T.A. (Acting) Harland, William Murray, Ivor John McCoy, R. (Acting) Ayres, Philip Bernard C. Atkinson, John Milford

1912–1923 1923–1929 1929–1936

1936–1938

1938–1941

Johnson, John Taylor Connell Addison, Joseph Bartlett Wellington, Arthur Robartes

Wellington, Arthur Robartes

Selwyn-Clarke, Percy Selwyn

Source:  Medical Reports, Medical and Sanitary Department Reports of Hong Kong Blue Books, Hong Kong Sessional Papers and Hong Kong Administrative Reports, 1842–1941.

This page intentionally left blank

Notes

Chapter 1 1. 2. 3. 4.

5. 6. 7.

8. 9. 10. 11. 12. 13.

S. Tsang, A Modern History of Hong Kong (Hong Kong: Hong Kong University Press, 2004), 16. G. R. Sayer, Hong Kong 1841−1862. Birth, Adolescence and Coming of Age. Introduction and additional notes by D. M. Emrys Evans (Hong Kong: Hong Kong University Press, 1980), 103. Ibid., 109–110. Most publications stated that 50 lots were sold at the first auction, but it was not true according to Mr. Gordon the Land Officer’s Report on the Northern Face of Hong Kong. A total of 440 lots were sold. 6 July 1943, CO 129/2, 52–76. Ho Puiyin. Challenges for an Evolving City. 160 Years of Port and Land Development in Hong Kong (Hong Kong: The Commercial Press, 2004), 25–27. Sayer, Hong Kong 1841–1862. Birth, Adolescence and Coming of Age, 116–117. G. B. Endacott, A Biographical Sketch-book of Early Hong Kong (Singapore: Eastern University Press, 1962), 15. In 1842, there was a change in British Government when the Tories took over with Lord Aberdeen as the Foreign Secretary who made some important changes in policy in that acquisition of territories were not to be regarded as permanent colonies. It was more important for the British to secure a treaty which would open four or five additional ports, where the British consuls could be stationed. The islands seized should be considered as useful military bases, and as pawns in negotiations because colonies were expensive to keep and maintain. Pottinger, however felt that the settlement in Hong Kong was by then too far advanced not to retain it. (Endacott, A History of Hong Kong 1964 [Hong Kong: Hong Kong University Press, 1964], 20–21). G. B. Endacott, A History of Hong Kong, 2nd ed. (Hong Kong: Oxford University Press, 1964), 34. Pottinger to Lord Stanley (Secretary of State for the Colonies), Land Committee, 23 June 1843, CO 129/2 #2, 63–65. D. E. Evans, “Chinatown in Hong Kong: The Beginnings of Tai Ping Shan.” JHKBRAS10 (1970): 69–78. Ibid. Lieutenant General Hugh Gough to Rear Admiral Sir William Parker, Military Operations in China, 22 November 1841, CO129/1, 258. M. Bardin, Surgeon, HM 98th Regiment, Appendix B, Monthly Return of Sick

2 7 2   |   N otes ： C hapter 1

14. 15. 16. 17. 18. 19. 20.

21. 22. 23.

24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34.

European Troops in Hospital of HM 98th Regiment for the Months of June, July, August and September, CO 129/1, 143–146. Pottinger to Gough, Cause of Illness Among Troops, 10 October 1842, CO 129/1, 120. Gough to Lord Saltoun, President of Court of Enquiry, Cause of Illnesses, 29 November 1842, CO 129/1, 130–131. Pottinger to Saltoun (Major General Commanding Land Force in China), Land in Current Admiralty Area, 2 May 1843, CO 129/2 #186, 69–72. Aldrich’s Memoranda with Reference to Barrack and Hospital Accommodation and to Internal Defence Drawn Up on the Instructions of the Major General Commanding, 28 June 1843, CO 129/2, 120–127. Pottinger to Stanley, His Plan for Admiralty Area, 4 July 1843, CO 129/2, 130–137. Saltoun to Pottinger. “Battle” over Admiralty, 29 June 1843, CO 129/2, #163, 102–103. J. Thomson, Superintendent Surgeon of China Forces, Proceedings of a Medical Committee by Order of Major General Lord Saltoun, Commander of the Force in China to Report on the Causes of the Sickness and Mortality of Left Wing HM’s 55th Regiment, 15 July 1843, CO 129/7, 182–189. Stanley to Pottinger, Decision on Admiralty Area, 9 December 1843, CO 129/4, 216–220. Woosnam (Pottinger’s private secretary) to Captain D’Aquilar (Assistant Military Secretary), Military and Naval Hospitals, 18 March 1844, CO 129/10 #110, 705– 756 (Five Gun Battery occupied current day Battery Path). Reference 10. Evans, “Chinatown in Hong Kong: The Beginnings of Tai Ping Shan,” 70–71. The  Government Hill  is a hill in  Central, Hong Kong, bounded by upper section of Upper Albert Road on the south, Queen’s Road Central north, Garden Road east, and Glenealy, west of Hong Kong Island. Caine, Gutzlaff, and Gordon (Committee) to Woosnam (Pottinger’s private secretary), Decision Relating to the Lot Owners of Upper Bazaar, 2 April 1844, CO 129/6, 440–441. Woosnam to Committee, 17 August 1844, CO 129/6, 442–443. Endacott, A History of Hong Kong, 23. Davis to Stanley, Preparation of Land and Move of Chinese to Tai Ping Shan, 26 July 1844, CO 129/6, 435–436. Census and Registration Office to Mercer (Colonial Secretary), 4 July 1855, CO 129/51, 28–32. Sayer, Hong Kong 1841–1862. Birth, Adolescence and Coming of Age, 122. J. W. Norton-Kyshe, The History of Laws and Courts of Hong Kong: From the Earliest Period to 1898, vol. 2 (Hong Kong: Vetch and Lee Ltd., 1971), 5. H. Lethbridge, Hong Kong: Stability and Change (Hong Kong: Oxford University Press, 1978), 167. Endacott, A History of Hong Kong, 71. Tsang, A Modern History of Hong Kong, 58. Pottinger to Stanley, Executive and Legislative Council, 13 November 1843, CO 129/2, 348–350.

N otes ： C hapter 1   |   2 7 3

35. N. J. Miner, Hong Kong under Imperial Rule (1912–1941) (Hong Kong: Oxford University Press, 1987), 28–30. 36. Hong Kong Blue Books, 1845–1860. 37. Endacott, A Biographical Sketch-book of Early Hong Kong, 26. 38. Miners, Hong Kong under Imperial Rule, 212. 39. Endacott G. B., An Eastern Entrepot (London: Her Majesty’s Stationery Office, 1964), 77. 40. Endacott, An Eastern Entrepot, 82–87. 41. Colonial Surgeon Annual Reports for 1887–1893. 42. Colonial Surgeon Annual Report for the Year 1882, Hong Kong Blue Book, 1882. 43. House of Commons Debates, 6 May 1908, Vol. 188, 341–345; Lugard to Colonial Office, 6 May 1908, CO 129/347, 220–225. 44. Lugard to Colonial Office, 13 June 1908, CO 129/347, 499; 12 December 1908, CO 129/349, 228; Colonial Office to Lugard, 8 January 1909, CO 129/349, 76– 119. 45. Colonial Office Memorandum in CO 129/386, 44–46. 46. N. J. Miners, “The Hong Kong Government Opium Monopoly, 1914–1941,” The Journal of Imperial and Commonwealth History, Vol. XI (1983), 275–299. 47. Hong Kong Legislative Council, Memorandum Regarding the Stricter control of Opium in Hong Kong and China, Hong Kong Sessional Papers, 1909, 26–32. 48. Modified from Table 9 in Miners, Hong Kong under Imperial Rule, 232. 49. Miners, Hong Kong under Imperial Rule, 275. 50. Colonial Surgeon Annual Report for Year 1848. Hong Kong Blue Book, 1848, 178– 179. 51. Colonial Surgeon Annual Report on Population. Hong Kong Blue Books, 1845–1861. 52. Colonial Surgeon Annual Report for Year 1845, Table 2, Hong Kong Blue Book, 1845. 53. Davis to Stanley, Sickness of European Police, 2 November 1844, CO 129/7 #62,168–170. 54. Bonham to Earl Grey, Sickness in the Troops, 20 June 1850, CO 129/33 #56, 59–60. 55. Enclosure in Robinson to Duke of Newcastle, Type of Sickness Seen in Government Civil Hospital, 23 April 1863, CO 129/92 #89, 57. 56. Canton Press, 9 September 1843. 57. See note 20. 58. Woosnam to Gordon, Report of Committee of Public Health, 17 August 1843, CO 129/10, #59, 503. 59. Woosnam (Pottienger’s Private Secretary) to Caine, 15 February 1844, CO 129/10, 659; 19 February 1844, CO 129/10, 649; and 22 February 1844, CO 129/10, 671. 60. Dill (Colonial Surgeon) to Davis, Improvement in Health of Colony, 14 August 1846, Enclosed in Davis to Gladstone, CO 129/17, 34–36. 61. D’Aguilar to Colonial Secretary, Royal Engineers, 23 July 1845, CO 129/12, 61; Davis to Gladstone, Road around the Island, 15 June 1846, CO 129/16 #73, 438–439.

2 7 4   |   N otes ： C hapter 1

62. Dill to Governor Davis, Reduction in Mortality among Troops, Enclosed in Davies to Gladstone (Secretary of State for the Colonies), 19 August 1846, CO 129/17#99, 92. 63. Aldrich (Commanding Officer, Royal Engineer) to Bruce (Colonial Secretary), Tanks and Wells, 11 May 1846, Enclosure in Davis to Gladstone, CO 129/16 #70, 451–453. 64. Gough to Lord Saltoun, President of Court of Enquiry, Moira and Salaiman, 29 November 1842, CO 129/1,164–165. 65. Bonham to Earl Grey, Minden—A Hospital Ship, 22 May 1851, CO 129/36 #37, 237–238. 66. Bonham to Duke of Newcastle, 20 October 1853, CO 129/43 #81, 309–311; Adminstrator to Colonial Office, Appointment of Dr. J. Dempster Half Time Shared with Military, 22 September 1856, CO 129/57 #108, 25–26. 67. Lethbridge, Hong Kong: Stability and Change, 165. 68. D. Haynes, Imperial Medicine: Patrick Manson and the Conquest of Tropical Disease (Philadelphia: University of Pennsylvania Press, 2001), 126–128 (Doctors in colonial service). 69. Pottinger to Stanley, Appointment of Colonial Surgeon, 13 November 1843, CO 129/2 #23, 352. 70. Davies to Stanley, Colonial Surgeon, 19 July 1844, CO 129/6 #38, 377–378. 71. Colonial Office to Davis, Appointment of Dr. Morrison as Colonial Surgeon, 10 May 1847, CO 129/17 #118, 239. 72. Adminstrator to Colonial Office, Appointment of Dr. J. Dempster Half Time Shared with Military, 22 September 1856, CO 129/57 #108, 25–26. 73. Appointment of Dr. Harland as Colonial Surgeon, 13 April 1858, CO 129/70, 14. 74. Bowring to Lytton, Arrival of Dr. Murray, 12 April 1859, CO 129/73, #68, 453– 454. 75. Pottinger to Stanley, Seamen Hospital, 28 November 1843, CO 129/2 #25, 369– 372. 76. “Hospitals in the Nineteenth Century,” Hong Kong’s First, accessed on 7 August 2013, http://hongkongsfirst.blogspot.hk/2009/10/hospitals-in-nineteenthcentury.html. 77. Anderson to Pottinger, Charges of the Seamen Hospital, 1 August 1843, Enclosed in Pottinger to Lord Aberdeen, 20 November 1843, CO 129/8. 35–36. 78. Pottinger to Stanley, Fund to Seamen’s Hospital Combining Seamen’s Hospital with “Colonial Hospital,” 18 June 1844, CO 129/6 #16, 141–144. 79. Treasury Chambers to Colonial Office, Low level civil servants were not entitled to medical care, 31 October 1844, CO 129/9, 207–208. 80. Miners, Hong Kong under Imperial Rule, 101. 81. Davis to Stanley, Policemen Treated in Military Hospital, 8 May 1845, CO 129/12 #55, 49–51. 82. Bonham to Grey, Police (Civil) Hospital, 8 September 1848, CO 129/26 #70, 10–20. 83. Bowring to Lytton, Purchase of a House to be the Government Civil Hospital on IL24, 25 January 1859, CO 129/73 #16, 107–108.

N otes ： C hapter 2   |   2 7 5

84. Colonial Surgeon Annual Report 1860, Hong Kong Blue Book, 1860. 85. Robinson to Duke of Newcastle, Appointment of Dr. Scott, 1 October 1861, CO 129/82 #176, 153. 86. Colonial Surgeon Annual Report 1893, Appendix B, Government Civil Hospital, Hong Kong Sessional Papers, 1894, 388. 87. See note 86. 88. Whitfield (Major General and Lieutenant-Governor) to Earl of Kimberly (Secretary of State for the Colonies), The Government Civil Hospital Lack of Space, 10 June 1871, CO 129/150 #81, 364–365. 89. Surveyor-General to Austin (Colonial Secretary), Changing Lock Hospital to Civil Hospital, 2 September 1876, CO 129/175 #81, 335–344. 90. Colonial Surgeon Annual Report 1878, The Lock Hospital, Hong Kong Sessional Papers, 1879. 91. Marsh to Hicks-Beach, Erection of New Lock Hospital, 7 June 1879, CO 129/185 #5, 20–47. 92. Precis of papers referring to the conversion of Lock Hospital to a general hospital in letter from Marsh to Kimberley, 15 May 1882, CO 129/200 #64, 195–233. 93. Colonial Surgeon Annual Report for 1883, Hong Kong Sessional Papers, 1884, para 52. 94. Colonial Surgeon Annual Report for 1890, Government Civil Hospital, Hong Kong Sessional Papers, 1891, 328. 95. Des Veoux to Knutsford, Nurses at Government Civil Hospital, 2 July 1888, CO 129/238 #180, 3–4.

Chapter 2 1. 2. 3. 4. 5.

6. 7. 8. 9.

F. E. Cartwright, Disease and History (New York: Thomas Y. Corwell Company, 1972), 63. Ibid., 58. S. Watts, Epidemics and History. Disease, Power and Imperialism (New Haven: Yale University Press, 1997), 143. Cartwright, Diseases and History, 78–79. J. Forrai, “History of Different Therapeutics of Venereal Disease before the Discovery of Penicillin,” InTechOpen, accessed 6 June 2013, https://www. intechopen.com/books/syphilis-recognition-description-and-diagnosis/historyof-different-therapeutics-of-venereal-disease-before-the-discovery-of-penicillin. E. Sinn, “Women at Work: Chinese Brothel Keepers in Nineteenth Century Hong Kong,” Journal of Women’s History 19 (2007): 87–111. Population, Hong Kong Blue Book and Hong Kong Sessional Papers, 1847–1940. H. Lethbridge, “The Evolution of a Chinese Voluntary Association in Hong Kong: The Po Leung Kuk,” in Hong Kong: Stability and Change: A Collection of Essays (Hong Kong: Oxford University Press, 1978), 71. Report of the Commissioners Appointed by His Excellency Sir John Pope Hennessy, CMG to Enquire into the Workings of the Contagious Diseases Ordinance, 1867, published in 1879, 3.

2 7 6   |   N otes ： C hapter 2

10. Ibid., 4. 11. See note 6. 12. C. Henriot, Prostitution and Sexuality in Shanghai: A Social History 1849–1949, trans. N. Castelino (Cambridge: Cambridge University Press, 2001), 141–147. 13. Ibid., 150. 14. Stirling (Rear Admiral Cammander in Chief ) to Bowen, 12 January 1854 and Stirling to Bridges (Acting Attorney General), 7 March 1855, CO 129/50 #80, 352. 15. Colonial Surgeon Annual Report for year 1857, quoted in Letter of Kimberley to Hennessy, 26 July 1881, CO 129/188, 416. 16. Colonial Surgeon Annual Report for 1878, The Lock Hospital, Hong Kong Blue Book, 1878. 17. Ordinance 12 of 1857, CO 129/62 #52, 485–487. 18. Colonial Surgeon Annual Reports 1862–1868, Hong Kong Blue Books, 1862–1868. 19. Bowring to Labouchere, Draft of Venereal Disease Ordinance, 2 May 1855, CO 129/55 #69, 230–254. 20. MacDonnell to Duke of Buckingham and Chandos, Contagious Diseases Ordinance 1867, 10 August 1867, CO 129/124 #350, 92. 21. Report of the Commissioners, 1879, 10−28, Colonial Surgeon Report of 1869, IV The Lock Hospital, Hong Kong Sessional Papers, 1870. 22. Colonial Surgeon Report of 1869, IV The Lock Hospital, Hong Kong Sessional Papers, 1870. 23. Contagious Diseases Ordinance 1867, CO 129/124 #350, 88–130. 24. MacDonnell to Duke of Buckingham and Chandos, Medical Examination of Prostitutes, 3 July 1868, CO 129/131 #534, 252–254. 25. MacDonnell to Duke of Buckingham and Chandos, Medical Examination of Prostitutes, 23 August 1868, CO 129/129 #463, 406–424. 26. MacDonnell to Duke of Buckingham and Chandos, Medical Examination of Prostitutes, 23 August 1868, CO 129/129 #463, 412. 27. See note 16. Colonial Surgeon Annual Report for 1878, The Lock Hospital, Hong Kong Blue Book, 1878. 28. Correspondence between Medical Officers of the Army and Navy and the Colonial Surgeon, Enclosure in Military Secretary’s Office to Colonial Secretary in October 1879, CO 129/185 #104, 428–443. 29. Colonial Surgeon Report 1870–1877, Lock Hospital, Hong Kong Blue Book, 1870– 1877. 30. Colonial Surgeon Report of 1870, 134−135 and 1878, The Lock Hospital, Hong Kong Blue Book, 1870 and 1878. 31. The Lock Hospital together with Government Civil Hospital and its annexes formed a hospital complex in Sai Ying Pun, occupying land immediately east of Eastern Street bounded by Hospital Road on the south with an entrance to the complex from Queen’s Road west through a small slip road. The land currently is occupied by Prince Philip Dental Hospital, Tsan Yuk Hospital, and part of Sai Ying Pun Jockey Club Clinic. 32. Kennedy to Earl of Carnavon, Prevalence of Venereal Diseases in Troops, 4 January 1875, CO 129/170 #1, 13.

N otes ： C hapter 2   |   2 7 7

33. Report of the Commissioners, 1879, 33 (Prevalence of venereal diseases among naval men). 34. Report of the Commissioners, 1879, 27 (Two women tried to escape and were killed). 35. See notes 32 and 33. 36. Report of the Commissioners, 1879, 52–53. 37. The Right Hon Earl of Kimberley to Governor Sir John Pope Hennessy, KCMG on Report of the Commissioners on Inquiry into the Workings of the Contagious Disease Act of 1867, 26 July 1881, CO 129/188 #90, 414–420. 38. S. W. Poon, “Five years of Mischievous Activity. A Study of Governor Hennessy’s policies Towards the Chinese in Hong Kong, 1877–1882” (MPhil e-thesis, Hong Kong Baptist University, 1995), 13. 39. Halifax, Secretary for Chinese Affairs, Public Brothels in Hong Kong, 23 April 1923, Enclosure in Stubbs to Devonshire, 7 July 1923, CO 129/480 #235, 263. 40. Marsh, Administrator to Kimberley, Amendments to 1867 Contagious Disease Ordinance, 28 October 1883, CO 129/202 #237, 418–442. 41. “Brothel Slavery,” Daily Press, 29 September 1882. Enclosed in Marsh to Kimberley 27 September 1882, CO 129/202 #209, 666. 42. Registrar General to Colonial Secretary, 12 September 1882, 430, Enclosed in Marsh to Kimberley, 28 October 1882, CO 129/202 #237, 418–442. 43. Minutes by Bramston on Amended Contagious Disease Ordinance, 5 May 1883, CO 129/209 #51, 64. 44. F. B. Smith, “Contagious Diseases Act reconsidered,” Social History of Medicine 3, no. 2 (1990): 197–215. 45. C. Jones, “Women and the Law in Colonial Hong Kong,” in 25 years of Social and Economic Development in Hong Kong, eds. B. K. P. Leung and T. Y. C. Wong (Hong Kong: Hong Kong University, 1994), 111–113 46. N. J. Miner, Hong Kong under Imperial Rule (1912–1941) (Hong Kong: Hong Kong University Press, 1987), 193–194. 47. Idem. 48. Barker, Adminstrator for the Government to Chamberlain, Draft Bill on Venereal Disease, 18 November 1898, CO 129/286 #321, 74. 49. Chamberlain to Blake, Draft Bills on Venereal Disease, 11 May 1899, CO 129/286 #321, 103−118. The “Protection of Women and Girls” Ordinance was enacted in Hong Kong in 1897. 50. Blake to Chamberlain, Venereal Disease, 8 July 1899, CO 126/292, Confidential, 261. 51. Confidential Report, National Council for Combating Venereal Diseases (NCCVD) Combissioners Transmitted to the Colonial Office, April 1921, CO 129/472, 356–383. 52. Idem. 53. C. Neville-Rolfe to W. G. A. Ormsby-Gore, MP, 28 June 1923, Enclosed in CO 129/483, 71 and 160. 54. Grindle, Memorandum on Matters Discussed by Deputation Received by the Secretary of State at the House of Commons, 25 March 1924, CO 129/487, 45–71.

2 7 8   |   N otes ： C hapter 3

55. Stubbs to Thomas MP, Public Health Policy, 8 March 1924, CO 129/484, Confidential, 125. 56. See note 45. 57. Miner, Hong Kong under Imperial Rule, 196. 58. Halifax, Secretary for Chinese Affairs, Public Brothels in Hong Kong, 23 April 1923, Enclosure in Stubbs to Devonshire, 7 July 1923, CO 129/480 #235, 254–263. 59. See note 58. 60. H. MacFarlane and G. E. Aubrey, “Venereal Diseases among the Natives in Hong Kong,” The Caduceus April (1922): 22–27. 61. Society for the Prevention of Venereal Disease to Severn, Colonial Secretary, 7 April 1921, CO 129/474, 341–356. 62. Peel to Lord Passfield, 26 Ocotber 1930, CO 129/522 #3, 26–52. 63. Secretary of State for the Colonies to Peel, 29 September 1931, CO 129/533 #10, 6. 64. Medical and Health Department Annual Reports, Hong Kong Government, 1951–2011.

Chapter 3 1.

J. F. Tsai, Hong Kong in Chinese History (New York: Columbia University Press, 1993), 70. 2. C. Munn, Anglo-China: Chinese People and British Rule in Hong Kong 1841–1880 (Richmond, Surrey Curzon, 2001), 73–75; C. T. Smith, “The Emergence of a Chinese Elite in Hong Kong,” JHKBRAS; 11 (1971): 74–115. 3. W. K. Chan, The Making of Hong Kong Society: Three Studies of Class formation in Early Hong Kong (Oxford: Clarendon Press, 1991), 73. 4. C. T. Smith, “Notes on Chinese Temples in Hong Kong,” JHKBRAS 12 (1972): 133–139. 5. Tsai, Hong Kong in Chinese History, 45–47. 6. There used to be a Nam Pak Hong Street, later renamed Bonham Strand West. In this location, the firms set up dealt with native products from south and north China. The Nam Pak Hong Association was founded in 1868 to promote members’ welfare and market prosperity and to assist the police in maintaining law and order. 7. C. T. Smith, “Notes and Queries. The Nam Pak Hong Commercial Association in Hong Kong”. JHKBRAS 19 (1979): 216–226. 8. Chan, The Making of Hong Kong Society, 74. 9. Davis to Stanley, Constituents of police force, 1 June 1844, CO 129/6 #10, 110. 10. H. J. Lethbridge, “The District Watch Committee,” JHKBRAS 11 (1971): 116–141; The Registrar General’s office was established by Governor Davis in 1844 to assume the responsibility of all issues relating to the Chinese and to improve the communication between the government and the Chinese community. But in fact the appointment of the Registrar General did little to remedy the poor communication because of language barrier. Even though later the position of Registrar General was filled by cadets who had commands over the Chinese

N otes ： C hapter 3   |   2 7 9

11. 12.

13. 14.

15. 16. 17. 18. 19. 20. 21.

22.

23. 24. 25.

language, the need of someone with such a skill was so great that he was constantly asked to do other jobs. E. Sinn, Power and Charity: A Chinese Merchant Elite in Colonial Hong Kong (Hong Kong: Hong Kong University Press, 2003). A memorial tablet is a placard used to designate the seat of the spirit of a dead person or past ancestor or a deity as well as to enclose it. With origins in traditional Chinese culture, the spirit tablet is a common sight in many East Asian countries where any form of ancestor veneration is practiced. Spirit tablets are traditional ritual objects commonly seen in temples, shrines, and household altars throughout China and Taiwan. C. T. Smith, A Sense of History: Studies in the Social and Urban History of Hong Kong (Hong Kong: Hong Kong Educational Publishing Co. 1995), 147. Report of A. Lister, 24 April 1869, Report on Tung Wa Hospital (TWR), 1896, IX– X, Hong Kong Sessional Papers, 1896. Also in CO 129/138 #726, 162–168. Leung’s group subsequently built a hospital at the corner of King Sing Street and Stone Nullah Lane in 1867. It was listed on the 1872 Rate Evaluation as the Wah To (Hua To) Hospital. It lasted until 1886/1887 when it was called Wah To Temple. Lister to Colonial Secretary, 22 April 1869, TWR VI–VII. MacDonnell to Granville, 21 June 1869, CO 129/138 #726, 146. MacDonnell to Granville, Chinese Hospital, 18 August 1869, CO 129/139 #775, 62. Report of the Attorney General upon Ordinance No. 3 of 1870, 6 April 1870, Enclosed in MacDonnell to Granville, 9 April 1870, CO 129/144 #903, 151. Tung Wah Hospital (TWH) Annual Report 1873, TWH Archive. TWH Annual Report 1907, TWH Archive. The xieli were assistant directors and were elected to inspect all the patients and servants of the hospital and to ensure that the payments and receipts were kept correctly. There were twenty xieli in 1873. The zhishi were assistants to the zongli and xieli. They took monthly turns to audit accounts and ensured the correct procedures were adhered to in all departments. The zhishi were elected from various guilds. Each guild elected one or two zhishi and the larger guilds could elect up to five zhishi. There were ninety eight founding zhishi. Tung Wah Group of Hospitals. One Hundred Years of the Tung Wah Group of Hospitals 1870–1970. Book 2 (Hong Kong: Tung Wah Group of Hospitals, 1970), 2. The chairman of the committee was Leung On, alias Leung Hok-chau, comprador of Gibbs, Livingston and Co., one of the most prominent foreign firms. Other directors included Wong Shing, Dr. James Legge’s collaborator, and Lo Chen-kong, comprador of the Hongkong and Shanghai Bank. An important component of the hospital committee included those nominated by the guilds, such as the Nam Pak Hong, the Piece-Goods and Silk Guild, the Californian Merchants’ Guild, the Chinese Medicine Guild, and the Pawnbrokers Guild. H. J. Lethbridge, “Chinese Association in Hong Kong: The Tung Wah,” Contributions to Asian Studies 11 (1971): 144–158; J. Hayes, “Visit to Tung Wah Group of Hospital’s Museum, 2 October 1976,” JHKBRAS 16 (1976): 262–280. TWH Annual Report 1895, TWH Archive. MacDonnell to Earl of Kimberley. Chinese Hospital. 19 February 1872, CO 129/156 #947, 339. Gambling, an endemic problem in Hong Kong, when illegal

2 8 0   |   N otes ： C hapter 3

26. 27.

28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46.

was a source of police corruption. Licenced gambling proposed by Governor MacDonnell to control the vice had been rejected by the Colonial Office. However, MacDonnell quietly established a gambling licencing system in 1867 without the approval of the Colonial Office; later it was changed to a monopoly bringing in huge revenue for the government. The fund later proved to be “embarrassingly large” that the question of what to do with it became urgent. The Colonial Office then instructed that the Gambling Fund be kept separate, hoping that eventually it could be used to suppress gambling altogether. Sinn, Power and Charity, 37–38. I. Bird, The Golden Chersonese and the Way Thither. Oxford in Asia Historical Reprints. (Kuala Lumpur: Oxford University Press, 1967), 87–90. Shennong, a legendary ruler of China and culture hero and deity, is considered to have been one of the Three Sovereigns (also known as “Three Emperors”) who lived some 5,000 years ago. Shennong has been thought to have taught the ancient Chinese not only their practices of agriculture, but also the use of herbal drugs. Shennong is among the group of variously named heroic persons and deities who have been traditionally given credit for various inventions: these include the hoe, plow, axe, digging wells, agricultural irrigation, preserving stored seeds by using boiled horse urine, the weekly farmers market, the Chinese calendar, and to have refined the therapeutic understanding of taking pulse measurements, acupuncture, and moxibustion. TWH Annual Report of 1878, TWH Archive and note 20. See note 20. See note 28. See note 26. Colonial Surgeon Reports 1875–1896, TWH. Hong Kong Sessional Papers, 1876– 1897. Colonial Surgeon Reports 1875–1882. TWH. Hong Kong Sessional Papers, 1876– 1883. Sinn, Power and Charity, 62–63. TWH attempted to train doctors. Colonial Surgeon Report 1876, TWH. Hong Kong Blue Book, 1876. Colonial Surgeon Report 1873, TWH. Hong Kong Blue Book, 1873. Colonial Surgeon Report 1874, TWH, Hong Kong Blue Book, 1874. TWH Annual Report 1874, TWH Archive. Sinn, Power and Charity, 99–100. Philanthropy and awards. Sinn, Power and Charity, 109–10. TWH’s service to overseas Chinese. Sinn, Power and Charity, 89–98. TWH acting as a civic centre, hospital committee as judge. Sinn, Power and Charity, 113–17. Po Leung Kuk. H. F. Hance, (British Consul in Canton) to Foreign Office 5 November 1878, Enclosed in FO to CO, 30 December 1878, CO 129/183 #37, 269. Hicks-Beach to Hennessy, 20 February 1879, confidential, CO 129/183, 275. Marsh to Kimberley, Chinese Recreational Ground, 14 August 1882, CO 129/202 #161, 349. Marsh to Derby, Cargo Boatmen Strike, 6 October 1884, CO 129/217 #340, 414.

N otes ： C hapter 4   |   2 8 1

47. Hennessy to Hicks-Beach. Ng Choy on Legislative Council, 19 January 1880, CO 129/187 #4. 46. Ng Choy was the first Chinese to be appointed to the Legislative Council by Governor Hennessy in 1880. Wong Shing, Ho Kai, Boshan Wei Yuk, and Lau Chu-pak served at different times on the Legislative Council. 48. J. Lowson. Report of 1894 plague, 1 March 1895, Hong Kong Sessional Papers, 1896. 49. Robinson to Chamberlain, Lowson’s Report on TWH, 24 January 1896, CO 129/271, Confidential, 73–75. 50. Lowson’s Testimony, TWR, 1896, xxv. 51. Atkinson’s Testimony, TWR 1896, xxii. 52. Clark’s Testimony, TWR, 1896, xxvi. 53. McCallam’s Testimony, TWR, 1896, xxvii. 54. Commissioners’ decision, TWR, 1896, xxviii. 55. Commissioners’ recommendations, TWR, 1896, xxx–xxxii. 56. China Mail, 3 December 1896, Enclosed in Robinson to Chamberlain, 9 December 1896, CO 129/273 #294, 406–407. 57. Thomson’s Report on TWH, 9 December 1896, Enclosed in Robinson to Chamberlain, CO 129/273 #294, 406–407. 58. Thomson’s Report on TWH, 9 April 1897, Enclosed in Robinson to Chamberlain, 21 April 1897, CO 129/275 #83, 354–368. 59. Colonial Surgeon Annual Reports, 1897–1920, Hong Kong Administrative Reports, 1897–1920. 60. Tung Wah Group of Hospitals. One Hundred Years of the Tung Wah Group of Hospitals 1870–1970. Book 2 (Hong Kong: Tung Wah Group of Hospitals, 1970). 61. Sinn, Power and Charity, preface.

Chapter 4 1. 2. 3. 4. 5. 6. 7. 8. 9.

R. Porter, The Cambridge History of Medicine (New York: Cambridge University Press, 2006), 108–109. Hong Kong Academy of Medicine, Sapientia et Humanitas: A History of Medicine in Hong Kong (Hong Kong: Hong Kong Academy of Medicine, 2011), 44. C. K. Wong and L. T. Wu, History of Chinese Medicine: Being a Chronicle of Medical Happenings in China from Ancient Times to the Present Period. 2nd edition (National Quarantine service, Shanghai, China. 1936), xxvi. R. Temple, The Genius of China: 3000 Years of Science, Discovery and Invention (New York: Simon and Schuster, 1986), 131–132. Temple, The Genius of China, 133. F. I. Tseung, “Chinese Medicine and Its Contribution to Modern Medical Science,” JHKBRAS 12 (1972): 12–19. G. H. Choa, “Heal the Sick” Was Their Motto: The Protestant Medical Missionaries in China (Hong Kong: Chinese University Press, 1990), 63. Wong and Wu, History of Chinese Medicine, 20 (Organs). M. Topley, “Chinese Traditional Etiology and Methods of Cure in Hong Kong,”

2 8 2   |   N otes ： C hapter 4

10. 11. 12.

13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

26. 27.

28. 29. 30. 31. 32. 33.

in Asian Medical Systems: A Comparative Study, ed. Charles Leslie (Berkeley, LA: University of California Press, 1976), 243–264. S. M. Hillier and J. A. Jewell, Health Care and Traditional Medicine in China (London: Routledge and Kegan Paul, 1983), 221–241. G. H. Choa, The Life and Times of Sir Kai Ho Kai (Hong Kong:The Chinese University of Hong Kong, 2000), 52. Rance P. L. Lee, “Chinese and Western Health Care Systems: Professional Stratificatoin in a Modernizing Society,” in Social Life and Development in Hong Kong, eds. King, Y. C. Ambrose and P. L. Rance Lee (Hong Kong: The Chinese University Press, 1981), 260. Wong and Wu, History of Chinese Medicine, 43–44 (Acupucture points). Ibid., 307 (Morrison in China). Ibid., 316–317 (Dr. Parker). Choa, “Heal the Sick” Was Their Motto, 24–25 (Dr. William Lockhart). Wong and Wu, History of Chinese Medicine, 308 (Dr. Thomas Colledge). Choa, “Heal the Sick” Was Their Motto, 16. D. M. Haynes, Imperial Medicine: Patrick Manson and the Conquest of Tropical Disease (Philadelphia: University of Pennsylvania Press, 2001), 24–25. W. Lockhart, The Medical Missionary in China: A Narrative of Twenty Years’ Experience (London : Hurst and Blackett Publishers, 1861), 126. C. T. Smith, A Sense of History: Studies in the Social and Urban History of Hong Kong (Hong Kong: Hong Kong Educational Publishing Co., 1995), 299–302. Choa, “Heal the Sick” Was Their Motto, 67–68. Chinese Repository, 1844, 380–381. See note 21. The six medical books were: 1) Outline of Anatomy and Physiology; 2) An Outline of Natural Philosophy and History; 3) An Outline of Western Medicine; 4) Modern Views of the Diseases of Women and Children; 5) Modern Views of Internal Medicine; 6) Medical Vocabulary in English and Chinese. Hillier and Jewell, Health Care and Traditional Medicine in China, 11. (Hobson’s books used in Japan). T. M. K. Wong, “Local Voluntarism: The Medical Mission of the London Missionary Society in Hong Kong 1842–1923,” in Healing Bodies Saving Souls: Medical Mission in Asia and Africa, ed. D. Hardiman (Amsterdam, New York:, Rodopi, 2006), 91. Ibid., 92. See note 19. Smith, A Sense of History, 147. D. E. Evans, Constancy of Purpose: An Account of the Foundation and History of Hong Kong College of Medicine and the Faculty of Medicine of the University of Hong Kong 1887–1987 (Hong Kong: Hong Kong University Press, 1987), 27. Choa, The Life and Times of Sir Kai Ho Kai, 57–59 (Arrival of Dr. William Young from Canada). The Alice Memorial Hospital, Hong Kong, “Historical Sketch, Report of Six

N otes ： C hapter 4   |   2 8 3

34. 35. 36. 37.

38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54.

Months Work and Statement of Accounts Up to 1 September 1887” (Hong Kong: China Mail Office, 1887), 3. Edge (Missionary) to Thompson (Foreign Secretary, London Missionary Society, LMS), 27 February 1882 LMS Box 9, 1992, no. 176 (To establish a missionary hospital). Edge to Thompson, 11 March 1882 and 11 May 1882, LMS Box 9, 1882, no. 176 (Young left for Canada. Appeal for funds for a hospital postponed). Smith, A Sense of History, 325–326. (Dr. Ho Kai). Chalmers (Medical Missionary in Hong Kong) to Thompson, 15 January 1884, LMS Box 10, 1884, no. 182 (Hospital Committee: The Chinese members included Wong Shing and Wei Yuk, both would become unofficial members of the Legislative Council at a later date; Wong Wing-sheung, son of Wei Yuk; and Lau Say-tin, a prominent merchant. The members from the European community included Thomas Jackson, manager of the Hongkong and Shanghai Bank and a member of the Legislative Council; F. B. Johnson, a senior partner of Jardine Matheson; and Belilios, the philanthropist whose two scholarships remained untouched). Smith, A Sense of History, 329–333 (The proposal for a missionary hospital was not well-received by the public). Wong, “Local Voluntarism”, 95. Chalmers to Thompson, 18 November 1884 and 12 September 1884, LMS Box 1884, no. 184 (Dr. Ho Kai to build the hospital). J. Chalmers, 24 December 1884, LMS Box 10, 1884, no. 190 (The Hong Kong Charitable Hospital). Alice Ho Miu Ling Nethersole Hospital 1887–1967 (Hong Kong, 1967), 2. Chalmers to Thompson, 23 November 1886, LMS Box 10, 1886, no. 192 (Local doctors doing clinical work and teaching). Haynes, Imperial Medicine, 48–53 (Manson discovered mosquitoes as vectors for filaria worms). Ibid., 82–83 (Trained Chinese in Western medicine). Ibid., 25–26 (Reservation about mission medicine). Marsh to Granville, College of Medicine for the Chinese, 11 June 1886, CO 129/227 #200, 173. Chalmers to Thompson, 9 July 1884, LMS Box 10, 1884, no. 183 (Return of Dr. Young). Same as Note 33, 13. Report of the Alice Memorial and Nethersole Hospitals for the Year 1893 (Hong Kong: China Mail Office, 1894), 8. Thomson (Medical Superintendent of AMH) to Thompson, 20 May 1892, LMS Box 11, 1892 no. 208 (Donations from Mr. Davis). Thomson to Thompson, 11 September 1893, LMS Box 12, 1893 no. 214 (Nethersole Hospital for women and children). Choa, The Life and Times of Sir Kai Ho Kai, 60. M. Ho, When Science and Compassion Meet: A Turning Point in the History of Medicine in Hong Kong (Hong Kong: Hong Kong Museum of Medical Science, 1997), 6.

2 8 4   |   N otes ： C hapter 4

55. E. H. Paterson, A Hospital for Hong Kong: Centenary History of Alice Ho Miu Ling Nethersole Hospital, Hong Kong, 1887–1987 (Hong Kong: Alice Ho Miu Ling Nethersole Hospital. 1987), 74–75. 56. Choa, The Life and Times of Sir Kai Ho Kai, 63–64 (Grand Viceroy’s support). 57. The scholarships were donated by J. G. Humphreys and Belilios. 58. They included Frederick Stewart (Colonial Secretary), Sir James Russell (Chief Justice), Sir Fielding Clarke (Chief Justice), and Stewart Lockhart (Colonial Secretary). 59. J. C. Thomson, to Acting Colonial Secretary, College of Medicine for Chinese, 13 September 1900, CO 129/304 #82, 308–324. 60. Evans, Constancy of Purpose, 31. 61. Bowen to Earl of Derby, Medical Registration in Hong Kong, 25 April 1884, CO 129/215 #137, 576–584. 62. Blake to Earl of Crewe, Licentiates of Hong Kong College of Medicine, 24 January 1903, CO 129/316 #49, 104. 63. See note 59. 64. Choa, The Life and Times of Sir Kai Ho Kai, 69. 65. Sun’s address on 20 February 1923, Great Hall of the University of Hong Kong, in Sapientia et Humanitas, 50. 66. Robinson to Knutsford, Chinese Dispensaries, 23 September 1892, CO 129/256 #280, 198. 67. Also see note 59. 68. Nathan to Lyttelton, Request from the College of Medicine for Two Sites, 19 May 1905, CO 129/328 #135, 493. 69. Evans, Constancy of Purpose, 33. 70. F. C. S. Ho. Western Medicine for Chinese: How the Hong Kong College of Medicine Achieved a Breakthrough (Hong Kong: Hong Kong University Press, 2017), 83–85. 71. F. C. S. Ho, “The Beginning of Medical Education in Hong Kong 125 years ago— Its Unique Features in Comparison with Similar Efforts in China,” Hong Kong Medical Journal 18 (2012): 544. 72. Lugard to Earl of Crewe, 2 January 1909, CO 129/355 #12, 23 (The University of Hong Kong). 73. P. Cunich, A History of The University of Hong Kong (Hong Kong: Hong Kong University Press, 2012), 81–85. 74. Evans, Constancy of Purpose, 38. 75. S. Gould, et al, HKU Memories from the Archives (Hong Kong: Hong Kong University Museum and Art Gallery, 2013), 17. 76. Lugard to Earl of Crewe, Hong Kong University, 9 December 1909, CO 129/359, #380, 54; Cunich, A History of The University of Hong Kong, 120–121. 77. Lugard to Earl of Crewe, Laying of Foundation Stone, 16 April 1901, CO 129/366 #131, 128. 78. From a Correspondent, Tokyo, British and German Methods, 21 May 1909, Enclosed in Telegram, Lugard to Secretary of State for the Colonies, 12 June 1909. CO 129/356, 326.

N otes ： C hapter 5   |   2 8 5

79. Cunich, A History of The University of Hong Kong, 149–158. 80. Privy Council to the Undersecretary of State for the Colonies, 12 March 1913, CO 129/405, 7. 81. Des Voeux to Knutsford, 2 July 1888, CO 129/238 #180, 3 (Nurses for Government Civil Hospital). 82. Fleming (Administrator for government) to Knutsford, Nurses for Govrnment Civil Hospital, 29 Septmeber 1890, CO 129/246 #355, 844. 83. Robinson to Chamberlain, Nursing Institute, 25 November 1897, CO 129/278 #248, 219–220. 84. See note 81. 85. E. Y. W. Poon, “A Brief History of Nursing in Hong Kong,” Hong Kong Nursing Journal3 (1967): 119–123. 86. Clementi to Passfield, 19 September 1929, CO 129/519 #5, 12.

Chapter 5 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

R. Porter, The Cambridge History of Medicine (New York: Cambridge University Press, 2006), 19. F. E. Cartwright, A Social History of Medicine (London: Longman Group Ltd., 1977), 93–113. Ibid., 101–106. W. Lockhart, Medical Missionary in China: A Narrative of Twenty Years’ Experience (London: Hurst and Blackett, Publishers, 1861), 36–39. G. B. Endacott, A History of Hong Kong, second Edition (Hong Kong: Oxford University Press, 1964), 31–33. Hong Kong Blue Books, 1861–1883. Hong Kong Blue Book, 1845. D. M. Haynes, Imperial Medicine: Patrick Manson and the Conquest of Tropical Medicine (Philadelphia: University of Pennsylvania Press, 2001), 128–131. J. Dempster, Colonial Surgeon, Annual Report 1854, Hong Kong Blue Book, 1854. General Board of Health to the Colonial Office, 4 October 1855, CO 129/53, 382–385. Bowring to Labouchere, 18 February 1856, CO 129/54 #38, 331–333 (Disagreed with Colonial Surgeon’s Remarks). Cleverly (Surveyor General) to Mercer (Colonial Secretary), 11 February 1856, CO 129/54 #38, pp. 339–344. A. R. Wellington, Public Health in Hong Kong, 1930, CO 129/531 #13, 1. Robinson to Duke of Newcastle, 4 July 1861, CO 129/81 #109, 303 (Dissenting from Colonial Surgeon’s conclusion in Annual Report of 1860). “Hong Kong’s Water Supplies: 1960, A Year of Decision,” Hong Kong Annual Report, 1960, 6. Report of the Sanitary Committee, Enclosure in Mercer, Administrator to Duke of Newcastle, 12 December 1863, CO 129/94 #220, 176–201.

2 8 6   |   N otes ： C hapter 5

17. MacDonnell to Earl of Carnavon, Pokfulam Water Works, 1 April 1867, CO 129/121 #263, 138. 18. MacDonnell to Duke of Buckingham and Chandos, Legislation for Registration of Births, Deaths and Marriages, 11 September 1868, CO 129/132 #567, 317–320. 19. Kennedy to Earl of Kimberley, Water Supply in Hong Kong, 12 February 1873, CO 129/162 #31, 200–205. 20. Administrator to Earl of Carnavon, Building a Conduit from Pokfulam to Tanks in the City, 25 July 1875, CO 129/171 #108, 300–302. 21. Kennedy to Earl of Carnavon, Tai Tam Water Scheme, 25 August 1875, CO 129/171 #107, 286–294. 22. Colonial Surgeon Annual Report for 1874 (Original) in Hong Kong Adminstrative Reports, 1879, 25–41. 23. Copies of extracts of despatches from Governor, Sir John Hennessy to the Right Honourable the Earl of Kimberley, 8 July 1880, in Hong Kong Adminstrative Reports, 1881. 24. John Dudgeon (1837–1901) was a Scottish physician who spent nearly 40 years in China as a doctor, surgeon, translator, and medical missionary. Dudgeon attended the University of Edinburgh and the University of Glasgow. He graduated from the University of Glasgow and was awarded Master of Surgery in 1862. In 1863, he was appointed to the Medical Mission of the London Missionary Society to serve at the hospital in Peking established by William Lockhart. He arrived in China in December 1863. He was also Medical Attendant to the British Legation in Peking (Beijing) from 1864 to 1868. 25. Lieutenant General Edward Westby Donovan was Commander of British Troops in China, Hong Kong, and the Straits Settlements. Donovan was commissioned into the 33rd Regiment of Foot in 1840. He fought in the Crimean War and was severely wounded at the Siege of Sevastopol in 1855. For this he was made a Chevalier (Knight) of the Légion d’honneur. In 1878 he was appointed Commander of British Troops in China, Hong Kong, and the Straits Settlements, a post he held until 1882. He retired in 1887. 26. Observations by Surgeon General Mackinnon C. B. Army Medical Department on Sanitary Matters at Hong Kong, 1 September 1880, CO 129/196, 409–412. 27. Minutes of Meeting in Colonial Office, Sanitation in Hong Kong, CO 129/196, 379–386. 28. Hennessy to Kimberley, Tai Tam Project, 15 June 1881, CO 129/193 #90, 155– 160. 29. Hennessy to Earl of Kimberley, To Set Up a Separate Sanitary Department, 19 August 1881, CO 129/194 #124, 237–240. 30. Minutes of Meeting in the Colonial Office, Bucket and Dry Earth System Or Water Closet, 29 April 1881, CO 129/192 #50, 570–577. 31. O. Chadwick, Report on the Sanitary Condition of Hong Kong, CO 882/4, Hong Kong Government, 1882, 1–59. 32. Ibid., 7–10. 33. Ibid., 3. 34. Ibid., 10–14. 35. Ibid., 18–21.

N otes ： C hapter 6   |   2 8 7

36. Ibid., 15. 37. Ibid., 16–18. 38. J. A. Riis, “How the Other Half Lives” (1890), assessed on 5 May 2014, http://www. bartleby.com/208/26.html. 39. Chadwick, Report on the Sanitary Condition of Hong Kong, 21–42. 40. After Hennessy, Hong Kong had two short governorships by Sir George Bowen, from 1883 to 1885, Sir William Des Voeux from 1887 to 1891, and in between the Colony was governed by administrators: Sir William Marsh from 1882 to 1883 and from 1885 to 1887, and Sir Gordon Cameron in 1887. When Des Voeux retired, Major George Barker administered for a period of six months before the next Governor, Sir William Robinson, arrived. 41. Bowen to Colonial Office, Sanitatary Conditions in Hong Kong, 24 April 1883, CO 129/208 #41, 215–227. 42. Endacott, A History of Hong Kong, 198–202. 43. Marsh to Secretary of State for the Colonies, Sanitary Board, Appointment of Unofficial Members, 11 August 1886, CO 129/228 #259, 143–147. 44. Cameron (Adminstrator) to Holland, Public Health Ordinace First Reading, 25 May 1887, CO 129/232 #190, 367–395. 45. 1887 Public Health Ordinance, Hong Kong Government Gazette, 7 May 1887, 458. 46. Colonial Office, Minutes, Compensation for Unsanitary Properties, Enclosed in Cameron to Holland, 15 September 1887, CO 129/232 #190, 367–380. 47. Dr. Ho Kai’s Protest Against the Public Health Bill, Submitted to the Government by the Sanitary Board, and the Board’s Rejoinder Thereto, Hong Kong Sessional Papers, 1887, no. 30/87, 403–407. 48. Des Voeux to Knutsford, Overcrowding, 5 December 1889, CO 129/242 #363, 496–500. 49. See note 42. 50. See note 41. 51. Bowen to Earl of Derby, Other Sanitary Reforms, 27 June 1883, CO 129/210 #123, 167–172. 52. Marsh to Colonial Office, Water Famine, 1 June 1886, CO 129/227 #184, 3–8. 53. J. M. Price, Report on the Separate System of Main Drainage, 24 August 1888, Hong Kong Sessional Papers, 1888, no. 20/88. 54. Fleming to Knutsford, 25 August 1890, CO 129/246 #308, 293–295. 55. Colonial Surgeon Annual Report for the year 1893, Hong Kong Sessional Papers, 1894, 364.

Chapter 6 1. 2.

J. Duffin, History of Medicine: A Scandalously Short Introduction (Toronto: University of Toronto Press, 1999), 140–143. R. Pollitzer, “The History of Certain Infectious Diseases in China,” in Manchurian Plague Prevention Service Reports 1929–30, eds. L. T. Wu, Volume VII of the Series (National Quarantine Service, 1934).

2 8 8   |   N otes ： C hapter 6

3.

4. 5. 6. 7.

8. 9.

10. 11.

12. 13. 14. 15. 16.

The Chinese Maritime Customs Service was a Chinese governmental tax collection agency and information service from its founding in 1854 until 1949. Largely staffed at senior levels by foreigners, the Service was controlled by Chinese central government throughout its history. It was effectively established by foreign consuls in Shanghai in 1854 to collect maritime trade taxes that were going unpaid due to the inability of Chinese officials to collect them during the Taiping Rebellion. Its responsibilities soon grew to include domestic customs administration, postal administration, harbor and waterway management, weather reporting, and anti-smuggling operations. It mapped, lit, and policed the China coast and the Yangtze. It conducted loan negotiations, currency reform, and financial and economic management. F. S. A. Bourne, Vice Council, Canton, Plague in Canton, 30 June 1894, Enclosed in Brenan B. to Undersecretary of State, Foreign Office, 1 August 1894, CO 129/265, 216–236. J. F. Wales, Report on the Outbreak of Bubonic Plague in southern China, Enclosed in Brennan to Under Secretary of State, Foreign Office, 4 July 1894, CO 129/265, 219–223. J. Lowson, Medical Report on the Epidemic of Bubonic Plague in 1894, Hong Kong Sessional Papers, 1895 No. 16/95, 179. Lowson to Robinson, Plague Report, 16 May 1894, Enclosed in Robinson to Ripon, 17 May 1894, CO 129/263 #115, 48 (Dr. Ayres sent Dr. Lowson to Canton to investigate the rumours of an epidemic. On May 8th Lowson diagnosed the first case of plague in Hong Kong and isolated the patient). Hong Kong Telegraph, 9 May 1894. Lowson to Robinson, Plague Report, 16 May 1894, Enclosed in Robinson to Ripon 17 May 1894, CO 129/263 #115, 50 (Lowson found 20 patients dying with plague in Tung Wah Hospital on 10 May 1894 and informed Dr. Ayres immediately). Minutes of the Sanitary Meeting of 10 May 1894, Enclosed in Robinson to Ripon, 17 May 1894, CO 129/263 #115, 51–53. F. S. A. Bourne, Vice Council, Canton, Plague in Canton, 30 June 1894, Enclosed in Brenan B. to Undersecretary of State, Foreign Office, 1 August 1894, CO 129/265, 221 (When patients were forced against their will to be admitted to the Hygeia, all kinds of rumours were started about the foreigners). Eitel’s letter to the Education Department, 22 May 1894, Enclosed in Robinson to Ripon, 23 May 1894, CO 129/263 #122, 190–193 (Many schools were closed and attendance fell among those that remained open). Lowson to Robinson, 16 May 1894, 54–57, Hong Kong Weekly Press and China Overland Trade Report, 24 May 1894, 398, Enclosed in CO 129/263 #123 (Opening up of Kennedy Town Police Station as a hospital when the Hygeia was full). Hong Kong Weekly Press and China Overland Trade Report, 24 May 1894, 402 (On 19th May the Royal Engineers from the Shropshire Light Infantry were enrolled as special sanitary officers). Lowson’s Medical Report: The Epidemic of Bubonic Plague in Hong Kong 1894, Hong Kong Weekly Press and China Overland Trade Report, 24 May 1894, 402–404 (Death toll from 11 May to end of the month). F. S. A. Bourne, Vice Council, Canton, Plague in Canton, 30 June 1894, Enclosed

N otes ： C hapter 6   |   2 8 9

17. 18. 19. 20. 21. 22. 23.

24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37.

in Brenan B. to Undersecretary of State, Foreign Office, 1 August 1894, CO 129/265, 220 (Chinese attitude towards intrusion into their family). Hong Kong Weekly Press and China Overland Trade Report, 24 May 1894, 402 (21 May, Threatened riot in Chinatown). Ibid., 403 (21 May, Mr Lau Wai Chuen, a member of the Sanitary Board and the chairman of Tung Wah Hospital Committee, was caught in the middle). Ibid., 403 (21 May, Meeting at Tung Wah Hospital). Ibid., 403 (22 May. Conference at government house and the Governor’s made the first proclamation). Ibid., 404 (23 May, Deputation of Tung Wah Hospital Committee met with the Governor. The Governor made his second proclamation). Hong Kong Daily Press, 23 May 1894. Telegrams from B. Brennan (British Consul in Guangzhou) to Robinson, 24 May 1894 and 25 May 1894, Enclosure 1 and 2 in Robinson to Ripon, 29 May 1894, CO 129/263 #128, 249–255 (Demonstrations in Guangzhou and foreigners no longer safe). Hong Kong Weekly Press and China Overland Trade Report, 24 May 1894, 198 (Chinese plague patients were removed from the Hygeia to the Glassworks Hospital). Robinson to Ripon, Governor’s Despatch to the Secretary of State with Reference to the Plague, 20 June 1894, Hong Kong Sessional Papers, 1894, no. 21/94, 285. Robinson to Ripon, Bubonic Plague, 4 June 1894, CO 129/263 #132, 274–280 (Thousands in Hong Kong left for the mainland). Li Hanzhang to Zongli (Tsungli) Yanmen, 18 June 1894, Enclosed in O’Conor to Kimberley, 21 June 1894, CO 129/265 (Tung Wah Hospital directors were referred to as “Directors of the Benevolent Society of Hong Kong”). Robinson to Ripon, Bubonic Plague, 20 June 1894, CO 129/263 #151, 465–467. Government notification #208, 1894, Enclosed in Robinson to Ripon, 16 June 1894, CO 129/263 #146, 438–442 (Condemned infected houses). Hong Kong Press Daily, 16 June 1894. Viceroy of Canton to Zongli (Tsungli) Yamen, 18 June 1894, Enclosure in Robinson to Ripon, 11 July 1894, CO 129/263 #168, 555–557. O’Conor (British Minister in Beijing) to Robinson, Telegram, 19 June 1894, Enclosed in Robinson to Ripon, 11 July 1894, CO 129/265, #168, 553–554. Tung Wah Hospital Director’s Proclamation, Enclosed in Robinson to Marquess of Ripon, 21 June 1894, CO 129/263 #152, 479–484. The Straits Settlements consisted of the four individual settlements of Malacca, Dinding, Penang (also known as Prince of Wales Island), and Singapore (with Christmas Island and the Cocos Islands). Robinson to Ripon, Bubonic Plague, 20 June 1894, CO 129/263 #151, 469–470 (Effect of plague on the economy). Robinson to Ripon, Bubonic Plague, 4 September 1894, CO 129/264 #203, 57–61 (Hong Kong declared clean). Colonial Surgeon Reports, 1894–1929. Hong Kong Sessional Papers or Adminstrative Reports, 1894–1929. G. H. Choa, The Life and Times of Sir Kai Ho Kai, 2nd ed. (Hong Kong: The Chinese University Press, 2000), Appendix VI.

2 9 0   |   N otes ： C hapter 6

38. Yersin’s father died when Yersin was only three months old. He grew up among women, his mother, his sister, and young women who were attending his mother’s finishing school. As a young boy he discovered a trunk that belonged to his father and among the routine items he found a microscope, scalpels, and callipers—tools of a natural scientist. After his success at the Pasteur Institute, Yersin could no longer withstand the pressure from his mother to establish a family and decided to leave Paris. 39. S. Kitasato, “The Bacillus of Bubonic Plague,” Lancet 144, no. 3704 (1894): 428– 430. 40. Lowson Diary 1894, Volume V Hong Kong Museum of Medical Science Archive, 14 June 1894. 41. Lowson Diary 1894, Volume V Hong Kong Museum of Medical Science Archive, 15 June 1894. 42. T. Solomon, “Hong Kong, 1894: The Role of James A. Lowson in the Controversial Discovery of the Plague Bacillus,” Lancet 350, no. 9070 (1997): 59–62. 43. Ibid., 60. 44. J. Lowson, Medical Report on the Epidemic of Bubonic Plague in 1894, Hong Kong Sessional Papers, 1895 No. 16/95, 181. 45. Lowson Diary 1894, Volume V. Hong Kong Museum of Medical Science Archive, 16 June 1894. 46. “Discovery of the Plague Bacillus,” China Mail, 20 June 1894. 47. E. Marriott, The Plague Race: A Tale of Fear, Science and Heroism (London: Picador, 2002), 193. 48. Koch’s four criteria to establish a causative relationship between a microbe and a disease: 1) The microorganism must be found in abundance in all organisms suffering from the disease, but should not be found in healthy organisms; 2) The microorganism must be isolated from a diseased organism and grown in pure culture; 3) The cultured microorganism should cause disease when introduced into a healthy organism; 4) The microorganism must be reisolated from the inoculated, diseased experimental host and identified as being identical to the original specific causative agent. 49. A. Yersin, “Le Peste Bubonique à Hong Kong,” Annales de l’Institut Pasteur 8 (1894): 662–667. Cited in Note 42. 50. Lowson Diary 1894, Volume V. Hong Kong Museum of Medical Science Archive, 23 June 1894. 51. Cited in Note 42. 52. Choa, The Life and Times of Sir Kai Ho Kai, 120. 53. Anonymous, “The Plague in Hong Kong,” Lancet ii (1894): 391–392. 54. Lowson Diary 1894, Volume V. Hong Kong Museum of Medical Science Archive, September entry. 55. Robinson to Ripon, Two Japanese Attacked by Plague, 3 July 1894, CO 129/263, 523. 56. Choa, The Life and Times of Sir Kai Ho Kai, 120. 57. Solomon, “Hong Kong, 1894: The Role of James A. Lowson in the Controversial Discovery of the Plague Bacillus,” 59.

N otes ： C hapter 7   |   2 9 1

58. Colonial Surgeon Reports, 1894–1929; Hong Kong Sessional Papers and Administrative Reports, 1894–1929; G. Choa, Appendix VI “Morbidity and Mortality of Plague Cases, 1894–1923,” The Life and Times of Sir Kai Ho Kai . 59. Robinson to Chamberlain, Plague 1895, 16 July 1895, CO 129/267 #227, 146. 60. Robinson to Chamberlain, Plague 1896, 26 March 1896, CO 129/271 #49, 320. 61. Robinson to Chamberlain, Housing Commission, 6 May 1896, CO 129/272 #117, 36. 62. Petition to Chamberlain, 11 July 1901, Enclosed in Blake to Chamberlain, 13 July 1901, CO 129/305 #254, 657. 63. Colonial Office, Minutes, 7 August 1901, CO 129/305 #244, 453–59 (Two authorities on plague to advise Hong Kong). 64. Ordinance 1, 1902, 6 March 1901, Enclosed in Gascoigne, Administrator to Chamberlain, 6 March 1902, CO 129/310 #81, 285. 65. The Haffline serum against plague was first produced by Waldemar Mordecai Wolff Haff kine, a Russian Jewish bacteriologist who emigrated and worked at the Pasteur Institute in Paris, where he developed an anti-cholera vaccine. He moved to India and tried out the anti-cholera vaccine successfully in India. In India he also developed the vaccine against bubonic plague, but it was not very effective. 66. W. J. Simpson, Preliminary Memorandum on Plague Prevention in Hong Kong, 20 January 1902, Hong Kong Administrative Reports, 1902, 421. 67. W. J. Simpson, Second Memorandum, 20 March 1902, Hong Kong Administrative Reports, 1902, 425. 68. F. Clark, Medical Officer of Health to F. H. May, Colonial Secretary, 19 June 1902, Enclosed in Blake to Chamberlain, CO 129/311 #260, 387. 69. Blake. Bubonic Plague in Hong Kong, Memorandum by H. E. the Governor on the Result of the Treatment of Patients in their Own House and in Local Hospitals during the Epidemic of 1903, Hong Kong Sessional Papers, 1903. 70. G. Risse, Plague, Fear and Politics in San Francisco Chinatown (Baltimore: Johns Hopkins University Press, 2012), accessed on 26 March 2017, http://jhupbooks. press.jhu.edu/content/plague-fear-and-po;itic-san-francisco-chinatown. 71. Andrew B. Appleby, “The Disappearance of the Plague: A Continuing Puzzle,” Economic History Review 33 (1980): 161–173.

Chapter 7 1. 2. 3. 4. 5.

Robinson to Ripon, Prevention of Plague, 5 July1895, CO 129/268 #212, 53–56. Robinson to Colonial Office, Water Supply, 2 August 1894, CO 129/263, 673. Colonial Secretary and Surveyor General, Measures to Give Effect to Mr. Chadwick’s Recommendations of 1882, Enclosure in Blake to Chamberlain, 18 July 1901, CO 129/305 #262, 705–713. O. Chadwick, Memorandum on the Proposed Water Ordinance No. 29 of 1902, Enclosed in Crown Agent to Colonial Office, 4 March 1903, CO 129/320, 423–437. O. Chadwick, Preliminary Report on the Sanitary Conditions in Hong Kong 10 April 1902, Water Supplies, Hong Kong Sessional Papers, 1902, no. 17/1902, 441–472.

2 9 2   |   N otes ： C hapter 7

6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

16. 17. 18. 19. 20. 21.

D. Headricks, The Tentacles of Progress: Technology Transfer in the Age of Imperialism 1850–1940 (New York: Oxford University Press, 1988), 149. “Cross-harbour Underwater Pipeline Completed,” South China Mornng Post, 1 May 1930. “Hong Kong’s Water Supplies: 1960, A Year of Decision,” Hong Kong Annual Report, 1960, 3–10 P. Y. Ho, Water for a Barren Rock: 150 Years of Water Supply in Hong Kong (Hong Kong: The Commercial Press, 2001), 98. O. Chadwick, Preliminary Report on the Sanitary Conditions in Hong Kong, 10 April 1902, Hong Kong Sessional Papers, 1902, no. 17/1902, 457–470. Colonial Surgeon’s Annual Report or Medical Officer of Health Annual Report, 1874–1938, No. of Cases of Enteric Fever Each Year, Hong Kong Sessional Papers or Hong Kong Administrative Reports, 1874–1938. Cooper to Colonial Secretary, Public Latrine, 27 June 1895, Enclosure Robinson to Ripon, 5 July 1895, CO 129/268 #212, 72. Cooper, Public Works Department Report on the Resumption of Certain Properties in the Tai Ping Shan District in the City of Victoria, 6 March 1895, Hong Kong Sessional Papers, 1896. Robinson to Ripon, Tai Ping Shan Resumption, 30 August 1894, CO 129/263 #197, 715–718. F. A. Cooper, Scheme for the Improvement of the Resumed Area in the District of Tai Ping Shan, 22 March 1895, Hong Kong Sesstional Papers, 1895, no. 14/95, 143–146. Before the departure of the two scientists, Kitasato and Yersin, Robinson asked them to investigate whether the soil of Tai Ping Shan had been infected and how to prevent future epidemics. On the first question, he received somewhat different answers. Kitasato indicated that he had not been able to find the plague bacillus in the floor of houses or the soil of infected houses even from soil taken from considerable depth (Kitasato to Robinson, 19 July 1894, Enclosed in Robinson to Ripon, 30 August 1894, CO 129/263 #198, 729–742). Yersin found the plague bacilli present in many samples of soil at a depth of 2 inches below the surface (not 12 or 18 inches as reported in Hong Kong Weekly Press, 8 August 1894) similar to the ones that he found in the buboes. He was more thorough and meticulous and careful with his conclusion. He cultured the samples and when colonies developed on the culture plates, he injected them into mice and guinea pigs and found that the organisms did not kill the animals—the bacilli had lost their virulence. Blake to Chamberlain, Blake Garden, 24 April 1903, CO 129/317 #223, 123. Robinson to Ripon, Insanitary Dwellings, 4 January 1895, CO 129/266 # 6, 27–40. Report of the Commission to Enquire into the Existence of Insanitary Properties in the Colony (Hong Kong: Noronha and Co, Government Printers, 1898). Ibid., 445–576. Attorney General to the Marquess of Ripon, Report on Ordinance No. 15 of 1894, Enclosed in Robinson to Ripon, 4 January 1895, CO 129/266 #6, 25–42. Sanitary Board to Colonial Secretary Lockhart, Overcrowding in the City of Victoria, 3 June 1899, Enclosed in Blake to Chamberlain, 24 June 1899, CO 129/292 #153, 69–69.

N otes ： C hapter 7   |   2 9 3

22. O. Chadwick and W. J. Simpson, Report on the Question of Housing of Population in Hong Kong, 1902, Hong Kong Sessional Papers, 1902, no. 28/1902, 627–658. 23. Blake to Chamberlain, Resumption of Burnt Area, 17 May 1902, CO 129/311 #223, 234. 24. O. Chadwick and W. J. Simpson, Report on the Question of Housing of Population in Hong Kong, 1902, Public Health and Building Ordinance, Hong Kong Sessional Papers, 1902, no. 28/1902, 639–647. 25. “Public Health and Buildings Ordinance 1903,” Historical Laws Online, accessed on 4 May 2014, http://oelawhk.lib.hku.hk/items/show/1209. 26. Blake to Chamberlain, Public Health and Buildings Ordinance No. 1 of 1903, 10 March 1903, CO 129/316 #116, 305–346. 27. Ayers to Ripon, Medical Staff, 18 December 1894, Enclosed in Robinson to Ripon, 21 December 1894, CO 129/264 #277, 559–569; Medical Committee Report, Hong Kong Sessional Papers, 1895, 549–555. 28. Colonial Surgeon Report of 1894, Sanitatory Board Meeting, Hong Kong Sessional Papers, 1895, no. 34/95, 479–480. 29. J. J. Keswick to Governor, Reconstituting the Sanitary Board, 19 October 1894, Hong Kong Sessional Papers, 1896. Keswick was the chairman of the Hong Kong General Chamber of Commerce and an unofficial member of the Legislative Council appointed by the governor. He was the senior partner of Jardine Matheson Co. from 1889 to 1896. 30. G. B. Endacott, A History of Hong Kong, 2nd ed. (Hong Kong: Oxford University Press, 1964), 217. 31. Minutes of Discussion in Colonial Office, 18 September 1895, CO 129/267 #163, 437. 32. Minutes on Reorganization of the Medical Department and Sanitary Board, Colonial Office, Reorganization of the Sanitary Board, 18 May 1895, CO 129/267 #163, 407–416. 33. Endacott, A History of Hong Kong, 205. 34. Robinson to Chamberlain, Reorganization of the Sanitary Board, 5 March 1896, CO 129/271 #53, 365–371. 35. Blake to Lucas, Sanitary Board, 13 October 1902, Enclosure in CO 129/313, 57–61. 36. C. P. Lucas, Minutes in Colonial Office, Sanitary Commissioners, 12 March 1903, CO 129/320, 439. 37. Blake to Chamberlain, Sanitary Board Constitution, 28 August 1903, CO 129/318 #413, 320–334. 38. Nathan to the Earl of Elgin, Irregularities in the Sanitary Department, 26 November 1906, CO 129/336, Confidential, 132. 39. May to Elgin, Commission to Investigate the Sanitary Department, 29 May 1907, CO 129/340, 399–417. The commissioners were: E. A. Hewitt, Fung Wa-chun, Lau Chu-pak, Henry Humphreys, and A. Shelton Hooper. 40. Nathan to Colonial Secretary, 10 April 1906, Enclosed in May to Elgin, 29 May 1907, CO 129/340, 418.

2 9 4   |   N otes ： C hapter 7

41. Atkinson’s Response to the Report of the Sanitary Commission of 1907, Enclosed in May to Elgin, 29 May 1907, CO 129/340, Confidential, 420–432. 42. Lugard to Elgin, 8 November 1907, CO 129/342, Confidential, 2–6; and 28 November 1907, CO 129/335, Confidential, 135; and Minutes on Corruption in Sanitary Department December 1906. 43. A. R. Wellington, Public Health in Hong Kong, 2 October1931, CO 129/531, #131, 18–45. The Need to Reorganize the Medical and Sanitary Services and for the Establishment of an Up-to-Date System, 17. 44. A. R. Wellington, Changes in the Public Health Organization of Hong Kong during the Period 1929–1937, Hong Kong Sessional Papers, 1937, 103. 45. A. R. Wellinton, Medical and Sanitary Report for the Year 1935, Hong Kong Adminstrative Reports, 1935, M11–13. 46. Blake to Chamberlain, Bacteriologist, 12 June 1901, CO 129/305 #221, 350. 47. W. Hunter to Government House, Hong Kong, Requirements for a Bacteriology Laboratory, 25 October 1901, Enclosed in CO 129/307 #440, 300–304. 48. W. Hunter, Report of the Government Bacteriologist for the Year 1906, Hong Kong Sessional Papers, 1907. 49. W. Hunter, Report for the Year 1907, Enclosed in Lugard to Elgin, 12 October 1907, CO 129/341 #258, 464–540. 50. W. Hunter, Report of the Government Bacteriologist, 1905, Hong Kong Sessional Papers, 1906, 358. 51. Hunter’s research projects: 1) Route of entry of the plague bacilli. Hunter had found the plague bacilli in poor quality rice in a previous study, he postulated that one of the routes of entry of the plague bacilli was the gastrointestinal tract. He found that feeding rodents with plague tissue or cultures of the plague bacillus could lead to development of plague in guinea pigs and rats. 2) The life cycle of two types of Haemosporidia, a parasite in frogs. Parasitic diseases were very common then. For example, Clonorchis sinensis, a liver fluke, which causes recurrent pyogenic cholangitis and liver cancer in humans, has two intermediate hosts, snail and fresh water fish. The parasites gain into humans when the intermediate hosts are eaten not well cooked or raw. One type of frogs, the edible one, is considered a delicacy by the Chinese. 3) Infectious etiology of beriberi. He studied all the inmates of Po Leung Kuk who developed beriberi in one year and cultured their excretions repeatedly throughout their course of disease that year and found no pathogenic organisms. He concluded that beriberi was not an infectious disease. (Hunter, W, Report for the Year 1907, Enclosed in Lugard to Elgin, 12 October 1907, CO 129/341 #258, 464.) 52. University of Durham to the Colonial Office, 3 October 1907, CO 129/345, 640. 53. Secretary of Committee of Management, Colonial Office, 8 October 1907, CO 129/345, 643. 54. Officially Hunter was told that Hong Kong was too small a place to afford a research institute (Hunter to Sir Patrick Manson, 26 July 1906, Enclosed in Manson to Colonial Office, 30 July 1906, CO 129/338, 645.) When asked by the Colonial Office on the reappointment of Hunter, the Principal Civil Meidcal Offier (PCMO) requested Dr. Keith, the bacteriologist from Singapore to Hong Kong to replace Hunter. The PCMO was on leave in England at that time and had a meeting with the staff in the Colonial Office. One can surmise that the

N otes ： C hapter 8   |   2 9 5

55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66.

less than enthusiastic response from the Colonial Office to the reappointment probably came from this meeting and a letter received by the Colonial Office a couple of years ago indicating that Hunter was found intoxicated on one occasion but this had never happened again and that alcohol had never affected his work (Atkinson, PCMO, to Colonial Office, 26 July 1906, William Hunter, CO 129/338, Confidential, 645). Lugard to Colonial Office, Death of Hunter, 10 June 1909, CO 129/356, Telegram, 322. Some said that Hunter had been depressed and the death of his son aggravated his depression. Robison to Knutsford, Registration of Births and Deaths, 23 September 1892, Enclosure Colonial Surgeon to Colonial Secretary Public Dispensaries, 16 August 1892, CO 129/256 #280, 212–215. There were two convents that cared for orphans in Hong Kong at that time, ran by the French and the Italian nuns respectively. Registrar General’s Report for the year 1905, Hong Kong Sessional Papers, 1906, 13/1906, 230–231. Registrar General’s Report for the Year 1907, Hong Kong Sessional Papers, 1908, 191–192. There were a total of nine Chinese Public Dispensaries established before the Second World War. Registrar General’s Report for 1906, Hong Kong Sessional Papers, 1907, 337–338. Registrar General’s Report for the Year 1908, Hong Kong Administrative Report, 1908, C6. Registrar General’s Report for the Year 1911, Hong Kong Administrative Report, 1911, C12. Registrar General’s Report for the Year 1910, Hong Kong Administrative Report, 1910, C10. Y. W. Fung and M. Chan-Yeung, To Serve and to Lead: A History of the Diocesan Boys’ School, Hong Kong (Hong Kong: Hong Kong University Press, 2009), 25. May, Administrator, to Elgin, Hygiene Instruction, 23 April 1907, CO 129/340, 188.

Chapter 8 1. 2. 3. 4. 5. 6.

J. D. Spence, The Search for Modern China (New York: W. W. Norton & Company, 1990), 293. S. Tsang, A Modern History of Hong Kong (Hong Kong: Hong Kong University Press, 2004), 92–95. Ibid., 96–101. F. Hong, Footbinding, Feminism and Freedom (London: Frank Cass, 1997), 2–4 and 55. Anne, W. M. Chow, “Root of Hong Kong Midwifery,” HKJGOM 1 (2000): 72–80. Colonial Surgeon Report for 1884, Hong Kong Sessional Papers, 1885, 191, para 39–42 (Chinese Women died during labour).

2 9 6   |   N otes ： C hapter 8

7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27.

Colonial Surgeon Report for 1885, Hong Kong Sessional Papers, 1886, 303. Colonial Surgeon Report for 1897, Hong Kong Sessional Papers, 1898, 378 (Maternity Annex added to Government Civil Hospital). Thomson to Thompson, Nethersole Beds for Women and Children, 11 September 1893, LMS Box 12, 1893, no. 214. G. Chamberlain, “British Maternal Mortality in the 19th and Early 20th Centuries,” Journal of the Royal Society of Medicine 99 (2006): 559–563. I. Loudon, “Deaths in Childbed from the Eighteenth Century to 1935,” Medical History 30 (1986): 1–41. C. A. Corsini and P. Viazzo, “The Decline of Infant Mortality in Europe, 1800– 1950: Four National Case Studies,” UNICEF International Child Development Centre, Florence, Italy, 1993. Births and Deaths, 1885, Enclosed in Marsh to the Earl of Granville, 25 June 1886, CO 129/227 #220, 529. MacDonnell to Duke of Buckingham and Chandos, 28 June 1867, CO129/122 #315, 307; MacDonnell to Duke of Buckingham and Chandos, 11 September 1868, CO129/132 #567, 317. W. Hartigan to Sanitary Board, Correspondence Respecting Deaths in Italian and French Convents, 24 September 1886, Kong Kong Sessional Papers, 1886–1887, 184. W. Hartigan, “Cases of Tetanus Neonatorium,” Transection of the Hong Kong Medical Society 1 (1889): 146. Correspondence Respecting Deaths in Italian and French Convents, Hong Kong Sessional Papers, 1886 No. 43/86, 183; Hong Kong Sessional Papers, 1887, No. 6/87, 241. Medical Officer of Health, Report to the Sanitary Board for 1896, Hong Kong Sessional Papers, 1896, 357 (High infant mortality). Medical Officer of Health, Report to the Sanitary Board, Hong Kong Sessional Papers, 1896 to 1907 (Large number of unregistered births). Report of the Medical Officer of Health, Sanitary Report 1895, Hong Kong Sessional Papers, 1896, 349 (Burn marks and scars). May to Lytton, 21 July 1904, CO 129/323, 241 (The Chinese legislators thought that it was too premature to regulate Chinese midwives). Report of the Medical Officer of Health for 1900, Hong Kong Sessional Papers, 1901, 401. (Unbelievable high infant mortality—Chinese parents’ neglect). Hong Kong Daily Press, 3 June 1901. H. T. Ashby, Infant Mortality (Cambridge: Cambridge University Press, 1915), 6. I. C. Petrie, “The Problem of Infant Mortality in Hong Kong 1886–1937” (MA thesis, The University of British Columbia, August, 1996). The Committee, which was appointed by His Excellency the Governor to inquire into the Causes of Chinese Infantile Mortality in the Colony, included Drs. Ho Kai, W. Hunter, W.W. Pearse, G. M. Harston, and J. Atkinson. Report of the Committee Appointed by His Excellency the Governor to Inquire into the Causes of Chinese Infantile Mortality in the Colony, Hong Kong Sessional Papers, 1904, 1/1904, 1–5.

N otes ： C hapter 8   |   2 9 7

28. T. C. Wong, “Some Observations on the Clinical Aspects of Tetansu Neoatorium (Infantile Tetanus),” The Caduceus 6 (1927): 254. 29. C. Y. Wang, “Infantile Tetanus (Tetanus Neonatorium) in Hong Kong: Its Prevalence and Sources of Infection,” The Caduceus 6 (1927): 249. 30. Same as note 21. May to Lyttelton, 21 July 1904, CO 129/323 #291, 240–243 (Training local midwives). 31. Lugard to Harcourt, Land for the Nursing Institute, 25 July 1911, CO 129/378, 391–392. 32. Proposal for a Hospital for Women and Children, Jubilee Celebration Enclosed in CO 129/275, 468–469. 33. Chater to Blake, Jubilee Hospital and Nursing Institute, 30 June 1899, Enclosed in Blake to Chamberlain, 6 September 1899, CO 129/293 #254, 340–345. 34. Chalmers (Medical Missionary) to Cousins (Foreign Secretary, LMS in London), 4 November 1897, (London Missionary Society, hereafter, LMS) Box 13, 1897, no. 240 and no. 241 (Gibson became medical superintendent of Alice Memorial Hospital). 35. Gibson to Cousins, 1 February 1901, LMS Box 15, 1901, no. 263 (Gibson wished to increase the influence of the medical mission). 36. Pearce to Cousins, 14 May 1898, LMS Box 14, 1898, no. 245 (Gibson dismissed Hospital Committee). 37. Gibson to Cousins, 15 May 1903, LMS Box 15, 1903, no. 274 (Opening of Alice Memorial Maternity Hospital). 38. Gibson to Cousins, 12 September 1902, LMS Box 15, 1902, no. 268–269 (Dr. Sibree’s contract). 39. Gibson to Cousins, 9 February 1903, LMS Box 15, 1903, no. 273 (Gibson denied subordinate role of Sibree). 40. Sibree to Cousins, 20 December 1904, LMS Box 16, 1904, no. 284 (Opening of Alice Memorial Maternity Hospital). 41. Gibson to Cousins, 6 February 1909, LMS Box 18, 1909 no. 311 (Sibree excluded from general medical work). 42. Mitchell to Cousins, 20 April 1906, LMS Box 16, 1905, no. 288 (Chinese did not want female doctor). 43. Sibree to Cousins, 7 February 1905, LMS Box 16, 1905, no. 287 (Sibree excluded from Sham Shui Po Clinic). 44. Editorial, The Lancet 17 August (1878): 226–227. 45. Sibree to Cousins, 9 October 1906, LMS Box 16, 1906–1907, no. 295 (Sibree chose to stay). 46. Report of the Alice Memorial, Nethersole, Ho Miu Ling Hospital, Hong Kong in Connection with the London Missionary Society, 1909, Printer in China Mail Office, Hong Kong. 47. Minutes of Hong Kong District Committee, Annual Meeting of 1906, LMS Box 17, 1907, no. 297. 48. Report of Principal Chief Medical Officer and Medical Officer of Health for 1907, Hong Kong Sessional Papers, 1908, 409–410.

2 9 8   |   N otes ： C hapter 8

49. Minutes of Hong Kong District Commitee Annual Meeting, 2 March 1909, Box 18, 1909, no. 311 (A lady doctor should be regular staff of Alice Memorial Hospital). 50. Pearce to Cousins, 13 September 1909, LMS Box 18, 1909, no. 315 (Sibree left LMS). While on leave in England, she had a long meeting with the Joint Foreign Secretary of London Missionary Society who ended the meeting by saying that if Sibree were his daughter, he would not allow her to return. 51. Medical and Sanitary Department Report of 1918, Hong Kong Administrative Reports, 1918, Annex A, M3 (Sibree Acting Medical Officer of Health in 1918). 52. Alice Memorial, Nethersole, Ho Miu Ling Hospital Report 1926, London Missionary Society (Dr. Sydenheim). 53. Registrar General’s Report for 1906, Hong Kong Sessional Papers, 1907, 338; Registrar General Report for 1911, Hong Kong Administrative Reports, 1911, C12 (Increase no. of patients attending the Chinese dispensaries). 54. One of Dr. Tso’s main interests was in education, he participated in the founding of several schools such as the St. Stephen’s Boys’ College and St. Stephen’s Girls’ College and the University of Hong Kong. 55. Registrar General’s Report for 1919, Hong Kong Administrative Reports, 1919, C10 (Wan Chai Maternity Hospital). 56. Severn to Colonial Office, Site for a Maternity Hospital, 30 April 1919, CO 129/454 #139, 344; Registrar General’s Report for 1919, Hong Kong Administrative Reports, 1919, C10. 57. Registrar General’s Report for 1924, Hong Kong Adminsitrative Reports, 1924, C11 (Tsan Yuk Hospital). 58. H. K. Ma, “Obstetrics and Gynaecology in Hong Kong,” Hong Kong Journal of Gyanecology and Obstetrics1 (2000): 4–16. 59. Proposed Donation from the Rockefeller Foundation to the University of Hong Kong (Faculty of Medicine) 1922, printed by the South China Morning Post Ltd., Enclosed in Stubbs to Churchill, 21 April 1922, CO 129/474 Confidential, 562–571. 60. Browne O’Donel, The Rotunda Hospital 1785–1945 (Edinburgh: E & S Livingstone Ltd, 1947). 61. C. L-C. Tsang, “Out of the Dark: Women’s Medicine and Women’s Diseases in Colonial Hong Kong” (PhD thesis, University of Hong Kong, 2011), 70. 62. Ibid., 107–108. 63. W. C. W. Nixon, “Toxemia of Pregnancy,” The Caduceus 15 (1936): 89–93. 64. Peel to Cunliffe-Lister, Tsan Yuk—A Free Gift to Government, 4 May 1933, CO 129/544/1; Peel to Cunliffe-Lister Tsan Yuk—A Free Gift to Government, 7 May 1933, CO 129/549/6. 65. Medical and Sanitary Department Report of 1936, Hong Kong Administrative Reports, 1936, M67. 66. Clementi to Passfield, Nurses Registration, 19 September 1929, CO 120/519 #410, 12–13; Nurses Registration Ordinance 1931, Historical Laws in Hong Kong Online. 67. University of Hong Kong, Graduates List (Hong Kong: Hong Kong University, 1974).

N otes ： C hapter 9   |   2 9 9

68. Midwife Ordinance 1910, 2 September 1910, Historical Laws of Hong Kong Online. 69. Medical and Sanitary Department Report of 1938, Hong Kong Administrative Reports, 1938, M33. 70. J. George, “Moving with Chinese Opinion: Hong Kong’s Maternity Service 1881– 1941” (PhD thesis, University of Sydney, 1992), 195. 71. Gestational trophoblastic disease is a group of rare tumors that involve abnormal growth of cells inside a woman’s uterus. This group of disease does not develop from cells of the uterus like cervical cancer or endometrial (uterine lining) cancer do. Instead, these tumors start in the cells that would normally develop into the placenta during pregnancy. (The term gestational refers to pregnancy.)

Chapter 9 1. 2.

3.

4.

5. 6. 7.

F. E. Cartwright, Disease and History (New York: Thomas Y. Crowell Company, 1972), 141–144. “Overview of Malaria Treatment,” World Health Organization, accessed on 1 June 2014, http://www.who.int/malaria/areas/treatment/overview/en/. Ge Hong was a minor southern official during the Jin dynasty (265–420 C.E.) of China, best known for his interest in Daoism, alchemy, and techniques of longevity Sickle-cell anaemia, is a hereditary blood disorder, characterized by red blood cells that assume an abnormal, rigid, sickle shape. Sickling decreases the cells’ flexibility and results in a risk of various life-threatening complications. This sickling occurs because of a mutation in the haemoglobin gene. Individuals with one copy of the mutant gene produce a mixture of both normal and abnormal haemoglobin. Where malaria is common, carrying a single sickle-cell allele (sickle cell trait) confers a selective advantage—in other words, being a heterozygote is advantageous. Humans with one of the two alleles of sickle-cell disease show less severe symptoms when infected with malaria. Glucose-6-phosphate dehydrogenase deficiency (G6PD deficiency) is an X-linked recessive hereditary disease characterized by abnormally low levels of glucose-6phosphate dehydrogenase, a metabolic enzyme involved in the pentose phosphate pathway, especially important in red blood cell metabolism. Individuals with the disease may exhibit nonimmune hemolytic anemia in response to a number of causes, most commonly infection or exposure to certain medications or fava beans. G6PD deficiency is closely linked to favism, a disorder characterized by a hemolytic reaction to consumption of fava or broad beans. Carriers of the G6PD allele appear to be protected to some extent against malaria, and in some cases dominant males have shown complete immunity to the disease. D. Haynes, Imperial Medicine Patrick Manson and the Conquest of Tropical Disease (Philadelphia: University of Pennsylvania Press, 2001), 106–115. “Malaria,” World Health Organization, accessed on 23 January2018, http://www. who.int/mediacentre/factsheets/fs094/en/. Colonial Surgeon Report for 1890, Appendix A, Hong Kong Sessional Papers, 1891, 425–432.

3 0 0   |   N otes ： C hapter 9

8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27.

Medical and Sanitary Reports 1901–1938, Hong Kong Sessional Papers or Hong Kong Administrative Reports, 1901–1938. Report of the Commissioners Appointed by His Excellency Sir William Des Voeux, into the Case of Fever Prevailing in the Western District, Hong Kong Sessional Papers, 1888, vii–xii. Blake to Chamberlain, 6 December 1899, CO 129/294 #351, 489–494. J. C. Thomson, Report Regarding the Mosquitoes that Occur in the Colony of Hong Kong, Enclosed in Gascoigne to Chamberlain, 18 August 1902, CO 129/312 #365, 224–226. F. Clark, The Prevention of Mosquito-Borne diseases, Report for the Year 1912, Enclosed in May to Harcourt, CO 129/400 #128, 347–358. J. Bell, Clinical Report on Malaria, Hong Kong Sessoinal Papers, 1901, no. 27/1901, 493–500. Sanitary Report for Year 1900, Hong Kong Sessional Papers, 1901, 408. Europeans recommended to build their houses 400–500 yards away from the native houses. Medical and Sanitary Report for Year 1931, Hong Kong Administrative Reports, 1931, M45. Same as note 8. Medical and Sanitary Reports 1901–1938, Hong Kong Sessional Papers or Hong Kong Administrative Reports, 1901–1938. Medical Report 1910, Hong Kong Administrative Report, 1910, L13 (Cases of malaria from the New Territories reduced after the completion of the Kowloon-Canton Railway). See note 12. F. Clark, Report for the Year 1912, Enclosed in May to Harcourt, 16 April 1913, CO 129/400 #128, 347–358. K. C. Yip, “Colonialism, Disease, and Public Health: Malaria in the History of Hong Kong,” in Disease, Colonialism, and the State (Hong Kong: Hong Kong University Press, 2009), 20. “The History of Smallpox and Its Spread Around the World,” World Health Organization, accessed on 23 January 2018, https://biotech.law.lsu.edu/blaw/ bt/smallpox/who/red-book/9241561106_chp5.pdf. L. T. Wu, “Early Days of Western Medicine in China,” in Manchurian Plague Prevention Service Reports, 1929–30 (Shanghai: National Quarantine Service. 1934), 129. Cartwright, Disease and History, 120–112. C. K. Wong and L. T. Wu, History of Chinese Medicine: Being a Chronicle of Medical Happenings in China from Ancient Times to the Present Period, 2nd ed. (Shanghai, China National Quanrantine Service, 1936), 274–276. A. K. C. Leung, “The Business of Vaccination in Nineteth-Century Canton,” Late Imperial China 29 (2008): 7–39. Ibid., 25–26 See note 8. Medical and Sanitary Reports 1901–1938, Hong Kong Sessional Papers or Hong Kong Administrative Reports, 1901–1938. Ayers to Colonial Secretary, 22 June 1881, Vaccination in Hong Kong, Enclosed in Marsh to Kimberley, 3 May 1882, CO 129/200 #44, 7–10.

N otes ： C hapter 9   |   3 0 1

28. Barker to Knutsford, Vaccine Institute, 30 September 1891, CO 129/251 #321, 220–235. 29. Medical and Sanitary Report 1929, Hong Kong Administrative Report, 1929, Appendix A, M74–75. 30. “Ordinance No. 2 of 1890. All infants should be vaccinated before the age of 6 months,” accessed on 1 June 2013, http://oelawhk.lib.hku.hk/archive/files/551e3 79457b696ec233ab10383696e10.pdf. 31. May to Long, Vaccination during the 1916–17 smallpox epidemic, 29 June 1918, CO 129/448 #194, 575–577 32. Medical and Sanitary Department Annual Reports, 1916, and 1917, Hong Kong Administrative Reports, 1916, M19; and Hong Kong Administrative Reports, 1917, M 17 (No. of cases of smallpox during the 1916–17 epidemic). 33. Medical and Sanitary Report of Year 1917, Tung Wah Smallpox Hospital, Hong Kong Administrative Reports, 1917, 48. 34. Lugard to Earl of Crewe, Smallpox Hospital, 28 July 1908, CO 129/347, #194, 160–161. 35. Hong Kong Museum of Medical Sciences Society, Plague, SARS, and the Story of Medicine in Hong Kong (Hong Kong: Hong Kong University Press, 2006), 25–26. 36. S. H. Lee, Department of Health: Infectious Disease Surveillance (Hong Kong: n.p., n.d.), 43–45 (Smallpox eradicated from Hong Kong). 37. W. Hunter and W. C. M. Koch, A Research into the Etiology of Beri-beri, together with a Report on an Outbreak in the Po Leung Kuk, printed by Noronha and Co. 1906, in Hong Kong Sessional Papers, 1906, 295–314. 38. E. B. Veddar, Beri beri (London: John Bale, Sons and Danielsson, 1913), 1–9. 39. P. Manson, Tropical Diseases: A Manual of the Diseases of Warm Climates (London: Cassell and Company, Limited, 1898), 223. 40. See reference 37. 41. C. Eijkman Nobel Lecture, “Antineuritic Vitamin and Beriberi,” accessed on 4 March 2013, https://www.nobelprize.org/nobel_prizes/medicine/ laureates/1929/eijkman-lecture.html. 42. C. A. Pekelharing, Beri-beri: Researches Concerning Its Nature and Cause and the Means of Its Arrest, Made by Order of the Netherlands Government, trans. by James Cantlie (Edinburgh: Young J. Pentland, 1893). 43. H. Fraser, The Etiology of Beri-beri (Singapore: Kelly and Wash Ltd. Printers, 1911), 40–50. 44. D. Arnold, “Tropical Governance: Managing Health in Monsoon Asia, 1908– 1938,” Asia Research Institute (ARI), Working Paper Series No. 116, presented at the ARI Seminar Series held at the ARI on 11 February 2009, National University of Singapore, May 2009, accessed on 15 April 2014, http://www.ari.nus.edu.sg/ wps/wps09_116.pdf. 45. Veddar, Beri beri, 14–15. 46. See note 8. 47. See note 37. 48. R. M. Gibson, “Beri-beri in Hong Kong, with Special Reference to the Records

3 0 2   |   N otes ： C hapter 1 0

of the Alice Memorial and Nethersole Hospitals with Notes on Two Years Experience of the Disease” (M.D. thesis, University of Edinburgh, 1900), 1–21. 49. Medical and Sanitary Report for Year 1911, Hong Kong Sessional Papers, 1912, L23. 50. D. Arnold, “British India and the ‘Beriberi Problem,’ 1798–1942,” Medical History 54 (2010): 295–314. 51. P. W. C. Mao, “The Late Professor W. C. W. Nixon,” in The First Fifty Years of the Tsan Yuk Hospital (published privately in Hong Kobg, 1974), 31.

Chapter 10 1. 2. 3. 4. 5. 6. 7. 8. 9.

10. 11. 12. 13. 14. 15.

C. Hamlin, S. Sheard, “Revolutions in Public Health: 1848 and 1998”? BMJ 317 (1998): 587–591. A. R. Wellington, Memorandum, Changes in the Public Health Organization of Hong Kong during the Period 1929 to 1937, CO 129/563/3. Medical and Sanitary Department Report for 1938, Hong Kong Adminstrative Reports, 1938, M81-84 Administrative Structure of Medical and Sanitary Department. Revenues and Expenditure for 1929–1939, Hong Kong Blue Books, 1929–1939. Robinson to Chamberlain, Kennedy Town Hospital, 26 January 1897, CO 129/275 #25, 89. R. M. Pearce of Rockefeller Foundation to Vice Chancellor of Hong Kong University, 23 January 1922, Enclosed in Stubbs to Churchill, 21 April 1922, CO 129/474, 562. C. M. Fung, A History of Queen Mary Hospital, Hong Kong 1937–1997 (Hong Kong: Queen Mary Hospital Hong Kong, 1997), 5. Ibid., 6. Extract from Report of the Technical Committee for the Reorganization and Improvement of Existing Official Hospitals and Clinical Facilities of the Colony of Hong Kong 1938–1939, Annual Medical Report for 1939, Hong Kong Government Administrative Reports, 1939, Appendix 2 M105–M110. Annual Medical Report for 1938, Hong Kong Administrative Reports, 1938, M55–68. Annual Medical Report for 1938, Hong Kong Administrative Reports, 1938, M15–19 (Prevention of communicable diseases). Annual Medical Report for 1938, Hong Kong Administrative Reports, 1938, M30–31 (Port Health Program). Annual Medical Report for 1938, Hong Kong Administrative Reports, 1938, M42 (Social Hygiene Program). Annual Medical Report for 1938, Hong Kong Administrative Reports, 1938, M32 (Maternal and Child Welfare). Annual Medical Report, Maternal and Child Welfare, 1936, Hong Kong Adminsrative Reports 1936, M67–74. In 1936, of the 3,028 infants brought in to Wan Chai and Kowloon clinic, 47.4% had digestive disturbances, 44.2% malnutrition, 41.2% respiratory diseases, 25.3% conjunctivitis, 21.9% skin diseases, 5.5% congenital syphilis, 3% jaundice, and 2.7% anemia.

N otes ： C hapter 1 0   |   3 0 3

16. Annual Medical Report for 1938, Hong Kong Administrative Reports, 1938, M22 (School Health Program). 17. M. Topley, “Chinese Traditional Etiology and Methods of Cure in Hong Kong,” in Asian Medical Systems: A Comparative Study, ed. Charles Leslie (Berkeley, LA: University of California Press,. 1976), 243–264. 18. G. H. Choa, The Life and Times of Sir Kai Ho Kai (Hong Kong: Chinese University Press, 2000), 51–53. 19. S. Go, Chronology of Chinese Medicine in Hong Kong and Landmark Events (Hong Kong: MCCM Creations, 2003). 20. “A New Era of Chinese Medicine,” Chinese Medicine Division, Department of Health, The Government of the Hong Kong Special Administrative Region, accessed on 2 July 2014, www.cmd.gov.hk/html/b5/health_info/doc/A_New_ Era_of_Chinese_Medicine_in_Hong_Kong_(2007).pdf. 21. K. Mattock, Hong Kong Practice. Drs. Anderson and Partners. The First 100 Years (Hong Kong: Drs. Anderson and Partners, Linkprint Ltd, 1984). 22. J. Cantlie Stewart. The Quality of Mercy: The Lives of Sir James and Lady Cantlie (London: George Allen and Unwin, 1983), 49. 23. P. Cunich, A History of the University of Hong Kong (Hong Kong: Hong Kong University Press, 2012), 26. 24. Shu-fan Li, Hong Kong Surgeon (London: Victor Gollancz, 1964), 60–61. 25. Hong Kong Sanatorium and Hospital 1922–2012 (Hong Kong: Hong Kong Sanatorium and Hospital, 2013), 22. 26. Hong Kong Medical and Sanitary Report for 1936, Hong Kong Administrative Reports, 1936, C56. 27. Cunich, A History of the University of Hong Kong, 176. 28. Ibid., 239. 29. Hong Kong Government Gazette, 1904, 1905 (5 May 1905, 636–637), 1915 (7 May 1915, 240–242), 1925 (8 May 1925, 167–173), 1935 (10 May 1935, 573–592), 1941 (9 May 1941, 704–733). 30. Hong Kong Government Gazette, 1904. 31. Hong Kong Government Gazette, 1941, 9 May 1941, 704–733. 32. Cunich, A History of the University of Hong Kong, 187, 190, 238, 285, 287, 303, 362–363. 33. Hong Kong Census Report, 1891, Hong Kong Sessional Papers, 1891, no. 90/91, 373 (On the inaccuracy of the 1881 census). 34. E. Sinn, Power and Charity: A Chinese Merchant Elite in Colonial Hong Kong (Hong Kong: Hong Kong University Press, 2003), 9. 35. Annual Medical Reports or Medical and Sanitary Reports, Population, Birth Rates, Death Rates, 1921–1939, Hong Kong Administrative Reports, 1921–1939. 36. P. T. Ho, Studies of Population of China, 1368–1953 (Cambridge: [Mass] Harvard Univeristy Press, 1959), 76. 37. “History of the Development of the ICD,” World Health Organization, accessed on 2 July 2014, www.who.int/classifications/icd/en/HistoryOfICD.pdf. 38. A. R. Wellington, Medical and Sanitary Report 1936, Hong Kong Administrative Reports, 1936, M35.

3 0 4   |   N otes ： C hapter 1 0

39. See note 11. Medical and Sanitary Report for the Year 1938, Hong Kong Administrative Reports, 1938, M15–19. 40. After the Second World War, many medical graduates from China came to Hong Kong as refugees. They were not eligible for registration in Hong Kong. The Medical and Health Department employed a large number of these unregistrable doctors and at times they constituted almost half of the workforce. Without them the Medical and Health Department would not be able to function. Many “unregistrable” doctors also served in charity and other clinics. Several examinations were held in the late 1950s for these doctors to obtain the licence to practice. For more information please consult “Report of the Working Party on Unregistrable Doctors” published by the Colonial Secretariat of Hong Kong in 1975.

Glossary

acupuncture ambergris artemisia Beihai (Pakhoi) Beiyang Medical College Beriberi (kakke) chaulmoogra seed Chun, Daphne Chung King-ue Chung Wah School “Cleaning the Tai Ping floor” Convention of Chuenpi (Chuanbi) Fifty-Two Prescriptions fu Fuzhou (Foochow) Ge Hong Gough Street Government Civil Hospital Government Civil Hospital, the Guangxu (Kuang-Hsu) Hakka Ho Fuk-tong Ho Kai Ho Ko-tsun Ho Miu Ling Hospital Ho Tung, Eva

針灸 龍涎香 蒿 北海 北洋醫學院 腳氣 大風子 秦惠珍 鍾景裕 中華學校 洗太平地 穿鼻草約 五十二病方 腑 福州 葛洪 歌賦街 政府公立醫院 國家醫院 光緒 客家 何福堂 何啟 何高俊 何妙齡醫院 何嫻姿

3 0 6   |   G lossary

Hong Kong Daily Press Hong Kong Telegraph Hua Tuo Huangdi Jeu Hok kaifong (neighbourhood) Kaohsiung (Takow) Kwan Ato Kwan King-leung Kwong Fook I Tsz Kwong Wah Hospital Li Hongzhang Li Shu-fan Li Shu-pui Ma Ho-kei mahuang Ma Luk Man Mo Temple Mawangdui moxibustion mui tsai Nam Pak Hong Neijing Nethersole Hospital Ng Choy Pedder, the harbor master Po Leung Kuk Possession Point qi qinghaosu Qishan (Keshen) Ruttonjee Hospital san jiao



《每日雜報》/《孖剌報》/ 《孖剌西報》/《孖剌沙西報》 《每日電訊報》/《士蔑報》 華佗 黃帝 趙學 街坊 高雄市 關亞杜 關景良 廣福義祠 廣華醫院 李鴻章 李樹芬 李樹培 馬鍾可璣 麻黃 馬祿 文武廟 馬王堆 灸 妹仔 南北行 內經 那打素醫院 伍才 畢打 保良局 水坑口 氣 青蒿素 琦善 律敦治醫院 三焦

G lossary   |   3 0 7

Shennong 神農 Sun Simiao 孫思邈 Tai Ping Shan 太平山 Ts’o Seen-wan 曹善允 Tung Wah Eastern Hospital 東華東院 Tung Wah Hospital 東華醫院 Wan Man-kai 尹文楷 wanpo 隱婆 Wu Tin-po 吳天保 Wong Fun 黄寬 xieli 協理 Yamen 衙門 yang 陽 yin 陰 zang 臟 Zhen Quan 甄權 zhishi 值事 Zhouhou Beiji Fang 《肘後備急方》 (The Handbook of Prescriptions for Emergencies) Zhoushan (Chusan) 舟山 zongli 總理

This page intentionally left blank

Bibliography

Primary Sources Archives CO 129, Colonial Office. Hong Kong: Original Correspondence, 1838–1946. FO 228, Foreign Office. Embassy and Consular Archive: China; and FO 233, Foreign Office. Miscellanea. Council for World Mission Archives, South China. London Missionary Society (LMS) Boxes 9 to 19: 1882–1891. Lowson’s Diary from the Hong Kong Museum of Medical Sciences Society. Tung Wah Hospital Annual Reports, 1873–1907, Tung Wah Museum Archives.

Government Reports Printed or Online Hong Kong Administrative Reports, 1879–1883 and 1908–1939, from Hong Kong Government Reports Online. Hong Kong Blue Books, hard copies of 1845–1870 from Hong Kong University Library Special Collections and soft copies of 1871–1940 from Hong Kong Government Reports Online. Hong Kong Government Gazette, 1884–1940, from Hong Kong Government Reports Online. https://www.ha.org.hk/gallery/ha_publications.asp?Library_ ID=13&lang=en Hong Kong Sessional Papers, 1884–1940, from Hong Kong Government Reports Online. Hong Kong Medical and Health Department Annual Reports, 1939–1945.

Special Reports Report of the Commissioners Appointed by His Excellency Sir John Pope Hennessy, CMG to enquire into the workings of the Contagious Diseases Ordinance, 1867. Hong Kong: Noronha & Sons, 1879. Chadwick Osbert. “Report on the Sanitary Condition of Hong Kong,” London: George E. B. Eyre and Wiliam Spottiswoode. 1882. Report of the Commissioners Appointed by His Excellency Sir William Des Voeux into the Case of Fever Prevailing in the Western District. Hong Kong Sessional Papers, 1888, Hong Kong Government Reports Online.

3 1 0   |   B ibliography

Report of the Committee of Enquiry into the Medical Department of the Colony. Hong Kong Sessional Papers, 1895, 549. Hong Kong Government Reports Online. Report of the Commission to Report on the Workings and Organization of the Tung Wah Hospital. Hong Kong Sessional Papers, 1896. Hong Kong Government Reports Online. Report of the Committee Appointed by His Excellency the Governor to Inquire into the Causes of Chinese Infant Mortality in the Colony. Hong Kong Sessional Papers, 1904, 1/1904, Hong Kong Government Reports Online. Report on the Census of the Colony for the years 1891 (Sessional Papers 30/1891, 375– 395); 1901 (Sessional Papers 39/1901, 1–25); 1911 (Sessional Papers 17/1911, 1–62); 1921 (Sessional Papers 15/1921, 151–232), 1931 (Sessional papers 5/1931, 87–197). Hong Kong Council of Social Service. “Working Group on the Medical and Health Green Paper.” Comments on the Hong Kong Medical Development Advisory Committee 1973 Report, Hong Kong.

Newspapers China Mail, 1866–1941 Hong Kong Telegraph, 1894–1896 Hong Kong Daily Press, 1894–1896 (The above accessed via MMIS, Hong Kong Public Libraries at the following website: https://mmis.hkpl.gov.hk/old-hk-collection.) South China Morning Post, 1903–1946 (accessed via Hong Kong University Library Electronic Resource)

Secondary Sources Books and Journal Articles Alice Ho Miu Ling Nethersole Hospital. Alice Ho Miu Ling Nethersole Hospital 1887–1967. Hong Kong: Alice Ho Miu Ling Nethersole Hospital, 1967. Alice Ho Miu Ling Nethersole Hospital. Alice Ho Miu Ling Nethersole Hospital 1887–1977. Hong Kong: Alice Ho Miu Ling Nethersole Hospital, 1977. Appleby, Andrew B. “The Disappearance of the Plague: A Continuing Puzzle.” Economic History Review 33 (1980):161–173. Arnold, David. Colonizing the Body. State Medicine and Epidemic Disease in Nineteenth Century India. Berkeley: University of California Press, 1993. Arnold, David. “Tropical Governance: Managing Heath in Monsoon Asia, 1908–1938.” Paper presented at the ARI Seminar Series, Asia Research Institute, National University of Singapore, 11 February 2009. Arnold, David. “British India and the ‘Beriberi Problem’ 1798–1942.” Med History 54, no. 3 (2010): 295–314. Ashby, H. T. Infant Mortality. Cambridge: Cambridge University Press, 1915. Bard, Solomon. Light and Shade: Sketches from an Uncommon Life. Hong Kong: Hong Kong University Press, 2009.

B ibliography   |   3 1 1

Barker, Kathleen E. Change and Continuity: A History of St. Stephen’s Girls’ College, Hong Kong 1906–1996. Hong Kong: St. Stephen’s Girls’ College, 1996. Bird, Isabella L. The Golden Chersonese and the Way Thither. Oxford in Asia Historical Reprints. Kuala Lumpur: Oxford University Press, 1967. Braddon, W. L. The Cause and Prevention of Beri-beri. Charleston: Nabu Press, 2010. Browne, O’Donel T. D. The Rotunda Hospital 1745–1945. Edinburgh: Livingstone, 1947. Brunton, D. Health, Disease and Society in Europe, 1800–1930: A Source Book. Manchester: Manchester University Press, 2004. Carroll, J. M. Edges of Empires. Chinese Elites and British Colonials in Hong Kong. Cambridge, MA: Harvard University Press, 2005. Cartwright, F. E. Disease and History. New York: Thomas Y. Corwell Company, 1972. ———. A Social History of Medicine. London: Longman Group Ltd., 1977. Castells, M., L. Goh, and R. Y. W. Kwok. The Shek Kip Mei Syndrome—Economic Development and Public Housing in Hong Kong. London: Pion Ltd., 1990. Chan, J., and N. Patel. Digby. A Remarkable Live. Hong Kong: Hong Kong University Press, 2006. Chan Lau Kit-Ching, and P. Cunich. An Impossible Dream: Hong Kong University from Foundation to Re-establishment 1910–1950. Hong Kong: Oxford University Press, 2002. Chan, Ming K., ed. Precarious Balance, Hong Kong between China and Britain 1842–1992. With the Collaboration of John Young. New York: M. E. Sharpe, Armonk, 1994. Chan Wai Kwan. The Making of Hong Kong Society: Three Studies of Class Formation in Early Hong Kong. Oxford: Clarendon Press, 1991. Cheng, J. Y. S. Hong Kong in Transition. Hong Kong: Oxford University Press, 1986. Cheng, P. H. Early Hong Kong Brothel. Hong Kong: Hong Kong University Museum of Art, 2003. Choa, G. H. The Life and Times of Sir Kai Ho Kai. 2nd ed. Hong Kong: The Chinese University Press, 2000. ———. A History of Medicine of Hong Kong. Hong Kong: Medical Directory of Hong Kong, 1970. ———. “Heal the Sick” Was Their Motto: The Protestant Medical Missionaries in China. Hong Kong: The Chinese University Press, 1990. Chow, N. “Social welfare in Hong Kong.” Prepared by Hong Kong Organizing Committee for the 20th International Conference on Social Welfare, Hong Kong. July 16–22, 1980. Chun, D. The First 50 Years of the Tsan Yuk Hospital (1922–1972). Hong Kong: Tsan Yuk Hospital, 1972. Collins, C. H. Public Administration in Hong Kong. London: Royal Institute of International Affairs, 1952. Corsini, C. A., and P. Viazzo. “The Decline of Infant Mortality in Europe 1800–1950.” Four National Case Studies. UNICEF International Child Development Centre, Florence, Italy, 1993. Cunich, P. A History of the University of Hong Kong. Hong Kong: Hong Kong University Press, 2012.

3 1 2   |   B ibliography

Duffin, J. History of Medicine. A Scandalously Short Introduction. Toronto: University of Toronto Press, 1999. Eitel, E. J. Europe in China: The History of Hong Kong from the Beginning to the Year 1882. London: Luzac & Company; Hong Kong: Kelly & Walsh, Ld., 1895. Endacott, G. B. Government and People in Hong Kong 1841–1962: A Constitutional History. Hong Kong: Hong Kong University Press, 1964. ———. A History of Hong Kong. 2nd ed. Hong Kong: Oxford University Press, 1973. ———. Hong Kong Eclipse. Hong Kong: Oxford University Press, 1978. ———. A Biographical Sketch-book of Early Hong Kong. Hong Kong: Hong Kong University Press, 2005. ———. An Eastern Entrepot. London: Her Majesty’s Stationery Office, 1964. Endacott, G. B., and A. Hinton. Fragrant Harbour: A Short History of Hong Kong. Hong Kong: Oxford University Press, 1968. Eu, Gaik Choo Eleanor. The Rugged Winding Path. Penang: Privately Printed, 2006. Evans, D. E. Constancy of Purpose. An Account of the Foundation and History of the Hong Kong College of Medicine and the Faculty of Medicine of the University of Hong Kong (1887–1987) Hong Kong: Hong Kong University Press, 1987. Fraser, H. The Etiology of Beri-beri. Singapore: Kelly and Wash Lid Printers, 1911. Fung Chi-ming. A History of Queen Mary Hospital 1937–1997. Hong Kong: Queen Mary Hospital, 1997. Fung, Y. W., and M. Chan-Yeung, To Serve and to Lead: A History of the Diocesan Boys’ School, Hong Kong. Hong Kong: Hong Kong University Press, 2009. Gould, Stacey, and Pan Tina Yee-wan. HKU Memories from the Archives. Chinese eds. Jane Kwan-yuk Sze, Anita Yin-fong Wong, and Chun-tong Yeung, et al. Hong Kong: University Museum and Art Gallery, the University of Hong Kong, 2013. Go, Simon. Hong Kong Apothecary: A Visual History of Chinese Medicine Packaging. New York: Princeton Architectural Press, 2001. Hamlin, C., and S. Sheard.“Revolutions in Public Health: 1848 and 1998?” BMJ 1998; 317: 587–591. Hardiman, D. Healing Bodies, Saving Souls: Medical Mission in Asia and Africa. The Welcome Series in the History of Medicine. Amsterdam-New York: Rodopi, 2009. Hay, J. W. Health Care in Hong Kong. An Economic assessment. Hong Kong: The Chinese University Press, 1992. Haynes, D. Imperial Medicine Patrick Manson and the Conquest of Tropical Disease. Philadelphia: University of Pennsylvania Press, 2001. Hays, J. N. Epidemics and Pandemics: Their Impact on Human History. Santa Barbara, California: ABC CLIO, 2005. Headricks, D. The Tentacles of Progress: Technology Transfer in the Age of Imperialism 1850–1940. New York: Oxford University Press, 1988. Hillier, S, M., and J. A. Jewell. Health Care and Traditional Medicine in China 1800–1982. London: Routledge and Kegan Paul, 1983. Ho, F. The Silent Protector: History of Hong Kong Bacteriological Institute. Hong Kong: Hong Kong Museum of Medical Science Society, 2006. Ho, F. “The Beginning of Medical Education in Hong Kong 125 years ago ... Its Unique

B ibliography   |   3 1 3

Features in Comparison with Similar Efforts in China.” Hong Kong Medical Journal 18 (2012): 544. Ho, M. When Science and Compassion meet: A Turning Point in the History of Medicine in Hong Kong. Hong Kong: Hong Kong Museum of Medical Science Society, 1997. Ho Pui-Yin. Water for a Barren Rock: 150 Years of Water Supply in Hong Kong. Hong Kong: Commercial Press, 2001. ———. Changes for an Evolving City: 160 Years of Port and Land Development in Hong Kong. Hong Kong: Commercial Press, 2004. Ho, P. Y., and F. P. Lisowski. A Brief History of Chinese Medicine, 2nd ed. Singapore: World Scientific Publishing Co. Ltd., 1997. Hoe, S. The Private Life of Old Hong Kong: Western Women in the British Colony 1841–1941. Hong Kong: Oxford University Press, 1991. Hong, F. Footbinding, Feminism and Freedom: The Liberation of Women’s Bodies in Modern China. London: Frank Cass, 1997. Hong Kong Academy of Medicine. A History of Medicine in Hong Kong. Hong Kong: Hong Kong Academy of Medicine Press, 2011. Hong Kong Museum of Medical Sciences Society. Plague, SARS and the Story of Medicine in Hong Kong. Hong Kong: Hong Kong University Press. 2006. Hong Kong Sanatorium and Hospital. History of Hong Kong Sanatorium and Hospital, 1922–2012. Hong Kong: Hong Kong Sanatorium and Hospital. 2013. Hunter, W. A Research into Epidemic and Epizootic Plague. Hong Kong: Noronha and Co., 1904. Hutcheon, R. High Rise Society. Hong Kong: Hong Kong Housing Society, 1998. Ingham, M. Hong Kong. A Cultural History. New York: Oxford University Press, 2007. Jarvie, I. C., and J. Agassi. Hong Kong: A Society in Transition. London: Routledge and Kegan Paul, 1969. Jaschok, M. Concubines and Bond Servants: A Social History. Hong Kong: Oxford University press, 1988. Jaschok, M., and S. Miers. Women and Chinese Patriarchy: Submission, Servitude and Escape. Hong Kong: Hong Kong University Press, 1994. Jeffries, C. J. The Colonial Office. London: Oxford University Press, 1956. King, Ambrose Y. C., and Rance P. L. Lee. Social Life and Development in Hong Kong. Hong Kong: The Chinese University Press, 1981. King, G. “The History of Tsan Yuk Hospital, 1922 to 1955.” Bulletin of the Hong Kong Chinese Medical Association, 8 (1956): 31–39. Lau, Y. W. A History of Municipal Councils of Hong Kong 1883–1999: From the Sanitary Board to the Urban Council and the Regional Council. Hong Kong: Leisure and Cultural Services Department, 2002. Lee, S. H. Prevention and Control of Communicable Diseases in Hong Kong. Hong Kong: Government Printers, 1994. Lee, Rance, P. L. “Chinese and Western Health Care Systems: Professional Stratification in a Modernizing Society.” In Social Life and Development in Hong Kong, eds. King, Ambrose Y. C. and Rance P. L. Lee. Hong Kong: The Chinese University Press, 1981. Lethbridge, H. J. Hong Kong: Stability and Change. A Collection of Essays. Hong Kong Oxford University Press, 1978.

3 1 4   |   B ibliography

Leung, A. K. C. “The Business of Vaccination in Nineteenth-Century Canton.” Late Imperial China 29 (2008): 7–39. Leung, G., and Bacon-Shone J. Hong Kong’s Health System: Reflections, Perspectives and Visions. Hong Kong: Hong Kong University Press, 2006. Li, S. F. Hong Kong Surgeon. London: Victor Gollancz, 1964. Lockhart, W. The Medical Missionary in China: A Narrative of Twenty Years’ Experience. London: Hurst and Blackett Publishers, 1861. Ma, H. K. “Obstetrics and Gynaecology in Hong Kong.” Hong Kong Journal of Gynaecology and Obstetrics and Midwifery 4 (2000): 4–16. Mao, P. W. C. “The Late Professor W. C. W Nixon.” In The First Fifty Years of the Tsan Yuk Hospital. Hong Kong, 1974. Magner, L. N. A History of Medicine. New York: Marcel Dekker Inc., 1992. Manson-Bahr, P. Sir Patrick Manson: The Father of Tropical Medicine. London: Thomas Nelson and Sons Ltd., 1962. Marriott, E. The Plague Race: A Tale of Fear, Science and Heroism. London: Picador, 2002. Matthews, C., O. Cheung. Dispersal and Renewal: Hong Kong University during the War Years. Hong Kong: Hong Kong University Press, 1998. Mattock, K. Hong Kong Practice. Drs. Anderson and Partners. The First Hundred Years. Hong Kong: Linkprint Ltd, 1984. Mellor, B. The University of Hong Kong: An Informal History. Hong Kong: Hong Kong University Press, 1981. McCallum, H. Laws Relating to Public Health and Sanitation in the Colony. Hong Kong Sanitary Board. Hong Kong: Noronha and Co, Government Printers, 1895. Miners, N. Hong Kong under Imperial Rule 1912–1941. East Asian Historical Monographs. New York: Oxford University Press, 1987. ———. The Government and Politics of Hong Kong, 5th ed. Hong Kong: Oxford University Press, 1991. Munn, C. Anglo-China: Chinese People and British Rule in Hong Kong 1848–1880. Richmond, Surrey: Curzon, 2001. National Quarantine Service. Manchurian Plague Prevention Service Reports, 1929–1930. Volume VII of the Series. Paterson, E. H. A Hospital for Hong Kong. The Centenary History of the Alice Ho Miu Ling Nethersole Hospital. Hong Kong: Alice Ho Miu Ling Nethersole Hospital, 1987. Pearson, V., and Tim-keung Ko. A Sense of Place: Hong Kong West of Pottinger Street. Hong Kong: Joint Publishing Co., 2008 Pekelharing, C. A. Beri-beri: Researches Concerning Its Nature and Cause and the Means of Its Arrest, Made by Order of the Netherlands Government, translated by James Cantlie. Edinburgh: Young J. Pentland, 1893. Platt, J., M. E. Jones, and A. K. Platt. The Whitewash Brigade: The Hong Kong Plague of 1894. London: Dixon Noonan Webb Ltd., 1998. Poon, E. Y. W. “A Brief History of Nursing in Hong Kong.” Hong Kong Nursing Journal 3 (1967):119–123. Pope-Hennessy, J. Half-Crown Colony. London: AHK Notebook, 1969. Porter, R. The Cambridge History of Medicine. New York: Cambridge University Press, 2006.

B ibliography   |   3 1 5

Pryor, E. G. “The Great Plague of Hong Kong.” JHKBRAS 15 (1975): 61–70. Hong Kong Academy of Medicine. Sapientia et humanitas: A History of Medicine in Hong Kong. Hong Kong: Hong Kong Academy of Medicine, 2011. Sayer, Geoffrey R. Hong Kong 1841–1862. Birth, Adolescence and Coming of Age. Introduction and additional notes by D. M. Emrys Evans. Hong Kong: Hong Kong University Press, 1980. ———. Hong Kong 1862–1919: Years of Discretion. Edited and with additional notes by D. M. Emrys Evans. Hong Kong: Hong Kong University Press, 1975. Selwyn-Clarke, P. Selwyn. Footprints: The Memoirs of Sir Selwyn Selwyn-Clarke. Hong Kong: Sino-American Publishing, 1975. Simpson, W. J. Report on the Causes and Continuance of Plague in Hong Kong and Suggestions as to the Remedial Measures. London: Waterlow and Sons, 1903. Sinn, E. Power and Charity: The Early History of the Tung Wah Hospital, Hong Kong. Hong Kong: Hong Kong University Press, 2003. ———. “Opportunity Knocking: Female Brothel Keepers in Hong Kong.” In A Sense of Place: Hong Kong West of Pottinger Street, eds. Pearson, V., T. K. Ko. Hong Kong: Joint Publishing, 2008. ———. “Women at Work: Chinese Brothel Keepers in Nineteenth Century Hong Kong.” Journal of Women’s History 19 (2007): 87–111. Solomon, T. “Hong Kong, 1894: The role of James A. Lowson in the Controversial Discovery of the Plague Bacillus.” Lancet 350 (1997): 59–62. Smart, A. The Shek Kip Mei Myth: Squatters, Fires, and Colonial Rule in Hong Kong 1950– 1963. Hong Kong: Hong Kong University Press, 2006. Smith, Carl T. Chinese Christians: Elites, Middlemen and the Church in Hong Kong. Hong Kong: Oxford University Press, 1985. ______ A Sense of History: Studies of the Social and Urban History of Hong Kong. Hong Kong: Hong Kong Educational Publishing Co., 1995. Spence, J. D. The Search for Modern China. New York: W. W. Norton & Company, 1990. Spurr, R. Excellency: The Governors of Hong Kong. Hong Kong: Form Asia Books Ltd., 1995. Stewart, J. C. The Quality of Mercy. London: George Allen and Unwin, 1983. Temple, R. The Genius of China: 3000 Years of Science, Discovery and Invention, with a forward by Joseph Needham. New York: Simon and Schuster, 1986 Topley, M. “Chinese Traditional Etiology and Methods of Cure in Hong Kong.” In Asian Medical Systems: A Comparative Study, ed. Charles Leslie. Berkeley, LA: University of California Press, 1976. Tsai, J. F. Hong Kong in Chinese History: Community and Social Unrest in the British Colony 1842–1913. New York: Columbia University Press, 1993. Tsang, C. L. C. “Knowing Chinese Women: Richard Tottenham and Colonial Medicine in Interwar Hong Kong.” JHKBRAS 53 (2013):167–181. Tsang, S. A Modern History of Hong Kong. Hong Kong: Hong Kong University Press, 2006. Tseung, F. I. “Chinese Medicine and Its Contribution to Modern Medical Science.” JHKBRAS 12 (1972):12–19. Tung Wah Group of Hospitals (HK) Board of Directors, 1970–1971. One Hundred Years of Tung Wah Group of Hospitals 1870–1970. Hong Kong: The Group, 1971.

3 1 6   |   B ibliography

Veddar, E. B. Beri-beri. New York: W. Wood and Company, 1913. Wang, C. Y. “Infantile Tetanus (Tetanus Neonatorium) in Hong Kong: Its Prevalence and Sources of Infection.” The Caduceus 6 (1927): 249. Watts, S. Epidemics and History. Disease, Power and Imperialism. New Haven: Yale University Press, 1997. Wong, K. C., and L. Y. Wu. History of Chinese Medicine: Being a Chronicle of Medical Happenings in China from Ancient Times to the Present Period, 2nd ed. Shanghai: National Quarantine Service, 1936. Wong, T. C. “Some Observations on the Clinical Aspects of Tetanus Neonatorium (Infantile Tetanus).” The Caduceus 6 (1927): 254. Wu Lien-Teh. Manchurian Plague Prevention Service Reports 1929–30, volume VII of the Series. Shanghai: National Quarantine Service, 1934. Wu Lien-Teh. Cholera: A Manual for the Medical Profession in China. Shanghai: National Quarantine Service, 1934. Yip, K. C. “Science, Culture and Disease Control in Colonial Hong Kong.” In Science, Public Health and State in Modern Asia. Hong Kong: Hong Kong University Press, 2009 ———. “Colonialism, Disease, and Public Health: Malaria in the History of Hong Kong.” In Disease, Colonialism, and the State. Hong Kong: Hong Kong University Press, 2009.

Theses Cowell, Christopher A. “Form Follows Fever: Malaria and the Making of Hong Kong 1841–1848.” MPhil dissertation, University of Hong Kong, 2009. George, Janet. “Moving with the Chinese Opinion. Hong Kong Maternity Service 1881–1941.” PhD thesis, University of Sydney, 1992. Gibson, R. M. “Beri-beri in Hong Kong, with Special Reference to the Records of the Alice Memorial and Nethersole Hospitals with Notes on Two-Year’s Experience of Disease.” M.D. thesis, University of Edinburgh, 1900. Poon Suk-Wah. “Five Years of Mischievous Activity: A Study of Governor Hennessy’s Policies towards the Chinese in Hong Kong, 1877–1882.” MPhil E-thesis, Baptist University, Hong Kong, 1995. So, P. C. “The Development of Medical Services in Hong Kong.” Thesis, Master of Arts, The University of Hong Kong, Chapter 5, no page number. Tsang Chiu Long. “Out of the Dark: Women’s Medicine and Women’s Diseases in Colonial Hong Kong.” PhD Thesis, University of Hong Kong, 2011. Zhou Hong. “The Origins of Government Social Protection Policy in Hong Kong: 1842–1941.” PhD thesis, Brandeis University, Ann Arbor, 1992.

B ibliography   |   3 1 7

Websites https://commons.wikimedia.org www.chinesecol.com www.hongkongsfirst.blogspot.com www.scmp.com www.tungwah.org.hk www.amo.gov.hk www.nethersole.org www.en.wikipedia.org www.cnn.com www.shropshireregimentalmuseum.co.uk www.archsd.gov.hk www.docomomo.hk www.obsgyn.hku.hk www.blackpest.com www.livescience.com www.artandscience.com

This page intentionally left blank

Index

Aberdeen, 1, 4, 21, 93 Aberdeen Dispensary, 240 Aberdeen Reservoirs, 159, 160 Académie de Sciences, 150 acupuncture, 86, 212, 235, 280n27 Adams, William Stanley, 236 Ague, 19 air-borne diseases, 232 Albany Road, 22 Aldrich, Edward, Major (Commander of the Royal Engineers), 21 Alice Hospitals, 96, 104–105, 128, 190, 192, 195, 234, 239, 260 Alice Memorial Hospital, vii, xi, 88, 90, 93–96, 98–99, 105, 183, 190–191, 193, 196, 199, 200, 221, 239, 257–259, 261 Alice Memorial Maternity Hospital, xi, 96, 189, 190–192, 194–196, 199, 200–201, 239, 259 Alice Ho Miu Ling Nethersole Hospital, xiii, 96 Ambergris, 63, 65 ameba (E. histolytica), 231 Anderson, Alexander (Colonial Surgeon), 23–26, 269 Anopheles fatigans, 208, Anopheles jeyporiensis, 209 Anopheles mosquito, 8, 208–209 Anopheles minimus, 209 Anopheles maculatus, 208 Anopheles sinensis, 208

anthrax, 82, 256 Anti-opium League, 15, 17 Arbuthnot Road, 22 Arnold, David, 220, 222 artemisia (Qinghaosu), 86, 206 Associations of Chinese Medical Practitioners, 119 Atkinson, J. M. (Superintendent of Government Civil Hospital), 28, 73, 99, 169–170, 226, 237, 246, 269 Ayres, P. B. C. (Colonial Surgeon), 15, 17, 24, 27–29, 37, 40, 66, 82, 99, 113–115, 131, 135–136, 138, 148, 167, 177, 183, 214, 226, 269, 288n7 Bacillus anthracis, 82, 146, 256 Bacteriological Institute, ix, xi, 100, 166, 171–172, 175–176, 209, 214, 228, 231, 259 Balmis, D. F. X., 212 Barker Road, 190 Bazaar, Lower, 5, 7 Bazaar, Upper or Middle, 5, 7, 8 Beihai, 134 Beiyang Medical College, 98 Belcher’s Battery, 4 Belilios, Emanuel R., 90, 92–93, 99, 283n37, 284n57 Bell, John, 237 beriberi, xii–xiii, 174, 198, Chapter 9, 244, 294n51 Bird, Isabella, 61, 63, 70

3 2 0   |   I ndex

“Black Death,” 133 Blake, Sir Henry (Governor), 46–47, 155, 162, 165, 169, 172, 175, 179, 188, 208, 266 Blue Gum, 208 Bonham, Sir George (Governor), 12, 23, 26, 36, 109, 265 Bonham Strand, 5, 96, 102, 190, 261, 278n6 Bowen, Sir George (Governor), 125–126, 130, 168, 265, 287n40 Bowring, Sir John (Governor), 110–112, 265 Breezy Path, 96–97 British East India Company, 13, 87–88, 212 British India, 17, 220 British Medical Association, 82, 193–194, 237, 255 British Medical Journal, 149, 175, 237 brothel, x, 8, 31, 34–47, 49–52, 55, 69, 226, 262 bubonic plague, vii, ix–xi, 72, 78, 97, 109, Chapter 6, 226, 249, 258 Burma, 220 Burton, T., 191 Byzantine Empire, 133 Caesarean section, 198 Caine, William, Major (Chief Magistrate), 2, 10, 21, 265 Calcutta, 14 Canossa Hospital, 200, 234, 239 Cantlie, Sir James, 82–83, 88, 95, 99–100, 236–237, 257 Cantonment Hill, 1, 3–6 Cape of Good Hope, 22 Central Dispensary, 240 Central Market, 5, 130–131, 162 Central School, 90, 95 Certificate of Laboratory Instruction, 175

Chadwick, Edwin, xi, 107–108, 118, 253 Chadwick, Osbert, xi, 108, 118–120, 122– 125, 127, 130–131, 154, 158–161, 164–165, 169, 172, 179, 257–259 Chamber of Commerce, 47, 167 Chamberlain, Joseph (Secretary of State for the Colonies), 46, 154, 168, 188, 267 Chan Apun, 89 Charing Cross Hospital, 99, 236 Chater, Sir Paul, 73, 95, 236 Chaulmoogra seed, 86 Chek Chue (Stanley), 1 Cheun A Lok, 27 Cheung Chau, 34, 234, 239 China Medico-Chirurgical Society, 89, 254 China Sugar Factory, 141 Chinese Chamber of Commerce, 47 Chinese house bucket, 115–116 Chinese Lunatic Asylum (Victoria Mental Hospital), 229, 239, 258 Chinese midwives, 49, 182–183, 186–187, 189–190, 197, 201, 203, 296n21 Chinese Medicine Council of Hong Kong, 235 Chinese Pharmaceutical Merchants Association, 235 Chinese Public Dispensaries, xi–xii, 48, 100, 166, 176–179, 194, 196, 199– 200, 209, 214–215, 234, 237–238, 241, 244, 259–260, 295n60 Chinese Public Dispensaries Committee, 178, 196, 199, 209, 234, 235, 240 Chinese Recreational Ground, 71 Chinese tenement houses, 114, 120, 121, 163, 166 Chiu, H. Y., 197 chloroquine, 206 cholera, 5, 82, 107, 113, 115, 146, 172, 180, 214, 231–233, 247, 249–250, 253–254, 256–258, 262, 291n65

I ndex   |   3 2 1

Chun, Daphne Professor, 202 Chung King-ue, 75, 97 Chung Wah School, 68, City of Victoria, x, 4–6, 8, 111, 118, 122, 160, 164–165, 178, 209 Clark, Francis (Medical Officer of Health), 73, 99, 104, 164, 167–168, 185–187, 222, 237, 258 “Cleaning the Tai Ping floor,” 156 Clementi, Sir Cecil (Governor), 229, 266 Cleverly C. G. (Surveyor General), 111–113 Colledge, Thomas R., 88 Colonial Office, 17–18, 23, 25–26, 37, 39, 43–47, 49–50, 52, 72, 110, 113, 115–118, 125, 130, 144, 152, 157, 162, 172, 175, 184, 187, 203, 230, 279n25, 294n54 Colonial Regulations, 10, 11 Colonial Surgeon, 15, 19, 20, 21, 23–27, 37–38, 41, 43, 46, 58–59, 65–66, 73–74, 76–78, 99, 104, 108, 110– 113, 116–118, 125–126, 131, 135, 138, 166–167, 169, 183, 207, 214, 226–227, 246, 253, 256, 269 community hall, 70 Contagious Diseases Ordinance of 1867, 36, 39–43, 45, 52, 255–256, 258 Convention of Chuenpi (Chuanbi), 1, 14 Convention of Peking, 165 Corynebacterium diphtheriae, 147 Crown Lands Resumption Ordinance of 1890, 129 Culex mosquitoes, 200 Daily Press, the, 139, 142, 187 Davis, Henry William, 91, 96 Davis, Sir John (Governor of Hong Kong), 8, 11–14, 21–22, 25–26, 56, 254, 265, 278n10 Dempster, J. Carroll (Colonial Surgeon), 23, 37, 110–112

Dengue fever, 209, 232 Des Voeux, Sir William (Governor of Hong Kong), 45, 98, 128–130, 208, 214, 265, 287n40 diarrhea, 5, 19, 20, 135, 184, 186, 246 dichlorodiphenyltrichloroethane (DDT), 210 Dill, Francis (Colonial Surgeon), 19, 21, 23–24, 26, 269 Diploma of Public Health, 169, 175 Diseases of China contrasted with those of Europe, The, 116 District Watch Committee, 51, 57, 229 “Drs. Anderson and Partners,” 236 Dongjiang, 159 Donovan, E. W., General (Commander of British troops in China and Hong Kong), 117 Dudgeon, John, Dr., 116, 286n24 dysentery, 5, 19–20, 247 East Point or Eastern Dispensary, 178, 240 Ede, N. T., 126 Eijkman, Christiaan, Dr., 219, 220 Eitel, Rev. E. J., 42, 43, 117 Elliot, Charles, 1, 2, 9, 11, 265 Eugenic League, 198, 262 Executive Council, 10, 130, 142 Family Planning Association, 198 Far Eastern Association of Tropical Medicine, 222 febris remittens, 19 filariasis, 209, 296 First World War, 95, 181, 250, 260–261 “five elements,” 84, 85 Ford, Charles, 208 Foreign Office, 17 Forsyth, Charles, 236 Foundling Scandal, 184

3 2 2   |   I ndex

Fracastoro, Girolamo, 32 Francis, J. J. (Chairman of the Permanent Committee of the Sanitary Board), 167 French Sisters of Mercy, 29 fu, 84 Fukienese, 57 Fung Wa-chun, 177 Fuzhou (Foochow), 3 Ge Hong, 206, 211, 299n2 General Board of Health (in England), 111, 254 General Medical Council (in England), 82, 99–100, 104, 241, 255, 260 “germ theory,” 70, 134, 146, 255 Gibson, R. M. (Superintendent of the Alice Memorial Hospital), 99, 191–193, 195–196, 221–222, 297n34 Giemsa or Wayson’s stain, 150 ginseng, 63 Glassworks Hospital, 139, 141–142, 227, 289n24 glucose-6-phosphate dehydrogenase deficiency (G6PD), 207, 299n4 gonorrhea, 31–33 Government Analytical Laboratory, 231 Government Civil Hospital, 20, 24, 26– 29, 38, 40–41, 51, 58, 65–66, 72–73, 77, 99, 104–105, 135, 138, 141, 166, 182–183, 190, 198, 200–201, 215, 226–227, 229, 236, 241, 246, 254–256, 262, 276n31 Government Infectious Disease Hospital, 216 Granville, Lord (Secretary of State for the Colonies), 74, 267 Grassi, Giovanni Battista, 207 “Great Dying,” 133 “great pox,” the. See syphilis.

grosse vérole. See syphilis. Guangxu (Kuang-Hsu), 67, 144 Guangzhou (Canton), 1–3, 11, 14, 35, 56, 67, 69–71, 78, 87–89, 97, 103, 119, 122, 134–135, 138, 140–144, 151, 153, 155, 183, 213–214, 225, 244 Guangzhou Missionary Hospital, 67, 183 Haff kine serum, 155, 291n65 Hague International Opium Convention, 17 Hakka, 119 Hallam, R., 47 Harland, William A. (Colonial Surgeon), 47, 269 Hartigan, William, 93, 95, 99, 184–185, 236 Hayllar, Thos. C., 42–43 Heanley, C. M., 174 Hecker, J. F. C., 133 Henderson, James Orr, 236 Hennessy, Sir John Pope (Governor), 28, 36, 42–44, 61, 66, 69–71, 90, 115–118, 125, 265 HMS Minden, 22 HMS Moira, 22 HMS Salaiman, 22 HMS Victor Emmanuel, 137 HMS Winchester, 36 Hicks Beach, Sir Michael (Secretary of State for the Colonies), 70, 267 Hippocrates, 205 Ho Fuk-tong, the Reverend, 91 Ho Kai, Sir Kai, 73, 91–92, 96, 99, 103, 126–128, 136, 138, 187, 191–192, 194, 196, 201, 215, 281n47 Ho Kai’s Memorandum of Objections, 127 Ho Ko-Tsun, 238 Ho Miu Ling Hospital, 96, 190, 239, 259 Ho Tung, Eva, 201

I ndex   |   3 2 3

Hobson, Benjamin, 89 Hollywood Road, 4, 28, 56, 93, 96, 215 Home Office, 17 Hong Kong College of Medicine for Chinese, 93–94, 97–99, 257 “Hong Kong fever,” 5–6, 18, 19, 25, 26 Hong Kong Medical Society (Hong Kong Branch of the British Medical Association), 237, 257 Hong Kong Rope Works, 141 Hong Kong Sanatorium and Hospital, 105, 199–200, 238 Hopkins, Sir Frederick, 219 Housing Committee, 162 Hua Tuo, 83, 87 Hung Hom, 158, 160, 178, 259 Huns, 205 Hunter, William, 172–175, 217–218, 221, 259, 294n51, 294n54 Hygeia, 136–141, 227 India, 14, 32, 84, 104, 133, 152, 211, 220, 291n65 Indochina (Vietnam), 147 Infant Health Centers, 199, 233 infant mortality, vii, xi, 49, 176, 178, 182–188, 198, 202–203, 233, 243, 245, 250–251 Insanitary Properties Ordinance, 164 International Classification of Causes of Death (ICD), 246 International Labor Office, 17 International Sanitary Convention of 1920, 232 Ishigama, Tohiu D., 147 Jackson, R. B., 209 Japanese Imperial Army, 225 Jardine Matheson, 2 Jardine, William, 25

Jervois Street, 5 Jeu Hok, 238 Jeyes’ fluid, 136 Jiaqing, Emperor, 14 Jordan, Gregory, 95, 99, 104, 236 Johnston, A. R. (Assistant and Registrar to the Superintendent), 2, 10 Jubilee Reservoir, 160 Justinian Plague, 133 Kai Tak Airport, 166 kaifong (neighborhood), 56–57, 60, 197, 215 Kaohsiung (Takow), 94 Kennedy, Arthur Sir (Governor of Hong Kong), 69, 71, 114, 117, 265 Kennedy Town, 50–51, 75–76, 136, 138, 140, 216, 227 Kennedy Town Hospital, 141, 147–148, 152, 227 Kennedy Town Infectious Diseases Hospital, 227–228, 239 Kerr, John, 67, 87 Keswick, W., 42–43 Kimberley, Earl of (Secretary of State for the Colonies), 43, 116, 267 King, Gordon, 198, 202 King’s Shropshire Light Infantry, 137, 145 Kitasato, Shibasaburo, 82, 146–151, 257–258, 292n15 Knott, T. H., 166 Koch, Robert H., 82, 146, 148–149, 255–257, 290n48 Kowloon-Canton Railway, 166, 300n17 Kowloon Reservoir, 160, 260 Kowloon Wharf, 166 Kowloon City Dispensary, 240 Kwan Ato, 98 Kwan K. L., 238 Kwong Fook I Tsz, 57–58, 254

3 2 4   |   I ndex

Kwong Wah Hospital, 76–77, 199, 200, 234, 239, 241, 260 Labouchere, Henry (Secretary of State for the Colonies), 38–39, 267 Ladder Street, 136 Lai Chi Kok Hospital, 228, 239, 262 Lamma Island, 208 Lancet, The, 148–151, 175, 193, 237 Lau Chu-pak, 177, 281n47, 293n39 Lau Wai-chuen, 138, 289n18 Laveran, Charles Louis Alphonse Dr., 207, 256 League of Nations, 17, 51, 182 Legislative Council, 10, 14, 17, 39, 42, 44–45, 73, 96, 103, 126–127, 157, 164–165, 167–172, 187, 191 Lethbridge, H., 9, 60 Leung S. C., 197 Li Hanzhang, Viceroy of Guangdong and Guangxi, 140–141, 143 Li Hongzhang, Grand Viceroy, 98, 140 Li Shu-fan, 101, 237–238 Li Shu-pui, 238 Lin Zexu, Viceroy, 14 Lyndhurst Terrace, 50, 51 Livingstone, John, 87 Lock Hospital, 28, 38, 40–41, 46, 226, 229, 254–256, 276n31 Lockhart, J. H. Stewart, 73, 136, 184 Lockhart, William, 87, 89, 286n24 London Missionary Society, xi, 24, 88–93, 96–97, 104, 183, 191–193, 195, 200, 234, 239, 241, 249, 286n24, 298n50 London School of Tropical Medicine and Hygiene, 94, 258 Loo Aking, 55 Lowry, J. H. (Chinese Maritime Customs Service), 134 Lowson, J., (Assistant Superintendent of

Government Civil Hospital), 28, 72–73, 135–136, 141, 147–149, 151, 175, 226, 237, 288n7, 288n9 Lugard, Sir Frederick (Governor of Hong Kong), 17, 102–104, 175, 243, 266 Ma, Ho-kei, 202 mahuang, 86 Ma Luk, 238 MacEwen, A. P., 126 MacDonnell, Sir Richard G. (Governor), 14, 58–59, 61, 69, 74, 113, 265, 279n25 MacKinnon, W. A. (Surgeon General of the Army Medical Department), 117 McCallum, Hugh (Secretary of the Sanitary Board), 73, 125 malaria, x, xii, 8, 18–19, 22, 81, 86, 94, 174, Chapter 9, 226, 231–232, 247–248, 250, 253, 258, 262, 299n3, 299n4 Malaria Bureau, 209, 228, 231, 262 Manila, 212, 222 Manson, Sir Patrick, 88, 90, 93–95, 98–100, 126, 172, 207, 218, 236–237, 256–258, 283n44 Marasmus, 174, 188 Market Street, 136 Marquess of Ripon (Secretary of State for the Colonies), 144, 267 Marsh, Sir William Henry, (Administrator), 28, 44–45, 71, 95, 125–126, 265, 287n40 Matilda Hospital, 199–200, 237, 239 Mawangdui, 206 May, Sir Francis H. (Governor), 17, 138, 189, 266 Medical Missionary Society Hospital, 24, 88–90, 253–254 Medical Officer of Health, xi, 73, 99,

I ndex   |   3 2 5

164, 166–168, 170, 177, 185, 195, 214–215, 222, 226–227, 231–232, 246, 258 Medical Registration Ordinance of 1884, 99, 241, 257 mefloquine, 206 Member of the Order of the British Empire (MBE), 195 Mercurochrome-220, 33 mercury, 33, 40, 81 Metropolitan Health of Towns Associations, 107 Miasma, 146, 207 Midwives Ordinance of 1910, 201, 260 Military Court inquiry, 5 Military Hospital, Bowen Road, 22, 26, 236, 239, 253 Mody, Hormusjee N., 102–103 Mohammedan Rebellion, 134 Morrison Education Society School, 89 Morrison, J. R. (Chinese Secretary), 10, 21 Morrison, Robert, 21, 87 Morrison, William (Colonial Surgeon), 19, 23, 24, 26, 269 Mount Kellett, 237 moxibustion, 86, 280n27 mui tsai, 36, 49, 182 Murray, Ivor John (Colonial Surgeon), 20, 24, 27, 38, 58, 112–113, 269 Mycobacterium tuberculosis, 82, 146, 257 Nam Pak Hong, 56, 278n6, 279n22 Nathan, Sir Matthew (Governor), 96, 170, 175, 266 National Council for Combating Venereal Diseases, the, 47, 49–50, 182, 233, 261 Neijing, 83, 205 Neisser, Albert L. S., 33, 256 Neisseria gonorrhoeae, 33, 256

Nethersole Dispensary, 91, 256 Nethersole Hospital, 96–97, 105, 183, 189–191, 193, 239, 258 Neville-Rolfe, C., 47, 49, 181 New Territories, 159, 166, 194, 199, 208–210, 228, 231, 233, 238, 300n17 Ng Choy, 44, 96, 281n47 Ng Li-hing, 101 Night Pass law, 69–70 Nightingale, Florence, 27, 255 Ningbo, 3 Nixon, William, Professor, 198, 202, 223 Nurses Registration Ordinance, 1931, 105, 200, 262 O’Conor, N. R. (British Minister in Beijing), 143 Old Bailey Road, 22 opium, x, 11–18, 82 opium divan, 14, 17, 260 opium monopoly, 12–13, 17–18, 55, 254 Opium War, First, 1, 14, 55, 88, 182 Opium War, Second, 14 orthopoxvirus, 211 Pacific War, 17 Palmerston, Henry John, 1 Pang Ui-shang, 32 parasitic infestation, 231, 294n51 Parker, Peter, 67, 87–88, 99 Passfield, the Lord (Secretary of State for the Colonies), 51, 268 Pasteur, Louis, 82, 146, 255–257 Pasteur Institute, 82, 147, 149, 290n38, 291n65 Pasteurella pestis, 133, Peak Hospital, 237 Pearson, Alexander, 66, 88, 212–213 Pedder, William Lieutenant (Harbor Master), 10

3 2 6   |   I ndex

Peel, Sir William (Governor), 51, 266 Pekelharing, C. A., 219 Peking Medical College, 88 Peking Missionary Hospital, 88 Pig and Sheep Depot (a plague hospital), 142, 227 P. (plasmodium) falciparum, 206–207 P. malariae, 206–207 P. ovale, 206 P. vivax, 206–207 Po Leung Kuk (Society for the Protection of Women and Children), 194–195, 218, 294n51 Pok Fu Lam “highway,” 21, Pok Fu Lam Reservoir, 113–114, 160, 255 Port Health, 95, 226, 228, 232–233, 236 Pottinger, Sir Henry (Governor), 2–6, 8, 10, 21, 23, 25, 109, 265, 271n7 Price, J. M. (Surveyor General), 71, 114 Principal Civil Medical Officer, 48, 167, 169, 227, 229, 259, 269, 294 prostitution, Chapter 2, 67, 181–182, 233, 258–259 Protection of Women and Girls Ordinance, 45–46, 257–258, 277n49 Public Health Act (in England), 107–108, 254–256, 262 Public Health and Buildings Ordinance of 1903, 165, 169–170, 259 Public Health Ordinance of 1887, 49, 126–129, 226, 257 Punti Cantonese, 57 qi, 85 Qingming (Ching Ming), 243 Qishan (Keshen), 1 Quality HealthCare Medical Services Limited, 236 quartan fever, 206, 208 Queen Victoria, 105, 190, 228

Queen’s Road, 2, 4–5, 7, 92, 272n23, 276n31 quinine, 81, 206, 209 Rattus norvegicus (Brown rat), 156 Rattusrattus (Black Rat), 156 Rawling, S. B., 112 Registrar General, 39, 44, 46–47, 57, 59, 67, 73–74, 116, 125–126, 136, 167, 177–178, 184, 187, 196–197, 278n10 remittent fever, 19, 208 Rennie, A. H., 102 Report on the Sanitary Conditions of the Laboring Population of Great Britain, 107 Report on the Workings of 1867 Contagious Diseases Ordinance, 42, 256 Republic of China, 86, 95, 182 Robinson, Sir William (Governor), 72, 74, 138, 141–146, 152–154, 158, 162, 166–168, 176–177, 265, 287n40, 292n15 Robinson, Sir Hercules (Governor), 109, 112, 113, 265 Rockefeller Foundation, 198, 229 Roman Catholic Church, 90, 104, 115, 119, 234 Ross, Ronald, 94, 207, 209, 258 Rotunda Hospital, 198 Roux, Emile, 147, 258 Royal Navy Hospital, 22, 25, 239, 256 Russell, J. (Registrar General), 44 Rustomjee, Heerjeebhoy, 24–25 Ruttonjee Hospital, 24, 240 Sai Ying Pun, 2, 4, 21, 175, 197, 207, 229, 234, 276n31 Sai Kung Dispensary, 240 St. Francis’ Hospital, 90, 234 St. John’s Ambulance, 200, 234, 239

I ndex   |   3 2 7

St. Paul de Chartres Sisters, 199 St. Paul’s Hospital, 199–200, 234, 239, 258 Saltoun, A. F. (Major General Commanding Land Forces in China), 5–6 Salvarsan, 33 Sampan Street (Spring Garden Lane), 50, 51 san jiao, or “triple burner,” 84 Sanitary Board, xi, 72–73, 125–129, 131, 136, 138, 142, 162, 164, 166–171, 177, 214, 226–227, 257–258, 260 Sanitary Commission of 1902, 154, 169, 259 Sanitary Department, 169–171, 177–178, 227, 250, 259, 262, 269 Schaudinn, Fritz, 32 School Hygiene Program or School Health Program, 171, 233 Scott, C. (Assistant Superintendent of Government Civil Hospital), 27 sealing-cord powder, 188–189 Seamen’s Hospital, 22, 24–26, 37, 236, 253, 256 Second World War (World War II), ix, xii, 31, 33–34, 53–54, 156, 159, 160, 166, 175, 179, 201–202, 205, 210, 216–217, 223, 225, 230, 232–233, 235, 238, 242–244, 246, 248, 250, 263, 295n60, 304n40 Secretary for Chinese Affairs, 47, 50 Shameen, 181 Shamshuipo Dispensary, 240 Shandong Province, 181 Shanghai, 3, 5, 88, 181, 213, 288n3 Shanxi, 61 Shaukiwan Dispensary, 240 Shek Kip Mei, 166 Shek Lei Pui Reservoir, 160, 262

Shek O, 208 Shek Tong Tsui, 50–51 Shennong, 61–62, 280n27 Shing Mun Reservoir, 159–160, 229, 262 Sibree, Alice (Hickling), 190–191, 193–198, 259, 298n50 sickle-cell trait, 207, 299n3 Simpson, W. J., 154–155, 164–165, 169, 172, 259 Sinn, Elizabeth, xiii, 57, 79 Sino-Japanese War, 18, 216, 225, 244 Slaughter House, 162 smallpox, xiii, 20, 66, 76, 100, 109, 172, 173, Chapter 9, 227, 229, 231, 232, 233, 247, 250, 254, 258, 261, 262 Smith, George, Bishop, 9 Social Darwinism, 187 Society for the Protection of Children, 233 Solomon, Tom, 151 Stanley Dispensary, 240 Stanley, Lord, 6, 26, 267 Stewart, Charles (Treasurer), 10 Stonecutters Island, 153, 215, 236 Stubbs, Sir Reginald Edward (Governor of Hong Kong), 47–49, 266 Sun Simiao, 84 Sun Yat-sen, 95, 100–101, 237, 257, Superintendent of Police, 21, 27, 39, 46–47, 126, 137–138, 167 Surveyor General, 71, 111, 113–114, 116–118, 125–126, 167 Sydenham, Annie, 195 syphilis, primary, 18, 20, 31–33, 36–38, 40, 174, 213, 231, 259, 260 Tai O Dispensary, 240 Taiping Rebellion, 10, 56, 288n3 Tai Ping Shan, x–xi, 6–8, 22, 58, 96, 101, 108, 110–113, 115, 117–118, 125, 131–132, 135–137, 140–141, 145,

3 2 8   |   I ndex

155, 160, 162, 164, 184, 207, 254, 292n15 Tai Ping Shan Chapel, 91 Tai Ping Shan Resumption, 163 Tai Po, 208 Tai Po Dispensary, 200, 240 Tai Tam Reservoir, 114, 160 Tai Tam Tuk Reservoir, 160, 261 Taiwan (Formosa), 94, 279n12 Takaki, K., 219 Tam Achoy, 55 Tanemichi, Aoyama, Professor, 147, 151 Tank Lane, 136 Technical Committee for the Reorganization and Improvement of Official Hospital and Clinical Facilities, 230 Teochew, 57 tertian fever, 206, 208 tetanus, 82, 261 tetanus bacilli, 82, 146, 188–189, 257 tetanus neonatorium, 184 Thailand, 220 Thomas, G. H., 241 Thomson, J. C., 73, 75, 95, 99, 208 Thiamine, 218, 220, 222–223 Tissot, S. A. A. D., 32 Tottenham, R. E., 198, 202 traditional Chinese medicine (TCM), x, 55, 75, 81, 83, 186, 234 Training Institute for Nurses and Midwives, 190, 196, 260 Treaty of Nanking, 3, 10, 14 Treaty Ports, 11, 14, 88, 182, 271n7 Treponema pallidum, 32–33, 259 trismus or lockjaw, 188 Tsan Yuk (Maternity) Hospital, 26, 195, 197–203, 223, 228, 234, 239, 261, 262, 276n31 Tsim Sha Tsui, 158, 160 Ts’o Seen-wan, 194, 196, 198, 201, 214, 234

tuberculosis, 49, 82, 135, 146, 173–174, 205, 232, 246–248, 257, 260–262 Tung Wah Eastern Hospital, 76, 200– 201, 234, 239, 241, 261 Tung Wah Group of Hospitals, xiii, 76, 200, 235, 238 Tung Wah Hospital, x–xi, Chapter 3, 90– 92, 97, 98, 100, 105, 119, 135–136, 138–139, 141, 143–144, 152, 177, 183, 194–195, 199, 200, 214–216, 221–222, 234, 239, 241, 244, 236 Tung Wah Hospital Committee, 60–61, 68, 69, 71, 73, 97, 119, 138–139, 141, 143 Tung Wah Infectious Disease Hospital, 216, 239 Tung Wah Smallpox Hospital, 216 Tweed (gunboat), 141 Un Long (Yuen Long) Dispensary, 240 United States, 17–18, 87, 89, 152, 206, 246, 251 University of Aberdeen, 91, 94–95, 99, 236 University of Edinburgh, 193, 286n24 University of Glasgow, 236, 286n24 University of Hong Kong, the, vii, xi, xiii, 47, 88, 100–102, 104–105,198, 201–202, 223, 229–230, 237, 238, 241–242, 250–251, 260 University of Utrecht, 219 Urban Council, 171, 227, 262, 269 vaccination, Jennerian, 66, 212, 213 Vaccine Institute, 214, 258 Van Leent, F. J., 219 Vandals, 205 Variola major, 211 Variola minor (Alastrum), 211 Variola vaccinae (cowpox), 211 vector-borne diseases, 232

I ndex   |   3 2 9

venereal diseases, x, 19–20, 28, 31, 34, 36–43, 45–53, 81, 171, 181, 226, 229, 233, 240 Venereal Diseases Ordinance of 1857, 37–39, 255 Vibrio cholerae, 82, 146 Victoria Harbor, 4, 229 Victoria Jubilee Hospital for Women and Children (Victoria Hospital, or Victoria Jubilee Hospital), 105, 170, 190–191, 200, 227, 241, 259 Victoria Mental Hospital, 229 Visigoths, 205 Vorderman, Aldolphe Dr., 219, 220 Walkden, Alice, 91–92 Wan Chai, 2, 4, 6, 24, 90, 196, 199, 228, 302n15 Wan Chai Maternity Hospital, 196–197, 200, 234, 261 Wan Man-kai, 238, wan po, 182, 186–187, 201 Wang, C. Y., 101, 188 Wassermann test, 32, 259 Water Lane, 22 water-borne diseases, 161, 232 Wei Yuk, 187, 196, 215, 283n37 Wellington, A. R. (Director of Medical and Health Services), 171, 227, 230, 238, 246, 247, 269 West Point Barracks, 5–6, 21 West River, 155 West Point or Western Dispensary, 178, 196–197, 240, 260 Western medicine, x–xi, 24, 27, 55, 58, 66–67, 70, 74–79, Chapter 4, 116, 183, 190–192, 196–198, 203, 234–238, 240–242, 250, 253–263, 283n45 Wharry, Charles J. (Superintendent of Government Civil Hospital), 27–28

“white man’s grave,” 205 Whitehead, T. H., 73 Woodman, W. J. (Acting Medical Officer of Health), 214 Wong Nai Chung Gap, 158 Wong Nai Chung Reservoir, 160 World Health Organization, 216, Wu Tin-po, 238 Xenopsyllax cheopis pulex irritans, 152, 174 Xiamen (Amoy), 3, 90, 93, 94, 141 xieli (assistant director), 60, 279n21 Yamen, 61, 143 yang, 85 Yangtze River, 3, Yao Hochun—A-Hequa (Dr. Longhead), 212 Yaumati, 131, 158, 160, 178, 259 Yaumati Dispensary, 240 Yellow Emperor (Huangdi), 83, 205 Yeung Wo Nursing Home, 105, 237, 239, 261 Yersin, Alexandre, 82, 146–151, 258, 290n38, 292n15 Yersinia pestis, 133, 151 Yin, 85 Young, William, 90–91 Yunnan, 134, 147 zang, 84 Zhejiang, 1 Zhen Quan, 83 zhishi (assistants to zongli and xieli), 60, 279n21 Zhoushan (Chusan), 1, 3, 88 zongli (director), 60, 279n21 zongli (tsungli) Yamen, 143

This page intentionally left blank