The founding of the nursing profession [in China] by Christians was an even greater achievement than the introduction of modern medicine (...) young women would not have taken up nursing without the example set them by Christian women of the West.
Margaret H. Brown, Canadian missionary1
The modern Chinese nurse was named into being in 1914 when American missionary nurses in the newly established Nurses Association of China (NAC) adopted the term hu shih (literally, “caring scholar”) to describe the new professional role being taken up by their Chinese protégés. Thirty years earlier, when Philadelphia Woman’s Hospital graduate Elizabeth McKechnie arrived in China as the first “trained” nurse in 1884, there was no equivalent in Chinese culture to the conceptualization of nursing popularized by Florence Nightingale—that is, as a noble profession suitable for unmarried, God-fearing ladies. In late 19th century China, it was inconceivable that Chinese ladies “of good family” would care for the sick, other than their own relatives.2 Nor was there an equivalent of “the Christian ethic in which caring could be lifted onto a plane of moral obligation” to become a “respected profession in which the most unpleasant work could be ennobled.”3 The missionary ideal of nursing as an honorable profession was “so novel” that “the Chinese had no word in their language to express the concepts “nobly” and “properly” for the nursing pioneers.”4 Yet by 1914, there was a small but growing cadre of Chinese women and men poised to enter missionary-sponsored nurses training.5 In 1922, 8 years after its inception, the NAC joined the International Council of Nurses, bringing China into the growing imagined community of women from around the world with a shared identity of woman-as-nurse.6 By the 1930s, mission trained Chinese nurses had replaced many of the foreign missionary nurses as leaders in the mission hospitals, training schools, and the NAC itself. The expulsion of all foreigners from China after Mao Zedong’s 1949 victory marked the end of missionary nursing in China, making way for a secular version of the modern nursing it introduced.
An exploration of the history of missionary nursing offers valuable insight into an expression of religion in nursing. This chapter will focus on the origins and development of missionary nursing in China as an offshoot of the broader Protestant missionary movement in the late 1800s. Using a critical approach informed by postcolonial and feminist theories, it will examine how the evangelizing mission of the Protestant church in North America contributed to the internationalization of modern nursing, particularly in China. Drawing particular attention to the influencing factors of religion, race, and gender, it will explore some of the tensions inherent in the globalization of nursing as a hospital-based profession for unmarried, middle-class Christian women.
The political, economic and social questions, which cause so much agitation in every land are, fundamentally, spiritual problems, and they will only be solved aright when the majority of the people learn to love and serve Jesus Christ.
- Dr. James Frazer Smith, Pioneer missionary to Henan7*
Perhaps nowhere is the link between religion and health care more readily seen than in the historic role of the missionary nurse. And nowhere were overseas missions more ambitious than in turn-of-the-20th-century China. Although Catholic sisterhoods from Quebec had been sending missionary nurses to the West since 1844,8 a unique set of socio-political factors converged in the 1880s to set the stage for a new Anglo-Protestant brand of missionary nursing. That is, China’s defeat in the Opium Wars, the women’s suffrage movement, the establishment of professional nursing education, advances in transportation, and the evangelistic student missionary movement of the late 1880s together provided an unprecedented opportunity for unmarried, ambitious, bright women looking for a way to express their religion in practical terms—as missionary nurses and physicians.
The earliest factor to influence the eventual development of missionary nursing was China’s defeat in the Opium Wars (1842, 1860). These events led to the removal of political barriers to China through the establishment of unequal treaties by which Westerners gained access to most regions of China. By the late 1800s, Chinese were required by law not only to tolerate missionaries, but also to protect them. Missionary nurses would not have been allowed into China had it not been for the imperialistic aims of their own nations.
The women’s suffrage movement (1860s and 1870s) inspired a generation of women to recognize and resist existing social barriers to meaningful work outside of marriage and motherhood, and was a second factor to influence the development of missionary nursing. When Dr. Elizabeth Shattuck, a graduate of the Woman’s Medical College of Pennsylvania, was barred from entering the foreign missionary field in 1858 because she was an unmarried woman, a group of Christian women banded together to form the “Woman’s Union Missionary Society of America for Heathen Lands” (commonly referred to as the Woman’s Union Missionary Society, WUMS), in 1860.9 Founded to provide a way for single women to be sent to Asia “to address the physical, educational, and spiritual needs of the women there,” the WUMS exemplified the mission phenomenon referred to as “woman’s work for women.”10 In 1884, the WUMS sponsored the first missionary nurse, Elizabeth McKechnie, to China. In 1888, the first Canadian missionary nurse, Harriet Sutherland, was sponsored by the newly formed Women’s Foreign Missionary Society (later Woman’s Missionary Society, WMS) of the Presbyterian Church in Canada.11
A third influencing factor in the laying of the foundation for missionary nursing was the development of professional training schools for nurses (1870s and 1880s). The Philadelphia Woman’s Hospital, from which Elizabeth McKechnie graduated in 1883, was the first institution in the United States to offer organized training to nurses.12 The Toronto General Hospital (TGH) Training School for Nurses was the second English-language program for nurses in Canada. Opened in 1881, the TGH graduated most of the Canadian Protestant missionary nurses sent to China, including its first, Harriet Sutherland, and its longest serving, Margaret McIntosh.13 In 1894, the TGH was the largest nursing program in Canada, having graduated 210 nurses, with room to accept only 53 of the 647 applications for admission.14 In 1889, the year McIntosh graduated from TGH, the term “trained nurse” had come to epitomize the best in nursing care. According to the inaugural address at the opening of the Johns Hopkins Training School for Nurses in 1889 by Miss Isabel A. Hampton (later Robb), of all the professions open to women, none met with more public favor than the trained nurse: “The trained nurse is acknowledged superior (...) [because] technical skill can only be acquired by a systematic course of practical and theoretical study under competent teachers.”15
Nurses were expected to “morally recognize the sacredness of the work they engage in,” to be “fairly intellectual” and “strong and enduring physically.”16 State-of-the-art nursing practice in 1889 was considered an extension of physician care, where “the hands of a nurse are a physician’s hands lengthened out to minister to the sick.”17 For their part, missionary physicians, who had been in China since 1835, began to see the potential in having the support of a trained nurse. Harriet Sutherland went to China to support Dr. James Frazer Smith in Henan province; Elizabeth McKechnie, to support Dr. Elizabeth Reifsnyder in Shanghai.18
The 1881 minutes of the Woman’s Hospital of Philadelphia expounded the view that the female physician–nurse relationship was a sacred alternative to the traditional woman’s role in a family, and a high moral calling in itself. “It will be observed” the secretary wrote, “that not until in the order of time the true status of women in medicine was recognized and granted in the community, was the want fully met of a band of thoroughly trained nurses filled with a high sense of the moral responsibility of their profession.”19 The McKechnie-Reifsnyder missionary dyad represented well the high aims of Reifsnyder’s alma mater, where it was deemed in 1881 that “now and hence-forth through a century of progress, the trained woman-nurse may complement the educated woman-physician, and in each find her own field the fulfillment of a lofty ambition, and the realization of the triest [sic] ministry of women outside the family relation.”20 For the earliest missionary nurses, accompanying missionary physicians to China was a socially sanctioned way to exercise their independence, assert their authority, and plumb their intellectual, emotional, and spiritual capacities.
A fourth influencing factor—the advancement of transportation technologies—is not typically recognized as a factor in health care development (1880s). The internationalization of nursing in general and of missionary nursing in particular was dependent on middle-class women having access to affordable means of transportation. Although China became politically accessible to Westerners in the late 1800s, it was halfway around the globe from nurses in eastern Canada and the United States. The significance of the newly built transnational railways and steamships to the development of missionary nursing cannot be overstated. In 1887, for example, for the first time in history, Canadians in Toronto could travel west across the country to Vancouver, via the Canadian Pacific Railway (CPR), and then board a CPR passenger steamship to China. It is no coincidence that the first three groups of Canadian missionaries set off to China within 4 years of the CPR steamship’s launch: the Presbyterian Church in Canada and the China Inland Mission (CIM) in 1888, and the Methodist Church of Canada in 1891. Many of these earliest missionaries were from the Toronto area; China was suddenly within reach of “Toronto the Good.”
Toronto’s reputation as “the Good” emerged in 1885, the year that William Howland was elected mayor. Known for his dedication to the poor and disadvantaged, Howland reportedly put a 12-foot banner on his office wall: Except the Lord keep the city, the watchman waketh but in vain (Psalm 127:1).21 Howland’s conversion to “a vibrant evangelical faith” came on a wave of religious revival that had spread to Canada from England and the United States on the strength of preachers like Charles Spurgeon and Dwight L. Moody.22 This movement provided the greatest impetus for the missionary enterprise, which in turn launched missionary nursing. If political, economic, and social factors provided the opportunity to work in China, religious factors provided the motivation. Through the missionary movement (1880s), missionary nurses would join evangelists, teachers, and physicians as purveyors of the Christian faith, first to Asia, and then around the world.
Bringing in Chinese,
Bringing in Chinese,
We shall come rejoicing,
Bringing in Chinese.
-Sung to George Minor’s tune for “Bringing in the Sheaves,” 188023
Canadian historian Alvyn Austin’s germinal study of Canadian missionaries in China begins with a description of an unusual event in Toronto in late September 1888. “One thousand enthusiastic young people marched down the main street of Toronto in a torch-lit parade,” he writes, “singing hymns to escort ‘the first Canadian party’ of missionaries bound for China to the train station.”24 Hudson Taylor, founder of the CIM—300 strong and serving in 15 of the 18 provinces of China by 1888—arrived in Canada that summer from England en route to China. Taylor, the most famous missionary in the world since the death of Dr. David Livingstone 12 years earlier in Africa, discovered an evangelistic fervor in Toronto. He recruited 13 Canadians to the CIM. This group of young, unmarried men and women had little formal education, but shared a great enthusiasm for the Scriptures. The new recruits sailed for China with Taylor almost immediately. As part of his “faith mission,” CIM missionaries had no guarantee of a regular salary, just a mandate to preach the gospel to the “million a month” who were “dying without God.”25
The CIM recruits were not the first Canadians to arrive in China. Two months previous, on July 27, 1888, graduate nurse Harriet Sutherland boarded a ship in Vancouver with the newly married James and Minnie Frazer Smith as part of the first group of Canadian Presbyterian missionaries to China. Considering themselves “adventurers going out in faith,” they were on their way to the treaty port of Zhifu to meet up with fellow-Canadians Jonathan and Rosalind Goforth, who had arrived a few months earlier, in March.26 Bachelors Dr. William McClure and Donald McGillivray soon added to their number, bringing the total to seven. Dubbing themselves “the Honan Seven,” this small band of Canadians was to take up the daunting task assigned of establishing a Christian mission in Henan, the “second most hostile province in the whole of China.”27
Nurses were not part of the original plan for missionary work in Henan. When the General Assembly of the Presbyterian Church in Canada appointed the first two Canadian missionaries to Henan, Reverend Jonathan Goforth and Dr. James Frazer Smith, in June 1887, the option of sending single missionary women to China had not been considered.28 Having learned from local missionaries upon arriving in China in 1888 that Chinese mores would not allow missionary men to have contact with Chinese women, Goforth wrote to the Foreign Mission Committee (later Foreign Mission Board, FMB), requesting “single lady missionaries” because “I am told that without the latter the women can scarcely be reached.”29 Dr. Frazer Smith, seeing an opportunity to procure assistance with his own medical work, pressed the FMB to appoint a nurse.30 On May 25, 1888 the FMB appointed Harriet Sutherland. Her salary was paid by the newly formed Woman’s Foreign Missionary Society. During the next 3 years, while the expanding group of “North Honan” missionaries made unsuccessful attempts to acquire property on Henan soil, Dr. Frazer Smith engaged the services of two additional nurses, Jennie Graham and Margaret McIntosh, with the idea that they would assist him in his growing work of treating the illnesses of rural Chinese. By 1891, Sutherland and Graham had resigned due to marriage and illness, respectively, leaving Margaret McIntosh as the sole nurse at the mission for the next quarter century.
Missionary nursing, like other forms of missionary work, came to China on the wave of evangelistic fervor taken up by college students in the late 1800s. The Student Volunteer Movement for Foreign Missions (later Student Volunteer Movement, SVM) was a powerful catalyst in the development of missions and missionary nursing. In fact, Austin considers the birth of the SVM to be the “birth of the modern missionary movement.” 31 Founded in 1886 as a grassroots organization to recruit students for foreign missions, the SVM emerged from the new missionary zeal of the 1880s—the earnest 80s—where the complacent mid-Victorian church was increasingly being taken over by aggressive young people. Describing this shift from “the church sentimental” to “the church militant,” Austin notes, “It was the difference between saying ‘Oh, isn’t it wonderful what those missionaries are doing to civilize the heathen?’ and the young people’s response: ‘As a Christian, you are personally responsible for the salvation of the world. Think about it. Pray about it. Then give or go.’”32 The catchphrase of the SVM became, “Evangelization of the world in this generation.”33 Newly graduated nurses were among the first to respond to the call.
Woman’s work in the foreign field must be careful to recognize the head-ship of man in ordering of affairs in the kingdom of God. . . . ‘the head of woman is the man.’
- American Baptist Missionary Union, 188834
Between 1888 and 1949, the Canadian presence in China as a whole was most recognizable through six main missions: The Presbyterian Church in Canada mission in Taiwan (est. 1871), the Presbyterian mission in North Henan (est. 1888), the Methodist Church of Canada mission in Sichuan (est. 1891), the Presbyterian mission in Guangdong (est. 1902), the Catholic Scarboro Foreign Mission Society in Zhejiang (est. 1902), and the Anglican Church of Canada mission south of the Yellow River in Henan (est. 1910).35 The Presbyterian mission in Taiwan was the first overseas field of the Canadian Presbyterian Church, but the eccentricity of its founder George Leslie McKay, its remoteness from Mainland China, and its continuance with the Presbyterian Church after “Union” kept Taiwan on the fringe of Canadian missions.36 The union of all Methodists, Congregationalists, and most Presbyterians into one United Church of Canada in 1925 set the United Church apart as the largest Canadian mission in China, with the North China Mission in Henan, the West China Mission in Sichuan, and the South China Mission in Guangdong. The United Church was the largest employer of Canadian missionary nurses.37 An estimated 100 or more Canadian nurses worked in at least 9 provinces of China during this period.38
The revivals of the 1880s gained momentum in Canada and the United States through the message of preachers and missionaries traveling back and forth across the Atlantic between England and North America whose message caught the imagination of a generation of college students. One aim of the revivals was to reimagine the church as a social setting; to make people feel at home in their churches. Turn of the 20th century churches became communal centers where one could spend every night of the week, and where missions was the topic of the day.39 Unlike the CIM, the Presbyterian and Methodist missions preferred to sponsor missionary candidates with advanced education, including ministers, physicians, and nurses. And, also unlike the CIM, Presbyterian and Methodist missions developed and provided a formalized method of financial support for missionaries. Individual congregations would pledge support for “their” missionaries, raising funds through donations by church members, regular collections, and fund-raising activities like women’s teas and information evenings. This commitment to funding missions made the 1920s shift from evangelism to service possible, even if not sustainable. For example, when the Canadians determined to build a modern 250-bed hospital and training school for nurses at Weihui, Henan in the 1920s, church members provided funding. The total cost of the hospital project to the Mission was $58,614.52, of which the Woman’s Missionary Society paid $17,697.00. Other funding came from the Forward Movement Peace “Thank offering Fund,” and gifts from the Chinese. In addition to the cost of the hospital was the cost of a nurses’ residence; Mrs. Geo Bingham donated the requisite $4,000.00 in memory of her late husband.40
Missionary nursing for Canadians was, from the beginning, intrinsically linked with specific church institutions—particularly the Methodist and Presbyterian churches, later joined as the United Church of Canada. Financially and ideologically dependent on the church at home, Canadian missionary nurses both benefitted from and felt constrained by their sponsoring denominations. Individual missionary nurses could count on the financial support of their local congregations for their outfit, travel, language training, and housing for their 7-year terms. However, as will be seen, early Canadian nurses were also bound to the evangelistic priorities of the church and mission boards.
One of the most intriguing differences between early Canadian and American missionary nursing in China relates to the timing and extent of missionary nurse involvement in the training of Chinese nurses. Whereas nurses training in Shanghai began only 2 years after the 1884 arrival of Elizabeth McKechnie, it took almost four decades for Canadians to start nurses training in Henan. A closer look at the Canadian situation in Henan reveals some reasons why. First, Canadian missionaries did not actually secure property in Henan until 6 years after their arrival, in 1894, whereas the Americans had secured land within months of their arrival in Shanghai. By the time the Canadians had a property, the first two missionary nurses, Harriet Sutherland and her replacement Jennie Graham had resigned. The third Canadian nurse, Margaret McIntosh, did some work with Dr. James Frazer Smith, but she preferred evangelistic work over nursing. McIntosh spent considerable time with other female evangelistic workers, bringing the Christian gospel message to Chinese women and children at fairs, Sunday school classes, and in their homes. In 1894, Dr. Frazer Smith was invalided back to Canada; he had become sick with typhus, pneumonia, and thrombosis in quick succession; he did not recover sufficiently to return to China. Because none of the remaining physicians perceived a need for the assistance of a nurse, McIntosh removed herself from nursing—earning the criticism of the next generation of nurses: “How different the story might have been,” wrote Canadian missionary nurse Preston, “if Miss Margaret McIntosh, our first nurse, had used her gifts, with her courage and consecration in pioneering our nursing work instead of the evangelistic work.” 41
In fairness to McIntosh, the Canadian mission at Henan was hardly supportive of the advancement of nursing. In May of 1909, Dr. William J. Scott, a Henan missionary for 3 years, reported to the Henan Presbytery on some of the medical work, stating that he “deplored” the deficiency of nursing facilities there.42 According to Dr. Scott’s son, both Dr. Scott and his colleague Dr. O. Shirley McMurtry were “shocked” to discover “what was called a hospital in Henan,” and to find that the hospital was “totally lacking in nursing service.”43 Their request to improve medical facilities—in part via a financial grant from McMurtry’s father—was favorably received at first. However, Rev. Jonathan Goforth and other elders later objected to the scheme on the basis that it would undermine the evangelistic priority of the mission. The Henan Presbytery turned down the money, stating that it could not accept a grant that would be meant for materialist and non-religious purposes. Nurses were not consulted in the decision. It was not until the 1920s and 1930s, after Rev. Goforth quit the mission in protest of the Presbyterian amalgamation with the United Church that the vision of nursing education caught on.
Once the aims shifted from evangelism to social service, missionary nurses found their grounding, particularly as nurse educators, and nursing enjoyed a decade of unprecedented growth and productivity in Henan. However, it was short lived. Japan’s 1937 invasion struck a devastating blow to China and indirectly to the development of nursing. In 1939, Canadian mission sites in occupied China were evacuated; its nurses scattered throughout free areas of China.44 In 1941, missionary nurses, who remained occupied in China when Japan’s attack on Pearl Harbor brought the United States and Britain into the war, were imprisoned in civilian internment camps.45 By the time the 13,500 internees in China and Hong Kong were liberated in August 1945, missionary nursing had lost both momentum and motivation. Postwar attempts to rehabilitate the Henan mission were quickly abandoned in the face of a renewed civil war in 1947, rendering the last few months of Canada’s 60 year mission in China as a mere epilogue to the epoch of internment. Mao Zedong’s 1949 expulsion of foreigners from China spelled the end of missionary nursing there. The sense of failure that accompanied the end of the missionary era in China cast a shadow over missionary nursing from which it has never completely recovered.46
As a profession, we are beginning to feel an increasing necessity for some such definite moral force or laws that shall bind us more closely together in this work of nursing.
- Isabel Hampton Robb47
The study of missionary nursing is an emerging field. In most mission scholarship, missionary nursing has been subsumed under the rubric of missionary medicine. While helpful in providing the context for nursing, this nonetheless leaves gaps in terms of understanding how nursing developed as its own entity and overlooks the connection of missionary nurses to the broader community of professional nurses. Still, while to date there are no comprehensive studies of American missionary nurses in China, an originative article by Kaiyi Chen makes it clear that American missionary nurses wielded significant influence in the development of modern nursing in China.48 Missionaries are credited with the development of numerous, if not the majority, of nursing schools across China between 1886 and 1914.49 As nursing education burgeoned across China, American missionary nurses organized themselves as the NAC in 1909. The main thrust of the NAC was to raise the standard of nurses’ training in China by the adoption of a “uniform course of study and examination.”50 In the absence of uniform governmental authority on nursing education, the NAC took responsibility for setting the standard for all nursing schools in the country, formulating a model curriculum and holding certification examinations.51 At the national NAC convention in Shanghai in 1914, Miss Elsie Mawfung Chung (later Mrs. Bayard Lyon), a graduate of the Guys Hospital in London and the first Chinese nurse to be trained abroad, introduced the Chinese term hu shih (caring scholar) to represent the emerging role for Chinese women.52 First and foremost a missionary organization, the NAC expressed its “theology” in seven words: “For God so loved that He gave.”53
Compared with the Canadians in Henan, a preliminary review of early American missionary nurses suggests that these women enjoyed a fair amount of autonomy and agency. This is reflected in part by their role in establishing the first training schools for nurses in China. In 1886, Elizabeth McKechnie started a school in Shanghai with Dr. Elizabeth Reifsnyder. In 1888, Esther H. Butler, a missionary of the American Friends Mission (“Quaker”) and a graduate of the Chicago Training School started a nursing school in Nanjing. That same year, Ella Johnson started a training class in Fuzhou.54 Gage “supplemented” Johnson at Fuzhou in 1908, and then established a nurse training program in Hunan as part of the Yale University mission.55 Gage later became President of the NAC. By 1920, before the Canadians in Henan started nurses training programs, 48 Chinese graduate nurses had joined the NAC, 52 training schools had been registered, and 150 Chinese nurses had successfully passed the NAC examinations and received the NAC diploma.56
The achievements of the missionary nurses won praise from their medical colleagues. In 1914, the Medical Missionary Association of China declared, “Nothing in medical mission work in China of the past few years has been more marked in its development than the growth in training schools for both male and female nurses.”57 The remarkable progress of nursing under the NAC continued for two more decades. In 1920, the NAC commenced its own quarterly journal, the Nursing Journal of China, which carried each article in English and Chinese. In 1922, it formed the Committee on Nursing Education and was admitted into the International Council of Nurses—the first Asian country to do so. By 1926, there were 112 schools of nursing registered under the NAC, with 2,000 students enrolled. Most schools were associated with American mission organizations; five were Canadian.58 That same year, the NAC membership had shifted from predominantly Western to two thirds Chinese. By the late 1930s, there were 6,000 nurses in the NAC.59 In recognition of her status as the first graduate nurse in China, Elizabeth McKechnie was granted a lifetime membership to the NAC.60 Although she resigned from the WUMS in 1896 to marry Archdeacon E. H. Thompson [Thomson], McKechnie remained in Shanghai for 38 years, until her husband’s death in 1921.61
Elizabeth McKechnie and other early American missionary nurses seem to have been less burdened with church or mission board bureaucracy than Canadians. The emphasis on social justice that came later for the Canadian missionaries in North China was an integral part of the American understanding of mission work early on. Whereas the turn-of-the-20th-century Canadian mission in North China resisted the development of hospitals and nursing care as distracting from the primary evangelical aim of missions, American missions approached the establishment of nursing schools as mission itself. Rather than perceiving themselves as agents of their sponsoring church denomination, adapting their work to church priorities without protest, American missionary nurses seem to have developed early on a sense of solidarity with other professional nurses—from a variety of mission organizations, but also from nursing leaders in the United States. The notion of Christian duty was not reserved for the mission field; it was a central aspect of nursing education and practice as a whole. Tomes and Boschma note that, in the late 1800s, the language of Anglo-American Protestantism suffused science, domestic politics, and international affairs.62 At the same time, church life became a more exclusively female domain, with women outnumbering men as converts and church members. A shared sense of Christian purpose “became a powerful force unifying women from different regional and social backgrounds,” including nursing.63 The growing assumption that educated and refined women had a special obligation to strengthen their less privileged sisters carried over into what Tome and Boschma call “the crusade for international nursing uplift.”64 The missionary movement and the women’s suffrage crusade shared a sense of women’s work for women as a moral obligation, domestically and overseas. By 1900, 41 American women’s boards of varying size had come into existence, stimulating and reflecting a shift from American missions as a predominantly male enterprise to a female one.65
The same impetus that gave rise to the development of woman’s missionary societies also stimulated the development of the International Council of Women (ICW). And it was the ICW that birthed the International Council of Nurses, in 1900.66 Nursing leaders caught the vision of the ICN as an imagined community around the shared identity of woman-as-nurse. The seed of the international nursing movement was sown in conversations between British nurse leader Ethel Fenwick and American leaders Isabel Hampton (later Robb) and Lavinia L. Dock, at the Johns Hopkins School of Nursing where Hampton was superintendent. They continued to champion the cause of nursing as an international profession; it is no coincidence that Isabel Hampton’s foundational textbook Nursing: Its Principles and Practice was among the earliest textbooks used in China, available in Guangdong as early as 1896.67Nursing leaders envisioned the development of nursing into a standardized, moral vocation for intelligent women; missionary nurses enacted that vision.
In contrast to denominational mission boards that tended to view missionary nurses as minor—even unnecessary—players in the evangelical enterprise, the ICN viewed missionary nurses as key to its professionalizing aims. Missionary nurses were also a natural fit with the ICW, whose ultimate aim was cast in unmistakeably Christian terms—to apply “the Golden Rule to society, custom and law [which is to] do unto others as ye would that they should do unto you.”68 In China, as elsewhere, nursing leaders perceived it as their role to pave the way for a strong profession. From a professional nursing perspective, the gospel of intelligent caring was not at odds with the gospel of Christ; it was a natural extension of it.
Founder of this hospital; a pioneer missionary; a skilled surgeon and physician; an understanding loving friend of the Chinese; a devoted, untiring, self-sacrificing worker; a resourceful, strong, capable character; a loyal follower of The Great Physician.
- In memoriam for Dr. Elizabeth Reifsnyder69
It is doubtful that Elizabeth McKechnie would have had the opportunity to work in China had it not been for her association with two women of influence, Dr. Elizabeth Reifsnyder and philanthropist Mrs. Margaret Williamson. Indeed, were it not for the renown of Dr. Reifsnyder, who came to early fame in Shanghai following the successful removal of a patient’s massive (50 lb) ovarian tumor, the archival record of Elizabeth McKechnie may well have been confined to two lines—the record of her graduation on December 19, 1883 from the Philadelphia Woman’s Hospital, and a note in a 1925 hospital history celebration that McKechnie (“now Thompson”) was “first graduate nurse in China.”70 As it is, the fame of Elizabeth Reifsnyder allows us to trace the movements of Elizabeth McKechnie and gain at least a superficial sense of her work as a missionary nurse.
Elizabeth Reifsnyder and Elizabeth McKechnie were both appointed to China by the WUMS, sailing to China in September 1883 and March 1884, respectively.71 They likely met in Philadelphia in 1883 when both were at the Philadelphia Woman’s Hospital—Reifsnyder as a resident physician, McKechnie as a nursing student.72 Although Reifsnyder had originally been rejected by the WUMS in 1881 because of her young age (21), she seemed the perfect candidate the following year. That year, in 1882, two young women “laid before the [Women’s Union Missionary] society a need of a Hospital for Women and Children” in Shanghai.73 Chinese women were reportedly subject to a “great number of misfortunes and calamities,” which took the form of disease that was “intensified by their lives of seclusion, and the want of exercise and air resulting from the impossibility of their moving around much on their cramped [bound] feet.”74 Mrs. Margaret Williamson, a founding member of the WUMS, “responded most generously” to the news by offering a donation of $5,000 to build the hospital.75 Sadly—though fortuitously for Reifsnyder and McKechnie—Mrs. Williamson died the following year, leaving in her will the provisions to build and furnish the new hospital and provide “the salary of a physician and nurse for seven years, at an expense of $35,000.”76 Dr. Reifsnyder was selected to oversee the construction and work of the new hospital. It was a perfect situation for a bright young doctor and nurse: financial security with minimal accountability to, or interference from, one’s benefactor.
Armed with the ideological and practical support of the sisterhood back home, Elizabeth McKechnie and Dr. Elizabeth Reifsnyder were well positioned to take up their new role in China. Although ultimately it would be their acceptance among the Chinese population that would determine their success, the point here is that these women could not have even attempted this new work in China had it not been for the initial support from home. The two women secured a two-room house in Shanghai that they used as a dispensary, reportedly treating as many as a 100 daily.77 “I shall need nurses,” reported Reifsnyder in 1885 as soon as the hospital was under construction, “as well as other helpers in connection with the hospital and dispensary service, and can find Chinese girls who wish to study. One such I am now teaching at night.”78
Within an astonishingly short period, the new hospital was opened on June 4, 1885 “exclusively for relieving the suffering of Chinese women.”79 Initially, the hospital was promoted as a foreign enterprise, part of the Protestant ideal of women’s work for women—“for suffering women, who would otherwise be untouched by the means provided for the relief of suffering among men.”80 Very quickly, however, Reifsnyder established the importance of Chinese involvement and financial support. Perhaps recognizing that the Williamson endowment would eventually run out, she deemed it best “to have the wealthy Chinese pay for services rendered while the poor were being cared for at no cost.”81 By 1905, “over half a million patients have received attention” [emphasis in original].82 Considering that the hospital was run by two physicians and one head nurse for the first 20 years, the statistics from 1905 are remarkable: patients treated in the wards and hospital, 839; patients treated in the dispensary, 45,700; home visits, 321; prescriptions filled, 623, 119; money received from Chinese patients, $8,105.27.83
Although it is clear that religious values acted as an impetus for missionary medicine and nursing in China, what is less clear is how individual missionary women viewed the intersection between faith and practice. Formal mission reports, geared toward an audience of mission supporters at home, emphasize evangelical strategies like Bible studies, “hymn sings,” and the distribution of religious tracts to patients—the implicit intention being the conversion of patients to Christianity. The 1905 Margaret Williamson Hospital report reassured readers that through “Preaching every day to the dispensary patients, bedside talks and instructions, distribution of tracts to those who come daily (...) it can be readily seen that the object for which the hospital was built, namely, the spread of the Gospel, is being aided very greatly.”84 Whether or not the evangelizing efforts were effective, it is important to note that the religious activities reported in missionary reports may not have been an accurate reflection of the actual evangelistic efforts of medical staff, some of whom may have either subordinated emphasis on saving the soul to healing the body or who may have seen healing the body as necessarily prior to evangelism, or who may have embraced healing-as-evangelism.85 As I have noted elsewhere, reports of “preaching to patients” from Canada, for example, seem to have been more of a reflection of mission board expectations than actual practice.86 Scholars must be cautious, therefore, about drawing conclusions about the intimate aspects of missionary nurses’ religious faith from public records meant for an audience of religious supporters.
Although public records provide a sense of the socio-religious context within which nurses were acculturated, without personal documents such as diaries or letters home, one cannot examine in any depth how individuals like Elizabeth McKechnie understood and expressed their Christian faith. What is clear is that McKechnie did not have to choose between nursing and evangelism; providing nursing care was accepted as a religious expression in itself. “These women [at the Williamson Hospital] give their lives,” the American Consul-General in Shanghai later commented, “not for money, but for love for these people, which they get from Christ. It is the spirit of Jesus.”87
A nurse worthy of the name must have education and refinement, and a character above reproach. Go forth with love, faith and purity of heart; your hopefor the future is bright.
- Surgeon-General Ch’uan, Army Medical College, to NAC delegates, 191588
In 1922, the School of Nursing at the Margaret Williamson Hospital in Shanghai was registered with the NAC.89 Thirty-eight years after Elizabeth McKechnie sailed for China, the nursing program she founded was 1 of 50-some schools of nursing registered in China, with similar structures and purpose. Applicants to the Margaret Williamson training school for Chinese nurses were to be 20 and 30 years of age and had to bring certificates from two people as to their “mental and moral fitness.” 90 The course of study was 3 years, with board, laundry, and textbooks furnished. There were 55 students enrolled in 1922, the majority of whom received their high school educations from mission schools. Those who were graduates of approved high schools could gain entrance upon a letter of recommendation from the principal. Other applicants were subject to an examination. In terms of the religious underpinnings of the school, the recorded composition of the student population is telling: “Christians on entering, 39, Non-Christians on entering, 16. During the past year since entering 12 have become Christians and four who are not Christians are interested in Christianity.”91
Perhaps one of the most remarkable aspects of missionary nursing was not its lack of focus on direct evangelism—United Church of Canada missionary nurses, after all, did not see it as their role to evangelize patients—but its unapologetic expectation that Chinese nurses themselves be Christian.92 In the educational milieu in which North American-born missionary nurses were acculturated, nursing and Christianity were inextricably linked; Christian discourse and traditions were part of the larger social fabric. And yet, for the Chinese people, to be a professing Christian was relatively rare. As such, Chinese nursing students and staff were part of a small Chinese subculture comprised mostly of those connected to foreign missionaries—either directly, as graduates of mission schools, or indirectly, as members of the Church of Christ in China. This was the main pool from which potential students were drawn. Thus, although Canadian missionary nurses in Henan criticized the early emphasis on evangelism, they also benefited from it. To missionary nurses, nursing personified Christian service. They believed that Christianity, with its emphasis on moral responsibility toward the sick, poor and dying, provided the foundation upon which successful nursing services could be built. There seems to have been little debate among missionary nurse educators as to the intended outcome of nursing education: Chinese nursing was meant to be a sinified offshoot of missionary nursing.93
Religious activities in the Margaret Williamson School of Nursing in 1922 included chapel services every morning, “twilight prayers” every evening, church services on Sunday, and Bible study classes.94 Across China, the NAC encouraged schools of nursing to “instill the highest ideals of nursing ethics throughout the profession” and to “encourage Chinese nurses to regard their work as a true act of service to God and to their countrymen.”95 Following the Nightingale ideal, missionary nurses in China perceived a virtuous character as central to good nursing care. Although a detailed discussion about the extent to which Chinese nurses came to embody and express Christian ideals in their nursing practice is beyond the scope of this chapter, it is important to note that the development of nursing in China required significant changes in social mores there. For centuries, Chinese women had been denied the opportunity to obtain any schooling.96 As Chen notes, although Protestant missionaries began to establish boarding schools for girls in the mid-19th century, it was not until after the 1911 revolution that the republican government recommended that middle schools for girls be included in the national educational system.97 Furthermore, the Christian ethos of caring for strangers contrasted with traditional approaches to caregiving in China, where ill family members were cared for by family, or by servants of the same gender as the patient. Similarly, traditional gender mores prohibited Chinese women from serving men they did not know. Mission hospital schools of nursing responded by taking in male nursing students and having separate wards or hospitals for male and female patients and staff. “How long this necessity will continue,” Harold Balme wrote, “is, of course, impossible to predict, but there are already signs of changing sentiment in the more progressive cities.”98 The hope was that one day it would be possible to employ female nurses in any of the hospitals in the larger cities. Canadian superintendent Ratcliffe’s comments capture this attitude well: “Women,” she wrote, “naturally possess more aptitude for the work than the men.”99
As nursing education gained traction in China in the 1920s, missionaries began to recognize the potential of the ambitious project being undertaken by missionary nurses as a collective. Dr. Harold Balme, Dean of Medicine at the Shandong Christian University in Jinan, expressed with astonished pride that “at the present time the molding of the new nursing profession in China is almost entirely in the hands of missionary nurses from Great Britain and North America, and of Christian Chinese who have had their nursing training abroad.”100 It was an “extraordinary opportunity” to shape the Chinese nurse of the future, “and thus to inspire the whole profession with the loftiest ideals.”101 Balme also expressed a hope that western nursing, with its Christian underpinnings, would be well rooted in China “within the next ten or twenty years.” However, it was not to be. Nursing education was stalled, even halted altogether, when Japanese forces invaded China in 1937.
Between 1937 and 1949, China faced a barrage of calamities that brought it to the brink of disaster, and undermined the work of missionary nurses to the point of collapse. The 8-year war with Japan was compounded by catastrophes like famine, flooding, and widespread outbreak of communicable diseases like cholera and typhoid. Mission compounds and hospitals were evacuated. Missionaries who refused to leave areas of occupied China were placed under house arrest by the Japanese the day after the successful attacks on Pearl Harbor, in December 1941. Japan held 13,500 civilian “enemy aliens” captive in China and Hong Kong between 1941 and 1945, missionary nurses among them.102 Nurses who returned to China after 1945 with plans to rehabilitate the hospitals and schools of nursing found themselves in the middle of the civil war between Nationalist and Communist forces.103 By the time missionaries were forced to leave China in 1949, some of the missions had already been closed permanently. The missionary era in China came to an abrupt and unceremonious end.
From this standpoint the nurse’s work is a ministry; it should represent a consecrated service, performed in the spirit of Christ, who made himself of no account but went about doing good.
- Isabel Hampton Robb104
Missionary nursing as a lifelong career has all but disappeared from the landscape of professional nursing preparation and practice in 21st century North America. In the current lexicon, the term “missionary nursing” tends to connote short-term (2 weeks to 2 years) volunteer missions to poor, devastated, or disaster regions of the world. Ideologically, it is differentiated from international or cross-cultural nursing by explicitly Christian aims, whether service or evangelistic. Practically speaking, however, the distinctions between “international nursing” and “missionary nursing” are not clear. Individual nurses, for example, may consider themselves as missionaries (or not), regardless of the mandate of their employer or sponsoring organization. The point is that missionary nursing, understood today as having a core aim of “sharing your faith” or “reaching out in Jesus Christ’s name” has been long relegated to the margins of contemporary nursing practice. But then again, so has Christianity.
Elsewhere I have argued that the silencing of missionary nursing occurred after the abrupt closure of the mission field in China in the late 1940s.105 I identified three factors that helped shift missionary nursing from the center to the margins of nursing discourse: self-censorship of repatriated missionaries, the mission identity crisis catalyzed by the “failure” of the missionary enterprise in China, and the equation of the missionary movement with the devastating policies of colonialism and imperialism. Here I offer a fourth influencing factor—the shift of religious (Christian) discourse itself from the center to the margins of nursing preparation and practice.
As we have seen, Protestant missionary nursing emerged at a unique period in history. China’s defeat in the Opium Wars, the women’s suffrage movement, the establishment of professional nursing education, advances in transportation, and the evangelistic student missionary movement converged in the late 1800s to create a favorable climate for the development of missionary nursing. The central tenets of missionary nursing, however, were not unique to overseas work. The notions of nursing as a lifelong ministry and “a consecrated service performed in the spirit of Christ” were not sectarian ideals meant for a fragment of the nursing populace, missionary or otherwise. Instead, they were central to the professional nursing envisioned, developed, and propagated by a string of capable nursing leaders, starting with—but hardly limited to—Florence Nightingale. Missionary nursing, in other words, was neither unique in its religious impulse, nor in its propagating tendencies. Those who led the professional nursing movement at the turn of the 20th century were as relentless in their pursuit of new opportunities to advance the profession on North American soil as missionaries were in their pursuits overseas. The profession that leaders envisioned was rooted in Christian perspectives on suffering as a symptom of a broken world, with nursing as an enactment of Christ’s care for the poor, sick, and weak. Missionary nursing was not an outlier. It was simply the furthest extreme of a profession already suffused with internationalizing, religious ideals.
Research funding was provided by The Social Sciences and Humanities Research Council of Canada and The Isobel Sholtis Brunner Fellowship for Historical Research in Nursing, Barbara Bates Center for the Study of the History of Nursing, University of Pennsylvania.
1. Brown, Margaret H. History of the Honan (North China) Mission of the United Church of Canada, Originally a Mission of the Pres by terian Church in Canada. Toronto: United Church Archives. LXVI:8. Print.
2. Chung-tung, Liu. “From San Gu Liu to ‘Caring Scholar’: The Chinese Nurse in Perspective.” International Journal of Nursing Studies 28.4 (1991): 315–24. Print.
3. Ibid., 320.
4. Ibid., 322.
5. Chan, Sally and Frances Wong. “Development of Basic Nursing Education in China and Hong Kong.” Journal of Advanced Nursing 29.6 (1999): 1300–07. Print.
6. Brush, Barbara L., Joan E. Lynaugh, Geertje Boschma, Anne Marie Rafferty, Meryn Stuart, and Nancy J. Tomes. Nurses of All Nations: A History of the International Council of Nurses, 1899–1999. Philadelphia: Lippincott, 1999. Print.
7. Frazer Smith, James. Life’s Waking Part: Being the Autobiography of Reverend James Frazer Smith, Pioneer Medical Missionary to Honan, China and Missionary to Central India. Toronto: Thomas Nelson and Sons, 1937. Print.
8. Paul, Pauline. “Religious Orders of Canada: A Presence on All Frontiers.” On All Frontiers: Four Centuries of Canadian Nursing. Eds. Christina Bates, Dianne Dodd and Nicole Rousseau. Ottawa: University of Ottawa Press & Canadian Museum of Civilization: 125–138, 2005. Print.
9. Marshall, Clara. The Woman’s Medical College of Pennsylvania: An Historical Outline. Philadelphia: P. Blakiston, Son & Co., 1897. Print.
10. Foster, Arnold. Christian Progress in China: Gleanings from the Writings and Speeches of Many Workers. Hankow: The Religious Tract Society, 1889. Print.
11. Grypma, Sonya. Healing Henan: Canadian Nurses at the North China Mission, 1888–1947. Vancouver: University of British Columbia Press, 2008. Print.
12. Letter from Dora Ruland, Medical Director, to Miss Ella Best, Executive Secretary, American Nurses Association, New York. 8 November 1948. BBC.
13. Kirkwood, Lynn. “Enough But Not Too Much: Nursing Education in English Language Canada (1874–2000).” On All Frontiers: Four Centuries of Canadian Nursing. Eds. Christina Bates, Dianne Dodd and Nicole Rousseau. Ottawa: University of Ottawa Press & Canadian Museum of Civilization: 183–96. Print.
14. Celebrating Our History: The Toronto General Hospital School for Nurses. Web. 5 Mar. 2010.
15. Hampton, Isabel. “The Aims of the Johns Hopkins Hospital Training School for Nurses.” The Hopkins Hospital Bulletin 1 (December 1889): 2. UBC WLA.
16. Hampton Robb, Isabel. Nursing Ethics: for Hospital and Private Use. Cleveland: JB Savage, 1901. Print.
17. Hurd, Henry. “The Relation of the Training School for Nurses to the Johns Hopkins Hospital.” The Johns Hopkins Hospital Bulletin 1 (December 1889): 7. UBC WLA (emphasis in original).
18. Frazer, Smith, Kaiyi Chen. 129–149.
19. Woman’s Hospital of Philadelphia, Minutes (1863–1881). Drexel University College of Medicine, The Legacy Center, Archives and Special Collections (Philadelphia), DUCM.
20. Ibid.
21. Bus, Peter. Toronto the Good: William Howland, 1844–1893. Web. 24 Apr. 2010.
22. Ibid.
23. Austin, Alvyn. Saving China: Canadian Missionaries in the Middle Kingdom, 1888–1959. Toronto: University of Toronto Press, 1986. Print.
24. Ibid., 4.
25. Ibid., 6–8.
26. Brown 3:8.
27. Frazer Smith 74.
28. Lawrie, Bruce R. Summary of the Honan Mission. FA 186. United Church Archives (Toronto), UCA.
29. Letter from Jonathan Goforth to FMB in 1888. Cited in Brown 4: 8.
30. Frazer Smith 75.
31. Austin 26.
32. Austin 5.
33. Mott, John R. The Evangelization of the World in This Generation. New York: Student Volunteer Movement for Foreign Missions, 1905. Print.
34. Hunter, Jane. The Gospel of Gentility: American Women Missionaries in Turn of the Century China. New Haven: Yale University Press, 1984. Print.
35. Cheung, Yuet-wah. Missionary Medicine in China: A Study of Two Canadian Protestant Missions in China before 1937. Lanhan, MD: University Press of America, 1988; Austin, Alvyn. Saving China: Canadian Missionaries in the Middle Kingdom, 1888–1959. Toronto: University of Toronto Press, 1986; Maxwell, Grant. “Partners in Mission: The Grey Sisters,” in Assignment in Chekiang: Seventy-one Canadians in China, 1902–1954. Scarborough, ON: Scarboro Foreign Mission Society, 1984.
36. Austin 32–35. See also MacKay.
37. Beaton, Kenneth. Serving with the Sons of Shuh: Fifty Fateful Years in West China, 1891–1941. Toronto: United Church of Canada, 1941. Print.
38. This estimate includes married nurses.
39. Austin.
40. Grypma. Healing Henan.
41. Preston, Louise Clara. Flowers Amongst the Debris: A Canadian Nurse in War Torn China. Brockville, ON: Preston Robb, n.d. Print.
42. Brown 57:11.
43. Stursberg, Peter. The Golden Hope: Christians in China. Toronto: United Church Publishing House, 1987. Print.
44. Grypma. Withdrawal from Weihui, 306–319.
45. Grypma. (Almost) Chinese.
46. Grypma. Withdrawal from Weihui.
47. Hampton Robb 11.
48. Grypma. Healing Hena; Chen; Simpson.
49. Chen, Kaiyi. “Missionaries and the Early Development of Nursing in China.” Nursing History Review 4 (1996): 129–49. Print.
50. Chen 133.
51. Chen 134.
52. Simpson, Cora. A Joy Ride through China for the NAC. Shanghai: Kwang Hsueh, 1922. Print.
53. Simpson 11.
54. Chen.
55. Gage, Nina D. “Stages of Nursing in China.” American Journal of Nursing 20.2 (1919): 115–21. Print.
56. Balme, Harold. China and Modern Medicine: A Study in Medical Missionary Development. London: United Council for Missionary Education, 1921. Print.
57. Chen.
58. Simpson.
59. Chen.
60. Simpson.
61. McGillivray, Donald. Ed. A Century of Protestant Missions in China (1807–1907) Being the Centenary Conference Historical Volume. New York: American Tract Society, 1907. Print.
62. Tomes, Nancy J. and Geertje Boschma. “Above All Other Things – Unity.” Nurses of All Nations: A History of the International Council of Nurses, 1899–1999. Eds. Barbara L. Brush, Joan E. Lynaugh, Geertje Boschma, Anne Marie Rafferty, Meryn Stuart and Nancy J. Tomes. Philadelphia: Lippincott, 1999. 1–38. Print.
63. Ibid., 5.
64. Ibid., 5.
65. Hunter 14.
66. Tomes and Boschma.
67. Chen 130.
68. Tomes and Boschma 11.
69. Report of the Margaret Williamson Hospital, Shanghai, China, 1922. Women’s Co-operating Foreign Mission Boards. DUCM.
70. Tyng, Anita E. Report of the Training School for Nurses for the Year 1883. Woman’s Hospital of Philadelphia Annual Reports 1–25; BBC.
71. McGillivray 470.
72. Twenty-first Annual Report of the Board of Managers of the Woman’s Hospital of Philadelphia January 1882, DUMC.
73. McGillivray; Margaret Williamson Hospital, 1885–1935. Acc 69 Missionaries, Box 1, Folder 24. China: Margaret Williamson Hospital, Shanghai, 50th Anniversary Pamphlet. DUCM.
74. Foster 192.
75. McGillivray 470.
76. Selmon, Bertha. “Women in Medicine Early Service in Missions (Continued).” Medical Woman’s Journal 54.6 (1947): 44–6. Print.
77. Fiftieth anniversary booklet of the Margaret Williamson Hospital, 1885–1935. DUCM.
78. Ibid.
79. Foster, Arnold. Christian Progress in China: Gleanings from the Writings and Speeches of Many Workers. Hankow: The Religious Tract Society, 1889. Print.
80. Foster 192–193.
81. McGillivray 471.
82. McGillivray 471.
83. McGillivray 472.
84. McGillivray 472.
85. Grypma. Healing Henan.
86. Grypma, Sonya. “James R. Menzies: Preaching and Healing in Early 20th Century China.” Canadian Medical Association Journal 170.1 (2004): 84–5. Print.
87. Margaret Williamson Hospital 18. DUMC.
88. Balme 149.
89. School of Nursing. Margaret Williamson Hospital. DUMC.
90. Ibid.
91. Ibid.
92. Grypma. Healing Henan.
93. Grypma. Healing Henan.
94. School of Nursing. Margaret Williamson Hospital. DUMC.
95. Balme 150.
96. Chen 135.
97. Chen 135.
98. Balme 150.
99. Jeanette, Ratcliffe. “Weihwei Hospital.” Honan Messenger 13.4: 14–15. 83.058C Box 57 File 16 Series 3. UCA, n.d.
100. Balme 153.
101. Balme 153.
102. Leck, Greg. Captives of Empire: the Japanese Internment of Allied Civilians in China, 1941–1945. Bangor, PA: Shandy Press, 2006. Print.
103. Grypma. (Almost) Chinese.
104. Hampton Robb 11.
105. Grypma. Withdrawal from Weihui.
* The pinyin system of spelling is used here for easier recognition of places by contemporary readers.