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The problem of infant mortality in Hong Kong, 1886-1937 Petrie, Ian Christopher 1996

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T H E P R O B L E M OF INFANT M O R T A L I T Y I N H O N G K O N G , 1886-1937 by IAN CHRISTOPHER PETRTE B.A., Queen's University, 1994 A THESIS SUBMITTED IN P A R T I A L F U L F I L L M E N T OF T H E REQUIREMENTS FOR THE D E G R E E OF M A S T E R OF ARTS in T H E F A C U L T Y OF G R A D U A T E STUDIES Department of History We accept this thesis as conforming to the required standard  T H E UNIVERSITY OF BRITISH C O L U M B I A August 1996 © Ian Christopher Petrie, 1996  In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission.  Department of  fl ivfoy"  The University of British Columbia Vancouver, Canada Date J i i w u ^ f ,  DE-6 (2/88)  \H%  Abstract  In the late nineteenth century, the level of Chinese infant mortality in Hong Kong became a matter of grave concern to colonial officials. The significance accorded to the infant mortality rate reflected both contemporary Western notions about the health of the nation and good government, and long-standing associations of Chinese culture with infanticide.  Initial investigations focused on deaths from tetanus neonatorum in local  Western charitable institutions.  Further reports in the mid-1890s blamed Chinese  midwives for infant deaths, and some officials pressed for the regulation of these women. The course of the ensuing debate, which spanned a decade and a half, illustrated the politics of public health in the colony, whereby the Hong Kong government consulted with members of the Chinese elite and sought compromise, so as not to antagonise the Chinese population.  The resulting Midwives Ordinance of 1910 thus did not affect  Chinese midwives unless they claimed to have Western training. Rather than attempt to proscribe the native midwives, the government supported local training initiatives in the hope that Western-style birth professionals would gradually prevail.  n  Table of Contents  Abstract Table of Contents List of Tables Acknowledgements Introduction Chapter 1: Convents and Convulsions Chapter 2: Midwives and Mothers Chapter 3: Replacement and Regulation Conclusion Bibliography Appendix 1: Chinese Resistance to the Census  in  List of Tables  Table 1: Sex ratio of foundling deaths, Hong Kong 1887-1896  17  Table 2: Chinese infant mortality rate (TMR), Hong Kong 1895-1906  25  Table 3: Chinese birth counts and birth rates, Hong Kong 1890-1920  34  Table 4: The work of government midwives, Hong Kong 1905-1939  41  iv  Acknowledgements  I thank the Faculty of Graduate Studies and the Department of History of the University of British Columbia for the University Graduate Fellowship which made possible this thesis. I also am indebted to the staffs of the following institutions: the British Library; the British Newspaper Library, Colindale; the library of the London School of Hygiene and Tropical Medicine; the Public Record Office, Kew; the library of the School of Oriental and African Studies, London; the Wellcome Institute for the History of Medicine; and, not least, the inter-library loans office at the University of British Columbia. I received valuable advice from Robert Kubicek and Molly Sutphen, and the equally valuable use of a laptop courtesy of Rafe Engle. The company of Philip Chang, John Johnston and Nena Lafuente kept things in perspective in London, while friends and staff at Green College did the same in Vancouver. I am most grateful to Diana Lary, an exceptionally generous and patient supervisor and teacher. Finally, my greatest debt is to my parents and sister, without whose unflagging support even this modest achievement would have been impossible.  Introduction In 1901, a British medical official in Hong Kong calculated the infant mortality rate of the colony's Chinese population to be an astonishing 928 per 1,000 live births: 1  that is, of every thousand Chinese babies born in Hong Kong, only seventy-two survived their first year. Not surprisingly, this figure was received with incredulity, but, imbued with the credibility of a government statistic, the rate was accepted as fact.  2  This figure, to which we will return later, was the epitome of Hong Kong's infant mortality problem, a medical, statistical and administrative bugbear which vexed officials, doctors, and medical missionaries in the colony from the 1880s to the. Second World War. The routine annual recording of figures and expressions of dismay was punctuated in some years by more extensive inquiries, committees and policy recommendations, and, less frequently, by government action. The colonial state's interest in such a subject was noteworthy in several respects: here was a new type of medical concern (endemic rather than epidemic) and two segments of the population (women and children) that were new to scrutiny.  On the other hand, the issue also reflected the prevailing forms and  imperatives of decision-making in the colony with respect to public health.  The  remainder of the introduction will examine the context of Hong Kong's infant mortality problem, turning first to the general background of health issues, and subsequently to the specific significance of infant death.  That is, the total number of births in a given year, divided by the total number of deaths of infants under one year of age in the same year, multiplied by 1,000. 1  1  The Colonial State, the Chinese and Public Health From the colony's inception, sanitary and health issues were prominent in Hong Kong. As The Times famously put it in 1859, "Hong Kong is always connected with some fatal pestilence, some doubtful war, or some discreditable internal squabble."  3  As  was the case elsewhere in the empire, the state's initial forays into medical matters were concerned solely with the European population, and most specifically with military personnel It was this latter imperative which first brought numbers of Chinese women to the attention of the Hong Kong government, with the beginning of state regulation of prostitution (and so-called "contagious diseases") in 1857. Indeed, until the 1880s, prostitutes were the only Chinese whose health was of consistent interest to the state.  4  The colony's rapid growth after mid-century reflected economic growth but portended health problems. The early years of three successive decades — the 1860s, 1870s and 1880s — witnessed condemnations of Hong Kong's insanitary state by local or metropolitan specialists (most famously in Osbert Chadwick's report of 1882), all of which failed to spur substantive changes, thereby establishing a potentially dangerous pattern of scientific (and often press) outcry followed by administrative inaction. Matters culminated tragically in the infamous bubonic plague epidemic which struck in  For example, the figure was reprinted in a prominent popular work on Chinese life and customs by a long-time Hong Kong official: J. Dyer Ball, Things Chinese, 4th rev. ed. (Hong Kong, 1903), p. 349. The Times, 15 March 1859, cited in G.B. Endacott, A History of Hong Kong (London, 1958), p. 87. Hong Kong's efforts in this regard preceded the British CD Acts by a decade, and lasted nearly a century. Norman Miners, Hong Kong under Imperial Rule, 1912-1941 (Hong Kong, 1987), Ch. 9. 2 2  3  4  May, 1894, claiming 2,500 lives, shutting down the economic life of the colony, and generating much fear and animosity between the Chinese and European communities.  5  Perhaps such a sequence was inevitable in this, the most laissez faire of colonies, which virtually governed itself. British officials in the late nineteenth century frequently 6  balked at enacting sanitary reforms in Hong Kong for fear of provoking the Chinese population. This was considered especially likely with any issue involving Chinese home life, which was viewed as benighted but best left alone. While the prospect of being driven violently from the colony might never have been far from Europeans' minds (the bread poisoning incident of 1857 remained a touchstone for such anxieties), of greater concern was the possibility of provoking a large-scale exodus of the labouring population which would cripple Hong Kong's economy. Such a flight was to take place during 1894, when as much as half of Hong Kong's population fled not the plague itself (which was as rampant in Canton) but British quarantine measures.  7  Nevertheless, by the 1880s the Hong Kong government showed signs of becoming increasingly interventionist and seeking greater control over its Chinese subjects.  8  This  was not, however, a simple matter of the imposition of orders from the top down. A s recent histories of the colony have illustrated, Hong Kong witnessed the interplay of Endacott, pp. 114-15, 185-88, 199-203, 216-20. For a recent and acute account of the epidemic, see Elizabeth Sinn, Power and Charity: The Early History of the Tung Wah Hospital, Hong Kong (Hong Kong, 1989), Ch. 6. William Des Voeux, who governed from 1887 to 1891, recalled that, administratively, "the place would be a paradise to a man inclined to be idle." My Colonial Service, 2 vols. (London, 1903), 2: 244. Sinn, Power and Charity, pp. 167, 175, 180. 5  6  7  3  British officials, the Chinese elite (or elites, if one distinguishes between Westernized and non-Westernized) and the Chinese population. With regard to matters of public health 9  and sanitation, the colonial medical establishment (both official and unofficial) and, occasionally, metropolitan experts, also entered what was a field of consultation, negotiation, and compromise.  10  Neither the government's coercive powers nor its  inclination to use them were great. The alienation of either the Chinese elite or the Chinese masses would jeopardize the running of the colony. Hence when the government elected to take action (and there was no shortage of inaction), it did so in consultation and co-operation with its elite Chinese counsellors. Political expediency, therefore, could ally the government with certain Chinese (or in the ostensible interests of "the Chinese community") against the recommendations of its own medical officials.  The history of  infant and maternal mortality in Hong Kong illustrates these structures of conflict and mediation. The Regulation of Chinese Medicine Determining which Chinese practices could properly remain in a British colony was never an easy matter for Hong Kong officials, and this thorny realm was one in which the "man on the spot" was likely to come into conflict with office-holders and activists at  Jung-Fang Tsai highlights the pivotal role of the strike activity and riots of 1884 in provoking this transition. Hong Kong in Chinese History: Community and Social Unrest in the British Colony, 1842-1913 (New York, 1993), pp. 145-146,291. With the added element of mainland officials and residents. Tsai, op. cit.; Sinn, op. cit.\ Chan Wai Kwan, The Making of Hong Kong Society: Three Studies of Class Formation in Early Hong Kong (Oxford, 1991). This has been explored with regard to sanitary legislation, the plague epidemic and Chinese medical charities in both Sinn, Power and Cliarity and Chan.  8  9  1 0  4  home.  11  In terms of public health, this manifested itself most directly in the question of  the status of Chinese medicine and medical practitioners. Traditional Chinese medicine was almost universally derided by Westerners in the nineteenth century, particularly insofar as its practitioners appeared to lack any recognizable schooling or qualifications. It was a cliche to point out that "any coolie could become a quack." It was pointed out less often that British professional medical standards were themselves of recent vintage: the Medical Registration Act was passed in 1858. Colonial medical men were particularly insecure on this count, their qualifications frequently impressing neither indigenous populations nor metropolitan professionals. Indeed, the often substantial difference betwen home and colonial medical practice and thought calls into question the notion of a monolithic "Western medicine" in opposition to indigenous traditions.  12  Nevertheless, officials, medical missionaries and other commentators recognized that state intervention in such an intimate matter as the individual's health was fraught with uncertainty. As an 1888 editorial in the Hong Kong Daily Press observed: to attempt to force Western medicine on the native population on...a wholesale scale...would be calculated to arouse opposition, and might not be unattended with some danger. The matter is one in which the Chinese should be led rather than driven. 13  Moreover, the colonial state, like its parent, was often only too happy to let private charity, Western or Chinese, operate in this field. A textbook example being the later mui tsai controversy. See Miners, Chs. 8-9. A n interesting discussion of registration, status and a distinctive body of medical thought among British doctors in nineteenth century India is found in Mark Harrison, Public Health in British India (Cambridge, 1994), pp. 16-19, 36-59. 11  12  5  These considerations resulted in policies which frequently appear contradictory. The state sanctioned the opening of the Chinese-operated Tung Wah Hospital in 1872, which gave patients a choice of Chinese or Western treatment. Most officials and the British press in the colony, however, remained sceptical about or openly hostile to both its methods and the power wielded in the community by its executive. This culminated in a movement which nearly succeeded in closing the hospital in the aftermath of the 1894 epidemic.  14  It was often easiest for officials to sidestep the issue, as was the case with the Medical Registration Ordinance of 1884, which, following British precedents, established a medical register and board. It only applied, however, to Western medical practitioners. Their Chinese counterparts were exempt. Such legislation was the result of not cultural sensistivity, but expediency.  15  Counting and Controlling A Shifting Population From the beginning of British rule, the Chinese population of Hong Kong was overwhelmingly male, comprising sojourners who either were single or had families remaining on the mainland. The 1850s proved a key decade in the growth of the Chinese population, which numbered 22,496 in 1848 but increased nearly six-fold to 121,497 by 1865, sixty-five percent of whom were adult males. Europeans viewed this burgeoning community of labouring men with suspicion: transient at best, criminal at worst, this was,  Hong Kong Daily Press, 2 November 1888. Sinn, Power and Charity. "The Medical Registration Ordinance. 1884," The Ordinances of the Legislative Council of the Colony of Hongkong, A.J. Leach, ed. 2 vol. (Hong Kong, 1892), 2: 695-700. 13  1 4  1 5  6  in the words of one longtime official, "a population recruited almost from the dregs of society."  16  B y the late 1860s, however, officials expressed interest in the growing number of Chinese families in Hong Kong, which was cited as "evincing a gradual surmounting of old prejudices on the part of native residents ~ formerly deemed insurmountable...against bringing their wives and families to live in a British Colony." Such prejudice was said to have "almost entirely disappeared" by 1891: the census of that year counted 17,349 families in the colony, up from 11,859 a decade earlier. Women numbered some 40,000, and "boys and girls" over 42,000, out of a total Chinese population of just over 214,000. Yet to simply chart the absolute increase in the number of families or women is illusory: between 1861 and 1891, the proportion of women in the Chinese population remained constant at about one-fifth of the total population, or one-quarter of the adult population. The early twentieth century suggests the beginnings of a shift in the sex ratio: whereas the total population of the colony was seventy-two percent male in 1901, this proportion had fallen to under sixty-five percent in 1911. Nevertheless, this lower number signified no change over figures calculated in the 1860s.  17  The census data suggest that the increasing significance of family life in the colony perceived by late nineteenth century officials was more apparent than real. Regardless of any waning "prejudice", the high cost of living in Hong Kong remained the greatest Furthermore, the British blamed mandarins for preventing "respectable Chinese" from coming to the colony. Tsai, pp. 22, 39, 47; J.W. Norton-Kyshe, The History of the Laws and Courts of Hongkong, 2 vols. (London, 1898), 1: vii. 1 6  7  impediment to the establishment of working class families there; hence the continued prominence of the sojourning male.  18  On the other hand, the census data may be  incorrect, and one could conjecture that women and children were in fact less likely to be counted. Indeed, the whole question of the reliability of Hong Kong's official statistics must figure prominently in any consideration of the history of mothers and babies in the colony. Hong Kong's decennial census was plagued with problems. scheduled to coincide with the British census.  In 1881 it was  Unfortunately, that date also coincided  with the Chinese tombs festival, which drew thousands of Hong Kong residents to the mainland and hence beyond the reach of enumerators.  Although officials subsequently  were more attentive to such matters, scheduling the census remained problematic. well, Chinese resistance to the taking of the census was persistent.  19  As  This stemmed from  widespread misapprehensions and anxieties regarding the purpose of government inquiries (see the excerpt from the report on the 1896 census in Appendix 1, below).  20  The census  represented the acme of colonial information gathering, and, as will be seen, the mundane collection of vital statistics posed even greater problems for the colonial administration.  "Census Report 1891," HKSP 1892, pp. 375, 379; "Joint Report of the Principal Civil Medical Officer and the Medical Officer of Health," Administrative Reports for the Year 1912 , p. L10. "Report on the Census of the Colony for 1897," HKSP 1897, p. 469; Tsai, pp. 108109. "Census Report 1891," p. 373; "Report on the Census...for 1897," p. 467. Accounts from the mainland reveal that Hong Kong was by no means unique in this regard. For example, the provincial army had to suppress riots in Guangdong provoked by the 1910 census, as villagers believed that men were to be conscripted and taxes raised. Ping-ti Ho, Studies on the Population of China, 1368-1953 (Cambridge, Mass., 1959), p. 76. 8 17  18  19  2 0  The difficulty  in counting Hong Kong's Chinese population,  much  less  determining its proportion of women or families, stemmed from one irrefutable fact: it was a constantly shifting population. Elizabeth Sinn evocatively suggests that many Chinese "commuted" between Hong Kong and the mainland.  This phenomenon was  especially pertinent to the collection of vital statistics, for births and deaths were particularly likely to take place outside of the colony. It was well known that many women elected to return to their home villages on the mainland for their confinement. This practice could skew the colony's statistics in a number of ways. Arguably, those mothers who were the worst off were the least likely to be able to leave. Thus the babies most likely to be premature or ill were the most likely to be born (and die) in the colony. Moreover, any baby born outside the colony which died after returning to Hong Kong usually caused the registration of a death without a corresponding birth. occasioned such trips.  Illness also  The higher death rate of Chinese women in Hong Kong was  attributed to the greater ability of men to leave the colony when ill, and hence to die elsewhere.  21  Keeping accurate records on the vital events of the population was no minor  matter: for Victorians, the task was ineluctably bound up with good government and the health of the state.  As an editorial in the Hong Kong Daily Press stated in 1888,  "Statistics may almost be called the breath of life to the science of hygiene; it is by the light they afford that danger is seen and averted, and the unnecessary sacrifice of life  Sinn, Power and Charity, p. 9; "Registrar General's Report for the Year 1891," HKSP 1892, p. 232; "Report of the Medical Officer of Health for 1901," HKSP 1902, p. 526.  2 1  9  diminished."  22  Towards the turn of the century perhaps no single statistic was invested  with as much importance by Western health authorities as the infant mortality rate. The Significance of Infant Mortality In their consideration of infant mortality in Hong Kong, officials and the British press could not help but be influenced by the prominent place accorded to infanticide in the history of Western perceptions of China. But, by the late nineteenth century, matters were not as clear-cut as they had been for the authors of polemics a few decades earlier. Missionary and other popular accounts increasingly acknowledged that it was impossible to generalize for all of China, and that firsthand local reports frequently failed to confirm the stereotype.  What remained was an ambiguous vocabulary of abandonment, neglect,  and callousness, which occasionally invoked socio-economic conditions but also still relied on racial stereotypes.  23  Yet even without this history, the concept of infant mortality as it came to be exported from the West in the late nineteenth and early twentieth centuries, implied similar moral and cultural judgements, made only more powerful by their basis in science. The remarks of Sir George Newman are representative of British thinking at the turn of 24  the century. Newman stated that "the death-rate of infants is the most sensitive index we possess of physical welfare and of the effect of Sanitary Government." Furthermore, he  Hong Kong Daily Press, 13 July 1888. Ball, pp. 347-50; George Cockburn, John Chinaman: His Ways and Notions (Edinburgh, 1896), p. 186; E.J. Hardy, John Chinaman at Home (London, 1906), p. 191; William C. Milne, Life in China (London, 1857), pp. 38-42. See also Colin Mackerras, Western Images of China (Hong Kong, 1991), pp. 45-58. Chief Medical Officer of the Board of Education (1907-1935) and of the Ministry of Health (1919-1935).  2 2 2 3  2 4  10  contended that "a high infant mortality indicates the existence of evil conditions in the mothers and in the home-life of the people. It is an index of social evil."  A 1915 text  pronounced that "carelessness in connection with infant life is a sure sign of degeneracy in any country."  25  In this context, infant mortality may be seen as part of a continuum  regarding the fate of children which constituted particularly fertile ground for cultural conflict between British rulers and their Chinese subjects in Hong Kong.  26  The subject of infant mortality thus injected new and alarming concerns into longstanding debates about Hong Kong's population, health and government.  This study  emphasizes the government's perception of the problem, and its response to it, employing a critical reading of official reports and communications.  Complementary  materials and differing perspectives have been found in English-language newspapers and other contemporary publications and in the reports of medical missionaries sent to the colony by the London Missionary Society. Chapter 1 examines the first official investigations of infant mortality in two Western charitable institutions, in 1886, which emphasized environmental causes. Chapter 2 gives an account of further inquiries in the 1890s and 1900s, which targeted Chinese medical practitioners and midwives, while also considering the problems inherent in the government's attempts to measure the extent of the perceived infant mortality  Newman cited in Andrew Balfour and Henry Harold Scott, Health Problems of the Empire (London, 1924), p. 323; George Newman, The Health of the State (London, 1907), pp. 109-110; Hugh T. Ashby, Infant Mortality (Cambridge, 1915), p. 6. Indeed, ideas about Chinese child welfare continue to be of major concern to Westerners, as continuing reports of female infanticide and the recent attention paid to conditions in Chinese orphanages attest. See, for example, "The Lost Girls," Utne Reader, 75 (May-June, 1996), pp. 13-14.  2 5  2 6  11  crisis. The third chapter describes the evolution of Western midwifery training in Hong Kong, as the government sought to gradually replace native midwives rather than ban them outright. The course of the debate over infant mortality and Chinese midwives illustrates the limitations of the colonial government, as both an agent of change and a gatherer of knowledge about its subjects.  12  Chapter 1: Convents and Convulsions Foundling Deaths, 1886 The first official consideration of Chinese infant mortality in the colony took place in 1886. Sanitary Board member A.P. MacEwen raised the issue, in response to data gathered by the new Acting Registrar General, James Stewart-Lockhart, which revealed alarming numbers of infant deaths in two local Western charitable institutions, L'Asile de la Sainte Enfance (popularly known as the French Convent) and the Italian Convent. Between 1880 and September, 1886, the Italian Convent had admitted 4,309 foundlings. In that same period were registered 3,214 deaths of infants under one year of age.  1  A report by Dr. William Hartigan focused on the Italian Convent, and the leading cause of infant death, tetanus neonatorum.  In surveying the medical literature on the  malady, Hartigan noted its a variety of causes, including "wounds of nerves", rapid changes in temperature, dirt, indigestion and worms.  2  Although he bemoaned the overall  lack of information on the infants brought to the Convent, Hartigan ascertained that: the infants come from Tai-ping-shan, and any one 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...The children who come from such slums are truly in keeping with their surroundings. Always filthy; generally puny; their clothes saturated with soil and stinking; their bodies emitting a horribly fetid odour, which is, without exaggeration...overpowering; their eyes filled with purulent discharge; their foreheads, cheeks and abdomens seared with the cauterising cash [sic?]; the umbilicus, if attached, smelling foully and bathed in foetid [sic] pus, or, if detached, giving out a dirty greyish purulent discharge; the William Hartigan to Secretary of Sanitary Board, 24 November, 1886, in "Correspondence Respecting Deaths in Italian and French Convents," HKSP 1886-87, p. 184. William Hartigan, "Case of Tetanus Neonatorum," Transactions of the Hongkong Medical Society, Volume 1 (Hong Kong, 1889), p. 146. Although this paper was not published until 1889, the research dated from the 1886 investigation. 1  2  13  genitals and anus inflamed and moist with muco-pus, whilst an eczematous eruption spreads over the nates. 3  Taipingshan, in the western half of the city of Victoria, between Queens Road and Robinson Road, was home to a significant proportion of Hong Kong's labouring Chinese. The neighbourhood long had been the object of official attention and reform efforts, first as a den for criminals, and later as a fearsome pool of filth and disease, justifying the government's resumption of land there. Nevertheless, the living conditions of the Chinese population initially were not the focus of this investigation.  Rather, the charitable  institutions themselves were suspect. Hartigan observed that: the conditions in the Italian Convent are not very favourable for any treatment. The wards are much too small, low; ill ventilated; too cold in winter, suffocating in summer. Three infants are placed in one small cot, and the odour therefrom is sometimes overpowering...The drainage is extremely bad and the sanitary arrangements of a most primitive nature. The consequence is the children are exposed to almost as unhygienic conditions in the Orphanage as those from which they were brought, not through any fault of the nuns, but owing to limited accommodation and want of funds. 4  He concluded, however, that tetanus cases were not originating in the Italian Convent, although a number of infants had been sent out to wet nurses in Taipingshan and returned to the convent afflicted. In Hartigan's experience, tetanus neonatorum proved universally fatal, despite his use of such contemporary remedies as opium, bromides, chloral and tobacco.  5  Reporting to Hugh MacCallum, Secretary of the Sanitary Board, Hartigan stressed that little reduction of infant mortality at the convent could be expected, insofar as "the greater number of infants are moribund prior to their reception, this condition being the result of previous insanitary surroundings, insufficient or improper food, and general Ubid, pp. 147-48. Ibid, p. 158. Ubid, p. 157. 4  14  neglect."  6  Not surprisingly, this was the position taken by the convent authorities  themselves, one of whom, in a memorandum to the government, contended that "almost all [the infants] are brought in a hopeless dying state; in most of them the marks on their bodies show that they were under some medical treatment, and that they were taken to the Convents, only when they had no more hope to save them."  7  Raising the issue of infant mortality in the convents before Acting Governor E. Marsh (served 1885-1887), at a Legislative Council (LegCo) meeting of 26 November, 1886,  A.P. MacEwen acknowledged the efforts of the nuns, but pressed for state  intervention: I am convinced that [the infants] receive...every care and attention, in fact probably far more than they would at the hands of their own parents, or perhaps in Government institutions in this colony. But...I maintain that the system of receiving children suffering from disease without providing efficient medical attention is a matter that is deserving of the consideration of your Government.... 8  MacEwen advocated the creation of a new government post, Parochial Medical Officer, to deal specifically with the inmates of the convents. A subsequent report by Colonial Surgeon P.B.C. Ayres (served 1873-94) echoed previous praise for the efforts of the convents, and raised the spectre of female infanticide: The great majority of [the babies] are brought in in a moribund condition, or so ill nurtured that they are all but hopeless cases. The great majority are also female children, and all, if not received into the Convents, would be found on the hill sides (as many are already) dead. The greatest possible care and attention are given to them, and I know of nothing better that can be done for them by the Sisters than is done in the Convents. 9  Hartigan to Sanitary Board, in "Correspondence," p. 183. Memorandum by Revd. G. Burghignoli, 30 November 1886, in "Correspondence," p. 183. Hong Kong Daily Press, 27 November 1886. Report by the Colonial Surgeon, 30 November 1886, in "Further Correspondence  6  7  8 9  15  The practice of infant abandonment referred to by Ayres was frequently noted in the colony. In 1889, a popular guide to the colony observed that: Numbers of children are constantly taken to the Channel Rocks and there left exposed, to be eaten by birds and insects. Neither their births nor deaths are registered. The Channel Rocks jut out of the water within 4 miles of the heart of Victoria, but are supposed by the Chinese to be Chinese Territory. 10  Although little was known about the foundlings, records kept of convent deaths in the decade following this inquiry abundantly confirm Ayres's suggestion that they were predominantly female (see Table 1). Ayres made a second report on the subject in December, taking a somewhat different position than Hartigan on the causes of the affliction. Trismus [i.e., tetanus]...[is] caused by exposure to rapid changes in temperature, insufficient clothing and diet, and defective ventilation, such as are to be found in the crowded houses of the lower classes of the Chinese and amongst the boat population. The case of a child when once the attack has well set in is hopeless....These infants are received [at the convents] in all hours of the day and night and mostly naked or being wrapped only in a piece of old rag or paper...It would be impossible for any medical man to do any good among the Chinese, for nothing would be heard of a case until it was hopeless or dead; and it is not to be wondered at that, considering the condition of the lower classes of Chinese in their houses and boats, so many children die, but that so many live. 11  The lack of information available on the infants at the convents, however, encouraged some commentators to question whether or not the foundling deaths were indicative of  Respecting Deaths in the Italian and French Convents," HKSP 1886-87, p. 241. Bruce Shepherd, The Hongkong Almanack For... 1889 (Hong Kong, 1889), p. 139. A 1931 city guide pronounced that the "custom of killing unwanted girl children has practically died out in Hong Kong but babies are still left in the streets or at doors of charitable institutions." S.H. Peplow and M . Barker, Hongkong, Around and About, 2nd rev. ed. (Hong Kong, 1931), p. 76. Further Report by the Colonial Surgeon, 30 December 1886, in "Further Correspondence," p. 242. 1 0  11  16  Table 1: Sex ratio of foundling deaths, Hong Kong 1887-1896  Year  Convent  Total Deaths  Male  Female  Sex Ratio (F:100M)  1887  Italian French  557 459  163 168  394 291  242 173  1888  Italian French  604 500  192 187  412 313  215 167  1889  Italian French  509 545  140 204  369 341  264 167  1890  Italian French  472 506  128 195  344 311  269 159  1891  Italian French  555 696  166 303  389 393  234 130  1892  Italian French  436 773  150 298  286 475  191 159  1893  Italian French  526 993  184 372  342 621  186 167  1894  Italian French  430 867  136 304  294 563  216 185  1895  Italian French  376 907  113 304  263 563  233 185  1896  Italian French  323 888  93 448  230 440  247 98  Source: Medical and sanitary reports in Hong Kong Sessional Papers, relevant years.  17  the quality of Chinese life in the colony. At a Sanitary Board meeting in 1888, Ho K a i  12  contended that the convents in the colony took in children from "all parts of China," notably Canton and Macao, and thus the death rates of those institutions did not afford a true indication of living conditions in Hong Kong.  13  The absolution of the convents required that fault be found elsewhere. Hartigan's report emphasized the appalling living conditions in Taipingshan but both he and Ayres pointed toward seemingly more immediate causes that would  dominate  future  investigations: the behaviour of Chinese parents and the procedures of Chinese medical practitioners. For Western observers, Hong Kong's convents provided evidence of the failings of the Chinese character and community. In his memoirs, Sir William Des Voeux, governor from 1887 to 1891, remarked upon: the excellent work of the sisters of the French and Italian convents in endeavouring to rear the numerous infants left at their doors, many of them in almost moribund condition. These children, most of whom were females, were the victims of that disregard of individual life which the existence of a dense population disproportionate to the means of subsistence in the course of long ages has rendered characteristic of the Chinese. Such apparent heartlessness with regard to infants is all the more remarkable, as Chinese parents are particularly affectionate to the children which they permit to survive, and seems to indicate that their practice of abandoning to their fate superfluous members of their families is not the outcome of mere selfishness, but is due to a genuine belief that death is a lot more desirable than life for a considerable number of those born into the world, while at the same time rendering less bitter the struggle for existence on the part of the survivors. 14  The son of a Chinese London Missionary Society (LMS) pastor, Ho Kai (1859-1917) had received British medicine and law degrees by the age of twenty-seven. In 1886 he became the first Chinese appointment to the Sanitary Board. He also served on the LegCo from 1890 until 1914, and was knighted in 1912. See G.H. Choa, The Life and Times of Sir Kai Ho Kai (Hong Kong, 1981). Hong Kong Daily Press, 30 November 1888. G. William Des Voeux, My Colonial Service, 2 vol. (London, 1903), 2: 277. 1 2  13  1 4  18  Des Voeux, however, did perceive a difference along class lines among the Chinese, observing that the "tendency to benevolence in the more well-to-do Chinese is in singular contrast to the extraordinary indifference to human life so frequently shown by the labouring class."  15  More bluntly, a laudatory feature on L'Asile de la Sainte Enfance  which later appeared in the Hong Kong Telegraph dubbed the nuns' work "the highest form of charity, namely charity toward the uncharitable."  16  It is more difficult to ascertain Chinese opinions of the convents. Foreign missionary foundling institutions frequently were the objects of popular suspicion. Most infamously, rumours surrounding such an orphanage erupted into the Tianjin Massacre of 1870.  17  Although no such outburst ever threatened Hong Kong's institutions, that similar  fears existed is suggested by the statement in an article on the French Convent that: there is no reason or justification for the false notion that when once a child is put in the Convent it is lost to the world; can never be taken out. They can be taken away, and may be seen and handled by their parents whenever they feel disposed to call and ask for permission in a proper manner.... 18  In 1886 the overseer of the Italian Convent felt compelled to defend the practice of paying the person who left a child at the institution: "Now to  prevent  all  misunderstanding, I wish to say that the small sum of money never exceeds three cents."  19  Ibid., 2: 200. Hong Kong Telegraph, 22 and 25 August 1899, reprinted in pamphlet form as L'Asile de la Sainte Enfance, Hongkong. Description of the Establishment and Work (Hong Kong, 1902), p.4. Paul A. Cohen, China and Christianity: The Missionary Movement and the Growth of Chinese Antiforeignism, 1860-1870 (Cambridge, Mass., 1963), pp. 88-94, 101, 230-31. L'Asile de la Sainte Enfance, p. 15. Memorandum by Burghignoli, in "Correspondence," p. 184. 15  16  1 7  18  1 9  19  Folk Practices and Tetanus Neonatorum Accounts abounded of the barbarities inflicted upon infants by traditional Chinese medical practices.  It was reported that a baby admitted to the French Convent "not  infrequently bears signs of having been tortured by the remedies prescribed by Chinese quacks": "many of them are brought in suffering from burns all over the head, arms and legs, their mothers having tried Chinese remedies to cure them of the fever or diarrhoea."  20  Of tetanus neonatorum, Hartigan observed that "some Chinese old women are said to cure the disease by cutting something in the throat or cauterising it."  21  In the early twentieth century, the prevalence of tetanus neonatorum in Hong Kong became associated most explicitly with the routine Chinese treatment of the umbilicus. It was observed that, at the Italian Convent, "in nearly every case where a child was brought into the institution with tetanus-like  symptoms  the cord had  previously been treated with some kind of Chinese medicine...known as sealing-cord powder."  22  According to Chinese medical tradition, the most feared "fetal poison" was  the so-called "navel wind". The navel itself was known as the "gate of life" or "master of the one hundred apertures", a site of interaction between internal fetal poison (derived from the mother) and external influences. dry  Hence the navel was to be kept warm and  23  The traditional dressing of the umbilicus was explained thus: An old idea amongst the ignorant classes of Chinese is that if the cord is severed and not properly sealed the child will develop abdominal pain, due to winds entering into the abdominal cavity through the cord. Hence the use of a powder or a plaster for sealing the cord at birth. Neither Hong Kong Daily Press, 11 December 1902; L'Asile de la Sainte Enfance, p. 16. Hartigan, "Case of Tetanus Neonatorum," p. 157. C. Y . Wang, "Infantile Tetanus (Tetanus Neonatorum) in Hong Kong. Its Prevalence and Sources of Infection," The Caduceus, 6, 3 (1927), p. 249. Charlotte Furth, "Concepts of Pregnancy, Childbirth, and Infancy in Ch'ing Dynasty China," Journal of Asian Studies, 46, 1 (1987), p. 21.  2 0  2 1  2 2  2 3  20  substance is of uniform composition, the most simple being composed of burnt ashes of coarse paper or...powder which is a preparation of camphor. The following ingredients are commonly used by the Chinese druggists in the preparation of the cord dusting powder: — ashes of red cotton cloth, ashes of cow's dung, ashes of human hair, rouge and dragon bones, all being finely ground. 24  The colour of the powder could be red, white, grey or black. Despite the diverse recipes, common ingredients invariably were earth or manure. Half-ounce packets of such powder were sold by Chinese druggists for two or three cents. In 1926, an investigator in Hong Kong purchased 121 samples of such powder from shops throughout the colony, of which eight contained live tetanus bacilli. On the strength of this evidence, the author advocated not only the education of mothers regarding the proper dressing of the cord, but also the prohibition of the sale of sealing-cord powder.  25  Coda: Infant Deaths and Statistics, 1889 The subject of infant mortality next was raised in 1889, when Dr. Patrick Manson, the senior medical figure in the colony, read a paper on beriberi to the Hong Kong Medical Society. In his introduction, Manson bemoaned the British disregard for the lives of their Chinese subjects: The ignorance that prevails among us Europeans about the inner life of our Chinese fellow-citizens is only paralleled by our ignorance about the diseases they suffer from; and our indifference in the one case is just about on a par with our indifference in the other. There are signs, I am glad to say, that this state of ignorance and callousness tends to pass away and  T.C. Wong, "Some Observations on the Clinical Aspects of Tetanus Neonatorum (Infantile Tetanus)," The Caduceus, 6, 3 (1927), p. 254. Wang, p. 253.  2 4  2 5  21  that a beginning, if nothing more, is being made towards the acquisition of some reliable knowledge of native diseases. 26  The key to such knowledge, in Manson's opinion, was accurate record-keeping, and with regard to this he took encouragement from recent events in the colony: A first and necessary step towards scientific legislation of all sorts is the accumulation of a body of trustworthy statistics.... The Registrar General's mortality returns, after many years of absolute uselessness, have recently assumed a shape that in time must result in the accumulation of important data on which sanitary legislation may be founded. 27  This was particularly evident in the consideration of infant mortality. Manson derided the incompetence which permitted infant deaths in the convents to be clustered under the term "convulsions" or "quinsy", whereby "the Government and the public were kept for years in complete ignorance of the fact that the infant population is more than decimated by [trismus nascentium, that is, tetanus]."  The division of the death returns into age  cohorts revealed, according to Manson, that 84.5% of babies born in the colony died within their first year, one third of those deaths being attributable to trismus nascentium, "a preventable disease." This, proclaimed Manson, was a "massacre of the innocents through insanitation."  28  Hong Kong's first reports on infant mortality, by Hartigan and Ayres, emphasized insanitary conditions and the dangers of certain Chinese practices, but did not pay any particular attention to medical practitioners.  Manson, in  highlighting "the innocents", foreshadowed the more specific identification of the Patrick Manson, "Beri-Beri in Hongkong," in Papers on the Subject of the Prevalence of Beri-Beri in Hongkong (Hong Kong, 1889), p. 5.  2 6  2 7  Ibid., pp. 5-6.  22  guilty which was to come when the issue next arose.  This distinction is  significant, for it sheds light on the nature and imperatives of policy-making in the colony. Although the convents continued to be monitored, the initial investigation of Chinese infant deaths prompted no government action.  Such action was not  likely to result from reports highlighting the living conditions of the Chinese, for similar reports had been ignored for years.  Were reform to come, it would be  piecemeal, not sweeping. Hence it demanded a target even more specific than cord dressing, a custom of the Chinese community as a whole. A decade later, such a target had been found.  28 Ibid., p. 6. 23  Chapter 2: Midwives and Mothers The Reports of Francis Clark, 1896-1902 The specific issue of infant mortality arose again in 1896, along with a new concern with maternal mortality. Francis Clark came to Hong Kong from England in 1895 at the age of thirty-one, to become the colony's inaugural Medical Officer of Health (MOH).  1  Almost immediately he became the leading voice of medical officialdom, his  arrival coinciding more or less with the departure of Dr. Ayres, who had dominated medical issues as Colonial Surgeon for some twenty years. Clark brought youthful vigour and, equally importantly, current metropolitan medical thinking, to his task.  This was  evident in his first report, that for 1895, in which he candidly made a number of sharp criticisms and policy recommendations. Clark devoted considerable attention to Chinese infant mortality, which he calculated to be 680 per 1,000 live births in 1895 (see Table 2) — a figure which he corrected in his report the following year to have been an even more alarming 759 per 1,000 (compared to the rate of 116 for the European civil community). In these reports, he included a footnote defining the infant mortality rate, which suggests that this concept, as a precise measure, was new to official medical discourse in the colony.  2  Clark followed his predecessors in emphasizing the role of convulsive diseases in infant mortality and the physical evidence of Chinese malpractice:  Born in 1864, Clark was educated at Durham University and St. Bartholomew's and Middlesex Hospitals. Prior to coming to Hong Kong he served as M O H and Superintendent of the Fever Hospital at Lowestaff. "Report of the Medical Officer of Health [MOH] for the Year 1895," HKSP 1896, p. 349; "Report of the M O H for the Year 1896," HKSP 1897, p. 357. 1  2  24  Table 2: Chinese infant mortality rate (EMR), Hong Kong 1895-1906  Year  IMR (infant deaths per 1,000 live births)  1895  759  1896  745  1897  593  1898  630  1899  848  1900  928  1901 1902  796  1903  832  1904  784  1905  872  1906  979  Sources: "Report of the Medical Officer of Health" in Hong Kong Sessional Papers for relevant years.  25  many of [these diseases]...are doubtless produced by the foul atmosphere which these infants breathe in the ill-ventilated dwellings of the poor, but I am of opinion that not a few are the direct result of the forms of treatment to which these infants are subjected by the native midwives and quack doctors. It appears to be a Chinese medical custom to cauterize the face or body of an infant, as a remedial measure in the treatment of flatulence or other trivial ailment, and I am sure that the sores and scars thus produced are one of the most fruitful causes of these convulsive deaths. 3  Here, then, was a new enemy of public health: the Chinese midwife. Clark conceded that "it is no easy matter to induce the Chinaman to accept the teaching and practices of Western medicine," but he insisted that "something must be done...promptly, to check the waste of human life."  To this end, he contended that "the Government should,  without delay, introduce a Bill for the registration and licensing of all Chinese midwives practising in the Colony, so that some control may be exercised over them."  4  The attack on midwives was strengthened by additional evidence of maternal mortality, an issue never before raised. Clark noted that there had been twelve registered deaths from puerperal fever in the colony in 1895, ten of them amongst a boat population of 6,000 at Kaulung.  This fact constituted "another strong argument in favour of the  necessity for some control being exercised over these women, who are at present able to carry about in their persons and their clothing so fatal a malady...and thus produce a death-rate equal to 1.3 per 1,000 in a flourishing suburb of the city."  5  Clark's recommendations were adopted by the Sanitary Board and forwarded to Governor William Robinson (served 1891-98), with the Board's opinion that the matter  3  4  5  "Report of the MOH...1895," p. 349. Ibid, pp. 349-50.  Ibid, p. 355. 26  of medical registration merited the government's early consideration. A year later, no action had been taken, and Clark reiterated his conclusions. This is somewhat surprising, 6  given the tough stance Robinson had taken during the plague epidemic of 1894 with respect to Chinese objections to house inspections and other government measures. The absence of decisive government intervention at this time likely reflected both the perceived lack of urgency of the situation (in contrast to an epidemic) and Robinson's increased awareness of the difficulties posed by Chinese opposition. The deliberations 7  which did take place at this time attracted the attention of neither the Hong Kong press nor the Colonial Office, and no correspondence was published.  Apparently in 1896  Clark's recommendations were referred to Ho Kai and Wei Yuk , the Chinese members of 8  the LegCo. They argued that it was inexpedient and premature to attempt to regulate Chinese midwives at that time, urging the government instead to establish a local training school for midwives. The government took the view that it was impossible to regulate Chinese doctors due to their lack of recognizable qualifications, and that this difficulty would be even more acute in the case of Chinese midwives. Thus Clark was rebuffed.  9  But in 1897 the question of Hong Kong's infant mortality rate was raised among officials at the Colonial Office. Upon receipt of the Registrar General's report for 1896,  "Report of the M O H . . . 1896," pp. 355, 357. Sinn, Power and Charity, pp. 167-68. The latter point is borne out by the plague epidemic of 1896, when Robinson permitted Chinese sick and dead to be removed to Canton, an activity which he adamantly had opposed in 1894. Wei Yuk had just been appointed to the LegCo in 1896. A comprador to the Chartered Mercantile Bank of India, London and China, he, like Ho Kai, had been educated in Britain, served on the Sanitary Board, and was later knighted (in 1919). Wei Yuk also was a Tung Wah Hospital committee member at one time. F.H. May to Rt. Hon. Alfred Lyttleton, 21 July 1904, C0129/323, p. 241.  6  7  8  9  27  it was noted with some concern that the rate in Hong Kong appeared to be far higher than in the Straits Settlements. Nevertheless, it was recognized that "the Registrar General allows and it is perfectly evident that the figures are utterly unreliable." Thus it was resolved merely to monitor the situation. In 1900 home officials also registered their concern regarding the colony's infant mortality, but, once again, they took no action.  10  The problem of infant mortality, however, did not disappear, despite the attempt of both the Hong Kong government and the Colonial Office to soft-pedal the issue. Less than a year later, Clark again was at the fore, this time brandishing a statistic likely to spur even the most timorous official: he calculated that, in 1900, the Chinese infant mortality rate had reached the astonishing level of 928.  11  Clark explicitly blamed Chinese  mothers and fathers for this state of affairs, as "such an enormous mortality can only be the result of the gravest neglect on the part of the parents."  Indeed, he specifically  invoked the spectre of infanticide, a heinous anomaly in a British colony: 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. 12  Clark continued to press for the registration of Chinese midwives. He also sought to introduce a bill amending the Births and Deaths Registration Ordinance of 1896 so as to permit the M O H to order a post-mortem in any case in which the death was not certified. "Strong opposition from the Chinese" — presumably the Chinese members of the LegCo -  Minutes appended, Robinson to Chamberlain, 19 May 1897, C0129/275; minutes appended, Gasgoigne to Chamberlain, 30 May 1900, C0129/299, p. 321. "Report of the M O H for the Year 1900," HKSP 1901, p. 401. 10  11  28  - caused this bill to be dropped. Clark also recommended that midwives be paid a small sum for every birth they reported, and that female health visitors be engaged to verify such registrations.  In advocating such female visitors, Clark alluded to an unspecified  "recent lamentable accident" which reflected the Chinese fear of uniformed inspectors. A Sanitary Board committee, on the other hand, recommended a payment of fifty cents to either parent in the event of registration within one month of the birth.  13  Reaction to Clark's report was mixed. An editorial in the Hong Kong Daily Press referred to "the adverse opinion held of it [the report] in the Colonial Secretary's Office," while the newspaper itself hailed it as "a fearless, unexaggerated,  dispassionate  and...impartial record of unremitting honest effort," lauding Clark's "unselfish and devoted services."  Furthermore, the apparent integrity of the report permitted the  newspaper's generalization about the Hobbesian state of Chinese life in Hong Kong, insofar as Clark's figures afforded: 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 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. 14  12  Ibid. Emphasis added.  Report of the Committee Appointed...to Inquire into the Causes of Chinese Infantile Mortality in the Colony (Hong Kong, 1903), p. 1; Hong Kong Daily Press, 3 May, 17 13  May and 14 June 1901. Hong Kong Daily Press, 3 June 1901. The Colonial Secretary referred to was the senior civil servant in Hong Kong, not the Secretary of State for the Colonies. 14  29 r  Paradoxically, though the truly incredible nature of the statistics came to be appreciated by officials in both London and Hong Kong (see below), the judgements rendered on the basis of those figures were not called into question.  The Committee of 1903 Again the issue died down temporarily.  In 1903, however, both the Hong Kong  and home governments took action. In a despatch of 17 April, 1903, Governor Henry Blake (served 1898-1903) informed Secretary of State for the Colonies Joseph Chamberlain (served 1895-1905) that: I have approved of an attempt being made to train, in a practical manner, Chinese women as Midwives. It is proposed that three women should be trained each year and if at the end of a 12 months' course they have acquired a competent knowledge of the subject, Certificates as trained Midwives will be granted to them. As it would be most undesirable to allow these women while probationers to live in Chinese houses, on account of their liability to contract infection, arrangements have been made for them to lodge and board at the Church Missionary House. 15  Thus, "as this experiment may if successful prove a great boon to the Chinese Community," Blake requested approval for the allocation of $528 for the scheme. This was approved on 3 June, but, in the meantime, the Colonial Office had received a second mailing from Blake, this one enclosing Clark's latest report.  This  proved to be the straw that broke the camel's back, for on 5 June Chamberlain requested that Blake convene an official inquiry into infant mortality in the colony.  16  Thus Blake  appointed a six-man committee, which included Ho Kai, Principal Civil Medical Officer  Blake to Chamberlain, 17 April, 1903, C0129/317, pp. 72-73. Minutes and draft despatch attached, Blake to Chamberlain, 22 April 1903, C0129/317, pp. 113-16. 1 5  1 6  30  (PCMO)  J . M . Atkinson,  and  Bacteriologist, William Hunter.  17  the  recently  appointed  inaugural  Government  This group focused, like previous inquiries, on the  convents. A new source of evidence was a large number of post-mortems conducted b y Hunter.  The committee's findings substantially echoed those of years past.  Its first  recommendation advocated "the better education of the Chinese, especially the lower classes, to convince them of the necessity of proper sanitary procedure both personal...as well as in their own households."  More specifically, the group envisaged the  establishment of a maternity charity so as to enable the poor to receive medical attendance in their homes.  With regard to the registration of births, the committee  advocated a bonus of $2 — fifty cents not providing adequate incentive — to be paid to any mother, midwife, or person present at a birth who registered it within a month. The report also endorsed Clark's earlier proposal to appoint female health visitors in order to confirm the accuracy of registrations.  Finally, the convents should be compelled to  register all admissions, and foster mothers used by the convents should be forced to undergo medical examination. midwives was avoided.  Once again, the sensitive subject of regulating native  18  It does not appear that any of the 1903 committee's recommendations were put in place directly. Although the scheme for government midwives which took shape in Atkinson was educated in London and spent eight years as Resident Medical Officer of St. Mary Abbott's Infirmary, Kensington prior to coming to Hong Kong in 1887 to serve as Superintendent of the Government Civil Hospital. He subsequently was Acting Colonial Surgeon prior to becoming, in 1897, the PCMO and president of the Sanitary Board. Hunter, born in 1875, was a graduate of Aberdeen, with further studies in London/ 1 7  1 8  Report of the Committee, pp. 4-5.  31  coming years did conform to the committee's advocacy of a maternity charity and health visitors, as we have seen the plan's inception preceded the inquiry, and indeed such a program had been suggested by Ho Kai and Wei Yuk back in 1896. As was the case with all previous investigations, once the committee submitted their report, the issue of infant mortality receded from public interest. The Colonial Office, however, was surprised that the committee (which, after all, had been established at London's request) had not recommended the registration of Chinese midwives.  Thus, in 1904, F.H. May, who was then administering the  government, was forced to explain the colony's stance on the issue.  Registering native  midwives was out of the question, for "registration implies recognition and to recognise ignorant women as midwives would be to countenance mal-praxis." On the other hand, prohibition was also unfeasible until sufficient numbers of Western trained midwives provided an alternative for Chinese mothers.  As was customary, the Colonial Office  deferred to the opinion of the local official, and, indeed, when the issue next was raised, in 1910, the initiative came from Hong Kong.  19  The Problem of Birth Registration At this point we must consider a development parallel to the investigations of infant mortality in the 1890s and 1900s: the increasing recognition by colonial officials that counting babies born was as important as counting those that died. An ordinance in 1872 made the registration of births compulsory in Hong Kong. Either parent or an occupant of the house in which the birth took place could register it 1 9  May to Rt. Hon. Alfred Lyttleton, 21 July 1904, C0129/323, p. 242. 32  free of charge within thirty days. After a month, registration cost $1, while after two months the person responsible was liable to be fined up to $25. Registration was in the hands of the police, with district registers at police stations. In time, it became apparent that this legislation was a dead letter, as the bulk of the Chinese population either ignored it or were ignorant of it, and prosecutions for failing to register births were few and far between.  20  The defects of Hong Kong's birth registration were noted by Registrar General James Stewart Lockhart in his report for 1891. He observed that the official Chinese birth rate of 7.13 per 1,000 (see Table 3) was "abnormally low" and posited that this reflected the fact that "the conditions of life...among the Chinese in Hongkong, are peculiar": many residents maintained their families on the mainland, and those women resident in the colony preferred to give birth in their native place.  Furthermore, still  births had never been recorded, and a great number of births simply were not registered. The following year, however, Lockhart again considered the need for more accurate vital statistics and concluded that the Chinese "would offer strong opposition" to any changes which "would necessitate anything in the nature of an invasion of the privacy of Chinese domestic life, on which they lay so much stress." Were that the case, reform "so far from succeeding in accomplishing its object, would almost of a certainty defeat its own ends."  21  The mid-1890s brought two very different attempts to rectify the situation, one legislative, the other creative. The Births and Deaths Registration Ordinance of 1896  2 0  The Ordinances of the Legislative Council of the Colony of Hongkong, ed. A . J . Leach.  2 vol. (Hong Kong, 1892), 1:428-36. 33  Table 3: Chinese birth counts and birth rates, Hong Kong 1890-1920 Year  Chinese Births: Registered  1890 1891 1892 1893 1894 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920  1,450 1,529 1,660 1,575 1,250 1,195 978 1,125 963 852 678 848 966 749 942 988 1,028 1.124 — 1,202 1,233 1,406 2,328 3,392 2,668 2,332 2,361 2,119 2,022 1,900 2,113  Chinese Births: "Corrected"  Birth Rate: Registered  Birth Rate: "Corrected"  7.72 7.13 7.50 6.91 5.31 5.03 4.31 4.79  — — — — — — 1,582 1,605 1,501 — — — -1,514 1,728 1,904 2,803  2.43 — 2.7 3.35 3.62  5.3 4.39 4.9 4.79 5.26 8.06  2,588 2,315 2,601 3,549 4,758 3,968 3,701 3,575 3,005 3,435 3,386 4,166  3.7 3.7 3.9 6.5 8.9 6.8 5.7 5.8 4.9 3.6 3.9 3.96  7.0 6.1 6.3 9.0 11.7 9.3 8.4 7.9 6.9 5.6 6.3 7.23  —  2.73 3.02  Sources: Medical reports and Registrar General's reports in Hong Kong Sessional Papers and Administrative Reports,relevant years.  34  6.7 6.3 6.2  modified the existing law. A birth could be registered free of charge within forty-two days, after which, for a delay of up to a year, a fee of $1 applied. After a year, a fee of $5 was to be charged for each year elapsed. Birth registers were henceforth to be kept in both English and Chinese. These changes evidently did little to increase the inclination of the Chinese to register, birth totals remaining stubbornly low and even declining through the turn of the century, and prosecutions under the ordinance again were rare. Thus it is not surprising that, beginning with the figures for 1897, officials annually a "corrected" birth count, which added the total number of dead infants in the convents and found on the streets to the number of registered births.  22  Meanwhile, commentators continued to  seek other explanations for the low Chinese birth rate, such as the preponderance of men over women, and the high proportion of prostitutes among Chinese women.  23  The implications of such statistical gymnastics did not go unnoticed.  Large  numbers of unregistered births relative to registered (or otherwise counted) infant deaths would obviously skew the infant mortality rate sharply upwards. As early as 1897 this had been pointed out within the Colonial Office, one comment reading: "These figures are of course wrong."  Nevertheless, within the colony there remained faith in the  government's numbers. Thus, when Clark alleged the Chinese infant mortality rate to be 928, Sanitary Board member E. Osborne observed that were this not from an official source, it would "hardly be credible." Such faith was shaken the following year, however, "Registrar General's Report for the Year 1891," HKSP 1892, pp. 232-33; "Registrar General's Report for the Year 1892," HKSP 1893, p. 277. Such a calculation was first attempted in the report for 1893, then again for 1897 and routinely thereafter until 1920. "Acting Registrar General's Report for 1893" HKSP 1894, pp. 98-99. 2 1  2 2  35  when there was no published Chinese infant mortality rate for 1901: even with "corrections" there were fewer births than infant deaths, forcing Clark to acknowledge that "either...a very large number of births remains unregistered or...a large number of infants are brought into the Colony from the mainland and die here."  24  Thus, within the colony, there developed a certain scepticism about the magnitude of infant mortality. In contrast to the previous belief in a rate of 928, when the figure for 1906 was calculated to be 979, the government, though dutifully recording it, noted that it "prove[d] conclusively that a large proportion of the Chinese births must escape registration."  In subsequent years, such pronouncements on official vital statistics  became ever more candid. The medical report for 1919 stated: "It has formerly been the custom to call the higher birth rate a corrected birth rate. This is however not a suitable term. The actual birth rate is unknown." Later the official reports assumed a peculiar form, as the account for 1932 indicates: If the figures for the Chinese births registered represented the total births, which they do not, the infantile mortality rate...would be 525.28 as compared with 617.42 which was the equally incorrect rate for the previous year. Allowing that only one third of the births are registered this would still mean a very high infantile mortality figure. Here, perhaps, we can detect the vestiges of the late nineteenth century faith in statistics, as Hong Kong officials continued to tabulate and publish birth and infant mortality figures  "Report of the M O H ...1895," HKSP 1896, p. 348. Minute appended, Robinson to Chamberlain, 19 May 1897, C0129/275; Hong Kong Daily Press, 3 May 1901; "Report of the M O H for the Year 1901," HKSP 1902, p. 528. 2 3  2 4  36  which they knew were absurdly wrong, in the hope that, eventually, the truth would be revealed.  25  The failure o f the Chinese to comply with regulations pertaining to the routine collection o f vital statistics  reinforced the British impression that their subjects were  unruly or irrational. Officials were correct in identifying the mobility o f the population as a factor, and also later acknowledged that, due to custom, the Chinese would not be inclined to register a child until it had survived its first month. O f course, it was precisely at that time that the disincentive o f fines commenced.  The initial policy o f associating  registration with the police could hardly have made the process appealing to working class Chinese. Although some steps were taken to make registration more convenient, officials were correct in asserting that results could only be attained with certainty were the colonial state to attempt to extend its authority into the home. One such attempt, the creation o f a corps o f qualified midwives, forms the subject o f the next chapter.  25  General Report of the P C M O and the M O H . . . 1906," HKSP 1907, p. 395; "Joint Report of the P C M O and the M O H , " Administrative Reports for the Year 1919, p. M 1 3 "Medical and Sanitary Report for the Year 1932," Administration Reports for the Year 1932, p. M 3 0 .  37  Chapter 3: Replacement and Regulation Early Training Efforts  In 1892, Helen Stevens, matron of the London Missionary Society's Nethersole Hospital, first proposed the "training of Native Christian Women as Nurses, both for Hospital, and to go among the poor women acting as Midwives." At the time, however, she conceded that such an initiative was impossible due to a lack of both suitable facilities and recruits, "as among women with any degree of education or intelligence waiting upon the Sick and Suffering is looked upon as degrading work."  1  Nevertheless, Stevens  perceived that change was inevitable, if only because existing conditions were so dire: I can see a great field of labour opening up for Native Christian Women, trained as far as will be possible with our limited space, and the prejudice of the people. The ignorance of the native women who offer assistance in such cases is incredible, and the poor women suffer terribly....I doubt not that somewhere there are women who will come to the front as soon as we are ready to receive them. 2  This prediction proved correct, as the following year Stevens took on her first probationer, A Kwai, a young woman who had been educated, and herself had taught, in mission schools. At that time Stevens also reported having a "little room" in the hospital ready for obstetrical purposes.  From this modest beginning she dared to envision "the  crowning glory of a Womans [sic] Hospital and a Nursesf'] Home with native nurses coming and going on errands of mercy."  3  Helen Stevens, "Report 1892. Hospital Work in Hong Kong," Council of World Missions Papers, School of Oriental and African Studies (London) Library, South China Reports [henceforth CWM/SCR], Box 2, Folder 2 [henceforth 2/2], pp. 2,4. 1  2  3  Ibid., pp. 3-4.  Stevens, "Hong Kong. Report of Hospital Work 1893," CWM/SCR, 2/2, pp. 3-4, 6. 38  Although by 1896 Stevens had accepted two more trainees, she complained that "the midwifery threatens to increase too rapidly...for not yet have I been able to find a woman...of suitable age and education to train." Nevertheless, at this time she hoped that she might take A Kwai back to England with her for specialized obstetric training (this was not to be).  Stevens continued to handle a number of midwifery cases herself,  including some brought to her from the mainland. By the turn of the century, fund-raising had commenced for a separate maternity contributions came in slowly.  4  bungalow at the Nethersole,  though  While the initial training efforts by the L M S were  noteworthy innovations, and trainees from the mission hospitals remained prominent in the colony for years to come, the creation of the government midwives to provide maternity care free of charge to the poor was a signal event in the evolution of Hong Kong's maternal and infant welfare services. The Government Midwives  Hong Kong's first "lady doctor", twenty-seven year old Alice Sibree, arrived in 1904. Her father was an L M S missionary in Africa, and she came to the colony as a medical missionary, taking charge of the LMS-operated Alice Memorial Maternity Hospital.  Sibree had studied at the London School of Medicine for Women, with  additional specialized training in obstetrics and gynecology at the renowned Rotunda  Stevens, "London Mission. Hong Kong. Report of Hospital Work 1896," C W M / S C R , 2/3, pp. 3-5; idem., untitled report dated 26 January 1895, CWM/SCR, 2/3, p. 9; idem., "South China: Hongkong. Report on Nursing. 1898," CWM/SCR, 3/2, p. 7. The L M S was handicapped in this particular fund-raising by the fact that it "could not sanction a charity ball, private theatricals, &c." Idem., "South China. Hongkong. Report on Nursing, 1901," CWM/SCR, 3/2, p. 7. 4  39  Lying-in Hospital.  In addition to her hospital duties, which included midwifery  instruction, Sibree supervised the government midwives, the first two of whom were engaged in August, 1905. Through the end of the year they had attended a mere twentytwo confinements. The following year, the number of midwives was increased to four, who attended 188 confinements, while in 1907 the work of six midwives totalled 578 confinements. The attempt was made to "exercise a general supervision over the infants, during the first year of life," by offering mothers advice on feeding and general care. The rapid increase in the popularity of the government midwives continued throughout the program's first decade, culminating in 1913, when nine midwives attended  2,329  confinements (see Table 4). Alice Sibree, meanwhile, had taken home leave in 1909, and subsequently resigned to marry. She returned to Hong Kong, however, and in 1913 (now as Dr. Hickling) she took a supervisory position, under government auspices, at the Chinese-operated Wanchai maternity home. government supervisor of midwives.  In 1916 she once again became the  5  Government austerity during the First World War would appear to be the cause of the marked decline of the midwifery program beginning in 1915.  The number of  government midwives was halved, but the impact on the number of confinements attended was even greater: they plummeted to a quarter of their former level (from 2,157 in 1914 to 552 a year later). Although the staff was increased in the interwar period and For a summary of Alice Sibree's career, see Susanna Hoe, The Private Life of Old Hong Kong (Hong Kong, 1991), pp. 166-67. Figures for the government midwives are from: "General Report of the PCMO and the M O H , " HKSP 1906, p. 268; "General Report of the P C M O and the M O H , " HKSP 1907, p. 401; "General Report of the P C M O and the 5  40  Table 4: The work of government midwives, Hong Kong 1905-1939  Year 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939  Number of Registered Midwives ~ ~  •  — — — — — — — — — — —  Number of Government Midwives 2 2-4 3-6 — 8 9 ~  ~  10 9 9 4 5 5 5 5 7 7 7 7 7 7  ~  ~  ~  -— — ~  7 7 7 7 7 7 — 15 15 15 16 16 16  ~  183 161 165 211 248 287 283 317 — 395 712 765  Labours Attended By Government Midwives 22 188 578 1,043 1,381 1,799 2,076 1,937 2,329 2,157 552 488 553 625 550 628 688 714 837 869 856 — 952 1,115 1,194 1,248 1,420 1,296 ~  1,823 2,097 2,212 2,528 2,862 3,666  Sources: Annual medical reports in Hong Kong Sessional Papers and  Administration Reports, relevant years. 41  the caseload grew each year, the number of confinements attended did not again reach the 1913 level until 1937. Over this longer period, the relative decline of the government 6  midwives likely reflects the development of other maternity services for the working classes in the colony, notably through Chinese hospitals. Neither official nor missionary accounts shed light on the reception of trained midwives by Chinese households, save for reports of the increasing numbers of confinements attended, and such sources were unlikely to publicize the apathy or resistance which they may have encountered.  Working in that famous object of rural  reform, Dingxian, in Hebei in the 1930s, Dr. C.C. Chen faced numerous problems in attempting to replace or retrain traditional midwives. He recalled: The villagers would not accept an outsider of only twenty-five years of age as a trustworthy person....So we attempted to retrain the old traditional midwives...[They] resented the young, unmarried woman we selected as the trainer....they regarded her as an inexperienced upstart and demonstrated a good deal of jealousy....Eventually, rather than retraining the old midwives, we selected and trained one of their young relatives, who, as a member of their own family, would receive the older woman's support in her new role....We thought that at last we had made an encouraging start. After a time, however, we found that this was impractical; the young woman was usually too busy to fulfill the responsibilities of this extra and irregular work. 7  Chen also reported that mothers-in-law intervened to prevent young wives from giving birth at clinics under the supervision of trained midwives. British experience, as well, 8  M O H , " HKSP 1908, pp. 409-410; "Joint Report of the PCMO and M O H , " Administrative Reports For the Year 1913 , p. L28.  6 "Joint Report of the P C M O and the M O H , " Administrative Reports for the Year 1915 , p. M23; "Report of the Medical Department for the Year 1937," Administration Reports for the Year 1937 , p. M40. 7  C.C. Chen, Medicine in Rural China (Berkeley, 1989), p. 91.  8  Ibid, p. 90.  42  suggests that the transition from traditional to trained birth professionals was neither smooth nor inevitable from the point of view of expectant mothers.  There, women  continued to employ traditional midwives after the advent of certification in 1903, "not only because they were cheaper, but because they lent utensils, helped with the. washing, fed the husband and cared for the other children." The sense of community suggested here was also indicated, more crudely, by neighbours jeering at the health visitors who called on new mothers, "shouting 'bribery' if the mother let the lady in."  9  The Midwives Ordinance of 1910  When legislation regulating midwifery in the colony was introduced in 1910, neither its timing nor its content reflected the calls for regulation of the previous fifteen years.  Ordinance No. 22 of 1910 copied the British Midwives Act of 1902, thus  establishing a Midwives Board in Hong Kong to conduct examinations based on qualifications again transposed from Britain. The ordinance was not, however, a response to Francis Clark's long-standing complaints about native midwives. Indeed, it hardly affected them: The Ordinance does not apply to Chinese unless they use the name midwife in English, or any name[,] title or description implying that — [they] are certified under this Ordinance....This section was inserted at the request of the Chinese members [of the LegCo] who contended that the measure is premature in so far as Chinese midwives [are] concerned, but they protest that with a better knowledge of modern or European midwifery the exemption now granted to Chinese may hereafter be removed. 10  F.B. Smith, The People's Health 1830-1910 (London, 1979), pp. 46, 117. "Attorney General's Report on Ordinance No. 22 of 1910," enclosed in F.H. May to Earl of Crewe, 10 September 1910, C0129/368, p. 543. 9  10  43  A woman found guilty of misrepresenting herself in that manner would be liable to a fine of up to fifty dollars, while a non-Chinese woman "who habitually and for gain attends women in child-birth otherwise than under the direction of a medical practitioner unless she is certified" faced a maximum fine of one hundred dollars.  11  F.H. May, then administering the government, further explained the ordinance's impetus and intent to the Colonial Office: This legislation has been prompted by a recent case which formed the subject of a criminal prosecution, in which a Chinese woman without any training practised as a midwife under the English name of her Australian husband, and grossly mismanaged a case in which a Portuguese woman was confined. It is impossible at the present time to apply...the Ordinance to native midwives who practise among the native population only. 12  The exemption of Chinese midwives was inserted over the complaints of British members of the LegCo, who declared the final ordinance to be toothless.  May told the LegCo  himself that "we don't wish to stop the Chinese midwives practising among the Chinese."  13  It is not surprising to find that the venerable Ho Kai was behind the clause  which exempted Chinese practitioners, given his stance in 1896. In response to the objections raised, Ho Kai replied that the clause had been introduced by the "unanimous recommendation of the leading Chinese" who had met with the Registrar General to consider the bill. He reminded opponents of the exemption that: there are Chinese resident in this Colony numbering 400,000... A great number of these are married ladies...most of them will be having children "No. 22 of 1910: An Ordinance to secure the better training of midwives and to regulate their practice," in The Ordinances of Hongkong 1844-1923, ed. Arthur Dyer Ball, 6 vols. (Hong Kong, 1924), 4:1821. May to Earl of Crewe, 10 September 1910, C0129/368, p. 541. 11  12 13  South China Morning Post, 2 September 1910; Hong Kong Daily Press, 2 September  1910. 44  and the chances are that the number of midwives who are qualified according to Western methods are only about fourteen in number. They are quite inadequate to meet the demand...and until we have a larger number of midwives trained in Western methods it is impossible to make a sweeping Ordinance of this kind. Ho Kai went on to point out, with Wei Yuk's backing, that whereas native midwives charged fifty cents to a dollar, Western midwives' fees ranged from $5 to $15, and were the Chinese forced to pay such fees "the majority would have to go without any assistance whatsoever, and that would be worse than the present circumstances."  14  It is curious that, as with the original 1884 Medical Registration Ordinance, the 1910 legislation was inspired in part by the government's desire to protect Portuguese residents.  15  There also appears to have been confusion about the case which prompted  the ordinance. May's story concerned a Chinese woman named Lam practising under the name Lamb. Yet the court case to which May referred was rather different, according to press accounts. In January, 1910, a Mrs. Susan Lobina Lamb of the American Board Mission was charged with violating the 1884 ordinance by practising without being registered. Specifically, she had attended the confinement of a Portuguese woman who subsequently died. Lamb was an American identified as being of Anglo-Saxon descent. She claimed exemption from the ordinance on account of having married a Chinese, and thus taken his nationality. That is, she claimed to be a Chinese medical practitioner. This  14  Hong Kong Daily Press, 2 September, 1910.  Regarding the ordinance of 1884, Governor George Bowen informed the Secretary of State, Lord Derby, that "a measure of this nature is more required here than in more settled countries, for, in this floating and heterogeneous community, the great number of passing strangers, and the ignorant classes of the resident Portuguese population, require special protection from unqualified medical practitioners." Bowen to Earl of Derby, 25 April 1884, C0129/215, p. 582. 15  45  case, then, appears to be precisely opposite to the alleged events which spurred the drafting and passage of the midwives ordinance: not a matter of a Chinese representing herself as a Western practitioner, but one of a Westerner claiming to be a Chinese practitioner.  16  Short of gaining such notoriety individual birth professionals scarcely emerge from the records.  Save for the sweeping criticisms of officials and missionaries, we know  nothing about Hong Kong's traditional midwives, not even their number.  17  Although  trained midwives, too, remained largely anonymous as individuals, it is possible to sketch out a few generalizations pertaining to the careers open to them. Only a handful of those midwives trained in Hong Kong went on to work in government hospitals or dispensaries. During the 1920s, the number of government midwives remained constant at seven, whereas the total of registered midwives reached a high of 183.  In 1935, while the  government had doubled its staff of midwives, registered midwives numbered 317. Some licensed midwives gained employment in Hong Kong's Chinese hospitals, although the majority of them worked in private practice, either on their own or in association with various private lying-in facilities. The extent of this private work is apparent when one compares the total number of confinements attended by government midwives to the total number of births reported by registered midwives. In 1922, whereas the government midwives attended 714 confinements, all registered midwives reported a total of 5,304  16  Hong Kong Daily Press, 20 January 1910.  A n estimate was made by May in 1904, who reported to the Colonial Office: "As far as can be ascertained there are at present 33 midwives practising in Hong Kong, Of these 5 use the Western method having been trained...by local Medical Practitioners." May to Lyttleton, 21 July, 1904, C0129/323, p. 242. 17  46  births. births.  In 1929, the figures were 1,194 confinements compared to 11,781 reported 18  Obstetrical nursing was known to be "the branch which brings the quickest  remuneration", via wealthy clients, and, indeed, by the early 1930s, there were fears that Hong Kong's Chinese nurses were taking up such lucrative employment to the exclusion of work among the needy.  19  Job opportunities outside the colony beckoned Hong Kong's trained nurses and midwives from an early date. In 1902 the Nethersole's matron bemoaned the loss of nurses to higher-paying positions in Penang. In 1912, having qualified before the new Midwives Board the previous year, a Hong Kong woman gained an appointment in the Federated Malay States as a district midwife among the Chinese community of Kuala Lumpur. Twenty years later, it was reported that the city was home to a "little colony" of Nethersole graduates performing infant and maternal welfare work.  Hong Kong  midwives also found service in Singapore and elsewhere in the Straits Settlements.  20  Who Were the Mothers? Information on actual patients is difficult to come by, save for a number of clinical case histories.  Boatwomen, from Hong Kong's substantial floating population, were  Due to still births, the number of births registered by the government midwives would always be lower than confinements attended. The total births reported by registered midwives includes the work of the government midwives. L . K . Rayner, "Report. 1914," CWM/SCR, 5/2; A. Sydenham, letter dated 1 September 1925, C W M / S C R , 6/2, p. 2; idem., "Report of Work During the Year 1927," CWM/SCR, 6/4, p. 3; A . Hughes, "Nethersole Hospital Report. Nursing Department. 1931," CWM/SCR, 6/8. H.D. Stevens, "South China. Hongkong. Nursing. 1902," CWM/SCR, 3/2, p. 3; "Report of the Alice Memorial and Affiliated Hospitals, Hongkong... For the Year 1912," CWM/SCR, 4/8, p. 17; A. Hughes, "Nethersole Hospital. Nursing Department. 1932," 18  19  2 0  47  identified as a significant constituency for maternal health services in the 1900s, though they nevertheless were held to be "a class by themselves and very difficult to reach."  21  Referring to "the poor boatwomen, whose homes are in the boats," a 1926 editorial in The Caduceus noted that "we are not surprised...that [pjrolapse of the uterus is seen most frequently in boatwomen[;] presumably straining at an oar soon after pregnancy...must be the cause."  22  An account of medical work among the floating population by a female doctor appeared in the L M S Chronicle in 1914: A curiously thrilling experience in the earlier days of one's practice is a night visit among the boat population....The doctor is rowed out in a small boat to the junk where her help is needed. Hands stretched out in the darkness haul her on board and lower her into the hold, where, crawling on hands and knees into the tiny cabin, she finds her patient lying on the floor. So small are the quarters, there is only room for herself, her nurse, and the inevitable wooden tub of water, the roof being so low that she cannot even kneel upright. In this cramped posture, by the light of a few wax candles, [obstetric] operations that would be difficult in a wellequipped hospital have sometimes to be performed. 23  Coolies constituted another large and undifferentiated class of patients.  In 1926 The  Caduceus described: the poor coolie women, whose lives at all times are unenviable, but when a woman of this class is in labour or the puerperium, her condition is most pathetic indeed. Too poor to buy for herself the barest necessities of life,  CWM/SCR, 6/9, p. 4; L.K. Rayner, "Alice Memorial and Affiliated Hospitals...Report. The Nursing Department. [1924]," CWM/SCR, 6/1. "Report of the Alice Memo rial... and Alice Memorial Maternity Hospitals...For the Year 1905," in Hong Kong Charitable Institutions, 1903-1907 (Hong Kong, n.d.); Jane Stewart, "Report [dated 26 January 1910]," CWM/SCR, 4/4. "The Training of Students in Midwifery," The Caduceus, 5, 3 (1926), p. 254. Eleanor W. Mitchell, "Infant Life Saving," The Chronicle, n.s. X X I I (1914), pp. 27-28. 2 1  2 2  2 3  48  she lies neglected in a home in which the only place she can claim to be her own is her hard bed of planks. 24  Dr. Eleanor Mitchell described a call on such a woman in a 1914 account published for a home readership: the patient is sought in a native lodging-house, all the rooms of which are crowded with half-dressed Chinese coolies. Amid this confusion and babel of tongues the woman is found in a cubicle only partly curtained off from the main room, alone with her infant in this crowd of men. 25  Nevertheless, conditions in the city still were considered preferable to those in nearby mainland rural areas, where traditional midwives and superstitions prevailed.  26  Although they date from a later period, the profiles of women who attended the Hong Kong Eugenics League, founded in 1937, provide a valuable indication of the experiences of Chinese mothers.  In 1937 the League advised 217 mothers, with an  average age of thirty years and an average of 5.3 pregnancies, nearly one-third of which had ended in miscarriage, still birth, or the child's death. In 1938, 291 mothers averaged thirty-one years of age and 5.7 pregnancies.  The following year the averages for 574  mothers seen were 30.9 years and 6 pregnancies. The average family income was $46 a month in 1939, but for eighty-five percent of the patients this figure was $22 or less.  27  Individual cases prove more illuminating: Case 1: 44 years old; married 27 years; 15 pregnancies and 2 miscarriages; 6 children living; husband a sailor, monthly income $15.  2 4  2 5  2 6  "The Training of Students in Midwifery," p. 254. Mitchell, p. 28. Ibid.  "Annual Medical Report for the Year 1938," Administration Reports for the Year 1938, p. M33; "Annual Medical Report for the Year 1939," Administration Reports for the Year 1939, p. M34.  2 7  49  Case 2: 31 years old; married 14 years; 9 pregnancies, of which 3 miscarried; 5 children living; after eighth pregnancy was provided with sponge and foam; husband a casual labourer, monthly income $7. Case 3: 31 years old; married 11 years; 10 pregnancies; 5 children living. Case 4: 34 years old; married 15 years; 8 pregnancies, 7 live births, one child living. Case 5: 37 years old; married 19 years; 11 pregnancies, including 4 miscarriages; 6 children living; husband a coolie, monthly income $5. Case 6: 44 years old; married 25 years; 14 pregnancies, including 3 miscarriages; 7 living children, one of whom was given away; Is desperately anxious to avoid further pregnancies. Husband is unemployed, and has been taking Chinese pills to render himself sterile. Patient was examined and diagnosed as...early pregnancy, and advised to return after one month for confirmation. Unfortunately she did not return, until two months later but informed us that she had succeeded in aborting herself after taking some concoction of wild flowers boiled with rusty nails, putrefied eggs and urine....Her general health was very poor and she was referred to hospital for general treatment. 28  Despite the near doubling of the League's attendance in its first three years, progress was held to be "very slow partly because of the lack of organization of the poorer class women, which makes it extremely difficult to make contact with those most in need."  29  Initially, infant and maternal welfare services neither targeted nor attracted better-off Chinese. Such patients were considered, like the most impoverished, to be "a class very  2 8  "Hong Kong Eugenics League. Annual Report 1939-1940," Administration Reports for  the Year 1939, p. M l 16. Ibid., p. M l 14.  2 9  50  difficult to reach."  30  One contributing factor may have been the likelihood that well-to-do  families had long-standing relationships with one or more Chinese birth professionals. The fact that the legislation of 1910 blithely ignored Chinese midwives openly working by traditional methods reflected the government's realization that it could not eliminate such midwives by fiat. The state elected instead to await the emergence of an alternative body of trained women, and indeed, nearly three decades passed before it introduced legislation affecting Chinese midwives. A notification of 1930 amended the original regulations, specifying both the approved curriculum for midwifery instruction and a list of approved schools in the colony. The government identified six such schools, four of which were Chinese hospitals (Tsan Yuk, Kwong Wah, Tung Wah and Tung Wah Eastern).  31  Notably, while Chinese hospitals continued to be permitted to give patients a  choice between Chinese and Western medical treatment, this did not apply to "maternity benefits and infant welfare" which were to be conducted "by Western methods only."  32  As of January, 1937, it became illegal for wan p 'os, or handy women, to practise midwifery "habitually and for gain". Nevertheless, the ban was not total, as those women who had so practised in the colony for two or more years previously, and who enroled with the government, were exempt. The deadline subsequently was extended to the end  R . M . Gibson, "Alice Memorial & Affiliated Hospitals Hongkong. Report for 1916," C W M / S C R , 5/4, p. 2. "Government Notification No. 653 of 24th October 1930," The Ordinances of Hong Kong for the Year 1930, pp. 249-53. "Report of the Secretary for Chinese Affairs... 1932," Administration Reports for the 3 0  3 1  3 2  Year 1932, p. C15. 51  of 193 7.  33  Via this concession, 111 such women were registered in 1937, while the  marked swelling of the midwives' roll in 1938, from 395 to 712, suggests that as many as 259 wan p'os were admitted in that year.  34  It appears that the registration process did  not include a training component (in rudimentary hygiene, for example), as was the case in some mainland cities and the Malay States, nor did the notifications make explicit the punishment for violators. The government was confident that its gradual policy, which operated by redefinition as much as proscription, would have the desired effect: " B y degrees this type of untrained midwife will disappear in the same way as the 'Sairey Gamps' in the United Kingdom."  3 3  35  "Government Notification No. 863 of 1936," The Ordinances of Hong Kong for the  Year 1936; "Government Notification No. 911," The Ordinances of Hong Kong for the Year 1937.  "Report of the Medical Department for the Year 1937," Administrative Reports for the Year 1937, p. M41. In 1938, 58 midwives joined the roll by passing the examination, hence it may be inferred that most, if not all, of the 259 other additions were wan p 'os (immigration may have brought a small number of qualified midwives to the colony). Ibid., p. M40. It is worth noting that a transition period, albeit a much shorter one, also had been provided in Britain, as the Midwives Act of 1902 permitted untrained and unregistered women to continue practising until 1910. Smith, p. 44. 3 4  35  52  Conclusion By 1937 Hong Kong had witnessed fifty years of fulminating and hand-wringing over the issue of infant and maternal mortality.  Although the government consistently  temporized, a number of noteworthy changes had taken place. A small but busy cadre of state midwives had become institutionalized, while an ever-growing number of trained private birth professionals slowly, but inexorably, supplanted traditional midwives in the colony.  Furthermore, the turn of the century brought the inception of new health  institutions with particular relevance to mothers and children: the Chinese Public Dispensaries and a variety of ante-natal clinics and maternity hospitals, operated by the government, missions and the Chinese community.  What was the impact of these  changes? As should be apparent from our consideration of the problems plaguing Hong Kong's statistical apparatus, official figures provide no real basis for an assessment of the impact of trained midwives or other measures.  The publication of a Chinese infant  mortality rate was more or less abandoned in the 1920s, and, when resumed in the 1930s, was saddled with bulky caveats, as we have seen. The calculated I M R did fall — from between roughly 500-600 in the late 1920s, to a level of about 350 between 1934 and 1939 -- but this does not necessarily tell us anything about the real trends in the rate. As 1  E.g., in 1930 the rate was 557.5, in 1934, 347.34 and in 1938, 343. "Medical and Sanitary Report for the Year 1930," Administrative Reports for the Year 1930, p. M31; "Medical and Sanitary Report for the Year 1934," Administration Reports for the Year 1  53  unregistered births had pushed the infant mortality rate up to astronomical levels, any subsequent decline in the rate would likely reflect, first of all, an improvement in the proportion of births registered. The actual Chinese IMR could have remained constant at the extremely high level of 250 or even 300 for the entire fifty years, while the official statistics fluctuated above it. Hong Kong's vital statistics do not even give us a starting point, and indeed appear beyond rehabilitation. It seems fair to conjecture, however, that the introduction of basic hygiene into home deliveries would have had a substantial impact on infant and maternal survival. Quantification is, of course, only one way to assess the impact of medical intervention.  The course of the debate on infant mortality and midwifery, and the  responses to it, illustrates the changing approaches to both medical and more general issues of not only the colonial government but also its subjects. First we will consider the state. Given the amount of attention paid to midwifery and its reformation, it is somewhat surprising to find, in the late 1930s, officials dismissing the role of midwifery. In 1937, P S . Selwyn-Clarke, Director of Medical Services, echoed past attitudes in suggesting that, after all, race might well be paramount over public health intervention: In spite of the low standard of environmental hygiene met with in the poorer quarters of Hong Kong and Kowloon, a remarkably few women appear to lose their lives in child-birth as compared with the total mortality. It is difficult to believe that good midwifery is the principle 1934, p. M33; "Annual Medical Report for the Year 1938," Administration Reports for the Year 1938, p. M13.  54  [sic] reason for this and it seems more likely that the average Chinese women [sic] possesses some degree of racial resistance to the invasion of streptococci. 2  Two years later, a committee chaired by Selwyn-Clarke reported on health facilities in the colony, and again dismissed midwifery, this time in favour of a future dominated by the hospitalization of pregnancy: home midwifery is carried out under distinctly unsatisfactory conditions owing to the low standards of environmental hygiene and the overcrowding prevailing; hence, we conclude that efforts to improve the midwifery service should be towards the hospitalization of cases. 3  This recommendation came despite the fact that trained midwives consistently were lauded for their sanitary influence on the homes they visited.  4  It is ironic that just as  Hong Kong officials celebrated the gradual triumph of Western midwives over wan p 'os, such trained midwives were themselves judged inadequate. This raises the question of what constituted appropriate medical policy in the colony. In a 1936 survey of women and children's welfare in the British empire, Dr. Mary Blacklock criticized the frequent practice of simply copying methods and legislation from home, with little regard to local conditions:  2  "Report of the Registrar-General of Births and Deaths," Administrative Reports for the  Year 1937, p. M140.  "Extract from Report of the Technical Committee for the Reorganization and Improvement of Existing Official Hospital and Clinical Facilities of the Colony of Hong  3  Kong, 1938-1939," Administration Reports for the Year 1939, p. M106.  E.g., in the same volume as the committee's report it was noted that "Midwives...in addition to their obstetric duties, are proving a valuable means of improving the  4  55  In some colonies lack of progress in the work among women and children may arise from a too strict adherence to methods of organization in force in other more highly developed countries, the attitude of the authorities being that these are the 'right' methods, and that unless the work is done in the 'right' way it should not be done at all. 5  This was clearly the case in Hong Kong, as evidenced by both the advocacy of hospitalization and the previous rejection on principle of any proposal to even register, much less train, native midwives. More generally, the motivation of the Hong Kong government in addressing the issue of infant mortality was not clearly defined. Metropolitan pressures appear to have been of little consequence: the interest of the Colonial Office was sporadic (although under Joseph Chamberlain there emerged a new, general concern for health matters in the empire) and, as we have seen, officials there were inclined, on this issue at least, to defer 6  to those in Hong Kong. Locally, medical officers, notably Francis Clark, were at the fore of every resurgence of interest in the subject. Although the response of the government was indecisive, it did not simply ignore the issue, which raises the question of why the state cared about Chinese babies. The perpetuation  of Hong Kong's socio-economic order, specifically  the  replication and maintenance of its labour force, is a conventional explanation for  conditions in the homes of their patients." "Annual Medical Report for the Year 1939," Administration Reports for the Year 1939, p. M29. 5  Mary G. Blacklock, "Certain Aspects of the Welfare of Women and Children in the  Colonies," Annals of Tropical Medicine and Parasitology, 30 (1936), p. 229. See Robert V. Kubicek, The Administration of Imperialism: Joseph Chamberlain at die  6  Colonial Office (Durham, 1969), Ch. 7.  56  government and elite (Western and Chinese) co-operation in the realm of public health.  7  Although the economic costs of disease were strikingly evident during the plague epidemic of 1894, it is more difficult to demonstrate other cases of such awareness.  8  What statements were made about the deaths of babies and mothers — such Patrick Manson's "massacre of the innocents" or Clark's reference to "our infant population" suggest benevolent paternalism.  This is, in itself, significant, for it appears that the  concern with infant and maternal mortality both reflected and contributed to the government's growing perception that Hong Kong's Chinese population, despite its mobility, belonged to Britain, not China: there is a substantial gulf between the "dregs of Chinese society" and "our infant population". What this study shows, however, is that underneath the rhetoric of progress and improvement that came with Hong Kong's Chinese being British  subjects,  government's inclination and ability to effect change were quite limited.  the  Fears of  provoking the Chinese population, and more mundane political expediency dictated the sort of gradualist policy that emerged around the infant mortality issue.  Coercion was  rarely an option. The state was consistently forced to negotiate a place for itself, and the Western medicine it endorsed or proffered.  This entailed both haggling with Chinese  members of the LegCo and, more importantly, if less plainly, engaging the Chinese  Chan, The Making of Hong Kong Society, pp. 99-101; Tsai, Hong Kong in Chinese History, p. 91. 7  57  population as a whole. This leads us to consider briefly Chinese perspectives on the infant mortality issue, which suggest some of its broader social and cultural implications. LegCo members Ho Kai and Wei Yuk consistently acted to temper proposals pertaining to midwifery, and, as the official representatives of the Chinese community, seem to have enjoyed greater influence on the government's policy than its own medical officers. The extent to which a genuine desire to protect the Chinese from impractical legislation or simple self-interest lay behind their position is debatable.  What is more  important is the extent to which ordinary Chinese, as recipients or, indeed, consumers of health care could influence the nature of that care. Furthermore, a person's choice of care could be indicative of not only their immediate medical needs, but also their sense of identity. Thus, the creation of the government midwives (or, later, ante-natal clinics) for the benefit of Chinese mothers did not ensure that they would utilise the service.  But  increasing numbers of mothers did call on them, and as we have seen, the demand for Western trained midwives soon outstripped the government's provision of them.  For  Western methods to take hold, they had not only to be effective, but also accessible (in terms of price and location) and congenial to the Chinese, especially insofar as, via the Tung Wah Hospital and other means (including wan p 'os), they remained able to choose between Western and Chinese medicine, according to the circumstances.  One exception is a 1906 report holding beriberi "responsible for enormous national loss from an economic standpoint." William Hunter and Wilfred V . M . Koch, A Research into  8  58  It is significant that such choices, from the late nineteenth century, increasingly be made within the colony.  Movement between the colony and the mainland was an  established tradition for expectant mothers and the ill. It is impossible to ascertain the extent to which such flows changed over time. Elizabeth Sinn has provided a rich account of the role of the Tung Wah Hospital in the formation of not only a Chinese elite, but also a broader sense of community. Chinese institutions which emerged out of the turn of the 9  century concern with infant and maternal welfare — the Chinese Public Dispensaries and various lying-in facilities — lie beyond the scope of this paper, but seem to have played a similar role richly deserving to be chronicled. The emergence of local facilities for babies and mothers would seem to be a prime indication of the settlement of a permanent Chinese population in the colony. From this perspective, which this study admittedly only points to, the story of infant health in Hong Kong becomes one not of imperial history, but of local social history.  the Etiology ofBeri-Beri (Hong Kong, 1906), p. 1. Sinn, Power and Charity.  9  59  Bibliography  Unpublished Official Sources Public Record Office, Kew Great Britain. Colonial Office.  Original Correspondence: Hong Kong, 1841-1951, Series  129 (CO 129). Other Unpublished Sources School of Oriental and African Studies (SOAS), London Council of World Missions Papers, SOAS Library. South China Reports (CWM/SCR). Published Official Sources Hong Kong. Legislative Council. Hong Kong Sessional Papers (HKSP) . Administration Reports . Administrative Reports . The Ordinances of Hong Kong . The Ordinances of Hongkong 1844-1923. 6 vols. Hong Kong, 1924. . The Ordinances of the Legislative Council of the Colony of Hongkong. 2 vols. Hong Kong, 1892. . Papers on the Subject of the Prevalence of Beri-Beri in Hongkong.  Hong  Kong, 1889. . Report of the Committee Appointed., to Inquire into the Causes of Chinese Infantile Mortality in the Colony. Hong Kong, 1903. Newspapers Hong Kong Daily Press  60  South China Morning Post  Books and Articles Ashby, Hugh T. Infant Mortality. Cambridge, 1915. Balfour, Andrew and Henry Harold Scott. Health Problems of the Empire. 1924.  London,  Ball, J. Dyer. Things Chinese. 4th rev. ed. Hong Kong, 1903.  Blacklock, Mary G. "Certain Aspects of the Welfare of Women and Children in the Colonies," Annals of Tropical Medicine and Parasitology, 30 (1936), 221-64. Chan, Wai Kwan. The Making of Hong Kong Society: Three Studies of Class Formation in Early Hong Kong. Oxford, 1991. Chen, C.C. Medicine in Rural China. Berkeley, 1989.  Choa, G.H. The Likfe and Times of Sir Kai Ho Kai. Hong Kong, 1981. Cockburn, George. John Chinaman: His Ways and Notions. Edinburgh, 1896. Cohen, Paul A . China and Christianity: The Missionary Movement and the Growth of Chinese Antiforeignism, 1860-1870. Cambridge, Mass., 1963.  Des Voeux, G. William. My Colonial Service. 2 vols. London, 1903. Endacott, G.B. A History of Hong Kong. London, 1958.  Furth, Charlotte. "Concepts of Pregnancy, Childbirth, and Infancy in Ch'ing Dynasty China," Journal of Asian Studies, 46, 1 (1987), 7-35. Hardy, E.J. John Chinaman at Home. London, 1906. Harrison, Mark. Public Health in British India. Cambridge, 1994. Ho, Ping-ti. Studies on the Population of China, 1368-1953. Cambridge, Mass., 1959.  61  Hoe, Susanna. The Private Life of Old Hong Kong. Hong Kong, 1991. Hong Kong Charitable Institutions, 1903-1907. Hong Kong, n.d. Kubicek, Robert V. The Administration of Imperialism: Joseph Chamberlain at the Colonial Office. Durham, 1969. L Asile de la Sainte Enfance. Description of the Establishment and Work. Hong Kong,  1902. "The Lost Girls," Utne Reader, 75 (1996), 13-14. Mackerras, Colin. Western Images of China. Hong Kong, 1991. Milne, William C. Life in China. London, 1857. Miners, Norman. Hong Kong under Imperial Rule, 1912-1941. Hong Kong, 1987.  Mitchell, Eleanor W. "Infant Life Saving," The Chronicle, n.s., X X I I (1914), 27-29. Newman, George. The Health of the State. London, 1907. Norton-Kyshe, J. W. The History of the Laws and Courts of Hongkong. 2 vols.  London,  1898. Peplow, S.H. and M . Barker. Hongkong, Around and About. 2nd rev. ed. Hong Kong, 1931. Shepherd, Bruce. The Hongkong Almanack For... 1889. Hong Kong, 1889. Sinn, Elixabeth. Power and Charity: The Early History of the Tung Wah Hospital, Hong  Kong. Hong Kong, 1989. Smith, F.B. The People's Health 1830-1910. London, 1979.  "The Training of Students in Midwifery," The Caduceus, 5, 3 (1926), 253-56. Transactions of the Hongkong Medical Society, Volume 1. Hong Kong, 1889.  62  Tsai, Jung-fang. Hong Kong in Chinese History: Community and Social Unrest in the British Colony, 1842-1913. New York, 1993.  Wang, C.Y. "Infantile Tetanus (Tetanus Neonatorum) in Hong Kong: Its Prevalence and Sources of Infection," The Caduceus, 6, 3 (1927), 249-53. Wong, T.C. "Some Observations on the Clinical Aspects of Tetanus Neonatorum (Infantile Tetanus)," The Caduceus, 6, 3 (1927), 254-55.  63  Appendix 1: Chinese Resistance to the Census Excerpt from "Report on the Census of the Colony for 1897," HKSP 1897, p. 469: In Wanchai there was current a report that all persons born in Hongkong were to be at once re-vaccinated. One woman who had told the enumerator that her children were born in Hongkong ran after him after he had left the house, and was very urgent that he should correct what she said was her mistake. In the same district on the first day on which the [census] schedules were distributed several women left their homes and ran away to the hill-side at the back of the town. In Saiyingpun there was also a little commontion among the lower classes....There was the usual number of persons who thought that they were being served with writs. In many cases it required some persuasion on the part of the enumerator to induce people to take the schedule, and...where obstinancy [sic] seemed impervious to reason the enumerator was driven to refer rather roughly to the penal clauses of the Census Ordinance. The Registrar General's Office received the assistance of the Chinese press in an endeavour to give as much publicity as possible to the intention of the Government to take a census and to allay the usual suspicions, and I do not well see what more could have been done beyond perhaps making an attempt to reach the people through their children by...asking the Chinese teachers...to explain it to their scholars.  64  

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