Introduction
American philanthropy supported a range of projects during the first decades of the Republic of China. Medical activity, including hospitals, educational institutions, public health programmes, and research were notable recipients of money, institutional support, and personnel from the United States. In many cases, this investment can be seen as a secular evolution of the nineteenth-century interventions by European missionaries, which centred on the British colony of Hong Kong and the international settlements within the treaty ports where foreign influence was legally permitted and spatially concentrated after the signing of the Treaty of Nanking in 1842. Despite some continuities with this missionary foundation, American support for medicine in China after the overthrow of the Qing empire in 1912 was characterised by increasing cooperation with local stakeholders, the involvement of indigenous Chinese doctors (trained in Western medicine either domestically or overseas), and a greater degree of coordination with Chinese partners.Footnote 1 Ambitious Chinese, especially those with a foreign education, were enthusiastic participants in these international projects and regarded Western scientific medicine as a key pillar in the development of the nation as a whole.Footnote 2
This article examines the professional and personal relationship between the American physician Edward Hicks Hume (1876–1957) and his Chinese colleague Fu-ch’ing Yen (颜福庆, 1882–1970). Hume and Yen were physician–administrators working at the Yale University mission in Changsha, Hunan, from 1906 (Hume) and 1910 (Yen) until they were forced to abandon the city amid civil unrest during the winter of 1926. Hume, who trained at Yale and Johns Hopkins, nurtured a fierce ambition to build a medical college and hospital in China that would channel the reforming spirit outlined in Abraham Flexner’s influential 1910 report into American medical education.Footnote 3 Yen was a Shanghai-born Chinese Christian and fellow Yale graduate who joined the mission after completing his studies in the United States. As a foreign-trained doctor and member of a well-connected family with senior contacts in Beijing, Yen was an invaluable asset in building relationships with the provincial gentry and growing the local influence of the mission.
Hume and Yen developed a close mentor–protégé relationship, informed by their complementary talents for administration and networking, with Hume securing funding from major American donors and Yen preparing the ground among the Hunanese gentry. Their crowning achievement was Xiangya, a pioneering cooperative Sino-American medical college and hospital established in Changsha in 1914.Footnote 4 Nonetheless, this success was followed by a period of disagreement between the two men surrounding the next steps for the American-backed medical work in Hunan: Hume hoped to consolidate Xiangya through tireless administration, while Yen planned to return to the United States to begin training as a clinical specialist. Correspondence between Hume and Yen during this rift, when Hume implored his protégé to abandon specialist training and return to Changsha to support Xiangya, offers profound insights into two very different interpretations of the institutional, professional, and even spiritual obligations of Western (and Western-trained Chinese) doctors in China.
The partnership between Edward Hume and Fu-ch’ing Yen is illustrative of the compromise and cooperation required across a range of areas in the context of Sino-foreign medicine and highlights practitioners’ conflicting obligations to administrative leadership and their own sense of professional ambition. Biographical studies of Hume and Yen have reflected on the successes and specific challenges encountered during the introduction of Western medicine to provincial China,Footnote 5 however the unique relationship between the two men provides a rich case study that reveals important points of disagreement and debate. Their contrasting understandings of professional duty are indicative of broader tensions related to international collaboration and professional status amid the social and political upheavals unfolding across the country.
Hume and other US administrators of American philanthropy in China, most notably the Rockefeller Foundation’s China Medical Board, have been presented as well-meaning but embattled and often hamstrung bridge-builders between the two countries.Footnote 6 In her study of the Rockefeller-funded Peking Union Medical College (PUMC) in Beijing, Mary Bullock noted how these ‘middlemen’ were tasked with the complex responsibility of managing the expectations of American providers and Chinese recipients of philanthropic largesse.Footnote 7 While Bullock’s analysis focuses on an elite, foreign-funded institution in Beijing, this article examines how similar tensions were negotiated at the less richly endowed Yale mission in provincial Hunan, where financial investment and political support from the local Chinese community was a necessity.
Established scholarship has examined missionary medicine as a civilising tool in colonial contexts, however China’s semi-colonial status and the absence of direct colonial rule require a distinct analytical approach that highlights local agency and Sino-foreign cooperation.Footnote 8 This study focuses on the negotiated development of medical identity in provincial China, exploring how doctors engaged with, appropriated, and sometimes reshaped institutional frameworks that had been introduced and overseen by a Western mission. In doing so, it offers a perspective on Sino-foreign interaction that centres on institutional development and medical authority within an increasingly self-confident indigenous professional community, a group that sought to leverage the opportunities of Western medicine in service of national development. Xiangya’s location in Hunan, a central province with a reputation for hostility to foreigners, further distinguishes this case from studies focused on Hong Kong, Beijing, Shanghai, and the treaty ports, which had a long history of involvement, investment, and institutional contact with Westerners.Footnote 9
This article contributes to debates around Chinese medical modernisation by foregrounding a provincial case study that combines elements of missionary influence and indigenous development. As a Sino-US joint project, Xiangya required sustained negotiation between Chinese and American actors and was a site of necessary compromise. The development of Western medicine in Changsha demonstrates how Chinese professionals like Yen navigated the constraints and opportunities of missionary medicine, institutional authority, and local politics to craft a distinct professional identity. Following a review of the relevant academic literature, the article introduces the two individuals at the centre of this study and outlines the triumphs and challenges they encountered during two decades in Changsha before placing them in the broader context of Western medicine in Republican China.
Western medicine and medical education in China
The ability to establish effective professional and personal relationships with the Chinese community was central to the careers of the most successful nineteenth-century medical missionaries. The foremost foreign doctor of the century, the American missionary Peter Parker (1804–1888) demonstrated how physicians could establish relationships with the most senior Chinese officials.Footnote 10 Parker, a Yale graduate, arrived in Canton in 1834 and opened his ophthalmic hospital the following year, embarking on the slow process of overcoming what Edward Gulick described as the ‘hauteur and suspicion’ of the locals towards Western medicine.Footnote 11 From his hospital, Parker made inroads with various elite members of local society who became his patients, including the imperial commissioner Lin Zexu, who arrived in Guangdong in 1839 to suppress the opium trade. Parker acted as interpreter and secretary to American ambassador Caleb Cushing during negotiations over the first Chinese-US diplomatic Treaty of Wanghia in 1844, representative of doctors’ status among local Chinese leaders that conferred access unavailable to merchants and diplomats.
Successful medical missionaries navigated the conflicting pressures of religious evangelism and professional viability through pragmatic compromise and cooperation with their patients and the local community.Footnote 12 An obvious way to establish trust was to train and employ local Chinese as colleagues, although such arrangements were often structured to solidify the power imbalance between foreigners and locals, with Chinese colleagues commonly tasked with the ‘routine and drudgery work’ of missionary medicine.Footnote 13 The requirement for integration with the local community was challenging to some leaders within the missionary movement. During a series of visits to explore the potential for expanding Western universities in China, the British bishop William Cecil framed accommodation with the Chinese as mortally dangerous, stating that ‘the pleasing dream that you can arbitrarily select the good points of West and East and weave them into one is the very reverse of the truth’ and warning of the ‘terrible trial of having to live in two moral atmospheres’.Footnote 14 Medical missionaries on the ground were nonetheless obliged to work with Chinese partners to ensure the continued survival of their practices. These partnerships could lead to important financial and administrative support but risked diluting the Christian character of the work, resulting in medical missions that reflected different evangelical strategies and concessions to the local ‘moral atmosphere’. Yuet-Wah Cheung and Peter Kong-Ming New devised a typology to characterise missions that were either ‘local’, engaging solely in primary medical work, or ‘cosmopolitan’, active in areas that required greater coordination with the local community such as public health and medical education.Footnote 15
Western involvement in medical education illustrated foreign universities’ and philanthropic organisations’ active role in promoting scientific and institutional development in China, often building upon the foundations established by missionaries. Major projects included the Harvard Medical School of China (based in Shanghai between 1911 and 1916), Mukden Medical College (Shenyang, 1911–1949), the Rockefeller Foundation-funded PUMC, founded in 1915, and the Xiangya Medical College attached to the Yale mission in Changsha (1914). New and Cheung described the relatively short-lived Harvard school in Shanghai as a ‘harbinger’ of the Rockefeller-funded PUMC,Footnote 16 with the wealthy Beijing institution subsequently becoming the institutional figurehead of Western medicine in China.Footnote 17 These institutions placed less emphasis on religious evangelism and were administered along more secular lines, demonstrating a more collaborative attitude towards Chinese partners and commitment to training fully qualified Chinese doctors.Footnote 18 Nonetheless, as Bullock noted, the twentieth-century expansion of Western medicine in China, exemplified by the injection of Rockefeller funding at PUMC, brought together individuals from the worlds of philanthropy, medical science, and religion, most of whom ‘believed deeply in the superiority of Western civilization’.Footnote 19
The Xiangya Medical College established in 1914 was an outgrowth of the Yale mission in Changsha, Hunan Province. The project originated with a group of idealistic students at Yale University in New Haven, Connecticut, who in 1902 started the Yale-in-China Association to fundraise for a foreign mission, eventually choosing China as their proposed country of operation.Footnote 20 The decision to situate the mission in Changsha, the capital of central China’s Hunan Province, was to prove fateful: Hunan had a reputation as an anti-foreign province, with numerous recorded episodes of violence committed against foreigners and Christians.Footnote 21 After his visits to China during 1907 and 1909, Bishop Cecil described Changsha as ‘one of the most bigoted cities in China’.Footnote 22 Foreign-run institutions were lighting rods for political unrest, perceived by some as proxies for hostile foreign powers; however, the Yale missionaries stated confidently that they were uniquely placed to overcome anti-foreign sentiment, partly owing to the fact that the Americans did not have the same violent history in China as other Western powers.Footnote 23 The mission opened in 1906 with a middle school, ‘Yali’ (a transliteration of ‘Yale’), and a modest dispensary dubbed the ‘Yale Court of Medicine’ by its first physician, Edward Hume.
Despite their foreign funding and leadership, Western medical schools and their attached hospitals were sites of intellectual and cultural integration, often resulting in what Michelle Campbell Renshaw identified as the ‘Sinicisation’ of various elements ranging from patient care to hospital administration and architecture.Footnote 24 Concessions to the specific Chinese working environment added further nuance to unfolding trends in Western medicine that called for increased professionalisation, including the segmentation and specialisation of clinical practice, and monopoly of education and certification by an elite scientific medical establishment.Footnote 25 In China, as Bridie Andrews noted, the lack of both legislation and enforcement of formal medical licencing meant that during the 1920s ‘it was still possible for anyone to claim to be a doctor of Western medicine’.Footnote 26 Consequently, the strict entry requirements to professional organisations such as the National Medical Association, established in 1915, were the most reliable indicator of competence.
Negotiation, compromise, and ‘Sinicisation’ suggest that Western medical schools were engaged in the development of a uniquely Chinese medical professionalism, echoing the distinct trajectories of scientific medicine in Japan, Europe, and America. The foremost colleges became nexuses in an international flow of ideas, people, and money, with students and staff drawn from both Chinese and Western elites.Footnote 27 Western medical schools attracted students eager to develop both expertise and an international education, a response to the broader modernising political ideology taking shape among Chinese intellectuals and spearheaded by figures including Sun Yat-sen (a graduate of the Hong Kong College of Medicine) and Lu Xun (who had studied medicine in Japan but never graduated). Chinese advocates of the biomedical approach to public health drew parallels between addressing the physical health of the population and confronting deficiencies in the body politic and hoped that new medical ideas might remedy the widespread notion of China as the ‘sick man of Asia’.Footnote 28
Edward Hume’s vision and early efforts in Changsha
Edward Hicks Hume was born in 1876 to a family of American missionaries in Ahmednagar, India, where his father worked as a teacher. His childhood experiences later assumed an almost mystical significance for his colleagues at the Yale mission, who described his linguistic gifts and religious convictions as ‘nurtured in their natural Asiatic setting’.Footnote 29 He graduated from Yale in 1897 and received his Doctor of Medicine (MD) degree from Johns Hopkins in 1901. The medical school at Johns Hopkins represented the pinnacle of clinical and scientific medical instruction at the turn of the twentieth century, later singled out for praise in Flexner’s 1910 report into medical education.Footnote 30 During his medical training Hume studied under several of the internationally feted luminaries and founding professors of Johns Hopkins, including William H. Welch and William Osler, and the university set the standard for the medical school he hoped to establish in China. Upon graduating, Hume returned to India with the United States Public Health Service before accepting the offer to lead the medical work of the Yale mission in Changsha.Footnote 31 Hume’s specific justifications for leaving the familiarity and family connections he enjoyed in India to lead a fledgling medical mission in central China are unclear, especially as he had earlier declined an invitation to move to the country; however, his ambitious nature, idealism, and convictions as a third-generation missionary and Hopkins graduate gave him the confidence to relocate his young family to Hunan in June 1905.Footnote 32
The first challenge facing Hume following the opening of the Yale Court of Medicine in 1906 was attracting patients. As operators within a competitive market of therapies, medical missionaries were obliged to clearly demonstrate the advantages of their treatments, which in many cases constituted a direct challenge to established Chinese medical practice. Frequently, apathetic or suspicious Chinese patients aligned Western medicine with imperialism, obliging missionary doctors to adapt their methods and message to reassure the communities in which they worked.Footnote 33 Surgery was an important area where medical missionaries could demonstrate clinical superiority, as there were often few reliable local alternatives for treatment, and surgeries provided opportunities for Western doctors to make heroic and dramatic interventions that could help grow their reputation and influence.Footnote 34 Hume made his name in Changsha through operations on cleft lips, cataracts, and abscesses, later conceding in his memoir that even after decades in China most patients placed greater trust in Chinese medicine for the majority of ailments.Footnote 35 Hume’s China years inculcated in him an enthusiastic and scholarly interest in the practice, materia medica, and history of Chinese medicine. He published articles on the subject during and after his time in Hunan and authored a comprehensive monograph, The Chinese Way in Medicine, in 1940.Footnote 36
Hume recognised the importance of, at the very least, communicating with and, if possible, cooperating at a sophisticated level with the local Chinese community if he was to realise his ambitions for medical education in Changsha. He spent a year in-country studying Chinese intensely before arriving at the Yale mission, where he was the most capable American linguist among a group of colleagues who had mostly neglected the language study urged by the committee in New Haven.Footnote 37 Hume understood the limitations to easy communication and mutual understanding facing the missionaries, especially as they were operating from a limited foundation of linguistic and cultural comprehension in a setting with a reputation for hostility to foreigners. The arrival of Fu-ch’ing Yen, an American-trained Chinese, in 1910 was therefore greeted by Hume as nothing short of tantalising. He hoped Yen could serve as an intercultural mediator, describing his impression of his new colleague during their first meeting as a man who ‘seemed to both belong to the environment and be different from it’.Footnote 38 In spite of his commitment to studying the Chinese language, culture, and medical system during his first years in Changsha, Hume was realistic about the limited prospects of the American missionaries to have a major impact among a local community unused to foreigners. The addition of a Chinese colleague equally at home among Western physicians and the Chinese gentry was a great boon to the whole enterprise.
Fu-ch’ing Yen was born in 1882 into a cosmopolitan family in Shanghai, where his father and uncle had attended an American mission before travelling to the United States to complete their university education.Footnote 39 After his father’s death in 1898, Yen lived at St John’s College in Shanghai, the university established in 1879 by foreign missionaries in the city and where his uncle was the first principal.Footnote 40 After completing his medical training at St John’s in 1903, he travelled to South Africa to serve as a doctor for Chinese mineworkers dispatched by the Qing government, before enrolling as a medical student at Yale in 1906.Footnote 41 Yen was approached by the secretary of the Yale mission to join Hume in Changsha during his final year in New Haven, and after completing his diploma in tropical medicine in Liverpool, England, in the winter of 1909 returned to China, first to Shanghai and then inland to Changsha, in February 1910.
Establishing Xiangya, a Johns Hopkins in provincial Hunan
Hume and Yen forged a strikingly effective partnership during their first decade together in Changsha. Hume’s gifts for administration and tireless pursuit of opportunities to expand the reach and activities of the medical mission combined excellently with Yen’s abilities as a mediator between the Americans and Chinese. The Yale doctors conducted a range of medical work across Hunan and neighbouring Hubei Province during 1911 and 1912, including teaching hygiene in local schools, deploying Yen to lead the response to the plague epidemic in Hubei, and coordinating the Red Cross hospital for patients injured during the 1911 anti-Qing uprising in Wuchang.Footnote 42 These contributions, especially when made at the invitation of provincial officials, proved to be of great value to the missionaries’ expansionary goals. Yen reflected that involvement in public health and Red Cross work served to ‘cultivate the friendship and goodwill of the Chinese, and to win Chinese interest and confidence’ in the Yale mission through establishing close connections with influential figures in Changsha, Hunan, and across central China.Footnote 43 The development of these social and political connections encouraged Hume to act on his long-standing plans of founding a medical school. He returned to the United States on furlough to solicit funds from his Yale connections, leaving Yen in Changsha to win the support of the local gentry for the proposed project.
Debates over education reflected the increasingly scientific and professionalising direction of Western medicine during the early twentieth century. American medical education was shocked into reforming action following the publication of Abraham Flexner’s 1910 report, which presented a damning critique of institutions that failed to meet the standard set by the Johns Hopkins School of Medicine in Baltimore.Footnote 44 Flexner believed medical colleges should demonstrate commitment to scientific training, clinical instruction at hospital, and a greater role for research, with reform of medical education central to improving professional standards.Footnote 45 As a Hopkins graduate, Hume sought to bring the same rigour to his proposed institution in China and understood the expense and administrative challenge such an ambition represented. His 1911 furlough evolved into a fundraising tour on behalf of the proposed Sino-American medical school and hospital in Changsha. The crowning achievement of the trip was securing a major financial gift from his Yale classmate, and one of the richest men in the country, Edward Harkness. As the heir to a vast oil fortune, Harkness supported a range of philanthropic initiatives and agreed to a major donation to build the hospital in Changsha, stipulating that the new institution be regarded as a gift to the local community.Footnote 46 Meanwhile, Yen engaged in careful politicking with the Hunanese gentry to secure both permission and financial support for the proposed joint venture. In the face of opposition from local rivals from the Chinese and Japanese medical communities that had forced initial negotiations to be aborted in 1913, Yen travelled to Beijing and used his family connections to successfully petition on behalf of the Xiangya agreement (combining 湘 Xiang, a historical name for Hunan, and 雅 Ya, for Yale), signed in July 1914.Footnote 47
Under the terms of the Xiangya agreement, the Chinese provided land and money to the joint enterprise, with the Americans responsible for staffing (and using the Harkness gift to build a hospital at the site, completed in 1918). Leadership of the new institution was shared between the Americans and Chinese: Hume was director of the hospital and dean of studies, while Yen was appointed the first president of the college. Xiangya was a major example of Sino-American cooperation, representing the intersection of Chinese investment and interest in scientific medicine, and American educational standards and philanthropy. Collaborations of this kind were a key focus of the influential China Medical Board (CMB) of the Rockefeller Foundation, founded in 1914.Footnote 48 The CMB visited Changsha in 1914 and were sufficiently impressed with Xiangya to agree to pay the salaries of the American staff. In a letter to Anson Phelps Stokes, secretary of Yale University and a founder of the Yale-in-China Association, Yen enthused about how the CMB visitors had been treated to a joint dinner of local officials and gentry, with the visitors left ‘very much impressed with the enthusiasm of the Chinese’.Footnote 49 In May 1915, the CMB approved funding for a five-year period for instructors at the medical school and a further $30,000 the following year for buildings and laboratory equipment.Footnote 50
The support of the Rockefeller Foundation conferred important legitimacy on the expansion of the medical work in Changsha. In 1915, Xiangya physician Alfred C. Reed (1884–1951) published a recruitment notice in the Journal of the American Medical Association describing the aims of the institution as ‘quality and not quantity of work’ and promising ‘great opportunities in the orient’, making sure to note the work was being conducted with the ‘support of the Rockefeller Foundation’.Footnote 51 The new hospital was ready for occupation by December 1917 and fully completed the following year. In his history of the mission, Reuben Holden reflected that the successes of these years were mainly due to his belief that ‘from the beginning, cooperation with the Chinese had been a hallmark of Yale-in-China’.Footnote 52 Writing during a visit to Changsha in 1920, Stokes was pleased to note how ‘active cooperation of the Chinese members of the Board of Management’ had created a stable and financially solvent institution, a state of affairs secured as a result of the ‘resourcefulness of Dr Hume and Dr Yen’.Footnote 53 The implementation of the Xiangya agreement was attuned to the priorities of American philanthropic investment in China, demonstrating cooperation with local stakeholders and a commitment to building an institution that would represent the secular and scientific values of Western medicine.
Conflicting obligations: Fu-ch’ing Yen’s ambitions beyond Changsha
Hume’s years in Changsha prior to the establishment of Xiangya were in many ways a preparatory period spent studying Chinese, building an institutional foundation at the mission, and seeking a means of developing the necessary connections to realise his long-standing ambition to establish a medical school. Yen’s arrival in 1910 provided much-needed help in securing Chinese support for the Xiangya agreement, and Hume hoped that the two men would continue to work together in the administration and leadership of the new institution after 1914. Yen’s relationship with Xiangya was more complex: as a Shanghainese, he naturally maintained a close interest in the city of his birth, and through friends and family in Beijing he was involved in the national development of scientific medicine in China. Chinese intellectuals across the country pursued careers in Western medicine after the declaration of the Republic in 1912, viewing the profession as a means to develop a secular, scientific education and international outlook that would help support the development of the nation.Footnote 54
Yen was an exemplary figure in this national movement to leverage the tools and promise of scientific medicine to spur the development of the indigenous professional community. After attending the February 1915 meeting of the Western-led China Medical Missionary Association in Shanghai, Yen and the other Chinese attendees hosted a dinner during which they agreed to establish a separate body for indigenous practitioners of scientific medicine: the National Medical Association of China (NMA). Yen was elected the first president of the new association, which was officially recognised by the Ministry of Education in July of that year and published the first volume of the National Medical Journal of China in December.Footnote 55 Yen’s leadership of the society, limited to graduates of foreign medical schools or the Western medical colleges in China, was indicative of his broader interest in national questions of medical politics. The lack of effective medical licensing in China meant organisations such as the NMA, with its strict admission criteria, served as important gatekeepers to professional recognition.Footnote 56 Yen’s active involvement and leadership in national professional organisations and debates inevitably threatened to overtake his commitments to the fledgling Sino-American medical college in provincial Hunan.
The founding of Xiangya imposed a heavy burden of administrative duties on Yen, who spent several years shepherding the new institution before refocusing on his personal ambitions. The Western medical elite placed increasing emphasis on clinical specialism, a reflection of the growing complexity and segmentation of scientific medicine at the turn of the twentieth century.Footnote 57 Public health was the focus of major global investment and scientific research; however, within both the American and British profession (the two countries where Yen had completed his medical education) the speciality was often relegated to second-class status beneath more prestigious hospital-based practice.Footnote 58 Despite major international philanthropic support for public health in China, including a fellowship Yen received in 1917 from the International Health Board of the Rockefeller Foundation to conduct public health work in Jiangxi, he chose ophthalmology as the specialist area he wanted to pursue.Footnote 59 Specialist training marked the next step in a career trajectory that reflected Yen’s position among leading Chinese doctors seeking to align with international professional priorities. It would also require an extended period of postgraduate study and hospital work in the United States. In the spring of 1920, Yen informed Hume of his intentions.
Yen’s decision not to pursue a career in public health, the field in which he had valuable experience, received funding from American backers, and served as a valuable basis for Sino-foreign cooperation in central China, came as a blow to his senior colleague. The issue caused the first major rift between Yen and Hume, who had welcomed and defended his junior colleague against the anti-Chinese prejudice endemic to missionary medicine and shared with him the challenges and triumphs of establishing Xiangya.Footnote 60 Hume tried everything in his power to change his protégé’s mind, framing public health and preventive medicine as not merely a specialist field of equal status to ophthalmology but as a ‘leading’ area and appealing to him to ‘stick to what you have started’ on the course that ‘ought to fill you with joy and gratitude’.Footnote 61
In spite of these pleas, Yen travelled to the United States in August 1921 to begin training at the New York Postgraduate Medical School. Hume’s opposition came as an unpleasant surprise, prompting Yen to write to Herbert Vreeland, executive secretary of Yale-in-China in New Haven, of his puzzlement at both Hume’s response to his decision and the ‘bad taste’ it appeared to have left among the members of the International Health Board who had sponsored his public health work in Jiangxi. Given the arrival of Harvard graduate and public health specialist Reginald Atwater in Changsha to lead the ‘technical and scientific responsibilities’ of that field, Yen felt that pursuing ophthalmology would neither leave a gap in the staffing nor prevent him from ‘establishing a necessary contact between this department and the Chinese public’.Footnote 62 Furthermore, Yen feared that his pivot from public health to ophthalmology had already been interpreted as ‘fickleness’, an impression that would only be exacerbated if he were to heed Hume’s continued calls for him to abandon his studies and return to China midway through his postgraduate training.Footnote 63
The rift initiated a period of reflection during Yen’s absence in New York. The two men maintained a correspondence that touched upon their wider purpose as physicians and Christians, with Hume reminding Yen of the ‘spiritual attitude’ which called upon them to do ‘what the Kingdom of God in China requires, even though that means sacrifice’.Footnote 64 For his part, Yen sought to mollify his mentor, recognising ‘the great sacrifice’ Hume had made by ‘giving up [his] professional career to one of general usefulness’ but also reminding him that ‘in China your time is so taken up with the non-professional duties … it doesn’t leave any time for the practice of medicine, although you often told me how you love to teach and practice’. He held firm, writing that while ‘I must seem to you and the other men as hog headed and so stubbornly persistent’, the decision to go to New York and train as a specialist ‘honestly represent[s] my convictions’.Footnote 65
The question of Yen’s future was finally put to the Yale mission’s board of trustees in New Haven, towards whom Hume pursued a more forceful strategy, urging that Yen give up his postgraduate studies in ophthalmology and return promptly to Changsha to lead, with Atwater, the public health department. The appeal noted that Rockefeller Foundation money had been and would continue to be available for public health work, and the Yale mission should do everything in its power to make itself eligible for such support. During their mediation, the board considered a statement from Hume that plainly outlined his ‘fraternal advice’ to his junior colleague,
We have said vigorously what we feel. The field of Public Health is so great that Yen ought to be a leader in it instead of playing around the outskirts of a limited branch that he will not really become proficient in.Footnote 66
Hume’s description of ophthalmology as a ‘limited branch’ is indicative of his attitude towards Yen’s desire to follow the career path of ambitious physicians, namely choosing a specialist field, instead of the example of ‘great sacrifice’ he set as an administrator. The condescending judgement that by specialising Yen would be merely ‘playing around’ reflected a frustration at his perceived lack of commitment to the mission, institutions, and relationships the two men had spent over a decade building in Changsha.
In their final decision, the Yale mission board reached a compromise, permitting Yen to continue his specialist training in America while also committing some time to the study of public health and medical education, with the intention of also contributing to those fields on his return to China. Yen earnestly abided by these stipulations and used the latter to try and repair his relationship with Hume, writing to him from Chicago in the spring of 1922 while attending the Annual Congress on Medical Education, Medical Licensure, Public Health, and Hospitals that ‘discussion concerning medical education and public health are just the things I am here to learn and study, for my original plan in spending the year in America is to study these problems in addition to my work in ophthalmology’.Footnote 67
Hume grudgingly accepted this outcome, while not abandoning altogether his hopes that a public health dimension to the ophthalmological work might be found. He wrote to Yen a few weeks before his return to China in July 1922 of a plan to incorporate ‘eye hygiene’ in the schools of Hunan, an example of ‘how greatly we need you as a leader in the movement for national health. You will find great opportunities for using your training in eye in these directions.’ Hume more than anyone was aware of the precious and unique position that Yen occupied as a mediator between the Chinese and Americans, absolutely essential to the success of Xiangya. He regarded Yen’s background as a well-connected Chinese Yale graduate to be as much of an asset as the development of a specialist area of practice, advising him to cultivate each dimension of his professional identity to carve a niche which ‘your foreign colleagues cannot touch’.Footnote 68
Events in China far beyond the control of the Yale missionaries would shape the next phase of work at Xiangya. Changsha was a hotbed of political activity from a range of groups inflamed by the perceived injustices of the Treaty of Versailles, including the young Hunanese Mao Zedong, who in 1919 was briefly editor of the Yale mission student magazine and opened a bookshop on campus.Footnote 69 The anti-imperialist May Fourth Movement of 1919 was the basis for student unrest at the Yale mission during the following years, including numerous student strikes and protests against the foreign-dominated leadership and academic curriculum.Footnote 70 The warlordism of the 1920s manifested in Hunan through frequent changes in leadership, accompanied by differing positions on foreign cooperation. By the time of the May Thirtieth Incident in Shanghai in 1925, the Americans, including Hume, were receiving threats of violence, and despite a brief reprieve following the arrival (and treatment at Xiangya) of Chiang Kai-shek in the summer of 1926, temporary abandonment of the city appeared increasingly inevitable.Footnote 71
Yen and his American colleagues left Changsha in December 1926. Hume had returned to the United States on medical furlough in December 1925 and was fundraising for Yale in China in New York as the situation deteriorated on the ground in Hunan. The Americans returned home, and Yen gradually distanced himself from the missionary model of medical education, shifting towards secular and nationally oriented institutions while maintaining professional ties with Western-trained colleagues. He went first to Beijing, serving as vice-director of PUMC (where his cousin served as a trustee) for the academic year 1927/8. This brief appointment coincided with new ordinances issued by the Nationalist government’s health ministry requiring all foreign-owned educational institutions to have a Chinese director.Footnote 72 Another American-trained physician, J. Heng Liu (刘瑞恒), succeeded Yen at PUMC, enabling Yen to return to his native Shanghai, where he led the establishment of a new Chinese-led cooperative medical school.Footnote 73 Yen’s subsequent career, which included the consolidation and expansion of Shanghai’s medical education and services at the National Shanghai Medical College (now part of Fudan University), and a brief tenure as Minister of Public Health in 1938, reflected his orientation towards national concerns. In the years before his death in 1970, he faced personal attacks during the Cultural Revolution due to his Christian beliefs.Footnote 74 His reputation was later rehabilitated, and in 1997 a statue was erected in his honour on the Fudan University Medical School campus.
Conclusion
The formidable partnership between Edward Hume and Fu-ch’ing Yen resulted in substantial achievements for Western medicine in central China, with a legacy that far outlived the Yale mission (Xiangya medical college and hospital are now part of Central South University). The relationship between the two men provides valuable insights into the contrasting obligations of Western-trained doctors in the early years of the Chinese Republic. Hume felt that securing the viability of Xiangya was of paramount importance to his legacy in China, while Yen’s desire to specialise and participate in national professional developments led him to seek to disentangle himself from administrative burdens in the provinces. Hume was an enigmatic, eccentric, and dedicated individual who exemplified the conflicting pressures facing medical missionaries during the unsteady transition from religious to secular and Western-dominated to cooperative delivery. Jonathan D. Spence suggested Hume’s Chinese career reveals a transformation from a straightforward conviction in the medical and educational superiority of the West towards a more respectful view of the country.Footnote 75 Hume viewed the introduction and development of Western medicine in Changsha as part of a broader missionary enterprise that required intercultural relationship-building.Footnote 76 He would later describe his years in China as a demonstration ‘that medicine was a builder of bridges between nations and cultures’.Footnote 77 Despite a commitment to immersing himself in Chinese language and culture, he remained an outsider to the emerging indigenous Chinese medical profession. This new class oriented itself towards cutting-edge practice and elite standards, rather than the preservation of the missionary and philanthropic institutions that had originally helped to introduce Western medicine to the country.
Yen’s time in Hunan, during which he also emerged as a leading figure in the national medical community, was shaped by his international education, professional ambitions, and constraining structural realities. He benefited from Hume’s mentorship, his Yale connections, and American philanthropic funding for his public health work, and his status with the Americans and elevated family background undoubtedly influenced his ability to corral the Hunanese gentry to support Xiangya. Nonetheless, his leadership of the NMA and pursuit of specialist training are indicative of his commitment to objectives beyond Changsha. Unlike Hume, the prospect of abandoning a career as a hospital specialist for a life of administration and provincial medical politics was a sacrifice he was unwilling to make, even if it threatened to create a personal rift between the two men. A leading figure in the increasingly organised, ambitious community of Western-trained doctors in Republican China, the prospect of serving as the intermediary between a group of benevolent American missionaries and the gentry of Hunan was unable to satisfy his broader goals.Footnote 78 Yen’s early career had developed under the influence and stewardship of missionaries and Western institutions; however, his personal convictions and the evolving political situation in China ultimately led him to redirect his considerable talents and experience towards fresh opportunities in Shanghai.
This study contributes to debates on the development of Western medicine in Republican China by highlighting how foreign and Chinese actors navigated personal ambition, professional pressures, and provincial politics. The achievements and setbacks faced by the Yale doctors reflected the specific circumstances they encountered in Hunan, a region marked by anti-foreign sentiment and a limited international presence. In this provincial and sometimes hostile environment, the institutional viability of missionary medicine was contingent on the goodwill and investment from the Chinese community. This contrasts with more richly endowed Western medical institutions in China such as PUMC where, as Bullock noted, ‘the boundless munificence of the Rockefellers’ eliminated the need for financial partnership with local bodies.Footnote 79 While institutional power at Xiangya was nominally shared, American staff retained significant control over finances, hiring, and curriculum, reflecting sustained hierarchies within the missionary medical framework. Nonetheless, Chinese figures like Yen understood their value within this system and demonstrated substantial agency in pursuit of personal and professional development, even at the risk of contradicting the wishes of senior colleagues.
This case underscores the distinct developmental challenges of Western medicine in provincial settings, where compromise and cooperation were a requisite dimension of securing institutional viability. This case underscores the role of personal relationships in shaping the evolution of Sino-foreign medical cooperation, a dynamic that merits further investigation across different institutions and regions. The origins of Xiangya also highlight the role of personal relationships in shaping a major Sino-foreign project, made possible by a complex package of support ranging from Hume’s Ivy League alumni connections and Yen’s family ties to the central government in Beijing. While this study has focused on two individual actors, their experiences indicate broader patterns in republican-era professionalisation, including the leveraging of foreign credentials, the cultivation of elite networks, and the redefinition of medical authority. Future studies might consider how the specific conditions of Sino-foreign medical institutions tempered the development of a distinct Chinese professional identity, drawing on the models provided by Western staff and administrators while responding to the growing sense of self-confidence in the indigenous medical community.
Acknowledgements
The author acknowledges the patient and helpful support of the team at the Beinicke Library, Yale University, in providing essential primary materials for this study.
Conflicts of interest
None.
