DEVELOPMENT OF THE ARMY NURSING SCHOOL IN CHINA by Mei-Yu Chow IN ST , . 12 JAN 1945 ( IaRAVI
Submitted in partial fultillment of the requirements for the Certificate of Public Health
Department of Public Health
The Massachusetts Institute of Technology 1944
Signature of Author
Signature
redacted,
Departmental CertificationSignature redacted
-w----L i --. wt.';' li~O~i - .-4L
ACKNOWLEDGEMENT
The writer is greatly indebted to Professor C. E. Turner for his kind suggestion and valuable advice in preparing this thesis, and to Dr. R. K. S. Lim for his unfailing encouragement and guidance throughout the work. The writer wishes to express sincere appreciation and
gratitude to Dr. S. W. Ling for reviewing the entire thesis, to Dr. S. K. Chow for his valuable criticism, to Miss May Ling for rendering valuable assistance, to Dr. C. C. Li of the Army Medical Administration for supplying many important data and information, and to many other colleagues for
generous help in various respects in the preparation of this paper.
Acknowledgement is also due to Dr. L. C. Yen, Director of the Emergency Medical Service Training School for allowing me privilege to use the material in the school reports.
M. Y. Chow
T ABLLE JF60 21&:
Page
I. General Introduction ... ... ...
1
II. Development of Nursing Profession in China ... 4
A. The Birth and Evolution of Nurses' Association of China ...
4
B. Organization of Committee on Nursing Education of the Ministry of Education ... 8
C. History of Army Nursing of the Army Medical Administration ... ...
17
D. Nursing Status Before War of 1957 ... 25
E. Red Cross Nursing ... 26
1. Organization of Medical Relief Commission of Chinese Red Cross ... 26
2. Nursing Service ...
31
3.
Nursing System ...35
III. Nursing Conditions During War ... 40
A. At the Front ... ... 40
B. In the Conumunication Zone ... ... 44
C. In the Ra... 46
IV. Development of Emergency Medical Service Training School... ... 50
A. General Development and Scope ... 50
1. Organization of the School ... 53
2. Training Courses ... 55
4. Branch Schools ... * 60
5. Financial Resources ... 62
B. Development of Department of Nursing and its Mission ... 62
1. First Stage (From May, 1958 -March, 1959)* ... 64
2. Second Stage (From March, 1959 -July, 1943 ... ... 71
V. Establishment of the First National Army Nursing School in China ... 89
A. Aim of the Army Nursing School ... 89
B* Courses ... 90
C. Contents of the Courses ... 90
D. Future Developments ... ... 94
1. Preparation of Candidates for Nursing Instructors and Administrators 94 2. Courses for Specialization . 96 VI. Reasons for the Establishment of a Regular Army Nursing System ... 97
ILLU u1YlJiU
1. Sketch showing General View of E.M.S.T.S. Campus. 2. Sketch of the ArsW Nursing School building.
5. Sketch of the Practicing Hospital.
THE DEVELOPMENT OF THE ARia NURSING SCHOOL IN CHINA
I. General Introduction.
The Sino-Japanese war broke out on July 7, 1937 at Lu-ko-chiao, Hopei, China. Trains on the Peiping-Hankow railroad
stopped partly, local fighting began. After a month and six days, Japanese planes dropped bombs on Shanghai. On August 15, 1957
the entire nation was engaged in war. As time went by, war areas spread speedily each day, fighting became more and more severe, and the life of the people became harder and harder. Now, we are
in our seventh year of the war and no-one in the country is uneffected. With a war going on, numerous cities were destroyed; villages ruined; business establishments and schools closed, families
scattered, and millions of people killed. Bombs were dropped by enemy planes everywhere. Young men were conscripted to join the army, navy, and air force. All the hospitals were flooded with wounded. Refugees fled to safer zones from all directions. Due to the constant moving of the population from city to city, the morbidity rate of the people increased, and infections spread. In the first two years, the whole situation was in chaos.
During the first part of the war, the financial condition was good and, with high patriotic spirit, all the citizens were doing their part. Almost every woman in the country was making or doing something for the soldier. Ten thousand silk padded jackets were made within three days for the soldiers at the front. House-wives cooked special dishes for the wounded at the hospitals.
2.
Shops donated their enamel utensils for hospital use. Students knit gloves and socks for enlisted men. Big office buildings were turned into temporary hospitals or hostels. People in commercial circles volunteered their trucks and cars to help the government
transportation corps in bringing wounded down from the firing line.
In the meantime, the Army Medical Administration organized hundreds
of military hospitals to take care of the casualties. Dressing Units,
Operative Units, Preventive Units, Transportation Corps were organized
and assigned to different posts along the fighting line -- front or
rear. The demand for medical and nursing personnel was so pressing
that everybody had to work doubly hard. Even then, the need still
was far from being solved. Therefore, short courses in emergency training were started.
As the war progressed, the medical and nursing services demanded not only a larger quantity of personnel but also emphasized a better
quality of staff. Unfortunately, big cities like Shanghai, flanking,
Peiping, Tientsin, Hankow, Chinan, and Wuchang, where well-equipped
hospitals and good nursing schools were situated, fell one after the
other into the hands of the Japanese. Moreover, important railways, water routes, and some of the key spots of communication were either partly crippled or blockaded by the enemies. Due to these diffi-culties in transportation and the high cost of travel, many nurses who wished to come out could not help but give up hope. Only a com-paratively small number of nurses succeeded in overcoming the good many difficulties in passing through several fighting lines to reach
free China safely. The demand for a large number of properly educated youth could not be fulfilled. Personnel from short term training can not carry heavy responsibilities, nor can they go far. Therefore, a big scale educational program for the training of medical and nursing personnel has to be launched by the Government.
After six and a half years of continuous labor and organized nursing effort, together with immense help from the society as well as support and encouragement from the medical group, the first National Nursing School was established on July 1st, 1945, under the auspices of the Emergency Medical Service Training School.
This thesis is a report on why and how the first national army nursing school was established in China. In order to make it clear, the history of Chinese nursing, both in civilian and military sides, will be briefly reviewed. On account of the difficulties of obtain-ing literature and references durobtain-ing the war, and handicapped by
the lack of time, (because the writer is still engaged in full-time war service during the preparation of this thesis), it is only natural
that this thesis is far from being complete. Nevertheless, most of the available facts will be given in the following pages so that those who are interested in this topic may obtain a general idea of what Chinese hurses have done and are still doing for their country during this World War II.
II. Development of Nursing Profession in China.
A. The Birth and Evolution of the Nurses' Association of China.
Modern medicine in China has a short history of a little
more than one hundred years. Before that only old Chinese
medicine was practised. In the year 1807, the first missionary,
Robert Morrison, came to China to preach Christianity. Gradually
more and more missionaries followed his steps. In order to
preach Christianity successfully medical arts were wisely utilized as a means to approach the people, thus fundamental principles
of modern medicine were introdgced. In 1808, the first qualified
surgeon, Dr. J. Livingstone, came to China. Shortly after the
arrival of the missionary doctors, dispensaries and clinics were
opened. In 1835, Dr. Peter Parker established the first
hospital in Canton, which was responsible for taking care of eye cases only. Two years later, Dr. Parker began to enroll Chinese medical students. About 50 years later, 1884: Miss Elizabeth McKechnie, the first missionary nurse, came to China.
Since then more and more foreign nurses came in. With the growth
of missionary activities, more hospitals were established and more personnel was needed. Some hospitals started training
dressers and attendants more or less on apprentice's system.
Not until the year 1887. did D . Boone get some foreign nurses
together and started a nursing school at Shanghai. This is the
5.
Miss E. Johnson opened another nursing school at Fukien. Shortly
afterwards several other schools were established at different
localities, solely under the auspices of the missionaries. A Medical Association was organized by foreign doctors in China in 1938 . Regular bulletins and journals were published by this Association for the purpose of enabling the medical personnel to communicate with each other about the progress of their work, and also to print abstracts of outstanding professional papers. Dr. P. B. Cousland was the chief Editor of this Medical Journal during the year 1908.
Miss Cora E. Simpson was sent to China by the Methodist Mission Board in 1908 to take charge of nursing service at a hos-pital in Fukien. She was most courageous and enthusiastic in organizing nurses' work in China. Shortly after her arrival, she corresponded with Dr. P. B. Cousland of the Chinese Medical
Assoetation, expressed the need of a Nurses Association in China, and wondered if the Medical Association could give her support and help. The letter was written in November 1908. Dr. Cousland replied to her letter promptly, and generously offered a page in the medical journal for nursing activities and news. Through this journal which touches every hospital, the nucleus of Nurses
Association was formed. In the following year, the Nurses
Association of China was formerly organized. Coincidentally, the first Chinese nurse, Miss Mao-fang Chung, came back home after
graduation from the Nursing School of the Guy's Hospital of London. She joined the Association immediately. A few meetings were held at Ku-ling, Kiang-si, to discuss the regulations and by-laws. Mrs. Hart of the Wu-hu General Hospital was elected
the First President of the Association, and Miss Maude Henderson of St. Andrew's Hospital of Wu-shih, Kiang-su, General Secretary.
For all these years, the Chinese nurses have been grateful for what Miss Simpson accomplished years ago. Miss Simpson is an old lady now, near to her seventieth birthday, and is still with us, serving as the English General Secretary of the
Associa-tion. Words can hardly express how much we are indebted to what Miss Simpson and those pioneer nurses in China have done for us. The only way through which we may reward them is perhaps to
uphold our profession and serve humanity the best we can.
In 1912, three years after the Association was established, a mass meeting was called at Ku-ling. Through the inspiration and broad visiont of Miss Nina D. Gage (President) and Miss A. Clarke (General Secretary), and a few others, fruitful results were obtained at the end of the meeting. Their main aim was to organize all nursing activities in China under one organizatiom. to standardize the curriculum of nursing schools, and to enforce nation-wide examinations to the nursing students before they are
considered as qualified nurses. The association will not only look after the growth of professional nursing in China, but also put the nursing education on a solid foundation leaving enough
7.
room for future expansion.
The following proposals were resolved:
1. To set up regulations for registration of nursing schools, and to enforce them.
2. To standardize curriculum for nursing schools.
3. To give nation-wide examinations to nurses.
4. To issue diplomas for those who pass the examinations
satisfactorily.
5. To translate and prepare Chinese nursing books.
(Textbooks and references)
Since the meeting of 1912 up to 1935. the Nurses'
Associa-tion of China (N.A.C.) with the cooperaAssocia-tion and support from all the memers has been able to stick at its aims firmly and
successfully. In 1935, the Government took over the educational responsibilities. Since then N.A.C. serves as a regular professional
organization.
In 1918 N. A. C. printed its first Association leaflet.
Gradually this leaflet developed into a respectable journal
published quarterly. In 1922, N. A. C. joined the International
Countil of Nurses as a regular member, and attended their meetings once in every three years regularly, thereafter.
During the first World War 1914-1918, there were only four registered nursing schools in China with a small number of students. Graduates were so few that the number may easily be counted
hostilities, 1957, there were one hundred and seventy-four N.A.C. nursing schools, with a total of 6,572 graduates.
Financially, Nurses' Association of China is self-supported, maintained mostly by the membership fee. Only on rare occasions, when there were special projects which needed communities'
support, did the Association hold money raising campaigns. Practically no subsidy or funds are received from the Govern-ment.
B. Organization of Committee on Nursing Education of the Ministry of Education.
Thirty-three years ago, when China was still under the control of the Manchurian Emperor, Chinese girls were not
allowed to attend schools. They could only be taught by private tutors at home. At the age of fifteen, most of the girls were supposed to stop studying books and to concentrate their minds and efforts upon sewing, embroidering, and general housekeeping.
Until 1911, when the Republic of China was established, some educators began to think thoughtfully and to advocate laborously that girls should attend schools too. Since then girls have been given equal chances as the boys and allowed to come out of homes to attend schools. Although the "Door of Study" is open to
girls, the traditional prejudice towards women can not be changed with a short period. Therefore, it is quite natural that only a small portion of the girls attended school during that time.
All this hindered the progress and growth of the professions for women.
When the missionaries introduced "nursing" to China in the early days of the Republic their work progressed extremely slowly. The reasons were three fold. In the first place there weren't enough educated girls to be trained to enter the nurbing pro-fession; secondly, no girls from decent homes wanted to come
out to serve the sick in the hospitals, and thirdly, it was not the Chinese custom to stay in hospitals when they were sick. When people were sick, they stayed at home. A native physician would be consulted. The patient would be attended by his or her mother, wife or sister, or even servants. With these obstinate
traditional ideas in most people's minds, nursing was not popular in the early stages. Gradually people became more open-minded, new ideas were accepted more readily, and little by little a new
social set-up emerged in the society.
In those early days, the government was busily occupied in war affairs of either international or civil nature. Not until
1928, did the actual unification of the nation take place. Under the direction and control of the Central Government, Nanking, the national construction program soon began. At that time, most of
the hospitals and nursing schools were under the care and patron-age of the missionaries with fairly good development. Although there were already a few municipal and provincial hospitals with
some small nursing schools, most of them were so badly equipped
and poorly administrated that they could not compete or compare with
the missionary ones. In 1952, Dr. J. Heng Liu, the first director
of the National Health Administration, called the Ministry of Health at that time, established the First National Central School of
Nurs-ing in Nanking, cooperating with the Central Hospital and using it
as the practising hospital. This nursing school was the only one
owned by the Government and was of the proper standard.
With his deep interest and unfailing effort, Dr. J. Heng Liu convinced the Ministry of Education that the Medical Education (in its broad sense) should be taken into the government educational system, and that a Commission should be appointed to work and plan
for the national needs. In the spring of 1955, the Commission of
Medical Education was officially inaugurated, under which there were
six committees; namely, medical, nursing, midwifery, pharmaceutical,
health education and dental.
The Committee on Nursing Education consists of nine to eleven
members. Among them, five or six members are prominent nurses, one
or two distinguished medical educators, and the rest government
officials. A full time general secretary was appointed (the secretary is also a member of the committee) to carry out routines and
resolu-tions of the committee. All these members were appointed by the
Minister of Education. The functions of the Committee are as follows:
1. To formulate national policies on Nursing Education.
5. To compile and translate nursing textbooks for reference. 4. To furnish information and offer opinion to the
Ministry on problems of nursing education.
5. To take charge of the national examination for graduating nurses.
Unfortunately, two years after the Government took over the responsibilities of nursing education from the Nurses' Association of China, the Sino-Japanese hostilities broke out. Plans for
peace-time work had to be substituted by programs for war service. Most of the plans had to come to a temporary suspension. However, dur-ing those first two years, the secretary of the committee made field inspections to most of the nursing schools, governmental or private. The length of time during training in different schools was found to vary from three to five years. Most of them fell
be-tween three and a half to four years. Some of the smaller nursing schools were inadequately furnished. The serious problem of short-age of teaching personnel and lack of facilities was generally felt. Many nursing students were overburdened with too much duty service and were not given enough time for study. Financially, they were dependent on their hospitals. To amend these faults the Ministry took the necessary actions immediately. The regulations for
school registration were published first, and enough time was allowed for the various schools to meet the government standard. Up to the present war, 87 schools have completed their registration; among them ten are public, while seventy-seven are privately owned.
1'.
Because of the war, those nursing schools which are situated in the occupied areas were unable to communicate with the
central government freely and, therefore, did not have a chance to complete the procedures for registration. Furthermore, the fact that many of the nursing schools and hospitals are .at present either under the control of the Japanese or have already been turned into enemy military hospitals, made the whole problem even more serious.
Through the recommendation of the general secretary of the Nursing Committee, the Ministry has given financial support to those schools which need help. Before the war, two teachers' courses were started; one at Peiping, in cooperation with the Peiping Union Medical College and Hospital, and the other at Nanking in cooperation with the Central Hospital. Both of them were one year courses. The candidates for admission were to be graduates of registered nursing schools, with two or three years of teaching experience. Two classes had completed their studies successfully, and the graduates all returned to their respective nursing schools to teach. The third class was started in 1957 but was soon broken up and discontinued because of war.
Chinese nursing textbooks were mostly prepared by the Nurses' Association of China. This work occupies the fourth chair in the International Council of Nurses. Since the Ministry of Education took over the nursing educational programs,
arrangements made with the authors to have some new books published for the schools to use.
The work on national examinations for graduating nurses was taken over by the Ministry shortly after 1937. The examiners were invited by the Committee on Nursing Education to prepare questionnaires on different subjects. The questionnaires were sent to the different schools and regional examinations were held. The papers were sent back to the Ministry. The results of the examination were announced by the Ministry to the school authorities. Those nursing students who passed the examinations satisfactorily were qualified to receive the diploma and the name list was referred to the National Health Administration for application of nursing certificate and license. They are then recognised as registered nurses.
Standard Curriculum of Nursing School (Three Years)
(Prepared by Ministry of Education)
Name of Courses Number of Hours
Recitation & Lab. Practice
Sociology 20 Civics 60 Chinese 120 Foreign Language 80 History (General) 40 Geography 40
Name of Courses
Re Psychology
Chemistry
Anatomy & Physiology
Bacteriology & Parasitology Nutrition
Pharmacology Personal Hygiene First Aid
Household Management Nursing Ethics & History Nursing Principles
Nursing Arts Surgical Nursing
(Including nursing in diseases of the eye, ear, nose, and throat)
Medical Nursing
(Including nursing in infectious diseases and skin diseases)
Nursing in Mental Diseases Obstetrical Nursing
Gynecological Nursing Pediatrical Nursing
N ecitation & Lab.
40 40 100 50 40 60 20 10 10 20 100 120 unber of Hours Practice 60 60 20 50 15 50
L5.
Name of Courses
Public Health Nursing Midwifery
Physiotherapy
Professional Problems Case Study
Number of Hours Recitation & Lab. Practice
40 30 10 10 10
Hospital Nursing Practice 4,161
Public Health Nursing Practice _ 284
1,265 4,445
Grand Total 5,710 Hours Arrangements and agreement haye been made between the Committee of Midwifery Education and the Committee on Nursing Education that it is possible for any registered nurse to become a registered midwife by taking a one year special course on midwifery. The same principle and arrangement hold good for registered midwives to become registered nurses in the nursing schools. Several good midwifery schools have been chosen and appointed by the Government to offer such courses.
Just last year (1942) the Ministry started a school, with three years curriculum, for post-graduate training for nurses. The aim of the school is to prepare nursing teachers. The follow-ing subjects are given in this course:
1Ii. Subjects San-ming-chu-yi Chinese Foreign Language Sociology Psychology Principles of Education Nursing education
Medical & Nursing administration Teaching & administration, applied Principles of nursing
Anatomy & physiology
Bacteriology & parasitology Pharmocology
Pathology Nutrition
Public Health Nursing
Public Health Nursing practice Hospital nursing practice
Number of Credits 4 6 -6 2 5 4 4 4 16 4 .5 4 6 6 5 5 4 37 Total 126
In China, the School of Nursing of the Peiping Union College is the obly collegiate nursing school. This school was endowed by the Rockefeller Foundation in the year 1920, and registered under the Ministry of Education in 1950. It is most
up to date. Its chief aim is to prepare nursing teachers and administrators. Up to the present, many of its graduates are holding important positions in the various fields of nursing. Unfortunately, the college has been occupied by the Japanese
since the outbreak of the Pacific War. Through the efforts of the Graduate Society of the P.U.M.C., the School of Nursing was reopened in Cheng-tu in August, 1945.
As the need for nurses both for war-service and for post-war national construction is so urgent, the Ministry is now
making great effort to try and generalize nursing education in the whole country. More schools have to be established. That is, sufficient number of teaching staff have to be trained and adequate teaching equipment and facilities prepared. In every middle school and normal school, girl students are at present required to take a course in "Home Nursing." It is hoped that this may prepare the girls to understand the actual meaning and need in nursing, so that those who are interested may come to join the profession upon the completion of their high school education. With the cooperation of the Nurses' Association of China the building of a strong nursing program for the coun-try is very possible.
C. History of Army Nursing of the Army Medical Administration.
The Army Medical Service was organized under the
"Revolutionary Army" back in the year 192 . At that time it was just a small medical section organized to help the enlisted
men and officers in the fighting forces. The director of the medical section always travelled with the army headquarters. In 1928, the victorious "Revolutionary Army" (Ke Meng Chun) unified the entire nation, and a strong Central Government was established in Nanking. The army headquarters was reorganized and became the "Ministry of War." At the same time the medical section was enlarged to become the present "Army Medical Adminis-tration." Since then, this Administration has been responsible for all medical problems concerning the army for the whole Country.
The Army Medical Administration is under the direct control of the Ministry of War. Besides the Director's (Surgeon-General) office, there are six departments; namely, Department of General Administration, Department of Medical Service, Department of
Public Health and Education, Department of Pharmacy, Department of treasury, and Department of Inspection. There are hundreds of military medical organizations attached to and receiving orders from the Army Medical Administration. Some are giving direct medical service to the soldiers; while others are responsible for the transportation of patients. A group of organizations are responsible for the purchasing, manufacturing, preparing, issuing,
transporting and safe-keeping of medical supplies. Others are responsible for carrying out educational work. A special technical program committee was organized to study the various problems and research projects, thus guiding the development of various
organiza-tions to meet the national needs. (The organization of the Army Medical Administration is shown on page 20.)
In the Army, there are many kinds of soldiers - nursing soldiers being one of them. The name "Nursing Soldier" was
started in 1926. Before that they were called "medical soldiers." The position of the nursing soldier is somewhat equivalent to that of the orderlies in the hospitals. They are either assigned to the field troops such as battalion, regiment and division, or to different kinds of military hospitals such as divisional field hospital, army field hospital, army hospitals at rear, hospital for the severely wounded, base hospital, etc. The highest rank for a nursing soldier to attain along the nursing line is non-commissioned officer (N.C.0.). There are no higher regular nursing officers in the army. The highest nursing offi-cers (N.C.0.) in a base hospital do not do nursing work. They are responsible for registration of patients and caring for hospital linen supplies.
The training for the nursing soldiers varies. The Army Medical Administration issued a curriculum to be used ad a guide for teaching nursing soldiers. The topics are as follows.
1. Military drill.
2. Organization and responsibilities of different military medical units.
5. International law of "Red Cross."
4. Structure and function of the human body. 5. First aid.
ORGANIZATION OF THE Af(Y MEDICAL ADMINISTRATION
Ministry of War
Am3 yMedical Administration
'-.---~-.---.--.---..---~ I - Y
Dept. of Medical Ser-vice
l.Medical Section 2.Project Section 3.Control &
Manage-ment of Wounded and
Sick SodiA' r Surgeon.General' a Office 1.Secretarial Section 2.Statistical Section .Technical Expert Section
Dept.of General Admin-istration
1.Personnel Section 2.Business Section 3.Clerical Section 4.Contral and
Manage-ment Section
Dept.of Public Health and Education
l.Educational Section 2.Technical Section 3.Public Health
Sec-tion
Dept.of Inspection Dept. of Pharmcy
l.Manufacture &
Pre-paration Section 2.Supply Section 3.Supervisory Section Dept .of Treasury 1. lst.Section 2.2nd.Section 3.3rd.Section 4.4th.Section I
7. Disinfection.
8. Different kinds of wounds and their treatments. 9. Introduction of Communicable Diseases.
10. Introduction of common diseases seen in the army. 11. Nursing:
a. General principles of nursing.
b. Observation of symptoms and care to be taken. c. Nursing care of communicable diseases.
d. Nursing care of mental cases. e. Assisting in treatments. f. Operating room nursing.
g. Care after death. 12. Massage.
13. Transportation of wounded. 14. Drugs and solution.
15. Preparation and management of supplies and equip-ments.
16. Regulations of army hospitals. 17. Practice (clinics and hospital). 18. Ethics.
The above subjects constitute the teaching materials for a six month's study. Because of the war and the urgent need for trained personnel, the Army Medical Administration issued an
Since the birth of nursing in the army until the Sino-Japanese war, eleven years have gone by. Under the Ministry of war there is the Army Medical College for the
training of army doctors and there is the Army Pharmaceutical Course for the training of pharmacists for the troops. How-ever, there is no Army Nursing School for the training of nurses for the Army.
The nursing soldiers are taught in their respective clinics or hospitals more or less as servants and appren-tices. The pay for the soldiers is so low that most of the time only the illiterate and dull ones are employed to perform the hospital nursing duties. Good and intelligent soldiers are usually assigned to the fighting forces. Furthermore, because of the lack of nursing officers in the army medical organization, very few qualified nurses join the army. When they do join, they have to do medical officers' duty instead of nursing. Since there are no nurses or not enough nurses in the army, the nursing soldiers are taught by the medical officers. The background and foundation of the nursing soldiers vary a great deal. No suitable textbooks have been prepared for them. The result of the training, of course, is far from satisfactory. Thus, army nursing service falls into the hands of a group of people who do not understand nursing intelligently. When one does find bright students among the
soldiers, they are bound to get promotion through their intelligence and ability. But the promotion will carry them up to be medical officers instead of nursing staff. As it has already been pointed out that the highest rank for nursing in the Base Hospitals and Field Hospitals is
but a non-commissioned officer, no ambitious young man
would like to stay in such a post for life. So up to the
present war, proper nursing service simply did not exist in the Army. All these difficulties link into a vicious cycle which could only be broken by the establishment of a satisfactory army nursing system and an extensive
edu-cational program for the training of army nurses. After
reviewing the situation one is bound to realize that the civilian nursing is much better off than the Army Nursing.
D. Nursing Status before the War of 1937.
Up to the war most of the big cities possessed quite a number of good nursing schools. They had good buildings,
teaching faculty and practising hospitals. The teaching
had been carried on regularly and progressively. Each year
a few hundred nurses graduated from these schools.
Since 1925, nursing has not been confined to hospitals and clinics only but it has spread and come in contact with society at large. Public health work was first started at
*;L.
country both in urban and rural areas. In ten year's time work on maternity, child health, school health, industrial health, control of commnicable diseases, sanitation, tuberculosis pro-gram and health education was started by the health organizations. Nurses began finding new posts, as health educators, in differ-ent fields.
The nursing schools' authorities changed their curriculum, and improved their teaching methods so as to meet the new demands. The teaching fields expanded to families, schools, factories, and all sorts of community organizations. Centralized systems and decentralized systems were applied in different organizations according to the nature of that particular locality. Urban
health work could be found in almost every big city of thQ principal provinces, even in Mongolia. As for the communities
-mothers received health training either in their own homes or through mothers' clubs. New babies were delivered either by trained modern midwives or by doctors. Health habits were taught in the schools. "Knowledge of health" was a required course for students from kindergarten up to senior high school. Sanitation was enforced and managed by the health department, combined with police force. Sanitoria were built for tuberculosis cases.
Factory workers received physical examinations, medical treatment, correction of defects, and preventive innoculations regularly. Everything along the line of health was beginning to pick up. Although the health activities had not spread as widely as
desired, yet the demand for nurses was tremendous. More nursing schools had to be established to answer the call.
As China is an agricultural country, rural reconstruction is even more important than city establishment. From 1928, several localities such as Ting Hsien of Hopei, Hsiao Chuang of Nanking, Kao-chiao of Shanghai, had been selected for exper-imentation in rural health work. Five years afterward health work had become even more popular. It was required by the Central Government that each county should have a hospital.
With the increase of inter-provincial and inter-county highways, the "difficulty of travelling" of the past was greatly reduced. Some of the county magistrates by utilizing local labor and finance, with perhaps some subsidy from the provincial
government, built up many good county roads, laid telephone
systems, started cooperatives, and even established more schools. With all this construction and work, the growth of health work had been speeded up either directly or indirectly. The
open-ing ap of highways usually brought a change in the pbople of
the locality. They became more open-minded, and intelligent; and more willing to accept new things. Nurses or health teachers became quite popular among the country folks.
Then suddenly came this war of 1937. The military budget had to be increased for the urgent need. The people who usually lived at coast regions had to come inland to work. Many of the newly established industries had to declare a temporary closing,
26.
Nursing is such a young profession in China in comparison with other well established professions that the blow was really hard and the suffering tremendous.
E. Red Cross Nursing.
1. Organization of Medical Relief Commission of Chinese Red Red Cross.
When Shanghai was engaged in war on August 15, 1957, the Central Government realized that the war was going to be a long one. Therefore, a "Central Medical Relief Administration of the Ministry of Medical Service" was organized under the National Military Council. Dr. J. Heng Liu was appointed as the Minister. This Central Medical Relief Administration was the combination of the Army
Medical Administration and the National Health Administration of the Civil Service.
As the fighting went on, many local hospitals were organized to take care of the wounded. The National Red Cross Society of China was very actively engaged in this respect. On November llth, 1957, the Chinese army in Shanghai withdrew, and one month later Nanking fell. At that time the whole national situation was in great con-fusion. All the government institutions were evacuating and many were on their way to Hankow. Above all, all wounded had to be evacuated, and supplied transported.
Many of the volunteer workers of the medical relief work were not expected to follow the troops or the wounded. Just at that time, Dr. Robert K. S. Lim arrived in Nanking. He was asked to help the medical relief service. Wo'rking under great difficulties, they succeeded in getting all the wounded out either to Hankow or Nanchang. Up to December of 1937, some seven hundred hospital workers gathered in Hankow. A conference was held by Dr. J. Heng Liu, Dr. P. Z. King, and Dr. Robert K. S. Lim, and some others. Dr. Lim suggested
the reorganization of the Red Cross. The suggestion was immediately accepted, and details planned. Unfortunately,
just
at this time the Ministry of Medical Service wasabolished by the Government, and the Central Medical Relief dissolved automatically. Dr. J. Heng Liu resigned from the directorship of the National Health Administration and
Dr. F. C. Yen became his successor. Dr. Yen lost no time in re-organizing the medical relief service. Dr. Lim proposed
to organize the Medical Relief Commission under the National Red Cross Society of China. They all agreed to this proposal
and the resolution was forwarded to the Chinese Red Cross Society H.Q. at Shanghai. It met with the Board's approval, and Dr. Lim was appointed as the Director-General of the Commission.
General Administration, Medical Service, Transportation, and Supplies. Besides, there was an independent Account-ing Department. (The Organization of Medical Relief Commission of the Chinese Red Cross is shown on page 29.)
Since the reorganization of the Red Cross Medical Relief work, the old policy has been changed in' such a way that the Red Cross would no longer run hospitals by themselves but insert their personnel into other military medical organizations. The reasons for this are two fold. First, the fighting line is too long and the means of
transportation so poor that it is impossible for the Society to establish hospitals in each war area with reasonable amount of success. Secondly, a large number of hospitals and stations have recently been established and organized by the Army Medical Administration. Therefore, it would be a great help to both sides if they could cooperate with each other by inserting Red Cross units into the military medical organizations. Both parties agreed to the plan so it was put into practice at once.
Under the Department of Medical Service, there are five different kinds of Units, namely; ambulance unit, nursing unit, curative unit, X-ray unit, and preventive unit. There were 15 to 20 members in each unit. Nurses are the indispensa-ble members to every unit except X-ray. At the beginning,
21 .
oR-AKi!'A 'oN oC :EDIuA RELIEF COY"I5ION OF CHRa:SO RED GhOS
Direetar's Staff
Dep't. ef General [.Dep't. ef Medieall
Administration Servise Organization Personnel Training Ambulanee Unit Nursing Unit Curative Unit X-Ray Unit Preventive Unit Planing Regulsti Operation
Dep't. ef Dopt. of Supply
TransportationI Finanee Doeuments Statistios Transportation of supplies, personnel, and wounded purchase, preparation, and distribution of supplies
the Medical Relief Commission of the Red Cross organized 57
units, with a total number of a little over 200 nurses.
Gradually the number of units increased, and more people came to Join the work. The financial resources of the Red Cross were largely dependent on the contributions from friends in China or abroad. Government funds constituted only a small portion.
By the middle of 1958, it became extremely difficult to secure doctors and nurses. Many of them could not come out from the occupied areas as travelling was getting more
diffi-cult and more expensive. At that time the National Health Administration started to organize a number of Preventive Units and Highway Health Stations to take care of the civilian popu-lation. This absorbed a large number of available medical and nursing personnel.
As the war developed further, the moving of the population from place to place was greatly increased. With this tremendous moving about under hard life and unpleasant travelling, epidemics such as malaria, cholera, typhus fever, etc., broke out and
spread like forest fire. The responsibility to maintain or keep the civilian health under such dreadful conditions was indeed a heavy responsibility. Most of the big cities were then the targets of frequent bombing. Air raid casualties inevitably increased. All of this increased the need for people to serve. With the small handful of technical personnel divided among
51.
civilian and army organizations, no institution then had
enough staff to carry out their duties successfully. In order to help solve this problem, the National Health Administration started "Emergency Medical Service Training School" at Changsha
in May 1938. Both the Red Cross Medical Relief Commission
and the Army Medical Administration were invited to participate in this program. The Director of the Red Cross Medical Relief Commission, Dr. Lim, was appointed concurrently as the Director of the School. As soon as the training program was started hundreds of middle school students enrolled to prepare
them-selves as junior workers in the Red Cross Medical Relief Service. When the students finished the planned course successfully,
they were assigned to serve in the different units under the supervision of doctors and nurses.
2. Nursing Service.
As it has been mentioned before, there are nurses in all. the Red Cross Units except X-ray. Because of the small
number of nurses we had, we could only assign five to eight nurses to each unit with some student nurses and other subordi-nates. They worked in different kinds of military medical organizations from the Field Hospital of a Division up to the Base Hospital at the rear.
In China, we have both men nurses and women nurses. How-ever, the women nurses outnumber the men nurses. This is also true in the Red Cross. The girls in the Red Cross certainly
have shown outstanding courage. Almost none of the nurses has ever refused an assignment, no matter how near to the firing line it was. In those roadless areas, travelling was not easy. People could only travel on foot. To cross muddy rice fields, climb mountains, pass through creeks and streams with enemy planes hovering over head, to walk in the pitch dark night without light and with Japanese chasing behind, demands extraordinary courage, will power, and love for one' s country. Once during one of the main battles, a girl (nurse), while planning to escape in a great hurry with enemies close behind, still had the nerve to get two horses fully loaded with unit supplies, and brought them back single-handedly and safely to the Red Cross Field Headquarters. In another
instance, one of the Red Cross Units was dispersed by enemy attack. Two girls had to walk nine days before they rejoined
their unit again. Several nurses sacrificed their lives. Some died of typhus fever while serving the sick soldiers in a
bad epidemic. Some were killed during air-raids while trying to save civilians.
When there was no actual fighting going on,, the life of the unit was peaceful. The members of the units, situated in mountainous regions, drilled themselves early in the morning, and practiced mountain climbing. They would come bak in time for breakfast with minds fresh. Then they were ready for another long day's work in the hospital. In the afternoon they
they attended ward duties, prepared dressings for the next day, or conducted some classes for the hospital nursing orderlies.
At the front, where heavy bombing and shelling continued
the whole day long, dressings of the wounded were changed at
three o'clock in the morning. During daytime, both the patients
and the staff hide themselves in some comparatively safer places
to avoid unnecessary sacrifice. Work was resumed after sunset,
and usually continued throughout the night.
The Red Cross nurses not only worked in the military medical institutions, they also worked in the refugee camps, war
orphanages, air-raid casualty stations, first aid stations, preparation section of the Supply Department of M. R. C., and teaching.
In the refugee camps and war orphanages public health
nurs-ing was applied. The units spent much time in improving the
sanitary conditions '6f the environment and in running Clinics.
Preventive innoculation and education were rendered.
Arrange-ments were made for the refugee women to spend their time more constructively by doing sewing work and in return to receive financial help.
In big cities where air raids were frequent, the Red Cross Units prepared five teams ready to serve during any air raid.
They are: the ambulmee team, stretcher team, dressing team,
operating team and hospital team. After bombing, the severely
poured in by the thousands; some came by themselves, others were carried by their own relatives. As soon as they
arrived at the gate, the stretcher team took the wounded down to the dressing team, while the ambulance team went away to collect some more. The dressing team began washing the wounds and sorting cases immediately. According to specific needs,
some were given first aid treatment and T.A.T. innoculation; some were taken to the operating team for operation, while the bad cases were taken to the hospital team for treatment in the hospitals. After a certain length of time the fully recovered ones would be discharged, while others were transferred to local hospitals for longer treatment and care.
In the Red Cross, only standard supplies were issued to the units. All medical supplies are divided into three main
groups. "C" stands for chemicals; "D", for dressings and
linen supplies; and "E" for equipment. Each main group was again subdivided into small groups, some for surgical use,
some for medical use, some for certain kinds of diseases which are very common in the army, etc. Each of them was given a code number and a limit for its size and weight. Those who need any of the supplies just put down the code number, such as C.I. or D.5, on the requisition, and they will get them in standard packages. This policy has been upheld until now. The reason for issuing a standard supply is simply because we
of prescribing. To make the necessary budgeting, planning,
purchasing, packing and issuing so as to suit all the individuals' needs and desires is utterly impossible. Therefore, since the reorganization of R. C. M.R.C., the policy of using "Standard Supplies" has been followed, Some of the nursing units were assigned to the Supply Department to work. To prepare ,dressings
is the most time consuming job. In China, due to lack of
machinery, all have to depend upon hand-work. Due .to the limited budget and personnel, volunteer services were encouraged. The nurses went to schools, refugee camps, women's organizations,
clubs,. and churches to ask for help. In those busy days we
succeeded in getting thousands of school children who volunteered to spend two hours each day to fold gauze and roll bandages for the wounded. The women volunteers helped in sewing and cutting. Each day we were able to prepare 100,000 men's dressings. All were sterilized in the main supply depot.
Nursing teaching work will be discussed more fully under the title "Development of Emergency Medical Service Training School" in the latter chapters.
5. Nursing System.
In the Chinese Red Cross Society there are nursing con-sultants, supervisors, head-nurse (for each unit), staff nurses, nursing students, and subordinates. Up to the latter part of 1940 there were about 100 units in the field. The work was running
on a decentralized basis. The field supervision and guidance were important activities. Through them the efficiency of the work would be measured regularly, and a thorough understanding between field units and headquarters
would then be established. During the first two years, field
trips were made by nursing consultants. Because of the
limited number of personnel and heavy training
responsibili-ties, trips had not been made as regularly and systematically
as wished. Towards the end of 1939, suitable nuroet's were
available to take up the supervisory duties. Each of the
supervisors was assigned to stay at the headquarters for four
to six months for observation and participation in nursing
activities, both in the Nursing Department of the Emergency
Medical Training School and the practising hospital before
being sent out for field service. In this way they became
familiar with the Red Cross Nursing work and the general policy of the Headquarters.
Objectives for the supervisor's field trip:
a. To study field situation in a generalized way.
b. To visit and study different kinds of military
hospitals where the Red Cross Units work.
c. To study field nursing problems.
d. To make suggestions and try out the nursing program
for improving the situation.
General impressions of nursing supervisors during their field visits:
a. The Unit members were glad to know that hereafter Headquarters will send nursing supervisors to visit them regularly.
b. The efficiency of field nursing work could be improved greatly if more nursing leaders were provided in the field.
c. Most of the military hospitals at rear were far below any "hospital standard." Their difficulties were many but the main ones seemed to be the lack of medical and nursing equipment and insufficient
enthusiasm among the hospital staff.
d. Most of the field nursing staff were willing to co-operate with the nursing supervisors provided the Unit Leader was keen on nursing activities.
e. The cooperation of hospital staff and .Red Cross members should be strengthened, so the efficiency of the work can be increased.
General duties for Nursing Consultants: a. To plan for the progress of the service. b. To collect and analize field nursing problems
through reports, personal interview, and field visits.
c. To guide and check up the supervisor's work regularly.
d. To keep in close contact with field work and to find out the possible causes for going up, decline, or remaining stationary.
e. To answer special calls and try out new projects in the field.
f. To measure the efficiency of nursing service done by the Group and give regular report.
g. To help and keep up the staff education.
The instance on how the Special Diet Program was started may serve to illustrate one of the achievements done by the consultant. In the early part of 1940 sick soldiers, especially the nutritional cases, became a very seidous problem. Appeals were sent out to the various philanthropic and patriotic organizations of the community. The society, known as "Friends of the
Wounded", responded very enthusiastically. They requested the Red Cross to send them a nursing consultant to demonstrate the need of special diet among the sick and wounded in the military hospitals. The demonstration was done at the 5th Army Hospital at Chungking, during which some of the government high officials attended with much interest. When they saw the actual conditions, they were much impressed. Later on, lots of money was
As the project of special diet has awakened so many people who realize its importance for the recovery of the wounded and sick soldiers, almost every province has since contributed money for this work. Red Cross nurses were asked to take the responsibility of teaching the Base Hospitals' nursing group, and also assigned members of the Friends of the
Wounded to do it in different hospitals. Now the project of
special diet is one of the four main programs of the Friends of the Wounded, and Army Medical Administration has a special budget for this work in all military hospitals.
III. Nursing Conditions During War.
A. At the Front.
During the first part of the war there were sufficient
means of transportation to have all wounded taken down. Very
few were left at the front. But after the fall of Hankow and Canton, most of the fighting took place in roadless areas. Highways were destroyed and turned into rice fields and
narrow passes in order to prevent the advance of the enemy's
mechanized troops. Under such difficult conditions in
transportation, many of the wounded had to be carried down on stretchers. Motor convoy, boats, and railway could only be used in a few localities. The harder the problems concerning transportation became, the larger the number of wounded and sick soldiers had to be kept in the field hospitals.
In rural China, there are many temples; some belong to
the public, some are owned by certain families or private concerns. During peactimes these temples were mostly used as school buildings. Besides the temples there are store-houses and local factories, such as water mill for treating grains or making sugar. All these big houses were turned into temporary field hospitals. The furniture of the hospitals was usually either borrowed from the local people or made by the soldiers. All available natural resources such as bamboo, wood, clay or bricks that they could gather from the
particular locality were utilized. In south China where bamboo is abundant, they used it for making beds, tables, chairs,
window screens and even operating tables. Straws were used for making mattresses, quilts, and sometimes partitions with pretty designs.
At the front, the supplies had to be cut to the minimum so as to avoid unnecessary waste and burden. The bedding for the wounded is confined to army blankets. Some of the better places issued linen sheets besides the blankets -to the hospital. As a whole, the linen supplies were very short.
The food for the wounded and sick soldiers was far from being sufficient. Usually, two kinds of diet were issued; one is considered as a full diet which consists of cooked rice, one vegetable and one soup, and the other is congee and vegetable. Due to the insufficient ration and comparatively high cost for food stuff, many soldiers developed nutritional diseases. In the summer and fall there was a large number of cases of gastro-intestinal diseases, especially diarrhea and dysentery. Those
soldiers who had a chance to station at one place for a compara-tively long duration had the opportunity of cultivating garden vegetables, raising pigs and chickens, and thus became better off. But those who travelled long distances continuously, or moved
constantly from post to post suffered the most. Frequently, troops were ordered to strategic points where it was so desolate that it was not suitable for living. The conditions were worst when the land was not suitable for cultivation. In such cases
get hold of.
Water has always been a very serious problem. In most of the hospitals, water for either external or internal use was far from being well supplied. The reasons are: firstly, the Chinese have the habit of using hot water and drinking hot
tea, and soldiers are not accustomed to using cold water or drinking it. Fuels were so expensive and the budget so limited
that the water could not be heated. Secondly, most of the villages were so -overcrowded that the water supply was far too limited to meet the demand. In order to overcome these diffi-culties we had to have a large quantity of fresh water at hand and to convince the soldiers that cold water would do them no harm as long as it is safe water, and to teach them how to use water intelligently and economically.
With regard to the medical and nursing services in the field hospitals, there is lots of room left for improvement. Due to the sudden expansion and the urgent need for military medical and nursing services, there were not enough qualified doctors and nurses in the whole country to meet the demand. Even in peactime, we had felt the shortage. The enlisted men usually came from farms and villages. They had no adequate knowledge as to how to keep themselves in healthy condition. When they were sick or wounded, they had to exist under poor medical and nursing care. Therefore, mortality and morbidity
were high. In the first few years of the war the number of wounded cases was far greater than that of the sick, but in the later days the situation was just the reverse. On account of
the poor situation, bone cases lasted for years; ordinary wounds refused to heal within a reasonable period. All the wards were flooded with medical cases. The nursing soldiers who were responsible for looking after the-patients were inadequately trained. Many of them did not even have the sense of asepsis. Though some of them were anxious to serve the wounded, they just did not know how to do it intelligently. Many of the army leaders really love their men. They visited the field hospital quite
often and tried hard to improve them. As a whole, the general appearance of the hospitals may be acceptable but actually they are far below the technical standard.
Around 1958 and 1959, Dr. Robert K. S. Lim,, Director of the Medical Relief Corps of the Chinese Red Cross Society, sent many of his units to the field hospitals. They were assigned to take care of serious cases and to improve the sanitary condition of the army as a whole. Special wards were organized for that purpose. The nurses in the units offered short course training to the nursing soldiers. The Society of Friends of the Wounded
joined in and gave some financial support. Arrangements were made with the military commanders for improving their sanitary, medical
troops, shower baths (bamboo tubes were used as pipes), portable delousing outfits, sanitary latrines, mosquito nets, special diet kitchens, chlorinated water supply, boiled water stations, laundry servicesoperating rooms,portable laboratories, and special wards for serious cases were set up. Health posters were shown and health talks were delivered to the soldiers regularly by the company leaders. The units supplied all the necessary materials. Cleanliness inspections were carried out regularly on both men and their living quarters. In a half year' s time, the conditions were greatly improved. The only regret felt was that there were not enough units to go to every
single division. It seems to the writer that the most fundamental things are (1) that the junior military officers should possess adequate health knowledge to teach their men, as they stay with them constantly; and (2) that the military medical officers and nursing staff must know how to run their services efficiently
with-out depending on others. B. In the Communication Zone.
The Communication Zone is the most vital spot. Many military organizations are located here in order to keep the fighting
forces at the front efficiently supplied with ammunition and food. Owing to the important function of linking the rear to the front, this locality is frequently subjected to heavy bombing. Many times an entire village may be levelled to the ground and literally
even articles of daily need. The condition is worse here than at the front.
In this zone the hospitals, called temporary hospitals or
evacuation hospitals, were inadequately staffed and poorly operated. When fighting was going on, hundreds of wounded came down in one day. Naturally, these wounded needed food, water, and dressing
immediately. The hospitals were unable to render all these services; and the wounded were simply put on the floor of the temporary
buildings without technical assistance. Severely wounded were not attended to, nor were the minor igpjuries treated. As a consequence most of the wounded either succumbed to the injury or became
chronically invalided. Even simple leg ulcers took months to heal. Medical cases met the same fat. Patients newly recovered from dysentery and diarrhea were given full diet, and relapses of the condition invariably followed. Patients with beri-beri, who were unable to take food themselves (due to the multiple neuritis), were not fed by the nursing orderlies. Thus the diseases progressed from bad to worse and often ended in death. To persons with high fever, force fluid is so important and yet there was not enough boiled water available. It was not uncommon to see twenty to thirty deaths within twenty-four hours in one hospital.
To the writer, a good temporary hospital should be provided with a simple bath house, delousing station, drinking water station, good dressing station, and wards. When the wounded come down,
