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Oral Cancer
Oral Cancer:

From Prevention to Intervention

By

Peter Thomson
Oral Cancer: From Prevention to Intervention

By Peter Thomson

This book first published 2019

Cambridge Scholars Publishing

Lady Stephenson Library, Newcastle upon Tyne, NE6 2PA, UK

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Copyright © 2019 by Peter Thomson

All rights for this book reserved. No part of this book may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording or otherwise, without
the prior permission of the copyright owner.

ISBN (10): 1-5275-2279-2

ISBN (13): 978-1-5275-2279-4
 CONTENTS

List of Illustrations .................................................................................... vii

List of Tables ............................................................................................. xii

Preface ....................................................................................................... xv

Part One – Problems

Chapter One ................................................................................................. 2

A Personal Journey

Chapter Two .............................................................................................. 11

Oral Cancer

Chapter Three ............................................................................................ 35

Potentially Malignant Disorders

Chapter Four .............................................................................................. 56

A Question of Risk

Part Two - Theories

Chapter Five .............................................................................................. 72

Diagnosis

Chapter Six ................................................................................................ 88

Management

Chapter Seven.......................................................................................... 104

Outcome

Chapter Eight ........................................................................................... 110

Hypotheses
vi Contents

Part Three – Studies

Chapter Nine............................................................................................ 114

Discoveries

Chapter Ten ............................................................................................. 131

Perspectives

Chapter Eleven ........................................................................................ 143

Demographics

Chapter Twelve ....................................................................................... 175

Cohorts

Part Four – Solutions

Chapter Thirteen ...................................................................................... 212

Prevention

Chapter Fourteen ..................................................................................... 230

Intervention

Chapter Fifteen ........................................................................................ 245

The Future

Chapter Sixteen ....................................................................................... 260

Conclusions
 LIST OF ILLUSTRATIONS

Figure 1.1: The author, graduating BDS from Manchester University,

December 1982.

Figure 1.2: Hong Kong, March 2018.

Figure 2.1: Irregular and ulcerated oral SCC arising from the floor of
mouth and adjacent ventral tongue tissue, invading underlying
musculature.

Figure 2.2: Principal Steps in Oral Carcinogenesis

Figure 2.3: Microscopic appearance of (A) mild dysplasia affecting only

the basal third of oral epithelium and (B) full-thickness change
commensurate with severe dysplasia.

Figure 2.4: Microscopic appearance of oral SCC invading underlying

connective tissue, arising from adjacent dysplastic oral epithelium.

Figure 2.5: Intra-Oral SCC Resection demonstrating (A) excision

specimen containing mandibular gingiva SCC, (B) extensive surgical
defect involving loss of mandibular alveolus, labial sulcus and floor of
mouth and (C) reconstruction with locally-based naso-labial skin flaps.

Figure 2.6: Surgical Management of Oral SCC illustrating (A) neck

dissection, (B) in-continuity SCC and neck dissection excision
specimen, (C) forearm flap reconstruction of oral defect, (D)
osseointegrated implants in-situ and (E) rehabilitation with implant-
borne dental prostheses.

Figure 2.7: Radiotherapy Morbidity illustrating (A) immediate mucositis

affecting buccal mucosa, (B) significant xerostomia leading to (C)
extensive, destructive radiation caries and (D) osteoradionecrosis of
dead, infected mandibular bone.
viii List of Illustrations

Figure 3.1: Thick homogenous leukoplakia on the floor of mouth and

ventral tongue, including an ‘ebbing tide’ pattern seen on the patient’s
left side.

Figure 3.2: Irregular, non-homogenous leukoplakia extending widely

across the buccal mucosa, with a faint appearance posteriorly.

Figure 3.3: Localized band of non-homogenous leukoplakia presenting on

the lateral tongue.

Figure 3.4: Proliferative Verrucous Leukoplakia (PVL) arising on

maxillary gingiva.

Figure 3.5: Erythroplakia presenting on the floor of the mouth.

Figure 3.6: Erythroleukoplakia (speckled leukoplakia) arising at the labial

commissure.

Figure 3.7: Isolated oral lichenoid lesion arising on buccal mucosa.

Figure 3.8 SCC presenting on the lateral tongue as a painful, non-healing

erosive plaque.

Figure 4.1: Irregular, non-homogeneous leukoplakia affecting the

edentulous mandibular alveolar ridge, floor of mouth and postero-
lateral tongue. What is the risk of SCC development for this patient?

Figure 5.1: The VELscopeR showing (A) hand-held device used in clinic
(B) dark appearance of dysplastic buccal mucosa and (C) white
hyperkeratotic lateral tongue leukoplakia.

Figure 5.2: Use of the OrcellexR Brush (A) as applied during floor of
mouth sampling, (B) Papanicolaou stained thin-layer LBC preparation
showing dyskaryotic cells under microscopy (x40) and (C) high Ki67
labelling seen in severe dyskaryosis (x100).

Figure 6.1: CO2 laser comprising hand-held delivery device connected to

generation chamber via a series of articulated arms and mirrors.

Figure 6.2: Laser Excision showing (A) buccal erythroleukoplakia which

showed severe dysplasia on incision biopsy, (B) excision margin
 Oral Cancer: From Prevention to Intervention ix

marked 5mm outside visible mucosal disease, (C) excision margin

established, (D) dysplastic lesion resected at constant sub-mucosal
level, (E) post-excision laser vapourisation of lesion margins and base
to eliminate residual disease and facilitate haemostasis, and (F)
excision specimen for histopathological assessment.

Figure 6.3: Healing Post-Laser Surgery (A) immediately following

excision of dysplastic lateral tongue lesion, (B) 2 weeks post-surgery
with creamy fibrinous exudate and pink, healthy granulation tissue,
and (C) healing at 2 months with minimal scarring, good appearance
and excellent functional mobility.

Figure 6.4: Laser Surgery Ablation (Gingiva) showing (A) the pre- and (B)
the post-ablation appearance of posterior maxillary gingiva, following
superficial destruction of a patch of mildly dysplastic proliferative
verrucous leukoplakia.

Figure 9.1: Photomicrograph of double-labelled human mandibular

gingiva showing single BrdU labelled cells (brown), single 3HTdR
labelled cells (black dots) and double labelled cells (brown + black
dots) arising in the basal and parabasal layers (magnification x40).

Figure 9.2: Topographical map of the oral cavity showing the anatomical
site-specific: (1) labelling indices (%); (2) cell influx values (% per h);
(3) cell efflux values (% per h); and (4) S phase durations (h).

Figure 9.3: Photomicrograph of cyclin A labelled dysplastic floor of

mouth leukoplakia demonstrating increased supra-basal labelling
(magnification x40).

Figure 9.4: Kaplan-Meier analyses showing influence of cyclin A (A)

cyclin B1 (B) and Ki-67 labelling indices (C) on disease-free survival
following laser surgery treatment of PMD lesions.

Figure 11.1: PMD patient attendances each week during the period 12
January to 6 February 2015 (w/c week commencing).

Figure 11.2: Interventional Laser Surgery showing (A) CO2 laser in use
in the operating theatre for PMD treatment under general anaesthesia,
and (B) intra-operative view during excision of dysplastic lateral
tongue mucosa.
x List of Illustrations

Figure 11.3: Number of Interventional Laser Surgery Operations carried

out each year between 1996 and 2014.

Figure 11.4: Number of Laser Excision and Ablation Procedures carried

out each year between 1996 and 2014 (total number of procedures =
773).

Figure 11.5: Type of Anaesthesia Used for Laser Surgery each year
between 1996 and 2014 (total number of procedures = 773); GA
General Anaesthesia, LA Local Anaesthesia, LA/IV Sed Local
Anaesthesia supplemented by intra-venous sedation.

Figure 11.6: Laser Ablation showing (A) localised, small patch of non-
homogeneous, mildly dysplastic leukoplakia arising in the left floor of
mouth and (B) appearance post-CO2 laser ablation following
superficial mucosal vapourisation without excision.

Figure 11.7: Number of Laser Surgery Procedures Performed Each Month

During 2015 (total number of procedures = 67).

Figure 11.8: Number of Laser Surgery Procedures Performed versus

Anatomical Site (total number of procedures = 67).

Figure 11.9: Number of GA and LA Laser Surgery Procedures versus

Anatomical Site (total number of procedures = 67).

Figure 11.10: Number of Laser Excision and Ablation Procedures versus

Anatomical Site (total number of procedures = 67).

Figure 12.1: Time Points During the Course of PMD Patient Management.
Figure 12.2: Kaplan-Meier Analysis plotting Time to Malignant
Transformation (months) for PMD Precursor Lesions.

Figure 13.1: Multiple lesion disease affecting (A) left buccal mucosa
showing leukoplakia with erosive features erosion, (B) widespread
right buccal leukoplakia, and (C) nodular leukoplakia arising on right
mandibular buccal sulcus and alveolus.

Figure 14.1: Excellent healing, with minimal scarring and good function,
6-months following CO2 laser excision of PMD lesion arising at right
floor of mouth and ventral tongue.
 Oral Cancer: From Prevention to Intervention xi

Figure 15.1: SCC arising on the left ventral tongue in a patient with no
recognisable risk factor behaviour.

Figure 16.1: Exophytic squamous cell carcinoma arising from pre-existent

but untreated leukoplakia on the right lateral tongue.

Figure 16.2: PMD Management Pathway.

 LIST OF TABLES

Table 2.1: Mechanisms and Markers Active during Oral Carcinogenesis.

Table 2.2: Histopathological Features of Dysplasia in PMD.

Table 2.3: Principles of Oral Cancer Management.

Table 3.1: Problems Associated with Diagnosis and Management of PMD.

Table 3.2: Management Goals in Treating PMD.

Table 4.1: High and Low Risk Factors in Oral Carcinogenesis.

Table 4.2: PMD Risk Factor Data Collection.

Table 5.1: Investigation of the PMD Patient.

Table 5.2: Diagnostic Adjuncts for PMD Detection.

Table 6.1: Treatment Modalities for PMD Management.

Table 6.2: Principal Medical Treatments Used in PMD Management.

Table 6.3: Surgical Approaches to PMD Management.

Table 7.1: Definitions of PMD Clinical Outcome.

Table 11.1: Reasons for Patient Attendance at the PMD Service.

Table 11.2: Smoking Habits of PMD Patients.

Table 11.3: Clinical Appearance of PMD Lesions.

Table 11.4: Anatomical Site Distribution of PMD Lesions.

Table 11.5: Histopathology Diagnoses for PMD Patients.

 Oral Cancer: From Prevention to Intervention xiii

Table 11.6: PMD Patient Management.

Table 11.7: Number of Laser Procedures Required per Patient each Year.

Table 11.8: Clinical Appearance of Treated PMD Lesions.

Table 11.9: Histopathology Diagnoses for Treated PMD Lesions.

Table 11.10: Use of General Anaesthesia (GA) and Local Anaesthesia

(LA) for Laser Excision and Ablation Procedures.

Table 12.1: Advantages of PMD Patient Cohort Studies.

Table 12.2: Demographic, Clinico-Pathological and Outcome Data

(No. of Patients = 590).

Table 12.3: Univariate Analysis of Clinico-Pathological Factors

Influencing Disease Free Status.

Table 12.4: Final Multivariate Model of Clinico-Pathological Factors

Influencing Disease Free Status.

Table 12.5: Statistical Comparison of Clinico-Pathological Features

between Disease Free and Persistent Disease Patient Groups (Pearson
Chi-Square Testing).

Table 12.6: Comparison of Clinico-Pathological Variables Between

‘Unexpected’ (n=71) and Progression SCC (n=28).

Table 12.7: Clinico-Pathological Variables Influencing Time to SCC

Development (Progression n=28).

Table 13.1: Clinico-Pathological Features Associated with Clinical

Outcome.

Table 13.2: Preventive Approaches to Oral Cancer Management.

Table 14.1: Criticisms of Interventional Treatment for PMD.

Table 14.2: Alignment of PMD Management Goals with Interventional

Principles.
xiv List of Tables

Table 14.3: Advantages of Patient Follow-Up & Surveillance Strategies

Post-Intervention.

Table 14.4: PMD Management Goals and Treatment Efficacy.

Table 15.1: Priorities for Managing Oral Cancer in the Future.

Table 16.1: PMD Clinical Service.

 PREFACE

It is often said that, ‘prevention is better than cure’. Whilst the origins of
this popular proverb remain obscure, it is an undeniable and simple truism
based upon common sense and ultimately life experience. In essence,
prevention literally means stopping something happening and it is clearly
far better to stop ‘something bad’ from happening than having to deal with
the resultant consequences. Perhaps there is no better example of
‘something bad’ happening to someone than development of a life
threatening disease such as cancer in which prevention can be effective
and relatively economical, whilst cure may not only be elusive but also
expensive in terms of financial and emotional costs. Cancer is the term
colloquially applied to all malignant disease, although strictly speaking
actually refers to those invasive and metastasizing tumours that arise from
disturbed cell growth and replication within the ubiquitous epithelial lining
tissues of the body.

Oral cancer, principally squamous cell carcinoma (SCC), thus arises from
the specialized stratified squamous epithelium that, together with its
underlying lamina propria of fibro-vascular connective tissue, forms the
functional lining mucosa of the mouth, which is of course a significant
entry-point into the upper aero-digestive tract and thereby the body itself.
Often, though not exclusively, the consequence of over-use of tobacco and
alcohol, resultant tumours present as non-healing erosive or ulcerative
lesions that subsequently progress to invasive and ultimately painful
growths. Established oral cancer is one of the commonest head and neck
malignancies, and is a lethal and deforming disease due to local tissue
invasion, oral and facial destruction, metastasis to cervical lymph nodes
and widespread blood-borne dissemination to the lungs and the liver.
Worldwide, it is estimated to be the 6th most common cancer with 5-year
survival rates of only 50%, much worse than other more common and
better known cancers such as breast or colon. Indeed, annual mortality
rates are predicted to rise from around 370,000 to over 600,000 by 2030,
raising the genuine spectre of a global epidemic. Individual patient
prognosis is compromised by late presentation of advanced and aggressive
disease which is sadly all too common in contemporary clinical practice
and even initially successful treatment, often a combination of extensive
surgical resection and debilitating chemo-radiotherapy, may be
xvi Preface

complicated by recurrence or new, multi-focal disease extending

throughout the upper aero-digestive tract as a result of widespread
epithelial changes; a phenomenon described as ‘field cancerization’.

Immediately prior to invasive SCC development, however, earlier epithelial

disorganisation and dysmaturation changes can be identified microscopically
and delineated by pathologists into increasingly severe grades of ‘epithelial
dysplasia’, thus representing an increased risk of cancer development.
Importantly, such changes may be clinically recognizable during
conventional oral examination and characterized as mucosal abnormalities,
most commonly leukoplakia (a mucosal white patch), and termed potentially
malignant disorders (PMD). Whilst all PMD share an increased risk of
cancer development compared to ‘apparently normal’ mucosa, not all will
inevitably transform, thus creating a challenging management dilemma for
clinicians and patients alike.

Is there, therefore, an opportunity for prevention, early diagnosis and low-

morbidity therapeutic intervention during this clinically identifiable ‘oral
pre-cancer window’ that might ‘stop the oral cancer clock’ and help
reduce the long-term risk of malignant transformation? This is an essential
question, and forms the fundamental theme of the book you are about to
read.

It is important to stress at this juncture that I have not attempted a

systematic review of the global oral cancer literature, nor have I
undertaken a meta-analysis of treatment intervention. Although of
undoubted scientific validity and interest, such a work would be difficult
to read and would not serve the particular purpose of this book, which is to
guide the reader through a more personalised journey documenting a
clinically orientated research programme undertaken by the author, in an
attempt to improve both knowledge and understanding of the natural
history of oral cancer. Nonetheless, detailed references will be provided in
each chapter for those wishing to pursue their studies further.

Perhaps to explain this approach more fully, I should refer the interested
reader to the preface of a previously published work on oral pre-cancer, in
which I first detailed an approach to the diagnosis and management of
PMD and described the genesis of my interest in studying this most
intriguing and beguiling of disorders1. Nearly 40 years has passed since, as
an undergraduate dental student, I first attended specialist oral surgery and
oral medicine clinics at a well-known dental teaching hospital in North-
West England. It was here that I was introduced to the fascinating and
10 Chapter One

Carcinoma and the Interventional Management of Potentially

Malignant Disorders. DDSc Thesis, University of Manchester. 2014.
9. Thomson PJ. An investigation into the efficacy of interventional
therapy for oral potentially malignant disorders. MD Thesis,
University of Bath. 2016.
10. Thomson PJ. Building an Alliance: A new future for academic
dentistry ‘Down Under’? Faculty Dental Journal 2017 8: 122-127.
11. Thomson PJ. Oral & Maxillofacial Surgery: A View from the East.
Faculty Dental Journal 2018 9: 70-73.
12. Thomson PJ, Su R, Choi S-W. Oral cancer in Hong Kong: identifying
and managing the ‘high-risk’ population. Faculty Dental Journal
2018 9: 116-121.


Another random document with
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opportunity such as never before had come to a missionary in
Shantung,—all the highest officials of the province, and half-a-
hundred others of lesser degree, being present. He took as his
theme “The Importance of an Upright Character,” and more than
rose to the height of the occasion. One of his most memorable
sermons was delivered before a convention of some three hundred
women gathered at Wei Hsien from the native church members of
that region.
His ministry at Tengchow was fruitful of great good in many ways.
One of these was the growth of the church by the conversion of the
natives. Just before he removed to Wei Hsien, he recorded the fact
that during all his pastorate there had not been one of the quarterly
communions at which there were no additions. The beginning of his
pastorate was signalized by the accession of eighteen,—eight being
from the college and six from the girls’ school. Its close was marked
by an accession of twenty-six, of whom twenty-one were baptized,
the largest number up to that date ever receiving that sacrament, at
the same time, in the Tengchow church. Only one was from the
college, all the rest having come in through the labors of two
associates in the station, Miss Snodgrass and Dr. Seymour.
Just as soon as by evangelistic itineration and other means
converts were made in the neighboring region, outside of Tengchow,
it became necessary for the missionaries to look after these
scattered sheep in the wilderness; and for a good while a large share
of that work fell to Dr. Mateer and his wife. In fact, it had been partly
through their labors, direct or indirect, that these converts had been
won, and therefore they felt it especially a duty to care for their
nurture. That, of course, involved a large variety of efforts. In the
earlier years these frequently consisted in part of interposition, so far
as it was wise and practicable to shield native Christians from gross
wrongs to which they were exposed. The hatred of the rulers and of
most of the people for foreigners and the foreign religion was bitter.
Even at Tengchow the very tombstones in the little cemetery where
the missionaries buried their dead were repeatedly broken,—an act
regarded by the Chinese as the most gross and cowardly insult that
can be offered to a living man; yet it was slow work to secure from
the officials protection, or justice as to the criminals. The case of
Miao, of Chow Yuen, a district capital situated fifty miles to the
southwest of Tengchow, is specially notable. Early in 1869 the
Mateers and Margaret Brown, with a Chinese assistant, went to
itinerate, and on the way they visited him. When converted out in his
native district of Tsi Hea, he immediately began to endeavor to win
others to Christ. So he sent word to his clansmen and friends that he
had important business with them, and invited them to come to his
house. This occurred while the missionaries were there, and they
witnessed what took place at the gathering. Miao made a reception
speech, in which he said: “I have sent for you, and you have come. I
said nothing in my letter, but for you to come, and that I had an
important matter to tell you. It is this: I have led you in serving the
Devil. There was nothing I would not dare to do, and nothing that you
would not care to follow me in doing. I have now found something
better. We have often engaged in doubtful enterprises. I have now
found something that there is no doubt about: it is thoroughly
reliable, resting on the strongest possible proof. I have left the
service of the Devil, and I want you to leave it. As I have led you in
his service, I want now to lead you out of it. I want to show you the
way and to present you to the true God. Examine for yourselves;
search to the bottom; and know that I am not deceiving myself nor
you. This doctrine of Jesus is absolute and unmistakable truth.” In
writing of this, Dr. Mateer adds: “These words were spoken with a
fervor and an emphasis that brought tears to my eyes. I thanked God
for them, while I prayed that they might not be in vain. Rice was then
brought, and this young Christian sat down with his friends and
asked a blessing,—the first they had ever heard,—praying for them
directly and specifically. The whole village came to hear, with many
from neighboring villages. Save the time occupied in eating, we
preached to them nearly all day, keeping it up till far into the night.
The ladies also had crowds to hear them all the time.” It was not long
until Miao, partly of himself and partly at the instigation of other
native Christians, came to Chow Yuen, with the determination to
establish himself there as a preacher of his new faith. In August of
the same year the Mateers again visited him, this time at his new
place of residence, and did what they could to help him in his chosen
work. His education and character were such as to promise well.
Following the usual custom of a Chinaman when about to start a
new enterprise, a feast was made; some eighteen guests responded
favorably to invitations to be present, and at the close of the
entertainment a sort of meeting was held, and Dr. Mateer made a
brief statement of what Christianity is, what was the nature of this
enterprise, and what was Miao’s relation to it. He told the audience
that the mission would pay the rental of a small chapel, but that Miao
would work gratuitously, except so far as he might be assisted by the
voluntary contributions of his friends. All the Chinese present, with
the exception of two members from the Tengchow church, were non-
Christians, yet the guests subscribed a sum sufficient to meet the
expenses of the feast and to leave a surplus to go toward the
support of the preacher. Some of his friends had already promised to
help to support him, and had presented him with a fine signboard to
hang in front of the room he occupied as his chapel, and another for
the back of the stand where he stood when speaking. All this was so
exceptional and so hopeful that Dr. Mateer came away rejoicing in
this apparent readiness even of the unevangelized to welcome the
gospel. But here begins quite another turn of the story. Miao had
continued but a few days at this work when a couple of constables
seized him and the man from whom he had rented the room for a
chapel, and hurried them to the office of the magistrate. The owner
was accused of having rented a house to “foreign devils,” and was
forthwith beaten most cruelly to the extent of two hundred blows.
Miao was then called, charged with evil doctrines and practices,
such as kneeling in prayer and calling on unseen personages. In
reply he rehearsed the chief truths of the gospel, and in answer to a
taunting question, whether Jesus could suffer for him, he said that he
so believed. The magistrate ordered him to be beaten fifty blows with
the large bamboo and sent him chained to prison. That evening he
had a second hearing, and the next morning he was marched off,
with a chain about his neck and his hands bound together, thirty
miles away to Tsi Hea, but comforting himself in his weariness and
suffering by singing Christian hymns. The morning after his arrival he
was called before the magistrate and confronted with charges
forwarded from Chow Yuen—such as being in league with foreign
devils, using false pretense of preaching religion, seducing the
people by artful works, being possessed of secret magical arts,
taking forcible possession of a house, influencing the people to form
combinations dangerous to the state, and a whole rigmarole of
offenses, big and little. He was commanded to confess, and when he
would not, he was first beaten three hundred blows with the small
bamboo, and then he received a hundred more in the face. The
second day he was recalled, and when he still would not confess he
was again beaten. The magistrate being especially searching in his
inquiry as to how Christians prayed, and as to what they prayed for,
Miao as the best explanation he could give kneeled and prayed in
his presence. At this stage of the affair Dr. Mateer, having been
informed of the situation, arrived, and secured a promise from the
officer that he would go no further until he heard from his superiors;
and on his return to Tengchow he reported the case to the American
consul at Chefoo, though with little hope that under the prevalent
policy of the American government anything would be done. In an
article in “The Presbyterian Banner” he said: “I shall not soon forget
my feelings when I saw this Christian brother with a chain round his
neck and his body disfigured with bruises for the gospel’s sake. I
could not restrain the tears as I looked him in the face. It is one thing
to talk of persecution a thousand miles away, and another to see it
face to face. I assured him of our sympathy and unceasing prayers
in his behalf, and that I would do my utmost to rescue him....
Numbers of the native Christians have boldly visited Miao in prison,
and some of them even prayed with him. All have been stirred up to
pray as never before, and made to feel that their only hope is that
God will interpose on their behalf. This young Christian has been
guilty of no offense against the state. The charges preferred by the
officers are pure fabrications, the inventions of malice and hatred to
the truth, and would never have been entertained by the officer had
he not been only too glad of a pretext to get the Christians in his
power.” So soon as possible Dr. Mateer went to Chefoo to see the
American consul, and on his return home he learned that Miao had
been released, under some restrictions as to his whereabouts; but
no amends were made for the gross injustice done.
 There was still a long sequel to this affair. After the period which
has since intervened the story seems to be unworthy of the dignity of
a full recital here; though it might be interesting to some as an
example of obstacles encountered by the work of missions away
from places where foreign influences are commonly powerful enough
to prevent them. A condensed account must suffice. It should be
remembered that it was in August that the persecution of Miao
occurred. The purpose of it, at least in part, was to shut Christianity
out of Chow Yuen. To allow this would have been to inflict on that
cause a blow that probably would encourage opposition of a like kind
in other localities; and therefore it evidently was the duty of the
missionaries to prevent it if practicable. Especially was it true of Dr.
Mateer that he was too resolute a spirit to yield to such a violation of
rights secured under treaty with foreign governments. Consequently
late in November he went again to Chow Yuen, in order to secure a
house that could be used as a chapel; for in the interval between
these visits the room previously occupied for this purpose had gone
into other hands and was no longer available. The magistrate also
had been promoted, and another filled his place. Dr. Mateer soon
found a house, rented it, and secured the approval of the magistrate.
Then followed a series of chicanery, brutality, deceit, low cunning,
and petty meanness running over several months, and compelling
two more trips by him in the dead of winter. Once he took with him
two other missionaries, and they went armed with pistols in order to
defend themselves if attacked. The old woman who rented the room
to him, and who in so doing had been animated by ill will to her
relatives and by a desire for money, was seized and beaten by
members of her own family, and likewise by the magistrate. The
same gang beat the middleman who, according to Chinese custom,
had negotiated the bargain. The whole rental was only about ten
dollars. Petty and miserable as the affair was, it had its ludicrous
features; as, for instance, when Dr. Mateer, in his determination not
to be ousted from the house until some satisfactory arrangement
was made, picked up the old woman and set her down on the
outside, where she exhausted her strength in billingsgate. It was not
until the beginning of March that the trouble at Chow Yuen was
finally ended. The issue was a triumph in the main for the
missionary; another acceptable room was, with the official approval
of the magistrate, secured for a chapel, and the money that had
been paid for the rental of the other house was refunded. The best of
all was the fate that overtook the man who had been the ringleader
in the long series of wrongdoings toward the representatives of
Christianity. The magistrate did his best to shield this fellow, but at
last he had to yield. He called the man into his presence, and this is
what was done, as related by Dr. Mateer: “He was required to knock
head to me; and then I took him in hand, and though he tried to
evade, I compelled him to own up to his sin, and to make a distinct
promise of amendment; and then the substance of what he said was
put on record by the clerk, and a copy was given me.” It all illustrates
what a determined man who has right on his side may accomplish
even in an out-of-the-way city in China. It is characteristic of Dr.
Mateer that in one place in his Journal during this wearisome affair
he says that if it were not for his school he would go to Chow Yuen,
and stay there until a settlement is reached. Perhaps in later years
Dr. Mateer and his associates would have regarded it as inexpedient
to go so far in the defense of a convert; but in those earlier days this
was a battle for toleration of Christianity, and not a mere struggle to
right the wrongs of an individual convert.
Other incidents of the dark side to the work of caring for the native
Christians might be given, but I have thought it best to turn chiefly to
the brighter phases of the subject. Of these there were many, and
they were of many kinds; but they were of so unsensational a
character as not now to be likely to awaken much interest in the
reader. They belong to the day of small things for the gospel in
China; but let them not be despised; by and by they will be
treasured, if the record of them is preserved, as the beginnings of
the evangelization of Shantung. When they occurred they brought
the joy of approaching harvest. For example, in connection with that
last trip out to Chow Yuen, Dr. Mateer wrote:

As it was Saturday, however, I felt I must try if possible to

get home, so that the Sabbath service should not be
neglected, when so many inquirers were waiting to hear. I
 found not only the ten who had come from Ping Tu, but some
seven or eight from other places. I had, of course, to
commence teaching them at once. I gave the half of each day
to them, and continued it without interruption for three weeks.
They gave diligent attention to the business of learning. At the
same time Mrs. Mateer had a class of women who were
seeking admission to the church. Last week all who were
considered ready were examined by the session and passed
upon. Twenty were received,—fifteen men and five women.
They were all baptized together yesterday. It was a new sight
in Tengchow, to see such a number standing up at once to
profess the Lord Jesus Christ. I hope that we are all grateful
as we should be for such a signal token of God’s presence
with us. Our hearts are enlarged to look for still greater things
in the future. Our schoolroom was packed to its utmost
capacity, so that when the twenty rose up to present
themselves for baptism, it was with great difficulty that room
could be made for them to stand. Let us hope that the day of
small things is past in this part of China. Chinese officials may
persecute us, and foreign governments ignore us, but they
cannot restrain God’s Spirit. There are still a number of
inquirers.

In the earlier part of his missionary life he frequently made trips of

greater or less length to various places in the province to help the
native Christians by organizing churches, assisting their pastors,
holding services, stimulating to work for the gospel, administering the
sacraments, and in every other available manner forwarding the
cause of Christianity. Hospitality was gladly extended by the people;
and it was as gladly accepted, though not infrequently it introduced
to quarters that were odd and even uncanny. Dr. Mateer described
guest rooms in which he was entertained, and which were a strange
combination of granary, receptacle for lumber, bedchamber and
“parlor,” crammed with all sorts of corresponding articles, not
excepting a coffin conspicuously displayed in a corner. However, in
his own home he lived without ostentation; and on his journeys he
did not find it hard to adapt himself to the customs of his native
entertainers.
In later years, though for the most part he left itinerations to the
younger members of the mission, yet he did not entirely discontinue
them. In February, 1896, for instance, he wrote to the secretaries of
the Board of Missions:

Three weeks ago Mrs. Mateer and I returned from a trip of

seventeen days to the district of Lai Chow, eighty miles
distant. Our friends protested against our taking such a trip in
the winter and in our state of health. We acted on our own
judgment, however, and went, and are benefited rather than
otherwise. The trip was exceedingly profitable. We confined
our visit to two stations, holding special services each day—
morning, afternoon and night. I received eight to the church.
At one station a new church was organized, with twenty-six
members, a branch from the older station. At this older station
there are many inquirers, and the work is in a very hopeful
condition, very largely as the result of the influence of a young
man, an undergraduate of the college, who has been there
teaching a day school for three years.

One of his last journeys of this sort was made not long before his
seventieth birthday, and the following is his record concerning it:

From Tengchow we came overland to Wei Hsien in

shentzas. I made it a point to spend the Sabbath at Lai Chow
fu, and went out and preached morning and afternoon to our
little church at Ning Kie, which is three miles from the city. Dr.
Mills and I were instrumental in founding the station some
thirty-six years ago. It has grown very slowly. Mrs. Mateer had
visited it frequently in subsequent years, and had taught the
women, and there are now a goodly proportion of women in
the church. In the earlier years evangelists were sent to labor
in the region, and to preach to and teach the people. In those
days opposition to the gospel was very great, and progress
 was very slow. In later years, owing to change of policy,
evangelists were not sent, save on an occasional visit, and
the church declined, though it still lived. A few years ago
special efforts were made, and the church increased
somewhat, and finally a native pastor was settled over this
church, in connection with another about fifteen miles away.
Before the expiration of the first year the Boxer uprising
brought the arrest and beating of the pastor and much
persecution to the church. The pastor did not return. The
church was discouraged, and the pastor was called
elsewhere. If we now had an available man, he could be
located at Lai Chow fu; but there is no man.

His last country trip was made some time in December, 1907. This
is the record: “Two weeks ago I went down on the railroad to
Kiaochow to assist our native pastors in a meeting for the women.
There were about seventy there from various other stations, besides
those in town. The meeting was most interesting, and must do a
great deal of good. It was projected and managed by the native
pastors on their own account. There were five native pastors
present, and helping in the meeting. Many women spoke and some
made set addresses.” There were approximately one hundred and
fifty present, many of whom walked miles to be there. His own
speech was a plea to the mothers to consecrate their sons to the
ministry, and the tears ran down his cheeks as, while making it, he
spoke of his own mother.
The reader needs to bear in mind that Dr. Mateer did not operate
as an independent individual, but as the agent of a thoroughly
organized system, in conformity with the government of the
Presbyterian Church and the regulations of the Board of Missions. Of
these agencies there is one that lies wholly outside the constitutional
provisions of the denomination, but that is approved as a part of the
machinery needed for the foreign field. This is what is called the
“mission.” Its members are the missionaries sent out by the Board
and residing near enough to meet together for the transaction of
business. To the mission belong such duties as to locate members
and appoint their work, to make annual estimates of funds and
reënforcements needed, to receive the money from the Board, and
to apply it, according to directions, general or specific. Dr. Mateer
had much to do with inaugurating the “executive committees” now so
widely adopted by the missions. Many questions affecting the
operations sustained through the Board, of necessity came before
the annual mission meeting for discussion and action. Lines of policy
as to conduct of the work out in the field, if involving important
features, are left for decision to the Board; but full and frank
consideration of them by the members of the missions, either when
in session or as individuals, is usually welcomed.
An important discussion in which Dr. Nevius and Dr. Mateer were
especially conspicuous arose on their field over a theory advanced
by Dr. Nevius in his “Methods of Missions.” It was no personal
controversy, though, of course, the respective personalities of two
such strong, positive, earnest men inevitably tinged it. The question
at issue mainly concerned the pecuniary support of native Christians
as agents in the evangelization of their own people. No attempt need
here be made to state with fullness the positions taken or the
arguments employed. Broadly, the policy advocated by Dr. Nevius
was that the main work of evangelization should be thrown on the
native Christians, and that those who could read and understand
“the doctrine” should voluntarily and without compensation instruct
those who could not; while the foreign missionaries, paid as
heretofore by the Board, should give themselves to a general
superintendence and to periodical examinations of the catechumens
and scholars taught by the native church members. Dr. Mateer was
just as earnestly as Dr. Nevius in favor of utilizing native Christians in
the evangelization of their people, and was just as eager to develop
among them self-support, but he was thoroughly convinced that
conditions were not ripe in China for the radical policy of withholding
from native laborers, as a rule, all pay from the funds of the Board;
and that an attempt of this sort before the proper time would result in
serious disaster. This brief statement will suffice to show that it was a
question over which wise and good men might readily differ, and that
the fact that they discussed it earnestly and fully is a sign of healthy
life. It seems to me to be a problem that cannot be satisfactorily
solved by theoretical argument, or by votes in a mission, or by even
the decision of a board. The only crucial test is actual trial. All that
needs to be said further as to this discussion is, on the one hand, to
emphasize the fact that Dr. Mateer, in his care of the native
Christians and churches, often labored hard and long to bring up
congregations, in the support of their pastors and evangelists, to the
measure of giving for which they were able; and, on the other hand,
that he thought he saw in certain fields evidence of the bad
consequences of the policy he controverted.
Until it is desirable to organize the churches of a given foreign
missionary field, after the order prescribed by the Presbyterian form
of government, the mission must continue in the entire supervision;
but it is the practice, just as soon as the way is open, to set up
presbyteries and synods, and to commit to them those matters which
belong to their jurisdiction. In these bodies ruling elders, as the
official lay representatives of the native churches, and all the native
ordained ministers sit as the equals in authority with the ordained
foreign ministers. The Board, unless in exceptional cases, has not
been accustomed to turn over to them the administration of the funds
forwarded for use on the field, or such matters as concern the policy
and plans it adopts; but all that pertains to the organization of
churches, the settlement of pastors, the acceptance of candidates
for the ministry and their licensure and ordination, and the
administration of discipline for the ministers, with complaints and
appeals from the churches, is left to the presbytery. Of course, as
converts and churches and native ministers increase, the tendency
is to put them, as the majority, in control in these bodies. It is a
system which opens the way for some dangers; nevertheless it is, in
the nature of the situation, the only course to pursue, and unless
abused, it has a most wholesome influence on the native Christians.
It brings home to them the fact that, equally with the foreigners who
have given them the gospel, they have privileges as members of the
church of Christ, and also their responsibility as such. Dr. Mateer
believed with all his heart in the setting up of these regular
ecclesiastical bodies so soon as possible. Late in November, 1865,
he was one of the little band who organized the Presbytery of
Shantung, at a meeting held at Chefoo, when as yet there were no
native ministers to take part. The next meeting was held the
following October at Tengchow, and he was elected moderator and
stated clerk. It is evident that if a presbytery is to be of any
considerable value to a native member the language used must be
his own, not that of the foreign missionary. With this understanding,
the following from Dr. Mateer’s Journal concerning that meeting can
be better appreciated: “It was voted that hereafter all the
proceedings be in Chinese, and at it we went. It was very awkward
at first, making and putting motions, but after some practice we got
along better. We had a very pleasant meeting indeed. One of the
chief items of business was a call presented by the native church for
Mr. Mills, which he accepted, and we arranged for his installation.”
It was ten years before such progress had been made out in the
province that it was practicable to hold a presbytery in the rural
regions. In a letter to his mother, dated December 24, 1877, Dr.
Mateer said: “The meeting of the presbytery in the country marks an
era in our progress in Shantung. Many of the Christians from all the
region were assembled, and evidently got much good from what they
saw and heard. Our presbytery is getting to be an important event,
and a power among the native churches. Our desire is that it may be
more and more felt.” Sometimes the meetings were saddened by the
cases of discipline, after a native ministry began to be enrolled; but if
the case demanded it, even deposition from the sacred office and
excommunication from the church were imposed, and the native
elders and ministers were sturdy supporters of adequate sentences.
In contrast with this was the joy of receiving candidates for the
ministry, and sending them out to preach the gospel as they seemed
to be ready for that work. Occasionally a man up in years, and
without thorough education, but apparently qualified to be effective
as a preacher, is authorized by the presbytery to “exercise his gifts”;
but usually those who offer themselves are young men who after
long courses of study, and careful examination, are sent on this
errand. For instance, in his report for 1874 as stated clerk, Dr.
Mateer said:
 Considerable time was taken up in the presbytery by the
examination of candidates for the ministry. These were
thorough, and so far as they went were sustained with great
credit. One candidate was licensed to preach. He is not
young, as licentiates usually are, being about sixty. He is,
however, full of zeal for God, and may yet do good service.
One of our licentiates was ordained as an evangelist. This is
the first native preacher who has been ordained by this
presbytery. It marks a new step in our work, one for which we
are devoutly thankful to God. We have no more important
work to do than to raise up well-qualified natives to preach the
gospel to their countrymen. We trust this one will soon be
followed by others.

Dr. Mateer was careful to treat the native elders and ministers as
the equals of the foreign missionaries, in the ecclesiastical bodies
and elsewhere; and as a consequence he commanded their
confidence, so that he was able sometimes to render important
services by healing threatened dissensions. This, as might be
supposed, was especially true of his own “boys,” who had as
students learned to revere both his judgment and his fraternal spirit.
In writing to “The Presbyterian Banner” concerning the meeting of
the Presbytery of Shantung, in September, 1869, he said: “The
matter of the formation of a synod in China was discussed, and a
circular letter was prepared, and ordered to be sent to the other
presbyteries urging the propriety of such a step at once. It is now
twenty years since the General Assembly took action looking toward
and opening the way for the formation of this synod.” That body held
its first meeting at Shanghai in October of the following year. The
synod in the Presbyterian system is the next higher organization
above the presbytery, and consists of all the ordained ministers of a
larger district already containing three or more presbyteries, and of
ruling elders representing the churches; or it may be constituted from
delegates appointed by the presbyteries on a fixed basis. It has the
right to review all presbyterial action, and also has authority to
originate measures within its constitutional jurisdiction. Among the
missionaries in China at that time there was a considerable number
who regarded the synod as a sort of fifth wheel to the coach, and as
not likely to be capable of rendering a service worth its cost in money
and time. Under indirect form this phase of the subject came into
warm and protracted debate in that first meeting, and may be said to
have been fought out to a settlement. Dr. Mateer was a strong
believer in the importance of the synod, and in debate, and in other
ways, he threw the whole weight of his influence avowedly on that
side of the issue, and helped to win. Other problems were of such a
character as also to arouse his interest to a high degree. Ought the
language used in the body to be limited to the Mandarin or ought it to
include local dialects? On this question, of course, he stood for the
Mandarin. Ought a theological institution to be established; and if so,
where? As to this, a sort of compromise was effected, and an appeal
was sent home for a share in the “Memorial Fund,” to establish in
China one or more such schools, but leaving location to be
determined later. The synod consisted of twenty-four members, ten
of them being foreign missionaries, and fourteen native pastors and
elders. The proceedings had to be translated, during the various
sessions, into several different dialects, in order to be made
intelligible to all. The body sat for ten days, and then adjourned to
assemble the next year at Ningpo. It was in connection with Dr.
Mateer’s attendance at Shanghai that he was induced to take
temporary charge of the mission press.
The second meeting of the synod was held at Ningpo. Dr. Mateer
was chosen moderator. Writing in his Journal concerning that
meeting, he said:

The great difficulty of the synod was the language, and this
was indeed no small embarrassment. As I was moderator, I
felt it more than any other. It was all I could do to tell what was
going on at times. If it had not been for the practice I had
through the summer in Shanghai, I should have been quite
lost. The most interesting discussion we had was on the
qualifications of candidates for the ministry. The native
members insisted that they must learn English, and the
 foreign members opposed. The native brethren finally carried
their point. The discussion at some points of its progress was
really exciting, and not a little amusing.

The next meeting was held at Chefoo, and as the retiring

moderator he preached the opening sermon. In his Journal he says:
“I had prepared the sermon quite carefully, having written it all out,
and so had to read it. It is the only sermon I ever wrote out fully in
Chinese. I found reading a Chinese sermon very awkward and
embarrassing.” A committee of which he was a member had been
appointed by the preceding meeting at Ningpo to prepare for
deliberative bodies a compendium of technical terms,—for the lack
of which in Chinese they had been seriously hindered,—and also to
formulate rules of order. They made a report which was approved,
and authorized for use in the synod and in the presbyteries.
One other excerpt from the records of his pen must conclude the
story of his work in the synod, though it was continued down through
his subsequent years. He said:

Delegates, officially deputed, were present from the mission

of the Presbyterian Church South; also from the mission of
the United Presbyterian Church in Scotland; and from the
independent Presbytery of Amoy, composed of the missions
of the American Dutch Reformed and the English
Presbyterian Churches combined. They all expressed a
desire for mutual coöperation, and for the ultimate union of all
the Presbyterians in China into one Chinese Presbyterian
Church. A committee was appointed to correspond with the
various Presbyterian bodies or missions in China, and
prepare the way for an ultimate union. This union may not be
accomplished for many years, but that it should come as soon
as practicable seems to be the almost unanimous opinion of
all concerned.

In 1907 one long advance was made toward the realization of the
desire so earnestly expressed by that synod a third of a century
before. After preliminary consultations extending over a number of
years, representatives of eight distinct missions, operated by as
many different Presbyterian denominations of Europe and America,
met together, and constituted “The Presbyterian Church of China,”
and also offered a welcome to any other Chinese churches of like
faith and practice to unite with them. Dr. Mateer thought that on
account of the size of China and the consequent expense of travel
and variety of speech, it would be better to make two ecclesiastical
bodies out of this material. Belonging to the new organization, there
were, besides the foreign missionaries, about a hundred native
ministers, and forty thousand communicants. Dr. Mateer was not a
member of the body which met to declare and organize this union;
but, being present, he was invited to sit as a corresponding member.
Under the regulations of his American denomination, the names of
ordained foreign missionaries entering such new churches on the
foreign field as that just mentioned are enrolled in the minutes of the
home General Assembly on a separate list; and these ministers are
entitled to be received by the presbyteries without the examination
required of those who come from other denominations in foreign
countries. This was the ecclesiastical status of Dr. Mateer when he
died. He was a member of the Presbyterian Church in China; but he
was still enrolled by the church of his fathers.
The highest of all the organizations within the Presbyterian system
is the General Assembly. Its supervision, within constitutional limits,
extends over synods, presbyteries, and individual ministers and
churches, and it has other distinct functions pertaining to the entire
denomination throughout the world. Dr. Mateer was a commissioner
from his presbytery in China to the Assembly which met in 1880 in
New York; and again to the Assembly which met in Los Angeles in
1903. In this last he was nominated for moderator, but failed of
election, for reasons not in any way disparaging to him. It is well
understood that an election to that office is contingent on so many
incidental things that the choice can seldom be foreseen. Local
influences at Los Angeles were strongly thrown in favor of the
successful candidate, meaning by these the representation in the
Assembly and the Presbyterian visitors from all the Rocky Mountain
country and from the Pacific coast. Besides, to many of the
commissioners Dr. Mateer was a man but slightly known. His work
had been great, but it had also been quiet. Nor when on his
furloughs had he in speaking to the churches won renown by bursts
of missionary eloquence. He made a very creditable run for the
moderatorship, and was beaten by a man of high standing in the
church. He was appointed chairman of the Judicial Committee.
 XI
THE SHANTUNG COLLEGE

“While I live I cannot cease to have a vital interest in the college.... I

cannot bear to be wholly away from the college to which my life has
been given.”—letter to secretary brown, April 10, 1907.

The change of the name of the school which Dr. Mateer had
founded and nurtured for nearly two decades was made at the
formal request of the members of the Shantung Presbyterian
Mission, sent to the Board under date of February 14, 1881. It was
accompanied by a “plan,” and that part of the paper was as follows:

I. That the Tengchow Boys’ High School be organized into

and constituted a college, to be called “The College of
Shantung.”
II. That it be carried on and governed by a board of six
trustees nominated by the Shantung Mission, and confirmed
by the Board of Foreign Missions.
III. That the college embrace a six years’ course of study in
Chinese classics, general science, and Christian ethics;
including particularly “The Four Books” and “Five Classics,”
Chinese history, with Biblical and general history,
mathematics, physical, mental and moral sciences, evidences
of Christianity, and so forth.
IV. That the aim of the college be to educate thoroughly
both in Chinese and western learning; and to do this from the
standpoint and under the influence of Christianity.
V. That the Chinese language be the medium of instruction
throughout the course, English being taught only as an extra
in special cases.
 VI. That there be connected with the college a department
to prepare pupils to enter it.
VII. That it be the ultimate design to make the students
attending the college self-supporting; and that in order to do
this the style of living be strictly on the Chinese plane; and
that natives be trained as fast as possible to man the college
with efficient professors.
VIII. That the college be located for the present at
Tengchow, leaving open the question of its removal to a more
central position at some future time.

For this request the main reasons were added in extenso. They
are too long to be given here; but they can be, in the main,
compressed into two general statements. One of these was the need
of a high-grade institution of this sort in northern China, and
especially in the great province of Shantung. It was conceded that
Tengchow was not as central a location as the college might
ultimately require; but, being a literary city and a treaty port, and as
yet free from the special temptations and corrupting influences of a
mixed foreign population, it at least temporarily had marked
advantages. The other general statement is that the institution was
already in fact a college by reason of its curriculum, and was
equipped with buildings and outfit suitable for the advanced work
which a college ought to do. In order that it might retain the position it
had won, and in order to secure endowment and reputation, the new
name was very desirable.
In a letter dated April 4, 1885, the mission appealed to the Board
for a new house to be built for the accommodation of the chief
foreign assistant in the college, and incidentally gave a statement as
to the plant. They said: “At a remarkably small cost to the Board it
has come into possession of plain but extensive premises, which are
very well adapted to the purpose. With the small additions and
changes proposed for the current year it will have good boarding and
dormitory accommodations for eighty or ninety pupils, with roomy
yards and courts. It has also two large schoolrooms, three recitation
rooms, one large lecture room, a philosophical apparatus room, a
chemical apparatus room with a shop and storeroom. It has also a
substantial stone observatory, costing one hundred and sixty
dollars.” In 1894, a grant for new buildings having been made by the
Board, steps looking to their erection were taken. Writing of these,
March 23, 1895, Dr. Mateer said, “We staked off the ground to-day,
and will make a start at once.” That year, however, on account of his
duties on the committee for the revision of the Mandarin translation
of the Scriptures, he laid down the presidency of the college, though
he did not cease to assist in the instruction and in the management
of it. February 8, 1896, he wrote to the Board: “The headship of the
college is now in Mr. Hayes’s hands, and with it the major part of the
work. I am especially thankful that the interests of the college are in
the hands of a capable man; nevertheless, when I am in Tengchow a
considerable share of the general responsibility still clings to me, and
no inconsiderable share of the work, and Mrs. Mateer’s share is in
nowise decreased. Our new buildings are finished, and are an
unspeakable convenience. The wonder is how we did without them
so long. They have served to raise our college in the estimate of the
people of the whole city.” These new buildings consisted of a main
edifice of two stories, dormitories, and chemical laboratory. The old
temple structure was converted into a chapel and various alterations
were made as to uses of the smaller houses. The original estimate of
the outlay was eight thousand dollars. Whether this sum was
sufficient is not stated in any of the records that have come into my
hands; but inasmuch as nothing is said about a deficit, it is probable
that there was none, except such as Dr. Mateer and others on the
ground met out of their own pockets. The new buildings were
supplied with steam heat and electric light from a house specially
fitted for the purpose, with a tall chimney that seemed as if a
landmark for all the region; and some other additions were
subsequently made by means of special contributions. Taken
altogether, the plant, into the possession of which the Tengchow
College eventually came, though consisting largely of houses that
were externally without architectural pretension, and in part of the
Chinese order and somewhat inadequate, was extensive enough to
indicate the magnitude of the work the institution was doing.