Government: There was no settled government so people lived nomadic lifestyles. Because of the lack of government planning, intervention or funding of medicine was not possible.
Technology: Primitive tools such as flints and arrow heads.
Education and Communication: There was no written language, no schools, no records of prior knowledge of medicine or education about medicine and skills and ideas were passed along simply by word of mouth.
Religion: A belief in the spirit world was an important influence on pre-historic life. They believed that good spirits caused good things and bad spirits caused bad things, such as disease and illnesses. Because of a thorough belief in the afterlife there was no reason for people to search for natural, rational explanations about the causes of disease and cures were restricted to supernatural ones, such as charms and amulets and chantings from the Medicine Man. Trepanning, although an early form of surgery, was carried out for religious reasons - pre-historic people believed that trepanning released the evil spirit inside somebodies skull which was the cause of illnesses such as headaches.
Religion: Egyptian religion relied heavily on a belief in the afterlife and in the Gods. The Goddess Sekhmet was believed to have the ability to cause and cure epidemics. A belief in the afterlife meant that bodies were preserved (mummification) and, therefore, not dissected properly. The Egyptians believed that the body was important for the afterlife so they would not have dissected it. Through mummification knowledge of the human anatomy was known - albeit only a little.
Natural ideas: Herbs, Purging the body, Mosquito nets, Covering wounds with honey, The use of bronze surgical equipment's.
Supernatural ideas: Gods, Charms, Spells, Chanting, Sacrifices. Priest physicians cleaned and shaved themselves frequently so that they were pure for the Gods. They also observed,examined and recorded the treatments they used on papyrus.
Writing: They developed their own writing (papyrus) which allowed them to document their medical findings on and use to communicate with others.
Trade: Egyptians had many trade links with other countries which brought in new herbs and plants that were useful to medicine and allowed Egyptian healers to build up their knowledge about medicine.
Ancient Egyptian 2
Wealth: Because of the wealth of the Egyptians they could create improvements to surgical equipments, such as bronze tools.
The Nile and Farming: Due to the channels in the Nile, Egyptians believed that human bodies contained channels too and that people could become ill if their channels became blocked. The annual flooding of the Nile meant that farming boomed and trade was good.
Who treated the sick? Priest Physicians, Priest Magicians, Women, Specialist doctors (such as Imhotep, the doctor of Pharaoh Zoser). Few women doctors were known - Peseshet was a woman physician.
What did they know about the body? Egyptians had some knowledge of the heart, liver, lungs, brain, pulse and blood.They believed that the body contained channels like the Nile but did not know how the parts of the body worked.
What did they think caused disease? They believed that blockages in the channels in the body caused disease or rotting food in the bowels (which is why they purged themselves regularly).
How did they prevent or treat illness? By using herbs, potions and charms. They washed regularly and also cleaned things regularly. They used nets at night to prevent mosquito's from biting them and bathed in holy water to purify themselves.
Religion: Religion was still an important influence on people's lives. They believed in the Greek God Asclepius and looked to him to cure illnesses.
Rational ideas: Observation, Examination, Diagnosis, Recordings, The Theory of the Four Humours, Asclepions (although Asclepions were set up because of supernatural ideas, the belief in the Gods, they had natural effects).
Supernatural ideas: Asclepions, Charms, Prayers, Sacrifices and offerings.
Continuity: Women still treated their families, using remedies that had been passed down through time such as herbs. Herbs and charms were still used in treating and preventing illnesses. The Ancient Greeks also believed that hygiene was important, as can be seen in the layout of Asclepions. A belief in the Gods was still present.
Change: Herophilus discovered that the brain controlled the body, not the heart - Greeks were beginning to understand about the function of organs. They knew that fitness was important but also that people needed rest when they were ill. Careful observation was stressed.
Ancient Greece 2
The Theory of the Four Humours - Hippocrates:
Hippocrates believed that there was a natural cause for diseases and illnesses. He put forwards his theory about this. The theory stated that the body contained four humours and we became ill when the humours were unbalanced. For example, in the winter we sneeze and cough because the body contains too much phlegm.
Summer - Yellow Bile - Fire - Fevers, Vomiting, Yellow skin.
Winter - Phlegm - Water - Sneezing, Colds.
Spring - Blood - Air - Dysentery, Nose Bleeds.
Autumn - Black Bile - Earth - Dry Skin, Vomiting.
Hippocrates also believed that careful observation was important. He wrote many books that were used for hundreds of years and even suggested the Hippocratic Oath - an oath which is still used today by doctors and which promises professionalism.
Galen expanded on Hippocrates' Theory of the Four Humours. He suggested not only reasons for disease (which is what Hippocrates did) but also suggested how to cure these problems. Galen's work relied heavily on a theory of 'opposites'.
Spring - Blood - Air - Dysentery and nose bleeds are common.
Hippocrates suggests that nose bleeds are common because there is too much blood in the body.
Galen suggests that the patient with these symptoms should be bled so that the excess blood in the body is removed.
Galen also suggested that there were 'seeds for disease' in the air, but did not expand upon this idea. He wrote many books, which were used for over 1500 years, about his natural approaches to medicine which stated that he believed the body fitted together perfectly, an idea which Christians approved of. Galen was able to dissect bodies in Alexandria.
Ancient Rome 2
Although Galen was an important individual in Roman times, he was not the only person who was looking for causes or cures of illnesses.
The Roman Empire was large, wealthy and powerful. The government realised that they needed a clean, healthy empire to keep their soldiers healthy and fighting so they built up Public Health systems and measures which prevented illnesses. These included:
1. Building aqueducts (large lead pipes) to bring fresh water to towns.
2. Providing fresh water and sewage collection to all cities.
3. Public baths available to everybody at only a small fee.
4. Public toilets also available to everybody.
5. Extra precautions against preventing fires so that the spread of disease was limited.
6. Fixed policies about burying the dead, including introducing graveyards.
Early Middle Ages
After the Roman Empire collapsed there was no stable government, therefore no money, no roads meaning no easy way for communication, and no public health.
The most powerful and influential organisation after the collapse of the Roman government was the Church.
The Church was able to bring back the supernatural ideas that people had about the causes of disease, meaning they no longer looked towards natural causes.
Books that did not agree with the teachings in the Bible were banned - this included some medical books that could have helped doctors in the Middle Ages develop medicine. The ideas that Galen had suggested were allowed because the Bible also taught that God had created the human being as a perfect image of himself.
Towns were heavily populated. there was a high infant mortality rate and a low life expectancy. Women were known to die young, especially as a result of the poor care during childbirth. Bone and joint disease was common. Streets were tightly packed and animals could roam freely through the streets. Water collection pits were often situated near poorly-lined cesspits.
Late Middle Ages
Living conditions improved slightly during the later half of the Middle Ages.
Although over-population was still a problem and specific Public Health measures were not put in place, things did improve during this period. Improvements include: Better harvesting, steadier houses with proper roofs and walls were built by carpenters, cesspits were lined with brick or stone and emptied when full, the Abbey of Saint Mary's had a stone built sewer and a supply of clean water.
London - 13 Hundred to 14 Hundred:
Butchers selling bad meat were punished and, in 1343 animals had to be killed away from towns. People were not allowed to throw things into the streets, gutters were installed, rakers were employed to remove waste from streets. Fines were also set up to stop people from throwing items into the streets or if they had filth outside their houses. In 1364 people could be arrested for throwing rubbish into the streets.
The Middle Ages
Who treated the sick? The Church provided hospitals and monks would treat the patients. Doctors, such as Rhazes (an Arab doctor), and Barber Surgeons (mainly for the poor). Wives and mothers were still important, including Wise Women and Midwives. There were even a few women surgeons. At one point, people believed that the King's Touch could cure scrofula.
What did they think caused illness? Supernatural ideas included: Sins from parents, the Devil, God was punishing them, Jewish people, stars, astronomy, chance. Natural ideas included: An imbalance of the Four Humours or poisonous air.
How did they try to prevent illness? Supernatural ways included: Praying to God, flagellating themselves (they believed that punishing themselves meant that God would see they were already punished and so did not deserve illnesses, such as the Plague), astronomy, astrology, lighting candles to keep spirits away. Natural ways included: Using a pomander so that the 'bad smells' in the air could not get into their body, avoiding contact with the sick (watchmen and crosses were posted outside houses that contained people with the Plague), clearing streets, lining cesspits,sewers to take away waste.
The Middle Ages 2
What types of treatment were there? Natural ways included: Plaster of Paris to fix broken bones,ointments, plasters, using Galen's Theory of Opposites to balance the Humours, herbal remedies,amputations, wine and herbs (which were effective as anaesthetics). Supernatural ways included: Charms, cutting crosses into foreheads to ward off the Devil and evil spirits.
- The Black Death (1348 - 1350)
- The Great Plague (1665)
The Arab World
Similarities - Medical books, strongly influenced by religion, did not use dissection (was against the ideas of their religion), looked to rational approaches for answers, used the ideas of Galen and Hippocrates, did not have a cure for the Black Death.
Differences - Had good libraries, more hospitals, caring for the sick was an important part of their faith.
Avicenna is a well-known individual. He wrote many books on medicine which were used in universities as late as the 1650's. His most important medical books were called "The Book of Healing" and "The Canon of Medicine".
Who treated the sick? Some healers had to be licensed, such as physicians (all were men and were expensive), surgeons (both women and men) and midwives (supervised pregnancies). Other healers did not have to be licensed, such as wise women (had a deep knowledge of herbs but wrong treatments caused them to be accused of witchcraft), members of families, the Lady of the Manor (girls from wealthy families would have a few medical books and could treat local people) and travelling quack (would travel around in fairs and markets but not all actually had much knowledge of medicine or anatomy).
What did they think caused illness? The imbalance of the Four Humours, 'seeds of disease' settling in the infected part of the body (poisonous air), astrology (stars and planets), God (was punishing them), bad meat. People also believed that disease was passed on through the breath, by sweating or simply by smell.
What types of treatment were there? Lady Grace Mildmay used complicated treatments made up of herbs. Other herbs, seeds, metals and minerals, such as amber, gold, turpentinw, mercury, tin, lead, tobacco and more. The use of opposites to balance the humours, cleaning wounds, shaving off hair, rhubarb. Wounds were cauterised using hot oil and bandaged.
Amputations were used to remove the painful body part. Supernatural treatments included using amulets and charms, praying to God and the belief in the King's Touch (Many believed that King Charles' touch could cure scrofula).
The role of women and how it changed: The number of women surgeons in the early 17 hundreds declined due to a lack of education as women could not attend universities to qualify as doctors. Men gradually took over delivering babies due to the invention of forceps because they required some knowledge of the human anatomy, something which many women lacked.
Renaissance - Important Individuals
Andreas Vesalius (1514 - 1564): Realised that Galen had made mistakes about the anatomy of humans once he dissected human bodies and changed the way dissection was carried out. He also taught students who wanted to learn about medicine and anatomy. He published a book titled: "The Fabric of the Human Body".
Paracelsus (1493 - 1541): He also disagreed with Galen's ideas. He thought that disease was caused by things outside the body attacking the body.
Ambroise Pare (1510 - 1590): Pare worked as an army surgeon and published books. His oil supply ran out so he had to come up with another way to cauterise wounds - he used a combination of egg yolk, oil of roses and turpentine. He decided to tie up arteries (ligatures) and bandage wounds.
William Harvey (1578 - 1657): Proved the circulation of blood and that it was pumped around the body by the heart and not created and used up by the liver, as Galen had stated. He published books on his work
The work of Vesalius, Paracelsus, Pare and Harvey all contributed to help develop medicine and knowledge of anatomy. These individuals proved that Galen's work was wrong, which helped other doctors to realise that they needed to look to other ideas about anatomy and medicine rather than just accept Galen's work.
The Industrial Revolution - Important Individuals
Edward Jenner (1798): Developed a vaccine for smallpox by using cowpox. Because of his work a way had been found to prevent the spread of some infectious diseases.
James Simpson (1847): Discovered the use of chloroform as an anaesthetic. As a result of his work, patients could be put to sleep when operated on, reducing the number of deaths from shock during surgery, and no longer suffered through much pain during surgery.
Florence Nightingale (1850): Developed new attitudes towards the importance of health and cleanliness in hospitals. Patients were given more privacy and wards were kept clean with better trained, more professional nurses.
Edwin Chadwick and John Snow (1854): Chadwick carried out surveys and reports for the government on the living conditions in towns and cities. His reports showed that there was a link between poor living conditions and disease. This conclusion was one factor that led to the 1848 Public Health Act. Snow published a few books on the effects of Ether and Chloroform as anaesthetics. He proved that the 1854 Broad Street outbreak of Cholera centralised around the local water pump.
Industrial Revolution - Important Individuals 2
Louis Pasteur (1861): Founder of the Germ Theory, a theory which stated that germs caused disease, rather than vice versa. At long last people realised that evil spirits, bad humours or bad smells did not cause disease and could finally look for more suitable treatments to disease. He corrected the 'Spontaneous Generation' theory (which stated disease caused germs). Technology, such as microscopes, helped Pasteur look in detail at bacteria and the rivalry between himself and Robert Koch meant that he was determined to find and answer and proof to his theory before Koch did. He used experiments to prove his findings. His work was seen as the 'stepping stone' for other scientists to expand upon, such as Robert Koch.
Robert Koch: Proved Louis Pasteur's Germ Theory. He also developed the vaccines for Cholera, Tuberculosis and other diseases. He also used experiments to prove his findings. Good communication allowed Koch to hear about Pasteur's ideas and expand on them.
Joseph Lister (1867): Discovered the use of carbolic spray as an antiseptic. As a result of this doctors were able to keep wounds clean and clear of infection. He received opposition though - spraying carbolic acid meant that surgery times increased and, due to his history of changing his mind, his idea of carbolic spray was not considered reliable at first.
The Industrial Revolution
Edward Jenner and Vaccinations: Inoculation was used by people before Jenner to try to stop people from developing Smallpox. Jenner's treatment was known as Vaccination. Jenner realised that Cowpox doses could be used to prevent Smallpox. The King supported this and he was granted some money by the government to open a vaccination clinic once his ideas were proved to work.
Jenner realised, through observation, that farmers who had already suffered from cowpox were not likely to suffer from smallpox. He vaccinated a young boy with cowpox and, once the boy recovered, inoculated him with smallpox. The boy did not produce any symptoms of smallpox or suffer in any way from the disease. After retesting this theory many times, Jenner recorded his results and wrote up his findings.
His work was rejected by the Royal Society so he published it himself. Some people opposed his work, not believing that a disease from cows could be good for them - some even believed they would turn into cows.
By 1803 his vaccination was used in the USA. By 1805 Napoleon's soldiers were vaccinated. By 1812 his work was published in Arabic and Turkish. In 1852 the government made vaccinations compulsory.
The Industrial Revolution - Surgery
Surgery: The three main barriers from surgery in the 19th Century were: Pain, Infection and bleeding.
Lister used Carbolic Spray to prevent the spread of infection (1867).
Koch believed that bacteria on Surgeons hands could cause infection. He grew bacteria from the hands of surgeons and proved that the germs on surgeons hands matched those in the patients. He also suggested boiling equipment as a more effective way of sterilising items.
1870s - Designated rooms were now used for surgeries, a small audience was allowed but not a larger one, as previously allowed. Surgeons started wearing rubber gloves, hats and masks.
Rubber gloves were brought into surgical theatres by William Holtstead.
Equipment was sterilised by soaking them in chemicals, placing them in gas ovens or steaming them in steam autoclaves.
The Industrial Revolution 5
The new cleanliness in operations allowed more invasive surgeries, such as abdominal operations.
Shock started to become increasingly common. Simpson's use of Chloroform (1847) allowed the patients to be put to sleep meaning less died from shock.
The first human Blood Transfusion took place in 1818.
However, only some were successful because it was not known that there were different Blood Groups.
Karl Steiner discovered that there were different blood groups in 1900.
During World War One the many problems with blood transfusions were solved because an anti-clotting chemical was found and an effective way of storing the blood was sorted.
The Industrial Revolution 6
The Role of Women:
Elizabeth Garrett Anderson (Born 1836): Received a diploma to practice medicine and built a medical school for women.
Elizabeth Blackwell (Born 1821): She was the first woman physician in America. She opened the first women medical college in America.
Sophia Jex-Black (Born 1840): She persuaded universities to allow her to attend lectures and wrote a book. With the help of an MP she got the law to change, allowing women to be awarded a medical degree.
Florence Nightingale (Born 1820): Published books about nursing, such as her "Notes for Nursing". She improved the conditions in many hospitals, allowing patients their privacy and improving professionalism and cleanliness.
Opposition women faced: They received opposition from men because many men did not believe that women should have the same rights as men, such as going to university, and because the law stated that women could not have a medical degree.
The Industrial Revolution 7
Public Health before 1848: Poor people did not get much help but richer people did because they could afford it. Diseases such as Cholera and Typhoid were common. Diet and hygiene was poor. Urbanisation meant that cities and towns were overcrowded. There was a lack of sewage system, fresh water supply and drainage in towns. The government did not help or develop Public Health because they did not believe it was their duty to (laissez-faire) and they were reluctant to spend rate payers' money.
Why was the 1848 Public Health Act passed? Public Health was deteriorating and the rate of diseases were increasing. Cholera was becoming increasingly common and the public grew almost afraid of it because outbreaks were frequent and the disease hit both the rich and poor. The report by Edwin Chadwick showed the government that something had to be done about the poor living conditions in towns. His findings were published in 1842.
The measures in the 1848 Public Health Act: Suggested the need for cleaner conditions, the removal of sewage from streets, cleaner water and higher taxes. It was also suggested that towns borrowed money from the government to invest in a good sewage system, drains, waste removal and pipes supplying fresh water. They should also appoint a Medical Officer of Health to each town.
The Industrial Revolution 8
What were the effects of the 1848 Public Health Act? Eleven million pounds was borrowed from local councils between 1848 and 1872 but only a few towns made improvements and only 50 towns appointed Medical Officers of Health.
Why could Public Health not really improve after 1848? The rich did not want to pay taxes because they did not want to spend their money on the poor. There was no specific scientific evidence that proved the link between disease and germs (the Germ Theory was in 1861). The 1848 Public Health Act only encouraged towns to make changes, it did not make these changes compulsory.
Louis Pasteur discovers the Germ Theory, proving that germs caused disease, in 1861.
Were there any other factors which affected the passing of the 1875 Public Health Act? In 1867 working class men gained the right the vote, meaning that Members of Parliament had to pay more attention to the needs of the poor. The governments attitude of 'laissez-faire' weakened. They realised that they had to interfere in the public lives to stop more outbreaks of diseases and prevent more deaths.
The Industrial Revolution 9
The 1875 Public Health Act meant that it was compulsory for local authorities to provide clean water, proper drainage and sewers to towns. They also had to appoint a Medical Officer of Health who would check the health standards in towns were maintained.
What factors brought about the medical changes of the 19th Century?
1. The Germ Theory - 1861 - Louis Pasteur
2. Surgery - Anaesthetics by Simpson and Antiseptics by Lister
3. Weakening of Laissez-faire and increase in Public Health improvements - the government and public worked together
4. Statistics - William Farr showed that there was a link between unhealthy living conditions and high deaths rates and Edwin Chadwick showed that there was a link between poor living conditions and disease.
5. New votes.
6. Increase in diseases and outbreaks of cholera.
Twentieth Century Medicine
Problems doctors faced at the start of the 19th Century included blood loss, the inability to see inside the body, internal infections after operations, anaesthetics were still hard to control.
Pain - The discovery of Chloroform as an anaesthetic by James Simpson.
Infection - The discovery of Carbolic Acid as an antiseptic by Joseph Lister.
The Impact of World War One on surgery:
Medical challenges during World War One: Conditions in trenches, new illnesses (such as trench foot), mass death and mass injuries (including bullets and shell shock), blood loss.
Why did war improve surgery? Industry spent more money and time developing new surgical equipments for surgery on soldiers, surgeons worked closer together to save lives rather than in competition, surgeons did more operations and worked harder to save lives.
Head wounds and brain damage: Surgery of the eye, ear, nose and throat improved rapidly and surgeons were able to set up practices back home. Doctors had to experiment for cures. New technology such as skin graphs allowed further improvements.
Twentieth Century Medicine 2
Bullets and shrapnel lodged in soldiers wounds: This could cause infection. Technology, such as X Rays, allowed surgeons to remove the fatal shrapnel without causing damage to body. Doctors tried harder to find a way to prevent infection.
Soldiers bled to death whilst waiting for an operation: Doctors search for a way to store and transfer blood which was found when doctors discovered plasma could be removed. The discovery of blood groups meant that doctors could know if a blood transfusion would work or not. The government pressured public not fighting to give blood to save soldiers.
Many recruits were very unhealthy: The government realised just how unhealthy the general public were. Soldiers who fought in the war were promised good lives back at home for defending their country (Homes for Heroes) and, therefore, Public Health improved. Slum housing was to be demolished.
Twentieth Century Medicine 3
In 1928, Alexander Flemming discovered Penicillin by accident. He noticed that the staphylococci near the mould had disappeared. Flemming experimented with Penicillin and the bacteria seemed to have an effect at ridding patients of infection, however, Flemming could not produce enough penicillin from penicillin (the mould) so he simply recorded his findings and gave up.
In 1939 Howard Florey and Ernst Chain read about Flemming's research into penicillin. They asked for funding from the government so that they could research the properties of penicillin. In 1940 they tested the mould on mice and saw that the mice which received penicillin did not die whereas the other mice did. The first test on humans was in 1941 and, in 1942, the British government funded the production of penicillin from a different source to Fleming's, meaning that enough could be extracted and used to treat soldiers.
Technology: Flemming did not have the right technology to prove his theory about penicillin and create enough to use effectively against infection but Florey and Chain did.
Government: Funded research and production of penicillin.
Twentieth Century Medicine 4
War: There was desperate need for a drug which could fight infection inside the body after surgery as many soldiers died from it.
Experimentation: Florey and Chain experimented with different uses of penicillin in mice before trying the drug on humans.
Public Health in the 20th Century:
Despite the 1875 Public Health Act, living conditions and health were still bad for the poor. Towns were still overcrowded and infant mortality was worse than before.
The Liberal Party introduced acts to improve life for the poor.
1906 - Meals for school children meant children had at least on proper meal a day.
1907 - All births had to be registered with midwives.
1909 - Back-to-back housing was banned and building regulations were enforced. By 1939, 700,000 houses were built away from towns and with good ventilation.
Twentieth Century Medicine 5
1911 - National Health Insurance was introduced.
1918 - Local authorities were required to build new houses for the working class (this linked to the idea of 'Homes for Heroes' and meant that people lived in less cramped conditions).
Diphtheria and TB were still a problem for many people.
National Health Insurance Scheme:
Who contributed? Both workers and employers contributed towards the scheme.
What benefits did they receive? People recieved free medical care from a panel doctor and had a sickness benefit.
Who were not included in the scheme? Unemployed people were not included in the scheme, which meant most women as the majority did not work due to having children to look after. The chronically ill could not benefit from this either.
Twentieth Century Medicine 6
What treatments did they rely on? These people had to rely on cheap, easy-to-find remedies or one handed down through generations. People cared for their family or neighbours when they were sick.
Due to the 1929 Wall Street Crash, many people became unemployed. This meant that there was a high number of people who could not benefit from the National Health Insurance Scheme but they could also not afford doctors outside the scheme because they had no money.
People could also not afford clean water or proper housing. Due to a lack of food, infant mortality rates rose.
What positive measures did the government take during this period? They forced local authorities to rehouse 80 percent of people living in poor housing conditions. Large housing estates were built away from town centres.
How was public health affected by World War Two? Rationing meant that food was shared equally and people received the right nutrients in their diet, doctors could improve their knowledge of medicine for after the war.
Twentieth Century Medicine 7
'Homes for Heroes' encouraged governments to provide the public with better homes, services were reorganised to cope with the high number of casualties which gave everbody much better access to health care, women were given better jobs meaning there was a rise in family income and they could afford to live a little better.
The NHS, 1948:
William Beveridge founded the NHS so that it covered both rich and poor from 'cradle to grave'.
Before 1948 there was still a high infant mortality rate and twenty percent of people still lived in slum housing.
William Beveridge wrote a report in 1942, "The Beveridge Report" proposing that people only paid one sum of money towards the Health Care System and that the service provided by doctors was free.
Beveridge and Bevan told the public that the system would be expensive but that it was worth the money.
Twentieth Century Medicine 8
The government knew that something had to be done about the death rates and so a Bill to introduce the NHS was passed by parliament in 1946.
What services did the NHS provide? Hospitals, specialist doctors, blood transfusions, dentists, medicines, family doctors, ambulances, vaccination, health centres, home nursing, after-care of sick, maternity and child welfare, controls on medical training and research, teaching hospitals, medical research.
Opposition to the NHS included:
1. Local authorities and voluntary organisations - Because hospitals would be nationalised these people, who ran the hospitals, would lose their jobs.
2. Ratepayers - Because they did not want to pay medical bills for the poor and those who did not work.
3. Doctors - Some did not want to be employed by the government and told where to work.