Article on the Month: March/April 2013
Discretionary Anaesthesia
Dr J E Riding
Presented at the Llangollen Meeting, 25th-26th June 1993
Proceedings of the History of Anaesthesia Society 1993; 13: 25 – 29
There are many accounts describing how quickly and enthusiastically etherisation was taken up. Medical histories generally convey the impression that very soon after October 1846 painless surgery became the rule. Major,[1] in his History of Medicine wrote that by the middle of the 19th century pain had been banished from surgical operations. Bishop's History of Surgery [2] uses similar terms. According to Cartwright,[3] within a year hardly an operation was performed throughout the civilised world without the aid of ether. Garrison, [4] referring to obstetrics and to experimental work in animals, as well as to surgery, concluded a section on the introduction of ether 'In these fields anaesthesia was, in the memorable phase of Weir Mitchell the 'Death of Pain'.'
It is easy to assume, therefore, that ether and later chloroform were readily accepted within a few years by all surgeons for use in all the operations then performed in the advanced world. That this agreeable view might not represent the true state of affairs was long ago remarked by Duncum [5] who noted from the Medical Times of 18686 a 'complete failure' of some French surgeons even as late as 1868 'to recognise the importance of anaesthesia…'. Morton himself was subjected to bitter attacks, denunciations, abuse and ridicule, as indeed was Simpson, although the latter was better able to defend his views. Initial resistance was perhaps inevitable, but there are many indications that reluctance to use anaesthesia persisted for several years.
Evidence of failure to use anaesthesia
According to Pernick [7] the use of ether in the Pennsylvania Hospital began only in 1853. Further, he found from the records of that hospital that a substantial proportion of major limb amputations were performed without anaesthesia over the following ten years, the same being true in other leading American hospitals. Ogston,[8] according to Levack, recorded that as a student at Aberdeen in 1860, there was debate amongst the surgeons about whether chloroform was to be used and usually it was not. Youngson [9] states that Syme removed a chimney-sweep's cancer of scrotum without anaesthesia in 1861 and according to Sykes [10] the same surgeon performed glossectomy and mandibulectomy without anaesthesia in 1864. [11] Morris, [12] in his History of the London Hospital stated that some surgeons continued to operate without anaesthesia for years after 1846. There are occasional reports of major amputations under the influence of rum or brandy; for example, in Bristol in 1852. [13] On the other hand, chloroform was already widely used for limb amputations in Glasgow in 1848. [14]
Charles Kidd [15] in his Manual of Anaesthetics dated 1859, describes an operation for vesico-vaginal fistula without anaesthesia. He states also that the older ophthalmologists of the day preferred to go on as before without anaesthesia. In 1853 Cooper [16] reported that he had been using chloroform for eye surgery for two years. Yet as early as 28th January 1847, Neill, [17] a Liverpool eye surgeon, performed five operations under ether on the same day. At the same institution, eye surgery was still performed in some cases without anaesthesia as late as 1867. Frank Hamilton, a New York surgeon, had used ether within a year of Morton's demonstration. According to Pernick, [18] who studied his case books, Hamilton '....through a quarter of a century of surgical practice, lasting into the 1870's ... continued to carry out occasional amputations even of arms and legs, without resort to ether or chloroform..'
'The advantages derived from the use of anaesthesia are perhaps more evident and appreciated in the field than in civilian practice' wrote George MacLeod [19] in his History of the Surgery of the War in the Crimea, published in 1859. This suggests that even at that time anaesthesia was not universally employed. He stated that: 'In one division of our army it was not so commonly used as in others, from an aversion to it entertained by the principal medical officer of the division.' Kidd [20] quoted an army surgeon, Mr Cole, as holding the view that he would abolish chloroform altogether.
Others had doubts about anaesthesia. Thus, Gross [21] in about 1850 felt strongly that chloroform ought to be avoided in operations for bladder stones in adults. The operation he said is ‘ usually unattended with much pain' and having a patient with a clear mind he regarded as advantageous to the safe performance of surgery of this type. The reviewer of Gross' book added that anaesthesia should be withheld also in children for fear of causing injury to the bladder. John Snow [22] commented in 1855 on a lecture given by Syme, which included a statement that chloroform was given in London in certain cases when Edinburgh surgeons refrained from its use, as in lithotomy and tumours of the jaw. Rees [23] drew attention to the belief of J Mason Warren of Boston, writing in 1867, that the use of anaesthesia was inadmissible in operations for cleft palate in children, while Collis in Dublin had well established by that time that chloroform could be safely used in children of a very young age. Some forms of surgery were considered too minor to warrant anaesthesia. Boyer [24] in 1851, giving an account of occasions when chloroform should or should not be used, considered it superfluous in trivial surgery, but unfortunately did not detail what constituted triviality.
Why was anaesthesia withheld?
There were many reasons for reservations about the use of anaesthesia during the first years. Administrations were not always successful. Techniques had to be developed. There were difficulties about the purity of preparations used and, as Kidd [24] wrote in 1859: 'Very grave objections have been raised against chloroform for its destroying consciousness of the central organ of which we know so little…’. The role of anaesthetics in death associated with surgery was a common concern. There were the problems associated with particular types of surgery, especially of the eye or the mouth.
Some surgeons adopted a cautious approach and were suspicious of the new development. Wakley [26] writing at the beginning of 1847, having referred to the 'priceless treasure' at the dawn of a new era, noted nevertheless that 'the most terrible operations are much less painful in reality than they are imagined to be' - a view doubtless confined to medical men. There was an understandable concern about the risks of anaesthesia in the seriously exhausted, blood-depleted and shocked patient. Skey [27] reporting in 1851 the results of the use of chloroform in over 9,000 patients at St Bartholomew's Hospital, concluded that the agent was better avoided in these circumstances. Kidd [28] said that he was afraid of chloroform where the patient had been using digitalis or hydrocyanic acid as a medicine or had suffered mania. As late as 1879,Turnbull [29] gave a list of cases in which ether should not be employed. These included very aged patients with emphysema, those with cardiac hypertrophy and habitual drunkards.
Medical education at this period had little to do with research and was founded largely on the authority of the past. It is understandable that assessment of the balance of advantage against risk of anaesthesia was a difficult matter and caused anxiety for many years. Kidd [30] in 1859 observed: 'We still perhaps notwithstanding all the advantages of local and general anaesthesia allow too much pain in surgical operations' and added: 'There is no peculiar bravery in the surgeon wishing a fellow creature pain; there is nothing in all surgical science now to the man of delicate feeling worth one half-minute's pathological cutting open alive of a human being...'. The controversy about whether anaesthesia itself, or the slower and more deliberate surgery it allowed added to or lessened the risk of shock , was bedevilled by lack of scientific knowledge. Some surgeons took early advantage of the new conditions. Stanley, [31] in 1852, described a procedure lasting 1 ¼ hours for careful dissection of a parotid tumour and said there was no good ground for the opinion that chloroform interfered with wound healing. It is understandable that not all surgeons were immediately enthusiastic about the ability of ether or chloroform to make painless surgery possible for all who needed it, but after the initial conservatism and scepticism had been overcome, how widely was anaesthesia used for the range of surgical procedures then available?
It is possible to surmise that factors other than medical and technical may have influenced the extent of use of anaesthesia. The question of 19th century attitudes to pain is beyond the scope of a short paper but, according to Pernick's study, had considerable influence in America over the decision to use anaesthesia. This may well have been true in Britain. Humanitarianism had not by 1851 reached the point of abolition of labour by children under ten as chimney sweeps. [32] Records frequently make no mention of minor painful procedures such as removal of necrotic bone, minor amputations, avulsion of toenails. These were performed, but were they done without anaesthesia? Pernick's study [33] of American practice cites several authorities of mid and late 19th century as advising against anaesthesia for minor surgery. Turnbull's 1885 textbook on anaesthesia is quoted as advising that, inter alia, amputations of fingers and toes, surgery of the eye and of the anus were too minor to need anaesthesia.
Inevitably, reliance can only be placed on the records of those who chose to leave them. These were mainly the more eminent and articulate persons associated with the chief hospitals of the day. How did the less favoured amongst the population fare surgically? Bristow and Holmes [34] in their remarkable survey of hospitals in the United Kingdom, published in 1864, discovered that in most hospitals no operative records were kept. Almost no records exist of the substantial proportion of surgery performed in the home.
Importance of Surgery
How important was operative surgery within the general field of medicine in the middle of the century? Steele's statistics [13] of Glasgow Royal Infirmary for 1848 record 207 surgical procedures. During the same period almost 1600 patients were seen in the fever department, almost 1000 of whom suffered from typhus. In Liverpool in 1847 it was estimated that some 10,000 citizens died, 6,000 of fever, 3,000 of diarrhoea and about 1,500 with tuberculosis. [35] By comparison with the havoc wrought by the infections it may be that operative surgery was relatively unimportant and that the great discovery made small impact for the first few years.
The archives of the principal hospitals in Liverpool, Chester and North Wales, for several years after Morton's discovery, offer no suggestion of any substantial change in the activities of the hospitals as a result of the availability of anaesthesia - still less of any excitement being aroused. At the Northern Hospital sited alongside both docks and railway in Liverpool, fewer than 30 operations were noted for the years 1861-62. At the Liverpool Royal Infirmary the numbers amounted to fewer than 80 for the years 1860-62. No mention is made in either hospital's records of anaesthetic usage or of minor surgery.
When large scale suffering, united with evil social conditions, was the preoccupation of the day, it may be that individual suffering had little importance, and there was no widespread will to alter radically the status quo of surgery. Much later, when the great infections, pestilence and hunger had been largely vanquished, individual pain assumed a degree of importance previously inconceivable. Certainly, many years elapsed following Morton's demonstration before the benefits of painless surgery actually became available to patients for the full range of surgical procedures.
References
1. Major RH. History of Medicine.Vo1 11. Oxford: Blackwell, 1960; 754.
2. Bishop WJ. The Early History of Surgery London: Hale, 1960; 152.
3. Cartwright FF. The English Pioneers of Anaesthesia. Bristol: Wright, 1952; 317.
4. Garrison FH. An Introduction to the History of Medicine. 4th Edition. Philadelphia: Saunders 1929; 506.
5. Duncum B. The Development of Inhalational Anaesthesia. Oxford University Press: 1947; 16.
6. Non-administration of anaesthesia in French hospitals. Medical Times, 1868; II: 9
7. Pernick MS. A Calculus of Suffering. New York: Columbia U.P, 1995; 36.
8. Ogston A, quoted by Levack ID in: Aberdeen Archives and Anaesthesia. J Hist. Anaesthesia Soc 1989; 69: 79.
9. Youngson AJ. TheScientific Revolution in Victorian Medicine. London: Croom Helm, 1979; 26.
10. Sykes WS. Essays on the First Hundred Years of Anaesthesia. Vol I. Edinburgh: Livingstone, 1960; 116.
11. Syme J. Excision of the tongue. Lancet 1865; 1: 115.
12. Morris EW. A History of the London Hospital. London: Amold,1910;174.
13. Hospital Reports. Bristol Royal Infirmary. Amputation of both thighs; recovery. Provincial Medical Journal 1919; 353, 456.
14. Steele JC. Statistics of Glasgow Royal Infirmary 1848. Edinburgh Medical Journal 1849; 72: 241-277.
15. Kidd C. A Manual of Anaesthesia. London: Renshaw, 1859; 234.
16. Cooper W. On the use of chloroform in operations on the eye. Association Medical Journal 1953; Jan 7: 6.
17. Neill H. Painless surgical operations. Report of the Liverpool Eye and Ear Infirmary for the year 1846. Liverpool 1847.
18. Pernick. Ibid: 192.
19. MacLeod GHB. Notes on the Surgery of the war in the Crimea. London: Churchill; 131.
20. Kidd C. Ibid: 23.
21. Gross SD. A practical treatise on diseases and injuries of the urinary bladder, Am. J. Med. Science. 1851; 22: 415-434.
22. Snow J. Chloroform in London and Edinburgh. Lancet 1855; 1: 108.
23. Rees GJ. An early history of pediatric anaesthesia. Paediatric Anaesthesia 1991; 1: 3-11.
24. Payer M. Surgical operations in reference to the employment of chloroform. Am. J. Med. Science 1951; 20: 233-9.
25. Kidd C. Ibid: 23.
26. Wakley T. Editorial. Lancet 1947; 1: 74.
27. Skey MR. Results of the use of chloroform in 9000 cases at St Bartholamew's Hospital. Am. J. Med Science 1851; 21: 438.
28. Kidd C. Ibid: 82.
29. Turnbull L. Artificial Anaesthesia. Philadelphia: Lindsay 1879; 27.
30. Kidd C. Ibid: 20.
31. Stanley E. Operations on the cheek and lower jaw. Am. J. Med. Science 1852; 23: 255.
32. Mainwaring J. British Social History. Vol II. London: Odhams 157.
33. Pernick .MS. Ibid: 185.
34. Bristow JS, Holmes T. House of Commons Parliamentary Papers: Reports from Commisioners Vol 23. HMSO, 1864; 153-742.
35. Evans CC. Merseyside’s Magic Mountains. Transactions of Liverpool Medical Institution 1991-1992: 6-21.
It is easy to assume, therefore, that ether and later chloroform were readily accepted within a few years by all surgeons for use in all the operations then performed in the advanced world. That this agreeable view might not represent the true state of affairs was long ago remarked by Duncum [5] who noted from the Medical Times of 18686 a 'complete failure' of some French surgeons even as late as 1868 'to recognise the importance of anaesthesia…'. Morton himself was subjected to bitter attacks, denunciations, abuse and ridicule, as indeed was Simpson, although the latter was better able to defend his views. Initial resistance was perhaps inevitable, but there are many indications that reluctance to use anaesthesia persisted for several years.
Evidence of failure to use anaesthesia
According to Pernick [7] the use of ether in the Pennsylvania Hospital began only in 1853. Further, he found from the records of that hospital that a substantial proportion of major limb amputations were performed without anaesthesia over the following ten years, the same being true in other leading American hospitals. Ogston,[8] according to Levack, recorded that as a student at Aberdeen in 1860, there was debate amongst the surgeons about whether chloroform was to be used and usually it was not. Youngson [9] states that Syme removed a chimney-sweep's cancer of scrotum without anaesthesia in 1861 and according to Sykes [10] the same surgeon performed glossectomy and mandibulectomy without anaesthesia in 1864. [11] Morris, [12] in his History of the London Hospital stated that some surgeons continued to operate without anaesthesia for years after 1846. There are occasional reports of major amputations under the influence of rum or brandy; for example, in Bristol in 1852. [13] On the other hand, chloroform was already widely used for limb amputations in Glasgow in 1848. [14]
Charles Kidd [15] in his Manual of Anaesthetics dated 1859, describes an operation for vesico-vaginal fistula without anaesthesia. He states also that the older ophthalmologists of the day preferred to go on as before without anaesthesia. In 1853 Cooper [16] reported that he had been using chloroform for eye surgery for two years. Yet as early as 28th January 1847, Neill, [17] a Liverpool eye surgeon, performed five operations under ether on the same day. At the same institution, eye surgery was still performed in some cases without anaesthesia as late as 1867. Frank Hamilton, a New York surgeon, had used ether within a year of Morton's demonstration. According to Pernick, [18] who studied his case books, Hamilton '....through a quarter of a century of surgical practice, lasting into the 1870's ... continued to carry out occasional amputations even of arms and legs, without resort to ether or chloroform..'
'The advantages derived from the use of anaesthesia are perhaps more evident and appreciated in the field than in civilian practice' wrote George MacLeod [19] in his History of the Surgery of the War in the Crimea, published in 1859. This suggests that even at that time anaesthesia was not universally employed. He stated that: 'In one division of our army it was not so commonly used as in others, from an aversion to it entertained by the principal medical officer of the division.' Kidd [20] quoted an army surgeon, Mr Cole, as holding the view that he would abolish chloroform altogether.
Others had doubts about anaesthesia. Thus, Gross [21] in about 1850 felt strongly that chloroform ought to be avoided in operations for bladder stones in adults. The operation he said is ‘ usually unattended with much pain' and having a patient with a clear mind he regarded as advantageous to the safe performance of surgery of this type. The reviewer of Gross' book added that anaesthesia should be withheld also in children for fear of causing injury to the bladder. John Snow [22] commented in 1855 on a lecture given by Syme, which included a statement that chloroform was given in London in certain cases when Edinburgh surgeons refrained from its use, as in lithotomy and tumours of the jaw. Rees [23] drew attention to the belief of J Mason Warren of Boston, writing in 1867, that the use of anaesthesia was inadmissible in operations for cleft palate in children, while Collis in Dublin had well established by that time that chloroform could be safely used in children of a very young age. Some forms of surgery were considered too minor to warrant anaesthesia. Boyer [24] in 1851, giving an account of occasions when chloroform should or should not be used, considered it superfluous in trivial surgery, but unfortunately did not detail what constituted triviality.
Why was anaesthesia withheld?
There were many reasons for reservations about the use of anaesthesia during the first years. Administrations were not always successful. Techniques had to be developed. There were difficulties about the purity of preparations used and, as Kidd [24] wrote in 1859: 'Very grave objections have been raised against chloroform for its destroying consciousness of the central organ of which we know so little…’. The role of anaesthetics in death associated with surgery was a common concern. There were the problems associated with particular types of surgery, especially of the eye or the mouth.
Some surgeons adopted a cautious approach and were suspicious of the new development. Wakley [26] writing at the beginning of 1847, having referred to the 'priceless treasure' at the dawn of a new era, noted nevertheless that 'the most terrible operations are much less painful in reality than they are imagined to be' - a view doubtless confined to medical men. There was an understandable concern about the risks of anaesthesia in the seriously exhausted, blood-depleted and shocked patient. Skey [27] reporting in 1851 the results of the use of chloroform in over 9,000 patients at St Bartholomew's Hospital, concluded that the agent was better avoided in these circumstances. Kidd [28] said that he was afraid of chloroform where the patient had been using digitalis or hydrocyanic acid as a medicine or had suffered mania. As late as 1879,Turnbull [29] gave a list of cases in which ether should not be employed. These included very aged patients with emphysema, those with cardiac hypertrophy and habitual drunkards.
Medical education at this period had little to do with research and was founded largely on the authority of the past. It is understandable that assessment of the balance of advantage against risk of anaesthesia was a difficult matter and caused anxiety for many years. Kidd [30] in 1859 observed: 'We still perhaps notwithstanding all the advantages of local and general anaesthesia allow too much pain in surgical operations' and added: 'There is no peculiar bravery in the surgeon wishing a fellow creature pain; there is nothing in all surgical science now to the man of delicate feeling worth one half-minute's pathological cutting open alive of a human being...'. The controversy about whether anaesthesia itself, or the slower and more deliberate surgery it allowed added to or lessened the risk of shock , was bedevilled by lack of scientific knowledge. Some surgeons took early advantage of the new conditions. Stanley, [31] in 1852, described a procedure lasting 1 ¼ hours for careful dissection of a parotid tumour and said there was no good ground for the opinion that chloroform interfered with wound healing. It is understandable that not all surgeons were immediately enthusiastic about the ability of ether or chloroform to make painless surgery possible for all who needed it, but after the initial conservatism and scepticism had been overcome, how widely was anaesthesia used for the range of surgical procedures then available?
It is possible to surmise that factors other than medical and technical may have influenced the extent of use of anaesthesia. The question of 19th century attitudes to pain is beyond the scope of a short paper but, according to Pernick's study, had considerable influence in America over the decision to use anaesthesia. This may well have been true in Britain. Humanitarianism had not by 1851 reached the point of abolition of labour by children under ten as chimney sweeps. [32] Records frequently make no mention of minor painful procedures such as removal of necrotic bone, minor amputations, avulsion of toenails. These were performed, but were they done without anaesthesia? Pernick's study [33] of American practice cites several authorities of mid and late 19th century as advising against anaesthesia for minor surgery. Turnbull's 1885 textbook on anaesthesia is quoted as advising that, inter alia, amputations of fingers and toes, surgery of the eye and of the anus were too minor to need anaesthesia.
Inevitably, reliance can only be placed on the records of those who chose to leave them. These were mainly the more eminent and articulate persons associated with the chief hospitals of the day. How did the less favoured amongst the population fare surgically? Bristow and Holmes [34] in their remarkable survey of hospitals in the United Kingdom, published in 1864, discovered that in most hospitals no operative records were kept. Almost no records exist of the substantial proportion of surgery performed in the home.
Importance of Surgery
How important was operative surgery within the general field of medicine in the middle of the century? Steele's statistics [13] of Glasgow Royal Infirmary for 1848 record 207 surgical procedures. During the same period almost 1600 patients were seen in the fever department, almost 1000 of whom suffered from typhus. In Liverpool in 1847 it was estimated that some 10,000 citizens died, 6,000 of fever, 3,000 of diarrhoea and about 1,500 with tuberculosis. [35] By comparison with the havoc wrought by the infections it may be that operative surgery was relatively unimportant and that the great discovery made small impact for the first few years.
The archives of the principal hospitals in Liverpool, Chester and North Wales, for several years after Morton's discovery, offer no suggestion of any substantial change in the activities of the hospitals as a result of the availability of anaesthesia - still less of any excitement being aroused. At the Northern Hospital sited alongside both docks and railway in Liverpool, fewer than 30 operations were noted for the years 1861-62. At the Liverpool Royal Infirmary the numbers amounted to fewer than 80 for the years 1860-62. No mention is made in either hospital's records of anaesthetic usage or of minor surgery.
When large scale suffering, united with evil social conditions, was the preoccupation of the day, it may be that individual suffering had little importance, and there was no widespread will to alter radically the status quo of surgery. Much later, when the great infections, pestilence and hunger had been largely vanquished, individual pain assumed a degree of importance previously inconceivable. Certainly, many years elapsed following Morton's demonstration before the benefits of painless surgery actually became available to patients for the full range of surgical procedures.
References
1. Major RH. History of Medicine.Vo1 11. Oxford: Blackwell, 1960; 754.
2. Bishop WJ. The Early History of Surgery London: Hale, 1960; 152.
3. Cartwright FF. The English Pioneers of Anaesthesia. Bristol: Wright, 1952; 317.
4. Garrison FH. An Introduction to the History of Medicine. 4th Edition. Philadelphia: Saunders 1929; 506.
5. Duncum B. The Development of Inhalational Anaesthesia. Oxford University Press: 1947; 16.
6. Non-administration of anaesthesia in French hospitals. Medical Times, 1868; II: 9
7. Pernick MS. A Calculus of Suffering. New York: Columbia U.P, 1995; 36.
8. Ogston A, quoted by Levack ID in: Aberdeen Archives and Anaesthesia. J Hist. Anaesthesia Soc 1989; 69: 79.
9. Youngson AJ. TheScientific Revolution in Victorian Medicine. London: Croom Helm, 1979; 26.
10. Sykes WS. Essays on the First Hundred Years of Anaesthesia. Vol I. Edinburgh: Livingstone, 1960; 116.
11. Syme J. Excision of the tongue. Lancet 1865; 1: 115.
12. Morris EW. A History of the London Hospital. London: Amold,1910;174.
13. Hospital Reports. Bristol Royal Infirmary. Amputation of both thighs; recovery. Provincial Medical Journal 1919; 353, 456.
14. Steele JC. Statistics of Glasgow Royal Infirmary 1848. Edinburgh Medical Journal 1849; 72: 241-277.
15. Kidd C. A Manual of Anaesthesia. London: Renshaw, 1859; 234.
16. Cooper W. On the use of chloroform in operations on the eye. Association Medical Journal 1953; Jan 7: 6.
17. Neill H. Painless surgical operations. Report of the Liverpool Eye and Ear Infirmary for the year 1846. Liverpool 1847.
18. Pernick. Ibid: 192.
19. MacLeod GHB. Notes on the Surgery of the war in the Crimea. London: Churchill; 131.
20. Kidd C. Ibid: 23.
21. Gross SD. A practical treatise on diseases and injuries of the urinary bladder, Am. J. Med. Science. 1851; 22: 415-434.
22. Snow J. Chloroform in London and Edinburgh. Lancet 1855; 1: 108.
23. Rees GJ. An early history of pediatric anaesthesia. Paediatric Anaesthesia 1991; 1: 3-11.
24. Payer M. Surgical operations in reference to the employment of chloroform. Am. J. Med. Science 1951; 20: 233-9.
25. Kidd C. Ibid: 23.
26. Wakley T. Editorial. Lancet 1947; 1: 74.
27. Skey MR. Results of the use of chloroform in 9000 cases at St Bartholamew's Hospital. Am. J. Med Science 1851; 21: 438.
28. Kidd C. Ibid: 82.
29. Turnbull L. Artificial Anaesthesia. Philadelphia: Lindsay 1879; 27.
30. Kidd C. Ibid: 20.
31. Stanley E. Operations on the cheek and lower jaw. Am. J. Med. Science 1852; 23: 255.
32. Mainwaring J. British Social History. Vol II. London: Odhams 157.
33. Pernick .MS. Ibid: 185.
34. Bristow JS, Holmes T. House of Commons Parliamentary Papers: Reports from Commisioners Vol 23. HMSO, 1864; 153-742.
35. Evans CC. Merseyside’s Magic Mountains. Transactions of Liverpool Medical Institution 1991-1992: 6-21.
