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Lawson Tait(1845-1899)*
By
Robert Lawson Tait, born May 1, 1845 in Edinburgh, Scotland, was educated in his earlier years at Heriot’s Hospital. (1) The purpose of this institution was the education of poor fatherless sons of freemen. At age 15 young Tait went to the University of Edinburgh on a scholarship. The first year he studied the Arts, but the following year he changed to Medicine. At age 17 he made an autopsy on a case of Dr. Mathews Duncan, a prominent gynecologist surgeon of the day, in which the patient had died from hemorrhage due to a myoma of the uterus. Tait was influenced greatly during those early years by James Syme, the Professor of Surgery at the University of Edinburgh. Syme was named Professor at age 24, in which year he performed the first hip joint amputation. When 28 years of age, he removed the lower jaw for a large tumor. In the same year, for the first time, Syme divided the sternocledo-mastoid muscle for wry neck. At age 47 he performed his subsequently famous ankle-joint amputation. Syme was said to be a deliberate surgeon, extremely meticulous and clean, and able to perform his relatively slow operative procedures because of the recent introduction of ether anesthesia from the United States. This great surgeon was small of stature, well-dressed, and commonly was washing his hands, particularly after examining a patient and before and after operative procedures. His habits were in contrast to those of the majority of surgeons of the day, who wore blood-stained and dirty frock coats for their surgical operations and whose assistants carried the silk sutures in the lapels of their rarely laundered coats as a badge of their position. Many of these characteristics of Syme appeared in Tait’s professional activities in succeeding years. At age 21 Lawson Tait qualified as L.R.C.S. and L.R.C.P., but he never earned an M.D. degree. At age 22, in 1867, he became the House Surgeon in the small village of Wakefield, a market town in Yorkshire. Here he married Miss Sybil Stewart. During the next three years, he performed five ovariotomies for ovarian cysts. The first patient died of peritonitis but the remainder recovered. During his years at the University of Edinburgh he had learned that thirty consecutive patients had succumbed after operations for ovarian cysts. In an issue of Science Gossip in 1868 Tait described minute grayish tubercules on the pleural surfaces of lungs of swallows.(2) Later in the same year in the Lancet he described the tape worm in birds.(3) At age 25 (in 1870), Tait moved to Birmingham. Here he joined the various local medical societies, debated frequently, and soon was well known to the local professors. He joined the staff of the newspaper, “The Morning Post” and wrote leading articles regularly, both to augment his funds and to extend his acquaintance and reputation. In most of his medical papers, he attached his name in some manner with a distinguished man. (4) In the same year he passed the examination for a fellowship in the Royal College of Surgeons of Edinburgh. The following year, at age 26, he became Lecturer on Physiology for the Ladies’ Class at Midland Institute. This improved his practice by extending his acquaintances and friendships. During this year he wrote on Hospitalism, a term introduced by James Y. Simpson, although Tait changed the subject name to Hospital Mortality. Now we must digress to describe Lawson Tait’s associations with Sir James Y. Simpson. James Young Simpson was elected to the Chair of Obstetrics at the University of Edinburgh at the age of 28 by one vote. (5) He proved to be a popular physician because of his winning ways, his courtesy, and his smile. Before the age of 40 he was very famous. During Lawson Tait’s years in medical school at the University of Edinburgh the young bow lived in the home of James Y. Simpson and subsequently became his assistant for a year. Because of their striking resemblance, both being rather short, heavy-set men with thick neck and heavy shoulders and with magnificent, large heads (size 8 hat), apparently it was widely considered that Simpson was the father of Tait, and it was surmised that his mother a lady of gentility (Fig. 1,2.)(6) A quotation from one of Simpson’s papers has a philosophic quality. “It is a social observation that philandering and prosperity go together.” Simpson was an obstetrician of merit; he wrote on pelvic cellulitis, hematocele, uterine cancer, hermaphroditism, version and extraction in patients with deformed pelves, uterine displacements, and cervical dilatation with sponge tents. He felt that the uterine sound was of tremendous value in treatment of many conditions in the pelvis, particularly in the reposition of the displaced uterus. He was said to have invented acupressure, in which an incision or a blood vessel could be closed by passing a needle back and forth between each side of a severed area as in fastening a flower in the lapel of a coat. This technique was ridiculed by Syme. In 1847 Simpson discovered the anesthetic qualities of chloroform and introduced it into obstetrics. Queen Victoria received chloroform with each of two deliveries. One of Simpson’s dramatic contributions was his protest against Hospitalism. He was appalled at the frightful statistics of deaths among patients who entered the large hospitals throughout the British Isles. He stated that there was a greater chance of death on an English operating table than at the Battle of Waterloo. Throughout Tait’s life he was affected by Simpson’s teachings, later stressed hospital mortality in a monograph (7) and was proud of his association and resemblance to Simpson. It was said that he was not unhappy with the suggestion that he may have been Simpson’s son. (8) In the same year (1871) a Hospital for the Diseases of Women was founded in Birmingham. A chief surgeon was required to have fellowship in the London College of Surgeons. Tait studied intensely for four months and passed the examination. He was promptly made one of the three chief surgeons of this hospital. In the same year he wrote a paper of “The Strange Course of a Uterine Sound”. (9) In 1872, at age 27, he gave a case report of chronic abscess of the ovary. This was a description of the first removal of a small ovary for pain. The same year he removed both ovaries for menstrual hemorrhage and subsequently performed this procedure on many occasions for hemorrhage associated with myomas of the uterus. (10) In 1873, at the age of 28, Sir William Fergusson, President of the British Medical Association, presented Mr. Lawson Tait with the Hastings Gold Medal for his essay, “On the Pathology and Treatment of Ovarian Disease.” The President indicated that this was a great honor in as much as an award was not made as a matter of course and for some years none had been given. The subject was considered one of the most original of the century. He further stated that the essay had done great honor to the teaching of Sir James Y. Simpson. (11) The Essay discussed the anatomy and physiology of the ovary, various diseases, dysmenorrheal, ovarian hyperemia, chronic ovaritis, acute ovaritis, tumors, and ovariotomy. The essay was sub-divided and printed in seven parts in the British Medical Journal through the year 1874. (12) The essay, its appearance as a chapter in his textbook and finally the enlarged essay in book form, Diseases of the Ovary, published by William Wood and Co. of New York (1183), (13) contained various illustrations of the development of the ovary and various pathological findings including hydrosalpinx. He describes his trocar for abdominal paracentesis, another for ovarian cysts, his modification of arterial forceps, his ether apparatus, his wire clamp, the Staffordshire Knot, and the Double-hitch Knot. Tait felt that the former knot, suggested by the Coat of Arms of Staffordshire which he saw in a railway carriage on one occasion, was the perfect hemostatic method for controlling hemorrhage, particularly from the ovarian pedicle. The Staffordshire Knot is difficult to understand and is illustrated in this paper (Fig.3). The double-hitch knot is the surgical knot commonly used today. In this book, it was of interest that Tait elaborated on various subjects in regard to women. In a discussion of the education of young girls, it was his opinion that undue effort and attention to education was unwise for young women, particularly that “Musical exercises are especially hurtful, for the further reason that music, in those who are devoted to it and gifted with its necessary peculiarities, is a strong excitant of the emotions; while to those not so gifted, and who do not care for it, musical exercises are an intolerable and useless burden… But it is useless to disguise the fact that, inasmuch as women have functions to fulfill which men are free from, it is not to be expected that women can, with safety, do the work of men, and at the same time properly fulfill their own special functions as women. The questions raised by the advanced advocates of women’s rights are to be settled, not on the platform of the political economist, but in the consulting-room of the gynecologist.” For women to become too highly educated and compete with men would be disastrous. “To leave only the inferior women to perpetuate the species will do more to deteriorate the human race than all the individual victories at Girton will do to benefit it. This over-training of young women is wholly unnecessary in the interests of human progress, and it is mischievous alike to themselves and to humanity.” In the same year (1873) he performed laparotomy for excision of a term, dead, extra-uterine fetus. He did not remove the placenta. Subsequently he performed four other operations for advanced extra-uterine gestation of this type. He advised that the placenta not be removed because of the possibility of severe hemorrhage. In 1874 at age 30 he performed an abdominal subtotal hysterectomy for fibromyoma, by placing clamps around the cervix which were removed on the eighth day through the abdominal incision. (14) In 1877 at the age of 33 Lawson Tait published his textbook, Diseases of Women. (15) The eight sections included the Morns Veneris; Vulva; Vagina; Urethra; and Bladder; Uterus; Broad Ligaments; Fallopian Tubes; Ovaries; and Pelvic Bones. The Lancet (16) stated that this work was sketchy, that the discussion of symtomatology, diagnosis and treatment were too brief, while an obscure point in pathology was discussed too fully. On the other hand, this book had a tremendous influence not only in the British Isles but in America, Australia and elsewhere. Previously both he and Professor Simpson had described the reposition of the inverted uterus after delivery by continuous pressure with a cup pessary attached by elastic bands to a waist belt. Here he described dilatation of the extremely small and rigid cervix by means of continuous pressure with a very small straight dilator. Within 24 hours the smallest cervix became dilated to a very considerable size. In the same year (1877) a monograph by Tait was published by J. & A. Churchill of London, An Essay On Hospital Mortality, (17) based upon statistics of the hospitals of Great Britain for 15 years. In this book he studied the total hospital mortality in Great Britain, and demonstrated a lesser mortality in the small hospital. He concluded that any hospital with more than 100 beds presented a grave danger. “I can only reiterate the opinions of Miss Florence Nightingale and Mr. Cadge, that it would be infinitely better to leave the sick and hurt in their own homes than to place them in buildings where they are exposed to the risks apparent in the returns of certain hospitals.” Throughout his essay Tait never referred to the work of Joseph Lister, whose original publication in 1868 on the antiseptic treatment of compound fractures, by now was being extended to all surgical procedures both in England and on the Continent. In 1879, at the age of 35, Tait performed many interesting operations and offered numerous papers. In this year he performed cholecystotomy, removed multiple gall-stones, and thought he was first to perform it. As a successful operation, this was true in England and on the Continent, but subsequently it was learned that Bobbs of Indianapolis had performed this operation in 1867. Also, in this year he wrote on pyosalpinx and hydrosalpinx and demonstrated the involvement of the tubes and ovaries in pelvic inflammatory disease. Excision of tubes or of the tubes and ovaries for inflammatory disease became known s “Tait’s operation” in subsequent years. Unfortunately many surgeons removed normal ovaries under the guise of Tait’s operation which caused Tait to take great pains to correct this misunderstanding. On the other hand, during this time, Tait became interested in the removal of essentially normal ovaries for neurotic conditions as practiced by Battey of Georgia. Battey had believed that castration or removal of the normal ovaries was of great value for the treatment of neuroses in women. For a short period Battey’s operation was widely accepted in America and to some extent abroad, but it was quickly condemned by the leading men. Tait reported that excision of the ovaries in a few cases with severe epilepsy was followed by great improvement. He did not press this approach. In the same year (1879) Tait described operations for repair of the perineum. (18) Perineorrhaphy, also known as “Tait’s operation”, included the V operation, which reflected the posterior vaginal wall at the mucocutaneous border in a U-shaped manner and drew the levator muscles together in the midline. For repair of complete tears through the sphincter and rectum, the H operation extended the incisions alongside the anus; the mucosa was separated by a transverse incision in the perineum; the rectal mucosa was brought together and the divided sphincter was reattached in the midline. This operation, as performed today, is simpler because of intestinal antisepsis. In 1880 at age 36 he performed the first hepatotomy for hydatid cyst of the liver. The very large cyst was incised, a great amount of cystic material was removed, and the patient recovered. (19) In this year he read frequent papers in London and spoke in many cities over the British Isles. Frequently he was highly critical of others, made very strong remarks in his own defense, and replied to his critics by letters to the various medical journals or in person before medical societies. During this time he began his ridicule of Mr. Spencer T. Wells, the most distinguished elder gynecologic surgeon of the day. Wells by this time had operated on approximately 600 cases of ovarian cystic tumors with a twenty-five per cent mortality. This great surgeon continued to believe that the use of the hemostatic clamp on the ovarian pedicle was the proper treatment, the clamp being removed several days later. Tait believed that the relatively large mortality of Wells was caused by this clamp, and undoubtedly there were many complications from its use. On the other hand, Tait in his first 50 cases had a mortality of 38 per cent; in these he either ligated the pedicle and drew the ligature out of the incision or he used the Wells clamp. In his second fifty cases, only three patients died; in this group either the pedicle was cauterized and returned to the abdomen (Baker Brown) or was ligated, the suture trimmed and the pedicle returned to the abdomen. Tait believed these approaches were great advances. During this time Tait disagreed with the antiseptic theory constantly, never would accept Lister’s carbolic acid spray, although he did permit some carbolizing of instruments and materials within his operating room. This brings up the technique of Lawson Tait, who by now was one of the most famous surgeons in the British Isles and was visited frequently by other surgeons from the Continent and America. While he was controversial on the one hand, probably he was the most skillful operator of the time. He never believed in the germ theory, at least that germs would multiply and putrefy except in dead tissue. In the living body they were unimportant. On the other hand, his technique, undoubtedly affected by his earlier years with Syme, was most exceptional. He insisted on complete cleanliness, both in his own person and that of his nurses, who must be not only attractive, have bathed frequently, but have worn only the cleanest of fresh clothing. He operated primarily in the Crescent, the hospital for women in Birmingham, although on occasion he operated in various cities and towns throughout the country. In this small hospital the rooms contained relatively little furniture, the floors were caulked in order that they might be scoured thoroughly and frequently, particularly before and after operations. All bed linen was scrupulously clean and freshly laundered. The patient was anesthetized within the room with a mixture of chloroform and ether; Tait believed that ether was safer than chloroform. After being put to sleep in her bed, she was lifted onto the flat operating table which was wheeled into the room. The abdomen was cleaned with soap and water. The instruments had been boiled to clean them (Tait did not realize that this was a superior method of asepsis), and they were neatly placed on clean linen at his right hand. His sponges were prepared with meticulous care, and only 12 were allowed on the operating table. They had been soaked for long periods of time, boiled, dried in the sun, and re-used at different operations but only after most careful cleansing. Tait was insistent on the identity of the number of sponges and clamps used. Only one assistant was present. Tait operated from the right side of the table, and always made as small an incision as possible, commonly only two inches in length. The forefinger and middle finger of his left hand were exceedingly capable at dissection and at determining the pathology in the abdomen. All large ovarian cysts were aspirated completely and gradually drawn out through the small incision. After ligating the pedicle (in his mid-period he cauterized the pedicle routinely) and returning it back to the abdomen, the incision was closed with only three or four sutures. All blood was removed if there was any excess. The abdomen may have been washed free by very clean and boiled water, particularly if pus or excess blood were present. The operations were of short duration; it was the practice in this period of surgery to emphasize speed as an important preventative of infection. The Lister carbolic acid spray was never used by Tait. At the age of 37 (1881) at the International Medicine Congress in London, (20) Tait described his cholecystotomy, drainage of the kidneys, surgery for the spleen, pelvic laparotomy for drainage, five successful operations for term ectopic pregnancy, operations for pyosalpinx, and castration for hemorrhage from myomas. In 1884 at age 40 Tait traveled to Canada by invitation, and visited Quebec, Montreal, Albany, New York and Philadelphia. He spoke frequently and made a great impression on the American surgeons, particularly Joseph Price of Philadelphia. In 1886 at age 42 his many papers included one on ovariotomy. (21) In this paper he defended the claim that Robert Houstoun of Glasgow had performed the first ovariotomy in 1701. Actually in Houstoun’s description mucinous material was scooped from a large cystic tumor through a very small incision, but removal of the tumor and ligation of the pedicle were not mentioned. Tait did give great credit to the later work of Ephraim McDowell, who performed his first ovariotomy in 1809 where he definitely removed the ovarian tumor and repeated this operation successfully a number of times. Yet Tait remained zealous of Houstoun’s first and stressed it continually. In 1888 at age 44 he was president of the Medical Defense Union, an organization to defend doctors against lawsuits. In his annual address he stressed antivivisection so strongly that, following much criticism, he resigned the post. (22) Throughout his life he continued to be an antivivisectionist of great vehemence, although he did agree that the use of small animals in bacteriology may be necessary. In 1888 he presented his Lectures on Ectopic Pregnancy and Pelvic Hematocele. (23) This was printed as a monograph by the Journal Printing Works of Birmingham. Here he described early ectopic pregnancy, (and he believed that all originated in the tube although they may become secondary abdominal pregnancies), and though he made an accurate diagnosis in these instances he was unable to bring himself to explore the abdomen because of their condition. An autopsy revealed the accuracy of the diagnosis. Subsequently he determined to operate for ruptured ectopic pregnancy. His first case died, which he attributed to his slowness in separating adhesions. In this monograph he described one case who died and 43 cases who lived. Often he operated on the patient in extremis and without blood, at times without any anesthesia, but with remarkable success because of his rapid procedure of ligating the pedicle, removing the clots and closing the abdomen. This procedure is recommended today and was a first presentation by Lawson Tait. While Tait made many more speeches at intervals, he continued to express a derogatory opinion of Lister and the antiseptic system of surgery, which he repeated in no uncertain terms. In 1890 he gave the address in surgery before the British Medical Association. (24) This was a prolonged address and within it he urged that the surgeon should take a long apprenticeship before beginning practice on his own. (It is to be noted that Tait, on the other hand, began his surgery at age 21 alone.) From 1891 to 1899, when he died, which here is exuded between the ages of 47 and 54, Tait continued to go to London frequently, attended various societies, but presented few important papers. There were no new discoveries. In 1892 he was offered a baronetcy, but he declined the honor. At about this time, early in 1893, he was involved in a libel action, and on top of this, a nurse accused him of being the father of her child. (25) This he denied, but the two unfortunate accusations so damaged his reputation that his practice suffered and declined. He lost heavily financially and had to sell many of his possessions, such as the country house in the New Forest which he had bought for £40,000, his house boat and steam launch on the Severn, and his yacht on the Solent. Apparently the last paper by Tait was on the Hospital bed. (26) Here he described and recommended a metal frame with particularly small springs that were intertwined with steel in small portions to form a very stiff bed. He designed it to arch up in the center so that one would lie perfectly flat without sagging. This bed was not only recommended for hospital use but also for general use. He stated that he had not patented the idea, but that if he had he would have become a rich man. Tait died on June 13, 1899 at the early age of 54. He had suffered from urinary mollecus earlier, and had had a urethral calculus removed in 1897. It was typical that he had made a bad patient. He went black under the anesthetic and nearly died. He was ordered to remain in bed, but next day he was sitting by the fire, “with a Tam o’Shanter on his head, a big cigar in his mouth, and a pint of Champagne at his elbow.” But this was sometime before his death. The death certificate stated “Nephritis. Uraemia 10 days.” On the day he died his usual doctor was away, and the young locum was worried about his responsibility and asked Tait if he would like another opinion. Tait said “No”, and looked at the cigar he was smoking, “I am smoking a very good Laranaga, and the last I shall ever smoke.” He died that afternoon. Mrs. Tait died in 1909. They were a childless couple. On the cross over their joint grave was inscribed, “She hath done what she could.” (27) Lawson Tait was a hard fighter, used direct and uncompromising language, undoubtedly was difficult to live with, had a raging temper, but was exceedingly kind to the poor and unfortunate, often operating and giving his services free, and was extremely compassionate toward animals. He was no ordinary man; he was determined, masterful, and self-reliant, had great ability, and an indomitable will. He was a good speaker and entered many fierce controversies. Tait was a pioneer in female pelvic surgery and made it safe for his time. Undoubtedly and apparently unconsciously he was a leading man in the development of present-day aseptic surgery. Perhaps this was his greatest contribution. However, he did open the abdomen to many intra-abdominal diseases, including particularly pelvic inflammatory diseases, and more dramatically the diagnosis and treatment of ectopic pregnancy. *This biographical sketch was stimulated by an address by Mr. John Tompkinson, Gynecologist to Guy’s Hospital, London, given before the Continental Gynecologic Society, meeting at Rochester, Minnesota, May 24-25, 1964.
ILLUSTRATIONS 1. Laws on Tail. A photograph from 1891 when Tait was age 51. Reproduced from Lawson Tait, His Life and Work by W. J. Stewart McKay, London: Baillere, Tindall, and Cox, 1922, by permission. 2. Sir James Y. Stewart. A photograph of a painting reproduced from Lawson Tait, His Life and Work by W. J. Stewart McKay, London: Baillere, Tindali, and Cox, 1922, by permission, and from 3. Drawing of Tait’s own Staffordshire Knot.
REFERENCES 1. McKay, W. J. Stewart, Lawson Tail, His Life and Work, London: Baillere, Tindall, and Cox, 1922, p. 3. 2. Medical News, Lancet, 1: 31, Jan. 4, 1868. 3. Tait, Lawson, Tapeworm in birds. Lancet, 1: 145, Jan. 25, 1868. 4. McKay, W. J. Stewart, op. cit., p. 28. 5. Robinson, V., J. Y. Simpson, Medical Life, 100: 57, 1929. 6. Ibid. 7. Tait, Lawson, An Essay on Hospital Mortality, London: J. & A. Churchill, 1877. 8. McKay, W. J. Stewart, op. cit., p. 8. 9. Tait, W. J. Stewart, Strange Course of a Uterine Sound, Lancet 1: 594, April 29, 1871. 10. McKay, W. J. Stewart, op. cit., p. 36. 11. Minutes, Forty-first Annual Meeting of the British Medical Association, Lancet 2: 195, Aug. 16, 1873. 12. Tait, Lawson, Hastings Prize Essay, Brit. Med. J., 1: 701, May 30, 1874. Tail, Lawson, Hastings Prize Essay, Brit. Med. J., 1: 733, June 6, 1874. Tail, Lawson, Hastings Prize Essay, Brit. Med. J., 3: 765, June 13, 1874. Tail, Lawson, Hastings Prize Essay, Brit. Med. J., 1: 798, June 20, 1874, Tait, Lawson, Hastings Prize Essay, Brit. Med. J., 1: 825, June 27, 1874, Tail, Lawson, Hastings Prize Essay, Brit. Med. J., 2: 8, July 4, 1874. Tail, Lawson, Hastings Prize Essay, Brit. Med. J., 2: 27, July 11, 1874. 13. Tait, Lawson, The Pathology and Treatment of Diseases of the Ovaries, New York: William Wood and Co., 1883. 14. Tait, Lawson, Case of successful removal of a large fibro-myoma from the fundus uteri, Lancet, 2: 680, Nov. 7, 1874. 15. Tait, Lawson, Diseases of Women, New York: William Wood and Co., 1879. 16. Reviews and Notices of Books, Lancet 2: 809, Dec. 1, 1877. 17. Tait, Lawson, An Essay on Hospital Mortality, op. cit. 18. Tait, Lawson, On new methods of operation for repair of the female perineum, McKay, W. J. Stewart, op. cit., p. 119. 19. McKay, W. J. Stewart, op. cit., p. 141. 20. Tait, Lawson, paper read before the Surgical Section of the International Medical Congress, London, Aug. 1881, McKay, W. J. Stewart, op. cit., p. 205. 21. McKay, W. J. Stewart, op. cit., p. 263. 22. McKay, W. J. Stewart, op. cit., p. 308. 23. Tait, Lawson, Lectures on Ectopic Pregnancy and Pelvic Haematocele, Birmingham: The "Journal Printing Works, 1888. 24. McKay, W. J. Stewart, op, cit., p. 403. 25. Flack, I. H., The Thomas Vicary Lecture, Ann. Roy. Coll. Surg., Eng., 2: 165, 1948. 26. McKay, W. J. Stewart, op. cit., p. 457. 27. Martin, C., Lawson Tait: the Man and his Work, Birmingham Med. Rev., 6: 109, 1931.
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