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Research Article
RoydenMcIntoshMuir andHis Anesthetic Links Between South Africa,
London, and the United States
Peter Crichton Gordon, MBChB, FFA(SA) ⁎Emeritus Associate Professor and Part-Time Lecturer, Department of Anaesthesia, University of Cape Town, Anzio Road, Observatory, 7925 Cape Town, South AfricaHonorary Curator, Nagin Parbhoo History of Anaesthesia Museum, University of Cape Town, Cape Town, South AfricaArchivist, South African Society of Anaesthesiologists, Durban, South Africa
a b s t r a c ta r t i c l e i n f o
⁎ Corresponding author at: Department of AnaesthesiAnzio Road, Observatory, 7925 Cape Town, South Africa.
Article history:Received 22 February 2016Received in revised form 24 April 2016Accepted 16 May 2016
Keywords:History of anesthesiaCyclopropaneAnesthesia equipmentForegger MidgetWater-sight flowmeter
New Zealand born, Dr. Royden McIntosh Muir, MBChB(Edin), DA(RCS&RCP), emigrated to Cape Town in1921 having specialized in anesthesia in London after World War 1 and became one of South Africa's ear-liest and leading anesthesiologists. He was appointed honorary anesthetist and clinical teacher by the Uni-versity of Cape Town at South Africa's first medical school in 1922, and lecturer in 1927. Aware of CapeTown's isolation at the southern tip of Africa, he undertook extensive tours studying anesthetic practiceat major hospitals in London, the United States and Canada in 1933 and 1938. He became a lifelong friendof RalphWaters inMadison, who coached him in the use of cyclopropane, and he subsequently introducedcyclopropane into England and South Africa. In the United States, he met Richard von Foregger, founder ofthe NewYork based Foregger Company, fromwhomhe later commissioned a purpose-built anestheticma-chinemarketed by Foregger as “TheMuirMidget.”Muirwas a foundermember of the South African Societyof Anaesthetists in 1943 and was elected as its second president the following year. Based on what he hadseen in academic hospitals in the United States and England, he fought until his retirement for the im-proved recognition of the specialty in South Africa and the establishment of adequately staffeddepartmentsof anesthesia at teaching hospitals in that country.
Roy (Royden) M. Muir was born British, of British parents, inWellington, New Zealand, in 1891 (Figure 1). His parents wereJames McIntosh Muir and Annie Isabel Jacob Muir (née Sisson).After commencing studies at the Victoria University College inWellington, New Zealand, he studied medicine at the University ofEdinburgh, graduating with an MBChB in 1914. Brought up with aroving spirit, his choice ofmedicine as a career was largely influencedby the possibilities of working as a ship's surgeon.1
After graduating,Muir entered the services of a steamship compa-ny and traveled around theworld. At the outbreak ofWorldWar 1, heenlisted in the Royal Army Medical Corps and saw service in France,becoming a lieutenant, and then temporary captain in 1915.2 Becauseof his love of the sea, he applied for a post as a ship's surgeon. Afterworking as senior casualty surgeon at the Royal Infirmary Home in
ersity of Cape Town,
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Hull where treatment was accorded to batches of wounded fromthe battlefront,3 he served on several hospital ships includingthe HMS Hospital Ship Dongola that took part in the 1915 GallipoliCampaign (Figure 2).4
During the war, he developed an interest in anesthesia. After de-mobilization, he traveled to London to take up the study of anesthe-sia, then establishing itself as a full-time specialty. He returned tothe sea in 1919 as ship's surgeon on the Union Castle Line BerwickCastle, and in 1920 on the White Star Line/Shaw, Saville & AlbionLine R.M.S. Corinthic that provided a passenger and freight service be-tween Britain and New Zealand via Cape Town.
Muir Emigrates to South Africa
During his voyages, Muir decided that the proximity of sea andmountains in South Africa's (SA's) Cape Province suited his lifestyleand he emigrated to Cape Town in 1921 to join the country's first“specialist anesthetist,” English born and trained, Dr. GeorgeBampfylde Daniell, in private anesthetic practice1,5. At the timethere was no formal training or accreditation of anesthesia in SA
Fig. 1. Dr. R.M. Muir, MBChB(Edin), DA(RCS&RCP). Image courtesy of Nagin ParbhooHistory of Anaesthesia Museum.
90 P.C. Gordon / Journal of Anesthesia History 2 (2016) 89–95
and the term “specialist anesthetist” is used to refer to medical prac-titioners who confined their practice to the specialty. Muir had beentrained in the use of ether and chloroform and brought with him aPinson ether “bomb” that he used for maintenance of anesthesiaafter induction with the Hewitt's wide-bore ether inhaler6
Fig. 2. HMS Hospital Ship SS Dongola. Image courtesy of King's
(Figure 3; both items are now displayed in the University of CapeTown's (UCT's) Nagin Parbhoo History of Anaesthesia Museum).
Bampfylde Daniell emigrated to SA in 1889 and returned to En-gland in 1902 to devotemore time to anesthesia. Heworked at sever-al hospitals in London and Edinburgh, becoming a Lecturer andInstructor in Anesthetics at the Edinburgh Royal Infirmary.5 Hereturned to SA in 1906 and the following year became the first doctorin SA to be appointed as an anesthetist to a hospital in SA when hewas appointed to the post at Johannesburg Hospital.5 Daniell de-signed or modified anesthetic equipment and published over 20 arti-cles on various aspects of anesthesia.5 In 1919 he was appointedhonorary anesthetist to the New Somerset Hospital, the UCT's andSA's first teaching hospital. Honorary anesthetists were appointedto the hospital as unpaid nonteaching medical staff. They came tothe hospital together with the surgeon they worked with in privatepractice and fromwhom theywere paid for cases anesthetized in pri-vate. In 1921 anesthesiawas introduced tomedical students as a sub-ject in their fourth year of a 6-year Bachelor of Medicine and Surgerydegree. Daniell was appointed the first Lecturer and instituted acourse of 12 lectures on the theory and practice of general surgicalanesthesia.5,6
Muir soon established himself in Cape Town as an exceptionallyable anesthetist and his practice thrived.1 In 1922 he was appointedas a clinical teacher in anesthesia by UCT and became a salaried lec-turer in 1927.6
Although thepublic hospitalswhere the honorary doctorsworkedat that time were reasonably well equipped, the majority of privatepatients in Cape Townwere operated on at a number of small, poorlyequipped private nursing homes where anesthetists had to providetheir own equipment and oxygen cylinders.7 Nitrous oxide was ex-pensive and not readily available. It had to be imported fromEngland,and the turnaround time for empty cylinders to be sent to England fortesting and refilling before returning to SA as deck cargo was at leastthree months. The first commercial manufacture of nitrous oxide inSAby thefirmAllen-Liversidge Industrial Gas Ltd commenced in 1928.
In November 1923, Muir married novelist and poetess DaphneAimee deWaal, only daughter of Sir Frederic deWaal, the first Admin-istrator of the Cape Province andhiswife Lady Sara deWaal (Figure 4).At their “society wedding” attended by more than 500 guests, SirJames Rose-Innes, Acting Governor General of SA, proposed the healthof the newlywed couple and commented on the international aspectof the marriage, which united SA and New Zealand.8 Early on in
Own Royal Regimet Museum, Lancashire, United Kingdom.
Fig. 3. Pinson and Wilson Ether “Bomb” brought to South Africa by Dr. Muir. Imagecourtesy of Nagin Parbhoo History of Anaesthesia Museum, Cape Town.
91P.C. Gordon / Journal of Anesthesia History 2 (2016) 89–95
their marriage, Daphne went blind apparently after an accidentcaused by anesthetic agent spilling onto her corneas during an appen-dectomy operation in Cape Town.9,10 Details of the incident have notbeen found. The Muirs separated and in 1927 Daphne emigrated toEngland. Nine years after the accident, she made medical history, be-coming the first person to undergo a successful bilateral cornealgraft, using healthy corneas from a blind donor, in an operation per-formed by Welsh surgeon, Dr. (later Sir) Tudor Thomas. As a resultof the success of the operation, she agreed to appear before theAmerican College of Surgeons at their meeting in Boston held in Octo-ber 1934 as a guest of family friend, British surgeon, Sir HaroldGillies.9,10 Shewas divorced fromher husband in 1935 and died in En-gland in 1971.
Fig. 4. Themarriage of RoydenM.Muir to Daphne deWaal. From left to right: Sir Nicolaas Fre(Best Man), and unidentified page girl and pageboy.
Muir's Overseas Voyages and the Influence ofRalphWaters
In October 1933, Muir embarked on an extensive tour investigat-ing anesthetic practice in hospitals in London, the United States, andCanada. He became the first South African anesthetist to deliver apaper on anesthesia in America when he attended the InternationalFellowship Session of the 12th Annual Congress of Anesthetists, inChicago.7 In the United States, he visited anesthetic departments in10 of its principal cities including Madison, New York, Boston, andRochester.11 He was also present in Montreal when Harold Griffithsadministered cyclopropane for the first time in Canada. One of thehighlights of his visit was meeting with Ralph Waters, who coachedhim how to administer cyclopropane.11 They became lifelong friendsand corresponded regularly until Muir's death in 1948.
In the United States, he met the New York–based instrumentmaker Richard von Foregger, who, together with Ralph Waters, haddesigned the Foregger Midget anesthetic machine for use withcyclopropane and oxygen, using water depression flow meters andthe Waters to-and-fro carbon dioxide absorber canister.12 Muirordered a Midget anesthetic machine from Foregger with two yokesfor oxygen, two for cyclopropane, and a water depression flowmeter for both gases. The machine was delivered to Cape Townearly in 1934 (Figure 5A-C). Before returning to SA, Muir ordered asupply of inflatable cuffs for endotracheal tubes from Waters andtwo 100-gal cylinders of cyclopropane from the Ohio Chemical andManufacturing Company, Cleveland, Ohio. Waters' daughter, Elva,manufactured the cuffs.13 On his return voyage to Cape Town, Muirdisembarked in England, becoming the first anesthetist to usecyclopropane in that country, when he demonstrated its use at fiveLondon hospitals—St Bartholomew's Hospital, Charing CrossHospital, Cancer Hospital, All Saints Hospital, and the Metropoli-tan Hospital at East Ham.11,14 Correspondence received by Muirafter his return to SA intimated that as a result of his demonstra-tion, the Cancer Hospital ordered cyclopropane for furtherinvestigations.11
deric deWaal, KCMG LLD, and Lady deWaal, RoydenMuir, DaphneMuir,Major Prynne
Fig. 5. A, Foregger Midget with 2 yokes for oxygen and 2 for cyclopropane. Image courtesy of Nagin Parbhoo History of Anaesthesia Museum, Cape Town. B, Foregger Midget seenfrom above with two yokes for oxygen, two yokes for cyclopropane with cylinders in situ, flowmeter, and ether vaporizer. Image courtesy of Nagin Parbhoo History of AnaesthesiaMuseum, Cape Town. C,Water depression flowmeter for cyclopropane and oxygen usedwith the ForeggerMidget. Oxygen is being administered at 350mL/min. Image courtesy ofNagin Parbhoo History of Anaesthesia Museum, Cape Town.
ig. 6. ForeggerMuirMidgetwith single yokes for oxygen and cyclopropane, andwater-sightowmeter. Image courtesy of Nagin Parbhoo History of Anaesthesia Museum, Cape Town.
92 P.C. Gordon / Journal of Anesthesia History 2 (2016) 89–95
Ffl
Comments on cyclopropane in letters written between WatersandMuirmake interesting reading. In a letter to Muir dated 27th No-vember 1933, Waters expressed concern with the widespread use ofcyclopropane before it had been fully tested, writing—“I am havingconsiderable difficulty in restraining the enthusiasm of some of myfriends in regards to cyclopropane. I should like very much to havenothing published on it for another year other than DoctorMeek's re-port of his electrocardiographic studies. I very much dread and fear apremature introduction of cyclopropane and a black eye for it as aresult.”13 In his next letter to Muir written 8 months later, Waterssounded more confident and wrote—“Cyclopropane now replacesethylene completely and at least seventy-five percent of the etherformerly used by us. Nitrous oxide is retained.”15 In correspondencewritten in July 1934, Muir informed Waters that he was gettinggood results with cyclopropane but that it was terribly expensiveby the time it arrived in SA. In the letter he mentioned, he hadcommissioned Foregger to make “another apparatus on very simpleand portable lines.”16 This was delivered in Cape Town and
Fig. 7. The newly built Groote Schuur Hospital in 1938. Image courtesy of Chief Executive Officer, Groote Schuur Hospital.
93P.C. Gordon / Journal of Anesthesia History 2 (2016) 89–95
advertised in the 1935 Foregger Catalog as the “Muir Midget,”17 de-scribed as being “the most midget amongst the midgets but also themost limited in capacity” with only one yoke for each gas(Figure 6). Muir intended it to be used with an “A” size cyclopropanecylinder (30 gal) together with a large commercial oxygen tankcoupled to the other yoke, although it could also be used with two“B” cylinders. Theflowmeters for oxygen and cyclopropanewere cal-ibrated to allowmaximumflows of 700 and650 cm3/min, respective-ly. A Foregger bubble–type ether vaporizer could be attached to thecommon gas outflow if required.
Muir required a simple portable machine to facilitate transportbetween hospitals. Themachinewasfittedwith a handle for this pur-pose. The cost of the Muir Midget in the United States in 1935 was$125.00 for the Midget alone and $225.50 for the Midget togetherwith ether attachment, to-and-fro filter, obturation valve, corrugatedsection, Sparklet connection for carbon dioxide and connections to alarge oxygen cylinder.17 After Muir's introduction of cyclopropaneinto anesthetic practice in SA, it was widely used there for manyyears. Dr. H.H. Samson, a Johannesburg anesthetist, administeredmore than 10,000 cyclopropane anesthetics without a fatality18 Sam-son was a great innovator. He improved the design of theWaters' to-and-fro carbon dioxide absorber by using a metal spring attached tothe screw-in end to compress the soda lime granules, therebypreventing channeling, and made the canister of a transparent butunbreakable material so the soda lime could be visualized.19,20
In October 1937,Muirwas awarded the conjointDiploma in Anes-thetics without examination by the Royal College of Physicians ofLondon and the Royal College of Surgeons of England under the fol-lowing conditions;
“Until May 1st, 1938, it shall be open to the two Royal Colleges onthe recommendation of the Committee of Management of the Ex-amining Board, to grant the Diploma without examination to anAnaesthetist to a general hospital associated with a recognizedmedical school in the British Empirewhohas held this appointment
for not less than ten years. The fee for such Diploma is six guineas.”(H.L. TIDY, Chairman of the Committee of Management.21
In 1938 Muir was appointed as a Senior Anesthetist to the newlybuilt Groote Schuur Hospital that had replaced the New SomersetHospital as the UCT'smajor teachinghospital (Figure 7). (The hospitalreceivedworldwide recognition in 1967when it became the site of theworld's first successful human to human heart transplant.)22
Muir returned to England, the United States, and Canada in 1938and presented a paper on “Capetown Anesthesia” at the 17th AnnualCongress of Anesthetists held in New York.23 In his presentation, hebrought the news that anesthesia had recently been recognized bythe South African Medical Council as a “distinct specialty alongsidesurgery, medicine, radiology, ophthalmology and so forth.” Special-ists had to confine themselves to their specialty andwere not allowedto augment their income by general practice or form a partnershipwith a general practitioner.
Muir's two visits to the United States, Canada, and England openedhis eyes to the inadequacy of anesthetic staffing and formal postgradu-ate training in SA teachinghospitals, and to the lowesteem towhich an-esthesia and anesthetists were held in SA. On his return to SA, he wrotea paper in the South African Medical Journal entitled “Whither Anesthe-sia?” in which he highlighted the positive changes he had seen in thosecountries since his previous visit five years earlier.24 Muir expressedconcern at the death rate at Groote Schuur hospital and suggestedthat conditionswereunlikely to improveuntil the attitude of the profes-sion towards the subject changes. He also pointed out that the manda-tory requirement for medical students to administer 10 supervisedanesthetics (2 of which were dentals) was inadequate.24
Changes Brought About by the SecondWorld War
SA joined the Second World War on the side of the Allies on 5thSeptember 1939. In that year, there were only 10 specialist
94 P.C. Gordon / Journal of Anesthesia History 2 (2016) 89–95
anesthetists on the register of the SA Medical and Dental Council.Anesthetists were needed urgently both at the Front and in base hos-pitals in SA. Many doctors and medical students volunteered for mil-itary service and joined the South African Medical Corps.
During thewar, regularmeetings were held between anesthetistsin Johannesburg and out of thosemeetings, the suggestionwasmadebyMajor R.A. Moore-Dyke to form a national society, with the objectof promoting the interests of practicing anesthetists.25 Invitations toattendwere issued to every anesthetist in SA. At the inaugural meet-ing held at the Johannesburg Hospital on 1st August 1943, the SouthAfrican Society of Anaesthetists became the world's ninth oldest na-tional society.25 Muir was elected to represent the Cape Province onthe Society's first Council and succeeded Dr. Benjamin Weinbren asthe Society's second president the following year.25
At the first Annual GeneralMeeting of the Society in 1944,Muir de-livered a presentation on “Teaching in Anaesthesia” thatwas publishedin full in the South African Medical Journal.26 In his address, Muirbemoaned the state of academic and anesthesia training in SA in com-parisonwith the highly organized andwell-staffed departments of an-esthesia that he had seen in the United States and, to a lesser extent, inBritain. He pointed out that a ten-fold increase in the number of med-ical students in Cape Town meant that they were getting less trainingthan they had 23 year previously, and that anesthesia as taught andpracticed had “little appeal” to graduates. He suggested that recognizedDepartments of Anesthetics be established at SA's medical schoolsstaffed on a similar basis to Waters department in Wisconsin, with afull-time Head of Department supported by a full-time assistant, twoto three interns (residents) only doing anesthesia, and other residentsspending 2 weeks of their 6-month contract in anesthesia. He also rec-ommended that medical students should be allocated to anesthesia ona full-time basis for 2weeks at a time, and that the SA'smedical univer-sities should offer postgraduate courses and a postgraduate diploma inanesthesia.26
At the Annual General Meeting of the Medical Association of SA in1946, a proposal by a surgeon, Mr Aubrey Radford, for “the immediateinstigation of a Chair of Anaesthesia for SA”was carried unanimously.25
It was another 13 years, however, before Dr. OVS Kokwas appointed toSA's first Chair of Anesthesia, at the University of Pretoria.
Dr. Muir retired from active anesthesia in 1946 to spend more timetravelingandwriting.Hewasanaccomplishedmountaineer, heldapilot'slicense, survived a plane crash in 1936, and had spent much of his freetime climbing or hiking in the Cape mountains. After retiring he traveledto East Africa and the Congo, then to London before returning to CapeTown on first leg of the sailing yacht Cariad's voyage around the world.
RoydenMuir died in Basutoland (now Lesotho) on 21st November1948while on a hiking tripwith friends in theDrakensbergMountains.He had no relatives in SA and was buried in Lesotho. A well-attendedMemorial Service was held for him at St George's Cathedral in CapeTown on 26th November 1948. Obituaries appeared in the SouthAfrican Medical Journal and the 1949Mountain Club of SA Journal.1,27,28
Muir's Legacy
In his opening address at the Chicago meeting in 1934, Muir statedthat he hoped that his visit would help to establish another link in theinternationalization and furtherance of our specialty. His travels to theUnited States and England opened his mind to new advances in anes-thesia and to the deficits in the system for training anesthetists in thepost-war SA. He brought these ideas back to SA and opened the wayfor further collaboration between the Southern and NorthernHemispheres.
In 1934,Western Australian Dr. Gilbert Troup undertook a similarextensive tour of anesthetic facilities in the United States and Canada.In his address to the 14th Annual Congress of Anesthetists at AtlanticCity, Troup referred to Muir's earlier visit and the similarities that
existed in anesthetic conditions concerning hospitals and medicalpractice in both Cape Town and Australia.29
Royden Muir sowed the seed for major changes in the status andpractice of anesthesia in SA. In the obituary to Muir by G.S. publishedin the South African Medical Journal (most likely written by his surgicalcolleague, Dr. George Sacks, who was head of a surgical firm at GrooteSchuur Hospital and a lecturer in surgery at UCT), the authorwrote—“His close friends knew that a mixture of two motivesprompted his early retirement. One was his overwhelming passionfor mountaineering and the sea. The other was a chronic resentmentof what he imagined was the thankless role of the anaesthetist. Hewas entirely justified in this for it is only in the past two or threeyears that surgeons have belatedly and grudgingly recognized the ines-timable value of thework of the anaesthetist. The pyrotechnics ofmod-ern surgery are possible only because of the services of highly skilledand able anesthetists. From being the handmaiden of surgery anesthe-sia has advanced to the status of complete equality. RoyMuir lived longenough to see this change and to rejoice in it.”27
One of the factors that contributed to the poor status of anesthe-tists in SA in that era was the teaching hospital system of appointingunpaid honorary anesthetists who were then reliant on the privatesurgeon that camewith them for remuneration fromprivate practice.In thepost-warperiod, the rapid growth of surgical specialties requir-ing anesthetists together with a sudden increase in medical studentsled to the realization that more full-time specialists were needed.Recognized departments of anesthesia were established with full-time salaried staff underHeads of Department replacinghonorary ap-pointments. Unfortunately, Muir did not live long enough to fully seethe changes for which he had strived so hard.
Acknowledgments
Thanks to Michael F.M. James for proofreading the manuscript;Malcolm Lewis, Christine Ball, and TonyWildsmith for help with ref-erences;Mark E. Schroeder and theUniversity ofWisconsin-MadisonArchives, in Wisconsin, for access to correspondence between Muirand Waters; and Lance Howell for assistance with photography.
References
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