John B. Murphy

John-Benjamin-Murphy 150

John Benjamin Murphy (1857 – 1916) was an American physician and abdominal surgeon

Arguably the first surgeon to perform a biliary tract endoscopy and first to perform femoral artery anastomosis after gunshot injury. Murphy described his clinical experience and experimentation with injured blood vessels in resection of arteries and veins injured in continuity– end-to-end suture (1897)

Multiple eponyms named after him including Murphy’s Sign (1903) for clinical diagnosis of cholecystitis describing a hooking technique rather than an anterior subcostal approach to detect gallbladder hypersensitivity. Notable advocate for early surgical intervention in appendicitis

William J. Mayo described him as “the surgical genius of our generation”; and Loyal Davis termed the fabled surgeon “extraordinary” and the “stormy petrel of American surgery”


Biography
  • Born in Appleton, Wisconsin on 21 December 1857.
  • 1879 – Doctorate from Rush Medical College
  • 1882 – Worked closely with Theodor Billroth (famous for the Billroth Gastrectomy) in Vienna
  • 1890 – Professor of Surgery at Rush Medical College
  • 1892 – Professor of Clinical Surgery at the College of Physicians and Surgeons
  • 1895 – Surgeon in Chief at Mercy Hospital
  • 1901 – Professor of Surgery at Northwestern University Medical School
  • 1912 – Performed the first biliary tract endoscopy (this claim is argued)

Medical Eponyms
Murphy’s Sign (1903)

Pain elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the subcostal region

The most characteristic and constant sign of gall-bladder hypersensitiveness is the inability of the patient to take a full, deep inspiration, when the physician’s fingers are hooked up deep beneath the right costal arch below the hepatic margin. The diaphragm forces the liver down until the sensitive gall-bladder reaches the examining fingers, when the inspiration suddenly ceases as though it had been shut off. I have never found, this sign absent in a calculous or infectious case of gall-bladder, or duct disease.

Murphy 1903: 827-828
Murphy's sign 1903 - picture 1910
Shows the surgeons hands hooked under the costal arch to determine the sensitiveness of the gallbladder. The patient cannot inspire against the pressure with an acutely inflamed or distended gall-bladder – Murphy 1910

Murphy’s Percussion Test: Murphy described a perpendicular percussion technique for evaluation of the inflamed gallbladder

Murphy percussion text 1910

Fig 2; Shows the hand elevated, with the middle finger flexed perpendicularly at the tip of the ninth costal cartilage.
Fig 3; Shows the finger struck with the right hand when the patient is in deep inspiration. This causes great pain if the gall-bladder is distended or inflamed. Murphy 1910
Murphy’s Punch Test

Pain upon percussion / punch tenderness at the costo-vertebral angle indicative of perinephric abscess, pyelonephritis, renal stone or haemorrhagic fever with renal syndrome


Fig 4; Shows the palm of the left hand pressed firmly over the right renal zone and the right elevated to make the stroke.
Fig 5; The stroke completed. When the kidney is actually inflamed, the pelvis distended or the ureters obstructed, there is great pain elicited by the blow: if the lesion is in the appendix or in the gall-bladder there is no pain produced. Murphy 1910
Murphy’s sequence [Murphy’s Triad, Murphy’s Quadrad]

1895 – Murphy initially presented a quadrad of signs in his report and analysis of one hundred and forty-one histories and laparotomies

Upon what cases should we operate? Upon every case of appendicitis, or better, upon every case where we have present the four cardinal symptoms: 1. Sudden attack of pain over appendix. 2. Always nausea, frequently vomiting. 3. Elevation of temperature, and 4. Local tenderness in the position occupied by the appendix

Murphy 1895: 14-15

1904 – Murphy recognized an ordered sequence of signs and symptoms in his analysis of Two Thousand Operations for Appendicitis and Deductions from His Personal Experience. He included low grade fever in the sequence but with the proviso that a raised temperature at any given stage of the attack is not invariable and is not an essential feature in establishing a diagnosis. Murphy’s sequence (quadrad) is often shortened to a triad of signs and symptoms excluding fever.

The symptoms in the order of their occurrence may be mentioned as: first, pain in the abdomen, sudden and severe, followed by (second) nausea or vomiting, even within a few hours, most commonly between three and four hours after the onset of pain; third, general abdominal sensitiveness most marked in the right side, or more particularly over the appendix; fourth, elevation of temperature, beginning from two to twenty-four hours after the onset of pain…The symptoms occur almost without exception in the above order, and when that order varies I always question the diagnosis. If the nausea and vomiting or temperature precede the pain I feel certain that the case is not one of appendicitis

Murphy 1904: 190
Murphy Button [Anastomosis Button] (1894)

Murphy’s preferred cholecystoenterostomy over cholecystostomy or cholecystectomy for the operative management of cholecystic disease. Murphy created a surgical device to create the anastomosis between the gallbladder and the duodenum. The ‘anastomosis button’ was a hollow-cored spherical device divisible into two hemispheres, over which the purse-stringed segments to be anastomosed could be affixed.

Murphy Button Anastomosis Button 1894
The Murphy Button, 1894
1. Anastomosis Button
2. Half button threaded for introduction into gallbladder

The two halves of the brass ‘anastomosis button,’ were joined and then locked together, facilitating rapid apposition of the two segments. The button was then ‘passed’ a few weeks following insertion, leaving the anastomosis intact.

Approximation of button halves for cholecystoenterostomy
Approximation of button halves for cholecystoenterostomy. 1894

Murphy performed first cholecystoenterostomy on a 35-year-old, severely jaundiced woman, joining the gallbladder with the jejeunum by means of the button. The gallstones were not removed. ‘Time from opening of the peritoneum until the closing of same, eleven minutes.’ reducing the standard operating time for the anastomosis tenfold. The Mayo brothers, William and Charles, visited Murphy’s clinic and adopted the ‘Murphy Button’ for use in the Mayo Clinic, where it remained in common use until 1935.

Other Medical Eponyms
  • Murphy-Lane bone skid – Surgical instrument used primarily for femoral head procedures
  • Murphy’s Drip – The administration of rectal fluid by proctoclysis in patients with peritonitis

Key Medical Attributions

1912 – Described the first biliary tract endoscopy by inserting a cystoscope into a cholecystostomy drainage tract, passing a hook through the cystoscope and removing a residual stone. He describes the procedure:

It showed that a small stone was present in the hour-glass contraction zone, where the large stone had formerly been lodged. The cystoscope was pressed on this to the round ligament; a hook passed through the cystoscope to the stone. The stone was rotated and jammed against the edge of the cystoscope, and by this means it was extracted for its position.

Cholelithiasis. Surgical Clinics of JB Murphy 1912

Controversies

The offspring of humble Irish immigrants born in a log cabin on a farm in Appleton, Wisconsin, he was originally named simply John Murphy. As every other child in his school had a middle name, he added a ‘B’ to his name, later this became Benjamin.

JB Murphy is most probably the source of the quote most commonly attributed to Osler

Dr. NC. Gilbert tells how Dr. Murphy used to shake his finger in the students’ faces and say in his shrill voice, “Listen, listen to the patient’s story! He is telling you the diagnosis.

Gilbert NC. JAMA 1939

Anecdotally, 2 days before his death he correctly predicted his own autopsy findings: ‘I think the necropsy will show plaques in my aorta


Major Publications

References

eponymictionary CTA

eponym

the person behind the name

Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM with a passion for rugby; medical history; medical education; and informatics. Asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | vocortex |

Dr Michael Leith is an Emergency Doctor at a tertiary hospital in Perth, Western Australia.| LinkedIn |

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