Frank J. Murphy, M.D., C.M., 1900–1972

FIRST suggested in 1941, the “Murphy eye” is the hole through the right tip of the endotracheal tube, between the leading edge of the bevel and the inflatable cuff.1By mid-century it appeared on most Magill endotracheal tubes, and the eponyms “Murphy eye” and “Murphy tube” became standard. The man Murphy, however, remains a relatively obscure historical figure in the specialty of anesthesiology.Murphy's life is well worth examining, however, in the context of anesthesiology emerging as a fully developed medical specialty, around the time America began to recover from the Great Depression. Frank J. Murphy, M.D., C.M. (1900–1972), began his training in the late 1920s, and judging by today's standards, conditions were primitive. Residencies were apprenticeships with minimal formal didactics, professional meetings were infrequent, the only anesthesia journal in North America was a quarterly supplement to a surgical journal, and a specialty certification board was only a remote future possibility. As the specialty grew, organizations were developed to further its professional mission on a regional and national basis. Through this period, the American Society of Anesthetists,†the American Board of Anesthesiology, and the journal Anesthesiology increased educational activities in the specialty, to improve the quality of anesthesia care delivered in the community. Regulatory efforts based on national standards followed, and enforcement of the standards was occasionally called for, especially in the area of residency training.The core of Murphy's career spanned the years 1930–1960, and the impact of professional organizations can be seen repeatedly affecting his work, in early hospital practice, wartime service, running a university anesthesia service and a residency program, and finally in private practice. As the specialty matured, significant changes in Murphy's career demonstrated the results of regulation, for good or ill. As we consider our progress from those primitive beginnings to our current regulated practice pattern, we see ourselves and Murphy as participants in the same process. Thus, as historical narrative, the more we learn about Murphy, the more we may learn about ourselves.Francis John Murphy was born on March 11, 1900, in Oldham, South Dakota.‡Both his mother, Cecilia Regan, and his father, Mike Murphy, were from Irish farm families.§The first of three sons, Francis was named after his mother's brother and, like his uncle, preferred to be called Frank. All three Murphy brothers became physicians. Born 3 yr after Frank, Donald Joseph Murphy was linked to him closely for much of their lives.∥The youngest brother, Eugene (Gene) Murphy, practiced radiology in South Bend, Indiana, and had limited contact with his older brothers over the years (Jack O'Brien, personal communication, interviews, northern Idaho, September 28–October 1, 2009).When Frank was 9 yr old, the family moved to a farm near High River, Alberta, Canada.#After finishing high school in 1918, Murphy applied for a Canadian permit to travel to the United States to attend Gonzaga University in Spokane, Washington, and affirmed his US citizenship on the application form. He listed his height as 5′5" and his weight as 135 pounds, close to his adult stature. Murphy spent only 1 yr at Gonzaga and then transferred to the University of Alberta in Edmonton for a 4-yr combined premedical and basic science curriculum. Because the University of Alberta did not offer a medical degree at that time, he transferred to Montreal's McGill University for his last 2 yr, receiving his M.D., C.M. degree in 1925 (fig. 1).**This conjoined degree in medicine and surgery was commonly granted by Canadian medical schools of his day (C.M. refers to a Master of Surgery degree).2Murphy often spoke of his poverty during his Montreal years. To save money, he worked on cattle cars managing livestock during travel to Montreal, putting his farm background to good use and riding for free. During the school year, hospitals supplied meals to medical students on weekdays, but over the weekends, some of the less affluent students like Murphy lived on bread and water. Murphy also mentioned to his family in later years that he had promised his parents to support his brothers Don and Gene during medical school with income from his future practice (Jack O'Brien, personal communication, interviews, northern Idaho, September 28–October 1, 2009).After graduation Murphy married Anne Scullin, a Montreal native and nurse at one of the McGill hospitals. Her father worked at the Montreal Customs House; her mother operated a family grocery store.††Frank remained married to Anne his entire life.During his first year after graduation, Murphy took a rotating internship in the Western Division of Montreal General Hospital. It is likely that he and other interns were recruited to administer anesthetics under an apprenticeship system. This was a common practice in Montreal, where the number of trained physician anesthetists was small and the clinical load was heavy.2In 1925, he became licensed to practice in the State of Maine and did a year of general medicine in Atlantic, a small island community near Bar Harbor.‡ A lobster pot full of fresh catch would often appear at their door, a gift of the local fishermen for the doctor and his wife. Anne would keep one to cook for herself and slip the others back into the bay since Frank did not care for lobster (Jack O'Brien, personal communication. September 2009).In 1927, Murphy returned to Canada to begin training in anesthesia at Montreal General Hospital, where he came into contact with three important senior anesthetists. The first was Charles C. Stewart, M.D. (1888–1958), the hospital's Chief of Anaesthesia from 1928 to 1954, and a forceful early advocate for endotracheal anesthesia in Canada.3The second was the eminent Wesley Bourne, M.D., C.M. (1886–1965), a respected physiologist, pharmacologist, and clinician who became the first Professor and Chair of Anaesthesia at McGill University near the end of his career and who was elected president of the American Society of Anesthetists, the only Canadian ever so honored.4The third mentor was Harold Griffith, M.D. (1894–1985), who reported the first clinical use of curare in 1942.5The anesthesia trainees regularly spent free afternoons helping the senior anesthetists with private cases in community hospitals, so clinical contact with these teachers was extensive. Later events suggest that Murphy kept in touch with Stewart, Bourne, and Griffith throughout his career.Montreal was a point of contact between innovators in airway management in England and investigators in North America. Ether insufflation using small endotracheal catheters had been introduced in Montreal around 1912 by F. W. Nagle, M.D. (sole anesthetist at the Royal Victoria Hospital, 1890–1918).6The experience of Ivan W. Magill (1888–1986) (Westminster Hospital, London, United Kingdom) with airway management for reconstruction of facial injuries during World War I was influential in popularizing insufflation and pointed toward greater use of endotracheal anesthesia in a wide variety of procedures. With insufflation, patients breathed spontaneously as anesthesia gas was delivered through flexible small bore tubes inserted into the trachea or pharynx, and vapor was exhaled freely through the natural airway. By 1925 Griffith in Montreal was abandoning insufflation and moving on toward techniques using cuffed large-bore endotracheal tubes that would allow to-and-fro respiratory exchange.7Murphy would have seen these innovations in airway management as they first developed.Murphy initially planned to stay in Montreal, but in 1930, he moved to Detroit to become a very young Chief of Anesthesia at Harper Hospital. His brother Donald, after graduating from medical school in 1931, also came to Harper Hospital for training in surgery and stayed on to practice general surgery for 30 years. During their early years in Detroit, Frank and Anne Murphy started a family. Their two daughters, Margaret and Elizabeth, were born in 1931 and 1934.Murphy earned certification by the American Board of Anesthesiology in 1939, number 60 on the list of diplomates.‡‡Murphy joined the Wayne County Medical Society, the American Medical Association, and three anesthesia organizations: the Michigan Society of Anesthetists, the American Society of Anesthetists, and the Associated Anesthetists of the United States and Canada, one of the organizations founded by Francis H. McMechan, M.D. (1879–1939), an early organizer of regional and national anesthesia groups.§§Murphy first met John S. Lundy, M.D. (1894–1973), the influential Chief of Anesthesia at the Mayo Clinic, when they jointly commented on a paper at McMechan's Congress of Anesthetists in October 1934.∥∥Lundy would have been familiar with Murphy's work in Detroit, because three reviews of publications by Murphy appeared in Anesthesia Abstracts, which Lundy edited at the Mayo Clinic.1,8,9Murphy was elected to membership in the elite Anesthetists' Travel Club late in 1941, nominated by his three mentors in Montreal, who were long-term members.##For reasons not entirely clear, John Lundy, the founder of the Travel Club, objected to Murphy's election after the fact.***Murphy remained the 39thand last member of this renowned organization and became a charter member of its successor, the Academy of Anesthesiology.During his Detroit years, Murphy published a series of short papers dealing with atelectasis, preoperative medication, and shock, all concisely and clearly written.8–10His most impressive publication was written in 1940, criticizing the use of high concentrations of nitrous oxide in hypoxic gas mixtures during “secondary saturation” inhalation anesthetics.11The great popularizer of these techniques was E. I. McKesson, D.D.S., M.D. (1881–1935), the inventor and manufacturer of the first anesthesia machine with controlled-flow nitrous oxide-oxygen blenders. Murphy questioned the safety of the technique in the first sentences of his article: “Unfortunately some recognized authorities have set forth the dictum that anoxemia during the administration of nitrous oxide is a normal and harmless condition.12This has been thought to be true especially if the person administering the anesthetic agent has had a large number of previous asphyxiations to his credit.”11The reference to one of McKesson's publications leaves little doubt as to the identity of at least one of the recognized authorities mentioned, and the accusation of previous asphyxiations is hard to dismiss lightly. After listing the advantages and disadvantages of nitrous oxide, Murphy pointed directly to hypoxemia as the cause of most injuries attributed to nitrous oxide anesthetics: “The abandonment of the secondary saturation technique … will soon prove that asphyxia, not anesthesia with nitrous oxide, is responsible for the untoward effects which recently have been receiving attention.”Murphy chose Surgery, Gynecology, and Obstetrics , a prominent surgical journal, to publish this paper, and not the American Journal of Surgery Quarterly Supplement of Anesthesia and Analgesia , founded by Francis McMechan. McKesson had been an editor of McMechan's journal and had served as president of the National Anesthesia Research Society, founded in 1919 by McMechan, who described this group as “an organization financed by manufacturers of anesthetics and apparatus.”13Only 1 yr after McMechan's death in 1939, it was unlikely that his journal would publish a paper that criticized a prominent former editor or would offend commercial sponsors. The next year, however, Murphy published his most important paper, on the improved intratracheal catheter with the extra eye, in Anesthesia and Analgesia .1Simple endotracheal tubes were used in the 1930s, fashioned by individual practitioners from standard urethral catheter and rectal tube stock; manufactured endotracheal tubes did not become available until the 1940s. In his 1941 article, Murphy described two designs for “intratracheal catheters” that introduced the idea that multiple-orificed tubes could increase the safety of endotracheal anesthetics (fig. 2.).1The tubes had one hole on the end, cut diagonally across the tip, resembling the familiar bevel described by Magill two decades before, to facilitate passing the tube through the vocal cords. Murphy's significant alteration to the Magill tube added one or two oval-shaped holes to the side of the tube, describing their purpose that “should one or both of the eyes become obstructed with mucus, breathing is not obstructed.” Murphy called the side holes “eyes,” a term previously used to refer to the holes on the end of small insufflation tubes manufactured in the 1920s.14Murphy did not mention anatomical obstruction as another cause of occlusion of a single outlet on the tube. The next year, John Lundy, in his comprehensive textbook of anesthesia, commented on obstruction of endotracheal tubes with long diagonal bevels, when the tip was placed on the medial wall of the right mainstem bronchus.15He suggested cutting a hole into the bevel of the tube to allow gas to flow into the trachea. Anatomical obstruction was also well illustrated in Gillespie's book on tracheal intubation (fig. 3.).16Lundy may have known of Murphy's tube design before his textbook was published, or he may have independently recognized anatomical obstruction on the bevel and proposed a solution similar to Murphy's for the second problem. Murphy gets precedence by date of publication, and his innovation altered endotracheal tube design almost immediately. It was a simple solution to two simple problems, anatomical obstruction and mechanical obstruction by secretions.The position of the eye under the bevel on the right leading edge of the endotracheal tube also helps preserve ventilation of the right upper lobe orifice when the tube is advanced past the carina into the right mainstem bronchus. Whereas a Magill tube without a Murphy eye might not ventilate the right upper lobe adequately during right endobronchial intubation, a Murphy tube would preserve ventilation to the right upper lobe under most circumstances. Whether Murphy ever recognized this additional function of the eye is not known.Later evolution of the endotracheal tube placed the Murphy eye past the cuff next to the leading edge of the Murphy as the inventor of both the eye and the cuff tube that is into the wall of the endotracheal tube” for cuff was first suggested by M.D. at the Mayo used tubes in his practice, and Murphy's family has one of these tubes, by Murphy his of the first Murphy eye tubes, as in the in his personal Murphy in the United States in (fig. He was first to the hospital in Washington, and then to set a training in northern After training were on large to from was on in the of Spokane, Murphy the hospital and the anesthesia During the became a for almost one time, its was of and of used as It was the of the in at that Murphy a small to his family. Anne and the two lived until the end of the was so Frank could only it on The most of their in after Detroit, they the a Murphy was by because the with full of and was so similar to his in High River, only to the The family thought Frank was a at and it was that he joined the only to be to a so near to his The into the and both returned as Anne and Frank were back to as to their Murphy was moved to to for as Chief of Anesthesia at After the he returned to to close the Murphy the in March he had to Detroit, because he and the family to stay in the (Jack O'Brien, personal communication, interviews, September Murphy an anesthesia practice in Spokane, moving the family from Murphy a offer that was hard to Chief of Anesthesia at the University of Hospital, Chief of Anesthesia at the University of Hospital in had in and, to very some of the who had returned from the suggested Frank Murphy for the he might be available from the Murphy was almost on a University of then used that him to on at and set his based on M.D., personal communication, The was as a of the of Surgery, and was not under Murphy's were by nurse and medical Murphy two Frank and to with and The was and running by October and his clinical support for some with basic science of the medical dealing with Murphy published the first large clinical series of anesthetics using an and this at meetings (fig. was so much of the was by the basic and anesthesia and clinical was often young who the when Murphy the years Murphy was of the service … He to a a He his and in those in or that was a of He two young a year, or so we to the the early these were through the anesthesia community in by local who to the University Hospital for private practice. about the at the University the American Society of and the American Board of Anesthesiology in In the American Board of Anesthesiology two in that were not regularly residency reviews personal communication, two interviews, two and that the were receiving minimal the the and the however, were very with the quality of care and the Murphy as and during the first that community was a significant the and reported by local to during the process. He finally that the residency training did not appear it was not under based on his of national of this first more to the a second was to the the residency on the second of the training to the After the University Frank Murphy as and to the training to with the of the Murphy did not the and his family that the was all to (Jack O'Brien, personal communication, interviews, September University administration then recruited a Chief of Anesthesiology, M.D. of the of Anesthesiology at the University of of and later of the Medical University of and an of Anesthesiology in of the he recruited had in the to and remained on the after Murphy's the early the family began to at in and where Frank and Anne could In Murphy a cattle in the near He named it the the to Frank, and the two Murphy his O'Brien, to the in the and lived until her death in on the and it is on the that Murphy's and have been the University of Murphy worked for a year in He later to where he practiced from until he in He was joined in practice by his brother Don Murphy, who had from his surgery practice in Frank Murphy the clinical load in and his brother to the in to a year of training in anesthesiology Donald M.D., personal communication, by September of surgical and anesthesia in had idea that he had in the specialty, and he is as a finishing his medical Murphy to Idaho, his of cattle was by a of the before he that to his death 2 yr He is in Idaho, with his who was him in year, of endotracheal tubes used throughout the and almost one of has a Murphy that we about Frank Murphy's we learn from As an the of his and may be the he with his in who him for his position in his and he was well trained and current with in the He was also of when it to be to clinical He could a and a solution as the Murphy eye, which is in its and has its His career repeatedly demonstrated the of and in his family Murphy his of to the that this is a as The end of Murphy's time in was and The second that were and that Murphy was not the person who could some were standards for specialty as was the American Board of As much as Murphy as a and the standards of in anesthesiology at mid-century him to be less as an an but The Murphy remains his to M.D., of the of Anesthesiology and University of Medical for his and a at the of the American Society of I to the and and of the who over yr of also to M.D., Professor of Anesthesiology, Mayo Medical and of the Mayo for their I for the of of the of and Donald M.D., Professor of Anesthesiology, University of of for further and historical the professional and personal of Murphy's was because of limited available Murphy's written in only a publications and some short He historical or in the hospitals he and local of his clinical activities have the national organizations of the specialty became good of on Murphy's The of the Anesthetists' Travel Club, the American Society of Anesthetists, and the American Board of Anesthesiology, at the of Anesthesiology much The of the Mayo was an for the Anesthetists' Travel with who Murphy more allow to only a who important on Murphy's I would like to the Frank M.D., M.D., Professor and of Anesthesiology, University of M.D., of Anesthesiology, Clinic, M.D., Professor and of Anesthesiology, Mayo of and E. M.D., of Anesthesiology University of of were limited until Murphy's family was in Idaho, to from his and a by at the County Society, suggested I O'Brien, in the who to be Murphy's and his two Murphy's and with and have of his and a “Murphy tube” to the of I for their and

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