The Irish American Contribution to Surgery

Churchill once stated, "Everything that needs to be said has already been said but not yet by everyone." So today I would like to give a talk that is a little different from that usually heard at the Pacific Coast Surgical Association [PCSA] and that hopefully will be both instructional as well as entertaining.

I have been fascinated for a long time that one of the great strengths of America is the unique mixture of talents, experiences, and outlooks that come from the different ethnic groups that comprise our country. Homogeneity does not describe America at all. The differences at times may produce conflict, but, in general, are enriching and not only additive to the overall product but synergistic and complementary. Various ethnic groups bring different personalities and talents to the table at which we all share. Surgery in America also benefits from this wealth of different alloyed qualities, which are often ethnically derived.

This talk could be about numerous ethnic groups that have been involved in the progress of surgery in America. Each has made significant and lasting contributions, and their special traits and attributes could be examined and appreciated. I chose to reflect on the Irish contribution for 2 reasons. First, I am an Irish American and know that ethnic group best. Second, I do not know when the next Irish American will be elected president of the PCSA and have such an opportunity. You need to strike when you can.

When I mention a talk about the contributions of Irish Americans to surgery, the first thought you may have is that this is going to be a very short address. However, I must inform you that one of the Irish traits is that there are no short talks or conversations. Also, as I examined the involvement of Irish Americans in surgery, it surprised me with both its breadth and depth, and I actually had a difficult time paring the talk down to fit the time allotted.

Obviously, I also wanted the subjects to have some connection with the Pacific Coast Surgical Association. I first reviewed the names of former presidents of the PCSA who were Irish American; these include C. J. Berne, David Dugan, Tom Whelan, John Connolly, and Tom Berne. I then sorted through PCSA members who are or were chairmen of their surgical departments at the medical schools on the Pacific coast. I easily found a considerable group of Irishmen. Bert Dunphy was chairman at both Oregon and UCSF, while Tom Whelan was the founding chairman at Hawaii. Stanford had John Collins, and UCLA, Jim Maloney. At USC there were 2 Irish American chairmen: C. J. Berne and Art Donovan. UCI also has had 2 Irish American chairmen in John Connolly and our own recorder, Eric Wilson, who was actually born in Ireland. Obviously, this formula did not work with Carlos Pellegrini or Haile Debas, although I haven't given up completely trying to find some Irish in their backgrounds.

My fear is that I would pick 1 or 2 of these individuals and perhaps slight the others. So instead I decided to choose 2 surgeons—1 from the distant past and 1 more contemporary, who are connected with PCSA but in a more obtuse way. Again, that was a difficult task with multiple Irish names appearing out of my research, but I finally narrowed it down to 2 surgeons. One is J. B. Murphy and the other, Joseph Murray. You may ask how these men are connected with the PCSA? The gavel of the president of the PCSA is called the "Murphy gavel" in honor of J. B. Murphy because it is made from wood from the Murphy House in Chicago. When the house, which was owned for years by the American College of Surgeons, was being dismantled, some of its wood was salvaged by Dr Wiley Barker and crafted into our gavel. Therefore, we have a connection with J. B. Murphy, at least through our gavel.¹ Joe Murray, as you remember, was one of our invited speakers and became an honorary member of the PCSA. In this address, I wish to comment on both these famous surgeons and their contributions to surgery. The underlying theme will be how they both possessed attributes that are part of their ethnic heritage and how these attributes have considerably aided their success and the progress of surgery in America.

John Murphy was born in 1857 in Appleton, Wis, the son of poor Irish immigrants who in their early youth fled from the potato famine and who met and married in Wisconsin. He was the youngest of 5 children. Education was extremely important to all 5 as the basic method to improve their status in life and insure success. This dedication to education was nurtured in them by their mother. Later in life, J. B. Murphy quoted his mother, "If you are educated, there is no man's achievements which you cannot equal or excel provided you have industry and integrity and are temperate."² He was first introduced to the idea of a career in medicine by the local MD who had an office above the drugstore where Murphy worked during high school. After graduation from high school, Murphy became an elementary school teacher but quickly became bored by teaching the basic ABCs. He wanted to learn more and share more with others. However, from this early experience he dedicated himself to be "a lifelong teacher."

How did John Murphy became J. B. Murphy, the famous innovator, teacher, and surgeon whose work influences us to this day? The first part was the easiest, a simple name alteration. The "B" was not part of his given name; however, John Murphy added the "B" for Benjamin in his late teenage years, "to give his name more weight." This may reveal something about the personality of the man.

Now as the more dignified and weighty J. B. Murphy, he entered Rush Medical School in 1879. After graduating he took his initial surgical training in Chicago but had additional study in Europe with the surgical leaders of his day, including Billroth. He then returned to Chicago not only to enter practice but to educate his peers in both his own and others' innovations. While in Europe, and after returning to Chicago, he was often characterized as not being afraid of being the center of attention and actually performing better with an audience than without, another reflection of his basic personality and perhaps related to his Irish heritage.

The totality of his professional life was spent in Chicago, but he had a major influence on a whole panoply of surgical approaches not only locally but nationally and internationally.

In this area he is known for several major innovations. First, although Reginald Fitz, a pathologist, first theorized that early appendectomy would abort the subsequent risks and dangers of perforated appendicitis, it was J. B. Murphy, the surgeon, who put this theory into action and popularized it.² In 1889, he was one of the first to perform appendectomy early in the course of appendicitis and championed this approach throughout the United States. Second, he described "Murphy's sign" for the diagnosis of acute cholecystitis. This sign which is well known to all of us, is still utilized on a daily basis in our offices and emergency rooms. The term Murphy's sign is constantly recited by surgical residents even though they have no idea who J. B. Murphy is. His third innovation in GI surgery was the development and popularization of the "anastomosis button" better known as the "Murphy button."³ The button enabled anastomosis between sections of the GI tract without suture and was a vast improvement over the unreliable intestinal anastomoses of his day. Although this device has been abandoned for many years, it is a precursor and not significantly different in concept from our modern stapling devices.

In 1896, J. B. Murphy was the first surgeon to resect and anastomose a major artery in a human, a lacerated femoral artery. In 1909, he was also one of the first to perform a femoral embolectomy. In addition, Murphy was a pioneer in resection of cervical ribs for the treatment of thoracic outlet syndrome.²

In 1898, Murphy was invited to the American Medical Association's annual meeting to give the featured oration on the surgical treatment of pulmonary diseases. His articulation of both his and others' ideas and approaches became the foundation for pulmonary and thoracic care for many years. His oration included original research on the use of pneumothorax for treatment of tuberculosis and a theoretical approach to pneumonectomy. His laboratory research in dogs developed techniques that became the foundation of pulmonary surgery in humans, including (1) the use of the fifth interspace as the best approach to the hilum of the lung, (2) covering the bronchial stump with surrounding tissue to prevent leak, and (3) aspiration of the chest following pneumonectomy to stabilize the mediastinum.⁴

He made significant contributions in this area, including (1) the development of an operation for trigeminal neuralgia, (2) the treatment of meningitis by drainage of the cerebrospinal fluid, and (3) work on the regeneration of severed peripheral nerves.²

He was the first surgeon to remove a fibroid during pregnancy.

Murphy did research and published on methods to reduce scars after radical mastectomy.³

Again, Murphy was an active innovator here: (1) he published articles on the use of arthroplasties for the hip, knee, elbow, shoulder, and wrist; (2) he described the use of tension loops for fixation of olecranon fractures; and (3) he developed an original operation for recurrent dislocation of the glenohumeral joint.⁵

He also contributed in 2 areas to urology: (1) the conservative treatment of tuberculosis of the testicle, and (2) treatment of trauma of the urinary tract.³

Not only was J. B. Murphy a surgical innovator, but, more importantly, he was a surgical articulator, communicator, organizer, and teacher. The origin of the word "doctor" comes from the Latin meaning teacher, and this ability and obligation to teach is certainly one of the most important attributes of any surgeon. J. B. Murphy certainly was a teacher of extraordinary abilities. This was not only due to his prolific knowledge and surgical know-how but because his personality propelled him to be on center stage, not only to educate but to entertain those around him. George Crile said of him,⁶(pp1218-1219)

He taught the nurse, he taught the medical student, he taught the intern, he taught the young physician, he taught the veteran, he taught the laboratory worker, he taught the young surgeon, he taught the master surgeon, he taught the teachers of surgery, he taught us by example of his earnest intensive labor on behalf of his most humble patient, he taught by conferences, by lucid clinical demonstrations, he vitalized dull statistics with masterful logic, he wove and epitomized masses of evidence into convincing arguments and drew sound conclusions.

How exactly did he put his talent for teaching into practical applications? In 1901, J. B. Murphy wrote the first Yearbook of Surgery, which continues to be published annually to the present time. In 1904, he, with Franklin H. Martin, launched the journal Surgery, Gynecology and Obstetrics (SG and O). This was formulated to present the practical aspects of surgery written by surgeons rather than by nonsurgeons, which had been the common practice before that time. It was the first journal of its kind to have surgeons as editors, and in 1908, he became the second editor of SG and O.

For years J. B. Murphy ran teaching clinics 4 days a week at Mercy Hospital in Chicago. At these clinics, he demonstrated to 150 visitors a day the various approaches to multiple surgical problems . These clinics became increasingly popular and in 1910 evolved into the Clinical Congress of the Surgeons of North America, in which surgeons from throughout the United States came to Chicago to observe surgeries at the various hospitals, including the most popular, J. B. Murphy's. The popular success of these meetings led Franklin H. Martin in 1913 to convert it into the first meeting of the American College of Surgeons of which J. B. Murphy was a founding member.

In addition, his clinical demonstrations were published as the Surgical Clinics of John B. Murphy, MD, at Mercy Hospital, Chicago. This publication was started in 1912 and after his death was converted into The Surgical Clinics of North America, which continues to be published.⁶

Murphy was also a professor of surgery at multiple medical schools, including the Illinois Medical School, Northwestern, and Rush. Holding such professorships at various institutions probably reflects not only his significant abilities as an educator but also his difficult personality, which caused him to transfer from one medical school to another.

In addition to his contributions to the American College of Surgeons, he was also a leader in other associations in organized medicine and was president of the AMA in 1911.

His biographer, Loyal Davis, said of him²

Imagination is one of the qualities that raises a surgeon above mediocrity. An urge to reach new levels of care combined with personal and professional honesty, unselfishness, judgment and industry. His articulation of ideas moved us all to a new level. So much of our current practice is based on Murphy's work.

In 1915, J. B. Murphy died of coronary occlusion. On his death William Mayo said, "He was the surgical genius of our generation."⁶(p1217)

Joseph Murray was born in 1919 in Milford, Mass, third-generation Irish on his father's side and (I have to admit) second-generation Italian on his mother's side. Both parents had benefited greatly from education and stressed the values of education to their son. Murray's father was a lawyer and district judge in Massachusetts, and his mother was a school teacher. Not only did they stress the importance of education to their son but also the need of service to others.

Joe Murray attended the College of the Holy Cross in Worchester, Mass, majoring in liberal arts with just the minimum amount of science needed to qualify for medical school. He thought it was more important to be a well-rounded, educated man than to have additional science courses, which he would have in abundance in medical school. He subsequently attended Harvard Medical School and graduated during the second World War. After a 9-month internship, he joined the army and was assigned to Valley Forge Hospital where he spent all his military service. This was a great opportunity for him because Valley Forge was, at that time, the army's major hospital for treating burns and performing major reconstructive surgery. In the 1940s, extensive burns were treated with allografts, which sparked in Dr Murray a fascination with the process of tissue rejection. This assignment not only launched his career in plastic surgery but also gave genesis to his interest in transplantation and immunology. Although Dr Murray is known primarily for his work in transplantation, he contributed significantly to major advances in plastic surgery and the treatment of head and neck cancers.

After additional training at Sloan-Kettering Memorial Hospital in New York, he returned to the Peter Bent Brigham Hospital in Boston where he remained for the rest of his professional career. He was director of the surgical laboratory at Harvard Medical School for 20 years. During this time, he developed his pioneering work in transplantation. Obviously, as a plastic surgeon, he was first interested in skin transplantation. He observed that skin grafts between identical twins were universally successful and asked therefore whether this phenomenon also applied to the transplantation of other organs. Spurred by this idea, he developed techniques for autotransplantations of the kidney in dogs to prove that these transplants could be technically performed. One of his main contributions to the technique of renal transplantation was the use of the retroperitoneal approach to a pelvic position with iliac vascular anastomoses.⁷ Previously, renal transplantations in dogs had been done subcutaneously into the thigh with a cutaneous ureterostomy. This new position decreased trauma, assured good blood supply, and allowed implantation of the shortened ureter directly into the bladder.

After perfecting this technique in the laboratory, Dr Murray was looking for the opportunity to utilize it in the clinic realm. It should be emphasized that to this time, there were no reported successful renal transplants in humans. In 1954, he was presented with identical twins, 1 of whom was dying of renal failure. First, he needed to prove that the twins were identical and therefore that the graft should take. He did this (1) by examining their birth records to show that there was a single placenta, (2) by proving that their fingerprints were identical, (3) by confirming that each twin had a Darwin's nodule on the ear (this is unusual congenital variation), and (4)that they had identical eye pigment. However, the final element of proof came from his plastic surgery background. He did a skin graft between the twins which took completely.⁷ After immunologic identity was confirmed, Dr Murray performed the first successful renal transplant in a human.⁸

This, however, was not his only pioneering work in transplantation. In 1959, he performed one of the first renal transplants in dizygotic twins, in which the recipient was treated with whole body radiation. Although the graft took however, it only functioned for approximately 1 year before being rejected. He concluded that whole body radiation was not the answer to the immunologic problem of rejection. He turned instead to drugs to control the rejection episodes. In 1962, he performed the first nonrelated cadaveric renal transplant in a human, supported by the new drug azathioprine (Imuran) and steroids. By proving that transplants could be technically performed and that rejection could be successfully controlled, he opened the door to progress in the field of transplantation. It was the equivalent of the first 4-minute mile, the first flight, the first conquest of Everest; all of which proved to others that it could be done and allowed the rapid and significant progress in transplantation of not only the kidney but also the liver, heart, lungs, pancreas, and small bowel that we enjoy today. For these pioneering contributions in transplantation, he was awarded the Nobel Prize for Medicine in 1990.

It should be emphasized that he did not win the Nobel Prize just for these 3 monumental procedures alone but also for the accumulation of years of thoughtful and painstaking research that resulted in that final conquest.

I think it is more the measure of the man himself rather than his scientific ability alone, which allowed him to accomplish these significant goals. Joe Murray is seen by his colleagues as a real team member who supports interactive work with both loyalty and humility. He is able to appreciate what others have learned and done and then to build on this while moving the learning process forward. While he acknowledges what others have contributed, he is able to take the work of others and to develop it even further. He states, "We all have drunk from wells we did not dig and been warmed by fires we did not build."⁹(p945) His indestructible optimism in the face of insurmountable obstacle is legendary. He is a man with a positive outlook, who believes in himself and the science of medicine, but he is also a fierce competitor and not afraid of fighting for what he believes is right. He believes that "the truth is more important than the polite counsel of acquiescence."¹⁰(p1111) He determines what is right, then takes a personal responsibility and accountability for moving it forward to fruition. Obviously, the elements for success in transplantation were present for all to see and develop, but it took a man of Joe Murray's personality, dedication, articulation, and teamwork to fashion it together to produce this triumph by which society is so enriched today.

Finally, I would like to discuss some of the personality traits which you can perhaps see personified in the lives of J. B. Murphy, Joe Murray, and other Irish Americans who you know. These traits may either aid or impede them both in their personal lives and in their professional ones. Obviously, these attributes are shared in varying degrees by all cultures and ethnic groups, but some are more markedly pronounced in individual cultures and ethnic backgrounds. The Harvard Encyclopedia of American Ethnic Groups states that even 3 or 4 generations removed from Ireland, Irish Americans consistently score higher than most other Americans on measures of sociability, localism, trust, and loyalty. Since these attributes persist so long after leaving their cultural home in Ireland, it must be part of the basic fabric of the Irish American. At the same time, selecting the traits of the Irish American is difficult. In a lecture by the historian Dennis Clark (February, 2001), he observed,

Almost anything you can say about Irish Americans is both true and false. The Irish have a tremendous flair for the bravado but in reality tend to assume that anything that goes wrong is a result of their sins. They are good humored, charming, hospitable and gregarious without being intimate. They love the good time, yet they revel in tragedy. The Irish are wits and optimists who struggle with loneliness and depression. They are fighters of fanatic heart but assume much of life is predestined. Known for their extraordinary loyalty to family, friends and community, they can also be relied on to cut off relationships if crossed. The Irish value conformity and respectability but tend to have a high tolerance for eccentricity and subversion.

So as difficult as it may be, I would like to select and discuss some common attributes of Irish Americans.

The Irish are able to communicate not only their ideas but also even the ideas of others. This ability to articulate ideas and their organizational skills are largely responsible for their well-known success in American politics. (It has been said that the Irish American did not invent politics in this country but few did it better or with more warmth and understanding.) This ease of communication allows them to present even complex and intricate ideas in a simple and straightforward fashion. Often they are not the originators of the idea but can assimilate the ideas of others and organize them into a common coda of knowledge that can be easily transmitted to others. They also have a great love of sharing what they know with others, and this is the engine behind their communication. This attribute not only helps them in the area of politics but also as speakers, writers, and particularly as respected teachers. This is obviously very important in our surgical lives and is prominently displayed in the lives of J. B. Murphy and Joe Murray.

The Irish Americans have a craving and even an absolute need for the company of others. They have a difficult time remaining alone and no one would ever accuse them of introversion. They often have a desire to be on stage, and many of them have become famous actors. However, even off the professional stage, there are many Irish Americans who do a great deal of acting. They are often seen as the life of the party and the center of attention. Although at times this may be an impediment, it also can be an instrument, which allows them to share their ideas and knowledge with those around them. This gift to be gregarious and sociable is seen in their ability to remember and use other people's first names, to know how to ask questions and how to listen and how to maintain a warm communication with those around them. It is said that at social gatherings the hosts and hostesses sit them strategically assuming "they can talk to anyone."

These 2 traits are interwoven in that the Irish Americans are deeply loyal to their fellows, their community, and their institutions, such as their profession, government, and church. On the other hand, they trust that all those to whom they have been so deeply loyal will return that fealty to them. This loyalty and trust gives them a strong sense of team work and being able to work as a member of the team. So although they may be the center of the stage and the leaders, they can also appreciate their role in the overall team. An Irish story will probably communicate best this sense of loyalty, trust, and team work. The story goes, when you see geese flying, they always are in a "V" formation. This is done for very practical reasons. The leader not only guides the flock but also breaks the air and makes it easier for the rest to follow. All the honking that you hear from the rear of the flock is encouragement to the leader for the great job that he is doing and to spur him on. When the leader tires, he drops back into one of the wings of the "V" and then a new leader takes his place. With this rotation of labor, the flock continues to move surely forward. If one of the geese becomes sick or unable to fly and returns to the ground, 2 other geese accompany him. These other 2 geese will remain as long as it is necessary and support the sick or tired goose until he is able to fly again or until he dies. The motto is, "Shouldn't we be at least as smart as geese in our human interactions?"

This sense of humor probably comes from various sources. First, the Irish sociability, already mentioned, produces a great desire to laugh, have fun, and share joy and good feelings with others. But it also emanates from their way with words that allows them to appreciate subtle shades of meanings and nuances, which can turn the serious into something which is delightful and funny. This sense of humor allows them often to be the center of attention that they desire and gives them the ability to lead but with a degree of humanity and warmth. It also is utilized by the Irish American in 2 other ways. First, it is used to give a sense of balance to the events and circumstances surrounding them. Even though the situation may be very serious, complex, and difficult, there is always something to find in it to laugh at, which somehow puts it into a different perspective. Second, they often use it to tone down people whom they consider too serious, proud, and self-important. By poking fun at them, they attempt to disclose to them their humanness and bring them back down to earth. Self-deprecating humor can also be used to convey to others that we all share so many common human foibles and thereby in laughter share with each other a common bond. Sense of humor is such an inherent part of Irish culture that if one does not have it, one would suspect that they are not Irish at all. It has been said that their culture is the reason that the Irish always get the joke.

I hope this review of the accomplishments of 2 famous Irish American surgeons and the discussion of some traits of Irish Americans make you better appreciate their contributions to surgery in America. Hopefully, by sharing these positive traits of ethnicity, we may all be able to incorporate some of these elements into our own life and make us the better for them. In America with such a vast plethora of ethnic backgrounds, we can all learn from others so that the final amalgamated product is far superior to any of the individual parts.

In conclusion, I wish to leave you with an Irish blessing.

May the road rise to meet you, May the wind be always at your back, May the sun shine warm upon your face, May the rains fall soft upon your fields, And until we meet again May God hold you in the palm of His hand.

This paper was presented as the Presidential Address at the Pacific Coast Surgical Association, Las Vegas, Nev, February 16, 2002.

Corresponding author and reprints: Theodore X. O'Connell, MD, Department of Surgery, Kaiser Permanente Medical Center, 4747 Sunset Blvd, Los Angeles, CA 90027 (e-mail: Theodore.X.O'Connell@kp.org).