Stanford University School of Medicine and the Predecessor Schools: An Historical Perspective
Part III. Founding of First Medical School and Successions 1858-

Chapter 18. Professor Elias S. Cooper, University Surgeon

An Evaluation

John Bell (1763-1820) was a famous Edinburgh anatomist and surgeon, and one of the founders of vascular surgery, a field in which Dr. Cooper had a special interest. Bell introduced his classical monograph on The Principles of Surgery in 1801 with the following reflections on the evaluation of surgeons:[1]

In every profession, the daily and common duties are most useful; and in ours, the man who is capable of the great operations rises into public esteem, only because it is presumed, that he who is most capable in the higher departments of his profession will best perform all its ordinary duties. . .(Accordingly), operations have come at last to represent as it were the whole science; and a Surgeon, far from being valued according to his sense, abilities and general knowledge, is esteemed excellent only in proportion as he operates with skill.

We shall in due course show that Cooper was not only "capable of the great operations," but that he also drew upon his extensive surgical experience and laboratory experiments to make significant observations. It is these distinctive contributions that qualify him to be regarded as a "University Surgeon" in the modern sense, and set him apart from all other surgeons on the Pacific coast in his era.

Before proceeding with our evaluation, we should point out that Cooper's numerous publications in the medical literature are our major source of information on his achievements as a surgeon. Since a list of his papers had never been assembled, we searched the journals of his day and compiled a Bibliography of 139 original articles and commentaries. From these we will now draw some conclusions as to the significance of his surgical work, keeping in mind of course the state of the art at the time.

Many of Cooper's articles were accepted for publication in such well-known journals in the east as the American Journal of Medical Sciences (Philadelphia), Medical and Surgical Reporter (Philadelphia), American Medical Gazette (New York, American Medical Times (New York), Cincinnati Lancet and Observer, St. Louis Medical and Surgical Journal, Chicago Medical Journal and North-Western Medical and Surgical Journal (Chicago). Not only did this general acceptance of his papers indicate an interest at the national level in his case reports and ideas, but also assured them of wide dissemination. The recognition thus gained by Cooper was especially galling to the venomous Wooster who had unwittingly impelled him onto the national stage of medical literature by denying him access to the Pacific Medical and Surgical Journal. In the following editorial in the June 1861 issue of the Journal, Wooster sought to discredit Cooper with the editor of the American Medical Times, hoping that he and other eastern editors could be induced to refuse Cooper's manuscripts.[2]

The American Medical Times must have an intense desire to gratify its readers with original matter from remote sources. We are led to give this hint at seeing a California communication in the number of May 25th 1861, and also one in that of June 1st. The status of the author is so low here, socially and professionally, that we cannot imagine how the editor of the Times will lend himself to bolster up such an advertising pretender. Medical journals cannot ignore this allusion, for we definitely proved it to the profession some two years since. ( Pacific Medical and Surgical Journal 1859 Dec; 2 (12): 495-499)

The editor of the Times ignored the Wooster libel and continued to publish papers submitted by Cooper, as did other eastern editors.

We shall begin our assessment of Cooper's professional stature by calling attention to his technical proficiency and follow with comment on the exceptional range and complexity of the operations that brought him the "public esteem" to which John Bell referred. We shall then mention some of his noteworthy experiments in the animal laboratory before, finally, identifying certain surgical principles that he derived from personal experience, and for which he claimed priority.

Master Surgeon

There can be no doubt from the operations we have already described and the regional acclaim to which we have previously alluded, that Cooper was a fearless and skillful surgeon, with a self-assurance born of natural aptitude and intensive anatomical study. Incredibly, he was almost entirely self-taught. Levi Cooper Lane, a not impartial witness, assisted his uncle during many operations and was in awe of his surgical prowess:[3]

As an operator, he manifested, in a pre-eminent degree, that cool daring, that deliberate self-possession, - which the most untoward circumstance, so far from disturbing, seemed only to increase, - that instant comprehension of the difficulties which happen to arise during an operation, and that intuitive readiness to surmount them, which are the essential elements of great and original surgical genius. Not only was he self-possessed himself, but his manner was such as to thoroughly inspire his patient with the most perfect confidence that he was wholly secure in his hands; and of his spectator, no one who saw with what perfect ease the chisel and drill moved in his hand during his exsections, and the use of the silver ligature for ununited fractures, or with what rapidity, at one bold sweep, he deeply divided the structures of those regions of the body which most surgeons approach with caution, but who, in the one case, were thoroughly impressed with the superiority of his mechanical talent, and in the other, that his daring celerity could only be founded upon that accuracy of anatomical knowledge, which rendered the tissues, as it were, transparent under his eye. I think that no one, who ever stood by his side at such a time, feared for a moment, that the operation would not end successfully.

Such a paean from an experienced observer, albeit a biased one, leads us to conclude that Cooper was indeed an accomplished surgeon. For him, surgery was a true vocation. He was undaunted by the stress and complexity of difficult operations and he had the rare gift of responding to technical challenges by improvised measures. According to Dr. Lane, Cooper once remarked that at no time had he been happier than when, during an operation, some grave unforeseen complication arose which threw his mind wholly on its own resources, and for surmounting the difficulty compelled him to rely upon the suggestions of the moment.[4] We recall, for example, his remarkable extraction of a slug of iron from behind the heart of B. T. Beal with a special instrument; the control of major hemorrhage by ligating both iliac artery and vein in Frank Travers; and suture of the uterus to control bleeding during Mary Hodges' cesarean section. In all these operations Cooper made innovations, and they were life-saving.

Great Operations

The extraordinary scope of Cooper's operative experience is readily apparent from a scanning of his bibliography. He was capable of performing the most advanced procedures then being undertaken in the fields of ophthalmic; head and neck; thoracic; abdominal; orthopedic; and vascular surgery. Since his bibliography refers specifically to many of these operations and we have already described certain of them, we shall limit our further consideration of this subject to pointing out that Cooper performed, on two occasions in each, the most difficult and controversial operations in the surgical armamentarium at mid-century. These procedures were caesarean section and ligation of the innominate artery. We have already reported amply on Cooper's two caesarean sections and their outcome.

Ligation of the Innominate Artery

We have not, however, previously mentioned that he twice ligated the innominate artery. This artery, the first and largest branch of the aortic arch, ascends to the thoracic inlet where it divides behind the upper sternum into the right common carotid and subclavian arteries. These vessels are the main blood supply to the right side of the head and the right upper extremity. Aneurysm (i. e., circumscribed dilatation) of the innominate, carotid and/or subclavian arteries may occur at the bifurcation of the innominate, usually as the result of trauma or arteriosclerosis. Unless successfully treated, death from spontaneous rupture of aneurysm in this location is a near certainty.

At present, such aneurysms may be removed and replaced by synthetic vessels without undue risk. However, when Cooper practiced, the treatment consisted of ligating the innominate artery, a procedure considered the most formidable operation of that day. Valentine Mott (1785-1865), Professor of Surgery at Columbia College of Physicians and Surgeons in New York, was the first surgeon, world-wide, to ligate this vessel for aneurysm with survival of the patient. He performed the procedure on a fifty-seven year old sailor at New York Hospital on 11 May 1818. The only "anesthesia" administered was a drink containing seventy drops of tincture of opium. The operation occupied about one hour. Although the patient died of secondary hemorrhage on the twenty-fifth postoperative day, the case established the practicability of the operation. For that reason it was acclaimed throughout medical circles in Europe and America. In consequence of this operation, Professor Mott attained an international reputation by the thirty-fourth year of his age. As predicated by John Bell's postulate, Professor Mott is best remembered to this day for the great operations he performed, particularly his ligation of the innominate.[5][6]

During the forty-year period from 1818 to 1858, eleven surgeons from around the world, including Professor Mott, succeeded in ligating the innominate artery. The outcome was the same in every case - the patient died.[7]

The following data were derived from p. 1487 and pp. 1502-1517: The first fourteen surgeons to ligate the innominate artery were: Mott (1818), Graefe (1822), Norman (1824), Arendt (1827), Bland (1832), Bujalesky (1833), Unknown Surgeon reported by Dupuytren (1834), Lizar (1837), Hutin (1841), Pirogoff (1852), Gore (1856), Cooper (1859), Cooper (1860) and Smyth (1864).

In March 1859, Cooper was consulted by a man with a combined aneurysm of the right common carotid and subclavian arteries. Ligation of the innominate artery was the only known treatment for his condition. Undeterred by the knowledge that all eleven of the previous operations had been followed by death of the patient, Cooper decided to operate. He had the advantage of general anesthesia which had not yet been discovered when nine of the previous cases were done. During the operation, Cooper removed the medial end of the clavicle and a portion of the upper end of the sternum to improve the exposure, this being the first time this valuable maneuver was employed during ligation of the innominate.

The procedure went well and the vessel was tied off with minimal blood loss. Postoperatively, the patient was comparatively comfortable for five days. After that time he became restless, short of breath, and unable to void. He gradually sank until the ninth day when he died. An autopsy was done and failed to reveal the cause for the patient's rapid decline after an initial period of satisfactory progress. The major causes of death after ligation of the innominate in past cases had been severe wound infection and exsanguinating hemorrhage. Neither of these conditions were present in Cooper's patient. Since the patient had developed anuria postoperatively, Cooper believed renal failure to have been the cause of death rather than anything directly related to the operation. It was a tantalizing thought that, except for this unforeseen and unrelated circumstance, success would have crowned his efforts and the acclaim for a truly "great operation" would have been his.

Cooper's disappointment in the outcome was reflected in the brevity of his report on the operation which he mailed to the editor of the American Journal of Medical Sciences on 20 March 1859. His perfunctory description of the case, only a page and a half in length and lacking many relevant details, was published in the October 1859 issue of the American Journal.[8]

Cooper thought that he had done his duty by simply reporting the failure of the ligation, and that the case was closed. He was therefore quite unprepared for the harsh rebuke he was soon to receive from his former colleague and friend, Professor Daniel Brainard of Rush. As editor-in-chief of the Chicago Medical Journal, Brainard utilized the pages of the December 1869 issue of the Journal to attack Cooper for his temerity in undertaking the ligation, and for reporting the case so incompletely. Professor Brainard was quite stern:[9]

The October number of the American Journal contains a report of a (ligation of the innominate), if report it may be called, which omits nearly every important fact connected with the history of the case, the seat and extent of the disease, its effects, etc. . .

We notice this operation, to say that it is one which cannot receive the approbation of any judicious surgeon. Ligature of the arteria innominata had been performed (eleven) times (previously). In all the result was fatal. . .

Cases of this kind, published without comment, and thus partly endorsed by journalists, have given rise to the term "audace Americaine," used by Trouseau. If editors, in giving currency to this and similar reports, would express their opinions of the propriety of such operations, it is likely that fewer would be done, and the responsibility be thrown upon the individuals who, without any prospect of benefit to their patients, think fit to resort to them.

We know of Cooper's high regard for Professor Brainard who had been his mentor and paragon in times past, but the Professor's public attack on his competence, judgement and integrity was intolerable. Soon after he acquired his own editorial voice in the San Francisco Medical Press, Cooper responded to Brainard with a Commentary in the July 1860 issue of the Press:[10]

Nothing we commend more than just criticism even when touching the faults of our own performances, and such critique would have to be very severe indeed if we did not take it in good part with the writer.

Our report, as published, of the operation (mentioned in your editorial), was justly obnoxious to severe criticism, partly owing to our own carelessness and partly that of our Amanuensis; so much so that we were really chagrined on seeing it in print with so many imperfections. . . But a critique above all other productions is expected to be free from faults. (Your editorial), however, is not one of that kind. In addition to special pleading against the operation of ligating the arteria innominata under any circumstances, based solely upon assertion and individual authority, there are forced conclusions which show much more of a disposition to criticize, than industry in preparing for the same. . .

For the editor of the (Chicago Medical Journal) to say that no judicious surgeon would perform that operation, without giving any reasons for the statement, when Mott (and ten other) eminent (surgeons) thought proper to operate, is arraying individual opinion against an amount of authority which we conceive to be very bad taste to say the least. Why should not a judicious surgeon operate? Is it because patients demanding it (as is conceived) could ever recover without? No; every one would die at no distant period

We can readily imagine a case in which it would be very injudicious to operate. Take for instance a small aneurysm growing very slowly, especially in an old person. But such has not been the case with those upon whom the operation has been performed.

Surgeons will differ in opinion in regard to the propriety of hazardous operations in hopeless cases. Occasionally the wishes of a patient might rightfully have much to do with deciding whether to operate or not. . .

Again, the idea that a French surgeon would apply to American surgery the term "Audace Americaine," is or ought to be regarded as simply ridiculous by one who has ever witnessed much practical surgery in the Parisian hospitals. Everybody knows who knows anything of the matter, that no surgeons in the world operate upon more hopeless cases than those of the French Hospitals.

In his caustic response to Brainard's reproach, Cooper made it clear that he believed ligation of the innominate to be a justifiable operation under proper circumstances. Within a few months he had an opportunity to act on this conviction.

On 23 September 1860 a 31 year-old man, otherwise in excellent health, was admitted to the Pacific Clinical Infirmary with a large aneurysm of the right subclavian artery filling the entire supraclavicular triangle. On September 30th Cooper operated and for the second time ligated the innominate artery. As in his previous case he resected the medial end of the clavicle and a portion of the upper end of the sternum to gain the necessary exposure.

The operation was at once the subject of intense interest to the American profession. Cooper received a barrage of letters and made the following progress report to the editor of the American Medical Gazette (New York) on 30 October 1860:[11]

Today is the 30th day (since I ligated the arteria innominata), and the patient has every prospect of recovering, so far as could be judged by any other evidence than that based upon the results of past experience of other surgeons. . .

On the 20th day after the operation a most violent hemorrhage began, but was arrested at once by the promptitude of a medical student. . . I do not permit myself to hope that the case will terminate favorably; but still the patient is vigorous, cheerful, has a good appetite, sleeps well, laughs and talks to his friends, and declares that he will live, notwithstanding he has been informed that no other ever survived this operation.

Cooper's next, and last, progress note on this patient was published in the January 1861 issue of the San Francisco Medical Press:[12]

To the inquiries of several medical friends, in regard to the recent ligating of the Arteria Innominata, we would state, without further answer, that the patient died on the forty-first day. A slight hemorrhage occurred on the (20th), but not again until the 39th day. The bleeding (on this last occasion) stopped without any interference. On the next day, it began with considerable violence being difficult to arrest. The day succeeding, it was found impossible to prevent bleeding although we had invented an apparatus which pressed with much force directly upon the bleeding surface, and controlled the hemorrhage far better than any compress and bandage.

At three P. M. of that day, the patient was informed that all hope of recovery was lost, but that he had remaining a sufficient length of time to arrange his earthly matters. He expressed no wish to use the time in that way, and, as soon as he was alone, forcibly removed the apparatus, and bled to death at once.

From his vantage point as editor of the Pacific Medical and Surgical Journal, Wooster had kept a watchful eye on Cooper's every move, and saw in this case an opportunity to revile him:[13]

California is not behind any portion of the world in the art of crime. She is equal to other portions of the world in arts and science and experiment, quoad the ability. She merely lacks the development.

The arteria innominata has been tied in this city and the case is dead, and the autopsy has been made. Result: he died from the effects of the operation. Any surgeon who ties the innominata is either insane, a knave, or ignorant of hydrodynamics. This operation is necessarily fatal, as any physicist can demonstrate, without recourse to physiology. The ligation external to the tumor is rational, and should be sometimes successful.

Cooper's definitive report on his second operation finally appeared in the August 1861 issue of the Cincinnati Lancet and Observer. He gave details of the operation, postoperative course and autopsy. In this case, and presumably also in the first, the innominate artery was tied with "four strands of saddler's silk." In accordance with standard practice at the time, the ends of the silk at the knot were left long and brought out through the wound. Due to the inevitable wound infection, the tie around the artery gradually eroded entirely through the vessel and was then drawn out of the wound by traction on the long ends. In this second case the detachment of the ligature occurred on the eighteenth day. As might be expected, hemorrhages began shortly thereafter for the ligature had completely divided the artery and the force of the blood pressure expelled the clot that temporarily occluded its lumen.

The failure of early operations for ligation of the innominate was generally the result of ligatures cutting through the artery because of infection. For that reason, frequent success of the operation was not achieved until well into the aseptic era. Only then did it become possible, because of the sterile operating field and primary wound healing, to ligate the innominate with ligatures that remained permanently in place and did not slip off or cut through the vessel.

Cooper was devastated by the terrifying hemorrhages and fatal outcome of his second case. The patient's robust physical condition, the technical precision of the operation, and the prolonged postoperative survival had filled him with hope His report concludes with the following disconsolate thoughts:[14]

This case, more than any other that has yet occurred in my practice, made the strongest impression on my mind. Never before have I felt so humiliated by the inefficiency of the surgical art in rescuing patients from death. What are we to do with such cases? Is there no new process for treating these aneurysms more available than any yet established, and can the skill of the whole surgical world avail nothing? Time will prove. . .

I write for those who are inexperienced, because having had two cases terminating in the same way, I never expect to have more experience upon the subject, and would fain benefit those who are disposed to, but have not yet tried, this most hazardous of all operations upon the arteries.

The first surgeon, ever, to report long-term survival after ligation of the innominate artery was Andrew Woods Smyth at the Charity Hospital in New Orleans. On 15 May 1864, just four years after Cooper's second case, Dr. Smyth ligated the right common carotid and the innominate for an aneurysm of the right subclavian artery in a 32 year-old mulatto man. Thirteen days after operation the carotid ligature came away and on the fourteenth the first of several self-limiting hemorrhages occurred. On the sixteenth day the innominate ligature came away and at about this time hemorrhage recurred. Dr. Smythe happened to be in the hospital at the time of the bleeding and was about to go hunting. He promptly opened the wound and poured the contents of his bag of bird-shot into it and put on a compress. Miraculously this procedure, plus ligating the vertebral artery, controlled the hemorrhage. The patient survived for eleven years, and then died by hemorrhage from a recurrence of his subclavian aneurysm.[15][16]

Following Dr. Smyth's case, the next twelve ligations of the innominate ended in death.

It was not until 1889, after the beginning of the aseptic era, that a second patient had a long-term survival following ligature of the innominate. The operation was performed by J. Lewtas while in the British service in India. The patient was a twenty year-old man, an Indian national, who had a traumatic aneurism of the right subclavian artery secondary to a gunshot wound. The carotid and innominate arteries were ligated. No infection occurred, the wound healed by primary union, and the patient recovered. Mr. Lewtas remarked in his report that he probably wouldn't have undertaken the procedure if he had known how dangerous it was. Thereafter, only four successful ligations were reported until after the turn of the century when they became increasingly frequent.[17]

From Mott's operation in 1818 to the end of the century, only Cooper reported having twice ligated the arteria innominata.[18]

We have already mentioned Cooper's one lasting contribution to the procedure for ligating the innominate. He was the first to remove the sternal end of the clavicle and a portion of the summit of the sternum to gain adequate exposure for the removal of large and complicated aneurysms. He wished to be remembered for this significant innovation and made special mention of it in his summation of each operation. In 1922 Dr. Emile Holman was the 88th surgeon to ligate the innominate. The lesion was a very complicated post-traumatic aneurism of the subclavian artery. He was ultimately successful in extirpating the aneurism by gaining the necessary exposure through the approach pioneered by Cooper sixty-three earlier. When Dr. Holman performed this operation in 1922 he was a Resident Surgeon at Johns Hopkins Hospital. When he later became Professor and Executive Head of the Department of Surgery at Stanford Medical School in San Francisco from 1926 to 1955, he was, in effect, the linear successor of Professor Cooper.[19]

Cooper still lives in the annals of those who have performed truly "great operations." But we have seen that these cases brought him little acclaim and much criticism.

Ligation of the Carotids

The first experiment to be undertaken by Cooper after his arrival in San Francisco took place in the fall of 1855, soon after the organization of the Medico-Chirurgical Association. By this time he had advertised his "Course of Medical Instruction" which was to include "Experimental Surgery by Vivisections." He had also set up a laboratory for animal surgery in his new Infirmary at 14 Sansome Street and was prepared to inaugurate experimental surgery on the Pacific Coast with an experiment on the carotid arteries. He invited nine physicians, most of them members of the Medico-Chirurgical Association, to witness the event.

The question to be addressed by the inaugural experiment was a minor one, but nevertheless of keen interest to the physicians in attendance. The medical journals around the country had recently carried a report by Professor Alex Fleming, M. B., of Queen's College, Cork, Ireland, who claimed that pressure on the carotid arteries so as to arrest the circulation in them would cause anesthesia. Clearly, if such a simple procedure would serve in lieu of ether or chloroform, it would be a boon to humanity. Cooper doubted the claims of Professor Fleming but was loathe to try the experiment on a patient. He therefore proposed instead to ligate the carotids of a dog. While the witnesses watched intently, Cooper deftly tied both the animal's carotids. Instead of anesthesia, the procedure "produced only the slightest immediate stupor that was but little increased at the end of one hour."

Cooper concluded that, "I disproved (the claim of Professor Fleming) by the above experiment to the entire satisfaction of all present so far as I know." It is hoped that the demonstration at least dissuaded the observers from trying Professor Fleming's method in view of the possibility that, aside from not producing anesthesia, compression of both carotids might cause stroke or sudden death in the human subject. Cooper's modest first experiment, which he never published, reveals the elementary state of circulatory physiology in his day.[20]

Ligation of the Abdominal Aorta

In December 1855, soon after his experimental ligation of the carotids, Cooper conducted a series of experiments involving ligation of the abdominal aorta. We have already referred to these experiments in Chapter 10 where we mentioned that, according to Pancoast's Treatise on Operative Surgery[21] the abdominal aorta had been ligated on only three occasions. In 1817 Sir Astley Paston Cooper, Bart. (1768-1841) of Guy's Hospital, London, celebrated vascular surgeon, was the first to ligate this vessel. He performed the feat on a 38 year-old man who had a post-traumatic aneurysm of the left iliac artery. The patient's death after forty hours was, according to Sir Astley, "owing to the want of circulation in the aneurysmal limb" which was "cold and lacking in sensibility." An autopsy of the abdomen revealed no peritonitis and the aorta was completely occluded by the ligature. The autopsy did not include the chest.[22] In1829 Mr. James of Exeter Hospital was the second to ligate the aorta. The patient, who had an aneurism of the external iliac artery, lived only three hours. No autopsy report or other details are available to determine the cause of death.[23] In 1834 the third and last to ligate the abdominal aorta prior to mid-century was Mr. John Murray at the Cape of Good Hope. His patient was a Portuguese seaman with a large aneurism of the right iliac artery. Following the operation he developed numbness and paralysis of both legs and died at the end of twenty-three hours with severe pain in the lower extremities and the pubic area. There was no autopsy report.[24]

In addition to citing the above three cases of aortic ligation, Pancoast made the following related observations:[25]

Since the attention of surgeons has been called to this subject, more than forty cases have been reported of contraction or accidental obliteration of the aorta from the pressure of tumours or other causes, all of which tend to prove that possibility, as before observed, of a return of the circulation to the lower extremities after the obliteration of the lumbar portion of this vessel. Upon these facts, in cases admitting of no other chances of relief, has been founded the hope of success in cutting down upon and tying this important trunk, rather than upon the results of experiments on dogs, whose tenacity of life surpasses that of man. In the three cases in which (the abdominal aorta) has been tied in the living subject, the issue did not justify the boldness of the proceeding, and it is very questionable whether any case could occur that would fully sanction the step.

Cooper was well acquainted with Pancoast's Treatise. The accounts of failed aortic ligations, and of survival after gradual occlusion of the vessel, so intrigued him that he decided to seek answers to the following questions:

  • Why did the operated patients die so soon after operation?
  • Is the cause of death preventable?

Surgical authorities had assumed that death after ligation of the abdominal aorta would be caused by gangrene of the lower extremities for want of sufficient circulation, or by peritonitis or hemorrhage. Although deficient circulation to the legs was documented in two of the operated cases, Cooper reasoned that death occurred too rapidly for that to have been the sole cause of fatality. Furthermore, neither peritonitis nor hemorrhage was reported in any of the three patients. Thus, he argued, there was another factor that contributed to the mortality of the procedure.

Rather than to eschew "experiments on dogs" as others had done, Cooper proceeded with the following:[26]

Experiment 1. In order to eliminate the risk of peritonitis, one of the three hypothetical causes of death after ligation of the abdominal aorta, Cooper adopted the retroperitoneal approach through the left flank used by Mr. John Murray in his ligation of the aorta in 1834. This provided excellent exposure of the abdominal aorta without entering the peritoneal cavity. Meticulous surgical technique virtually eliminated the danger of hemorrhage, the second presumed cause of death. With these routine precautions, Cooper ligated the distal abdominal aorta.

The animal died at the end of sixty hours, showing symptoms of stupor after the first few hours. There was no peritonitis, no hemorrhage, and no gangrene of the lower extremities to account for the death. A similar operation was performed on a number of animals with identical results.

Post mortem examination "in every instance showed the right heart to be greatly distended with coagulated blood, and in many cases to its utmost capacity, so much so, in fact, that the distension equaled, if it did not even exceed, that produced by the most complete injection of the heart, effected by instruments, in making anatomical preparations. As this coagulated condition of the blood and engorgement of the heart was found to exist in every case, I was led to consider whether it were not the chief cause of fatality, seeing that the coagulum was formed prior to death, and whether cutting off nearly one-half the entire vascular system, thus confining the blood to so limited a capillary circulation, was the crucial factor. . ."

By his first experiment Cooper established engorgement of the proximal arterial vascular bed as the cause of death after acute ligation of the abdominal aorta in dogs. This finding suggested that reduction of the engorgement was the key to long-term survival after the procedure.

Experiment 2.. "In the second experiment I purposely admitted of a free discharge of blood before ligating the (abdominal aorta) upon the supposition that the loss of a quantity of blood corresponding to the amount of the circulating system cut off might remove the source of immediate death - engorgement. This animal lived sixteen hours and a post mortem examination revealed a similar condition of this as in the first, except the large vessels were not so much engorged, the aorta being almost entirely empty. But the heart on both sides was perfectly engorged with blood to its utmost capacity, the blood being coagulated completely. Abdominal viscera were healthy and nothing untoward resulted from the local violence of the operation."

Experiment 3.. "In order to produce an exact equilibrium in the circulating fluid cut off by the operation and that remaining undisturbed by it, I ligated the vein (inferior vena cava) in connection with the aorta knowing that, whatever might be the ill consequences of ligating a vein, that all other animals upon which I had tried this experiment died long before this would have interfered with the result. This animal lived about 16 hours and from post mortem examination it was found that, while the same amount of engorgement had not occurred in the heart as in the other cases, still the coagulation was almost as complete though not quite. The symptoms of stupor were the same as in the other cases for the last eight hours preceding death.

Experiment 4. Having failed to prevent fatal excess of engorgement by prior bleeding or simultaneous ligation of aorta and vena cava, Cooper decided to diminish the circulation through the aorta gradually as occurs in nature when the aorta is slowly obliterated by tumor or other cause. For this purpose he exposed the aorta and "applied a strap of leather lined by soft cotton cloth around the artery and so compressed it as to arrest the circulation through it principally but not so completely as to render the pulsation of the iliacs imperceptible." This tourniquet was brought out through the wound so that it could be tightened from the outside, and the wound was closed around it. On the seventh day of its application - the animal in the meantime doing quite well - the tourniquet was tightened so as to interrupt aortic circulation completely. "After the circulation was thus entirely arrested in the aorta, there were no symptoms of stupor, though this had been an early and constant attendant upon all the cases in which I had operated previously. This dog lived four days after the circulation was cut off from the lower extremities through the natural channel, but died at last of hemorrhage produced, as I supposed, by violent displacement of the tourniquet with his teeth."

"The (tourniquet) was much larger than was absolutely necessary as I could have an instrument constructed not over half the size that would answer the purpose better in every respect. . . I shall have one constructed and be ready to try it on the human subject."

Conclusion. Gradual occlusion of the aorta in a dog stimulated collateral circulation to the lower limbs, protecting them from gangrene and the upper circulation from engorgement.

Cooper reported these experiments in a paper delivered at the First session of the California State Medical Society in 1856. He concluded the report by saying:[27]

I do not consider that this experiment has proven the practicability of the process described, though it will have to be confessed that a most important step has been made towards it, seeing that every symptom of the animal was favorable until hemorrhage supervened, and that in the human subject, nothing would be easier than securing the vessel from violence offered by the patient, and that nothing in human calculation could be considered more certain than that the animal would have lived but for the hemorrhage. . .

But the strongest evidence in favor of the practicability of the operation for ligating the abdominal aorta, according to the above detailed plan, remains to be given, and that is this, viz., the circulation was restored, to a limited extent, in the animal alluded to, by the reproduction of a small vessel passing off from the terminus of the right (renal) artery and joining the aorta below the place of ligating it, as is proven by a preparation I made of the part, and fully injected, which I now show you.

Cooper's experiments demonstrated two important points. First, that early death after ligation of the distal aorta, at least in dogs, may be caused by acute congestion of the heart and proximal arterial circulation. Second that life-sustaining expansion of the proximal and collateral circulation occurs rapidly in response to gradual occlusion of the aorta, which therefore becomes a feasible method of achieving is safe complete ligation.

Following these experiments, had a patient with an aneurism of the proximal iliac artery come under his care, Cooper would doubtless have ligated the abdominal aorta after its gradual occlusion to stimulate proximal and collateral circulatory adjustment, as was done in his experiment. Unfortunately, It is also near certain that infection at the site of ligation would have resulted in sepsis and fatal secondary hemorrhage as in the innominate cases. However, in the coming era of aseptic surgery, Cooper's approach of stimulating collateral circulation by partial ligation prior to later total occlusion might have been successful - and would have been heralded as an historic surgical contribution. As an example of the applicability of Cooper's method, the highly-regarded vascular surgeon Harris B. Shumacker partially occluded the innominate artery by banding it at an initial operation to reduce flow, safely completing the occlusion at a later operation after adequate collateral had been established in the upper extremity.[28]

Cooper could not have known that, some years before, Sir Astley Cooper had ligated the abdominal aorta in two dogs. His purpose was to identify the collateral pathways that would develop after total occlusion of the vessel. Sir Astley reported his experiments in a paper read before the Medical and Chirurgical Society of London on 18 June 1811. In contrast to Elias Cooper's animals, both of Sir Astley's dogs survived the ligation, showing only a small degree of weakness in the hind legs. Post mortem injection of the vascular system of these animals demonstrated a rich network of anastomosing arteries circumventing the occluded site in the aorta. It is unclear why Elias Cooper's animals all died rapidly of cardiac and proximal arterial congestion after acute ligation of the abdominal aorta while those of Sir Astley lived. This outcome may have been due to the greater hardiness of the British dogs, but it is also possible that Sir Astley's ligature was tied more proximally on the aorta thus allowing for more branches in the distal portion through which blood could return to the lower limbs. There is insufficient information in his report to allow us to settle the issue.[29]

Simultaneous Ligation of the Iliac Artery and Vein

Finally, we will refer again to the case of Frank Travers on whom Cooper set out in December 1855 to ligate the iliac artery for aneurism of the femoral artery. During the dissection of the iliac artery, the iliac vein was torn. In order to control the severe bleeding that followed, Cooper was forced to ligate the iliac vein as well as the artery, a procedure thought to have dire consequences. When Mr. Travers unexpectedly made a rapid and complete recovery, Cooper wondered why. We discussed the case in Chapter 8 and described the crucial animal experiments which led him to conclude that, instead of having an adverse effect, simultaneous ligation of the artery and its satellite or accompanying vein slowed the venous runoff from the extremity, resulting in a more balanced and physiologically effective circulation.[30]

The experimental findings were unequivocal and compelling. In five dogs the iliac artery alone was ligated. In every instance the limb became cold and the sensibility was greatly diminished for several days. In five dogs the iliac artery and vein were ligated at the same time. In every instance the heat and sensibility of the limb remained nearly natural from the first.

Cooper concluded that ". . .the advantages resulting from the ligation of the satellite veins in connection with the arteries which they accompany (are) clearly shown. . ."

Cooper's observation that simultaneous ligation of the major artery and vein to an extremity had a beneficial effect was a significant discovery. Since the period of John Hunter (1728-1793), eminent surgeons had always stressed that the greatest care should be taken, when tying a main artery, to avoid all injury to the vein. In fact operative techniques for ligating the artery were so devised as to minimize the risk of interrupting the venous circulation.

Unfortunately, Cooper's important finding was essentially unknown to the profession at large because of its publication in the obscure California State Medical Journal which was discontinued after four issues. Some half-century later, cumulative field experience in the Boer War (1899-1902) and World War 1 (1914-1918) showed that simultaneous ligation of artery and vein, made necessary by wounds of both, was followed by a lesser incidence of gangrene of the extremity than when the artery alone was tied.[31] This prompted the following recommendation by the Inter-allied Conference of Surgeons held in Paris in May, 1917:[32]

Contrary to what has until now been believed, simultaneous ligature of both artery and vein when both vessels have been wounded does not give rise to increased risks of gangrene; in fact it diminishes them. Facts tend to prove, even when the wound is limited to the artery, that simultaneous occlusion of the unwounded vein is to be recommended.

After another decade, in March 1927, Emile Holman reported an elegant series of simple yet definitive animal experiments from which he also concluded that tying the vein as well as the artery results in a more balanced circulation. "It would appear, however," he added, "that ligation of the main vein should be done, not at the level of the ligation of the artery, but proximal to the venous tributaries that accompany the arterial branches furnishing the main collateral circulation."[33]

How are we to assess these unique research efforts of Elias Cooper whose laboratory investigations were undertaken with limited resources in a hostile milieu far from the mainstreams of medical science? Regrettably, his observations have hardly seen the light of day because of the parochial and transient nature of the California State Medical Journal in which he published. Nevertheless, his contributions were original and memorable, stamping him as the preeminent (and only) circulatory physiologist of the western region for some years to come.

Cooper's vascular operations and circulatory studies have previously received only passing mention in biographical sketches. Therefore, we have thought it essential to provide a sufficient account of his work to permit others to consider the significance of his efforts, and accord them such recognition as they deserve in the records of medical progress.

Clinical Investigations

In reading Cooper's papers, one is struck by the intuitive common sense and independence of mind with which he approached surgical problems. He constantly sought not merely to report cases but also to improve surgical results by identifying and promoting new surgical principles.

Anchylosis of Joints

For example, orthopedic conditions, that is, surgical diseases of the bones and joints, constituted a major portion of Cooper's practice throughout his career. As we have previously mentioned, one of his earliest papers, published in 1852[34], was on anchylosis (fixation) of the knee joint secondary to trauma or infection. He described the successful treatment of this severe disability by having the patient walk in an ingenious splint of his own invention. The method described by Cooper led to gradual extension and restoration of mobility in the joint with minimal discomfort. This was an immense advance over the procedure sometimes employed of forcibly wrenching the frozen joint apart under anesthesia in the false hope that its function would be thereby improved. Cooper's program presaged the later general adoption of the principles of progressive joint mobilization combined with weight-bearing in the rehabilitation of these cases. As a result of technological advances inconceivable in the mid 1800's, such conditions can now be treated by joint replacement.

Cooper published two additional papers on his method of managing joint anchylosis in the lower extremities. He claimed originality for the concept and the apparatus, and priority of publication on the subject. His claim was questioned but no evidence was ever brought forward to refute it. Since all three papers appeared in the Transactions of medical societies, they had limited circulation and Cooper therefore received scant recognition for a significant innovation.[35][36]

Joint Infection and Air in Joints

Cooper's empirical style is further illustrated by his approach to joint infection. From the beginning of time until the discoveries of Pasteur and Lister, wound infection was a major deterrent to surgical progress. The advent of anesthesia, by broadening the scope of surgical interventions, actually served to increase the adverse potential of postoperative septic complications. Cooper's practice included many patients with infections of bones and joints, anatomical sites where sepsis tends to be exceptionally persistent and disabling. In his perceptive and methodical fashion he began in 1859 a series of observations and publications on the cause and management of septic joints. He considered his work on this subject to be his most important contribution in the field of clinical surgery, and for that reason we will describe his findings and recommendations in some detail.

Joints and their adjacent tendons are sheathed by synovial membranes which secrete the synovial fluid that lubricates the moving parts. The synovial membranes are highly vulnerable to infection and the closed cavities they encompass are a fertile site for the incubation and delayed invasion of even a tiny inoculum of bacteria. In Cooper's day, the fact that infection is caused by microorganisms was still unknown. It was, however, common knowledge that small penetrating wounds into a joint such as the knee were frequently followed by severe inflammation. It was also observed that signs of inflammation were often delayed for a week or more after the injury, by which time the original wound may have completely healed.

It was widely, but not universally, believed (1) that these puzzling events were caused by the entry of air into the joint at the time of injury; (2) that air itself was harmful; and (3) that its admission into joints should therefore be prevented. This dictum was either supported, or not specifically contested, by major surgical authorities on both sides of the Atlantic, including such respected figures as Samuel D. Gross and Joseph Pancoast in America, Richard Barwell in England, James Miller in Edinburgh, and Dupuytren and J. Guerin in France.[37][38][39][40]

As examples of the advice from these eminent surgeons on the importance of excluding air from joints, we quote the following excerpts:

From the well-known Treatise on Operative Surgery, 1852, by Professor Pancoast of Jefferson Medical School:

Hydrarthrosis of the Knee Joint. All therapeutic measures having failed, after a thorough trial to cause a removal of the dropsical accumulation, we may discharge it either by incision with a bistoury, or puncture with a trocar. The great object in the operation is to avoid the entry of air, which might provoke irritation in the cavity of the joint, and give rise either to suppurative inflammation of the serous membrane, or even ulceration of the articular surfaces.

From the widely-used Principles of Surgery, 1856 edition, by Professor James Miller of Edinburgh University:

Removal of Loose Cartilage from Knee Joint. The operation, as we would advise it, is thus seen to consist of distinct parts. 1. The prophylactic preparation; occupying not less than several days. 2. The oblique valvular puncture; carefully avoiding the entrance of atmospheric air, even into the superficial areolar tissue, etc.

On the other hand, such distinguished surgeons as James Symes in England and Alf. A. L. M. Velpeau in France were opposed to the doctrine of the harmfulness of air.[41][42]

Under the circumstances, It is fair to say that in Cooper's time the effect of air on joints was an important unsettled issue from the surgical viewpoint. Furthermore, no credible surgical authority was taking a firm stand in the literature of the day against the presumption that air was injurious to joints - that is, there was no persistent dissenting voice until Cooper launched his campaign on behalf of the harmlessness of air.

The theory that air caused inflammation in joints had serious practical consequences. For fear of the noxious effects of the atmosphere, there was a disastrous tendency to defer the prompt and free opening of wounded joints at the earliest sign of inflammation lest the entry of air would aggravate the condition. Based on the same apprehension, the operation for removal of floating cartilage in the knee was considered very dangerous because of the frequent occurrence of postoperative joint sepsis, presumably caused by the entry of air during the operation. To prevent entry of air into the knee joint during such operations, Gross, Pancoast, Miller and many other leading surgeons recommended maneuvering the cartilage into a subcutaneous location whenever possible and then removing it through a subcutaneous tunnel or by cutting down on it directly. Dr. Toland appeared to believe in the adverse effects of air and in 1858 reported two cases of attempted airless removal of floating cartilage according to the above technique. Nevertheless, both cases later required incision and open drainage of suppurating wounds.[43]

In contrast, Cooper was thoroughly convinced that air was innocuous to joints. He observed in his practice that:[44]

Large wounds, or those opening freely the knee joint, are inclined to heal kindly by granulations, and if properly treated, to result in a complete cure, while a small punctured wound which heals on the external surface by first intention often, if not generally, results in the highest possible grade of inflammation, frequently passing rapidly into suppuration and destruction of the joint, if not even of the life of the patient.

Cooper argued that the inflammation which develops following a puncture wound is not caused by the minute amount of air admitted at the time of the injury, as generally supposed, but by the accumulation in the joint of "purulent matter" that could not escape through the small wound. The grand mistake, he said, was not in permitting air to be admitted into the joint, but in not keeping the external wound sufficiently open to allow the free discharge of serum and purulent matter. Groping vainly for the mysterious source of the "purulent matter" that produced inflammation in wounded joints, Cooper sought in the following soliloquy to exonerate the atmosphere:[45]

I would challenge the most industrious or ingenious to show by statistics, or any fixed physiological laws, why the mere admission of air into the knee, or any other joint, would cause inflammation. . . Many cases of dangerous symptoms, or of death, are (reported), where air was admitted into joints, even in cases of exceedingly slight wounds; but does that go to prove that air did the mischief? Who has any direct evidence to bring up in support of this hypothesis, further than that it is based upon the long standing opinion of able men? What poisonous agent can there be in the air that produces such destructive results as are attributed to it, when admitted into wounds? And if there were an indefinable something acting thus, why should it not show the effect at once?

Consistent with his thesis that air is harmless to joints, Cooper's procedure for the removal of floating cartilage from the knee joint was to make an adequate incision into the joint for good exposure, extract the cartilage under direct vision, and either to pack the wound open for gradual healing by granulation or, alternatively, to close it primarily with sutures. Whenever he closed the wound, he was prepared to provide free drainage by opening it widely again at once on the slightest evidence of inflammation. This unorthodox approach, characteristic of Cooper's independent thinking, was a radical departure from the convoluted procedures designed to exclude air from the joint that were recommended by Gross, Pancoast and Miller.[46][47]

In the four-year period from 1859 to 1862 Cooper engaged in a veritable crusade (1) against the concept that air is harmful to joints; (2) in favor of the prompt and wide opening of joints at the earliest sign of sepsis; and (3) in support of his regime of wound healing by granulation. During this period he published nine papers on these subjects, seven in eastern journals and two in the San Francisco Medical Press. In addition, he wrote ten Commentaries in the Press along the same lines.

Concurrent with Cooper's observations on inflammation in joints, historic developments were occurring in Europe. In 1860 Pasteur demonstrated bacteria in the air and showed that specific microorganisms were responsible for specific biological processes, including infection. He thus laid the foundation for the germ theory of disease and paved the way for Lister to demonstrate the control of surgical infection by antisepsis in 1867. These and later findings have shown that Cooper's deduction regarding the harmlessness of air per se was correct. Although the atmosphere does contain some bacteria, air is not responsible for the invasive sepsis that often follows closed wounds of joints. Instead, the infection is caused by entry into the joint of bacteria from the patient's skin and from whatever else makes contact with the joint cavity including, in the preantiseptic era, the unsterile hands and instruments of the surgeon.

Cooper's empirical conclusions regarding prevention and management of joint sepsis were equally as astute as his views on air. He did not hesitate to challenge traditional wisdom by vigorously promoting what he designated as his New Surgical Principles:[49][50]

1st. That atmosphere, admitted into the joints or other tissues, is not a source of irritation or injury, except where it acts mechanically; as, when admitted into a vein, by producing asphyxia; into the thoracic cavity, by its pressure producing collapsing of the lungs, or when, by the long-continued exposure of a large amount of surface of any of the internal organs, whose normal temperature is much above that of the atmosphere, it reduces it so as to produce a morbid action.

2nd. That the division of entire ligaments about the joints is no impediment to their ultimate strength and mobility; but, on the other hand, this operation will often greatly facilitate the cure, by enabling the surgeon to open the affected part fully, for the purpose of applying medicinal substances to the articular surfaces, when these are ulcerated or otherwise diseased.

3rd. That the only true mode of treating ulcerations of bone, however slight, within the joint, is to lay it open freely, and apply remedial agents directly to the part affected.

4th. That opening the joints early, in case of matter burrowing in them, is far more imperiously demanded than the opening of other parts thus affected, and the operation produces no further pain or inconvenience to the patient, in any respect, than when performed on parts remote from joints.

5th. That after opening a large joint, the knee for instance, by an incision several inches long, the wound should be kept open by the introduction of lint (a soft, fleecy substance consisting of either cotton or linen), or other similar material, until the parts within the articulation become healthy, and, in all cases, it should be made to heal by granulation.

6th. That extensive wounds, opening freely the large joints, such as the knee, (even when lacerated, as by a saw, which must necessarily heal by granulation), do not as often give rise to violent symptoms as very small wounds, such as are made by the corner of a hatchet, an adze, or a pen-knife, which heal on the outside by first intention.

7th. That there are no known limits beyond which a tendon will not or cannot be reproduced after division, provided the parts are made to heal by granulation, and that the present acknowledged rule of two inches being the maximum distance in which the divided ends of a ligament or tendon can safely be separated, has not the least foundation in fact.

Cooper proudly presented his New Surgical Principles as part of his Report of the Committee on Surgery at the Sixth Annual Session of the California State Medical Society in February 1861. As we have already learned, there were only thirteen members present at this, the last meeting of the original Society, and no Transactions of the Session were ever published.[51]

Cooper's fifth Surgical Principle refers briefly to wound healing, a subject of paramount importance in surgery. His contribution in this area therefore deserves further comment. With respect to wound healing, broadly speaking, both accidental and surgically incised wounds heal either by first intention (the edges of the wound are brought together and healing occurs rapidly without suppuration) or by second intention (the wound is left open, suppuration occurs and healing is by granulation). In the pre-antiseptic era, because of the failure to prevent bacterial contamination, accidental wounds that were closed by suture or other means commonly suppurated, broke open and healed by granulation. Wounds of major operations were also usually followed by varying degrees of suppuration and the death rate from sepsis was high. Cooper took special note of the fact that when accidental and operative wounds were left open, suppuration was minimized and invasive infection was rare. The resultant healing was by second intention and was slower, but the morbidity and mortality were less.

This observation was by no means original with Cooper, but he used it as the basis for a specific routine for the handling of certain wounds. The routine itself was also not strictly original, but it did prescribe a particularly effective combination of methods in common use. He repeatedly recommended it in many publications, and specified the circumstances under which it should be used. The following is a paraphrased outline of his regime as it appeared in several publications:[52][53]

In all surgical incisions made for drainage of inflammation in a joint or a bone, or for the treatment of a compound or ununited fracture, the wound should be laid open freely and packed with a piece of lint which is kept soaked with an evaporating lotion composed of one part of alcohol and ten parts of water (a mildly antiseptic solution). Thus the wound is made to heal entirely by granulation. The packing is held in place by a roller bandage wrapped around the limb from fingers to near the axilla or from toes to upper thigh. The roller is applied as tightly as the patient can conveniently bear in order to splint the limb and prevent the burrowing of purulent matter among the surrounding parts. After three to five days the evaporating solution is discontinued and warm poultices are applied. The roller and packing may be dispensed with at any time after the poultices are begun, but should remain or be replaced as long as necessary to support the limb and prevent the wound healing otherwise than by granulating from the bottom.

Cooper's New Principles and his regime for the healing of wounds by secondary intention, were sound guidelines for the pre-antiseptic era. They had the merit of being thoroughly validated in the course of his extensive practical experience with bone and joint infections, of which he gave many examples in his articles and commentaries.

Cooper was justifiably confident that no previous author had been so concise and explicit with respect to the issues he addressed.

He sought through the medical literature to reach a national audience with his proposals. In order to determine the kind of reception they received among the profession, he wrote a commentary in the January 1861 issue of the San Francisco Medical Press entitled, "We challenge criticism," in which he invited others to criticize and refute his principles if they could. Having for over six months received no response to the challenge, he was pleased to think that his New Surgical Principles were being recognized as an important and original contribution to the problems of septic joints and wound healing.

However, late in 1861, the editor of the Philadelphia Medical Reporter published the following editorial in which he questioned the originality of Cooper's observations and recommendations:[54]

To Dr. Cooper, of San Francisco, is due the credit of establishing the great advantage of free openings into suppurating joints, and of illustrating, by extensive practice the innocuousness of atmospheric air, when admitted into synovial and serous cavities. Dr. Cooper is in error in supposing, as is evident from a recent editorial in his journal, that the treatment of disorganized joints by incision is not, to any extent, adopted by surgeons. It has been, for some years, practiced by many surgeons in this country, as by Pancoast, Agnew, Morton, and others of this city; extensively by Bauer, of Brooklyn, and Walter of Pittsburgh. We believe that the latter named gentleman would dispute with Dr. Cooper the priority of the practice. We have repeatedly, during the last two or three years, relieved suffering and saved joints and limbs in the Philadelphia Hospital, by free incisions into suppurating articulations. The practice has also been, to some extent, adopted abroad, and we have seen the subject favorably noticed in European journals, with proper credit to Dr. Cooper.

While giving Dr. Cooper credit for really establishing the advantage of this treatment, in an extensive number of cases, and of being the author of its introduction as an established rule of practice, any real originality in the treatment cannot be claimed by him. It has been the practice of some surgeons, for a long period, to occasionally open suppurating joints for the escape of pus and the debris from the diseased articulating surface. If we could take the time to look up the literature of the subject, this assertion might be abundantly proved. The only case in evidence to which we can, at present, refer Dr. Cooper, occurred a long time ago, in the practice of Mr. Guy, of London, and is recorded in an article by him in Braithwaite's Retrospect, part xxiv., page 171.[55]

Cooper responded promptly to the editor of the Philadelphia Medical Reporter by publishing the following extended reply in the January 1862 issue of the San Francisco Medical Press:[56]

We do not claim to be the first who opened joints in a state of suppuration. There are several cases reported in standard works upon Surgery, but we know of no standard work in which the practice is recommended as a rule. The cases mentioned were generally regarded by the writers as exceptional ones. Whereas, we believe that in all cases where purulent matter is found, in any considerable extent, in a joint, it should be discharged by a free incision, if such an operation would be proper in the patient who has burrowing matter in any other part of the body; and that the operation is more imperatively demanded in the former than the latter case; and, further, that the more complicated the joint (such as the knee) the more the operation is demanded early.

Probably medical journalists have been led into the opinion that we urged an exclusive claim to this practice, in consequence of our articles upon the subject being generally accompanied with remarks in regard to the innocuousness of atmosphere admitted into the joint. Upon this subject we do claim priority. So far as we know, there is not another writer, either as a standard author or contributor to a medical journal, who claims to have any convincing proofs that atmosphere admitted into joints or other tissues is not generally a source of danger; on the other hand, they all urge, when dwelling upon the subject, that it is a most unfortunate, if not even a dangerous occurrence.

Although Pancoast occasionally practices opening the joints, when purulent matter is found in them, this he must do with misgivings as to the propriety of admitting air, if we are to judge from what appears to have been his opinions at the time of publishing his Operative Surgery. The most stringent directions are given, in his article on Club Foot, not to permit atmosphere to enter the wounds, in operations for dividing the tendons.

We were not aware, prior to reading (the above editorial from the Philadelphia Medical Reporter) that the plan of opening the joints was so extensively practiced in the United States, and do not know still whether the publication of our articles (several years since) were not commenced previously to the time this practice was so inaugurated. At least we have not seen the reports of any of these cases until since that period.

So far as the interests of the profession are concerned, the subject of priority is a small matter, in comparison with the importance of the practice in question, and we consider it the duty of all practitioners to report the results of their cases, because the profession have not universally, nor even generally, adopted it as yet. We hold that a practitioner owes no greater obligation to the medical world than that of reporting his more important cases. And, upon this subject, we would solicit communications and the reports of cases, from practitioners of this Coast, where the practice of opening suppurating joints early is rapidly gaining ground.

We shall now conclude our discussion of the harmlessness of air and the importance of early open drainage of suppuration in joints. The advance of medicine since the mid 1800's has made these and innumerable other medical questions of that day no longer relevant. Nevertheless, they were highly significant at the time and we should evaluate in context the contributions of a tenacious pioneer like Cooper who, under adverse conditions, probed the frontier of knowledge in search of answers to contemporary issues.

The editor of the Philadelphia Medical Reporter did not question the validity of Cooper's New Surgical Principles and acknowledged his role in bringing them to the attention of the profession on both sides of the Atlantic. We have seen that medical myths and antique precepts such as Cooper attacked were difficult to eradicate and there is no doubt that Cooper's crusade was a significant blow to popular fictions regarding the treatment of septic joints - a remarkable accomplishment for a beleaguered surgeon at the nation's far western fringe.

It was especially gratifying to Cooper that his friend and editor of the Chicago Medical Journal, Professor Daniel Brainard of Rush, published a full list of New Surgical Principles and had a few encouraging words about Cooper's campaign of enlightenment in the following editorial:[57][58][59]

Free Openings into Suppurating Joints. There is very decided progress in opinions with reference to the propriety of freely opening synovial cavities, where evidences of suppuration are present. The danger of admission of air has been clearly over estimated. The advocates of speedy opening have, recently, adduced powerful support of their position by published cases. . . We opine that pure air is not so dangerous, either to the internal or external parts of the body, as some . . seem to imagine. The advantages of freedom of discharge largely counterbalance all theoretical fancies about the disastrous effects of air.

Professor Brainard's comments are interesting in that they confirm Cooper's thesis that there was a widespread misconception as to the proper treatment of suppurating joints and to the effects of air. In fact, Brainard seems a little ambivalent on the subject himself. His editorial is not exactly the ringing endorsement of Cooper's position that one would expect from the truly converted.

The only major surgeon to come forward to question Cooper's priority in these matters was Dr. Lewis A. Sayre (1820-1900), Professor of Orthopedic Surgery at Bellevue Hospital Medical College in New York who has since been recognized as the founder of modern orthopedics in America.[60] He informed Cooper in a letter of 1 March 1862 that he had taught the harmlessness of air in joints "for the last eighteen years" and referred to an enclosed "pamphlet" as proof. The pamphlet never arrived and Cooper invited Dr. Sayre to send him any "published articles" on the subject that he may have authored. Cooper reminded him that "Of course the claim of priority will rest, as usual, upon the fact as to who published first." We have no evidence that Dr. Sayre ever responded.[61]

Based on the information we have in hand, it seems reasonable to credit Cooper with priority in dispelling widely-held false notions as to the effects of air on joints, and in defining the proper management of suppurating joints. He exposed current misunderstanding with respect to these subjects. He brought his New Surgical Principles to the attention of the medical profession in the United States and western Europe by publishing his views repeatedly in respected medical journals, marshalling abundant evidence gleaned from personal observations in his own practice. As in the case of Dr. Holmes' impassioned plea for the profession to avoid behavior known to be associated with the spread of puerperal fever, Cooper's message was also based on concepts and practices already in the "public domain." His contribution, like that of Dr. Holmes, was to mount a vigorous and persuasive advocacy which rescued valid methods from relative obscurity and brought them into more general application. For this single-minded and single-handed achievement, he deserves honorable mention in the annals of surgery as a clinical investigator.

Nulla Dies Sine Linea

In concluding this review of the highlights of Cooper's professional career, we return now to a consideration of the precepts that gave such unwavering direction and driving force to his endeavors. We earlier paid our respects to the wholesome and supportive effect of his Quaker family background, and to the further shaping of his character in the crucible of pioneer life in the Old Northwest. To these influences we can attribute his moral fiber and stoical outlook; acquisitive mind and independence of opinion; and fierce intolerance of arrogance and deceit. We have seen ample evidence of these elemental traits in the preceding pages, but we have previously had little from Cooper himself about the convictions he held, and could recommend to others.

Cooper's papers include the manuscripts of a prodigious number of surgical lectures. These were generally on clinical subjects but, fortunately for our record, two of them were of a general nature, devoted primarily to counseling the medical students. One was an Introductory and the other a Valedictory Lecture. These addresses were for Cooper a welcome opportunity not only to give fatherly advice to the students, but also to express his own professional philosophy.[62][63]

Introductory Lecture. Surgery is that branch of the healing art which is frequently represented as practiced by the hand, and many are disposed to apply the name of Surgeon to the mere operator, though nothing could be further from the true and practical acceptation of the term; for though no one can be really an able surgeon and not a skillful operator, still one may be a beautiful operator and not be a skillful surgeon; and a wide-spread, but temporary reputation is frequently acquired by one quality alone. Thus brilliant and bold operators frequently obtain renown very rapidly for daring operations, more particularly when they attempt those which have been denounced by others as impracticable. But sooner or later the genuine Surgeon, as well as the mere operator, will stand upon his true merits. Medical men take up this matter and pronounce a true verdict, not always true at first, but eventually so. Prejudice, jealousy, and many other causes may prevent the Surgeon from obtaining justice during life, but posterity will be sure to award him his due, and to the man of great soul this is a happy thought. . .

I wish now to occupy your time during a brief period for the purpose of considering matters more directly connected with the medical course we are about to enter upon; a course which, if properly conducted on the part of both teacher and pupils, must redound to the great good of all; but a course which cannot be properly conducted on the part of any without great industry and punctuality in attending to our respective duties. And in practicing industry, I do not only wish you to study and think industriously, but I wish you to act. Always let your knowledge be based upon experience as far as possible, and your experience based upon your own actions or observations. . .

There is no doubt but that Aristotle was one of the greatest philosophers and logicians the world ever produced. It is extremely probable, in my estimation, that he was really the greatest man in these respects that ever lived. . . Why was his philosophy more correct and his logic more powerful than any other? Because his philosophy was based upon actual experiments and his logic upon experience. What was old in philosophy he submitted to the test of experiment before either condemning or approving, and what was not known he tried to know by the same method; consequently his system of philosophy was composed solely of knowledge - not theory - and as facts and principles do not change with the changes of men's minds in regard to them, Aristotle's views are found to be more and more correct as ages advance and men are capable of comprehending them.

Nothing is really valuable in medicine which is not based upon experience, and nothing is so important to a medical student as a collection of those facts and principles which enable him early to obtain knowledge by experience.

In a profession still permeated by the dogmas of arcane medical "systems," and reliant on traditional remedies and methods, Cooper's advocacy of critical observation and experiment was in the vanguard of the modern era. On a personal level, he revealed his hope that he will be remembered as more than a "mere operator;" and that posterity will rebuke the prejudices and jealousies under which he labored by awarding him the laurels of a True Surgeon.

Valedictory Lecture: Labor and its Results. The most frequent cause of difference in the reputation of medical men is the difference in their habits and course of life. Men whose reputation places them far above their fellows are often by nature scarcely equal to those by whom they are surrounded in early life. But day by day and year by year they widen the distance between themselves and their associates until the one enrolls his name in the galaxy of great men, perhaps authors, and fills a continent, possibly the civilized world, with his fame. The others are only known within the precincts of their respective residences as moderate practitioners while a retrospective glance at life may in all probability show the very interesting fact that these men were side by side in the same class, acquitted themselves equally well in the same quiz - the man of reputation answered his questions no worse and yet no better than the one who is now obscure, while a true prophetic glance at life could have equally astonished both.

Was there indeed so great a difference in these men by nature so hidden that not only common observation but even the ordeal of quiz failed to detect it?

You anticipate my answer - there was not. What was then the source of so great a dissimilarity in the destiny of these men? This becomes a question not only interesting but important to be solved because its solution gives courage to the patient, energetic and constant laborer in our profession, and proves to him that his reward is sure; while to the one of contrary habits it but too plainly shows him that, without a change of his course, he is sooner or later to be outstripped and probably by one whom he would assume to regard as his inferior.

The whole secret of the difference is this - the one had a fixed object in view and never lost sight of it but labored day by day and year by year for its accomplishment, while continued pursuit (of excellence) gave vigor of intellect as well as confidence of success. By becoming every day more assured of his competency to compete with others, he received constantly accumulating evidence of final success, and daily encouragement to persevere.

He who like the Painter Apelles permits no day to pass without its mark - Nulla Dies Sine Linea - no time to elapse without a vigorous and well-defined effort to further the accomplishment of a great work in life, (shall attain) all the honors due his industry and perseverance. . .

Cooper was a tireless worker with the initiative and capacity, unprecedented in the Far West of his day, to acquire new clinical knowledge through observation and experiment. Thus he himself exemplified the conduct and principles he sketched in these lectures We may therefore accept them as a fair summation of his personal creed. In simpler terms, we can say that he subscribed to the contrived Latin adage - Labor vincit omnia.[64]

A Private Life

Conflict and acrimonious exchanges were such a prominent feature of Cooper's professional relationships in both Peoria and San Francisco that recounting his misadventures as we have done tends to portray him as contentious and disdainful of the accepted standards of medical ethics - which indeed he was. However, there was a more appealing side to his nature. When a powerful cabal of San Francisco physicians mounted an unscrupulous attack on his integrity and surgical competence, his spirited defense and demonstration of exceptional ability earned him increasing respect and support from the local profession. The tide of opinion began to turn in his favor at the Third Annual Session of the California State Society in 1858 when he angrily accosted one of his adversaries, Dr. Henry Gray, in the presence of Dr. Washington Ayer and others. It is to the reminiscences of the fair-minded Dr. Ayer, who became the first Dean of Toland Medical School, that we now turn for a balanced appraisal of Cooper's true character:[65]

He was remarkably easy and plain, yet earnest in his conversation - using terse, Saxon language to express his ideas, and if at times, in the accommodation of necessities, he seemed a little over-earnest, the occasion made his course pardonable. . .

While he could not be considered convivial, he enjoyed a wholesome repartee, and found no pleasure in seclusion; was always social without being familiar. He held no malice toward any one, and with a mind conscious of rectitude feared no harm from others. . .

He was a true friend, and by his life showed that he held friendship too sacred to be even exposed to suspicion, and no idle rumor of any change in affairs could change him or alter his devotion to his friends. He was a man of thought, ever on the qui vive, and ready to adopt new plans to new emergencies, and to this quality of mind may largely be attributed his success. If our colleges could give birth to more spirits like his, the world would be wiser, and the profession more highly honored. . .

While I do not intend to say anything in such extravagant words as might possibly be construed into an apotheosis, I must admit that language seems quite inadequate to express fitly the sentiments of lofty nobility of (his) character, energy, moral excellence, and sturdy manhood. . .

Residence

Cooper's papers include little reference to his personal affairs. Even about his places of residence in San Francisco we have scant knowledge. We recall that upon his arrival in the city in May 1855 he took accommodations at the Rassette House on Sansome Street. When and where he moved from there, we do not know. The next relevant information is found in an ad he published in 1859 to which we have already referred. The ad announced that "the state of his health has induced him to transfer his lodgings to Oakland (ten miles across the Bay) where he will treat a limited number of cases." How long he commuted to Oakland is unknown.

The last mention of a residence among his personal papers is found in his financial records where an entry indicates that he lived at The Hotel International in 1860-62. This elegant five-story, fireproof hotel, located on Jackson Street between Montgomery and Kearny, was the elite place to stay from 1854.[66]

Irrespective of outside arrangements, Cooper doubtless also maintained living quarters in the Pacific Clinical Infirmary. In fact, an obituary published in the San Francisco Daily Alta California on 14 October 1862 stated simply that he died "at his residence on Mission Street." This could have been none other than the Infirmary.

Since Cooper was unmarried and did not maintain a household, paucity of information regarding his residence and private life is perhaps not unexpected. Nevertheless we have diligently, but unsuccessfully, sought for information about his personal affairs in order better to understand how he coped with what must have been a lonely private life, plagued by enemies and the shadow of encroaching illness. Alone and beset, that is, until the arrival of Levi Cooper Lane in the spring of 1861 to take up the position of Professor of Physiology in the Medical Department. One can scarcely overestimate the relief and reassurance that Lane's devoted presence must have afforded the ailing Cooper.[67][68]

Financial Affairs and a "Shape of Ice"

Cooper was disciplined and industrious. However, in comparison with his main competitor, Dr. Toland, Cooper's practice was considerably less rewarding. His expenses included the operation of the Pacific Clinical Infirmary, publication of the San Francisco Medical Press, and the cost of his lodging and other personal needs. These expenditures were met by income from the Infirmary and, chiefly, by receipts from his surgical practice.

Cooper's annual gross income from practice was:

  • 1859
    $ 7300
  • 1860
    $ 8200
  • 1861
    $ 8900
  • 1862
    $ 2000

As we shall later see, at the time of his death, the total value of Cooper's estate was only $8,500.

On the other hand, Dr. Toland's practice income was phenomenal. By 1860 it had reached $ 40,000 a year, further augmented by the profits from his thirteen thousand acre ranch in the rich bottom lands of the Sacramento River. Toland was 54 in 1860 and in October of that year he married for the third time. His fame and fortune were secure, yet he was nevertheless dissatisfied with the state of affairs in the medical community. As he saw it, the standards and good name of the local profession, of which he was a pillar, had been compromised. The presumptuous and incorrigible Cooper had established a medical school in spite of the opposition of the old guard who had nothing but contempt for the adventure. To make the enterprise even more offensive to Toland, Beverly Cole was Dean of the Faculty.

Toland had never before shown the slightest inclination to teach. But now he was determined to extinguish this unworthy and unnecessary medical school (Wooster: "A Medical College was not yet needed here.") by supplanting it with one of his own. Would it be too harsh to attribute his new-found interest in medical education to mixed motives of vanity and vengeance?[69]

It was early in 1860 that Cooper first heard rumors of Toland's plan to found a second medical school in San Francisco, and wrote that he welcomed the competition. Yet even as he issued this generous challenge, Cooper could feel the chill from the looming "Shape of Ice" just off the bow of the frail vessel he had launched with hope and pride but two years before.[70]

Well: while was fashioning
This creature of cleaving wing,
The Immanent Will that stirs and urges
everything,

Prepared a sinister mate
For her - so gaily great -
A Shape of Ice, for the time far and desolate.

And as the smart ship grew
In stature, grace and hue
In shadowy silent distance grew the Iceberg
too. . .

Endnotes

  1. John Bell , The Principles of Surgery, 2 Vols. (London: Printed for R. Cadell, Jr., et al., 1801-1806), vol. 1 (1806): pp. 1-2 Lane Library catalog record
  2. David Wooster , "Editor's Table: American Medical Times and California communications," Pacific Medical and Surgical Journal 4, no. 6 (Jun 1861): 230 Lane Library catalog record
  3. Levi C. Lane , "Editor's Table: Obituary of Dr. E. S. Cooper," San Francisco Medical Press 3, no. 12 (Oct 1862): 237 Lane Library catalog record
  4. Levi C. Lane , "Editor's Table: Obituary of Dr. E. S. Cooper," San Francisco Medical Press 3, no. 12 (Oct 1862): 238 Lane Library catalog record
  5. Valentine Mott , "Reflections on securing in a ligature the arteria innominata: to which is added, a case in which this artery was tied by a surgical operation," New York Medical and Surgical Register, vol. 1 (1818): p. 9, and A. Scott Earle , Surgery in America: From the Colonial Era to the Twentieth Century: Selected Writings (Philadelphia and London: W. B. Saunders Company, 1965), pp. 96-118 Lane Library catalog record, Lane Library catalog record
  6. Samuel D. Gross , Memoir of Valentine Mott, M. D., LL. D. (New York: D. Appleton and Co., 1868), p. 39-42 Lane Library catalog record
  7. James Greenough , "Operations on the innominate artery," Archives of Surgery 19, no. 6 (Dec 1929): 1484-1544
  8. Elias S. Cooper , "Aneurism of the right carotid and subclavian arteries: Ligation of the arteria innominata" American Journal of Medical Sciences 38, no. 76 (Oct 1859): 395-396
  9. Daniel Brainard , "'Aneurism of the right carotid and subclavian arteries; ligation of the arterial innominata' by E. S. Cooper, M. D., San Francisco," Chicago Medical Journal, Dec 1869: 751-752 Lane Library catalog record
  10. Elias S. Cooper , "Commentary: Aneurism of the right carotid and subclavian arteries; ligation of the arterial innominata by E. S. Cooper, M. D., San Francisco," San Francisco Medical Press 1, no. 3 (Jul 1860):189-191 Lane Library catalog record
  11. Letter to the Editor from Professor E. S. Cooper, M. D., of San Francisco, Cal., dated 30 October 1860: "Ligature of the innominata," American Medical Gazette (New York) 3, no. 1 (Jan 1861): 9-10 Lane Library catalog record
  12. Elias S. Cooper , "Our case of ligating the arteria innominata," San Francisco Medical Press 2, no. 5 (Jan 1861): 52-54 Lane Library catalog record
  13. David Wooster , "Ligation of the arteria innominata," Pacific Medical and Surgical Journal 3, no. 10 (Oct 1860): 453 Lane Library catalog record
  14. Elias S. Cooper , "Case of ligating the arteria innominata; with remarks" Cincinnati Lancet and Observer 4, no. 8 (Aug 1861): 475-480 Lane Library catalog record
  15. Andrew W. Smyth , "Case of successful ligature of innominate artery," New Orleans Medical and Surgical Journal 22 (1869): 464-469 Lane Library catalog record
  16. Emmet Rixford , "Then and Now - Personal Recollections," Part 2, Western Journal of Surgery, Obstetrics and Gynecology 41, no. 8 (Aug 1933): 475 Lane Library catalog record
  17. J. Lewtas , "Traumatic subclavian aneurysm: Ligature of the innominate and carotid arteries; Recovery," British Medical Journal 2 (Aug 10, 1889): 312 Lane Library catalog record
  18. James Greenough , "Operations on the innominate artery," Archives of Surgery 19, no. 6 (Dec 1929): 1484-1544. The data were derived from p. 1487 and pp. 1502-1517
  19. Emile Holman , "Surgery of the large arteries with report of a case of ligation of the innominate artery for varicose aneurysm of the subclavian vessel," Annals of Surgery 85, no. 2 (1927 Feb): 173-184
  20. Scrapbook #2, Excerpta, Scrapbooks - Box 2, Folder 9, Elias Samuel Cooper Papers - MS 458, California Historical Society, North Baker Research Library
  21. Joseph Pancoast , A Treatise on Operative Surgery (Philadelphia: A. Hart, late Cary and Hart, 1852), pp. 68-69 Lane Library catalog record
  22. Astley Cooper and Benjamin Travers , Surgical Essays, Parts 1 and 2, First American from Third London Edition (Philadelphia: James Webster, Prop., 1821), pp. 83-103 Lane Library catalog record
  23. Editor of Lancet, "Exeter Hospital: Ligature on the aorta," Lancet 2 (Aug 8, 1829): 607 Lane Library catalog record
  24. John Murray , "Iliac aneurism and ligature of the aorta," North American Archives of Medical and Surgical Science 1, no. 4 (Jan 1835): 297-299 Lane Library catalog record
  25. Joseph Pancoast , A Treatise on Operative Surgery (Philadelphia: A. Hart, late Cary and Hart, 1852), pp. 68-69 Lane Library catalog record
  26. Vivesections: Ligating the Abdominal Aorta in the Dog, Scrapbooks - Box 2, Folder 9, Elias Samuel Cooper Papers - MS 458, California Historical Society, North Baker Research Library
  27. Elias S. Cooper , "Remarks upon the practicability of obliterating the abdominal aorta by gradual pressure, illustrated by vivisections," California State Medical Journal 1, no. 1 (Jul 1856): 69-72 Lane Library catalog record
  28. Harris B. Schumacker, Jr. , "Surgical cure of innominate aneurysm: Report of a case with comments on the applicability of surgical measures," Surgery 22, no. 5 (Nov 1947): 731-732
  29. Astley Cooper , "Dissection of a limb on which the operation for popliteal aneurism had been performed," Medico-Chirurgical Transactions (published by the Medical and Chirurgical Society of London) 2 (1813): 260-261 Lane Library catalog record
  30. Elias S. Cooper , "On the satellite veins in connexion with the arteries which they accompany: Operation of ligating the external iliac artery and vein; Rapid recovery of the patient" (A paper read before the Second Session of California State Medical Society, 11-13 February 1857) California State Medical Journal 2, no. 2 (1857 Apr): 441-445 Lane Library catalog record
  31. George H. Makins , On Gunshot Injuries to the Blood-Vessels: Founded on Experience Gained in France during the Great War, 1914-1918 (Bristol: John Wright and Sons, LTD., 1919), pp. 103-104 Lane Library catalog record
  32. Emile Holman , "Surgery of the large arteries with report of a case of ligation of the innominate artery for varicose aneurysm of the subclavian vessel," Annals of Surgery 85, no. 2 (Feb 1927): 176-177
  33. Emile Holman and Muriel E. Edwards , "A new principle in the surgery of the large vessels," Journal American Medical Association 88, no. 12 (Mar 19, 1927): 909-911 Lane Library catalog record
  34. Elias S. Cooper , "Remarks on the treatment of incomplete anchylosis of the knee-joint," Transactions, Illinois State Medical Society, 1-3 June 1852. Appendix D, pp. 37-44. Pamphlet No. 7, E. S. Cooper Collection, Lane Medical Archives, Stanford Lane Library catalog record
  35. Elias S. Cooper , "Walking rendered the primary element in the cure of deformities of the lower extremities; its early adaptation to white swelling and coxalgia, with apparatus for carrying out the designs of the same," Transactions, Illinois State Medical Society, 6-7 June 1854 (Chicago: J. F. Ballantyne, Printer and Publisher, 1854), pp. 39-54. Also based on material held at the Illinois State Medical Society. Lane Library catalog record
  36. Elias S. Cooper , "Deformities of the locomotive apparatus," (Annual address of the President of the California State Medical Society delivered February 12th, 1857, by the 1st Vice President, E. S. Cooper, A. M., M. D., of San Francisco.) Transactions, Second Session of the Medical Society of the State of California, 11-13 February 1857, pp. 17-22
  37. Samuel D. Gross , System of Surgery: Pathological, Diagnostic, Therapeutic, and Operative, 2 vols. (Philadelphia: Blanchard and Lea, 1859), vol. 1: pp. 1001-1002 Lane Library catalog record
  38. Joseph Pancoast , A Treatise on Operative Surgery, Third Edition (Philadelphia: A. Hart, 1852), pp. 84 and 371-372 Lane Library catalog record
  39. Richard Barwell , A Treatise on Diseases of the Joints (Philadelphia: Blanchard and Lea, 1861), pp. 69-70, p. 215 Lane Library catalog record
  40. James Miller , The Principles of Surgery, 4th American edition (Philadelphia: Blanchard and Lea, 1856), p. 465 Lane Library catalog record
  41. James Syme , Principles and Practice of Surgery, 2nd American edition (Cincinnati: Moore, Wilstach, Keys and Co., 1858), pp. 438-439 Lane Library catalog record
  42. Alf A. L. M Velpeau , New Elements of Operative Surgery, 3 vols. (New York: Samuel S. and W. Wood, 1856), v. 1: pp. 229-230 and v. 2; p. 754
  43. Hugh H. Toland , "Moveable cartilages in the knee joint: Operation; Cure," Pacific Medical and Surgical Journal 1, no. 12 (Dec 1858): 478-481
  44. Elias S. Cooper , "On incisions into the joints, in cases of synovitis: Articular wounds in general, with remarks," Medical and Surgical Reporter (Philadelphia) 2, no. 9 (May 28, 1859): 177-179 Lane Library catalog record
  45. Elias S. Cooper , "On the removal of floating cartilages from the knee joint, by a free incision; with remarks upon the admission of air into wounds of the joints in general," Cincinnati Lancet and Observer 2, no. 12 (Dec 1859): 724 Lane Library catalog record
  46. Elias S. Cooper , "On the removal of floating cartilages from the knee joint, by a free incision; with remarks upon the admission of air into wounds of the joints in general," Cincinnati Lancet and Observer 2, no. 12 (1859 Dec): 725 Lane Library catalog record
  47. Elias S. Cooper , "Commentary: Considerations in reference to healthy, in contra-distinction to diseased joints," San Francisco Medical Press 3, no. 10 (Apr 1862): 79-81 Lane Library catalog record
  48. Elias S. Cooper , "Commentary: We challenge criticism," San Francisco Medical Press 2, no. 5 (Jan 1861): 45-46 Lane Library catalog record
  49. Elias S. Cooper , "Commentary: New Surgical Principles," San Francisco Medical Press 2, no. 7 (1861 Jul): 148-149 Lane Library catalog record
  50. Elias S. Cooper , "Commentary: We challenge criticism," San Francisco Medical Press 2, no. 5 (Jan 1861): 45-46 Lane Library catalog record
  51. Elias S. Cooper , "On incisions into the joints, in cases of synovitis: Articular wounds in general with remarks," Medical and Surgical Reporter (Philadelphia) 2, no. 9 (May 28, 1859): 177-179 Lane Library catalog record
  52. E. S. Cooper , "Case of ununited fracture of the os humeri of four years' standing: Cure by the use of silver ligatures," American Medical Times (New York) 2, no. 21 (May 25, 1861): 337 Lane Library catalog record
  53. Elias S. Cooper , "Commentary: Free openings into suppurating Joints," San Francisco Medical Press 3, no. 9 (Jan 1862): 8-10 Lane Library catalog record
  54. John Gay, Esq. , Surgeon to the Royal Free Hospital, "Case of disease of the elbow joint," Retrospect of Medicine (Edited. by W. Braithwaite) 24 (Jul-Dec 1851): 212-214. No article by a Mr. Guy, as referenced by the editor of the Philadelphia Medical Reporter, could not be located on p. 171 of volume 24 of the Retrospect. However, volume 24 of the Retrospect contains the here- cited article by a Mr. John Gay. He describes his practice of free and open drainage of septic joints and reports his successful use of the procedure on a chronic infection of the elbow joint. Lane Library catalog record
  55. Elias S. Cooper , "Commentary: Free openings into suppurating Joints," San Francisco Medical Press 3, no. 9 (1862 Jan): 8-10 Lane Library catalog record
  56. Elias S. Cooper , "Commentary: Free openings into suppurating joints," San Francisco Medical Press 2, no. 7 (Jul 1861): 134-136 Lane Library catalog record
  57. Daniel Brainard , "Selections: New Surgical Principles," Chicago Medical Journal 4, n.s., 18, no. 4 (Oct-Nov 1861): 616 Lane Library catalog record
  58. Daniel Brainard , "Editorial: Free openings into suppurating joints," Chicago Medical Journal 4, n.s..18, no. 4 (1861 April): 251 Lane Library catalog record
  59. Richard A. Leonardo , History of Surgery (New York: Froben Press, 1943), p. 315 Lane Library catalog record
  60. Elias S. Cooper , "Correspondence," San Francisco Medical Press 3, no. 10 (1862 Apr): 119-120.D Lane Library catalog record
  61. Introductory lecture in surgery (holograph) no date - Box 1.13, Elias Samuel Cooper papers - MSS 10, Lane Medical Archives, Stanford Lane Library catalog record
  62. Valedictory Lecture: Labor and Its Results, Box 1, Folders 5 and 6, Elias Samuel Cooper Papers - MS 458, California Historical Society, North Baker Research Library
  63. Virgil[Publius Vergilius Maro] , Eclogues, X, l. 69. "Omnia vincit amor: et nos cedamus amor." (Love conquers all things; let us too surrender to Love.) In an age addicted to the classical allusion, Virgil's immortal line was sometimes modified to read, "Labor vincit omnia." (Work conquers all things.) - thus expressing the stern ethic that obsessed such men as Daniel Drake and Elias Cooper
  64. Washington Ayer , "Reminiscences of the life and labors of Elias Samuel Cooper," Occidental Medical Times 7, no. 11 (1893 Nov): 599-608 Lane Library catalog record
  65. Doris Muscatine , Old San Francisco, the Biography of a City (New York: G. P. Putnam's Sons, 1975), p. 136
  66. David Wooster , "Editors' Table: University of the Pacific," Pacific Medical and Surgical Journal 2, no. 12 (Dec 1859): 498 Lane Library catalog record
  67. Emge Research Materials-Correspondence, 1930-1978 - Box 3, Folder 14, Elias Samuel Cooper Papers - MS 458, California Historical Society, North Baker Research Library
  68. Frances T. Gardner , "The little acorn: Hugh Huger Toland, 1806-1880," Bulletin of the History of Medicine 24, no. 1 (Jan-Feb 1950): 65 Lane Library catalog record
  69. Thomas Hardy (1840-1926) , Poem: "The Convergence of the Twain (Lines on the loss of the Titanic)," in Collected Poems of Thomas Hardy (New York: MacMillan Co., 1925), pp. 288-289
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