Stanford University School of Medicine and the Predecessor Schools: An Historical Perspective
Part I. Background History & E.S. Cooper's Midwestern Years

Peoria was the "crucible" and proving ground where Elias Cooper gained professional experience and maturity. During the decade from 1844 to 1855 he worked tirelessly to improve his knowledge of anatomy and his mastery of surgery. Literally, there was "no day without a line." Like Daniel Drake and many other leaders of American Medicine in his day, he overcame formidable educational and other handicaps by relentless personal effort. With Drake he shared the firm belief that "labor omnia vincit" and, in later years, he made this the theme of his exhortation to medical students in California.

Peoria's historians write of Cooper as the leading surgeon of the city. "Large, powerful, earnest, vigorous and sensitive, he thought, talked and wrote only of surgery, begrudging even the few hours he slept daily as time lost from his work".^[1]

By all accounts he was single-minded and dedicated. He demonstrated uncommon enterprise and courage by conducting Anatomy Courses regardless of public censure in Peoria from 1848 to 1855. He competed creditably against considerable odds in the Anatomy Concours at Rush in June 1850. He attended a 4 1/2 month course of medical lectures in 1850-51 at St. Louis University where he finally received an MD degree in March 1851. And he founded Peoria's first hospital entirely at his own expense in September 1851. Meanwhile he developed an extensive surgical practice where he introduced innovative and advanced procedures to which we shall later refer. In his eagerness to expand his specialty practice and attract patients with eye and orthopedic disorders to his hospital, he advertised his services and the hospital in newspapers in the region. For this, his medical society colleagues accused him of unethical conduct, a subject to which we shall shortly return.

Cooper recognized the significance of the National Medical Conventions of 1846 and 1847 that founded the American Medical Association and stimulated the formation of state and local medical societies throughout the country. He had an abiding faith that such organizations were the best hope for raising medical standards and improving relations among physicians. This conviction led him to participate zealously in the founding of medical societies in Illinois and California. Understandably, he was dismayed when fellow society members, first in Illinois and later in California, accused him of unethical conduct for "advertising" his hospital and specialty practice. Throughout his career Cooper's medical ethics were questioned on one pretext or another by detractors whose often-spurious charges cast a still-lingering shadow over his reputation. Recently, however, we have discovered transcripts in his own hand that explain his actions and respond vehemently to his critics. When in the course of our continuing narrative the question of ethics arises, as it frequently will, these new findings should help us to understand, and possibly even accept, his point of view.

We cannot be certain when Cooper began to place advertisements for his hospital in regional newspapers but can assume from subsequent events that it was probably in the fall of 1851, shortly after the opening of his institution. The following advertisement, published in the Peoria Weekly Republican on 23 July 1852, is the earliest copy of the ad available.^[2]

Not reticent to claim the support of prominent citizens for his institution, Cooper appended a list of 27 References to his advertisement. The list included many high officials in Illinois State government as well as other notables from Ohio to Iowa. Most memorable of the references are Stephen A. Douglas, U.S. Senator from Illinois at the time, and Abraham Lincoln, an attorney at Springfield, who had served as an Illinois Representative to the U.S. Congress from 1847 to 1849. Lincoln had been elected to Congress as a member of the Whig Party which was superseded by the new Republican Party organized in 1854 to oppose the extension of slavery. Lincoln joined the Republican Party and became its successful candidate for the U.S. Presidency in 1860. There is no evidence among Cooper's papers to prove that he was acquainted with Abraham Lincoln or any of the other political figures listed as references. On the other hand, it is doubtful that even the brash Cooper would have used their names in a published advertisement without some personal link with them. It could be that Cooper was much more active in State and regional politics than we are aware. We have only one tantalizing clue. A simple notice was published in the Peoria Weekly Republican for 7 May 1852. It read: "(Dr. Elias Cooper was) at Whig meeting." Why should Cooper's presence at a meeting of the Whig political party be newsworthy? We must add this to the many unanswered questions about his personal life.^[3]

In the mid 1800s medical ethics was a highly sensitive issue among physicians. Since the self-confident and aggressive Cooper was destined frequently to test the boundaries of ethical practice, and provoke harsh criticism for his temerity, it will be useful for us to consider the status of American medicine and the attitude of the profession toward medical ethics in his day.

When the second session of the National Medical Convention convened in Philadelphia in 1847 it not only founded the American Medical Association but also passed a number of important resolutions. The Fourth Resolution stated: "That it is desirable that a uniform and elevated standard of requirements for the degree of M.D. should be adopted by the Medical Schools of the United States." This resolution was the basis for the A.M.A.'s continuous struggle to induce American medical schools to raise their standards, an effort frustrated over the next 60 years by the self-serving intransigence of the majority of the schools. General reform in medical education did not finally occur until after Flexner's fearless critique of 1910, to the preparation of which the A.M.A. lent its valuable support.^[4][5][6]

When the Fourth Resolution was framed in 1847, the parlous state of the medical profession was much on the minds of the delegates:^[7]

The National Convention's Sixth Resolution, also relevant to Cooper's future, asserted: "That it is expedient that the Medical Profession in the United States should be governed by the same code of Medical Ethics."^[8] Convinced that high ethical standards were vital to improvement of medical practice and the status of medicine, the National Convention drew up a comprehensive ethical code for the A.M.A. and, in due course, each state and local medical society adopted a code of ethics comparable to it. The Illinois State Medical Society of which Cooper was a founding member was organized at a Medical Convention in Springfield in 1850. On that occasion the Convention accepted the A.M.A. code with slight modification of the section on advertising. The following is the Illinois version of the section on advertising which Cooper was accused of transgressing:^[9]

During the Colonial period and throughout the 19th century American physicians were on the defensive against irregular practitioners who indeed swarmed "like locusts, " especially in newly settled regions of the country such as the Old Northwest. The irregulars were, to say the least, unconstrained by any ethical principles. Government regulations and licensure requirements were either non-existent or unavailing. On the other hand, the medical profession itself took no substantial steps toward self-improvement because the majority of medical schools were unwilling to raise their standards. As a result, public opinion was ambivalent regarding even regular medical practitioners in the mid 1800s. Another reason for the public's disaffection was that physicians often had little more to offer than did the botanics, sectarians, cultists, eclectics, electric healers, mesmerizers, hydropaths and other quacks. In fact, the punishing regimes that at mid century still often included bleeding, purging and calomel led many patients to believe that they were unsafe in the hands of the regular physician.^[10]

Under these circumstances, one of the profession's most effective means for distinguishing the regular from the irregular practitioner was the ban on advertising, and medical societies were committed to its strict enforcement. Given the contentious spirit latent in the medical fraternity, abundant manifestations of which we have already seen, it is not surprising that there was self-righteous vindictiveness in the persistence with which Cooper's enemies in the Peoria and Illinois State Medical Societies pressed a case against him for "advertising" his hospital.

The following chronological account of Cooper's role in these Societies will bring to light important features of his career in Peoria not yet addressed, and will provide background for our consideration of the dispute over ethics in which he became embroiled.

Peoria doctors were among the first, if not the first, in Illinois to organize a stable and continuing local medical association. They formed a medical society in 1846, reorganized it in 1847 and finally established a permanent society on 19 April 1848. It was on the evening of this latter date in the office of Dr. Frye - a dingy little room with a pine floor and three or four stuffed wooden chairs - that the following six physicians met by candlelight to found an association known originally as the Peoria Medical District Society:^[11][12]

• Elwood Andrew
• J.C. Frye
• John D. Arnold
• F.A. McNeill
• Edward Dickinson, Chairman
• J. Murphy, Secretary

Dr. Zeuch, historian of the early days of medical practice in Illinois, writes that "seven men met to organize the first medical society in Peoria County" and he names Cooper as the seventh man. Nevertheless, the account of the organizational meeting of 19 April 1848, recorded longhand in the Minute Book of Peoria Medical Society, states that the founding group consisted of only the six physicians named above - and Cooper was not among them.^[13]

Although it appears that Cooper may not have been a founding member of Peoria District Medical Society, we do find him present only seven weeks later on 6 June 1848 when 30 members convened at Peoria in the First Annual Meeting of the Society. During that meeting Cooper was appointed to membership on the Standing Committee on Medical Statistics. It was on this occasion that Cooper was initiated into the mysteries of medical society organization which remained a fatal attraction for him the rest of his life. In this particular aspect of professional affairs, he was ever after intensely involved.^[14]

This leads us here to the further observation that Cooper was never married and his records contain little information about his social life, apart from interaction with his own family and his ardent participation in medical societies.

There were several features of the First Annual Meeting of the Peoria Society that attest to the alertness of its members and the extensive region of the country over which they were scattered: (1) E.M. Colburn of Bloomington (40 miles southeast of Peoria) made a report on the use of ether in obstetrics practice (only a year and a half after its introduction as an anesthetic), and was elected President of the Society for the ensuing year; (2) the Society adopted the Code of Ethics of the American Medical Association which had been formulated only a year previously at the National Convention in Philadelphia. Among those present at the meeting were the men who later charged Cooper with unethical practice: Drs. John D. Arnold of Peoria and Dr. Thomas Hall of Toulon (30 miles northwest of Peoria). This is an opportune moment to introduce them and through their lives gain some additional insight into medical practice in Illinois at mid-century.

Sketches of Doctor Arnold's early life by historians of Peoria County are contradictory and create uncertainty as to the facts. He was born 8 June 1820 in the small town of Collins, Erie County, New York, 15 miles south of Buffalo. He probably began the study of medicine in 1840 as an apprentice to a practitioner in Buffalo. According to the annual Buffalo City Directory, Arnold was a "Medical Student" with M.W. Hill, a "Botanical Doctor," in 1840 and 1841. He attended Allegheny College in Meadville, Pennsylvania, as a Preparatory Student for one year in 1842. He was enrolled as a first year college student for part of 1843 before dropping out. He appears only once more in the Buffalo City Directory in 1844 when he is listed simply as a "Medical Student."^[15][16]

If and where he received an MD degree are unclear. The History of Peoria County records that he "attended for a considerable time the New York College of Surgeons;" that "he commenced the practice of Medicine at Springville, New York, with Dr. Emmons;" and that "in the Spring of 1847 he emigrated to Galveston, Texas, remaining there but one year, when he removed to Peoria and resumed the practice of medicine. . . "

The actual date of Arnold's arrival in Peoria is unknown although it was obviously prior to April 1848 because he was sufficiently established in practice by that time to be included among the six physicians who organized the Peoria District Medical Society. He was not a founding member of the Illinois State Medical Society that first met in Springfield in 1850, but he became a member of that Society when it convened in Peoria in 1851 for its First Annual Meeting. On that occasion he was listed as a delegate from the Peoria Medical Society.

Presumably he was primarily engaged in general practice as were virtually all physicians in Peoria, but it is evident from his appointment to the State Society's Committee on Surgery in 1853 that he also did some operating. This would have put him into competition with the hard-driving Cooper who considered himself a specialist in surgery and scorned dilettantes in his field, as he would have deemed Arnold to be.

A tall, slender man of a lively social turn of mind, Arnold is said to have enjoyed the esteem and confidence of all with whom he came in contact, and was rewarded by a flourishing practice. He had a delicate constitution and throughout his adult life suffered from what would now be termed latent tuberculosis. His tastes ran more to political affairs than to the intricacies of medical science, and this was reflected in his approach to professional matters. In fact, as his career unfolded, his interest and forte proved to be not medicine, but politics. He was a Whig and, when the Party dissolved, he cast his fortune with the Republicans. He campaigned for public office and in 1854 was elected to the Illinois State Senate where he served four years. In 1859 he was elected mayor of Peoria and served one year. During the 1840s and 1850s Abraham Lincoln emerged as the "wheelhorse" of the Whig and Republican Parties in Central Illinois and Arnold became his personal friend. This led in 1861 to Arnold's appointment by President Lincoln as Consul to St. Petersburg, Russia. Arnold left Peoria for his foreign post in May 1861. When the rigors of the Russian winter proved too severe for his fragile health, he was forced to return to Peoria in the spring of 1862. There, after a protracted illness, the Honorable John D. Arnold died of consumption in April 1863 at the age of 43.^{[17][18][19][20]}

According to a schoolteacher who was raised on a small farm north of Peoria, the country around the homestead where her family settled in 1838 was a wasteland broken only by distant groves of trees. She recalled that:^[21]

According to local tradition, one of the first settlers on Spoon River in what is now Stark County was a very religious man. He had great faith in the power of prayer, but he was also a practical man and never asked God to do the impossible. Among his petitions to the Almighty was the fervent request that a doctor be sent to the settlement where he and his family lived; that the doctor would be devoted to his work and labor for the benefit of the people; and that he would be accompanied by a well-educated wife who would be interested in the wives and daughters of the settlers. When in 1837 Dr. Thomas Hall arrived on the Illinois frontier, bringing with him his wife and family from England, it was regarded as undeniably an answer to the old settler's prayer.^[22]

Doctor Hall was born on 12 March 1805 near Hulland in Derbyshire, England, where he attended a local grammar school. Following apprenticeship under a practitioner in neighboring Stafford County, he studied at the Royal College of Surgeons in London, graduating as a doctor of medicine and surgery in 1828. His diploma bore the names of Sir Astley Cooper and Dr. John Abernethy, two of the best known medical men in England at the time. "When the young Dr. Hall was leaving home to begin life and practice for himself, his good mother followed him to the gate, and laying her hands lovingly on his shoulder said to him 'Tom, do your duty by all, but especially remember the poor'."^[23]

After nearly ten years of active and successful practice in his native county of Derbyshire, Dr. Hall had a wife and four children, and a desire to seek a new home for them on the American frontier in Illinois where two brothers and a sister had settled the year before. In 1837 he embarked for America, the land of promise, accompanied by his own family, his father and mother, and his sister, her husband and their five children. Overcome by sea sickness on the Atlantic, his mother died a few days before the ship reached New York and was buried at sea. An exhausting and hazardous journey inland still lay ahead for the sorrowing party of five adults and nine children. They traveled northwest by boat up the Hudson River; by way of the Erie Canal, and Lake Erie to Cleveland, Ohio; thence by boat on a canal to the Ohio River; and, from there, down the Ohio, and up the Mississippi and Illinois Rivers to Peoria, then only a hamlet on the west bank of the Illinois River where it widens to form Lake Peoria. The final stage of the odyssey, by horse and ox-drawn wagons, brought them to a happy reunion with Dr. Hall's brothers and sister at the frontier settlement of Osceola, 35 miles north of Peoria. The settlement was in open country later to become Stark County.

Assisted by his brothers and his father, Hall built a log cabin for his family including an office for himself. At the age of 32, and having "brought with him a library of choice medical works and surgical instruments of the most approved pattern then known to meet every emergency," he began the practice of his profession without delay. In 1842 he moved with his family ten miles south to the village of Toulon which had become the county seat, and from there he continued his peripatetic practice. We have already learned of the respect and affection in which he was held by his patients. He continued to serve them until incapacitated by the infirmities of age. Only a few days before his death he remarked to some of his friends, "I am not afraid to meet my mother, for she knows that I have done as she told me." Here was a man whose criticism Cooper was bound to respect.^[24]

Cooper found in the Peoria and the State Medical Societies a welcome forum for the scientific papers that he now began to produce regularly.

We have already mentioned the first publication of his career, a paper entitled "Remarks on Congestive Fever" printed in 1849, on which paper he prematurely listed himself as "E.S. Cooper, M.D.," two years before he actually received a medical degree from St. Louis University in 1851. He presented a second paper, entitled simply "Congestive Fever," at the Peoria Medical Society and published it in 1850. Since both these papers were reviewed at the First Annual Meeting of the Illinois State Medical Society in 1851, we shall defer comment on them until we take up Cooper's participation in that meeting.

We learn from the Minutes of the Peoria Society that Cooper was a frequent contributor to their scientific program. His topics were:^[25]

• 1850 -Congestive Fever
• 5 Dec 1852 - Diseases of the Eye
• 7 Jan 1853 - New Operation for Congenital Scrotal Hernia
• 20 Feb 1853 - Treatment of Vaginal Ulceration
• 5 Mar 1853 - Surgery of Oceanea as Practiced by Natives
• 16 Jul 1853 - Surgery of the South Sea Islands
• 1 Apr 1854 - Treatment of Diseases of Hip Joint

As far as we can determine none of these presentations, except for that on "Congestive Fever," was ever published. They are listed here primarily to illustrate the range of his interests at the time and the fact that he enthusiastically supported the educational efforts of the new Society. We shall return to consider the disciplinary action taken against him by the Peoria Medical Society after we have reviewed his substantial contributions to the early history of the State Society, beginning with the Medical Convention at which the Society was founded.

The American Medical Association at its Second Annual Meeting, held in Boston in May 1849, adopted the following resolution:^[26]

In response to Resolution 5, the doctors of Illinois responded decisively. Forty-nine physicians from around the State assembled in a Medical Convention in Springfield, the State Capitol, on 4 June 1850. On the first day of the meeting, under the presidency of Rudolphus Rouse of Peoria, the Convention proceeded with clockwork precision to resolve into a Committee of the Whole; ratify a Constitution; declare itself the Illinois State Medical Society; elect officers for the ensuing year; appoint Standing Committees; and adopt a code of Medical Ethics based on that of the A.M.A. By any standard, a remarkable day's work.^[27]

While engaged in these heady organizational proceedings, Cooper was uncomfortably aware that he had not yet obtained an MD degree, or even attended a medical school (although, as we have seen, he had been signing himself as "M.D." since 1849). His position in this regard was now quite untenable because of the following resolution that had also been adopted by the A.M.A. at the Boston meeting in 1849:^[28]

The Transactions of the recently established A.M.A. were of extraordinary interest to the medical profession. Thus there can be no doubt that Resolution 6 came promptly to Cooper's attention and that he grasped the importance of his obtaining a legitimate MD degree as soon as possible. Accordingly, he took the steps necessary to acquire an MD ad eundem from St. Louis University in March 1851, just in time to avoid an embarrassing exposure by the strict constructionists of the Illinois State Medical Society at the forthcoming First Annual Meeting.

Cooper was one of the 49 founding members of the State Society. During the organizational meeting he was appointed to the Society's Standing Committee on Surgery, chaired by the dean of Illinois surgeons, Professor Daniel Brainard of Rush. Appointment to membership on this three-man surgical committee was a significant mark of recognition for the 30 year old Cooper. He was also named to the important Standing Committee on Arrangements which was charged with preparing for the First Annual Meeting of the Illinois State Medical Society to be held the following year in Peoria.

In order to trace Cooper's further involvement in the affairs of the Illinois State Medical Society, we shall summarize his participation in each of the annual meetings from 1851 through 1854.^[29]

Cooper was a member of the Committee on Arrangements that organized the program for this First Annual Meeting of the Society. During the meeting he was elected as an Alternate Delegate to the next meeting of the American Medical Association.

Also during the meeting Cooper proposed the following Resolution on Dissection to which we referred earlier:

The preamble and resolution were adopted and the following gentlemen were appointed as the Committee on Legalizing Dissections: Drs. E.S. Cooper (Chairman), J.C. Frye and William Chamberlain.

Two of the earliest scientific papers to be published by Cooper in a medical journal were reviewed at this meeting by the Society's Committee on Practical Medicine in an "elaborate report" read to the assembled Society, which must have been very gratifying to the author. The first of these two papers, entitled "Remarks on Congestive Fever," was published in two parts in the St. Louis Medical and Surgical Journal in 1849 and 1850. The paper is a report of three fever patients two of whom died. One of the deceased was autopsied by Cooper and the findings are reported. The second paper, entitled "Congestive Fever," was published in the North-Western Medical and Surgical Journal for November 1850 and is a report of three additional fever patients, one of whom died but was not autopsied. All six of Cooper's patients, diagnosed by him as suffering from "Congestive Fever," undoubtedly had malaria, the endemic pestilence that ravaged Illinois during Cooper's era, as we previously discussed. Being of unknown origin at the time and often fatal, speculations as to the cause and management of malaria were the subject of innumerable journal articles and textbook discussions that consisted chiefly of futile theorizing as to etiology and of frustrated groping for effective therapy.^[30][31]

Cooper's finding of venous engorgement in brain, heart, lungs and liver of his autopsied patient, whom he diagnosed as having died of "Congestive Fever," convinced him that "general internal venous congestion" was specific to the disease. This was a common hypothesis at the time and led to the frequent use of blood-letting to relieve the "congestion" as a primary mode of treatment, as we have seen. Quinine was not yet recognized as the ultimate specific for malaria. Nevertheless, it was being generally accorded a regular but rarely exclusive role in therapy. Cooper's regime in the autopsied patient had consisted of "brandy, quinine, camphor, calomel and morphine, in large and frequent doses; mustard poultices extending from ankles to knees and from wrists to elbows; bottles of hot water to the sides; and a large quantity of bruised horseradish to the region of the stomach and bowels. The pulse rose a little, and the skin became somewhat warmer under this treatment, but (the patient) died in a few hours."

Cooper's inclusion of large doses of quinine, and his exclusion of blood-letting and purging, in the treatment of his patients are the most notable features of his papers. They otherwise consist of tortured reasoning about the relationship of different degrees of "internal venous congestion" to various clinical manifestations of "congestive fever." For example: "Symptoms vary, owing to the part or parts which may be the seat of congestion, and the internal remedies have to be modified accordingly - thus in congestion of the veins of the liver and mesentery, there will be vomiting and purging; and should these organs be the principal seat of congestion, quinine would be of little avail during the paroxysm. The remedies in this case, should be calomel and opium, with brandy and the application of hot air, etc., etc."

Deficiencies in medical knowledge and practice in the mid 1800s as compared to the present are once again cited here not to belittle the doctors but to enable us to understand the difficulties they faced, and to entertain the thought that present-day physicians, provided with only their limited information and resources, would have responded to conditions much as they did. When Cooper boldly addressed the "fever question," the foremost medical problem of the period, he had never taken a course in a medical school. If he had, it would have made no difference to the outcome in his patients, except that he probably would have harmed them further by insisting on bloodletting.

Professor Brainard and the other member of the Standing Committee on Surgery failed to arrive at the Society meeting. Therefore, Cooper was called upon to make a report for the Committee, which he was happy to do. He had wisely brought with him a scientific paper he hoped to get on the program if time allowed. His presentation was on a subject far more congenial to his interests than "Congestive Fever." He spoke on the topic of "Chloroform in Surgical Operations."

At the time of the State Society meeting in 1851, general anesthesia was a recent innovation. Ether had been administered by a dentist, W.T.G. Morton, for an operation performed by Professor Warren at the Massachusetts General Hospital in October 1846. A year later, chloroform was introduced for childbirth by Professor Simpson at Edinburgh in November 1847.^[32][33]

There was immediate worldwide interest in these agents and reports of their use in childbirth and surgery promptly appeared in the medical journals of the Old Northwest. Cooper at once recognized the immense significance of these developments and was among the earliest in the region to experiment with general anesthesia. He reported that he "had an opportunity of testing the effects of Chloroform as an anaesthetic agent in seventy-nine cases of Surgical operations since the organization of the State Medical Society (in 1850)." He pointed out that, although most of the operations were minor, they nonetheless demonstrated the effectiveness of chloroform in producing insensibility. He further stated that, although there were no fatalities in his series of cases, a complication occurred in one patient which was the principal reason he decided to report on the subject of chloroform anesthesia. He then went on to describe the following harrowing incident:^[34]

Cooper's patient had suffered a cardiac arrest due to the paralyzing effect on the heart of chloroform administered in too high a concentration. He correctly inferred that the risk of this disastrous cardiac complication could be minimized by gradual administration of the agent while always assuring ample inspiration of room air. To test this conclusion, he later recalled Mrs. M. C. whose operation for strabismus he then performed without incident under chloroform anesthesia delivered in accordance with the above precautions.

The significance of Cooper's paper lies in his warning of the lethal potential of chloroform, then being widely and indiscriminately used by inexperienced practitioners. Soon after Professor Simpson's report in November 1847 "On an anaesthetic agent, more efficient than sulfuric ether," chloroform was being hailed In Europe and America as the agent of choice for general anesthesia in preference to ether, over which it indeed had many advantages. Ether is irritating to the air passages; has a disagreeable and lingering odor; is highly flammable; and is slow in action. On the other hand, chloroform is well tolerated by the airways; has a not unpleasant odor, is not flammable; and is ten times as potent as ether. Yet, ominously, within a few months of the introduction of chloroform, reports of sudden death during its administration for minor operations began to come in from around the world. First, in January 1848, a girl of 15 at Newcastle-upon-Tyne suddenly collapsed and died during removal of a toenail; next, in February 1848, a woman of 35 in Cincinnati died during extraction of teeth; then a young woman in Hyderabad died during excision of the end of a finger; followed by death of a woman aged 30 at Boulogne; a man from Glasgow; a boy of 17 at Lyon, and a laboring man at Westminster. These patients were cited in a classical paper "On the fatal cases of inhalation of chloroform" by Queen Victoria's anesthetist, Dr. John Snow of London, the first physician to devote his full time to the practice of anesthesia. Snow's sobering article was published in the Edinburgh Medical Journal in July 1849, just over a year and a half after the introduction of chloroform.^[35]

Although Snow demonstrated by personal experience that chloroform could be administered with relative safety by controlling the dosage of the vapor with a suitable inhaler, its deadly potential for arresting the normal heart led within a decade to its progressive decline in favor. Ether then became for many years the agent most widely used for general anesthesia until replaced by better drugs. As for Cooper, he continued to prefer chloroform until ten years later in 1861 when he wrote:^[36]

A myth has grown up that attributes to Cooper the first use of chloroform for surgical anesthesia in the Old Northwest, but Cooper himself made no such claim.^[37][38] In fact there is no record of the specific dates on which his operations were performed. He stated in his paper that his 79 cases had been done "since the organization of the State Medical Society." That is, after 1850. From a review of regional journals it seems likely that both Professor Brainard of Rush in Chicago and Professor Mussey of Ohio Medical College in Cincinnati both used ether and chloroform well before 1850, and were the first to administer these agents for surgical anesthesia in the Old Northwest.

Professor Brainard first used ether anesthesia when he performed two surgical procedures - amputation of a finger and resection of metatarsals - in January 1847, only 3 months after the introduction of ether at Boston in October 1846.^[39] In a second report, published in October 1847, Brainard said that "We have lately used (ether) for the extirpation of two cancerous breasts, extirpation of tumors, opening of abscesses, strabismus, etc., with most satisfactory results."^[40]

With respect to Brainard's use of chloroform, it was reported in December 1847, only one month after this agent was introduced in Edinburgh, that he had already performed several operations under anesthesia with chloroform which had been manufactured by Professor Blaney in the laboratory at Rush Medical College.^[41]

R.D. Mussey, Professor of Surgery at Ohio State Medical College, reported in September 1848 that he had "employed etherization in the amputation of all the members belonging to the human body" and various other operations such as excision of tumors, lithotomy and reduction of dislocations. Regarding his use of chloroform, Mussey said that soon after the announcement of Dr. Simpson's experiments with the agent had reached him, he proceeded to try it without hesitation in 38 surgical operations, and saw no unpleasant reaction in a single instance. The operations performed under chloroform included such procedures as removal of tumors, amputations, strangulated hernia, etc. Mussey cited the deaths from chloroform at Newcastle-upon -Tyne and Cincinnati to which we have already referred and attributed them to improper procedures in administering the agent. "On the whole", he concluded, "I regard the inhalation of chloroform for surgical operations, administered with due precaution, as entirely safe; and I look upon it as a boon of inestimable value, presented by Chemistry to our profession under the guidance of Providence."^[42]

These references to the use of ether and chloroform by Drs. Brainard and Mussey illustrate the rapidity with which the agents were incorporated into surgical practice even in the relatively undeveloped western section of the country. The evidence suggests that these two Professor of Surgery in the leading medical schools of the Old Northwest were the earliest to employ ether and chloroform in the region and that Cooper was not, as local tradition would have it, the first in the area to use chloroform. Nevertheless, Cooper's substantial series of 79 patients operated under chloroform anesthesia in the provincial town of Peoria, and his timely emphasis on the agent's lethal properties, bespeak his capacity for leadership in the new era of surgery that began with the advent of general anesthesia.

Cooper's presentation on chloroform anesthesia at the first annual meeting of the State Society was the only scientific paper delivered during that meeting at the initiative of an individual member.

Elias Cooper attended this meeting of the State Society as an elected Delegate of the Peoria Medical Society. On the first day of the meeting Levi Cooper Lane from Henderson, was elected a Permanent Member of the State Society on the recommendation of his Uncle Elias, thus establishing Lane's presence in Illinois in 1852.

As evidence of increased recognition of Cooper within the State Society, we find him appointed during this meeting to the Committee on Unfinished Business; to the Nominating Committee for Society Officers for the ensuing year; and to the Committee on Surgery for the ensuing year. He was also elected as First Secretary of the Society for the ensuing year, and as a Delegate to the A.M.A. at its next meeting to be held in New York in May 1853.

When Cooper was called on to report for the Committee on Legalizing Dissections, he pointed out that the Committee was charged to memorialize the Legislature rather than to submit a report to the Society. As already noted, we have no information on the steps the Committee may have taken to influence the Legislature. In any case no legislative action was taken on this subject until years later.

Cooper and Levi Cooper Lane were the only members of the Society, except those submitting reports of Standing Committees, to present papers on their personal scientific observations. Lane was unable to attend the meeting and Cooper read his paper for him. The papers by Cooper and Lane, published as Appendixes of the Transactions, are summarized here briefly to indicate the modest level of scientific communications at the meeting.

Entropion is inversion or turning inward of the margin of the eyelid bringing the eyelashes into contact with the eyeball and causing pain, irritation and possible corneal abrasion. Collodion is prepared by dissolving pyroxylin or gun cotton in ether and alcohol. When applied to the skin it dries rapidly, forming an adherent glossy contractile film that contracts the underlying skin. This short communication describes the effectiveness of collodion, painted along the cutaneous margin of the eyelid, in reversing inversion of the lid by contracting the underlying skin. Cooper, who took a special interest in diseases of the eye, considered the collodion method of treating entropion to be original with himself:

Although collodion is no longer listed among the now more sophisticated methods of treating entropion, it may well have had a temporary palliative value in Cooper's day.

Urethral strictures in men caused by gonorrhea, a common problem in the pre-antimicrobial era, were dilated by catheters and curved metal probes of various sizes passed down the urethra. When dilatation failed because of denseness of the stricture, it was common practice to apply a caustic via catheter to the strictured area in order to soften the contracted tissue and facilitate its dilatation. In this communication, Cooper described an instrument of his own design for this purpose. The instrument had the shape of a common catheter but was made of copper and perforated with small holes at its distal end:

Its mode of application is as follows: Having it well oiled, it is introduced as far as the stricture; after which, a solution of nitric acid and water is poured into it, which, passing down the holes, throws out to the parts corresponding the nitrate of copper just formed by the union of the acid and the copper. The degree of cauterization will be graduated by the strength of the solution and the length of time it is permitted to remain.

Cooper designed several models of the copper instrument for different types of stricture and also shaped its mouth like a funnel more freely to receive the caustic. He recommended his invention as easy to fashion by coppersmiths and convenient to apply by physicians, "especially in places remote from the largest cities."

John Hunter (1728-1793) was the British surgeon who elevated surgery to the status of an experimental science. Both he and the eminent French venereologist Philippe Ricord (1799-1889) used such caustics as silver nitrate to relieve resistant strictures. Cooper's copper tube was designed to facilitate the accurate application of a caustic solution. Nowadays sophisticated instruments passed down the urethra accomplish the same task with knife, cautery or possibly laser when dilatations alone are ineffectual.^[43][44]

Cooper's third paper to the Society concerned the treatment of orthopedic deformity which, like diseases of the eye, was a field in which he sought to cultivate referrals and establish preeminence in the region. He reported the treatment of three patients, two men and a little girl, who had marked chronic flexure of the knee joint which retained only the slightest motion, indicating that the fixation or "anchylosis" of the joint was almost but not entirely complete. By an ingenious apparatus consisting of splints, springs, rods and a boot, custom-designed for each deformity, he enabled the patient to walk. When bearing weight on the foot, pressure was transmitted through the apparatus to extend the knee joint which gradually straightened until the patient could walk again without crutches.

It is in the process of cure by walking that I claim originality in the treatment of these cases. Though many cures have been effected by gradual extension alone, or by extension and forced motion, a plan not new to the profession by any means, but one that must appear imperfect to all who are familiar with this class of deformities; since in many, if not a majority of cases, where anchylosis has been of 10 or 12 years standing, the limb is too weak to bear the patient's weight, even though the motion of the true joint was unimpeded.

Cooper was indeed an early advocate of the beneficial effects of weight-bearing in the management of orthopedic conditions of the lower extremities, a principle that later gained general acceptance. It is of further interest to note that he was always anxious to have his patients observed by other practitioners who could substantiate his claim of good results. In the case of his first patient with anchylosis of the knee joint (who consulted him on 26 January 1852), "The progress of cure, and the principles of treatment were frequently noticed by Drs. John L. Hamilton, J.T. Steward, W.R. Hamilton, and L.C. Lane, of Peoria."

Cooper read this paper at the meeting on behalf of Lane.

After stating the important principle that a wound associated with irregular laceration and heavy bruising heals poorly, Lane made the point that surgical excision of dead and badly damaged tissue leaves behind only viable normal structures capable of rapid healing. He then cited the case which led him to that conclusion - a 34 year old German bootmaker who on 31 December 1851 received a violent wound from the explosion of a gun in his hand, blowing away its palmar surface:

This rather elementary case report conveys two pertinent messages: Cooper was a gifted surgeon able to act intuitively on a basic surgical principle generations before its many applications were fully appreciated: and Lane was associated with him in practice in Peoria in December 1851.

The Society met in the Common Council Chamber of the City of Chicago and, in the absence of President Rouse (from Peoria Medical Society), the meeting was called to order and its preliminary session conducted by First Vice President Thomas Hall (from the Stark County Medical Society). Pursuant to the recommendation of the Committee for Nomination of Officers, Professor Daniel Brainard of Chicago was elected President of the Society and took the chair as presiding officer for the remainder of the meeting.

Delegates from the Society to the next annual meeting of the A.M.A. to be held in St. Louis in May 1854 were elected and Thomas Hall of Toulon was among those chosen.

During the Society's administrative deliberations, Elias Cooper took no significant part but, as before, he contributed to the scientific program by reading a paper. His presentation on "Medical and Surgical Diseases of the Eye" was discussed by Drs. Hall and Brainard. Unfortunately, this paper was not reproduced with the Transactions as was the case with his previous contributions, and a search of the medical literature did not locate its publication elsewhere.

It was at this Chicago meeting of the State Society that Cooper's opponents, Drs. Arnold and Hall, planned to bring against him the charge of unethical practice and call for his expulsion because he "advertised" his hospital in the public press. We shall return shortly to this issue.

Elias Cooper attended the A.M.A. meeting in St. Louis as a Delegate from the Illinois State Medical Society. However, according to the Minutes for the 1853 meeting of the State Society, he was not among the delegates elected to represent the Society in St. Louis. Dr. Thomas Hall was elected by the Society as a delegate to the St. Louis Meeting of the A.M.A. but did not attend. The Minutes of the 1852 meeting of the State Society show that Cooper was elected to serve as a delegate from the Society to the A.M.A. at its New York meeting in May 1853 but, according to the A.M.A. Minutes, he was not present. These data are cited merely to clarify the record with respect to Cooper's attendance at meetings of the A.M.A. As far as we can determine, Cooper attended only one A.M.A. meeting - that held in St. Louis in May 1854.

Cooper's surgical teacher, Professor Charles Pope, Dean of the Medical Department of St. Louis University, was elected President of the A.M.A. at the St. Louis meeting and presided over the sessions. This must have been a pleasing development for Cooper who no doubt took the opportunity to renew his friendship with Dr. Pope, and to revisit the familiar environs of his alma mater, the St. Louis University. Perhaps it was in part to this congenial ambiance that Cooper owed the signal recognition he received during the meeting. He was elected Chairman of the Committee on Orthopedics of the A.M.A. with the responsibility to report on the status of the specialty in the United States at the next meeting. For a surgeon from Peoria, without the aura of a large metropolitan practice or an academic title, to be elected to such a chairmanship suggests a far more than local appreciation of his work.

Two months later, in order to gather information for his report on orthopedic surgery, Cooper wrote the following letter:^[45]

The American Medical Association met for its Eighth Annual Meeting at Philadelphia, 1-4 May 1855. During the meeting there was a call for the Report on Orthopaedic Surgery by Dr. E.S. Cooper of Peoria. He was not present at the meeting and no report was submitted. He had left Peoria for the Pacific Coast the month before.

Dr. Cooper's participation in the routine business of the Society was minimal during this meeting The Minutes record no participation by him in any of the decisions. It is as though organizational issues and parliamentary maneuvering had lost their attraction for him. Perhaps in deference to his seniority in the Society, he was again elected as a delegate to the A.M.A. at its next meeting to be held at Philadelphia in May 1855.

As usual he contributed to the Society's scientific program. On this occasion he read a lengthy paper, published only in the Transactions, with the following wordy title: "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."

This paper is essentially a defense and further documentation of the effectiveness of the apparatus and methods previously described in the paper on "Incomplete Anchylosis of the Knee Joint" which Cooper presented to the Society in 1852, and which was later criticized severely in the medical press. For example, the editors of the Western Medico-Chirurgical Journal, organ of the Iowa State Medical School in Keokuk (an institution not unknown to Cooper), sent him a copy of that periodical containing a review of the anchylosis paper which conceded the apparatus to be Cooper's invention, but considered it worthless. An editorial in the Philadelphia Medical News and Library claimed that Cooper's methods had already been in use for many years, but the editors never supplied any reference to prove their point. To which Cooper responded:

Cooper's championing of progressive weight-bearing (walking) and joint mobilization, controlled by appropriate apparatus, and his insistence that these activities are essential to musculoskeletal development and restoration of function, find their counterpart in modern orthopedic practice - with the use of sophisticated "apparatus" that would have fascinated him. Current methods affirm basic principles he long ago espoused.

In one arena after another, Cooper was proving to be forward-looking, firm in his convictions, and self-assured in confronting his adversaries.

Cooper is not mentioned in the Minutes of the meeting. His name does not appear on the List of Members of the Society published in the Transactions - nor do the names of John D. Arnold and Thomas Hall. Cooper had arrived in San Francisco on 26 May 1855.

When Cooper printed notices in regional newspapers in the fall of 1851 describing the services available in his Peoria Infirmary, he embarked on troubled waters. The recently founded American Medical Association made strict adherence to its Code of Ethics a condition of legitimacy for physicians and medical organizations alike. The Peoria County and Illinois State Medical Societies adopted the Code which, among other restrictions, proscribed advertising. It was the responsibility of the Societies to interpret and enforce this ruling which they proceeded to do. Certain influential members of the Societies claimed that Cooper's newspaper notices regarding his Infirmary were "advertising;" that they were therefore unethical; and that he should be censured.

Cooper's dispute with the Peoria and the Illinois State Medical Societies over his newspaper notices was so complex and lengthy that we have deferred discussion of it until now when we have completed our summary of the founding and early meetings of these two organizations.

The first phase of the convoluted process that eventually ensnared Cooper began in June 1851 at the First Annual Meeting of the Illinois Medical Society. This meeting was about six months prior to Cooper's wide publication in regional newspapers of notices regarding his Infirmary. During the meeting a Resolution was introduced before the State Society to the effect that the time had come when the people of the State of Illinois ought to regulate, by statutory enactment, the qualifications of those who practice medicine and surgery (i.e., require that every practitioner have a bona fide MD degree). In addition, the Resolution enjoined the Society to take any other necessary steps (these would include suppression of advertising) to protect the good name of the profession:^[46]

Dr. Thomas Hall of Toulon was a member of the committee of three elected to implement the Resolution. As a result of his membership on the committee, Dr. Hall shared with the other two members the role of guardians of ethical standards for the Society, a responsibility he took very seriously - as one might expect from his background that he would.

It was a year later, at the June 1852 meeting of the Illinois State Medical Society, that the following incident occurred relevant to the Infirmary notices Cooper had then been publishing for the previous 9 months.

By an unfortunate coincidence, Dr. J.W. Halsted, an Oculist in neighboring Stark County, was carrying out a newspaper campaign of his own simultaneous with that of Cooper. This is Halsted's notice:^[47]

Dr. Hall, who was the delegate of the Stark County Medical Society to the 1852 meeting of the State Society, called the State Society's attention to Halsted's notice, which was in some respects similar to the notice that Cooper was running in newspapers at the same time. Hall reported to the State Society that the Stark County Society found Halsted's notice to be a form of advertising and offensive to ethical practice. The Society demanded that he withdraw it. When he refused to do so, Halsted was expelled from the Stark County Medical Society which now wished the opinion of the State Society on the propriety of the action they had taken. After considerable discussion, the members of the State Society voted that "such advertisement is a sufficient ground for expulsion," and adopted the following resolution:

Thus the ground was laid and the precedent established for a move to expel Cooper from the State Society for running a similar ad. What back-stage maneuvers took place at the State Society meeting in 1852 to censure Cooper, or to begin recruiting a consensus for such action, we do not know. However, later events suggest that the Halsted expulsion was a dress rehearsal for an attack on Cooper.

Cooper was aware of the implications for him of the action taken in the Halsted case; but he did not anticipate the circumstances under which open hostilities would break out. When the attack upon him came a year later on his home ground in Peoria, it took him by surprise. The circumstances were as follows. The Peoria County Medical Society met on 1 June 1853 in the office of Dr. Hamilton to transact routine business, including the election of delegates to the forthcoming meeting of the State Society to be held at Chicago 7-9 June 1853. The Minutes of the Peoria Society provide the following account:^[48]

When Cooper departed for the June 1853 meeting of the State Medical Society in Chicago, he was under the impression that his arraignment and acquittal before the Peoria Society only a few days previously had settled the advertising issue. In this assumption, he was sadly mistaken for he underestimated the vindictiveness of the clique determined to discredit and humiliate him.

Cooper was no stranger to conflict over his professional activities in Peoria where he had already faced down strident critics of his dissecting. But the coming challenge was far more serious for it threatened to undermine his professional "honor." The success of his Infirmary and surgical practice; his intense competitiveness tinged with a certain arrogance of opinion; and his flouting of conventional ethics by running newspaper notices regarding his Infirmary had provoked a malignant combination of jealousy and self-righteous zeal among a few of his erstwhile colleagues. He was soon to be introduced at the State level to the fratricidal infighting for which the medical profession of the day was notorious.

At this point we must call special attention to the fact that the Minutes of the June 1853 meeting of the State Medical Society do not so much as mention that charges of unethical behavior (advertising) were brought against Cooper during the meeting. Lack of record on this subject is not surprising since such information was commonly not included in medical society minutes unless some action was taken - and we assume that there was no formal indictment of Cooper's behavior by the State Society. Thus we have only Cooper's word that an attempt was made during the June 1853 meeting to expel him from the Society.

His version of the incident is detailed in the following lengthy and caustic letter to the President and Members of the State Society for consideration by the Society at its Fourth Annual Meeting to be held at Lasalle 6-7 June 1854. The letter reveals a determined and self-assured man (he was thirty-three), independent in thought, unafraid of controversy, and formidable in polemic. He claimed the right to inform the public directly about his Infirmary, based on the important specialized services it made available to the region; and he rejected the authority of a medical society to deny him that right.

The following letter from Cooper to the President and Members of Illinois State Medical Society, long and rambling though it may be, merits recording here in full for it reveals in Cooper's own emotional words his concept of specialization, the vexing realities of small-town specialty practice, and a combativeness to which we shall become more accustomed as we follow his career.^[49]

Here ends the controversy over Cooper's advertising of his Peoria hospital, as far as we can determine from existing records. In the absence of evidence that the State Medical Society took any action in the matter during either its June 1853 or its June 1854 meeting, we can assume that Cooper's cogent arguments and his vow to desist from further advertising were persuasive and led to a dropping of the complaint. Whether he learned from this experience that future advertising would likely again expose him to the censure of his medical colleagues is an interesting question. In the light of similar charges against him during the California phase of his career, we might be tempted to believe that the Peoria lesson was lost on him. On second thought, it seems more likely that the keenly perceptive and strong-willed Cooper simply meant it when he said:

This Manifesto and defiant challenge of the established order has about it the ring of conviction and an uncanny prescience. Cooper was simply ahead of his time, as is clearly evident in these excerpts from the A.M.A. Code of Ethics, as interpreted in 1989 by its Council on Ethical and Judicial Affairs:^[50]

Cooper would have had no difficulty operating within modern guidelines. Today's ethical codes allow publication, freely through all media, of advertisements and other releases by physicians, hospitals and health service organizations provided they are not deceptive or contain false, misleading or confidential information.

The enterprising spirit, moral courage, stubborn individualism and surgical talent that Cooper demonstrated during his Peoria years were attributes that fitted him uniquely for his California venture. By the time he left Peoria he was a hardened veteran of professional competition and intrigue. In consequence, when he arrived in San Francisco in May 1855, he was prepared to embark with scarcely a day's delay upon the vigorous execution of his plan to found a medical school.

As we have seen, Cooper's plan had been quietly germinating throughout his sojourn in Peoria. By mid 1854 he was ready to carry out its first phase comprised of visits to medical centers in Britain and France - a pilgrimage that would not only expand his knowledge of medical education and surgery, but also enhance his stature in the profession.

Our first indication of his planned departure for Europe is found in four letters written by the highly respected Nathan S. Davis, MD, Founder of the A.M.A., Professor at Rush Medical College and Editor of the North-Western Medical and Surgical Journal. These letters, dated 1 and 21 September 1854, were addressed to prominent surgeons at the College of Physicians and Surgeons in New York and at New York Hospital. Davis's message to each of these surgeons was substantially as follows: "I write to introduce my friend, Dr. Cooper of Peoria, who will be traveling to Europe and wishes to stop over in New York for a few days to observe your work." This would be Cooper's first journey east of the Alleghenies.^[51]

We have already referred to his transatlantic voyage on the Arabia from New York to Liverpool 4-14 October 1854. The only reliable information we have about Cooper's itinerary in Europe is found in the Diary of his younger brother Jacob who was at Edinburgh when Elias arrived in Britain. On 18 October Elias joined Jacob in Edinburgh for a joyous reunion. After three days in Edinburgh, Elias went down to London on 21 October where he spent nine days making contacts with eminent surgeons before crossing the Channel to Paris on 30 October. While in Paris, Elias became ill with "dyspepsia" which was of such concern to the tenderhearted Jacob that he went to Paris on 22 November to be with his ailing brother. A few days after Jacob's arrival in Paris, Elias received word from Peoria that his presence there was much needed to look after his business affairs. Although Jacob had planned to remain longer in Europe, Elias much desired his company on the voyage home and Jacob agreed. Thus Elias, after a month in Paris that was marred by persistent abdominal complaints, departed with Jacob for London on 30 November. During their stay in London from 1 to 7 December, Elias felt so much better that he again visited hospitals and principal medical gentlemen. Meanwhile Jacob went sightseeing until December 7th when he made the following entry in his Diary: "This day completed my twenty-fourth year! I can scarcely believe I am so old for I have done so little. . . Left London at 7 A. M. on the . . . Parliamentary train bound for Liverpool. The distance 200 miles. Arrived in Liverpool at 8 P.M." On December 9th he and Elias embarked on the S. S. America, a Cunard steamer bound for Boston where they arrived on 25 December 1854.^[52]

During his European interlude of 57 days from October 14th to December 9th, 1954, Elias while in Edinburgh attended the Clinics of Symes and Miller. In Paris he observed the methods of Velpeau, Jobert, Nelaton and Ricord. The dexterity of the French surgeons impressed him, but he found deficiencies in their pre and postoperative care which in his view contributed to their less than optimum results. In London, he visited the surgical services of Fergusson and Erichsen. Even brief exposure to the practice of internationally recognized surgical authorities and the surroundings in which they worked would be of significant benefit to a keen observer like Elias who was already familiar with their contributions to the medical literature.^[53][54]

The America docked at 10:30 A. M. on Christmas Day and at 1:30 P. M. Elias and Jacob were southbound on the Boston and New York Railroad. They changed trains in New York and headed west, arriving at the Cooper farm outside Somerville on 30 December 1854. On 9 January 1855 Elias took the train to Peoria, there to dispose of his hospital, close out his practice and prepare for the journey to California.

Dr. Armor, born in Pennsylvania in 1819, was Cooper's contemporary. He received his MD degree in 1844 from Missouri Medical College where he was a pupil of the controversial Joseph McDowell. In 1849 he became Professor of Physiology, Pathology and Jurisprudence in the Medical Department of the University of Iowa at Keokuk. When Cooper was offered the professorship of Anatomy at Keokuk in 1851, Professors Armor and Hudson had the delicate task of withdrawing the offer because of an administrative technicality, as we have already related. Neither Armor nor Cooper was likely to forget that unpleasant incident.

In 1853 Armor won the prize offered by the State Medical Society of Ohio for the best paper on the subject: "Zymotic Theory of the Essential Fevers." This brought him to the attention of the trustees of the Medical College of Ohio who offered him the chair of Physiology and Pathology, which he accepted. This is how Armor chanced to be located in Cincinnati when Cooper returned from Europe and called on him there to discuss their joining forces and migrating together to San Francisco.

After their meeting in Cincinnati, there was the following exchange of letters.^[55]

To which Cooper promptly replied:

(The letter ends here abruptly at the bottom of a page, and all the rest has been lost.)

What a dazzling prospect with which to tempt an adventuresome spirit, but it did not attract the hesitant Armor for whom California's greatest appeal was its climate. It was fortunate for him that he did not join Cooper who, above all, saw California as the land of the future where great deeds were possible for those with an abiding faith in their destiny. Had Armor teamed with Cooper, he would have found himself in harness with a tiger. Better for his peace of mind that he should spend the rest of his days gliding from professorship to professorship in established medical schools in the East, which he did - joining the faculty of Missouri Medical College in 1858, moving to the University of Michigan in 1863, and finally to Long Island Medical College in Brooklyn in 1866 where he became Dean in 1868. He continued on the Long Island faculty until his death in 1885.^[56]

Better, also, for Cooper that he should travel alone to California. His searing ambition and contemptuous disregard for the sensibilities of San Francisco's self-anointed medical elite would have strained relations with any partner except his devoted nephew, Levi Cooper Lane, whom Providence later sent at a crucial juncture to sustain him.

By early April 1855 Cooper had concluded his business affairs in Peoria and terminated his practice. Jacob, who was visiting Esaias in Henderson at the time, came over to Peoria by stagecoach on April 17th and was delighted to find Elias looking very well - indeed, he "never saw him better." But when Elias told him that he was on the eve of departing for San Francisco, Jacob was greatly distressed. On April 19th the sad and trying hour of their separation came and Jacob accompanied Elias to the railroad station. "I went with him into the car and there took my long - I greatly fear my last - farewell." Elias set out for New York quietly, leaving Peoria without even giving notice to friends, one of whom later wrote of his disappointment in finding Cooper no longer among them.

When Jacob returned to Somerville on May 10th he received news that must have eased his sadness over his brother's departure for the West. Awaiting him was a letter from Centre College in Danville, Kentucky, announcing his appointment as Professor of Greek in the College. Now that he had a good situation that would enable him to support a family, there was nothing in the way of his marriage to Caroline. They were wed on 31 May 1855.

On about 23 April 1855, Elias left New York on a steamer that carried him down the Atlantic Coast to Central America on the first stage of his journey to San Francisco. He chose the route that involved crossing the Isthmus through Nicaragua.

The discovery of gold in California on the American River in 1848 created the Gold Rush of 1849 and a massive wave of migration that Cooper now joined. There were three possible routes from the East to the Pacific Coast - by wagon train across the western plains and mountains; by sea around Cape Horn; and by sea to a crossing in Central America and thence again by sea to San Francisco. The route by way of Central American was the most rapid and convenient of the three, being the itinerary followed by an increasing proportion of passengers, mail and treasure from the gold fields. Until completion of the transcontinental railroad in 1869, the Central American route remained the preferred way for the ordinary person or message to travel between the Atlantic and Pacific Coasts.

At the time of Cooper's journey, Central America could be crossed either through Panama or Nicaragua. The southern crossing at the Isthmus of Panama was the shortest. The distance between the Atlantic and Pacific Oceans was only 47 miles, with less than 300 feet elevation at the highest point. Nevertheless the hardships and perils of crossing the Isthmus through malarious tropical swamps and rain forest by mule-back and shallow-draft boat made this route at first relatively unattractive. This changed when on 27 January 1855, after heroic exertions, the last track was laid on the Panama Railroad, and on the following day a locomotive passed over it from ocean to ocean. From that time forward, it was possible to cross the Isthmus in half a day in the comfort of a railroad car. This assured that the Panama crossing would eventually become more popular than the northern option through Nicaragua. Sixty years later the Panama Canal was excavated along the same route as the Panama Railroad. On 15 August 1914 the Canal was opened by the United States to the commercial vessels of all nations. Not only was the Canal the greatest construction project the world had ever seen, the practical eradication of malaria and yellow fever in Panama by controlling the mosquito vectors during building the canal was one of the greatest triumphs of sanitation in history.^[57][58]

Cooper chose to book passage on a shipping line that used the northern route. He landed in Nicaragua at San Juan del Norte on the Atlantic Coast then traveled by boat up the San Juan River and across Lake Nicaragua to its far shore, beyond which there was an overland trek of only 18 miles to San Juan del Sur on the Pacific Coast. Although the distance between oceans at Nicaragua was 174 miles as compared with 47 miles at Panama, all but 18 miles of the Nicaragua passage could be covered by boat. Also the higher latitude of Nicaragua was thought to make the climate cooler and tropical fevers less prevalent. The most obvious advantage of the Nicaragua route lay in its shorter over-all distance. The journey from New York to San Francisco via Panama was 5,245 miles; whereas it was only 4,871 by way of Nicaragua, a difference of 374 miles in favor of the northern crossing. This small advantage, however, was later more than offset by the convenience of rapid rail transit across Panama when that service became well established.^[59]

Competition between shipping lines carrying traffic on a fortnightly basis between New York and San Francisco was fierce, Bankruptcies, mergers and rate-wars were frequent. Passenger volume on the Panama and Nicaragua routes was closely watched. In 1855, 15,000 passengers traversed Panama and 11,000 crossed by way of Nicaragua. Fares fluctuated erratically according to the state of hostilities among the carriers so we are unable to determine with certainty what it cost Cooper to travel from New York to San Francisco. We do know that in June 1854 steamers via Nicaragua charged $ 225 for first cabin accommodations, $130 for second cabin and $ 75 in steerage. At that time the trip from New York to San Francisco required approximately 33 days (11 on the Atlantic and 22 on the Pacific leg).^[60]

On 4 May 1855 Cooper boarded the S. S. Sierra Nevada at San Juan del Sur on the Pacific. After 22 days at sea, steaming north off the Mexican and California coasts, his ship docked at San Francisco on Saturday, May 26th.

Cooper had the happy faculty of making interesting friends while on sea voyages. We have previously referred to his correspondence with the Honorable Hugh Keenan, U.S. Consul to Cork, Ireland, whom he met aboard the S.S. Arabia when on his way to Europe in October of 1854. He had a similarly pleasant experience in May of 1855 on the S. S. Sierra Nevada where he encountered a congenial fellow passenger named Captain James M. McDonald whose friendship and generosity continued throughout Cooper's life, and beyond. As sometimes occurs when facts are few and memories dim, an intriguing myth arose that attributed to Captain McDonald a decisive influence on Cooper's career. Stanford's Professor Rixford, a principal biographer of Cooper, wrote the following:^[61][62]

Professor Rixford did extensive research on Cooper's life, but the Rixford papers contain no hint of the origin of the "Captain Jim" legend. It is possible that Cooper himself was inadvertently responsible for the birth of this romantic fiction regarding his decision to settle in San Francisco. We have seen from his letters to Keenan and Armor that he was secretive about his plan to found a medical school in the city by the Golden Gate. Obviously these letters never came to Professor Rixford's attention. We assume that it was Cooper's reticence to speak openly of his seemingly quixotic plan to found a medical school in San Francisco that led to the poetic conception that he was bound for Oregon and that Providence in the person of Captain Jim influenced his fateful decision to disembark at San Francisco. We know that the Captain was a great admirer of Cooper, lent him money on very favorable terms, and was later a generous donor to Cooper Medical College.^[63]

In any case, the entire sequence of events somehow led to the fanciful "Captain Jim Story" that was reported in good faith by Professor Rixford. Under the circumstances, those who prefer to believe the appealing notion that it was Captain Jim who convinced Cooper to remain in San Francisco should feel free to do so - but should keep in mind that the now available evidence indicates that Cooper had long before made up his mind on his destination.

When Cooper visited Europe he was just 34 years of age but was already beset with early symptoms of the strange neurological and gastrointestinal disorder which was to bring his tempestuous career to a close in just 8 more years. Levi Cooper Lane made the following reference to the onset of Cooper's chronic and ultimately fatal disease in the Obituary he wrote in 1862:^[64]

Soon after coming to this coast, he was attacked with an obscure nervous affection, which manifested itself by an attack of left hemiplegic facial paralysis, and wandering neuralgic pains in the extremities, with indigestion.

There can be no doubt that facial palsy accompanied by recurrent neurologic and digestive symptoms would be a significant handicap to a young physician newly arrived in the maelstrom that was San Francisco in 1855. Political corruption and crime in the streets were rampant. There was a surplus of physicians, and an additional doctor was looked upon by those already present as an unwelcome intruder. This would be especially true in the case of a newcomer with the aggressiveness and pretensions of Elias Cooper. He indicates from time to time during the following years that he is unwell, but provides insufficient detail to allow us to hazard a diagnosis. Although we lack specifics, we should keep in mind when considering his behavior and achievements during his residence in San Francisco that he was burdened throughout by a serious and progressive chronic illness.^[65]

1. Peoriana Notebooks, vol. 15, p. 26, Peoria Public Library
2. Emge Research Materials-Typewritten copies of Cooper Correspondence - Box 3, Folder 16, Elias Samuel Cooper Papers - MS 458, California Historical Society, North Baker Research Library. See material labeled Illinois Period for a copy of the advertisement of Peoria Eye Infirmary and Orthopedic Establishment as published in Peoria Weekly Republican on 23 July 1852
3. Based on materials held at Peoria Public Library. See quotations from Peoria newspapers
4. James G. Burrow , AMA, Voice of American Medicine (Baltimore: Johns Hopkins Press, 1963), pp. 8-9 and pp. 33-36 Lane Library catalog record
5. Abraham Flexner , Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (Boston: D.B. Updike, Merrymount Press,1910), 346 pp Lane Library catalog record
6. Proceedings of the National Medical Conventions, New York, May 1846, and in Philadelphia, May, 1847 (Philadelphia: Printed for the American Medical Association by T.K. and P.G. Collins, Printers, 1847), pp. 63-78 Lane Library catalog record
7. Proceedings of the National Medical Conventions, New York, May 1846, and in Philadelphia, May, 1847 (Philadelphia: Printed for the American Medical Association by T.K. and P.G. Collins, Printers, 1847), pp. 70-71 Lane Library catalog record
8. Proceedings of the National Medical Conventions, New York, May 1846, and in Philadelphia, May, 1847 (Philadelphia: Printed for the American Medical Association by T.K. and P.G. Collins, Printers, 1847), pp. 83-106 Lane Library catalog record
9. Proceedings of the Medical Convention for the Purpose of Organizing the Illinois State Medical Society, Held at Springfield, June 4, 1850 (Chicago: Printed by Jas. J. Langdon, 1850), p. 22
10. Donald E. Konold , A History of American Medical Ethics - 1847-1912 (Madison, Wisconsin: Department of History, University of Wisconsin, 1962), pp. 14-31 Lane Library catalog record
11. David J. Davis , History of Medical Practice in Illinois, Vol. 2, 1850-1900 (Chicago: Lakeside Press, 1955), p. 492 Lane Library catalog record
12. See excerpt dated 19 April 1848 from Minute Book of Peoria Medical Society, Peoria County Medical Society. Also, letter, Hanni to Wilson, 20 July 1989, Peoria Medical Society - Box 2.31, John L. Wilson papers - MSS 39, Lane Medical Archives, Stanford
13. Lucius H. Zeuch , History of Medical Practice in Illinois, Vol. 1, Preceding 1850 (Chicago: The Book Press Inc., 1927), p 515 Lane Library catalog record
14. Editorial, "Peoria District Medical Society," North-Western Medical and Surgical Journal 1, no. 2 (Jan-Jul 1848): 183-184 Lane Library catalog record
15. Penny Press, "A glimpse of historical Peoria," June 4, 1981, page 8
16. Walker's Buffalo City Directory, (Buffalo, New York, 1844)
17. History of Peoria County, ed. not specified (Chicago: Johnson and Company, 1880), p. 623
18. James M. Rice , Peoria City and County, Illinois: A Record of Settlement, Organization, Progress and Achievement, Vol. 1 (Chicago: S. J. Clarke Publishing Company, 1912), p. 352
19. Newton Bateman , Historical Encyclopedia of Illinois and History of Peoria County, Vol. 2 (Chicago: Munsell Publishing Co., 1902), p. 404
20. "American Intelligence: Domestic Summary," American Journal of Medical Sciences 13, no. 26 (Apr 1847): 521-522 Lane Library catalog record
21. E.F. Wells , "Old Times in Illinois," Journal of the Illinois State Historical Society 5 (Apr 1912-Jan 1913): pp. 179 and 187
22. William R. Sandham , "Two pioneer doctors of Stark County, Illinois," Journal of the Illinois State Historical Society 13 (Apr 1920-Jan 1921): p. 538
23. William R. Sandham , "Two pioneer doctors of Stark County, Illinois," Journal of the Illinois State Historical Society 13 (Apr 1920-Jan 1921): p. 540
24. William R. Sandham , "Two pioneer doctors of Stark County, Illinois," Journal of the Illinois State Historical Society 13 (Apr 1920-Jan 1921): pp. 540-41
25. Letter, Hanni to Wilson, 25 May 1989, Peoria Medical Society - Box 2.31, John L. Wilson papers - MSS 39, Lane Medical Archives, Stanford
26. Transactions, American Medical Association, Vol. 2 (1849) (Philadelphia: T.K. and P.G. Collins, Printers, 1849), p. 40
27. Proceedings of the Medical Convention for the purpose of organizing the Illinois State Medical Society, Springfield, June 4, 1850, together with the Constitution, By-Laws and Code of Ethics adopted by the Society (Chicago: Jas. J. Langdon, Printer, 1850), 31 pp
28. Transactions, American Medical Association, Vol. 2 (1849) (Philadelphia: T.K. and P.G. Collins, Printers, 1849), pp. 40-41
29. Elias S. Cooper, "Chloroform in surgical operations," Proceedings of the Illinois State Medical Society (June 3-4, 1851): Appendix B, pp. 21-25. Elias S. Cooper, "Collodion in entropium," Transactions of the Illinois State Medical Society (June 1-3, 1852): Appendix B, pp. 31-32. Elias S. Cooper, "A new instrument for cauterizing the urethra," Transactions of the Illinois State Medical Society (June 1-3, 1852): Appendix C, pp. 33-35. Elias S. Cooper, "Remarks on the treatment of incomplete anchylosis of the knee-joint," (June 1-3, 1852): Appendix D, pp. 37-43. At the Third Annual Meeting of the Illinois State Medical Society held at Chicago, June, 1853, E.S. Cooper is reported in the Minutes to have read a "paper on the medical and surgical diseases of the eye ...". This paper was not printed in the Transactions of the Illinois State Medical Society, June 7-9, 1853. 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 of the Illinois State Medical Society (June 6-7, 1854): pp. 39-54
30. Elias S. Cooper , "Remarks on Congestive Fever," St. Louis Medical and Surgical Journal, Part 1: vol. 6, no. 4 (Jan-Feb 1849): 323-327; Part 2: vol. 7, no. 1 (Jan 1850): 20-25 Lane Library catalog record
31. Elias S. Cooper , "Congestive Fever.-.Part of a paper read before the Peoria City Medical Society," North-Western Medical and Surgical Journal 3, no. 4 (Nov 1850): 299-306 Lane Library catalog record
32. Henry J. Bigelow , "Insensibility during surgical operations produced by inhalation," Boston Medical and Surgical Journal 35, no. 16 (Nov 18): 309-317 Lane Library catalog record
33. James Y. Simpson , "On a new anaesthetic agent, more efficient than sulfuric ether," Lancet 2, no. 21 (Nov 20, 1847) 549-550 Lane Library catalog record
34. Elias S. Cooper , "Chloroform in surgical operations," in Proceedings of the Illinois State Medical Society, First Annual Meeting, Peoria, June 2, 1851, Appendix B. (Chicago: Jas. J. Langdon Book and Job Printer, 1851), pp. 23-25
35. John Snow , "On the fatal cases of inhalation of chloroform," Edinburgh Medical Journal 72 (Jul 1, 1849): 75-87 Lane Library catalog record
36. Elias S. Cooper , "Editors' Table: The frequency of death by chloroform," San Francisco Medical Press 2, no. 5 (Jan 1861): 40-41 Lane Library catalog record
37. David J. Davis , ed., History of Medical Practice in Illinois, Vol. 2, 1850-1900 (Chicago: Lakeside Press, 1955), p. 158 "Dr. E.S. Cooper of Peoria reported (to the State Medical Society) on an opportunity of testing the effects of chloroform as an anesthetic agent in 79 surgical operations. . . .This is the first record of the use of chloroform in the state." Lane Library catalog record
38. "Early Medical Practice in Peoria," Peoria (IL) Star, Sunday, March 11, 1934. "In this locality it is said that he administered the first general anaesthetic given west of the Allegheny mountains."
39. Daniel Brainard , "On the inhalation of etherial vapor for the prevention of pain during surgical operations," Illinois and Indiana Medical and Surgical Journal 1, no. 6 (Feb 1847): 544-549 Lane Library catalog record
40. Daniel Brainard , "On the inhalation of sulphuric ether," Illinois and Indiana Medical and Surgical Journal 2, no. 4 (1847 Oct): 382-384 Lane Library catalog record
41. "Chloroform," (Announcement) Illinois and Indiana Medical and Surgical Journal 2, no. 5 (1847 Dec): 480 Lane Library catalog record
42. R.D. Mussey , "Report upon ether and chloroform," Ohio Medical and Surgical Journal l, no. 1 (Sep 1848): 86-89 Lane Library catalog record
43. John Hunter , "The Application of Caustic to Strictures," in Treatise on Venereal Disease, 3rd edition (London: W. Bulmer and Col., 1810), pp. 134-140 Lane Library catalog record
44. Philippe Ricord , "Stricture of the Urethra," in A Practical Treatise on Venereal Diseases, 3rd edition (New York: J.S. Redfield, Clinton Hall, 1848), pp. 310-311 Lane Library catalog record
45. Printed Materials - Box 1, Folder 7, Elias Samuel Cooper Papers - MS 458, California Historical Society, North Baker Research Library
46. Proceedings, Illinois State Medical Society, June 3, 1851, p. 7, Pamphlets Collected by E.S. Cooper, vol. 3, Lane Medical Library Special Collections, Stanford Lane Library catalog record
47. Transactions, Illinois State Medical Society, June 1852, p. 15, Pamphlets Collected by E. S. Cooper, vol. 10, Lane Medical Library Special Collections, Stanford.Lane Library catalog record
48. Transcripts of Minutes of Peoria Medical Society, Peoria County Medical Society
49. Correspondence 1844-1854 - Box 1, Folder 1, Elias Samuel Cooper Papers - MS 458, California Historical Society, North Baker Research Library. This folder contains the rough draft of a letter handwritten in 1854 from Cooper to the President and members of the Illinois State Medical Society. In editing the letter for inclusion in the text, punctuation has been added, dates interpolated, abbreviated words spelled out, and wording minimally rearranged where necessary to clarify meaning
50. Council on Ethical and Judicial Affairs , Current Opinions (Chicago: American Medical Association, 1989), pp. 18-19 Lane Library catalog record
51. Correspondence 1844-1854 - Box 1, Folder 1, Elias Samuel Cooper Papers - MS 458, California Historical Society, North Baker Research Library
52. Diary of Jacob Cooper, in the personal collection of John McDonnell. The handwritten Diary of Jacob Cooper in eight bound volumes covering the period from 1847 to 1901 is held by his great grandson, Captain John R. McDonnell of Houston, Texas. Captain McDonnell has generously made excerpts from the Diary available to Lane Medical Archives where they are filed in the John L. Wilson papers (MSS 39)
53. James Morison , "Obituary of Dr. E.S. Cooper," Pacific Medical and Surgical Journal 5, no. 10 (Oct 1862): 307-309 Lane Library catalog record
54. Correspondence 1844-1854 - Box 1, Folder 1, Elias Samuel Cooper Papers - MS 458, California Historical Society, North Baker Research Library. (1) Letter from Jacob Cooper in Edinburgh to ESC dated 31 Oct 1854 acknowledging receipt of letters from ESC posted in London and Paris.. (2) Letter from ESC in London to a "Dr. Welch" (? in Edinburgh) dated 3 Dec 1854 in which ESC refers to dexterity of French surgeons, etc. Folder: Correspondence 1855. (1) Letter from Mr. McKnight of Granville IL to ESC in Peoria dated 24 Jan 1855 in which McKnight states that he received ESC's letter from Paris dated 16 Nov 1854 and his letter from Peoria dated 14 Jan 1855. (2) Letter from Consul Kennon of Cork, Ireland, to ESC in Peoria dated 22 Feb 1855 in which he mentions the anticipated departure of ESC from Liverpool for New York "on or about 8 December 1854."
55. Correspondence, 1855 - Box 1, Folder 2, Elias Samuel Cooper Papers - MS 458, California Historical Society, North Baker Research Library
56. Otto Juettner , Drake and His Followers (Cincinnati: Harvey Publishing Co., 1909), pp. 220-223 Lane Library catalog record
57. F. N. Otis , History of the Panama Railroad (New York: Harper and Brothers, Publishers, 1867), pp. 1-36
58. C.-E. A. Winslow , Man and Epidemics (Princeton: Princeton University Press, 1952), 183 Lane Library catalog record
59. John Haskell Kemble , The Panama Route, 1848-1869, University of California Publications in History, Vol. 29 (Berkeley: University of California Press, 1943) pp. 58-59
60. John Haskell Kemble , The Panama Route, 1848-1869, University of California Publications in History, Vol. 29 (Berkeley: University of California Press, 1943) pp. 70; 73 and 147-148
61. Emmet Rixford , "Early medical schools on the Pacific Coast," Pacific Medical Journal 56, no. 3 (Mar 1913): p. 158 Lane Library catalog record
62. Emmet Rixford , "Early history of medical education in California," Annals of Surgery 88, no. 3 (Sep 1928): p. 323 Lane Library catalog record
63. Correspondence, 1856 - Box 1, Folder 3, Elias Samuel Cooper Papers - MS 458, California Historical Society, North Baker Research Library. (1) Letter, McDonald to Cooper dated 25 Feb 1856; (2) Letter, McDonald to Cooper dated 18 May 1856
64. Levi C. Lane , "Obituary of Elias Samuel Cooper," San Francisco Medical Press 3, no. 12 (Oct 1862): 231 Lane Library catalog record
65. Emge Research Materials-Correspondence, 1930-1978 - Box 3, Folder 14, Elias Samuel Cooper Papers - MS 458, California Historical Society, North Baker Research Library. (1) Letter, Jacob Cooper to ESC dated 21 August 1855; (2) Letter, Mary Cooper to ESC dated 30 September 1855; (3) Letter, Carrie Cooper to ESC dated 10 February 1856; (4) Letter, Jacob Cooper to ESC dated 11 Feb 1856