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An Instrumental Figure: The Legacy of Constantin Cope

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Constantin “Stan” Cope, MD, a physician and inventor, was impish, clever, and practical-minded, according to those who knew and loved him. After serving as a longtime faculty member in the department of Radiology at the Hospital of the University of Pennsylvania (HUP), Cope died peacefully in November 2016. Yet his impact is still unfolding and shaping the future of medicine, and his story, even the parts that are known, is widely underappreciated.

At the time I learned of Cope’s passing, I had just signed on as the new editor of Penn Medicine magazine. (Any very longtime readers of the Penn Medicine News Blog may remember I worked in a digital communications role at the blog’s start.) I had first heard of Cope a little over six months ago while working as a science writer at Children’s Hospital of Philadelphia (CHOP), when I was reporting on some exciting innovations happening in collaboration between CHOP and HUP to treat a rare condition called plastic bronchitis. One of the doctors behind these innovations, Maxim Itkin, MD, had emphasized that his esteemed mentor, Cope, was a vital part of that story. As I began to inquire into Cope’s life and work, I found more than I imagined. Cope led a fascinating life and may have been instrumental in the founding of multiple medical specialties. (A long-held secret in his family history may link him into a deeper legacy in yet another medical specialty—but more on that another time.)

“I remember when I was a kid, I went to the circus. The most impressive thing I saw was a man who was able to stay balanced on a ball with his finger,” Stanley Baum, MD, an emeritus professor and longtime chair of Radiology at Penn, told me, to place Cope’s impact into perspective. “The remarkable thing wasn’t that he was able to do that. It was that he was able to think that he might be able to do that. That’s what Stan Cope was like. He would do things nobody would ever think possible.”

This is a short glimpse of a story of his life as an inventor that gives an idea of the medical legacy and the lasting impact of his work—while much more of his remarkable personal history remains to be told in an upcoming issue of Penn Medicine. I invite his friends, former colleagues, and trainees to contact me if you’d like to share your own memories.

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Who Would Think to Catheterize Thin Spaghetti?

Plastic bronchitis occurs as a side effect in a small percentage of children who undergo surgery for right-side congenital heart failure, and it is devastating. The condition causes a child’s lungs to repeatedly fill with fluid that hardens into rubbery casts. When coughed up, those casts, which have molded to match the shape of the bronchial passages, look like tiny branching trees—beautiful if they weren’t so often deadly. Once only treatable with a heart transplant, plastic bronchitis was usually a near-hopeless condition if it didn’t subside naturally, until Itkin and Yoav Dori, MD, PhD, began to work on an innovative new treatment.

When I reached out to him about this work over the summer, Itkin told me that the procedure’s true origin was two decades ago, when Cope was the first person to successfully access and intervene on the lymphatic system. The lymphatic system is a low-pressure fluid circuit throughout most of the body in which colorless fluid, cells, and proteins from soft tissues and organs collect and then flow into tiny lymphatic vessels that ultimately lead toward the largest lymphatic vessel, the thoracic duct in the chest. From there, lymphatic fluid is reabsorbed safely into the blood—at least in healthy people. During certain surgical procedures, there is a risk that the practically-invisible thoracic duct, which can be as small as two millimeters in diameter, may be inadvertently nicked or severed, leading to swelling and fluid collecting in the chest, a condition called chylothorax. The condition may also arise spontaneously in people who have not had surgery for unknown reasons. Cope figured out how to see the thoracic duct well enough to know where it was leaking, and he determined a way to insert a tiny catheter and push still-tinier tools through that catheter to seal the leaks, pioneering the minimally invasive procedure known as thoracic duct embolization.

 “Who would think of being able to catheterize a thoracic duct? The thoracic duct structure is like a thin piece of spaghetti,” Baum remarked, in recalling what made Cope’s contributions to medicine so unique.

Itkin came to Penn for his fellowship in interventional radiology soon after reading about thoracic duct embolization in some disbelief—the idea sounded outlandish, like science fiction—not realizing at first that this meant he would be working alongside Cope himself. He began to learn by observing the procedures that could last eight hours, while the taciturn Cope offered little in direct didactic instruction or commentary. 

As Cope neared his 2004 retirement, he performed the procedure less and less, while Itkin performed it more. Itkin stayed on as faculty at Penn and ultimately refined the procedure to complete it in as little as 40 minutes. His further refinements on lymphatic imaging in recent years, some initially on his own, and even more once he joined forces with Dori, an MRI expert and CHOP pediatric cardiologist who is also an assistant professor of Pediatrics at the Perelman School of Medicine, dramatically improved the ability to see the lymphatic system in ultra-fine detail.

“Suddenly we discover the whole world of lymphatic abnormalities,” Itkin told me in an interview for the CHOP story last year. “Nobody had ever done that before. We can actually light up almost the whole lymphatic system and see abnormalities there.”

Once seen, those lymphatic flaws could be treated like the simple plumbing problems they were, sealing up the leaks and unclogging the blockages. Itkin, who is now director of the CHOP/HUP Center for Lymphatic Imaging and Interventions, along with Dori, the director of Pediatric Lymphatic Imaging and Interventions and Lymphatic Research at CHOP, is able to intervene and treat the root cause of conditions and symptoms with previously unknown origins—beginning with plastic bronchitis, but extending far beyond it to numerous other lymphatic conditions, both known and unknown. Itkin is confident that within five years, lymphatics will be widely seen as a new subspecialty in medicine.

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Founding Father of Interventional Radiology

Cope’s seminal role in the new field of lymphatics would be impressive enough for any great doctor. But it was not even the first time he had a leading role in the founding of a new medical specialty. Back in the 1960s, he was a founding father of interventional radiology, too. Philadelphia was then a major hub of invention of procedures and approaches that ultimately expanded radiology as a field beyond its origins using radiation to create images that visualize the body’s interior. The newer interventional specialty combines imaging with minimally invasive procedures to address illness or dysfunction by inserting catheters, wires, and coils in imagery-guided techniques.

Cope, then an internal medicine physician at Albert Einstein Medical Center in Philadelphia, joined Baum and several other radiologists in a core group that gathered to share ideas and methods for the earliest pioneering versions of these procedures. Cope was the only non-radiologist in the group. Catheters and other tools for interventional radiology were not widely available at the time because the field was so new—so Cope made them using materials he purchased at hardware stores and the Army/Navy supply shop.

“At home when I was growing up, I would hold a lighter under his catheters so he could stretch the catheter,” recalled Cope’s daughter Evelyn Stainthorpe. “I never knew what he was doing. There were always drills and all kinds of stuff lying around the dining room table.” Later, when Stainthorpe came to work with her father at HUP, initially as a subcontractor doing data entry and eventually managing research in Interventional Radiology, little changed. “Sometimes he’d be working in his office, and say, ‘Hold the lighter for me.’ I was his lighter girl.”

Cope’s inventions included not only catheters, but also guide wires and once-new approaches to difficult problems that are now commonplace.

The locking Cope loop, for example, is an exceedingly common tool in medicine. Before its invention, doctors who inserted a catheter to drain excess fluid from an organ ran into a common problem: The catheters tended to slip out.

“Stan came up with idea to have the tip of the catheter attached to a string,” Baum said. “After the catheter was in you would pull the string so the tip of the catheter in the organ makes a curve on itself. That was a very simple thing, and in short order it became the standard of how everyone was doing this.”

Such elegantly simple solutions to seemingly complex problems were Cope’s hallmark. “His genius was to work out a solution that others would look at and they’d go, ‘Why didn‘t I think of that myself? Wow!’” said Joe Roberts, vice president of corporate development at Cook Medical. “Well, that’s genius, so often.”

Cook Medical, now a major international medical device and supply company that manufactures thousands of products, has a history deeply intertwined with Cope’s. Cope met William Cook at a professional conference in the 1970s, when Cook and his wife ran a small manufacturing company out of their garage. The two men discussed numerous ideas about new catheters and other equipment. Their fruitful friendship resulted in dozens of products, including entire product lines used in fields from gastroenterology to neurology.

A few years after Baum returned to Penn as department chair following a time in Boston, he invited Cope to join him. Cope stayed at Penn for more than two decades and continued inventing, right up to his retirement.

“He didn’t invent one thing to revolutionize something,” Roberts said. “He invented an entire range of things that touched on so many different areas and inspired other people to go and solve their own problems, using his genius as sort of the bedrock.” 

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