Q J Med 2000; 93: 695-698
© 2000 Association of Physicians
Occasional paper |
A.M. Cooke: an informal memoir
From the Royal College of Physicians, London, UK
I shall try to explain the unique appeal of one physician, Alexander Cooke. He was not famous for any specific reason—no great discovery, no famous positions held, no unique talent. Yet by all those who knew him, or even those who only encountered him lightly, he was cherished.
He was physician to the Radcliffe Infirmary, Oxford, for over 30 years. Alec Cooke told the story of his professional life in My first 75 years of medicine, published by the Royal College of Physicians in 1994. I was his registrar from 1952 to 7 and his friend for the rest of his life. He was born in Oxford in 1899, and wanted to live to be 100 and three months so that he could have lived in three centuries. Later he lost this ambition, and at the age of 99
, he was happy to go.
Our relationship might have been a disaster, at least for me. I was due to start my job as his registrar on 17 October 1952. The night before, my predecessor John Pease gave a farewell party, attended it seemed, by the whole of Oxford. I knew nobody, so John kindly gave me the task of wine waiter. My commission on each act of service was small, but the guests were numerous. The result was that next morning, my first in Alec's service, when I turned up at 9 am for an outpatient clinic, I still felt overtired and had the reverse of an appetite. If he had arrived then, he might have dismissed me on the spot. But fortunately the clinic didn't begin until 10 am, and by then, time, water and air had done their work and I could face the patients.
Alec Cooke was essentially a general physician in the days when specialism had already started its development. He stayed one all his life. He was the physician—mercifully there seems to be one on the staff of every hospital—you turn to when you had a completely baffling patient or, more likely, you or one of your family were ill. In his case he disclaimed any such ability—he said that he owed his success to his wife. Whenever they disagreed about an illness, she was always right, notably about their own daughter. ‘She has appendicitis’ said Vera. Alec explained why for many reasons this could not be right. ‘She has appendicitis’ repeated Vera. She had.
He told this story against himself, as so many of his stories were. For a confident, busy successful physician he was very modest. Telling stories was one of his main ways of teaching, at the least the continuous, informal teaching that is part of hospital life especially on ‘business’ ward rounds.
The facts are straightforward. His whole medical life was spent at Oxford and St Thomas's. He was swept up into the Royal Flying Corps in 1918, but the war ended and he was allowed to go to Oxford straight away. He got a first class degree in physiology and for a time was a demonstrator to Sir Charles Sherrington. He won scholarships at St Thomas's and after qualification started to climb the medical unit ladder. En route, he became resident assistant physician. In this capacity he had to see all admissions with acute abdominal symptoms, together with his surgical opposite number. They usually agreed on the diagnosis but they decided to compare notes—each wrote down his diagnosis and then the final diagnosis. They found that 75% of all cases were of acute appendicitis; they didn't draw the obvious epidemiological conclusion that there was no point in examining the patient, simply operate on them all.
Alec seemed set for a consultant job on the staff of St Thomas's but when a vacancy occurred which he was widely expected to get, he did not. He was terribly disappointed then, but a few months later he did get on the staff at the Radcliffe (because of the unexpected death of Billy Collier, son of the man after whom Collier ward is named. How much such chance happenings affect all our careers, rough-hew them how we will).
Alec took to Oxford at once—and it to him. He had the intelligence, wit, amiability and sharpness of tongue that suits the Oxford atmosphere so well, especially the habit of levity about serious subjects. A nice example is the assessment of risks to Oxford if the Germans invaded in 1940. It was agreed that Oxford would probably be spared as it had no commercial or military importance nor, as the wits added, academic.
He took up diabetes because in the 1930s it was agreed that there should be more organised care of diabetics—this was happening all over the country. Once he started, he became enthusiastic about the subject and was a contributor nationally and internationally. In his cautious way, he was slow to adopt the sulphonylureas and kept his patients who needed more than diet only on insulin. He may have been ahead of his time in this as there is a tendency now to seek the best control of type II diabetes by ready resort to insulin treatment.
At this time—mid 20th century—there were only four physicians, other than the medical professorial unit, who were ‘general’ at the Radcliffe in the sense that they did emergency duty. Francis Avery-Jones had not invented gastroenterology, cardiology was tube-less, neurology had no scanners; the doctors had to rely on clinical methods, inaccurate as they were soon shown to be by Archie Cochrane, Charles Fletcher and others' studies of observer error. They showed that our student teaching weapons were very inaccurate—a most irritating discovery for those of us who had nothing else to rely on.
Alec became ‘dean’ of the medical school. The school was tiny in those days. The few students, about 20 a year, were a mixture of overseas students who had difficulty in finding a place in this country and young Oxford dons who wanted a degree in medicine on their way to college fellowships, and did not want the trouble of going to London. The medical school of those days was a trifling affair compared to the mighty place it is now—although thoughts were turning in the direction of creating a super medical school as early as the 1940s. Accommodating the students who before the war went to London medical schools for their clinical training was Alec's special responsibility, and very well he did it with his usual mixture of firmness and friendliness.
His teaching of pre-clinical students was famous. Every Tuesday and Thursday afternoons in term time he would give clinical demonstrations to the bright young men and women, steeped in science but straining to get on to the clinical part of their training. Many of his students remembered those teaching sessions for decades afterwards.
Alec was becoming increasingly recognized for his general qualities such as examining and editing. He was on the editorial board of the Quarterly Journal of Medicine for nearly 30 years. Once he lost a manuscript he had been sent by the editor and, in a panic, he and his secretary searched the town's rubbish dump. They found it. I have never heard of this happening to any other editor, but maybe it is the explanation of odd experiences I and others have had over the years. Does this explain why editors are often so slow to respond? I'm a layman, I know, but there must be some explanation. For example, colleagues and I sent a paper (important, original and unique we thought) to the New England Journal of Medicine which now occupies the position that the Quarterly Journal of Medicine, at least in this country, used to hold. It took the NEJM 3 (three) months to reject the paper. Alec would not have stood for that, nor for any slovenly or unclear language. He wrote and spoke beautifully. There was nothing obvious, calculated or affected about his writing or speaking. Plain, preferably Anglo-Saxon words and as few of them as could convey the meaning with a minimum of repetition.
He was a marvellous teacher of those who had to present papers. When I first gave a paper to the Association of Physicians in 1956, I told him that I knew my stuff and didn't need to practise. ‘You will practise’ he said and took me to a deserted lecture theatre, sat at the back and called out fierce and helpful comments—‘Speak up’, ‘Not so fast’, ‘Point to the slide’, ‘Face the audience’, ‘Keep your mouth close to the microphone’, ‘Time yourself’. There you have it, the rules for presenting papers. I have never forgotten them and have always insisted that my juniors follow them. ‘You can't speak too slowly’ was advice for those who indulged in the common tendency to gabble. Alec would explain the need by saying, ‘Remember you are speaking to deaf morons’, not to be superior or offensive but to remind speakers that what was familiar to them was new—or should be—to the audience. When Alec himself was speaking you could hear and understand every word. He was such a good speaker that it was essential if you were on a programme with him that he came after you.
In order to keep to these rules Alec always insisted on his juniors practicing before every meeting, as I did mine. It is disappointing that more speakers have obviously still not practised, to judge by the number of the them, even the most senior such as Harveian Orators, who go well over time or speak too quickly in order not to do so. It is an entirely avoidable offence.
Alec was equally severe with himself and others over written papers, but there the situation is easier because all written papers are seen by other eyes—friends, colleagues, referees and editors. The result is a reasonably high standard of writing in medical papers excluding the pervasive and tenacious tendency to use jargon.
Alec was, as I have said, above all a physician. That meant that his concern was for patients, not for ‘cases’. In order that doctors should feel the same as their patients (which is not always the case although my impression is that doctors, even surgeons, are more sympathetic than they used to be) he advocated that medical students when they started on the wards should have some experience as patients. This might consist merely of being sent for an investigation, preferably mildly invasive such as a blood count, when they weren't quite sure what was involved. They would then have a period, perhaps longer than it should be, of doubt before the result came back. In all this the student would learn how it felt to be ignorant, helpless and worried—above all to be in another person's hands. It is very easy to be undisturbed by someone else's anxiety.
This fellow feeling of Alec's is encapsulated in a penetrating comment he made after he had had a wisdom tooth extracted—‘Only a minor operation’ he had been told. After the operation his face swelled and he was in pain for days. This led him to the definition ‘A minor operation is an operation done on somebody else’. That remark sums up the man.
These qualities of the ideal general physician led David Weatherall and his colleagues in 1983 to invite Alec to write the preface for the first edition of their great book The Oxford Textbook of Medicine, the last word in modern medicine being introduced to today's students by an octogenarian. There could not have been a better choice of someone to lead readers, mostly used to an older style of medicine, to the modern molecular-based subject. Alec reminded his readers that whatever the future of medicine, the most important person in the hospital would always be the patient.
In all his teaching, writing and conversation, Alec was witty. I think his wit came not from any conscious intention to amuse but from a very sharp intelligence and a very clear mind (not necessarily the same thing). He simply put his ideas in the clearest, shortest way he could. His great experience and intelligence led him to introduce two precepts which came to be known as Cooke's Laws (there must surely be other Cooke's Laws, many of Alec's former juniors and students have developed their own). The point of these laws is their self-evident truth, once enunciated, and their brevity and of course their universal applicability. The two original Laws are (i) it takes longer than you think and (ii) it costs more than you think. Like all great discoveries or formulations one asks ‘Why hadn't I thought of that?’
My Cooke's Law is ‘public actions have only one effect, the opposite of that intended’. I think this is true but it doesn't have the ring of universal truth that Alec's laws are immediately seen to have, and I suspect that I may have made it up myself.
Alec gave sound career advice to the aspiring young doctor in the same lighthearted way. ‘Get to 40 as quickly as you can and stay there.’ Most people can follow the first part of this advice, but not the second.
A piece of advice which might have made him into a politician (which he certainly would not have wanted) was ‘if you are cornered in an argument imitate the action of the squid and emit a cloud of words’. I never saw Alec cornered. I thought I had got him once but he started his squid imitation. I said ‘Don't argue with me’. ‘I'm not arguing with you’ he replied ‘I'm correcting you.’
He had a lovely turn of phrase, for example his description of the typical old oarsman at Henley Regatta—large, overweight, plethoric, loud-voiced and pink-capped—as ‘leanderthal man’.
His humour was often against himself. He prided himself on his ability to get a history from any patient and was once showing off to his examining colleague in the membership who was baffled by an inarticulate man. Alec waded in but got nowhere. Finally he asked ‘What is it that you chiefly complain of?’ ‘My wife,’ was the answer.
In 1988 during the Olympic Games in South Korea, at a time of great interest in the doping of athletes, he asked me ‘Do you know why I'm not at Seoul?’ Well, I thought at the age of 88 he might be past his best but didn't like to say so. ‘Because I am on anabolic steroids’ he said. Incidentally he never took exercise of any kind and prided himself on it. When an undergraduate, he had joined the Pheidippides Club whose purpose was to repeat the run from Marathon by Pheidippides two and a half millennia ago, after which he immediately fell down dead. The club met every Sunday morning, drank sherry and planned the next run. The only rule was ‘Never run today’. If Alec wasn't a life member of that club, he deserved to be.
Alec was not a great committee man. He said that he either forgot to go, or fell asleep or found himself arguing furiously about a matter which had been settled at the last meeting, which he had missed. Alec was very far from the modern teaching hospital physician travelling, lecturing, attending committees in Britain and all over the world and generally being important somewhere, if not at the bedside.
Everything Alec did, he did with zest. Nothing in life seemed to bore him, not even his colleagues. Truthfully, that is unfair: he got on very well with all but two of his colleagues at Radcliffe, and with all at the College. He had a very sweet and proper respect, for example, he was exemplary in his respect for the President of the College on all occasions, even when the President was a former house physician of his. His mixture of wit and civility was irresistible. His zest was nicely shown at his 90th birthday party when he said how much he enjoyed life. ‘I should have been furious if I hadn't been born.’
His professional life spanned three-quarters of a century, from the introduction of liver treatment for pernicious anaemia (‘Whatever will they think of next?’ was his reaction) to modern molecular medicine, and he understood it. Oxford—the Radcliffe and Merton where he was a Fellow for over 50 years—provided the perfect millieu for postgraduate medical education. His colleagues and innumerable visitors saw to that. Of his retirement in 1965 he said ‘There is more rejoicing in heaven over one sinner that retireth than over 99 just-appointed persons’.
Alec was widely known throughout the hospital, so he got more than his fair share of casual requests for informal consultations. If someone stopped him in the corridor, undid a shirt button and said ‘I've got a pain here, is it all right?’ he would reply ‘If you will come to my room and take off all your clothes I will try to find out’—‘medicine with the clothes off is difficult enough, with the clothes on is impossible,’ he said. ‘Corridor medicine’ he called it.
It is gratifying, at least to me, that Alec without the obvious claims to fame and popularity of a leading member of our profession should have been so widely respected, appreciated and even loved. He left his mark on everyone who knew him even quite briefly. For those who got to know him well, he embodied everything that was good in a man and a doctor.
Notes
Address correspondence to 17 College Road, London SE21 7BG 
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