6—
Aberrant Medical Humor
There is a kind of medical humor that is, on the face of it, revolting and unprofessional. To some extent, medical sociology has noted it: in this type of humor doctors laugh at, or make fun of, their patients.[1] Certain physician-writers also use this type of humor. For instance, Rabelais sometimes delighted in describing a person's death in humorous and anatomical detail: "Gymnaste with one blow sliced him through the stomach, colon, and half the liver, so that he fell to the ground; and as he fell he threw up more than four pot-fulls of soup and, mingled with the soup, his soul."[2] Aberrant medical humor also appears in William Carlos Williams's "Jean Beicke" (a story in which the doctor-narrator sometimes ridicules, but also reveals, his great sympathy for the sick babies of poor families he had to treat during the Depression),[3] in Richard Selzer's essay "Liver,"[4] and in the title of pathologist-essayist William B. Ober's article "Can the Leper Change His Spots?"[5]
It must be emphasized that not all doctors use this type of humor. But it is noteworthy that many who do are among the most skilled of their profession as well as among the most sensitive to their patients' pains, hopes, and fears. Why do some outstanding and intensely feeling physicians at times use humor that, on the surface, is not only aberrant but also abhorrent? We turn to two instances from the wards.
Case Histories
Swollen Ankles
I was a medical intern at a large teaching hospital. On rounds every morning, our group of ten to twelve would visit all the patients on our service. This group generally included the attending physician, two residents (senior and junior), three or four interns, and three or four medical students. Invariably, the group was composed of serious, dedicated people who really cared about their patients and were very sympathetic to them.
Before going on rounds, we would meet in the doctors' room where the intern who had been on call for the past twenty-four hours would present each new patient. Our conference was private: a discussion by doctors for doctors. Because we were among colleagues, we would sometimes inject humor or light banter into our discussions. Of course, we would never have talked that way in front of our patients.
After our conference we would see each patient individually. Since this was a teaching hospital, some patients were used as teaching tools. When we visited a new patient, the intern who had admitted that patient (or perhaps one of the residents) would ask one or two questions to try to elicit crucial information to pass on to the medical students.
Dr. M, one of my fellow interns, had admitted that night. In the doctors' room he had presented, along with three other patients, Mrs. F, who had come into the Emergency Room because of severe congestive heart failure. During this presentation, Dr. M had indicated that Mrs. F was very obese, but the fact did not really register with us. Not until we saw her.
As our large contingent entered Mrs. F's room, we beheld a woman who must have weighed four hundred or five hundred
pounds. She was so huge that she was spilling over the sides of the bed. In itself, such a sight would have struck us (and almost anyone) as bizarre.
We assembled around her bed. Although Mrs. F was having difficulty breathing, as part of the teaching exercise the junior resident asked her what had brought her into the Emergency Room the night before.
In a voice strangely weak for a person so huge, Mrs. F replied, "I noticed a little swelling in my ankles."
That such a thing could bother someone of her size seemed to one or two of us, at least, rather funny With all her rolls of fat everywhere, how could she possibly have been disturbed by—or even noticed—a little swelling in her ankles?
We retired to the conference room to discuss our cases.
Dr. M was in charge. "Let's begin with the case of . . ."
"Swollen Ankles!" one of the residents said. Somehow that image elicited in our group the beginning of a ripple of laughter that grew and grew until, within moments, all twelve members of our team were roaring with laughter. We could not control ourselves.
For days after that, whenever one of us mentioned Mrs. F we would explode in laughter. For some reason, the image of that pitifully enormous lady who had noticed a little swelling in her ankles was too pathetically funny.
The Gynecology-Oncology Conference
Because I treated gynecological cancer, I went to our hospital's weekly gynecology-oncology conference. This rather large meeting was attended by about twenty people, including radiation therapists, gynecological oncologists, and pathologists from our medical school faculty, some private gynecologists from the community, residents from the departments of radiation therapy and gynecolpgy, and several medical students. Together, we went over all the new cases of the week and decided on a mode of treatment. The general atmosphere of the conference was serious, professional, and academic. One doctor would present a case and then the physician in charge of that case would ask for the group's recommendation for treatment. Some cases were (relatively) simple and some were difficult. One case, however, was almost unbelievable. It may be summarized as follows.
Mrs. I, age fifty-three, had had a history of multiple, serious medical problems, including severe diabetes, high blood pressure, heart disease, kidney failure, and pulmonary disorders. Her medical problems made her an extremely bad risk for any kind of therapeutic intervention. She had developed a very advanced cancer of the cervix that had progressed beyond a curable stage. Because of it, she was having a lot of pain and bleeding. As if all this were not enough, there was also her social history. Her husband had died during the past year, her son had just been sent to prison for breaking into a liquor store, and her daughter had recently been hospitalized and was still sick. These additional problems were making it even more difficult to manage the patient.
As usual, after the case had been presented, the gynecologist in charge of the case asked the conference: "What do you recommend for this woman?"
There was silence as everyone reflected on this terrible story. Suddenly, one of the doctors said, "Her case sounds so bad, maybe we should just shoot her"
The whole room exploded in laughter.
Literary Parallels
Why did the doctors use such horrible hospital humor? Renée Fox has noted a resemblance between medical humor and the humor of soldiers in combat.[6] Literature provides some excellent examples of war humor.
War and Peace
In Tolstoy's epic, the Russians have been retreating toward Moscow. In one battle, "tens of thousands fell."[7] By 10:00 A.M.,
cannon balls fell more and more frequently. . . . But the men . . . seemed not to notice this, and jokes were heard on all sides.
"A live one!" shouted a man as a whistling shell approached.
"Not this way! To the infantry!" added another, with loud laughter, seeing the shell fly past.[8]
How can there be joking and laughing in this death-charged scene? Paradoxically, it is probably the atmosphere itself that occasions the laughter, for through their laughter the soldiers try to trivialize, defy, or nullify the anxiety and anguish surrounding, and within, them. "'Are you afraid . . . ?'" Pierre Bezúkov, who had come to observe the battle, asked one of the soldiers. "'One can't help being afraid,' [the soldier said] . . . laughing."[9]
In some ways, this atmosphere of fear, pain, dying, and death recalls the hospital scene. Is it possible, then, that doctors' humor—like soldiers' humor—seeks to combat anxieties about the atmosphere of suffering, death, and dying from which one cannot escape? Can the reactions of a soldier offer insights into those of a doctor?
Something About A Soldier
Jacob Epp, age eighteen, the protagonist of Mark Harris's novel, is in a training camp, preparing to fight in Europe in World War II. Captain Dodd likes him, but in the excerpt below Dodd seems heartless and mean. Jacob has just received a newspaper clipping announcing that his best friend, also eighteen, has been killed in action in Italy.
And Jacob said to the Captain, My friend is dead.
Who, said the Captain.
My friend, said Jacob. Dead in a burning airplane between Salerno and Naples, Italy.
That's what happens, said Dodd, when you fly around in burning airplanes.[10]
On the surface, Dodd appears cruel. But later in the novel, Dodd, who likes and pities Jacob, helps him get a discharge
from the army before Jacob is even sent abroad, whereas Dodd himself will die fighting in Europe. Dodd's insensitivity thus is only apparent, not real. In fact, his grimly ironic quip voices the opposite of what he really feels, and his humor is therefore a defense and a mask. It helps protect him from his own fear of death and conceals—although to those who understand its irony it actually reveals—his sympathy for another person.
War humor, then, like medical humor, continually jostles against death, the fear of death, or one's own feelings of sympathy. Often such humor is ironic; it pits grim wit against the grim facts. How else may the grimly humorous combat the grimly serious? There is a very thin line between them.
The Thin Red Line
In James Jones's novel fictionalizing the Guadalcanal campaign, semihysterical laughter, obscenity, and bravado are three ways in which grim humor combats grim reality
Semihysterical laughter, which is akin to tears or helplessness, implies a person's lack of control over himself or over events. (We think here of the doctors' behavior in the case of "Swollen Ankles.") In Jones's novel, such laughter erupts after a confrontation with death. While debarking, the soldiers have seen one of their landing boats blown to bits by a Japanese air attack. Those who are unhurt have to march miles into the jungle to set up camp. Then they are drenched by a pouring rain. Suddenly they turn everything into a semihysterical lark.
A hollow and pathetic lark, to be sure, when associated with the dead, dying and wounded from the air attack whom they could not forget;—but perhaps for that very reason the clowning and laughter rose to an even higher pitch, one that in the end resembled hysteria. . . . In the end, however, it did not lessen their painful new tension.[11]
Although the soldiers' clowning and laughing are described as reactions to their recent exposure to terror, horror, pain,
and death, their semihysterical laughter "did not lessen their painful new tension." Grim reality is not so easily vanquished—at least not by fits of laughing.
In a way, their laughing is a kind of bravado, indecent and almost obscene. This becomes clear in the next episode. Some of the soldiers explore the jungle and come upon the bloodstained shirt of an American soldier. They hold up the death shirt, examining it nervously, curiously, and almost guiltily. Then they drop it and proceed in the jungle until they come upon a mass Japanese grave.
It was here that the delayed emotional reaction to the death shirt caught up with them in the form of a sort of wild horse-play of bravado. . . . [They] pushed or poked at this or that exposed member, knocked with riflebutts this or that Japanese knee or elbow. They swaggered impudently. . . . They boisterously desecrated the Japanese parts, laughing loudly, each trying to outbravado the other.[12]
The key words here are "bravado" and "outbravado": they imply pretended courage or defiant confidence where there is really little or none. Bravado, therefore, explains something about war humor and—because it resembles it—medical humor.
Are the bravado of war humor and medical humor wholly horrible, unnecessary, and perverted? Or might this humor actually be helpful and even healing? A final example from literature attempts to analyze or explain, very briefly but very insightfully, why this horrible humor exists and is helpful.
All Quiet On the Western Front
Paul Bäumer, the narrator of Erich Maria Remarque's remarkable novel, is a soldier in the German army during World War I. His company has just returned from two weeks at the front. On their last day there, 70 of their 150 men were wounded or killed. The remaining soldiers are waiting to eat.
"Say, . . . open up the soup-kitchen," [one soldier called]. . . .
[The cook said,] "You must all be there first." Tjaden grinned: "We are all here." . . .
"That may do for you," . . . [the cook] said. "But where are the others?"
They won't be fed by you today. They're either in the dressing-station or pushing up daisies."[13]
Like the cook, the reader is probably startled or repelled by the soldiers' joking about their dead comrades. How can we accept—or understand—such offensive humor?
First, like the narrator, Bäumer, we should always see it in context, that is, in an atmosphere of fear, pain, dying, and death from which one cannot escape.
Second, we can understand this humor as both offensive and defensive; it is an armament, at once a weapon and a protective shield. As an offensive device, this humor causes the men using it to appear insensitive, cruel, or gross. As a defensive device, it is protective, helpful, and healing. As Bäumer explains, it keeps the men from going mad, upholds their resistance, cheers them, and gives them courage.
The terror of the front sinks deep down when we turn our backs upon it; we make grim, coarse jests about it, when a man dies, then we say that he has nipped off his turd . . . ; that keeps us from going mad; as long as we take it that way we maintain our own resistance. . . .
We have to take things as lightly as we can,. . . and nonsense stands stark and immediate beside horror. . . . [T]hat is how we hearten ourselves.[14]
Third, we can see that their offensive-defensive humor functions like an anesthetic, for in making those who use it appear insensitive, it dulls their fear and pain. There is a parallel, therefore, between the soldiers' humor and the emotional numbness that soldiers develop in battle. The most startling—and revealing—aspect of Bäumer's analysis
below is that into his insightful discussion of soldiers' numbness he himself injects, when speaking of Hans Kramer's body, a typical bit of offensive-defensive war humor.
I soon found out this much: terror can be endured so long as a man simply ducks;—but it kills, if a man thinks about it. . . . We want to live at any price; so we cannot burden ourselves with feelings which, though they might be ornamental enough in peacetime, would be out of place here. Kemmerich is dead, Haie Westhus is dying, they will have a job with Hans Kramer's body at the Judgment Day, piecing it together after a direct hit.[15]
The Battlefield and the Hospital
For several reasons, then, war humor is akin to medical humor. Soldiers and doctors cannot avoid facing fear, pain, dying, and death. Both groups understand that they themselves are as vulnerable as the wounded or dead around them. Of course, soldiers in combat may be wounded or killed at any moment whereas doctors tending their patients are not in imminent danger. Still, physicians cannot help but see in their patients' ills their own mortality; they cannot help but realize, like Shakespeare's Cymbeline, that "death/ Will seize the doctor too."[16]
To this grim situation from which they cannot escape, soldiers and doctors sometimes respond with a grim humor that is at once offensive and defensive. Why do they do it? A number of answers are possible.
1. This humor masks, mocks, or makes light of what one fears, including one's own vulnerability.
2. This humor makes the joke teller appear strong, insensitive, or cruel instead of weak and vulnerable.
3. This humor-armament interposes a protective shield between the object of one's fear and oneself. In that way, it keeps one from staring directly at the Medusa head of horror and death.
4. This humor is a coat of armor.
5. This humor has an anesthetic effect. It helps to mask pain, feelings, and fears with apparent numbness and insensitivity.
6. This humor pits obscenities of word and thought against the obscenities of suffering and death.
7. This is a humor of bravado, masks, and appearances which seeks to defy or deny realities that are too horrible.
8. This humor substitutes defiance for capitulation, aggressive action for surrender, courage or bravado for fear. It thus enables the soldier and doctor to defy death and fear instead of giving in to them. For example, as bombs fall on Bäumer and his company, he fires back with his wit:
There is always plenty of amusement, the airmen see to that. There are countless fights for us to watch every day. . . . [S]hrapnel and high-explosives begin to drop on us. We lose eleven men in one day that way. . . . Two are smashed so that Tjaden remarks you could scrape them off the wall of the trench and bury them in a mess-tin.[17]
What exactly is this horrible-helpful humor used by soldiers and by doctors?
Gallows Humor
Gallows humor (in German, Galgenhumor ) is humor with an eye always on death. Basically, it implies two things: ghoulish or macabre humor or the amused cynicism of a person facing disaster. There are excellent examples of gallows humor in Hamlet , Act V, scene 1, where the grave diggers. called First Clown and Second Clown, enter to dig Ophelia's grave. As they work, they talk—and jest.
First Clown . What is he that builds stronger than either the mason, the shipwright, or the carpenter?
Second Clown . The gallows-maker; for that frame outlives a thousand tenants.
First Clown . I like thy wit well. . . .
[While digging, the First Clown sings a ditty about love.]
Hamlet Has this fellow no feeling of his business that a sings in his grave-making?
Horatio Custom hath made it in him a property of easiness.
Hamlet . 'Tis e'en so. The hand of little employment hath the daintier sense. . . .
[Hamlet addresses the grave digger who is standing in the grave he is making.]
Hamlet . Whose grave's this, sirrah?
First Clown . Mine, sir.
Hamlet . I think it be thine indeed, for thou liest in't.
First Clown .. . . For my part, I do not lie in't, yet it is mine. . . .
Hamlet . What man dost thou dig it for?
First Clown . For no man, sir.
Hamlet . What woman, then?
First Clown . For none, neither.
Hamlet . Who is to be buried in't?
First Clown . One that was a woman, sir; but rest her soul, she's dead.[18]
Watching the tragedy, we appreciate the wonderful wit of this scene, which helps relieve the mounting tension created by the deaths that have already taken place and the deaths yet to come. We note, too, the grave diggers' apparent insensitivity to death, and we echo, perhaps, Hamlet's reactions: first his shock or offense at their joking and then his realization that their occupation has numbed and thus protected them from feelings that are too dainty or painful.
Gallows humor, therefore, makes use of protective numbing. But is that numbness freely gotten, or is it acquired at some cost?
In "Jokes and Their Relation to the Unconscious," Freud touches on the numbing and protective—and also costly—qualities of gallows humor. He gives two examples of this humor: (1) "A rogue who was being led out to execution on a Monday remarked: 'Well, this week's beginning nicely,'" and (2) "the rogue on his way to execution asked for a scarf for his bare throat so as not to catch cold."[19] Freud continues:
In the case of the rogue who refuses to catch cold on the way to execution we laugh heartily. The situation that ought to drive the criminal to despair might rouse intense pity in us; but that pity is inhibited because we understand that he, who is more closely concerned, makes nothing of the situation. . . . We are, as it were, infected by the rogue's indifference—though we notice that it has cost him a great expenditure of psychical work.[20]
Several things are significant here. First, instead of feeling pity, we laugh. We have exchanged a painful feeling for a happy one. Second, we understand that the rogue's apparent indifference—his protective coat of humor—has cost him "a great expenditure" of mental and emotional energy. Third, we realize that this cost applies to other tellers of gallows humor as well.
What do these findings about benefits and costs tell us about gallows humor, in general, and about the humor some doctors use, in particular? Are doctors different from other people who use gallows humor? Do patients sometimes use gallows humor?
In Experiment Perilous , Fox describes both the doctors who worked in an all-male, fifteen-bed metabolic research ward of a teaching hospital associated with a major medical school and the patients who were treated there over a period of time. Many of the patients had diseases that were not well understood and could not be effectively controlled. The doctors had to take care of these patients; they also had to experiment on them to try to devise better treatment
modalities. Not infrequently, the situation was tense and/or depressing. Several patients did not respond well, and several died. What is fascinating, however, is that doctors and patients coped with this grim situation in a similar way: gallows humor.
Here is how some of the doctors talked at one of their conferences:
Dr. D .: What you're doing, Bob, is evaluating these people as good merely on the basis of their not being dead, because so many of the others have died . . .
Dr. C .: Bill Pappas is a good result . . .
Dr. R .: And Walter Cousins was . . .
Dr. D .: Except now he's dead.
Dr. R .: Well, you can't liver forever! (Group laughter )[21]
Of the patients, Fox notes, "Like the humor of their physicians, the humor of patients was antithetic in nature: counterphobic and inversely reverent. . . . [They] joked about things which especially disturbed or frightened them, and about those to which they were positively committed or about which they deeply cared."[22]
It is significant that both physicians and patients used the same type of humor. That is, physicians confronting pain and death are not different from other people confronting the same situations and fears. Although to an outsider the doctors' aberrant humor might seem blasphemous, cold-hearted, or downright disgusting, it is—like the humor of others in the face of death—a bravado, a defense, and a means to fortify themselves against me horror and pain they feel and wish to conceal or overcome. When a doctor mocks his patients, his behavior is actually a symptom of his own distress as well as a kind of self-prescribed medicine to relieve his own pain and anxiety. Although this aberrant medical humor, like other forms of gallows humor, is macabre, it is also extremely helpful and healing. Gallows humor is, ironically, a lifeline.
Some Grave Conclusions
"The closest thing to humor is tragedy," wrote James Thurber.[23] We sense this fully in gallows humor, which includes medical humor. Such humor is, of course, ambivalent. It is filled with love and hate, hope and fear, laughter and tears. It can be understood, in part, by this insight from William Blake: "Excess of sorrow laughs."[24]
Why, then, do some doctors mock their patients? They mock them because—like soldiers in combat, the patients on the metabolic research ward, Freud's rogues, the grave diggers in Hamlet , and innumerable others—they need to defend themselves against anxiety and anguish, fear and pain, dying and death. And they mock them because, as Mark Van Doren said,
Wit is the only wall,
Between us and the dark.[25]