Note

The following is the full text of an article by my late father (10 Feb 1922- 18 March 1979). It has been typed up for web publication by my mother, Alice Zeitlyn.

We are making available online to mark what would have been his 90^th birthday having realised that the short-lived journal History of Medicine (ISSN 0046-7618) in which it appeared has not been indexed by PubMed or any other similar indexing service, hence has become invisible unlike his other publications.

The full citation is:

Jokes and the Doctor-Patient Relationship

by Bernard B. Zeitlyn

Reprinted from the History of Medicine Spring Issue 1972, Volume 4 No. 1 pp 10-12.

Doctor: "How do you feel, Colonel, when you have actually killed a man?"

Colonel: "Oh, not so bad. How do you?

This 1915 joke from Punch would perhaps shock if it did not produce laughter because of its implications are so much at variance with the traditional notions of the doctor-patient relationship, where the doctor is the benevolent healer and the patient the grateful recipient of his services. By placing both participants outside their customary roles and by allowing the patient to voice something which should be unspoken if not unthought, the joke achieves its humerous effect. It also points to some of the complex factors influencing the doctor-patient relationship as described, for example, by Balint (1957 1965), Browne and Freeling (1967) and Clyne (1958)

The importance of the hostile element in many jokes is generally acknowledged (Koestler, 1964) and has been studied experimentally (Byrne, 1956); (O'Connell, 1960, 1964); (Freud, 1905) distinguished between tendentious jokes, providing indirect expression for aggressive or sexual drives, and 'innocent' ones, in which pleasure derives from the mental activities associated with the verbal technique of the joke (puns, play on words, etch.) These two forms often occur together, with the distraction necessary for the enjoyment of the tendentious joke being provided by its 'innocent' component (Gollob and Levine, 1967).

To see how attitudes to doctors, dentists, patients, and to illness were portrayed in jokes, those in Punch were examined in the fifty years from 1900. Although Punch jokes express a middle-class English sense of humour (Brien, 1968), they may perhaps also illustrate factors in the doctor-patient relationship of general application. In the series of some 560 examples, the middle- and working-classes were the subject of the joke in almost equal proportions in the first three decades. Afterwards the middle-class and in deed the classless joke became more frequent. Those about the 'upper' class were generally fewer and occurred particularly in the early years.

As can be imagined a wide variety of topics were joked about. Gout, obesity, drink, 'flu and vaccination provided the subject for a small regular number of jokes until the 'thirties especially, There were rather more about the dental situation during the time in question, while jokes about psychiatrists and psycho-analysts, although generally not appearing until the early 'twenties, became quite frequent by 1940-49.

All the jokes collected were found in roughly equal proportions in each decade. Apart from one joke in 1907 in a series about women in the professions, and another in the First World War, all the doctors portrayed were male and until latterly, were depicted in their 'traditional' clothes.

The two world wars showed interesting differences. Wounded soldiers, often shown in a sentimental light as perhaps rather nave or childish heroes and the misunderstood victims of over-solicitous civilians, figured frequently in the first world war but rarely in the second. Jokes set in a military hospital were a feature of the 1914-1 8 period but not later, and while civilian hospital wards became the site of some jokes from the early thirties, no special emphasis in the Second World War seemed to have occurred. Army-board and sick parade jokes turn up in both wars and indeed to some extent replace the consulting room and bedside situation of other times.

Throughout the series a number of jokes concerned the doctor's life and the events affecting it. The 1911 National Insurance Act led to some anticipation of the crowded waiting-rooms that would follow, with the wealthy patient having to take his turn in the queue with everyone else. A larger number of jokes concerned the advent of the National Health Service in 1948. They centred on the bonanza of free spectacles, beards and trips abroad it would bring, as well as about its bureaucratic consequences.

The jokes lent themselves to no simple classification and were often open to several interpretations. Many showed the patient as ignorant and foolish, and misunderstanding medical terms and procedures. He is suspicious of the doctor, sceptical of his motives, and endowing him

with sentiments about his patients foreign to the Hippocratic tradition. In this respect too a group of jokes portrayed the patient's dealings with his doctor as a form of battle with the patients deflating or defeating the doctor or protecting himself and his family from the doctor's attentions.

In the first three decades especially, a good number of jokes, as indeed with non-medical ones too in this time, depended on puns and play on words. The poor, the proverbial 'sweet old lady' or a child provided the literal or mistaken remark to achieve the joke's effect. In 1904, to the doctor who enquires whether the patient has taken his medicine, the latter replies:

"Yes, doctor, I've taken all the tabloids you sent, and now I want a new persecution."

Visitor: "But those attacks of malaria don't last long, do they?"

Tommy: "Mine isn't ordinary malaria. The doctor calls it 'malingering malaria'."

Most jokes of this type, however, had a less obvious meaning and perhaps approximated more to Freud's 'innocent' variety.

Doctor: (to Mrs. Perkins whose husband is ill): "Has he had any lucid intervals?"

Mrs. Perkins (with dignity): "he's 'ad NOTHINK except what you ordered, doctor!" (1903)

Doctor: "Has your husband religiously followed the diet I prescribed?"

Cottager: "Well, sir 'e always says grace at every meal." (1921)

Maidservant: "I went to the oculist, Ma'am, and 'e says I want long-distance glasses.

But I shan't get 'em as I never goes further than Tootin'." (1930)

Doctor: "Bring the auriscope, nurse."

Old lady: "Oh, doctor, are you going to tell me the future?" (1935)

Other jokes of this group play on the use of temper for temperature, dognose for diagnosis, convex for complex, vituperate for recuperate, barometer for thermometer, and so on. But apart from these 'mistakes' the joke no doubt also achieves its point through disparaging the ignorant on the basis of 'they're foolish and I'm not'. Sometimes the patient's ignorance seems too good to be true and to amount to a provocative misunderstanding of the doctor's instructions or intentions. In addition jokes, by ridiculing and reducing unknown and threatening experiences to everyday terms, make these dangers less frightening and therefore more manageable.

Class is no barrier to the idea of the foolish patient and the fads, snobbishness, and hypochondriasis of the wealthy are used to make this point:

"I've got such a pain in my heart, doctor, - just here."

"But your heart isn't there!"

"Ah! Then that's what's the matter it's moved!" (1932)

"..... but you must be fair, doctor you have my rheumatism, so I've given my lumbago to Dr. Jervis." (1948}

The doctor too receives his fair share of attention. The jokes indeed seem to delight in picking out qualities in him at variance with his conventional role. Thus there is always the joke where a slip of the tongue or an 'unfortunate' figure of speech shows him as other than benign and benevolent:

Doctor (in his own consulting room to [obese] lady whom he has always hitherto seen at home: "Well, madam, this is indeed a case of the mountain coming to Mahomet!" (1903)

"I'm sorry the place is such a pig-sty, doctor."

"Ah, my dear lady, the sty doesn't matter if the pig's all right. " (1935}

Then there is the group in which the doctor is viewed as useless or as a burden to his patient and even as downright dangerous:

Wife: "I'm sorry, doctor, but my husband can't see you today. He's not feeling well enough." (1927)

Panel Doctor: "Did that last bottle do you any good?"

Patient:"Yus I got tuppence on it." (1935)

Physician: "And would you like to be a doctor, Jack?"

Mother: (While Jack is still hesitating)

"No, no! The dear boy couldn't hurt a fly!" (1910)

Patient: "I've been awfully troubled lately, doctor, with my breathing."

Doctor: "Hum! I'll soon give you something to stop that." (1911)

She: "Oh, doctor, I am so anxious about poor Mrs. Perkins. She is in your hands is she not?"

Doctor: "She was; but I've left off attending her for the present."
She: "Oh, that's good! She's out of danger then !" ( 1901)

While the doctor's omniscience and omnipotence are brought out as well in these last examples:

Patient "I hear they're saying that Jones, the man you've been treating for liver complaint, has died of heart trouble."

Doctor (acidly) "When I treat a man for liver trouble he dies of liver trouble." (1911)

Heart Specialist: (meeting patient whose case he had pronounced hopeless a year ago): "You still alive! What confounded quack has been tinkering with you!" (1931)

The 'battle' jokes are self-evident: they indicate the patient without awe or respect for the doctor and on a familiar or equal footing with him. They also illustrate the situation where the doctor is defied, checkmated, and survived.

Patient's wife: "Well, doctor, I say it's influenza. What's your humble opinion?" (1909)

Distinguished physician (handing prescription to patient): "if this doesn't put you right, come to me again"

Patient: " How many guesses will you want?" (1926)

Patient: "One moment, doctor, before you start, I dont drink, I don't smoke. I never take tea or coffee, and I never in my life ran for a train or a bus.

So what?" (1937)

"And on your way here, doctor, would you mind calling at the fishmonger's" (1944)

One patient to another about departing doctor at a ward-round:

"Every damn day I want to ask HIM how I am and he always gets in first asking ME how I am." (1945)

"Well, doctor, if YOU say I'm well enough to come to you and I say I'm ill enough for you to come to me, let's meet each other halfway - say at the bottom of Acacia Grove?" (1949)

That jokes serve to allay anxiety (Levine and Abelson, 1959) is generally recognised and the part they play in dealing with the anxiety of illness is understandable. What is perhaps less clear are the reasons for the hostility they appear to express. Zilboorg (1941) emphasises, however, that originally the fear and the threat of illness caused the patient to impose on the doctor an idealised character and way of life. Any departure from this idealised position could therefore be expected to provoke anger which would be better dealt with jocularly than by the actual rejecting of the doctor. A predicament of illness lies, no doubt, in the difficulty of tolerating human failings in someone

who should be more than human to deal with so threatening an experience.

Jokes try to solve this dilemma by laughing the doctor's failings away and by safely ventilating the anger his ineffectiveness produces. The fact that the doctor could actually be defeated, that he might fail to cure, is so disturbing that the possibility perhaps needs to be worked through in jokes. The idea that the doctor may feel hostile or reciprocate hostile feelings is also less disruptive in jokes than outside them.

Although this is not the place for a detailed consideration of psychopathology, it might be helpful to recall that childhood reactions to parents are transferred to the doctor-patient relationship. Flugel (1921) points out that the attribute of benevolent omniscience is especially liable to be transferred to the doctor because of the contrast between his special knowledge and the patient's relative ignorance. The doctor's role also emphasises the latter's sense of helplessness, akin to that experienced by young children, and increased by the regression that illness can bring. Jokes make helplessness and dependency more tolerable. These states are perhaps recognised by the not infrequent portrayal of the patient in rather childlike postures.

But jokes which portray the patient as childlike may be giving recognition too to the fact that the doctor-patient relationship is coloured by the earlier one between parent and child, and that in childhood the doctor has an especially significant role. In the 'defeat' of the doctor, for example, it could be relevant that the child can view him as punitive or as a threat to secrets which should be preserved. The patient's innocence and ignorance in the jokes may likewise have something to do with the child's needs to deny certain types of knowledge.

The jokes generally give no impression that pain or the threat of it is so integral a part of patient experience. Pain seems to figure when it is 'imagined' by hypochondriacs; or if due to gout, although here the frustration of an immobilised irascible old man in fact appears often more important than his pain; or when it is inflicted by the dentist.

While the specific problems of the dental situation require separate attention, certain features of these jokes can serve to illustrate general reactions to pain and to those who inflict it. Normally the dentist is visited without too much difficulty although no doubt with some trepidation that is usually well controlled. The dental joke, however, in all decades gives open expression to the fear and cowardice felt in these circumstances.Thus in 1925 there is the picture of a man crouching under the waiting-room table, with the caption 'Mr. Bigheart decides to let his turn pass.' And in 1929:

Dentist: "You're next, Mr. Smith."

Mr. Smith (his courage departing) "Well, as a matter of fact I only came along to know if you'd mind drilling a hole in a lucky sixpence."

Dentist: "Anyone in the waiting room?"

Maid: "Yes Sir, a gentleman; but he's locked hisself in." (1930)

There are also those showing the dentist as callous or sadistic and his treatment especially painful:

Dentist: "I didn't know you had this tooth filled before. I see there's some gold on my drill."

Patient: "I haven't. I think you must have struck my back collar-stud." {1926}

Dentist (cheerfully, to terrified gagged patient in dental chair): "Personally I can always see the funny side of things, but I find so many of my patients have no sense of humour." (1929)

Dentist: "Now, if I hurt you, just let out an agonised shriek." (1947)

A smaller number of jokes have the patient quite without fear or maybe denying it, but certainly not cowered by the dentist:

Dentist (as usual): "Now, my little man. I am not going to hurt you."

Small boy (who has been before): "Liar!" (1925

Patient: "Well, thanks very much for pulling that out. By the way, I hope you don't mind if I go back into the waiting room for a bit. I rather want to finish a story in one of your magazines." (1928)

There are, too, examples, particularly towards the end of the series, when the tables are turned, the victim gives as good as he gets, a case, literally, of the biter bit:

Cheerful dentist with drill, to aghast colleague in dental chair: "I suppose I needn't tell YOU the excruciating agony this one's going to give you." (1940}

"Now remember, Mrs. Barton, no biting." (1944)

Calm patient comforting smaller dishevelled dentist with black eye:

"There it wasn't so terrible after all, was it?"(1945)

Dental jokes then allow grown men to express fear and cowardice not normally tolerated. They provide for retaliation impossible outside fantasy or humour. But to some, dental attention can relate to profound neurotic problems and have altogether a greater significance. Dental jokes perhaps convey something of these private nightmares. They also ward off danger and unarm the aggressor whose defeat reassures that we can survive attack and live to fight and joke another day.

REFERENCES

Balint, M. (1957) The Doctor, his Patient and the Illness. London. Pitman

Balint, M. (1965) "The doctor's therapeutic function," Lancet. I 1170-80

Brien, A. (1968) "Mr. Punch's Merry Pranks". The Sunday Times, 6 October

Browne, K. and Freeling, P. (1967) The Doctor- Patient Relationship. Edinburgh: Livingstone.

Byrne, D. (1956) J. Abnorm. Psychology. 53, 84-89.

Clyne, M.B. (1958) "The doctor's attitude to his patient".Lancet I 232-5

Flugel, J.C. (1921) The Psycho-Analytical Study of the Family. 120ff. London: Hogarth press

Freud, S. (1905) Jokes and their relation to the Unconscious. (trans. J. Strachey 1960).

London: Routledge & Keegan Paul.

Gollob, H.F. And Levine, J. (1967) J. Personality &Social Psychology, 5. No. 3. 368-372

Koestler, A. (1964) The Act of Creation. London: Hutchinson.

Levine, J. and Abelson, R. (1959) J. General Psychology, 60, 191-200

O'Connell, W.E. (1964) J. Abnorm. & Social Psychology. 61. No. 2. 263-270.

O'Connell, W.E. (1964} Psychoanal. Rev. 51, 49-56.

Zilboorg. G. (1941) A History of medical Psychology. New York: Norton.

Acknowledgements

The author wishes to thank the Editor of Punch for permission to reproduce the material from that magazine.