Humor in medicine: Can laughter help in healing?

Norman Cousins. If you recognize the name you probably will connect it with the one-man movement championing laughter as a form of medical therapy back in the 1960s. The controversy over this has simmered on and off ever since and perhaps is due for a revisit. But, before exploring the element of humor in the literature of medicine and its potential as a therapeutic agent, an overdue confession is in order.

In the fall of 1963, having completed 2 years of training in cardiovascular research at the University of Utah, I took my first step up the academic medical ladder with an appointment as instructor of medicine at what was then Seton Hall College of Medicine in Jersey City, New Jersey, and is now Rutgers New Jersey Medical School in Newark. On one fateful afternoon, I entered the office of my new chief to deliver some paperwork that needed his approval. The office was completely deserted. As I dropped the papers on the secretary's desk, I saw a file resting there with my name on it. The urge was irresistible. Without even pausing to consider the propriety of my act, I opened the file and found on top of the contents the letter of recommendation that my former chief in Salt Lake City had sent to my current one.

“Dr. Weisse is not the best fellow we have ever had,” it read, “but he is not the worst.” Then, as if to compensate for this less than resounding endorsement, he added, “Dr. Weisse does have a good sense of humor.”

The words jolted my memory back to an even earlier period when I was labeled the good humor man. When I was in the senior graduating class at George Washington High School in New York City in 1946, my schoolmates, in selecting “Senior Celebrities,” saw fit to name me as Best Natured. When I reported this honor to my family, they could not stop laughing. At home I was known as the one with the short fuse and towering tirades. They thought it was hilarious that I had received such an award. “Allen the Terrible,” I am sure they would have picked as a better fit.

I wonder now if, all the years since, I have been trying to live up to this reputation, to soften my image and become a nicer person for my colleagues, patients, and students. Beyond my personal attributes, I began to think about how “good nature” and its first cousin “good humor” may have been part of medical literature over the ages and also whether or not this may have had any bearing on the course or outcome of illness in the patients we have attempted to serve.

To evaluate in some way how much humor had permeated the literature of medicine in the past, I began by examining the creative writing of those physicians who were well recognized as having distinguished themselves in this way instead of or in addition to their contributions to medical science. How much of this writing was humorous? Then I tried to identify the works of nonphysicians who had achieved renown by poking fun at the profession in some way.

In the first category, as early as the 16th century, we have the example of Dr. François Rabelais producing his comic masterpiece Gargantua and Pantagruel. Since that time I am sure there have been others of whom I am not aware. But what I did find impressive was the cluster of candidates for such recognition from the mid 19th century and well through the 20th century.

We remember Anton Chekhov mainly through his plays. Although it has been observed that there is a vein of humor through this body of work skewering a certain segment of Russian society, when I think of Chekhov's plays I am more often seized by thoughts of unrequited longing, self-delusion, depression, and death.

Arthur Conan Doyle was indubitably one of the most successful physician-authors with his widely popular Sherlock Holmes stories. However, engrossing as they may be, funny they are not. There is another Holmes, closer to home, who merits consideration. Oliver Wendell Holmes, the physician father and not the jurist son, was one of Boston's Brahmins and a celebrated practitioner as well as a man of letters. He was known for his witty pronouncements, one of which is often quoted today. In expressing his dismay about the many nostrums, unproven and sometimes dangerous, prescribed by the doctors of his day, Holmes quipped, “I firmly believe that if the whole materia medica as now used could be sunk to the bottom of the sea, it would be all the better for mankind—and all the worse for the fishes.” But a venture into one of his major works, The Autocrat of the Breakfast Table (1), fell short of humorous expectations. In it Holmes surrounded himself with imaginary characters contributing to what turned out mainly to be almost 400 pages of monologue with a few memorable verses and just a scattering of verbal gems among long stretches devoid of such rewards.

S. Weir Mitchell, a contemporary of Holmes, has been called the father of American neurology. Clinically he made his reputation by introducing the rest cure for neurasthenia and hysteria, popular diagnoses in the post–Civil War era, as well as his work on nerve injuries and gunshot wounds. Toward the end of his career, he devoted himself more to novels and these, at the time, were once popular but devoid of humor, with the possible exception of a sardonic novella entitled The Autobiography of a Quack (2).

Outstanding among this group of late 19th and 20th century physicians was William Osler, one of the founding professors at Johns Hopkins Medical School and the most revered physician of his time. Unlike these other doctors afield, from early childhood Willy was an indefatigable prankster whose practical jokes got him expelled from one grammar school and punished by a few days in jail while attending another. By the time he reached adulthood, he chose to follow his mischievous inclinations in another way within a professional world still dominated by Victorian rules of conduct. He adopted the pseudonym of Egerton Yorrick Davis, in which guise he contributed to the medical literature amusements that ranged from the relatively tame “Burrowings of a Bookworm” on bibliomania to the frankly salacious and completely bogus case report of vaginismus causing penile entrapment of an imaginary coachman and a housemaid who, reportedly, could not uncouple following a roll in the hay (3).

Of all the physician authors identified, W. Somerset Maugham must be considered the most prolific and successful. Although he earned a medical degree in 1897, he never practiced medicine but went right to work as a creative writer. Over a career spanning almost 70 years, he produced over two dozen novels and even more plays. Although best remembered for serious works that included “Of Human Bondage” and “The Razor's Edge,” the tireless Maugham also produced 90 short stories, among them nine very funny ones including “The Facts of Life” and “Three Fat Women” (4).

Bringing this list up to date, we should consider authors Sherwin B. Nuland, Oliver Sacks, Michael Crichton, and, more recently, Atul Gawande. But their worthy contributions have all been deadly serious with no room for frivolity.

In the second category, that of nonphysicians who have made their mark by setting their humorous fictional work within the field of medicine, there is Molière, who achieved great success by ridiculing the physicians of his day in plays like “A Doctor in Spite of Himself” (1666) and “The Imaginary Invalid” (1673). More recently, we have had Joseph Heller as a prime example. His antiwar book Catch 22 was published in 1955 (5). The locale is an American air base and hospital located in the Mediterranean during World War II. The world Heller creates is one that, due to the ravages of war, has lost its moral compass, where perversity has become the casual norm and logic has disappeared. Amid the outbursts of laughter that reward the reader there persists a frisson of despair.

Thus far we have only considered what traditionally has been thought of as literature: the printed words of novels, plays, and nonfiction. However, motion pictures and television play an increasing role in our lives, and I have included these two modalities in what might be called our cultural heritage.

Dr. Peter E. Dans has been an avid film buff all his life, with a special interest in the portrayal of physicians in this medium. His book, Doctors in the Movies: Boil the Water and Just Say Aah (6), catalogues 176 features that appeared between 1931 and 1997. Although there is a good representation of biographies (Louis Pasteur, Paul Ehrlich, Walter Reed) and melodramas (Men in White, The Hospital), the yield of comedies is small. Small but far from inconsequential. M*A*S*H, with a screenplay by Ring Lardner Jr. based on a book by Richard Hooker, is set in a mobile army surgical hospital during the Korean war. The main characters are two trauma surgeons, ill-suited to the military roles they have been forced to play. They maintain their equilibrium amidst the carnage surrounding them by perpetrating a series of practical jokes fueled by a seemingly endless supply of homemade martinis. Produced in 1970, 5 years before the end of the Vietnam War, M*A*S*H reflected the growing antiwar spirit spreading throughout the country. The television series that followed was one of the most successful in television history, with 256 episodes and a viewing audience of over 121 million for the final broadcast.

Another notable entry of quite a different comedic character is Doctor in the House, actually a British film rather than American. In it we follow a group of medical students through their training. With an impeccable cast and sparkling dialogue delivered with a mixture of tongue-in-cheek and slapstick humor, the story is told in a style that only the Brits seem to have mastered. It led to a number of American television imitations, but none with the panache of the original.

A final category of medically derived humor, one not mentioned so far, is that of cartoons involving medical subjects, as have appeared in The New Yorker (7) and other periodicals much to the delight of their readers.

To summarize, it appears that, although humor occupies a relatively small space in our cultural canon, the public's appetite for such material is large. Next question: What role, if any, can humor play at the bedside when we are unfortunate enough to fall seriously ill?

Such questions immediately invoke the memory of Norman Cousins, who took charge of his own illness and turned conventional medicine on its head. His story is related in his memoir, Anatomy of an Illness as Perceived by the Patient (8). In 1964, Cousins, at that time editor of the Saturday Review, was stricken with a debilitating inflammation of the spine (then diagnosed as ankylosing spondylitis). He lay mortally ill in the hospital, unresponsive to the various medications being prescribed for him, mainly painkillers. He had become desperate about his condition and, somewhat aware of the writings of those such as Walter B. Cannon and Hans Selye which dealt with the “wisdom of the body,” he took charge of his own care. He set himself up in a hotel room and, monitored by a sympathetic physician, instituted a new regimen, which consisted primarily of massive doses of vitamin C—later research would show that the analgesics he had been receiving could block absorption of this vital substance—and equally large dollops of laughter induced by exposure to such entities as Marx Brothers movies and episodes of Candid Camera. Gradually his symptoms began to recede. Cousins even felt he could quantify the amount of improvement with the degree of laughter engendered. The only objective gauge of his status that he kept was the red blood cell sedimentation rate, an indication of the amount of inflammation within his body. This dropped precipitously from very high levels toward normal as his condition improved.

News of Cousins's remarkable recovery resulted in great interest and considerable celebrity. He became an invited lecturer at conferences throughout the country and even received a faculty appointment as adjunct professor of medical humanities at the medical school of the University of California in Los Angeles. He died in 1990 from coronary heart disease and congestive heart failure, 26 years after his experience with inflammatory spine disease.

A less dramatic but nonetheless moving testimonial to laughter was recorded by Joseph Heller and his friend Speed Vogel in the book No Laughing Matter (9). In 1981 he was felled by a crippling paralytic disease (Guillain-Barré syndrome). Heller recounts how his many friends assisted in his recovery by contributing their presence at the bedside with encouragement and an endless stream of anecdotes, gossip, and jokes.

In 1982 paleontologist Stephen J. Gould, then 40 years old, was found to have an abdominal mesothelioma. This is a rare but aggressive tumor, and Gould learned the median survival time was only 8 months. If this held for half of the patients so afflicted, there were the remaining patients, including some who might survive much longer. Rather than sink into hopelessness and despair, Gould decided to fight with proper attitude lined up with excellent medical management. He survived 20 years following the diagnosis, finally succumbing to unrelated metastatic lung cancer in 2002. Gould never gave up. He wrote about that first battle with cancer in 1985 in a paper entitled “The Median Isn't the Message” (10). In it he concluded, “The swords of battle are numerous, and none more effective than humor.”

An unusual approach to alternative therapy has been practiced by Dr. Hunter D. “Patch” Adams. For over 45 years, he has been donning a clown costume to entertain and raise the spirits of severely ill patients, especially children (11). His work continues thanks to the Gesundheit Foundation he established for this purpose. Adams has urged other physicians to join him in the movement, which he describes as “a dedication to goofiness.” He claims, “Laughter is the white noise of happiness. … Comic relief is a major way for happy folk to dissipate pain.”

However, most physicians are constitutionally incapable of smearing on grease paint and donning rubber noses, baggy pants, and oversized shoes in preparation for ward rounds. There are those, like Osler, however, who manage to sustain their youthful sense of wonder and use this to communicate particularly to the sick children and others who come under their care. But how do you quantify all this? How to measure the width of a smile? How to determine the weight of a guffaw? We live in a medical world of statistics and worship at the altar of the randomized prospective trial—and if double blinded so much the better. And every once in a while some brave soul will attempt to present a sober assessment of the problem. Such a one is Robin Nunn who, in 2011, entitled a PhD thesis “How Do We Know What Is the Best Medicine? From Laughter to the Limits of Biomedical Knowledge” (12). In it, the author wrestles with the vagaries involved in such efforts without really resolving the difficulties in undertaking such a project. Not surprisingly, no hard conclusions are reached, and certainly none that would have dissuaded enthusiasts from establishing the Association for Applied and Therapeutic Humor and hundreds of “laughter clubs.” These have spread all over the world, with all of them dedicated to the proposition that laughter can extend the joy of our healthy years as well as ameliorate the burdens of illnesses when they do befall us.

Finally, I feel compelled to provide my own testimonial as to the effects of humor on illness as well as comment on my role as a sometime humorist writing for the enjoyment of others.

Some years ago, following extensive surgery, I was given a humorous novel to cheer me up during my hospital convalescence. Some passages were screamingly funny and elicited uncontrollable bursts of laughter. Even though these produced painful stretching of the recently applied sutures holding me together, I nonetheless felt, on balance, that these sessions had unequivocally speeded up the stages of recovery, much in the way that early ambulation does for postsurgical patients.

Looking back on over a hundred articles and chapters I have written on various topics over the last four decades, I found only a half dozen purely comedic in intent. One of these, composed back in 1979, was especially instructive and pertinent to the unpredictable role of humor (13). It was an article submitted to the magazine New Jersey Monthly recounting—in an amusing way, I thought—my responses to a program of major dental reconstruction. Although the piece was cast in a comic mold, I was unrelenting in depicting my ignorance and naiveté as a patient.

I recalled a visit to the diagnostic clinic at the dental school where the director took one look inside my mouth and reeled at the extent of the wear and tear he beheld. Only in betel nut–chewing South Sea islanders and Eskimos who softened seal skin with their teeth had he seen such a sight. In my case it was the result of lifelong grinding of the teeth (bruxism). With my permission he invited a group of students to my side, where they could gaze within, barely suppressing their “oohs” and “aahs” over the scene of dental devastation that greeted them.

What disturbed me the most, however, was my ignorance over the stratospheric costs involved in restoring my teeth to a functional state. One night, the evening before I was to visit with the prosthodontist to be informed about the cost of this reconstruction, I awoke in a cold sweat, nearly knocking my wife out of bed. I had dreamt that the cost would be $7000. My wife reassured me that this was just a result of my exuberant imagination. It could not nearly be that expensive. The next day I was informed by the dentist that the figure would be about $11,000—$39,000 in 2016 dollars.

The editor at the magazine was enthusiastic about the subject matter and made my article the lead piece of the September 1979 issue, complete with an illustration on the front cover. Of course he had some ideas about “juicing up” the article, to which I readily agreed. The original title was replaced by a more provocative one: “Drilling for Gold: An Odyssey Through the World of Oral Surgery, Reconstruction, and High Finance.” The fictional physician on the cover was represented by a snarling, overweight middle-aged fellow waving an accusing finger under the lines “A Doctor Speaks Out Against Dentists.” Providentially, it was decided to conceal my identity as author with the pseudonym of “John Q. Physician.” I say “providentially” because I was about to be whacked by the law of unintended consequences. Although my personal dentists were amused by the piece, accepting it as originally intended, they appeared to be the only two dentists in the state of New Jersey who did. The rest, apparently, considered it an attack on the whole dental profession. It also seemed that most of them had subscriptions to New Jersey Monthly and, in addition to letters of protest came cancellations so numerous that the financial status of the magazine, already in a precarious condition, was severely threatened. Fortunately, the uproar finally abated and the magazine survived to continue in print until the present—without any assistance from me.

Such an experience only emphasized the difficulty in coming to any firm conclusions about the use of humor in medical practice. What we can do is remain hopeful when it will do no harm and, perhaps, provide some benefit. What we must do is remain humble. I recall the words of a famous actor on his death bed. While friends, family, and colleagues tearfully gathered around him, he tried to comfort them.

“Dying is easy,” he claimed. “Comedy is hard.”