In Part One, Bromden recalls how Nurse Ratched has always run the hospital ward. He uses a simile and an allusion to convey the way she exerts power through a vicious hierarchy:
The technicians go trotting off, pushing the man on the Gurney, like cartoon men—or like puppets, mechanical puppets in one of those Punch and Judy acts where it’s supposed to be funny to see the puppet beat up by the Devil and swallowed headfirst by a smiling alligator....
The man on the gurney in this memory is Maxwell Taber, a former patient who often resisted taking medication. Bromden recalls how Nurse Ratched ordered the hospital technicians to force Taber into electroshock therapy over and over until it altered his personality, making him docile and obedient. Bromden compares the technicians and Taber alike to "mechanical puppets in one of those Punch and Judy acts." Punch and Judy are characters in a traditional puppet show that has been especially popular at English seaside carnivals since the 17th century. A married couple, the Punch and Judy puppets get up to any manner of violent exploits. Sometimes they fight adversaries like the Devil or an alligator, and sometimes they fight each other. There are recurring themes and characters in Punch and Judy shows, but what happens in any given show is up to the puppeteer. The show has faced criticism for the way it depicts violence, especially domestic violence. Puppeteers still put on the show, but many have attempted to turn Punch and Judy's violence toward societal issues rather than each other.
By comparing Taber and the technicians to Punch and Judy, Bromden highlights the repetitiveness of the power struggle between the hospital staff and the patients. The same fights play out over and over again, just as they have in Punch and Judy acts for the past several centuries. Taber refuses his medicine, the technicians try to force him to take it, and they end up in a physical fight all the way to the electroshock therapy room. At the same time, the comparison highlights that neither Taber nor the technicians are in charge of the situation. Ultimately, Nurse Ratched is behind the whole show. She is the puppeteer pulling the strings, enforcing the hierarchical power struggle. She wants to put on a show for the other patients not to make them laugh, but to warn them not to refuse their medication lest they end up held down on a gurney.
The comparison furthermore highlights the fact that Nurse Ratched is not acting on her own to enforce hierarchy on the ward. A puppeteer inherits the characters of Punch and Judy from generations of Punch and Judy shows. They are somewhat in control of what happens in their own show, but they must abide by the basic rules that make for a Punch and Judy show. Nurse Ratched, likewise, has inherited societal ideas about what a psychiatric ward should look like. She is in charge of how hierarchy is enforced on her own ward, but she is ultimately serving a system that is much larger than herself.
In Part One, McMurphy delights the rest of the patients by getting Doctor Spivey to announce some changes he has suggested during his admission interview—changes Nurse Ratched has not previously approved. Bromden uses a hyperbolic simile (and a racial slur) to describe the power struggle that is beginning to simmer:
One by one the patients are sneaking looks at her to see how she’s taking the way McMurphy is dominating the meeting, and they see the same thing. She’s too big to be beaten. She covers one whole side of the room like a Jap statue.
Bromden compares Nurse Ratched to a huge Japanese statue that takes up half the room. There is no way the nurse truly takes up half the room, but Bromden often perceives her as a larger-than-life figure. He hallucinates that she is giant because her power makes her feel giant to him. By exaggerating her size in his mind, he accounts for the threat she poses to the entire room. Bromden also imagines that McMurphy is a giant. This moment is when these two "giant" characters lock in on one another as adversaries. In Bromden's imagination, the hospital is literally "not big enough for the both of them."
The simile also hints at Bromden's past fighting in World War II. He does not compare the nurse to a "Japanese" statue, but rather uses a racial slur for a Japanese person. This slur was popular in the United States during and after World War II because of Japan's alliance with Nazi Germany. It was still common (though nonetheless hurtful) when Kesey was writing. Bromden does not share very much about his military history, but moments like this serve as a reminder that he is just as embroiled in the politics and trauma of the twentieth century as anyone living outside a mental hospital.
In Part Three, McMurphy signs Bromden up to go on the fishing trip. Bromden notices the jealousy of the other "Chronics" and uses a simile to describe what differentiates him from the rest of them:
They could sense I had been singled out as the only Chronic making the trip. They watched me—old guys welded in wheelchairs for years, with catheters down their legs like vines rooting them for the rest of their lives right where they are, they watched me and knew instinctively that I was going. And they could still be a little jealous it wasn’t them.
A catheter is a tube that drains urine from the bladder when patients are, for various reasons, unable to urinate regularly on their own. Bromden compares the men's catheters to "vines rooting them for the rest of their lives right where they are." Needing to drain a catheter bag or change a catheter may be an inconvenience, but it does not necessarily stop a patient from participating in daily activities. In fact, catheters are adaptive devices that allow many disabled people to take care of an important bodily function and move about their days with dignity. However, in the context of the novel, the need to use a catheter represents a major loss: it means the men no longer have control over their own genitals, and they depend on the hospital's technology and care to perform a basic bodily function. In the context of the novel, to need a catheter is to be emasculated and to lose control over one's own body. This emasculation and loss of control, more than the physical limitations of having a catheter, are what "roots" the men in place with no prospect of fun or adventure.
Bromden feels that his lack of a catheter is what distinguishes him from many of the other "Chronics." Unlike them, he thinks, he is not slowly turning from a human into plant matter, a "vegetable" rooted to the floor of the hospital with medical "vines." The way the book pities disabled men with greater support needs, as though they are lost causes, is worth a critical look. However, this is an important moment in Bromden's realization that maybe he doesn't need to be a lost cause himself. Unlike the men who really do rely on round-the-clock care, Bromden has the ability to walk out the door of the hospital and live a life beyond Nurse Ratched's control.