Heard the one about the two

doctors?

One great specialist says to the other as they lean over a new patient, "Well, doctor, shall we treat him -- or let him live?"

That one is making the rounds in the Soviet Union, where comedian Arkady Raikin uses it to regale his audiences.

But medical humor knows no national boundaries. Jokes, says Dr. Frederick Goodwin of the National Institute of Mental Health, are "legitimate coping mechanisms. They offer a sense of relief and give a feeling of mastery over a scary situation," such as illness.

So, if you're told that you're sick, laugh.

Or -- brace yourself -- if you're told that you might even die, laugh harder.

It sounds crazy, but there is good evidence that if you force yourself to smile, no matter how you feel, you start feeling better. Even when you make yourself smile, there seems to be a chemical reaction in the brain, perhaps a reaction to increased blood flow or facial temperature, that creates a sensation of pleasantness.

When you actually laugh, scientists believe, the brain is so stimulated that it pours out endorphins and enkephalins, powerful chemical pain relievers. There is a shower of adrenaline and similar hormones throughout the bloodstream, stimulating the heart and lungs.

The heart beats faster, arteries contract and blood pressure temporarily rises. The blood is more thoroughly oxygenated. The body's production of immune cells increases.

Facial muscles, the diaphragm, heart, lungs, thorax and abdomen -- all vibrate in a muscular massage that writer and laughing advocate Norman Cousins calls "internal jogging."

When you stop laughing, arteries and muscles relax, reducing blood pressure. The whole process, some researchers believe, may help digestion, work as a healthful laxative and even burn up some calories.

Whatever happens in the body and brain when you laugh -- and it is certainly a lot -- scientists make one thing clear: Humor will not cure disease or prevent death.

But there is a growing belief that a sense of humor is good for your health and can make you feel better. A strong dose of laughter may relieve or reduce fear, stress, pain and depression. And in recent years, some people in the medical community have started to take advantage of the healing power of humor to help people accept the unacceptable. ::

Pianist-comedian Victor Borge spoke at the National Press Club last month. He told of his father's funeral in Denmark and how the pallbearers who carried the casket wore formal outfits and hats, none of which quite fit them.

"And I turned to my mother, who was grief- stricken and whose arm I was holding, and said, 'If father could see this, he'd be dead anyway.' " ::

When it comes to life, babies virtually enter laughing. Charles Darwin, the British naturalist who was the father of the survival-of-the-fittest theory of evolution, explained that laughter is an adaptation, a way an infant can signal well-being and elicit more adult behavior that enhances its well-being. Lacking sophisticated language, prehistoric peoples may have laughed as a self-preserving signal of peace or friendship.

In the middle ages, some doctors used mirth as medicine. Henri de Mondeville, a famous 13th century surgeon, told jokes to his patients. He said: "Let the surgeon take care to regulate the whole regimen of the patient's life for joy and happiness . . . Remind him that the body grows fat from joy, thin from sadness."

In the American wilds, the Ojibway Indians were using clown medicine men to make the sick laugh.

This practice continues today. One need only notice that "Laughter, the Best Medicine" has for years been a section of Reader's Digest.

Many patients know this. One is Ronald Reagan. When he was shot and taken to George Washington University Hospital, he said to his surgeons on his way to the operating room, "Please tell me you're Republicans."

A surgeon later wrote in the Journal of the American Medical Association: "His laugh-in-the-face-of-death humor helped soothe a nation of anxious citizens and drew them closer to their wounded commander-in-chief. Under the delightful guise of humor, he sent out a message of courage to the world." ::

True story:

A nurse woke up a patient to ask for a urine specimen. He ignored her and turned over. A few minutes later, another nurse awoke him and left his breakfast.

He looked at the apple juice on the tray, frowned and poured it into the urine bottle. When the first nurse returned, he held it up and said, "Don't you think this looks funny?"

"Yes," she answered.

"Maybe if I run it through again, it'll come out better the next time," he said, and drank it.

She fainted. ::

The classic modern story of survival by smiling is that of Norman Cousins. In 1964, when he was editor of the Saturday Review, he landed in a New York hospital with a severe paralytic illness and was doing badly. He was allergic to the pain-killers he was getting. The very touch of his bedsheets gave him terrible pain. A doctor gave him a 1-in-500 chance of survival.

He checked out, checked into a hotel with a movie projector -- this before the VCR era --

watched Marx Brothers movies and episodes of "Candid Camera" and gradually recovered.

"I made the joyous discovery," he wrote, "that 10 minutes of genuine belly laughter had an anesthetic effect and would give me at least two hours of pain-free sleep."

He credited his recovery to "a full mobilization of resources, including those that medical science offers and those of {my} own healing system," as well as "my physician {who} encouraged me to believe I was a respected partner in the process of recovery and who recognized the importance of the patient's own psychological resources."

Now, he teaches this kind of humanism to medical students. He is an adjunct professor in the department of psychiatry and behavioral science at the University of California at Los Angeles School of Medicine.

Some doctors have pointed out, and Cousins agrees, that his is a single case report, and single cases prove little. Certainly, laughter is not the answer for every patient or the right tool for every doctor.

Kaye Herth, assistant professor at the University of Texas School of Nursing, says "Attempts at humor can be inappropriate and possibly harmful" if a patient needs quiet time "or perhaps time to cry." To some persons, either laughter or crying can mean loss of control and inadequacy. The prescription of laughter, like other prescriptions, must be individual.

"It's wrong to encourage sick people to regard laughter as a cure-all or an easy substitute for competent medical treatment," Cousins says.

Still, in emotional or mental therapy, one psychologist points out, "one of the best signs that the client is getting better is that he or she can laugh at the problems brought to you."

In mental or physical ills, Cousins explains, "laughter interrupts the 'panic cycle' of an illness," a cycle that affects both ailing minds and ailing bodies. ::

Dr. Oscar London is the pseudonym of a Berkeley, Calif., internist who writes a humor column in the San Francisco Chronicle and is the author of "Kill as Few Patients as Possible" (Ten Speed Press).

"Telephones and Eggs Benedict are the leading causes of premature death among doctors," he writes. To discourage long-winded and insensitive callers, he uses a loud recording that comes on after three minutes: "This is Dr. London. Thanks to your deadly monologue, I can no longer continue this conversation; you have talked me into an early grave. At the sound of the explosive tone, please leave your name and phone number. You have the right to remain silent. Anything you say can and will be used against you. You are permitted one phone call to your lawyer, God help him." ::

Doctors have always used humor, including large doses of black humor, to help themselves live with illness and death and their inability to defeat either.

The process begins in medical school. Dr. Anne Eva Ricks, a New York ophthalmologist and author of the humorous "The Official M.D. Handbook," told Medical World News: "A sick person is a sick person, and a brain-damaged kid is a brain-damaged kid. Medical school is very sad and depressing, and we all use humor as a defense mechanism."

Nancy Dickey, a family physician in Texas, puts it this way: "When we've got patients going sour in every direction" in intensive care or emergency "and the physician really wants to throw things on the floor and cry," macabre humor helps.

In a new oral history of American women in Vietnam, a nurse tells how land mines and anti-personnel bombs inflicted such gruesome wounds that to deal with them "we used to call them horriblectomies and horridzomas."

The letter column of the otherwise solemn New England Journal of Medicine is replete with doctors' serious yet slightly off-the-wall reports of the new diseases of our times: frisbee finger, slot-machine tendonitis, Space Invaders' wrist, disco felon (caused by continuous finger snapping) and water-skier's enema (in skiers who fall and suddenly hit the water in a sitting position).

With seasoning, says Dr. Ricks, the medical "sense of humor changes from the gross and brash to a more subtle, self-deprecating understanding of human failures." ::

Doctors -- well, some doctors -- also tell stories on themselves.

One told Medical Economics how an elderly heart patient in the hospital passed out. The heart monitor signaled cardiac arrest.

The resuscitation team went to work and after 20 seconds he came to.

"Did you see anything unusual?" the doctor asked.

"I saw a bright light and in front of me a man dressed in white."

Aha, the doctor thought excitedly. A near-death experience. "Could you describe the figure?" he asked.

"Sure, doctor. It was you." ::

Patients have their own brand of jokes about doctors, those superhumans who sometimes cure disease and earn undying gratitude -- and who also make people wait for hours and charge exorbitant rates.

"Since we can't beat 'em, we might as well laugh at 'em," says Larry Wilde, author of "The Official Doctors' Joke Book" (Bantam). "Besides, it's healthy!"

The incomparable, now aging Dr. Seuss (who also answers to Theodor Seuss Geisel), after recovering from a heart attack, cataracts and a gaggle of other ailments, published another of his wildly rhyming books of verse and drawings last year.

This one is for adults. "I discovered I was spending more time in hospital vestibules than I was at my drawing board," he said. "To keep from going batty, I began drawing what was happening."

From "You're Only Old Once!" (Random House, $9.95) -- a bargain prescription for anyone who's ailing:

You'll be told that your hearing's so murky and muddy,

your case calls for special intensified study . . .

Then they'll say, "My dear fellow, you're deafer than most.

But there's hope, since you're not quite as deaf as a post.

We'll study your symptoms. We'll give you a call.

In the meantime, go back and sit down in the hall."

Humor is obviously a way for people to deal with frightening situations. When the Chernobyl atomic power plant had an accident, people did not panic although the specter of a global nuclear disaster is a recurring nightmare in the atomic age. Instead, people cracked Chernobyl jokes, like, "What's stuffed with butter and glows in the dark?" "Chicken Kiev."

Freud saw jokes as liberators of the psyche to free people from fears of a Chernobyl or illness. Jokes, he said, are also devices of acceptable aggression and anger, and safety valves to release excess psychic energy, including sexual energy. Humor can soften adversity, he said, by enlisting the powerful "pleasure principle."

Most patients who use humor to cope don't tell outright jokes but achieve goals like these in less boffo ways, often by remarks that may not have much meaning out of the context that gives them great momentary value.

A friend of mine was in the hospital, in pain after heart surgery and subsequent complications. Returning to bed near the end of her stay, she accidentally pushed the wrong gadget on her electric bed, and it started rising toward the ceiling. A nurse,

finding her several feet off the floor, asked, "How did you get there?" "I'm levitating," she answered.

At the National Institutes of Health Clinical Center, a man had been waiting much of the day for orthopedic surgery. The operation had been scheduled to start in the morning. Now it was 2 p.m. Meanwhile, as his wife explained to a Red Cross volunteer, the staff was "putting my husband's leg through a lot of motions."

And he quipped: "I didn't know you wanted me to be a ballet dancer."

Sometimes a disease is so grim, a sense of humor may seem out of place. But it's not. Even in cancer.

Dr. Samuel Sanes was an outstanding Buffalo physician and pathology professor. In 1973, he learned that he had an incurable form of lymphoma. He spent five grueling years fighting it and wrote a book, "A Physician Faces Cancer in Himself," published by the State University of New York Press after his death.

"I don't mind joking about my condition," one patient told him, "provided I do it myself."

"There is in fact," Sanes wrote, "a certain amount of good-natured needling, joshing and banter among physicians and other members of the medical team and their patients in the lymphoma-leukemia clinic . . .

". . . For some cancer patients, {humor} saves them from denying their predicament, from indulging in self-pity. It releases inner tensions. And it permits them to make

other patients and themselves feel brighter and better." ::

Ronald Firbank, a turn-of-the-century British author, said on his death bed: "Either this wallpaper goes or I do." ::

A psychologist at Antioch University-West in Los Angeles gives students a test to assess their sense of humor. The test seeks responses to many kinds of humor, then tries to get the students to be funny on their own. For one thing, they are asked to write humorous epitaphs for their graves.

One of the most common: "I told you I was sick."

A number of doctors and hospitals are taking these lessons to heart.

After hearing a talk by Norman Cousins, executives at one California hospital started passing out cassettes of George Burns-Gracie Allen sketches. Others have new "laughter programs."

But getting humor into medical care has to mean more than a good joke. It has to mean creating an air of "We feel good, not grim, about you," an environment where there are many smiles as well as the inevitable frowns and grave faces. It has to be an attitude of celebrating life.

Dr. Armand Brodeur, professor of radiology and pediatrics at St. Louis University and Cardinal Glennon Children's Hospital, is one practitioner of that attitude.

"My appreciation of it developed very "I discovered I was spending more time in hospital vestibules than I was at my drawing board. To keep from going batty, I began drawing what was happening."

-- Dr. Seuss, whose most recent book is "You're Only Old Once"

gradually," he says. "I can remember my early residency when nay-sayers -- patients with feelings of gloom and doom -- as a rule did more poorly than those with a bright outlook. Maybe this accounts for some of the unexplained miraculous cures that don't seem to have any answer. Some patients get well, others don't."

In pediatrics, there is a given: "When a child's sick, everybody's sick.

"I developed a philosophy for myself and the staff," says Brodeur. "Smile. Smile for your 8-, 10-, 12-hour day, even if you don't mean it. On good days, bad days, you smile.

"Always greet a child with a smile, always with a grin. And I can tell you it works. It has worked with me for 31 years. When you approach a child and smile, and the child looks back smiling, something happens."

Brodeur is also an accomplished magician. "I can take my fingers off so realistically that the parents are sometimes more gasping than the child. But the child invariably stops what he's doing and looks at me. I say, 'You see, my fingers are magic, and when I do this little pinch on your arm with this needle, it's not going to hurt.' "

Brodeur recognizes that it is not possible for every doctor or nurse or other health worker to be humorous, that "some people feel threatened by letting go."

Expressing anguish, he emphasizes, is as important as laughing. A smile or a laugh, people like Brodeur and Cousins say, can unlock a whole range of emotions within both patient and practitioners. Anguish, of course. But also hope, faith, courage, determination, acceptance.

Dr. Annette Goodheart, a Santa Barbara, Calif., clinical psychologist, has been using laughter along with other strong emotional responses as therapy for 18 years.

"I work with tears and raging, all the cathartic processes," she says. "But laughter is the way in, and it's a very powerful one." ::

In July 1981 Charles Schulz, creator of the comic strip "Peanuts," awoke with a tight feeling in his chest and ended up having quadruple bypass surgery. When he was admitted to the hospital, a nurse placed a large felt-tip pen nearby and said: "Before you leave, we want you to draw something on the wall."

As he told it in an essay on "staying power" (sponsored by the Panhandle Eastern Corp.):

"I am not one who goes around drawing pictures on walls. But . . . late one night during recovery, it came to me suddenly . . . I climbed carefully out of bed and began to draw a series of Snoopys, showing him struggling with an inhalator to make the three balls rise to the top . . . The last panel showed him collapsing with exhaustion and triumph.

". . . There I was drawing, exhilarated, knowing I had gone through something I had not been sure I was brave enough to attempt . . .

"More good cartoon ideas come out of a feeling of sadness than a feeling of well-being . . . If you are a person who looks at the funny side of things, then sometimes when you are the lowest, when everything seems totally hopeless, you will come up with some of your best ideas.

"Happiness does not create humor. There's nothing funny about being happy. Sadness creates humor." ::

Sociologist Candace West, in her book "Routine Complications," tells of a series of observations in the pediatric wards of a large teaching hospital. They showed that less than 6 percent of doctors' communications to mothers were positive "in the form of friendly remarks, joking, agreement {or} support." Instead, "physicians' contributions tended to consist of 'neutral informational statements' . . . rarely interspersed with such commonplace courtesies as introductions, greetings or the use of patients' names."

"In and of itself," she concedes, "doctor-patient talk contains few 'laughing matters.' "

Over a period of time, West recorded 21 physician-patient relationships to try to detect attempts at humor or laughter as a prelude to communication. In 532 pages of transcript, patients only volunteered laughter on 49 occasions and physicians on 31. And in most cases the person on the receiving end, either doctor or patient, refused the invitation to smile or laugh.

The promoters of laughter in healing obviously have a long way to go.

Dr. Armand Brodeur has some sympathy for today's doctors, beset by hospital controls on how they treat their patients, limited by insurers on how they charge, under fire by the public and press for overcharging and maltreating, faced with new and complicated technologies to master, and accosted by lawyers and threatened with lawsuits if they do the wrong thing.

Perhaps, however, this means that today's hard-beset doctors need humor more than ever.

Some are trying. In response to all the new and threatened controls, a number of internists around the country have formed the Ancient and Elliptical Order of Alligators and wear little alligator pins on their white coats. The maxim: "If you're up to your ass in alligators, it's hard to remember that your initial objective was to drain the swamp."

Despite all the hassles and tragedy, says Dr. Brodeur, in the daily battle against disease, "the most important things a physician can have are compassion and a sense of humor."Next Week: Making humor work in a sickroom.