Hearty laughter can cause syncope,31 32 33 34 35 perhaps by a neural reflex response to the increase in intrathoracic pressure that accompanies intense laughter.36 37 Syncope after laughing has accompanied bilateral carotid stenosis in Takayasu arteritis.38 Laughing can cause conduction anomalies39 and arrhythmias.40 A woman with long QT syndrome and a history of torsade de pointes took ziprasidone, collapsed, and died after intense sustained laughter.41 Laughter in Angelman’s (“happy puppet”) syndrome can cause asystolic arrest, apparently of vagal origin.42 Laughing fit to burst can cause cardiac rupture.43The quick intake of breath that accompanies laugher can provoke inhalation of foreign bodies.44In patients with asthma, laughter sometimes triggers an attack,45 but cough after laughing is commoner than a good wheeze.46 47 Asthma was once perceived as a psychological disorder,48 but Gillespie noted that laughter probably had a physical rather than a psychological effect, and that even hollow (non-Duchenne) laughter could trigger an asthma attack.49Laughter can cause pneumothorax.50 51 Pilgaard-Dahl syndrome, named after two Danish revue actors, is pneumothorax in middle aged smokers induced by laughter.52 If the You Tube video we have watched53 is representative, non-Danish speakers are not at risk.Interlobular emphysema can reportedly result from “efforts of parturition and of defaecation, by the lifting of heavy weights, during coitus, by paroxysms of rage, excessive laughter, and hysterical convulsions.”54Exhaled airflow—from sneezing, whistling, and laughing, for instance—potentially disseminates infection.Jeg er også fræk rent verbalt, jeg er indlevende og kærlig.

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We discarded papers with opaque titles, such as “Gelotophobia and thinking styles in Sternberg’s theory”,5 and publications that proved irrelevant, such as “Another exciting use for the cantaloupe”6 (which described practising endoscopy on melons). and have found friendliness and celebrating life to be the heavy artillery of the love strategy.”7 However, the benefits of laughter have often been assumed rather than demonstrated.

We identified three classes of findings: benefits from laughter, harms from laughter, and conditions causing pathological laughter. Dr Patch Adams advocated therapeutic clowning, declaring that “I have done vast numbers of clowning experiments . We concentrated on mirthful or “unintentional” laughter, also called Duchenne laughter, since Duchenne first demonstrated that genuine laughter is characterised by contraction of both the zygomatic and the orbicularis oculi muscles (fig 2Life satisfaction and laughter have been associated with one another,9 but reciprocal causality has not been confirmed.

Laughter, like many pleasurable things, including ice cream, chocolate, and sex (separately, and perhaps together), may precipitate headaches.62 The Chiari malformation and colloid cysts of the third ventricle are occasionally associated with laughter induced headache.63 64A woman with a patent foramen ovale laughed uproariously for three minutes, became aphasic, and had a cerebral infarct.65A good belly laugh can make a hernia protrude, aiding diagnosis in children66—rapture unmasking rupture.

By contrast, failure to laugh is an important sign of intra-abdominal infection in children.67 Laughter is an unusual precipitant of Boerhaave’s syndrome, spontaneous oesophageal perforation.68Laughing like a drain can cause stress incontinence.71 It can also cause “enuresis risoria” (“giggle micturition” or “giggle incontinence”),72 73 a consequence of uncontrolled detrusor contraction induced by laughing, for which methylphenidate has been advocated.74We limited our search to “laugh$,” and did not explicitly seek cacchinations, cackles, chortles, chuckles, giggles, grins, guffaws, smiles, smirks, sneers, sniggers, teehees, or titters; we also ignored sources of laughter (comedy, drollery, humour, jest, jocularity, whimsy, wit, and wisecracks).

Embase and Medline do not yet index some potential sources of information, including (yet).75We categorised effects as beneficial or harmful, a usually clear-cut distinction; some effects, however, such as lowering the threshold for seduction, could not be unequivocally categorised.

Some readers may ignore the benefits of laughter—that would be serious; others may dismiss its harms—we call them the laughing cavalier.

Others, however, view jokes as undesirable, because they circumvent resistance to psychic exposure and may be regarded as seductive.15 Ken Dodd pertinently observed that Freud, who thought that laughter conserved psychic energy, never played second house Friday night at the Glasgow Empire.

Laughter reduces arterial wall stiffness16 and improves endothelial function.17 So perhaps it relieves more than one kind of tension.

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