Side Effects of the Best Medicine, and Sutton’s Law


I had to apply Sutton’s law

I couldn’t believe what I saw

            The effect of the laughter

            The pain which came after

Was sharp, not a stab, not a gnaw.

 

The teenage patient, accompanied by the parent came back for the second time in three days with abdominal pain worsening.

The ultrasound done on Monday came out OK; normal blood count and good appetite in the face of increasing pain, worse with activity.

The belly itself had no masses or lumps.  Symmetric tenderness, along the sides of the abdomen, worse when the patient raises the head off the pillow.d

A puzzling picture, one that I’ve never seen before, led me to bring out Sutton’s Law.

Willy Sutton, the a great bank robber, robbed more than two hundred banks.  Supposedly, a newspaper reporter asked him why he robbed banks, and he said, “Because that’s where the money is.”

In his book, Where The Money Was, he denied ever having had the conversation, but gave an excellent history of how Sutton’s Law became a legitimate medical principle.

Sutton’s Law states: Go where the money is. It means two different things: 1) think geographically and 2) think in terms of the most likely diagnosis.

(Sutton’s Law has a lot of applications in and out of medicine.  In my case, it meant that if I wanted to find a Jewish woman willing to live in a rural area, the place to look was the synagogue in Casper, Wyoming.  Which is where I met Bethany.)

In the presence of local tenderness, I tend to think geographically, which means I have to consider the anatomic structures close to the pain.  In this case, the line of the pain followed the edge of the main muscle of the abdomen (the rectus abdominis), the one that forms into a six-pack after 10,000 sit ups and 5,000 crunches. 

Yet the patient denies new exercise programs or trauma.

The parent recently took to heart my advice on diet and exercise, dropped dozens of pounds, and started sleeping better.  The parent and the patient showed healthy interchange of ideas and jokes.  I watched their body language, showing appropriate, functional communication.  All in all they looked like they got along well.

Then the patient asks if the pain could be from laughing.

Yes, I said, it could, especially if the laughter has been extra hard in the last three weeks.

Which it has.  As the parent has gotten healthier.

I nod.  I don’t tell the patient to stop laughing but I advise cutting down on athletics for the next two weeks, and icing the painful areas 15 minutes three times a day

It’s the first time I’ve seen a side effect from laughter, the best medicine. 

Sooner or later, it was bound to happen.

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