Forme Fruste!

Medical school is full of life and death crises. Thankfully, many do not have tragic endings.

An event that affected me the most happened on my surgical rotation decades ago. Our attending surgeon was a charismatic man. We all followed him around like chicks behind a mother. One day, Jimmy, a 30ish year old man was admitted with stomach pain. He was an old patient of the attending, someone he had treated as a child for Crohn’s disease. Apparently the boy had numerous surgeries, after long-term treatment with steroids. Crohn’s disease is an autoimmune condition, leading to the risk of bowel obstruction, which can be fatal.

The boy had improved and now was a man. Two decades had passed, and the surgeon hadn’t seen him again in the interim. But as soon as he returned to the hospital, the surgeon remembered his old patient well. So many surgeries years ago, so much effort and apparent success, but now Jimmy was back in the hospital with sudden abdominal pain.

A recurrence of the Crohn’s disease. Could it be? After all these years? It had gone away for decades and now it had come back, it seemed; that’s the nature of that illness; it’s recurrent. But not usually with such a long delay.

The surgeon was dismayed, disappointed. Jimmy was scared.

He was now a young adult, with curly blond hair and a blondish-brown fu-manchu moustache. Jimmy was short, though, the effect of steroids in childhood, which stunt growth. Except for his small stature, he was a healthy, happy, attractive man — excluding the new abdominal pain. He came with his girlfriend, who was a good deal taller than him, a thin pretty woman with a thick country accent.

Sudden abdominal pain usually is a reason to do emergency surgery. If there’s an obstruction, it can lead to bowel perforation, then infection from the bacteria in the bowel going all over the abdominal cavity, then sepsis, then death. Just as had happened to James Reid on the neurology service.

The senior surgical resident, who headed our team, wanted to operate. The surgeon was hesitant.

Jimmy had experienced many surgeries as a boy. When you operate on the belly, especially repeatedly, the tissue around the bowels reacts and becomes fibrous. These “adhesions” can then make it difficult to operate again. When you open the belly, you don’t see bowels in a clear fluid, as in a healthy person; you see white fibers as soon as you cut through the skin and enter the belly. And these white fibers go in every direction and adhere to the bowels. You have to cut them with your scalpel, including close to the bowel. And if you nick the bowel, the contents spill into the cavity, causing the deadly infection (called peritonitis) that can kill the patient right away. The patient would die on the surgical table.

The attending surgeon didn’t want to operate. He worried about adhesions; he worried about killing the patient.

Jimmy had arrived in the afternoon. We spent the rest of the day debating whether to operate or not. The surgeon left to go home at night. The senior resident and I stayed in the hospital overnight, on call.

As the night wore on, Jimmy’s pain got worse and worse. He didn’t have a fever; there were no signs of peritonitis or sepsis yet. But the resident was worried. He knew that at any moment, if the bowel perforated, it was all over.

The resident stayed up all night. So did I. We kept checking on the patient, over and over again, multiple times in an hour.

The surgery resident really wanted to operate, but he couldn’t do it without the attending surgeon’s permission. I was no help to him; I was just an extra set of hands ready to do whatever he wanted.

Finally, around 3 AM, when Jimmy’s pain kept worsening, the resident told me he was calling the attending surgeon at home.

I sat next to him as he picked up a phone. The surgeon answered.

“He’s really sick; he’s really sick,” the resident explained. “We have to do something. We can’t just watch him. I don’t know if he’ll make it through the night.”

The resident listened as the attending surgeon responded, looking at me incredulously.

“No we have to operate; I don’t think we can wait.”

The surgeon spoke some more.

“Forme fruste?!” the resident said in disbelief, raising his voice moderately into the phone. “Forme fruste?”

I didn’t know what forme fruste meant; I looked it up later. It means a mild early presentation of an illness, such that its full clear features might not be apparent. The surgeon was saying that the symptoms might represent atypical Crohn’s disease recurrence, even if they weren’t classic symptoms, perhaps an early manifestation of the recurrence — a forme fruste.

They talked more and the surgeon could see that the resident wasn’t giving up.

“OK thanks.” The resident slammed the phone down.

“We’re going to operate,” he told me matter-of-factly.

“What? Really? Did the attending finally agree?” I asked.

“Sort of. He said he didn’t recommend operating, but I could use my judgment based on what I saw on the physical examination now.”

“Which means?”

“Which means we’re operating! Go scrub up.”

Not ten minutes later, Jimmy was being wheeled down the hallway toward the operating room. Just before we left the floor, his girlfriend leaned over and gave a him a long, deep kiss.

I pushed Jimmy on; she stayed behind with a longing look, as if wondering whether she’d see him alive again.

We went to operating room, gowned up, masked up. The resident was in a hurry. Anesthesia was given. A few minutes later, everyone was ready.

“Let’s go,” the resident said softly, as he lifted the scalpel, and cut diagonally across the top of the stomach area.

We expected it to be hard, to see white adhesions, tightly holding onto the skin as soon as the scalpel entered the abdomen. But no. It was all smooth. The scalpel entered the abdomen easily; clear liquid was all around; the bowels were clean and visible; there were no adhesions at all.

“Huh!!” the resident exclaimed. He must have had a broad smile under his mask.

He looked around in the belly. There was no mass. There wer no bowel obstruction. There was no Crohn’s disease.

“Huh!”

He kept looking, and then he saw the stomach, with a 2 inch round ulcerated lesion. There it was, the cause of all the pain — a simple stomach ulcer.

“Huh!”

He looked at me, and again seemed to smile under the mask. “Well, that’s an easy thing to fix!”

I held the cavity open along with the nurses while the resident went to work. He cut out the ulcer and sewed the stomach together where it had been.

Within half an hour it was all over. The patient was cured.

He closed up the abdomen, and we walked out of the operating room.

He didn’t look at me or talk to anyone. He went straight over to the nursing station and picked up the phone.

The attending surgeon listened as the resident explained that it was just a stomach ulcer. Just a stomach ulcer? How could that be?

Later when we talked more to Jimmy and his girlfriend, we found out that he was a photographer, and he had been working hard on some projects in darkrooms for the prior months. But he had migraine headaches, which worsened when he would go from darkrooms into normal light. He had been treating his migraine with a lot of aspirin recently. Apparently, the aspirin had caused the ulcer.

It had nothing to do with Crohn’s disease.

We simply hadn’t bothered to get a careful history from him about his recent activities, otherwise we might have made the connection earlier. We had assumed it was the Crohn’s disease instead.

If we had kept waiting, the stomach ulcer might have perforated, which could have been deadly. A totally preventable and treatable condition could have been fatal.

But the resident knew something was wrong. He didn’t know what it was, but he sensed that he couldn’t wait.

And why were there no adhesions? We later understood that the many steroid treatments Jimmy had received around the time of his operations probably had prevented adhesions, since steroids have strong anti-inflammation effects, and thus prevented the fibrous reaction that tends to happen with abdominal operations.

It all ended well, even though we didn’t understand why until afterwards.

Jimmy survived. The surgeon was beaming the next day, as he came to the hospital room, where Jimmy lay, calm, pain-free, happy, holding his smiling girlfriend’s hand. The surgeon got the credit.

The resident, who had saved Jimmy’s life, was relieved.

As we walked out of the room, he looked at me, and whispered, with a smile:

“Forme fruste!”