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I was excited for Professor Dumms's third lecture. In her first lecture, she described a woman whose armpit gave milk. In the second, a case of an ovarian tumor containing teeth and hair. I expected another chapter in what she enthusiastically described as "the astonishing feat of biological engineering nature uses to build a human body."
"It begins with a fertilized egg--a single cell created by the union of a sperm cell and an egg cell--and grows through repeated division into an adult composed of thirty trillion specialized cells," she said, and then asked teasingly, almost cynically, "With such a complex process, what can go wrong?"
Her introduction to the third lecture was philosophical, as if it didn't belong in a lesson in pathology.
"Imagine a destination you are eager to explore," she said, pausing to give our minds time to take on the task. "Then imagine you embark on your journey and travel for quite a distance, only to realize you've lost your way, run out of fuel, or that your path is blocked. You're stuck. Has it ever happened to you? A dream that didn't materialize, a journey interrupted?
"Halted in a place you never desired. Surrounded by neighbors you didn't invite. Disappointed and dismayed. What are your options? To rest, recharge, then keep searching for a new map or path. To try crossing through or bypassing the obstacle. To adapt and accept. Or to boil in your own resentment, grow bitter, even turn violent against your surroundings and the strangers you never imagined as your neighbors."
The rest of Professor Dumms's lecture took the form of a case presentation: James, 47, came to the emergency room complaining of several weeks of vague discomfort on the left side of his abdomen. The doctor examined him but didn't notice anything out of the ordinary. A CT scan showed something surprising--a mass, about three inches in diameter, on the left side of his abdomen.
"What could it be?" Professor Dumms asked rhetorically, as if she herself were facing the patient, trying to make the correct diagnosis.
"If I were his doctor, I would first examine his scrotum," she said.
Then came the explanation: human organs can travel long distances across the body. The gonads--ovaries in women, testes in men--for example, don't form where they end up. They originate high up near the kidneys!
During fetal development, the testes undertake a remarkable journey down through the abdomen and groin into the scrotum, a complex process involving hormones and a structure called the gubernaculum. The name comes from the Latin gubernare--to steer, guide, or govern. The anatomist John Hunter gave it this name because he believed the gubernaculum steered the developing testis toward the scrotum, much as a rudder steers a ship. The actual process is more complicated, but the image--and the name--stuck.
Sometimes that journey is interrupted, and the testis remains somewhere along the route. The condition is called undescended testis, or cryptorchidism (crypto- comes from the Greek kryptos, meaning "hidden" or "concealed"; orchis means "testicle").
When the ER doctor saw the CT images, he returned to the patient and examined him, this time more thoroughly. The left side of his scrotum was empty. Suddenly, the abdominal mass had an explanation: it was likely an undescended testis.
Why is it important for the testis to reach its destination? First, because what man would want to walk around with a half-empty scrotum and only one testicle in its proper position? Second, because a testicle positioned higher in the body is exposed to higher temperatures than it would experience in the scrotum, and lower temperatures are essential for normal sperm production. And finally, because an undescended testis is more likely to become cancerous.
It isn't clear whether the reason for this malignant transformation is the environment in the abdomen--which is improper for testicular development--or whether the testis was abnormal in the first place, leading to both arrested descent and malignant transformation.
It's for these reasons that doctors should closely examine the scrotum in newborns. If a testis hasn't descended by six months, spontaneous descent becomes unlikely, and surgeons generally recommend bringing it into the scrotum during infancy. This improves the chances of preserving fertility, provides a more normal appearance, and makes the testis accessible to examination later in life.
"As for James," Professor Dumms said, "his journey had stopped decades ago. And now his undescended testis had turned malignant. It was time for the doctors to remove it."
She showed us slides--graphic images--of the malignant tissue as seen under the microscope and of the tumor submerged in a formalin jar.
Faced with an obstacle to a dream that won't materialize, halted in a place I do not desire, I sometimes recall Professor Dumms's philosophical guidance. I ask myself what options I have: to find a new map, a way out; to adjust, adapt, and accept; to respond in time; and, hopefully, never to turn melancholic or malignant.
EDITOR’S NOTE: Shahar Madjar, MD, MBA, is a urologist and an author. He practices at Schoolcraft Memorial Hospital in Manistique and in Baraga County Memorial Hospital in L’Anse. Find his books on Amazon or contact him at smadjar@yahoo.com.