Science Articles

Freckles where the Sun don't Shine

Wed, 21st Dec 2011

What do you do when you have freckles...um...down below? John Gamel's in a tight spot...

John Gamel

Since birth I have endured the Scots-Irish curse of spots. By this I mean freckles; in fact, freckles everywhere: face, chest, back, arms, and legs. At a swimming pool in Atlanta during my high-school years, a visiting Yankee gaped at the quarter-sized freckles on my shoulders and hollered, “Hey, kid, what’s wrong? You got leprosy or something?” Scattered among the freckles are also a few naevi (singular = naevus), also known non-medically as “moles”, which are pigmented bumps that afflict most of the human race.Freckles on an arm

But I didn't develop a really serious spot neurosis until after a lecture at medical school. A photograph showed a ragged black spot on a patient’s thigh and an X-ray revealed his lungs were filled with nodules the size of golf balls. The man had a malignant melanoma, an insidious skin cancer that can resemble a naevus during its early stages. My God, I thought - that could be me! I raced to the surgery clinic, where a resident agreed that a naevus on my chest had a worrisome pearly border. I still bear the scar of its almost instant excision. To my immense relief, pathologic examination showed no sign of malignancy.

My anxieties lay dormant for three years, until I examined a young law student who had dark nodules scattered beneath his skin, nodules that had spread from a melanoma on his scrotum. The poor victim was my age, almost to the day, and in the rush of an instant, this dreadful coincidence rekindled my old obsession with a vengence.

I tried to calm myself with reason: this was just a foolish neurosis, like all those that had gone before. But a terrifying truth kept fighting its way through my defenses: six of my spots are on a place where half the human race doesn’t even have a place. Not quite on the scrotum, like the malignant tumor that had spread through the poor law student’s bloodstream, but damn close by. Five of these spots look like innocent freckles, while the sixth was displaying, by a slight elevation above the surface of my skin, the features of a naevus. But was it really a naevus? Or was it…or could it be…a melanoma?

The moment the doomed patient left my exam room, I took an early lunch break. Sweaty and tremulous, I rushed to the dermatology clinic, where Doctor Gantry, the chief resident, listened to my story and examined me carefully, peering through a magnifying lens held inches from the organ under study. He was a good man. His deep, soothing voice calmed me down. He assured me this was not a crisis, since the lesion causing me so much distress was almost certainly benign, though there might be some risk. A small risk - very small - but one that had to be considered, since on rare occasions a melanoma can arise from what appears to be a benign naevus. He would consult his colleagues.

I was disturbed by the word “colleagues.” With how many doctors would he share the story of my worrisome spot? I heard a murmur of voices, zipped my fly shut, and cracked the door of the exam room, only to discover a squadron of white coats gathered in the hallway. Morning clinic had just ended, and it seemed that every student and resident and faculty member in the dermatology department had gathered for an avid discussion. Surely, God forbid, this wasn’t all about me?

It was. At last Gantry returned with a female colleague in tow. He closed the door and explained that, after some debate, two schools of thought had emerged concerning the management of my problem. One school - the more conservative, to which he belonged - recommended a policy of live and let live: keep an eye on the worrisome naevus, but if it changed, then a biopsy would be in order. From this debate there had also arisen the more aggressive approach of Doctor Taylor, the sturdy, dark-haired woman standing impatiently by his side.

To this day I remember her first words to me. Not “It’s good to meet you,” or “How are you today,” but “OK, let’s see it!” Even more disturbing were the words that came after Exhibit A had been hauled out and inspected with a magnifying glass: “Ah, there’s no question - they’ve all got to come off.”

“All!” I spluttered. “But those… those others… the five, except for this one… those…surely… they’re just freckles.”

“Freckles?” she said with a derisive snort. “To get freckles, you’ve got to have sunlight, and I don’t think…you tell me…have you?”

No, I confessed, my precious parts had yet to see the full light of the noonday sun. But surely, I argued, all six spots looked benign. Couldn’t we just wait and see, then do a biopsy if there was any change?

“Sure, we could wait. But if the pathologist found malignant cells, then the surgeon - to be sure he got all the tumour - would have to go back and excise several cubic centimeters of adjacent tissue. An alarming prospect, wouldn’t you say, given the, uh, body part involved?”

MelanomaAlarming indeed. My legs trembled so badly I could hardly stand. After she left, Gantry told me to sit down and stepped from the room to bring me a cup of water. No rush, he said. Everything was under control. His voice droned on and on, so gentle and reassuring I expected him to pat me on the head. In any case, he insisted, I needed to see a plastic surgeon, the specialist best qualified to perform such a delicate procedure.

The next morning I skipped a lecture and made my way down to the plastic surgery clinic, where the receptionist, a tiny blonde woman, got things off to a bad start by asking the fatal question: “What’s the nature of your problem?”

“Well, uh… I… uh…” I said. Then, after an awkward silence, “Let me wait…I’ll tell the doctor myself.”

“I’m sorry, but we need this information so the nurse can prepare you for the doctor’s exam.”

“Oh, God,” I said. I covered my mouth with my hand. We stared at each other. She held her pen poised over a clipboard, eager to record the nature of a problem that seemed so bizarre it would surely evoke fits of helpless laughter. I imagined the receptionist rushing about the clinic to share my riotous story with every female in sight, or leaning across the counter, her eyes wide in disbelief, shouting, “No, you’ve got to be kidding!”

“Look,” I said at last, “you’ll just have to take my word for it. I don’t need a nurse to help me show my problem to the doctor. I can do it all by myself, and it won’t take a second. Trust me, please…”

“Well…” she said, giving me the look one might give a stubborn child. “OK, if you insist.”

Relieved for the moment, chart in hand, I was led down a corridor to a small room that contained a sink, an examination table, and a metal stool. As soon as the door closed behind me, I unbuttoned my shirt, ripped two paper towels out of the dispenser above the sink, and tucked them into my sopping armpits. I sat on the stool for what seemed like an hour, listening to occasional footsteps and muffled voices in the hallway. At last a brief knock announced the arrival of my saviour.

It was Doctor O’Riley, the chief resident in plastic surgery, a squat Irishman with a cheerful lilt to his voice. The instant he stepped through the door, I gave a sigh of relief. He had red hair and fair skin. A constellation of reddish brown freckles spread across his nose and down his rosy cheeks. Three darker spots - naevi, no doubt - were clustered on the lower lid of one eye. I also recognized an irregular, yellow-brown conjunctival naevus on the white of that eye. Here was a fellow who could sympathize with my plight.

When I told him about Doctor Taylor’s dogged insistence that I submit my organ for multiple biopsies, he scowled.

“Damn that woman,” he said. “She’s at it again!” Apparently she had referred other terrified males to the plastic clinic for surgical removal of spots from their delicate parts. He explained the The Man Who Lived in an Eggcuphazard of her “whack-‘em-all-off” approach - bands of residual scar that might cause ripping pain when put under the tension of an erection. Moreover, a surgeon would have to excise thousands of benign naevi before he discovered one melanoma.

“OK,” O’Riley said at last, “let’s take a look.” When I unzipped my fly to expose myself for a third microscopic examination, he exclaimed, “Only six lesions! Hell, I’ve got more than that. Don’t worry about the damn things. Come on back if you notice any change. By the way, I think you’re right - those other five lesions are most likely freckles. And leave that little naevus alone. It isn’t nearly as dangerous as a drive down the Bay Shore Freeway.”

“Thanks… thanks a lot,” I said. “I can’t tell you…”

That was the truth - I couldn’t tell him. A painful lump in my throat made it hard for me to speak. I left the clinic in a rush, lest my spotted Irish saviour notice the tears of gratitude gathering in my eyes. Worse yet, had I stayed another moment, I might have lost all control, thrown my arms around the poor man, and kissed him on his rosy cheek.

My spots have now behaved themselves for four decades. In return, I have spared them the embarrassment of another microscopic inspection. And unlike some of Doctor Taylor’s victims, I don’t suffer from ripping pain every time my wife takes off her nightgown...

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