Nailing Burkitt lymphoma

‘Uganda is a fairyland. You can climb up a railway instead of a beanstalk and at the end there is a wonderful new world’. Winston Churchill wrote these words at the beginning of the 20th century, describing Uganda as the pearl of Africa. Had he climbed the beanstalk in the middle of the century he would have found another bright jewel in the form of Makerere University of Medical School and Mulago Hospital, its associated teaching hospital. These two institutions had a high reputation throughout Africa and beyond, with staff, including Denis Burkitt, actively engaged in research in many areas of medicine. Denis Burkitt was born in County Fermanagh, Northern Ireland where his father, James Burkitt, was the County Engineer. His was a deeply religious family and Denis’s Christian conviction acted as his guide throughout this life. James Burkitt was famous as a pioneering ornithologist and one of the first to use leg rings to identify individual birds and to study their behaviour and distribution. This may have had an influence on Denis’s later epidemiological studies, although he never followed his father’s interest in ornithology. This may have been due to the fact that, at the age of 11 years, he lost his right eye following a stone throwing fight between two gangs of boys (in later years it was said that Burkitt went to Africa with one eye but saw more than most men with two eyes). In 1929 Burkitt entered Trinity College, Dublin to study engineering. However, during his first year he became convinced that his calling was to medicine and he enrolled as a medical student. He had a distinguished undergraduate career and was placed second in the final qualifying examination. After appointments in Ireland and England, Burkitt passed the examination for the Fellowship of the Royal College of Surgeons of Edinburgh. His next adventure was to sign up as ship’s surgeon aboard a freighter of the Blue Funnel Line on a 5 month return trip to Manchuria. He had time to think about his future on this journey and formulated the view that his future lay as a surgeon in the developing world. On return to England, he was appointed as Residential Surgical Officer at the Prince of Wales Hospital, Plymouth. Here he met nurse Olive Rogers, who later became his wife. In 1940 Burkitt applied to join the Royal Army Medical Corps (RAMC) but was rejected. The next year he applied to the Colonial Office for service in West Africa but was again rejected. A second application to join the RAMC was however accepted. After training in the UK he embarked for Mombasa and served in Kenya and Somalia. During this time he was able to make a 6 week visit to Uganda. After postings to Ceylon and Singapore he returned to England for demobilization convinced that he had been called to work in Uganda. Burkitt’s second application to the Colonial Office was successful and he was appointed to the post of Medical Officer at Lira, in the Lango District of Uganda, responsible for the medical needs of 300 000 people. In 1948 he was appointed as a surgical specialist to Mulago Hospital, Kampala and Honorary Teacher in Clinical Surgery, Makerere University College Medical School. In his early years in Uganda Burkitt made a major contribution to the management of orthopaedic diseases resulting from poliomyelitis and tropical leg ulcers. In particular, he organized the production of callipers and crutches from cheap, locally available materials. In 1957, Hugh Trowell, a senior physician at Mulago, asked Burkitt to see a 5-year-old boy with tumours in all four quadrants of the jaw. A month later, while visiting Jinja Hospital, Burkitt saw a young girl with jaw tumours similar to the case seen in Kampala. This girl was transferred to Mulago Hospital where it was established that she had abdominal as well as facial tumours. Both children died. These two cases acted as the catalyst that prompted Burkitt to study the lymphoma that bears his name. He found further cases in the records of Mulago Hospital and established that the jaw tumours and abdominal tumours were part of a single disease entity and not separate entities as was often thought at that time. A later analysis of cases showed that the jaw involvement is age-related, with 100% of cases at the age of 3 years having jaw tumours falling to <20% in the teen years (Burkitt, 1970). As the median age of cases of Burkitt lymphoma patients in Uganda was 7 years, approximately 50% showed jaw involvement. Burkitt’s first clinical description of the tumour was published in 1958 in the British Journal of Surgery and appeared to receive little attention (Burkitt, 1958). More detailed descriptions of the clinical and pathological features (Burkitt & O’Conor, 1961; O’Conor, 1961) attracted much more international attention. Review of the medical literature from sub-Saharan Africa showed reports of small numbers of cases with clinical features of Burkitt lymphoma categorized either as small round cell tumours or as unusual variants of neuroblastoma. The detailed case notes of Sir Albert Cook, the first missionary surgeon to practice in Uganda, describe and illustrate in drawings cases with the typical clinical features of Burkitt lymphoma, indicating that the tumour was present in Uganda at the beginning of the 20th century. Burkitt’s second major contribution to the study of the tumour that bears his name was to determine its distribution in Africa. This was a daunting task at that time but it was